Medicare Compliance & Reimbursement

If you think the government is only cracking down on doctors, a new Department of Justice (DOJ) report shows that physicians' assistants are just as vulnerable to abuse and fraud accusations.

A Miami-based physician's assistant has pleaded guilty to defrauding Medicare out of $119 million in HIV infusion reimbursement, according to a Sept. 18 DOJ press release.

The physician's assistant, along with several accomplices, set up fake HIV infusion clinics around South Florida. Also guilty in the scam were a medical biller, several physicians, and other personnel members. The medical biller faces 120 months in prison, while the physician's assistant faces sentencing soon.

To read more about the case, go online to www.usdoj.gov/opa/pr/2008/September/08-crm-829.html.

• About a year from now, you'll need accreditation to supply durable medical equipment under Medicare, unless you're not a traditional DME supplier.

CMS "has issued an exemption for virtually every professional group except respiratory therapists, registered nurses, and pharmacists," the National Association of Independent Medical Equipment Suppliers notes in a message to members. The exempt list includes physicians, physical therapists, and other specialties.

The American Podiatric Medical Association and the American Physical Therapy Association are praising CMS' exemption decision. "This is a huge victory," APTA's R. Scott Ward says in a release. "Physical therapists already provide care of the highest quality," meaning these unnecessary requirements would have burdensome, costly and an obstacle for patients who need the services.

NAIMES opposes the exemptions, the trade group says in a letter to CMS. "The mandatory accreditation requirement [is] a vital element in the fight against fraud, abuse, and billing errors in DME," it says. The move exempts more than 45,000 National Supplier Clearinghouse-listed suppliers from the requirements.

• CMS Wants to Ensure That You Don't Miss The ICD-10 Boat.

The news that CMS intends to implement ICD-10 by 2011 is just sinking in for some coders, but CMS is already trying to prepare practices around the country for the big change that you'll face in three years.

CMS intends to host a series of conference calls including Q&A sessions which will cover the ways in which ICD-10 will differ from the current ICD-9 system.

If you are puzzled by the differences in code lengths or other disparities between the current method and ICD-10, tune into the calls on Oct. 14 (for hospitals), Nov. 12 (for other Part A and Part B providers), or Nov. 17 (for physicians). Or you can simply check out CMS' powerpoint presentation on the topic at http://www.cms.hhs.gov/ICD10.

• Hospices don't have to do all the heavy lifting when it comes to compliance for patients in nursing homes.

The OIG has issued its supplemental compliance guidance for nursing facilities, which covers hospice provisions.

For example: It's a kickback if a hospice nurse provides nursing services for non-hospice patients at no charge, the guidance makes clear.

Arrangements between nursing homes and hospices "pose several fraud and abuse risks," the OIG warns. Additional room and board payments, inflated payment rates for contracted hospice services, and referring patients to nursing homes in exchange for receiving their hospice referrals are just some of the kickback dangers the OIG names.

Hot spot: Watch out for reserved bed agreements with nursing homes, the OIG adds. They could be a kickback risk depending on how they are arranged. Under reserved bed agreements, nursing homes keep beds open for hospice patients in exchange for payment.

The guidance is in the Sept. 30 Federal Register and posted online at http://oig.hhs.gov/fraud/docs/complianceguidance/nhg_fr.pdf.