Medicare Compliance & Reimbursement

$100 Million Medicare Fraudster Pleads Guilty

Davit Mirzoyan, who pled guilty before United States Magistrate Judge Henry B. Pitman, fraudulently billed Medicare for over $100 million from 2006 to 2010 by creating dozens of "phantom clinics," in which the health care providers existed only on paper, according to an Oct. 26 Department of Justice press release. "At least 118 fraudulent Medicare providers, located in approximately 25 states, submitted fraudulent bills to Medicare totaling approximately $100 million, and received approximately $35.7 million," the release added.

"Davit Mirzoyan was a criminal parasite feeding on a grand scale off our country's health care system for personal financial gain and draining Medicare of needed funds. His guilty plea today ensures he will be held to account for his actions," said Preet Bharara, the United States Attorney for the Southern District of New York, in the release.

For pleading guilty to one count of participating in a racketeering conspiracy, and one count each of conspiracies to commit healthcare fraud, bank fraud, money laundering and identity theft, Mirzoyan faces a maximum penalty of 75 years in prison.

To read more about the case, visit www.justice.gov/usao/nys/pressreleases/October12/MirzoyanDavitPleaPR.php.

Primary Care Physicians Stand To Gain More Pay

Health and Human Services (HHS) Secretary Kathleen Sebelius announced the final rule implementing the part of the health care law that delivers higher payments to primary care physicians serving Medicaid beneficiaries, according to a Nov. 1 HHS press release.

"The health care law will help physicians serve millions of Americans across the country," Secretary Sebelius said in the release. "By improving payments for primary care services, we are helping Medicaid patients get the care they need to stay healthy and treat small health problems before they become big ones."

The final rule, which goes into effect in Jan. 2013, "implements the Affordable Care Act's requirement that Medicaid pay physicians practicing in family medicine, general internal medicine, pediatric medicine, and related subspecialists at Medicare levels in Calendar Years 2013 and 2014," the release pointed out.

Missing Documentation Leads to $7 Million Fraud Settlement

The Westchester County Health Care Corporation is at the center of a government case due to allegations that the center billed Medicaid for services that it did not have the documentation to support. The facility consequently settled with the Department of Justice and will pay $7 million in civil damages under the False Claims Act, an Oct. 24 news release revealed.

Under Medicaid guidelines, practitioners must "maintain certain documents, including progress notes and treatment plans, to ensure that billed services are actually provided, and that the providers are in compliance with the regulations," the DOJ announcement states. However, between August 2001 through June 2010, the mental health agency "repeatedly billed Medicaid for outpatient mental health services without having the core documentation required by the Medicaid regulations in order to bill for those services."

Worse yet, the DOJ maintains, the facility knew "for years" that documentation was missing, and only took minor steps, if any, to address the issue. Therefore, the facility continued to collect money from Medicaid for services that it was not entitled to bill.

To read the complete news release, visit www.justice.gov/usao/nys/pressreleases/October12/WestchesterCH.php.

Therapy Cap Approvals Must Use Latest Form, MACs Remind

If you're submitting pre-approval requests for therapy cap exceptions, you don't want to waste time using last-year's form, Part B MAC NHIC Corp. reminded practices in an Oct. 30 message. "Version 6.0 offers the ability to check off more than one discipline for physical therapy, speech language therapy, or occupational therapy for your pre-approval requests," the note said.

Practitioners who aren't submitting pre-approvals will get a request from their MAC asking for additional documentation, NHIC noted.

"As of October 17, 2012, providers identified in Phase II may now submit pre-approval requests for dates of service on or after Nov. 1, 2012 for beneficiaries over the $3,700 threshold," NHIC adds. "Please note that Phase I providers should continue to submit pre-approval requests."

For more information, visit www.medicarenhic.com.

CMS Puts Physician's Enrollment Responsibility In Writing

You may have heard that physicians are responsible for the details on their enrollment applications, but CMS now makes it crystal clear that this is the case. According to the agency's recent updates to Chapter 15 of the Medicare Program Integrity Manual, when filling out your enrollment application, you can make the "correspondence address" any contact you choose, including a billing agency, management services organization, chain home office, or attorney.

But, CMS makes clear, "The provider, however, remains ultimately responsible for all Medicare enrollment-related correspondence that the contractor sends to him/her/it at this address. For instance, if a provider uses its chain home office as the correspondence address, the provider is still the party responsible for replying to revalidation letters, requests for information, etc."

