Medicare Compliance & Reimbursement

Discrimination Costs Doc Federal Funding

The HHS Office for Civil Rights (OCR) lodged a complaint that a California surgeon’s refusal to perform much needed back surgery could be construed as intentional discrimination against an HIV-positive patient. It has led the OCR director Leon Rodriguez to announce the termination of Medicaid funding to the doctor, according to a July 18 HHS press release.

“An order, issued by the HHS Departmental Appeals Board, concluded that the surgeon violated Section 504 of the Rehabilitation Act of 1973, which prohibits disability discrimination by health care providers who receive federal funds,” the release said.

“Although OCR works with providers to provide technical assistance to ensure compliance with federal civil rights laws, this case demonstrates that we will not tolerate health care providers who refuse to comply and intentionally discriminate,” OCR director Leon Rodriguez said in the release.

To read the full text of the release see: www.hhs.gov/news/press/2013pres/07/20130718b.html.

Breakneck Speed Fraud

Austin-based Dr. Dennis B. Barson Jr., 40, and his Beeville-based medical clinic administrator, Dario Juarez, 53, reportedly tried to defraud Medicare of $2 million in less than two months, according to a June 25 Department of Justice press release.

“It is alleged that Barson and Juarez caused Medicare to be billed for procedures on 429 patients in just two months. Barson and Juarez also allegedly billed Medicare for seeing more than 100 patients on 13 different days, including a high of 156 patients on July 13, 2009,” according to the release. In addition Juarez is accused of practicing medicine without a license for which he is under custody.

“Each of the 19 health care fraud counts and the conspiracy charge carries a maximum penalty of 10 years in a federal prison and a $250,000 fine, upon conviction,” the release says.

To read the full release see: www.justice.gov/usao/txs/1News/Releases/2013 June/130625 - Barson.html.

RAC Auditors Target E/Ms During Global As Problem Area

When CMS sends out a “reminder” about appropriate billing practices, you know you should listen.

Recently the agency published MLN Matters article SE1323, which “reminds providers of the global surgery period” and urges practices to review the rules for how to bill E/M services in these situations. RAC auditors found errors for E/M billing during all of the global periods, from 0 to 90 days, the article notes.

Always remember the E/M services that you perform during the global period which are related to the surgery are included in the global payment, and are not separately billable even if you add a modifier such as 24 (Unrelated E/M service by same physician or other qualified healthcare professional during postoperative period) or 25 (Significant, separately identifiable E/M service by the same physician or other qualified healthcare professional on the same day of the procedure or other service). Therefore, before appending one of these modifiers, confirm that you are actually providing an E/M service that falls under the guidelines of the modifiers, and that the E/M is unrelated to the surgery (modifier 24) or significant and separately identifiable and performed on the same date (modifier 25).

To read the complete CMS article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1323.pdf.

Will Your State Loosen Medicaid Eligibility Requirements?

HHS Office of Inspector General (OIG) wants 11 states to bring their policies in line with the law. If your state requires Medicaid beneficiaries to be homebound to qualify for home care coverage, that may change.

“In a 2000 policy letter, [the Centers for Medicare & Medicaid Services] notified State Medicaid agencies that restricting eligibility for mandatory home health services to homebound individuals violates [federal] regulations,” the OIG says in a new report, “Some States Improperly Restrict Eligibility for Medicaid Mandatory Home Health Services” (OEI-07-13-00060).

But eleven states continue to have language in their Medicaid policy documents restricting eligibility based on homebound status. Two states did say they don’t enforce that restriction, however. The 11 states are Alabama, Arkansas, Indiana, Montana, Nebraska, New Mexico, North Dakota, Pennsylvania, South Dakota, Utah, and West Virginia, the OIG lists in the report at go.usa.gov/bJz9.

In July 2011, CMS published a proposed rule that would revise Medicaid regulations to clarify that home health services cannot be restricted to individuals who are homebound or to services furnished in the home, the OIG notes. “We encourage CMS to finalize its proposed rule clarifying that home health services cannot be restricted to individuals who are homebound or to services furnished in the home,” the watchdog agency says.