Articles Posted in Medicare

The U.S. Department of Health and Human Services (HHS) recently initiated the Bundled Payments for Care Improvement initiative (Bundled Payments initiative) in an effort to promote better patient health, better care and lower costs. Rather than paying for services separately, the Bundled Payment initiative will bundle payments for services delivered throughout an entire episode of care. Currently, health care providers bill Medicare separately for the services that a beneficiary receives. However, this new initiative seeks to bundle all of the services that a patient receives during a single hospital stay or during recovery from that stay, giving providers greater incentive to better coordinate care with other providers who treat that patient. The Centers for Medicare and Medicaid Services (CMS) believe that this enhanced coordination will reduce unnecessary duplication of services, reduce medical errors, improve patient health, and lower costs.

The new Center for Medicare and Medicaid Innovation recently released its Request for Applications which outlines four approaches to bundled payments. Providers will be afforded flexibility in determining which services will be bundled together, allowing providers of different sizes to decide which bundle payment schemes work best for them. This flexibility is expected to quicken providers’ desire to participate in the Bundled Payments initiative.

According to HHS, the initiative is based on research and successful demonstration projects, such as a Medicare heart bypass surgery demonstration that saved the program $42.3 million and saved patients $7.9 million in coinsurance. The Bundled Payments initiative is viewed as being a step forward in creating the kind of relationship that patients expect their providers to have with each other in an effort to promote better care and payment efficiency.

As part of healthcare reform, Section 6401a of the Affordable Care Act requires all providers and suppliers who enrolled in the Medicare program before March 25, 2011 to revalidate their provider enrollment under the new screening criteria. Providers and suppliers who enrolled after March 25, 2011 do not need to revalidate at this time as they have already been screened.

The Centers for Medicare and Medicaid Services (CMS) designed and instituted new screening criteria in the provider enrollment process as another tool to curb Medicare fraud, waste and abuse. Each provider or supplier, whether newly-enrolled or revalidating, is assigned a risk level, either “limited”, “moderate” or “high”, representing the level of risk to the Medicare program for the particular category of provider/supplier. The designated provider risk level determines the amount of screening to be executed during the enrollment application process by the Medicare Administrative Contractor (MAC).

MACs will be sending revalidation notices to individual providers and suppliers between now and March 2013. Providers and suppliers must complete the enrollment forms within 60 days of receiving the request from the MACs. If a provider fails to submit the provider enrollment forms after receiving the request, it may lead to a suspension of the provider’s Medicare billing privileges.

According to an article by the RAC Monitor, the U.S Department of Health and Human Services (HHS) recently reported that an estimated $48 billion was improperly paid to providers in 2010. However, due to HHS’s currently undeveloped comprehensive projection for the Medicare prescription drug benefit, the U.S. Government Accountability Office (GAO) has determined the estimated $48 billion in improper payments is incomplete and possibly underestimated. The GAO provided testimony before the U.S. House of Representatives Subcommittee on Government Organization, Efficiency and Financial Management, whereby the GAO produced a number of recommendations in an effort to aid the Centers for Medicare & Medicaid Services (CMS) in fortifying its ability to prevent or detect and recoup improper payments to healthcare providers.

Among other reasons, the GAO alluded to a number of key causes for the improper payments, such as coding and payment calculation errors, inadequate documentation and services deemed not to be medically necessary. In 2010, CMS initiated the Center for Program Integrity to handle all Medicare integrity issues. The GAO recently made recommendations to CMS to help strengthen its ability to minimize Medicare fraud, waste and abuse. According to the article, the GAO’s recommendations are as follows:

1. Strengthen provider enrollment standards and procedures.

According to a recent article written by the Detroit Free Press, 26 individuals have been indicted in an alleged Medicare scheme. The indictment alleged that a Michigan pharmacist gave kickbacks and other bribes to doctors in exchange for them writing prescriptions for opiate pain killers and depressants (e.g. Vicodin, Xanax and Oxycontin) and directing them to one of the pharmacies owned by the pharmacist. The alleged Medicare fraud was conducted at more than 20 pharmacies throughout the state, which billed $37 million to Medicare, along with over $20 million to Medicaid. The indictment included 12 pharmacists, 4 doctors, a psychologist, an accountant, and a number of patients who agreed to have their insurers billed.

This indictment is just one of many examples of the government’s focus on the Detroit area in Medicare and Medicaid investigations. For more information on Medicare Fraud defense, or assistance with interpreting and understanding Medicare and Medicaid regulations, including the anti-kickback statute, please contact a Wachler & Associates attorney at 248-544-0888.

