Medicare Compliance & Reimbursement

Plus: Practitioners in S. Florida made up 20 percent of Medicare fraud cases When it comes to the physician self-referral law, CMS doesn't kid around. So it was good news this week when CMS issued an advisory opinion in favor of a hospital's plan to develop software that will interface with physicians' electronic health records (EHRs). The hospital in this case wanted its software to be able to communicate with physicians' EHRs so hospital employees could send information such as lab results or surgical details between the two systems. In the advisory opinion, CMS states that the arrangement "does not create a compensation arrangement" but that the decision is applicable only to the hospital in question, and not to other entities. The CMS advisory opinion is available at www.cms.hhs.gov/PhysicianSelfReferral/Downloads/CMS-AO-2008-01.pdf. In Other News ... • If you like wagers, a pretty safe bet in the next few years will be that Medicare carriers will focus claims reviews on practices in South Florida. South Florida accounts for 120 criminal and civil cases, with more than 200 defendants charged with $638 million in fraud, according to a May 29 South Florida Sun-Sentinel article. • CMS will test 11 new quality measures for possible future adoption into the PQRI program. Between July 1 and Sept. 30, you should submit data for the potential new test measures so CMS can gather information to determine whether they qualify for the next scheduled PQRI update. Although you won't receive any bonuses for reporting the 11 new measures, you may be helping CMS decide whether they are worth implementing in future editions of PQRI, so it's a good idea to review them. "These new measures focus on kidney disease, skin disease, eye care, imaging, arthritis and cancer," a CMS release says. To read more about the measures, visit http://www.cms.hhs.gov/pqri. • Providers will be operating under revised claims appeals rules starting in August. CMS has finalized wide-ranging revisions to appeals in a May 23 Federal Register notice. Among the changes is a requirement that providers must add any issues to an appeal within 60 days of the original 180-day period for appealing the claim payment. Commenters argued that the change restricts provider appeal rights, denies access to appeals and fails to give providers enough time to identify issues, CMS notes.