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CGI Federal, RAC for Region B, added three new issues to its CMS-approved issues list for providers in all Region B states.

  • SNF consolidated billing. Services that are billed separately that should be included in the Skilled Nursing Facility Consolidated billing. Consolidated Billing is when services provided during the resident’s stay in a skilled nursing facility (SNF) are bundled into one package and billed by the Skilled Nursing Facility. Under the Consolidated Billing requirement, a Skilled Nursing Facility itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services).
  • DME while inpatient. The Medicare DMEPOS benefit is intended only for items that a beneficiary uses in his or her home. When a beneficiary is in a Part A inpatient stay, the institutional provider (e.g., hospital) is not defined as a beneficiary’s home for DMEPOS therefore; