Medicare Compliance & Reimbursement

Physician Who Alters Medical Record Is Charged With Obstruction of Justice

Ever wondered why following the regulations is of paramount importance when you’re amending a medical record? An Illinois physician found out the hard way, pleading guilty to obstruction of a criminal health care fraud investigator on Feb. 14 and now faces up to 10 years in prison and a $250,000 fine.

The physician received a subpoena for his medical records, but before turning them over to the government official, the doctor altered a progress note to show an in-office examination that hadn’t actually taken place. The physician had billed the visit to his insurer, so he created the fake note later to support his claim.

Because of physicians like this, insurers are on the lookout for backdated or altered medical records. Therefore, if you need to amend your medical record, stick to the rules, which require you to identify it as an amendment, and the practitioner should sign and date it. Never delete the original entry — instead, ensure that all original content is identifiable. You can do this on a paper record by using a single strike line through the original content. For an EHR, you must “provide a reliable means to clearly identify the original content, the modified content, and the date of authorship of each modification of the record,” CMS says.

To read about the Illinois physician, visit www.justice.gov/usao/ils/News/2013/Feb/02142013_Yassin Press Release.html.

Millions Being Bilked From Medicare

In a case in Miami, U.S. District Judge Cecilia M. Altonaga sentenced Arbilio Yanes to 151 months in prison after he “pled guilty to conspiracy to commit health care fraud and to pay health care kickbacks, health care fraud, payment of health care kickbacks, and money laundering,” according to a Nov. 30, 2012 Department of Justice press release.

Yanes, the president and one of two owners of Research Center of Florida, Inc., a purported medical clinic located in Miami-Dade County, Florida, submitted claims to Medicare for $21,043,982,  between October 13, 2003 and November 5, 2004. These claims were “almost exclusively for purported treatment of HIV-positive Medicare beneficiaries for the administration of prescription drugs. Based on these claims, Medicare paid Research Center $11,098,388.93. In fact, Research Center personnel generally administered smaller doses of the medications than the clinic billed in its claims, or offered no treatment at all,” the release said.

To read more about it, please see www.justice.gov/usao/fls/PressReleases/121130-02.html.

New Legislation Aims to Reform SGR System

Every year, physicians bite their nails at the end of December, waiting to find out whether Congress will vote to reverse the massive Medicare cuts that are projected annually, thanks to the Sustainable Growth Rate (SGR) formula that the government uses to set payment rates.

But could next year be different? If two legislators are successful, it could be. Representatives Joe Heck, DO (R-NV) and Allyson Schwartz (D-PA) introduced the Medicare Physician Payment Innovation Act on Feb. 6 to offer a new alternative to the SGR formula. The new regulations would offer an annual positive payment update to all physicians for four years, ensure access to preventive care, “aggressively” evaluate new payment and delivery models, offer more than one payment model, and stabilize payments for providers who demonstrate their “commitment to quality and efficiency within a fee-for-service model,” Heck notes on his Web site.

The AMA instantly supported the legislation. “Reps Schwartz and Heck clearly understand that this decade long cycle of scheduled cuts and short-term patches must end so we can protect access to care for Medicare patients, reward quality and reduce costs,” AMA President Jeremy Lazarus, MD, said in a Feb. 6 statement.

The AMA also noted that the cost of repealing the SGR would be $138 billion, which is over $100 billion less than the previous projection, “and less than the $146 billion Congress has already spent on short-term patches to the SGR over the past decade,” Lazarus added.

Resource: To read a summary of the legislation, visit Rep. Heck’s Web site at heck.house.gov/press-release/heck-and-schwartz-introduce-bipartisanlegislation-repeal-sgr-and-reform-medicare.

CMS Launches ‘Bundled Payments for Care Improvement’ Initiative

The Centers for Medicare & Medicaid Services is testing a new payment system, and if flies, you might be seeing a lot more financial “bundles” coming your way than in the past.

On Jan. 31, CMS announced that over 500 organizations would be participating in the Bundled Payments for Care Improvement initiative, which bundles payments for episodes of care. “The objective of this initiative is to improve the quality of health care delivery for Medicare beneficiaries, while reducing program expenditures, by aligning the financial incentives of all providers,” said Acting CMS Administrator Marilyn Tavenner in a Jan. 31 statement.

Because payments will be bundled, physicians will have to work carefully with hospitals, post-acute facilities, and other providers. The practices that have been selected to participate in the early phase program will begin in April, and another group of providers will begin the program in 2014. There are currently four models being tested and 48 episodes (ranging from amputation to stroke) that CMS will be testing for the bundled care project.

To read more about the program, visit http://innovation.cms.gov/initiatives/bundled-payments/.  

DOJ Nails Nurse Who Submits Claims Even Though Facility Is Closed For Snow Day

Providers who intend to submit claims to Medicare should at least confirm that their clinic was actually open on the date of service. That’s a lesson learned by a nurse who was busted for fraudulent billing after the Department of Justice nabbed him for falsifying records to make them look like patients were eligible for mental health care when they weren’t. In addition, the nurse submitted claims on dates that his facility was closed for a snow day, and routinely submitted claims for patients that weren’t present.

The nurse also admitted that he was involved in a money laundering scheme, and is accused of providing kickbacks. He faces 111 months in prison and three additional years of supervised release. To read the entire press release about the case, visit www.justice.gov/opa/pr/2013/February/13-crm-181.html.