Articles Posted in Medicare

In February, the Centers for Medicare & Medicaid Services published its Final rule implementing changes in the provider enrollment processes. Effective March 25, 2011, providers participating in Medicare, Medicaid and Children’s Health Insurance Program will undergo an initial screening process prior to enrollment. In addition, providers are now required to revalidate their compliance with CMS enrollment requirements every five years. Suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) must revalidate every three years. As a catch all, CMS may demand that any provider revalidate and undergo screening at any time.

The new rule, found in Medicare Program Integrity Manual Chapter 15, sections 19 though 19.4, finalized provisions related to the (1) establishment of provider enrollment screening categories, (2) submission of application fees as part of the provider enrollment process, (3) suspensions of payment based on credible allegations of fraud, and (4) authority to impose a temporary moratorium on the enrollment of new Medicare providers and suppliers of a particular type (or the establishment of new practice locations of a particular type) in a geographic area.

The screening process establishes 3 levels of risk – limited, moderate, or high – and each provider will be assigned to a risk category. The rule also addresses application fees. Providers initially enrolling in Medicare will pay an initial application fee, and current provides will pay the fee when they revalidate.

AARP recently unveiled an online tool aimed at helping senior citizen beneficiaries fully understand their quarterly health care statements. This tool will aid in fully informing seniors of all charges the Medicare program has paid, along with dates, billing codes and a description of the medical service. The AARP website urges senior citizens to use this tool to identify errors on their bill as well as to spot fraud.

CMS has made numerous efforts over the years to enlist the help of Medicare beneficiaries to detect and report Medicare Fraud.

An effective compliance program is the best defense against billing errors that can lead to complaints or allegations of Medicare fraud by beneficiaries. If you have any questions regarding Medicare billing or development of a compliance program, please contact a Wachler & Associates attorney at 248-544-0888.

The Office of Inspector General (OIG) recently reported that it believes Medicaid is being inappropriately billed for certain nonmedical services (e.g. bathing, dressing and light housework). As a result of two recent audits, OIG has requested that North Carolina and Washington refund the federal government more $61 million resulting from improper Medicaid claims. It was discovered that these claims lacked the necessary documentation. Additionally, it was determined that the claims weren’t included in the states’ plan of care, were provided without medical supervision and the qualifications for the in-home providers could not be verified.

If you have any questions relating to home health compliance or Medicaid/Medicare billing requirements, please contact a Wachler & Associates attorney at 248-544-0888.

A sleep medicine and durable medical equipment company, Areté Sleep LLC, Areté Sleep Therapy LLC, and Areté Holdings LLC will pay a $650,000 settlement pursuant to federal authorities discovering the company to have submitted false claims to Medicare over a seven year span.

According to federal prosecutors, the false claims were for diagnostic tests performed by unlicensed/uncertified technicians. These licenses/certifications are required by Medicare rules and regulations. Areté filed for Chapter 11 bankruptcy in early 2011 and has agreed to pay the settlement with the proceeds from its asset sales.

If you have any questions or concerns regarding compliance with Medicare rules and regulations, or if you have questions regarding compliance issues associated with billing for sleep studies and related DME, please contact a Wachler and Associates attorney at 248-544-0888.