Medicare Compliance & Reimbursement

The Obama administration obviously believes an ounce of prevention is worth a pound of cure and is taking innovative steps to protect vital healthcare dollars by uniting public and private organizations to fight fraud.

Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder "announced the launch of a ground-breaking partnership among the federal government, State officials, several leading private health insurance organizations, and other health care anti-fraud groups to prevent health care fraud," according to a July 26 press release.

The idea is to share information and best practices via this partnership "to improve detection and prevent payment of fraudulent health care billings," it said. The goal is to dig out and prevent scams that impact a number of public and private payers. "The partnership will enable those on the front lines of industry anti-fraud efforts to share their insights more easily with investigators, prosecutors, policymakers and other stakeholders," the HHS hopes.

For more information on this partnership and the Obama administration's work to combat health care fraud see: www.healthcare.gov/news/factsheets/2011/03/fraud03152011a.html and www.stopmedicarefraud.gov.  

Medicare Beneficiaries Protected From Significant Costs Increases

"Thanks to the Affordable Care Act, the Medicare Advantage and Prescription Drug programs have been strengthened and continue to improve for beneficiaries," said Health and Human Services Secretary Kathleen Sebelius in a September 19 HHS press release. "Since the law was enacted in 2010, average premiums have gone down, enrollment has gone up, and new benefits and lower drug costs continue to help millions of seniors and people with disabilities."

The Centers for Medicare & Medicaid Services (CMS) have taken advantage of the Affordable Care Act "to protect beneficiaries from significant increases in costs or cuts in benefits," while ensuring that they retain access to supplemental benefits.

With Medicare Advantage premiums falling by 10 percent and enrollment rising by 28 percent since the Affordable Care Act was passed in 2010, you can expect the average MA premium to increase by only $1.47 from last year. "Access to the Medicare Advantage program will remain strong, with 99.6 percent of beneficiaries having access to a plan," the release added.

In 2013, Medicare Part D's coverage of brand name drugs will begin to increase benefitting patients in the donut hole. Since ACA was enacted, over $4.1 billion on prescription drugs was saved by 5.4 million people in the donut hole.

For the announcement about Part D premiums check out: www.cms.gov/apps/media/press/release.asp?Counter=4425&intNumPerPage=10&checkDate.

To find helpful Medicare tools and information, and compare the cost or benefits of 2013 Medicare health plans in your area, please visit: www.cms.gov/center/openenrollment.asp.

Grants To Aid Veterans With Transition To Civilian Careers

"$2.3 million in grants to train primary care physician assistants (PAs) and help veterans transition from the military to civilian PA careers when they return home," were announced by Health and Human Services (HHS) Secretary Kathleen Sebelius according to an August 2 press release.

The main aim is "to increase the number of physician assistant graduates who become primary care clinicians and teachers ... the grants are part of the administration's initiative to increase the supply of primary care practitioners in the United States," the release said. "Funding priority was given to grantees that have strong recruitment, retention, and education programs for veteran applicants and students, including academic recognition of medical training and experience gained during military service," it added.

Revisit Your Record Retention Policy Or Risk Yanked Billing Privileges

The feds may have given you a motivating factor to help physicians maintain and submit documentation for home care patients, but it could increase your medical record workload as well.

Medicare's Conditions of Participation (CoPs) for home health agencies require providers to retain records for five years, notes the National Association for Home Care & Hospice. But a new transmittal from the Centers for Medicare & Medicaid Services ups that retention period to seven years for "written and electronic documents ... relating to written orders and certifications and requests for payments for ... home health services" and other items and services including DME, CMS says in Transmittal No. 431 (CR 7890).

CMS will hold ordering physicians to the same seven-year standard for record retention, it says in the transmittal. And CMS now requires the doc "to provide access to that documentation pursuant to a CMS or Medicare contractor request," the transmittal makes clear.

Consequences: HHAs, physicians, or other providers who fail to retain the documentation or submit it to a contractor upon request may see CMS "revoke the party's Medicare billing privileges," the agency warns. Specifically, "if a provider fails to respond to a letter request for documentation within 30 days of the Medicare contractor's request, the contractor may revoke the provider's Medicare billing privileges and impose a 1-year re-enrollment bar," CMS says in a related MLN Matters article.

Home care providers should consider keeping their records for 10 years, NAHC recommends. That timeframe matches "the requirements in the regulations and the statute of limitation in the Federal False Claims Act," the trade group advises.

The transmittal is online at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R431PI.pdf and MLN Matters article is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7890.pdf.

Selling Your Practice? Check in on New Owner Afterward

If you sell your medical practice, you may want to check in from time to time to ensure your NPI isn't left behind after you depart.

That's allegedly what happened to a radiologist in Flushing, N.Y. who sold his radiology practice to Warren Tai. Tai is accused of submitting more than $30 million in false Medicare and Medicaid billings using the identity of the former owner, without that physician's knowledge or consent. Property that Tai allegedly purchased with the "ill-gotten gains, including a Lamborghini automobile," was seized, the Department of Justice noted in an Aug. 30 news release.

The lesson: When you sell your practice, be sure that all of your confidential billing information leaves with you. Even if you're certain that you've left nothing behind, check in on your billings from time to time to ensure that claims for services you didn't perform aren't being submitted in your name.

To read the complete news release, visit www.justice.gov/usao/nye/pr/2012/2012aug30.html.

Physician Faces Jail Time For Exaggerating Complexity Of Two Surgeries

If you think exaggerating the complexity of even one surgery is okay, you could be in for a massive surprise -- and some jail time.

A Chicago vascular and thoracic surgeon was sentenced to 10 months last week after being convicted of falsifying post-op reports to collect $10,000 more than he deserved from Medicare.

The physician was also fined $40,000 and community service after the jury found that he included details in the op notes of two aneurysm repairs that were more elaborate than the services he actually performed.

To read the Department of Justice's news release about the conviction, visit www.justice.gov/usao/iln/pr/chicago/2012/pr0905_01.pdf.

Whistleblower Case Heads To Court

Add one more whistleblower action to the list of lawsuits the feds have joined. U.S. District Judge Anne C. Conway has cleared the way for a Department of Justice request to intervene in a suit against Altamonte Springs, Fla.-based Hospice of the Comforter, reports the Orlando Sentinel.

Last October, former Hospice of the Comforter VP of finance Douglas Stone filed a qui tam suit claiming he was fired after repeatedly urging hospice founder and CEO Robert Wilson and several board members to reimburse Medicare for billing for patients kept on service too long.

Among the allegations in Stone's suit are that the hospice discharged a large number of long-stay patients after Medicare initiated medical review; the hospice served some patients as long as five years; Wilson had an incentive to keep on service as long as possible because more than half his pay came from bonuses based on the number of billable patients each day, with his annual bonuses reaching nearly $200,000; and Wilson later insisted some patients discharged as not terminally ill be readmitted and their care billed to Medicare, reports the Sentinel.

In May, nine months after Stone filed his suit, the hospice signed a management agreement with Adventist Health System. The hospice has cooperated with investigators and has "endeavored over the last few years to become fully compliant with Medicare guidelines," L.T. Lafferty, an attorney representing the hospice, told the newspaper.