Published on:

by

On April 17th, 2013, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) released an update to its Provider Self-Disclosure Protocol (SDP).

The SDP was established in 1998 to incentivize healthcare providers and suppliers to voluntarily disclose potential fraud related to payments received under Federal health care programs. All healthcare entities who are subject to the OIG’s Civil Monetary Penalty (CMP) authorities are eligible to use the SDP.

The SDP dictates the procedures that healthcare providers must follow to identify potentially fraudulent conduct, determine damages, and report to the OIG. Successful use of the SDP leads to a settlement that reduces the healthcare entity’s liability under the OIG’s CMP provisions. To this end, the updated SDP states the OIG’s belief that providers who disclose fraud through the SDP deserve to pay less than they would be required to pay pursuant to an investigation initiated by the government. Notably, the updated SDP explicitly references the OIG’s general practice of imposing a multiplier of 1.5 times the single damages in CMP settlements of SDP cases; however, the OIG expressly reserves the right to determine whether a higher multiplier is warranted in each case. In addition, the OIG states that corporate integrity agreements are typically not required for providers utilizing the SDP in good faith.

Continue reading
Published on:

by

Intermountain Healthcare, the largest health system in Utah, has agreed to pay $25.5 million to resolve claims that it violated the federal Stark law and False Claims Act by engaging in inappropriate financial relationships with referring physicians.

In 2009, Intermountain disclosed to federal officials that the system may have illegally paid bonuses to 37 doctors based on their patient referrals. If true, Intermountain would have been in violation of the Stark law. In addition, Intermountain disclosed that it compensated more than 170 doctors in the absence of written agreements, including via rentals of office space in several cities without written lease agreements. In total 209 physicians were involved in the violations, which spanned over a 10 year period.

Intermountain discovered the violations through its regular review process, and reported them to the government in 2009. Intermountain cites the complexities of the Stark law’s regulations as one cause of its noncompliance. According to Intermountain’s Chief Medical Officer Dr. Wallace, Intermountain should have more closely monitored the situation and although Intermountain’s management realized that penalties could be significant, they chose to self-disclose the issues.

Continue reading
Published on:

by

On April 2, 2013, the Centers for Medicare & Medicaid Services (CMS) held an Open Door Forum to discuss CMS’s Administrator’s Ruling (CMS-1455-R) and Proposed Rule (CMS-1455-P) that provide for significant changes to Medicare’s Part B payment policy when a Part A hospital inpatient claim is denied as not medically necessary because the care was not provided in the appropriate setting.

During this Forum, CMS Representatives advised that hospitals do not have to wait until CMS’s Change Request 8185 implementation date of July 1, 2013 to rebill Part B for Part A inpatient claims denied as not reasonable and necessary pursuant to the interim ruling. CMS Representatives stated that additional instructions for rebilling Part B claims will be released shortly and should be similar to those found in the now defunct Part A to Part B Rebilling Demonstration Program. CMS representatives also confirmed that the interim ruling does not apply to Medicare Advantage.

For those unable to attend the Open Door Forum, a recording of the Forum is available by phone beginning at 5:00 pm on April 2, 2013. To access the recording, dial 1-855-859-2056 and reference conference ID: 78861443. The recording expires after two business days. If you have questions regarding these recent developments or questions about the Medicare appeals process, please contact an experienced health care attorney at Wachler & Associates at 248-544-0888.

Published on:

by

On Tuesday, April 2, 2013 (2:00-3:00 pm EST), the Centers for Medicare & Medicaid Services (CMS) will be holding an Open Door Forum for stakeholders in the healthcare community to call in and discuss the recent changes to the Medicare Part B payment policy in light of recently issued CMS Ruling. The CMS Ruling allows for hospitals to submit a Part B claim when a Part A inpatient claim is denied as not reasonable and necessary.

Tuesday’s Open Door Forum will be conference call only. To participate by phone, dial 1-800-837-1935 and reference conference ID: 78861443. Persons participating by phone do not need to RSVP. TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help. Encore is an audio recording of this call that can be accessed by dialing 1-855-859-2056 and entering the Conference ID beginning 2 hours after the call has ended. The recording expires after 2 business days. The number for Encore is 1-855-859-2056; Conference ID: 78861443.

