Medicare

Published on: May 26, 2011

OIG Reports that CMS has made Duplicate Payments to Home Health Services

On May 16, the Office of the Inspector General for the Department of Health and Human Services released the report from its audit of physician therapy services provided during home health episodes. The report outlines the OIG’s findings that the Centers for Medicare and Medicaid Services (CMS) made duplicate payments for the same home health services. Specifically, the payments for the same services were made to the physician under Medicare Part B and then to the home health agency under the Medicare home health prospective payment system (HH PPS). The OIG recommended that CMS eliminate duplicate payments by adjusting the HH PPS rate to exclude physician-provided therapy services or by making physician therapy services subject to the consolidated billing requirement. CMS has agreed with the OIG’s recommendations and has indicated that it will take action to address the recommendation.

For more information on proper billing practices for home health services, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.

Published on: May 17, 2011

RAC Recovered $237.8 Million in Six-Month Period

by Wachler & Associates, P.C.

Recovery Audit Contractors (RAC) recovered $237.8 million in the six-month period that ended in March. This amount is already three times more than the amount of money recovered in the previous year. According to recent estimates, CMS alleges that the total sum of Medicare improper payments exceeds $47 billion annually. If you have been audited by a RAC, ZPIC, MAC, carrier or other Medicare contractor and need assistance with the defense of the audit, please contact a Wachler & Associates attorney at 248-544-0888.

Published on: April 15, 2011

Phase 2 of DME Competitive Bidding Process Expected In Spring of 2011

by Wachler & Associates, P.C.

The Durable Medical Equipment (DME) Competitive Bidding Program was implemented as a means to lower costs and improve beneficiary services in the DME industry. It consists of a bidding and selection process based on certain criteria determined by CMS. The Round 1 Rebid competition went into effect in 2009 across 9 Metropolitan Statistical Areas (MSAs) (basically large metropolitan areas). Focus now turns to Round 2, which will increase the MSAs involved by 91, bringing the total to 100. CMS anticipates that the Round 2 contracts and payment amounts will become effective January 1, 2013. A list of the current and projected MSAs where the program is or will be implemented is available on the CMS website.

We will continue to provide updates on Round 2 as the information becomes available. Compliance with the program and its participation requirements are critical to all DME providers in the MSAs. If you have any questions or concerns, please contact a Wachler & Associates attorney at 248-544-0888.

Published on: March 30, 2011

The Regulations are coming! Ten things that we already know about Accountable Care Organizations.

by Wachler & Associates, P.C.

If the rumors are true, tomorrow the Centers for Medicare and Medicaid Services, the Office of the Inspector General and the Federal Trade Commission will be releasing voluminous regulations governing the formation of Accountable Care Organizations (“ACO”) and the Medicare Shared Savings Program. But before we receive all the minutiae of the regulations, we wanted to provide a brief overview of what is already known about ACOs.

1. The purposes of ACOs are to: (1) facilitate coordination and cooperation, (2) improve the quality of care and (3) reduce unnecessary costs.

2. ACOs were created by the Affordable Care Act, which was signed by President Obama approximately one year ago.

Published on: January 6, 2011

Federal Government Increases Fight against Medicare Fraud

by Wachler & Associates, P.C.

Time Magazine published an article on January 4 outlining the Federal Government’s increased measures to combat Medicare fraud. The article outlined that although there is not an official figure on the cost of government health program fraud, the National Health Care Anti-Fraud Association estimates that it is at least $60 billion per year, approximately 10% of Medicare and Medicaid’s combined annual funding. However, some experts believe this estimation is below the actual cost because most fraud goes undetected.

To decrease the amount of undetected fraud, the Federal government has enlisted the help of Medicare beneficiaries. According to the Times article, there are 47 million Medicare beneficiaries and the number is expected to rise to 80 million by 2030. The government intends to use Medicare beneficiaries for fraud detection. Senior Medical Patrols (SMPs) are volunteers that have been spread across the country to spread the word to seniors about detecting Medicare fraud. The government is requesting that seniors keep track of their Medicare Summary Notices (MSNs), which outline the services and equipment that a beneficiary has been provided through Medicare. Seniors that thoroughly check their MSNs can likely detect if the statement includes a service or equipment that the beneficiary did not receive. Although some complain that the MSNs are not user-friendly, Washington is trying to simplify them. In addition, the government has considered switching from quarterly MSNs to monthly MSNs. This would help the government detect fraud more quickly, before the money can change hands and the fraudulent practice closedown.

Finally, even absent Medicare beneficiary’s involvement, the government hopes that the publicity on Medicare Fraud crackdowns will help inform doctors of the legal risks of being lured into Medicare scams. However, criminal enterprises have begun to rely on identity theft to curtail the need of doctors at all.

