Medicare Compliance & Reimbursement

Although you may have heard much buzz about Medicare officials suspending fraudulent providers, the story goes much deeper than that, according to a new Associated Press (AP) report that was released on Oct. 16.

"Regulators fighting an estimated $60 billion to $90 billion a year in Medicare fraud frequently suspend Medicare providers, then quickly reinstate them after appeals hearings that government employees don't even attend," the AP story noted. Although the quick reinstatements have been a godsend for legitimate suppliers who are wrongly accused or are accused of minor violations, they have been an unfortunate symptom of the clogged system when dealing with fake suppliers that bilk the Medicare system out of money.

The problems are rooted in "poor communication between one set of contractors paid to inspect Medicare providers and alert officials to suspicious activity; a separate set of contractors that handles payments; and the agency that runs Medicare," the analysis notes.

CMS reps did not explain to the AP why they didn't show up at many of the hearings, the article noted. To read the article in its entirety, visit www.postbulletin.com/news/stories/display.php?id=1472289.

Beginning Jan. 1, you must use the new 2011 version of the Advance Beneficiary Notice, or ABN (form CMS-R-131).

CMS originally set the implementation date for the new ABN form for Sept. 1, but the agency extended the deadline to Jan. 1 "to permit providers and suppliers with pre-printed stockpiles of ABNs time to exhaust their supplies," the agency says in a message to providers.

The switch shouldn't bring any big changes to your organization. "The 2008 and 2011 ABN notices are identical except that the release date of '3/11' is printed in the lower left hand corner of the new version," CMS points out.

What will happen? "ABNs issued after Sun. Jan. 1 that are prepared using the 2008 version of the notice will be considered invalid by Medicare contractors," CMS warns. "2008 versions of the ABN that were issued prior to Sun. Jan 1 as long-term notification for repetitive services delivered for up to one year will remain effective for the length of time specified on the notice."

A copy of the 2011 version of the ABN (form CMS-R-131) is online at www.CMS.gov/ BNI, Revised ABN" link.

The feds continue to rack up fraud convictions of providers across the country.

An RN formerly employed by 13 different Miami-area home health agencies recently received a 43-month prison sentence and must repay nearly $336,000 following a fraud conviction. The nurse billed for administering insulin to patients who were not insulin-dependent or homebound. In addition, the nurse was in Panama, Mexico, or the Dominican Republic during dates that she claimed to be providing visits to beneficiaries, prosecutors said. Plus, the nurse signed dozens of documents claiming she was providing skilled nursing services when she was attending classes at Florida International University. She also claimed to be providing skilled nursing visits to two and three patients simultaneously, double and triple billing Medicare, the Department of Justice (DOJ) says in a release.

In addition, the DOJ announced on Oct. 12 that the owner of a Houston-based health care company was sentenced to 33 months in prison for Medicare fraud.

The man, who owned a durable medical equipment company, pleaded guilty to conspiracy to commit health care fraud. Court documents indicated that he paid kickbacks to patient recruiters in exchange for the names of beneficiaries in whose names he could submit Medicare claims. He then billed Medicare for orthotics and braces referred to as "arthritis kits" for about $4,000 each, then gave the patients cheaper products that weren't medically necessary. His fraudulent claims totaled $846,000, the DOJ indicates.

For more on these cases, visit www.oig.hhs.gov/fraud/enforcement/criminal/index.asp.