Published on:

by

On March 22, 2013, the Centers for Medicare and Medicaid Services (CMS) released Change Request 8185 to implement CMS Ruling (CMS-1455-R) and provide Medicare contractors with additional guidance for accepting claims rebilled from Part A to Part B. The CMS Ruling, which was released on March 13, 2013, permits hospital providers to rebill under Part B for Part A inpatient claims denied as not reasonable and necessary.

The Change Request reiterates the numerous revisions to the Part B payment policy when a Part A claim is denied as not reasonable and necessary. While the CMS Ruling remains in effect, the Change Requests instructs hospitals to submit Part B inpatient claims with the condition code “W2.” By attaching the “W2” condition code, the hospital is acknowledging that the Part B claim is a duplicate of the Part A claim that was previously denied, no payment shall be made for items or services included on the Part A claim, and the beneficiary will be refunded for any amounts collected from the beneficiary with respect to the Part A claim. Furthermore, by including the “W2” condition code, the hospital attests that no appeals are pending with respect to the previously submitted Part A claim and that any previous appeal of the Part A claim has become final, binding or dismissed, and no further appeal will be filed on the Part A claim. Any Part B inpatient claim submitted under the CMS Ruling that does not include condition code “W2” will be rejected by the contractor. The effective date of the Change Request mirrors that of the CMS Ruling, which took immediate effect on March 13, 2013. However, the implementation date of the Change request is July 1, 2013. Despite the delayed implementation date of the Change Request, hospitals may submit their Part B claims prior to the implementation date, according to CMS.

Wachler & Associates will continue to monitor the developments of CMS’s revised policy on Part B billing following the denial of a Part A inpatient hospital claim. If you have any questions regarding these developments or questions regarding the Medicare appeals process, please contact an experienced health care attorney at Wachler & Associates at 248-544-0888.

Published on:

by

The Office for Civil Rights (OCR) enforces the Health Insurance Portability and Accountability Act (HIPAA) and oversees health information privacy in the Department of Health and Human Services (HHS). On Tuesday, a notice was published in the Federal Register asking for input and comments on the OCR’s HIPAA Audit Review Survey. The Information Collection Request (ICR) collected in this online survey looks at 115 Covered Entities (health plans, clearinghouses and providers) that were audited in 2012 by OCR.

The survey looks to collect information on just how effective these audits are and solicits opinions on the audit process itself. As part of that review, the online survey will be used to:

• Measure the effect of the HIPAA Audit program on covered entities • Gauge their attitudes towards the audit overall and in regards to major audit program features, such as the document request, communications received, the on-site visit, the audit-report findings and recommendations • Obtain estimates of costs incurred by covered entities, in time and money, spent responding to audit-related requests • Seek feedback on the effect of the HIPAA Audit program on the day-to-day business operations • Assess whether improvements in HIPAA compliance were achieved as a result of the Audit program

Continue reading
Published on:

by

The Office of Medicare Hearings and Appeals (OMHA) has released its instructions and recommended request form for withdrawing a Part A appeal pursuant to the Center for Medicare & Medicaid Services (CMS) Ruling 1455-R. On March 13, 2013, CMS issued Ruling 1455-R, which allows hospitals to bill for certain services under Part B when a Part A inpatient claim was denied as not reasonable and necessary. The Ruling remains in effect until the proposed rule becomes finalized. Under the Ruling, a hospital must withdraw its Part A appeal in order to submit claims for Part B reimbursement.

Wachler & Associates will continue to monitor the developments of CMS’s revised policy on Part B billing following the denial of a Part A inpatient hospital claim. If you have any questions regarding these developments or questions regarding the RAC appeals process, please contact an experienced health care attorney at Wachler & Associates at 248-544-0888.

Published on:

by

Medicare administrative contractors (MACs) are expected to begin recouping money for annual wellness visits (AWV) erroneously paid to both facilities and physicians for the same visit.

For the past two years, CMS has erroneously allowed an AWV on a professional and institutional claim for the same patient on the same day. In some cases, this resulted in double billing to CMS. The erroneous collecting began with dates of service processed on or after April 4, 2011, and could continue through March 31, 2013 because the new policy will not take effect until April 1, 2013. CMS will recoup the double payments made from January 1, 2011 through March 31, 2013 from whoever billed the second claim. The new policy, Change Request 8107, will only allow payment for the professional service, regardless of whether it is paid on a professional or institutional claim.