Published on: December 20, 2010

Medicare Physician Rate Cut Delayed for One Year

by Wachler & Associates, P.C.

Last week President Obama signed legislation that will delay Medicare payment cuts for one more year. The reduction in pay, 25 percent, had been scheduled to begin on January 1, 2011. The American Medical Association strongly advocated for the delay that is longer than the previous five delays over the past year. Over the upcoming year, Congress will work to develop a long-term solution to the Medicare physician payment problem.

For more information on Medicare payments or the physician fee cut, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.

Published on: October 27, 2010

Joint Commission Announces Accreditation Standards for Patient-Centered Medical Homes

by Wachler & Associates, P.C.

In September the Joint Commission announced that it will begin to accredit patient-centered medical home models for physicians by July 2011. A medical home model is a method to deliver care that is based on the ability to demonstrate evidence-based protocols, self-management education and care coordination with specialists and other facilities. The Joint Commission’s final standards will be available in March 2011 and on-site surveys will begin in July 2011.

The American Medical Association supports patient-centered medical homes, but stated to American Medical News that it will continue to work with the Joint Commission to ensure that proposed accreditation standards will focus on patient safety and access to physician care. Currently, some of these practices follow the standards published by a Washington D.C.-based organization, National Committee for Quality Assurance (NCQA). NCQA argues that more accreditation or recognition bodies will complicate the accrediting landscape and will cause confusion among providers.

For more information on patient centered medical homes or other health care reform concepts, please contact a Wachler & Associates attorney at 248-544-0888.

Published on: September 23, 2010

CMS Publishes Proposed Rule Implementing Affordable Care Act Provisions

by Wachler & Associates, P.C.

The Centers for Medicare and Medicaid Services (CMS) published a proposed rule implementing provisions of the Patient Protection and Affordable Care Act (PPACA) that help tackle Medicare and Medicaid fraud. According to Peter Budetti, the Director of the new anti-fraud office at CMS, the proposed rules will provide federal authorities the power to identify fraud and reduce improper payments by an estimated $55 billion.

According to CMS, the proposed rule is essential to the implementation of healthcare reform since the expansion of healthcare coverage relies upon saving money on fraud and abuse in the healthcare systems. Specifically, the rules will provide increased scrutiny to $900 billion in annual spending in federal Medicare, and the state-federal Medicaid and Children’s Health Insurance Program (CHIP), but it is unknown how much money the proposed rules will actually save.

Increased scrutiny over Medicare and Medicaid Programs will include the following measures:

Published on: September 15, 2010

CMS Publishes a New Rule Affecting DME Providers

by Wachler & Associates, P.C.

The Centers for Medicare and Medicaid Services (CMS) recently published a new rule affecting Durable Medical Equipment (DME) providers. The rule, effective September 27, 2010, strengthens Medicare’s standards for marketing and solicitations and expands enrollment requirements for DMEPOS providers.

Important highlights from the rule include:

– DME providers will be required to remain open to the public for at least 30 hours per week, except for physicians or licensed non-physician practitioners furnishing services to their own patients as part of their professional service and DME providers working with custom orthotics and prosthetics.

Published on: August 23, 2010

The OIG Publishes Reports Targeting IRFs

by Wachler & Associates, P.C.

The Office of Inspector General (OIG) published two reports targeting inpatient rehabilitation facilities (IRF). Most notable, however, is the CMS response to the OIG reports. The first report reviewed IRF transmission of patient assessment instruments for calendar years (CY) 2006 and 2007. This report showed that IRFs failed to timely submit patient assessment data and this could reduce the case-mix group payment. Based upon the OIG findings, CMS concluded that fiscal intermediaries (FI) overpaid IRFs approximately $20.2 million in CY 2006 and 2007. Additionally, FIs may have overpaid $19 million because of a lack of clarity in the regulations regarding data for claims originally submitted within the 27-day timeframe, but then later resubmitted to correct errors outside the 27-day timeframe.

The second report addressed the issue of whether proper status codes were used on IRF claims. When a patient is discharged to his or her home, Medicare pays the full prospective rate. In contrast, if a patient is transferred from the IRF (to another IRF, a short-term, acute care prospective payment hospital, a long-term hospital or a nursing home that qualifies for Medicare or Medicaid payments), Medicare pays a reduced amount. The OIG review found that out of 220 claims sampled, 213 claims were improperly coded as discharges. This resulted in an overpayment of approximately $1.2 million. For the four year period ending in September 2007, CMS determined the overpayments for this issue totaled approximately $34 million. Of particular importance to IRFs is the fact that CMS has indicated that it will share the OIG audit information with the Recovery Audit Contractors (RACs) and encourage them to utilize the findings in their reviews.

For more information on Medicare audits, or for assistance with an audit, please visit www.racattorneys.com or contact a Wachler & Associates attorney at 248-544-0888.