To read the updates to the Integrity Manual, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R435PI.pdf

Background Checks May Cut Aide Misdeeds Up To 20 Percent

The Health & Human Services Office of Inspector General finds that many nursing home aides convicted of neglect, abuse or theft have previous criminal history. Every week across the nation, news stories pop up about home care aides stealing from or abusing their patients. Participating in federal background checks for aides may save your agency that grief and embarrassment, shows a new study.

The OIG requested FBI criminal background checks for nursing home aides who received substantiated findings of abuse, neglect, and/or misappropriation of property during 2010, it says in a new report. Nineteen percent of aides with substantiated findings had at least one conviction in their criminal history records prior to their substantiated finding, the OIG reports.

Among those aides, the most common conviction (53 percent) was for crimes against property (burglary, shoplifting, and writing bad checks). Home care providers may see similar patterns, experts suggest.

The OIG conducted the aide study to establish a baseline before implementation of the Affordable Care Act-approved background check program for direct care long-term care workers, it notes. Nineteen states have received grants so far to participate in the background check program, which is voluntary.

OIG investigators also found correlations between the substantiated findings and the types of crimes turned up by the background checks. "Aides with substantiated findings of either abuse or neglect were 3.2 times more likely to have a conviction of crime against persons than nurse aides with substantiated findings of misappropriation, and nurse aides with substantiated findings of misappropriation were 1.6 times more likely to have a conviction of crime against property than nurse aides with substantiated findings of abuse or neglect," the OIG explains.

The report is at oig.hhs.gov/oei/reports/oei-07-10-00422.pdf.

CMS Plans to Move Medicare SNF payments from Volume to Value-based

In June, CMS sent a report to Congress detailing its plans to implement a Value-Based Purchasing Program (VBP) for skilled nursing facilities. "We see the future of health care reimbursement moving from the current volume-based payment methodology to value-based purchasing," David Gifford, MD, MPH, senior vice-president quality and regulatory affairs, for the American Health Care Association (AHCA), tells Eli. Both AHCA and the National Center for Assisted Living (NCAL) strongly support this move, he notes.

The report, which was required by Section 3006 of the Affordable Care Act, discusses the current state of various elements that would be part of a SNF VBP and where the agency will go from there, explains Cassandra Black, senior technical advisor for CMS's Performance-Based Payment Policy Group. These include the following:

• The agency's current quality measures and process for developing them;
• Additional quality measures that the agency may want to add;
• A description of the process for reporting the measures;
• How payments could potentially be structured;
• Types of incentive payments;
• Possible funding sources for the payments; and
• How the agency would share any information gathered with the public.

The report concludes with a roadmap for implementation of a SNF VBP. CMS will analyze the results of the recently concluded Nursing Home Value Based Purchasing demonstration project, expected to be ready in the fall of 2013, before moving forward with a SNF VBP, Black notes.

Gifford says that this report summarizes many of the ongoing demonstrations on VBP which is a helpful guide as SNFs transition from fee-for-service to value based purchasing. Copies of the report are available at: www.cms.gov/snfpps.

Expect More Consolidated Billing Woes From This MAC

Consolidated billing is difficult as it is, but when a MAC makes an error in processing claims, those issues can balloon and create problems for your cash flow. Unfortunately, one MAC has discovered such a problem, but on the bright side, the contractor is already trying to fix it.

NGS Medicare, a Part B provider in Connecticut and New York, announced on Oct. 9 that it was incorrectly denying some services that are excluded from consolidated billing. On those claims, the reason code is "109: Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor."

Although NGS notes that the problem has been happening for nearly a year, it also admits that "the issue remains unresolved." NGS intends to notify impacted practices once the problem is rectified.

Hit ADR Deadlines Or Throw Away Cash

Don't be late in responding to additional development requests, or you could be very sorry. That's the message from Home Health & Hospice Medicare Administrative Contractor CGS, which reminds providers that they have 30 days to submit their ADR responses. "If documentation is not mailed within the 30-day request, it may begin to auto-deny unnecessarily," the MAC warns on its website.

This is a pertinent issue for hospices, who have been on the receiving end of multiple widespread edits lately. CGS lists six hospice widespread edits on its website at www.cgsmedicare.com/hhh/medreview/med_review_edits.html, compared to just two edit topics for home health agencies.

The edit generating the most ADRs is 5101T, which selects claims with a length of stay greater than 180 days and a primary diagnosis of 331.0 (Alzheimer's disease), 799.3 (debility), or 496 (COPD). CGS has sent out more than 3,920 ADRs for this edit, according to information CGS supplied to the National Association for Home Care & Hospice.