Medicare Compliance & Reimbursement

Medicare Fraudsters Put On Notice

In one of the biggest takedowns in Medicare history 91 individuals were charged with "participation in Medicare fraud schemes involving approximately $429.2 million in false billing," Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius announced in an October 4 Department

of Justice Office of Public Affairs press release. This came as a result of Medicare Fraud Strike Force operations in seven cities.

The indictments were unsealed across the country charging "more than $230 million in home health care fraud; more than $100 million in mental health care fraud and more than $49 million in ambulance transportation fraud; and millions more in other frauds," according to the release. The joint Department of Justice and HHS Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators and prosecutors in which agents from the FBI, HHS-OIG, multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies participate.

"Today's arrests put criminals on notice that we are cracking down hard on people who want to steal from Medicare," said Secretary Sebelius in the official statement. "The health care law gives us new tools to better fight fraud and make Medicare stronger. In addition to the arrests made today, HHS used new authority from the health care law to stop future payments to many of the health care providers suspected of fraud, saving Medicare resources and taxpayer dollars from being lost to fraud in the first place," she added.

"Today's enforcement actions reveal an alarming and unacceptable trend of individuals attempting to exploit federal health care programs to steal billions in taxpayer dollars for personal gain," said Attorney General Holder in the statement. "Such activities not only siphon precious taxpayer resources, drive up health care costs, and jeopardize the strength of the Medicare program -- they also disproportionately victimize the most vulnerable members of society, including elderly, disabled and impoverished Americans."

$16.5 Million Settlement For Violation of False Claims Act and the Stark Statute

If you think that it's alright for your physician group to accept financial benefits like preferential rental arrangements from facilities they refer patients to, take a lesson from the HCA Inc., one of the nation's largest for-profit hospital chains. As part of an agreement to settle a qui tam suit HCA "has agreed to pay the United States and the state of Tennessee $16.5 million to settle claims that it violated the False Claims Act and the Stark Statute," the Department of Justice Office of Public Affairs announced in a Sept. 19 press release.

"Improper business deals between hospitals and physicians jeopardize both patient care and federal program dollars," Daniel R. Levinson, Inspector General of the Department of Health and Human Services was quoted in the release as saying. "Our investigators continue to work shoulder to shoulder with other law enforcement authorities to stop schemes that imperil scarce health care resources."

"Physicians should make decisions regarding referrals to health care facilities based on what is in the best interest of patients without being induced by payments from hospitals competing for their business," said Bill Killian, U.S. Attorney for the Eastern District of Tennessee in the same release.

For details, please see the release at www.justice.gov/opa/pr/2012/September/12-civ-1133.html

Major Savings In The Cards For Americans With Medicare

The U.S. Department of Health and Human Services expects that people who have high prescription drug costs will save more than $18,000 from 2010 to 2022 if they are covered by Medicare, according to a September 21 HHS press release. The average American covered by traditional Medicare can look forward to a moderate $5000 savings during the same period, it added.

"I am pleased that the health care law is helping so many seniors save money on their prescription drug costs," HHS Secretary Kathleen Sebelius said in the release. "A $5,000 savings will go a long way for many beneficiaries on fixed incomes and tight budgets. Because of the health care law, more than 5.5 million seniors and people with disabilities saved nearly $4.5 billion on prescription drugs since the law was enacted," she added.

HHS Warns Hospital Organizations of EHR Upcoding Risks

Most coders have known for years that electronic health records (EHRs) can be incredibly useful tools -- but that they can also lead to inappropriate coding habits. The Department of Health and Human Services (HHS) now appears to also accept the potential for EHR errors, and sent a stern letter to several hospital associations warning them of potential audits in this area.

"False documentation of care is not just bad patient care, it's illegal," said HHS Director Kathleen Sebelius and Attorney General Eric Holder in the letter, which went to the American Hospital Association and other organizations. "These indications include potential 'cloning' of medical records in order to inflate what providers get paid. There are also reports that some hospitals may be using electronic health records to facilitate 'upcoding' of intensity of care or severity of patients' conditions as a means to profit with no commensurate improvement in the quality of care."

Many cases of EHR upcoding are not deliberate. When the physician marks that he reviewed all of the review of systems and physical exam areas, the EHR typically returns with a higher code, even if medical necessity is not met for going over all of those body systems.

Bottom line: If you can't justify a high-level code for the condition you're treating, don't bill it. Select the appropriate code based on the documentation of the medically necessary exam, history, and medical decision-making that you performed rather than the EHR-chosen code.

Therapy Caps Lead Some Home Health Patients To Cancel Appointments

Therapy caps are becoming a problem for providers and patients alike. CMS "began issuing its therapy cap letter to Medicare beneficiaries who are receiving home health under Part A, resulting in patients cancelling appointments," reports the American Physical Therapy Association. The letters fail to explain that therapy services furnished under a Part A home health plan of care aren't affected by the cap.

The solution: Providers will have to educate beneficiaries to avoid appointment cancellations and other related problems that are already occurring. "APTA has updated its patient FAQs to explicitly state that the cap does not apply to patients who receive skilled therapy at home under the Medicare home health benefit Part A, those who receive services under Part A in skilled nursing facilities, or those under a Part A inpatient hospital stay," the trade group says.