If you need assistance determining how this new policy may affect your practice, or if you have any other health care law questions, please contact an experienced health care attorney at Wachler & Associates at 248-544-0888.

Published on:

by

On March 13, 2013, the Centers for Medicare & Medicaid Services (“CMS”) released a Proposed Rule and Administrator’s Ruling that provide for significant revisions to Medicare’s Part B payment policy when a Part A hospital inpatient claim is denied as not medically necessary because the care was not provided in the appropriate setting. CMS’s Administrator’s Ruling (CMS-1455-R) was issued to address the significant number of pending appeals of Part A hospital inpatient reasonable and necessary denials while the new Proposed Rule entitled, Medicare Program; Part B Inpatient Billing in Hospitals, (CMS-1455-P), which proposes a permanent policy that would apply on a prospective basis, goes through notice and comment rulemaking. As a result, the Part A to Part B Rebilling Demonstration Program has been terminated.

CMS’s Interim Ruling and Proposed Rule differ in many important aspects from the Medicare Appeals Council’s longstanding position articulated in In re: O’Connor Hosp., that hospitals are entitled to full Part B payment, including observation and underlying services, following a denial of Part A reimbursement and that any Part B payment is subject to the rules governing administrative finality and will not be time-barred. For example, although the Interim Ruling and Proposed Rule would allow a hospital to submit a Part B claim for more services than just the limited number of ancillary medical and other health services listed in Chapter 6, Section 10 of the Medicare Benefit Policy Manual (“MBPM”), services that require an outpatient status, such as observation services, will not be reimbursed for the time period the beneficiary spent in the hospital as an inpatient.

In addition, although the Interim Ruling explicitly waives the potential timeliness of filing requirements with regard to the billing of a Part B claim following the denial of a Part A claim and provides hospitals with 180 days from the denial to bill for an outpatient stay, the Proposed Rule, should it become final it its current form, would deny Part B claims if filed more than 12 months after the date of service. Accordingly, if a RAC waits 12 months to deny a claim or should 12 months elapse from the date of service while a hospital is in the appeals process, the hospital will be left empty-handed.

Continue reading
Published on:

by

On January 31, 2013, the Senate Finance Committee released a report aimed at combating waste, fraud and abuse in Medicare and Medicaid. In May of 2012, the Senate Finance Committee invited interested stakeholders to submit white papers offering recommendations and innovative solutions to improve program integrity efforts, strengthen payment reforms, and enhance fraud and abuse enforcement efforts. In response, a variety of healthcare industry experts, including Wachler & Associates, submitted nearly 2,000 pages of input and recommendations. Wachler & Associates submitted instances of egregious contractor errors, including improper recoupment of alleged overpayments, contractors sending appeals correspondence to the wrong addresses and improper referral of alleged overpayments to the Department of Treasury. Based on the Finance Committee’s review, the white papers discussed five broad themes: improper payments, beneficiary protection, audit burden, data management, and enforcement.

Improper payment issues were discussed by 44 percent of health insurers and providers who submitted white papers. Solutions regarding improper payment issues included allowing reimbursement at the outpatient service level if inpatient status is denied or for certain types of complex cases; and clarifying the guidance on or abolishing outpatient observation status. Beneficiary protection was discussed by 57 percent of insurers and providers, many of whom discussed the use of outpatient observation status by hospitals to avoid recovery audit contractor’s (RAC) scrutiny of claims, as well as provider and patient frustration with payer documentation requirements, which may lead them to forfeit certain courses of treatment or care. Furthermore, 60 percent of providers and insurers discussed audit burden issues, and were specifically concerned with the number of audit entities involved, the volume and complexity of payment rules and regulations, whether payment rules are applied consistently and whether audit entities are inappropriately overturning medical necessity decisions, audit entities interactions with providers during the audit process, difficulty communicating with audit entities during the audit process, and financial burden of payment suspensions and the impact on business.

Ninety-four percent of white papers included recommendations to combat waste, fraud, and abuse. Some of the recommendations included were:

Continue reading
Contact Information
210 E 3rd St #204
Royal Oak, MI 48067
Phone: 248-544-0888
Fax: 248-544-3111

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. The contact form sends information by non-encrypted email, which is not secure. Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship.

Copyright © 2016 – 2024, Wachler & Associates, P.C.
JUSTIA Law Firm Blog Design