Articles Posted in Medicare

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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.

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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.

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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.

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Wachler & Associate’s attorney Amy Fehn, as a member of the ABA’s ACO Task Force, recently participated in the drafting of comments on CMS’ proposed regulations for ACO participation in the Medicare Shared Savings Program. The proposed regulations will govern the way in which ACOs will contract with CMS to become responsible for the delivery of care to an assigned population of Medicare fee for service beneficiaries. The ABA’s ACO Task Force prepared comments to help CMS properly develop ACOs by highlighting some of the problematic areas of the proposed regulations. Click here to view the full version ABA’s comments on the ACO proposed regulations.

For assistance with interpreting the ACO Shared Savings program regulations, or for assistance with creating an infrastructure conducive to ACO participation, please contact a Wachler & Associates attorney at 248-544-0888.

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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.

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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.

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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.

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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.

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On June 1, 2011, the Office of Inspector General (OIG) announced that it expects to recover an estimated $3.4 billion in connection with its Medicare and Medicaid investigations, audits, and reviews. The amount was accrued between October 2010 and March 2011 in the form of penalties, fines, and settlements. Of the estimated $3.4 billion in recoveries, $222 million stems from audits while $3.2 billion arose from 349 criminal and 197 civil actions. The OIG featured the following items in its Semiannual Report to Congress:

•· 100 healthcare professionals were arrested for their participation in various healthcare-related crimes (e.g. violating the anti-kickback statute and money laundering) which resulted in $225 million in false billing.

•· Two drug companies, GlaxoSmithKline and Allergan USA, agreed to pay $750 million and $600 million, respectively, to resolve various charges.

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The Centers for Medicare & Medicaid Services (CMS) intends to roll out its Part D RAC program during the third quarter of 2011. In implementing the program, CMS has contracted with ACLR Strategic Business Solutions to be the Part D recovery audit contractor. This company has already recovered tens of millions of dollars through its auditing process for government contractors. John Spiegel, director of the Medicare Program Integrity Group, stated that “CMS is working on business planning, technology requirements, staffing and communications initiatives to achieve the program goals.” He also mentioned that CMS intends to implement a website that will provide additional Medicare Parts C and D RAC information.

Medicare Part D plans and sponsors should consider conducting internal audits and implementing compliance programs at this time in order to be in the best position to avoid or defend against a RAC audit.

If you need assistance in preparing for, or defending against Part D RAC audits, or implementing a corporate compliance program geared toward identifying and correcting potential risk areas for Part D RAC audits, please contact a Wachler & Associates attorney at 248-544-0888.

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