Detroit Free Press Article: http://www.freep.com/article/20110803/NEWS05/108030363/Metro-doctors-pharmacists-charged-1-largest-drug-scams-Michigan-history

A Miami resident and Detroit clinic owner, Arnaldo Rosario, was recently sentenced to 27 months in prison for his role in recruiting patients to three clinics in the Detroit area. According to the FBI, the Medicare fraud scheme involved remuneration to Medicare beneficiaries for visiting the clinics and fraudulently representing that they had received treatments that were either not provided or not medically necessary. The services were then billed to Medicare and the beneficiaries would receive cash kickbacks for their role in the scheme. Rosario was responsible for obtaining cash from the clinics to pay the kickbacks to the beneficiaries and also to other co-defendants for their role in recruiting and paying Medicare patients. Over a span of one year, Medicare had paid approximately $10.8 million to the clinics based on the fraudulent claims. This case was brought as part of the Medicare Fraud Strike Force, which in its four years of operations, has already discovered more than $2.3 billion worth of allegedly fraudulent Medicare claims. Both Miami and Detroit are cities targeted by the Medicare Fraud Strike Force and providers in these cities should be aware of this heightened scrutiny.

If you have any questions regarding the Anti-Kickback Statute, inappropriate remuneration to beneficiaries, medical necessity issues, or any other compliance issues relating to Medicare fraud or allegations of Medicare fraud, please contact a Wachler & Associates attorney as 248-544-0888.

Health and Human Services (HHS) Office of the Inspector General (OIG) has reported that skilled nursing facilities (SNFs) may be a possible suspect for receiving fraudulent Medicare payments. Auditors for HHS have discovered that many nursing homes are collecting Medicare payments that are much higher than the national average. For example, the average cost for some patients was in excess of $150 per day, whereas the national average is only $3.39 per day. The OIG believes that fraud, waste, and abuse are the likely causes of such payments. These suspicions were highlighted in a report that focused on situations in which Medicare does not cover the patient’s stay in a nursing home but does cover certain procedures during the patient’s stay at the home. The report demonstrated that some nursing homes were paid more than three times the national average for services such as drug treatments and medical equipment.

In light of this recent report, nursing homes can expect increased scrutiny related to the medical necessity of services provided to Medicare beneficiaries. An effective skilled nursing facility (SNF) compliance program, including internal compliance auditing and monitoring, can help SNFs to identify any potential compliance issues prior to a government investigation. If you have compliance questions relating to SNF billing compliance, medical necessity of services provided to SNF beneficiaries or are in need of assistance preparing for or appealing a SNF Medicare audit, please contact a Wachler & Associates attorney at 248-544-0888.

On Tuesday, the Obama Administration announced that it decided to abandon its “mystery shopper” survey. The survey was created as a way to address concerns about the shortage of primary care doctors, a problem that could continue to grow if more than 30 million Americans gain health care coverage as expected by the Obama Administration. The decision not to move forward with the survey came after doctors and politicians criticized the project for needlessly wasting taxpayer dollars, along with a number of privacy issues. According to Senator Mark Steven Kirk, Republican of Illinois, there have already been a number of reputable studies confirming the difficulties for Medicare patients to find doctors to see them. Kirk was joined by a number of others who ultimately persuaded the Obama Administration to put the survey on what a spokesman for the health department labeled as an “indefinite hold.”

Physicians should understand their options when dealing with Medicare patients. Physicians can choose to limit the number of Medicare patients that they see. Physicians can also choose to be “nonparticipating” or can choose to “opt-out” of Medicare. If you are a physician with questions about your Medicare participation options, please contact a Wachler & Associates attorney at 248-544-0888.

The Obama administration has labeled the increasing shortage of primary care doctors as a “critical public policy problem.” In an effort to address this issue, the administration intends to assemble a team of “mystery shoppers” to pose as patients, call doctors’ offices, and request appointments in order to see how difficult it is for people to obtain care when their health problems arise. In addition to better understand the problematic shortage of primary care doctors, the survey will also attempt to discover whether doctors are accepting patients with private health insurance while at the same time refusing to attend to those insured by government health care programs.

The survey will be conducted by a federal contractor who will call 4,185 doctors’ offices. The number of surveys will be evenly conducted throughout nine states: Florida, Hawaii, Massachusetts, Minnesota, New Mexico, North Caroline, Tennessee, Texas, and West Virginia. Each office will be called at least twice, one call from a person claiming to be privately insured while another federally insured, inquiring about whether the office is accepting new patients. Some mystery shoppers will pretend to be in need of a routine checkup, while others will claim to have symptoms necessary of more urgent care. Furthermore, mystery shoppers will not identify themselves as government workers and will block the caller ID of the incoming calls. A third call will be made to eleven percent of doctors, in which the callers will identify themselves as calling on behalf of the U.S. Department of Health and Human Services. The caller will ask doctors about which types of insurance they accept and then compare those answers with the mystery shopper calls, noting any discrepancies. The survey data collected will be kept confidential and will not identify any individual doctors. With last year’s passing of the new health care law, it is predicted that more than 30 million people will obtain health care coverage. Therefore, the federal government finds it necessary to conduct this mystery shopper survey in an effort to fully understand the shortage of primary care doctors and ultimately fix the problem.

Physicians should understand their options when dealing with Medicare patients. Physicians can choose to limit the number of Medicare patients that they see. Physicians can also choose to be “nonparticipating” or can choose to “opt-out” of Medicare. If you are a physician with questions about your Medicare participation options, please contact a Wachler & Associates attorney at 248-544-0888.