Medicare Compliance & Reimbursement

Warning: HIPAA enforcement is ramping up.

The feds don't seem afraid to use their HIPAA fining power, and it was one employee's innocent mistake that cost $1 million.

The Department of Health and Human Services' Office of Civil Rights (OCR) has fined the General Hospital Corporation and Massachusetts General Physicians Organization Inc. in Boston $1 million over an incident where a Mass General employee left files on a subway train that were never recovered.

"We hope the health care industry will take a close look at this agreement and recognize that OCR is serious about HIPAA enforcement," OCR Director Georgina Verdugo says in a release about the settlement. "It is a covered entity's responsibility to protect its patients' health information."

And OCR has fined insurance plan Cignet Health of Prince George's County, Md., more than $4.3 million for breaching the HIPAA Privacy Rule. "The fine is the first civil monetary penalty (CMP) ever imposed for a covered entity's violations of the HIPAA Privacy Rule," notes law firm Sidley Austin on its website.

Cignet's fine came from failing to give patients' access to their protected health information (PHI) in their medical records, rather than accidentally revealing PHI.

"These cases, and HHS's apparent willingness to put them in the spotlight, demonstrate the agency's newfound commitment to investigating, uncovering and imposing penalties for HIPAA violations," notes law firm Duane

Morris in an alert on the topic. And HHS now can more easily track possible violations, thanks to HITECH Act provisions that require providers to notify the agency of HIPAA data breaches, Duane Morris points out.

OIG Offers Free, Pre-Written Presentation for Teaching New Physicians About Compliance. When your practice hires a new physician, the job of training the doctor on healthcare compliance may fall to more than one person in your practice, including the office manager, compliance officer, coder, and fellow physicians. But that job may be a little bit easier now that the OIG has created a ready-made presentation that teaches new physicians how to steer clear of fraud.

The presentation, entitled, "Avoiding Medicare and Medicaid Fraud and Abuse," covers the five main areas of Medicare abuse: the False Claims Act, Anti-Kickback Statute, Physician Self-Referral Statute, Exclusion Statute, and Civil Monetary Penalties Law.

For example, the PowerPoint presentation, which the OIG offers in a .pdf format, reminds new doctors that prohibited kickbacks include "cash for referrals, free rent for medical offices, and excessive compensation for medical directorships." It also reminds physicians that it's illegal to sell free samples, and that you should always consider gift reporting requirements when accepting gifts.

To read the entire presentation, along with a booklet for physicians' self-study regarding how to avoid Medicare and Medicaid fraud, visit http://oig.hhs.gov/fraud/PhysicianEducation/.

If your home health agency is submitting claims for five-visit episodes with a single nurse or social worker visit, you're at high risk of denials. Regional home health intermediary Cahaba GBA is continuing to run widespread edits on these two types of claims, it says in its March newsletter for providers. And both types of claims are turning up high denials rates -- 83 percent for the claims with one nurse and four therapy visits, 75 percent for the claims with one medical social worker and four other visits.

For the single nurse visit edit, "the top denial reason ... was related to medical necessity of the one-time skilled nurse visit," Cahaba explains. If the nurse opens the case and performs the start of care assessment, that visit is not billable -- unless the nurse also delivers a medically necessary skilled nursing service.

Tip: "If the skilled need for the nurse is observation and assessment, there is greater need than a one-time visit," Cahaba says. And don't forget that the therapist can perform a SOC assessment. For the single MSW visit, "many of these denials are related to the medical necessity of nursing and/or the MSW visit," Cahaba reports. "Routine evaluations for community resources where no needs were previously identified would not be considered a covered MSW service."

More information is in the Newsline at www.cahabagba.com/rhhi/news/newsletter/201103_rhhi.pdf.