Medicare Compliance & Reimbursement

CMS instructs MACs to suss out sham health care operations. A favorite tactic of some Medicare fraudsters is to set up 'dummy' storefront operations that have billing addresses but no real health care going on.

The feds are on to this trick, and that's good. But wellmeaning home health providers and suppliers that have moved recently need to take steps to make sure they don't get caught in the dragnet.

According to Transmittal 306 from the Centers for Medicare & Medicaid Services, effective Nov. 2, "all providers and suppliers are subject to unannounced site visits prior to receiving Medicare billing privileges or subsequent to receiving Medicare billing privileges."

In certain cases, CMS will instruct a Medicare Administrative Contractor (MAC) to make a visit to a medical provider or supplier to determine if it's operational at the address on file. If the MAC representative can't tell from an external check-up whether the place is in operation, the MAC rep "shall conduct an unobtrusive site verification by limiting its encounter with provider or supplier personnel or medical patients."

If your office is closed when the MAC rep arrives, but it doesn't appear that the office is nonoperational, the MAC will come back to re-check.

If the MAC determines that the office is not operational at the address on file, the MAC will revoke the provider's billing privileges within seven days, unless the provider has submitted a change of address to Medicare.

The transmittal most likely aims to discourage "sham" operations from setting up shop -- those storefront buildings that set up Medicare billing privileges and submit fraudulent claims but don't actually see patients. However, the new regulations could bleed over to affect legitimate providers who simply forgot to update an address change.

Tip: If you've moved recently, make sure your MAC has the right contact information on file for your practice.

"The best and most effective way for providers to verify their information would be to contact customer service at the appropriate MAC," advises Sandie Becker, coding and reimbursement specialist with the Santa Clara County Medical Association and Monterey County Medical Society in California.

Resource: Read the transmittal at www.cms.hhs.gov/transmittals/downloads/R306PI.pdf.

• Senators have many fights in front of them these days when it comes to health care, but the most important issue to Part B providers has not been solved just yet. Last week, Senate majority leader Harry Reid (DNev.) helped shepherd a bill that would have changed the Medicare payment formula, thus permanently stopping the cuts that physicians face each year in Medicare payments.

The bill failed to pass after some senators questioned whether the bill's price tag (over $240 billion) was excessive.

"The reason we have to take care of this so-called doctor fix is that seniors need to be able to have a doctor when they're sick. Medicare patients need to have a doctor when they're ill or hurt," Reid said in a statement on his Web site.

• What's "meaningful use?" That definition could be part of your holiday gift this year from CMS. As most medical practices know, the government will offer annual bonuses for five years to physicians who participate in the federal healthcare programs (such as Medicare) that use meaningful electronic health records (EHRs).

Over the five year period, this amount could total $44,000. Although many Part B providers are already using EHRs, it's the definition of "meaningful use" that's a bit sticky right now. Those practices who aren't demonstrating "meaningful use" may not be eligible for bonuses.

To that end, CMS intends to publish a formal definition by Dec. 31, according to an Oct. 15 press release

from David Blumenthal, MD, the government's national coordinator for health information technology. "We expect that any formal definition of 'meaningful use' must include specific activities health care providers need to undertake to qualify for incentives from the federal government," Blumenthal indicated.

To read the complete statement, visit http://healthit.hhs.gov.

• The Centers for Medicare & Medicaid Services is lining up its interest rate with what private consumers pay. Effective Oct. 22, CMS wants Medicare contractors to apply a 10.875 percent interest rate to all overpayments and underpayments to match the Treasury's fixed rate, according to Change Request 6651 and Transmittal 160 published on Oct. 15.

Why: Regulation 42 CFR Section 405.378 allows Medicare to assess interest at whichever rate is higher -- the current value of funds (which is 3 percent for 2009) or the Department of the Treasury's rate for private consumers.

Resource: Read the transmittal at www.cms.hhs.gov/transmittals/downloads/R160FM.pdf.

• CMS formally debuts new geriatric psychiatry specialty code. Next time your physician updates his PECOS enrollment, make sure he designates the appropriate specialty code, because CMS has debuted one code and removed three from the list of available specialties.

Effective April 1, physicians who are geriatric psychiatrists will be able to use the new specialty code 27 to designate their work in this field. CMS will be deleting the following codes from the specialty list, as they are "non-physician specialty codes," according to Transmittal 1836, issued on Oct. 27:

• 32 -- Anesthesiologist assistant

• 74 -- Radiation therapy center

• 75 -- Slide preparation facilities

To read CMS's complete transmittal, visit www.cms.hhs.gov/transmittals/downloads/R1836CP.pdf.

• Brush up on your ICD-9-CM coding with a free online course from intermediary Cahaba GBA at www.cahabagba.com/rhhi/education -- select "Online Courses." New codes took effect Oct. 1 for episodes with dates of service on or after that date.

You'll find the new and deleted codes online at www.cms.hhs.gov/Transmittals/downloads/R1770CP.pdf.

Cahaba also offers courses on enrollment, Medicare coding, and secondary payer status on its Web site.

-- Part B payments for services and medical supplies provided to beneficiaries in home health episodes.

-- Accuracy of coding on claims, focusing on home health resource groups and documentation.

-- Outlier payments for high rates of home health visits for insulin injections.

-- Compliance with various aspects of home health prospective payment system billings, including location where services are provided and number of visits provided.

Resources: You can read the Work Plan at http://oig.hhs.gov/08/Work_Plan_FY_2010.pdf.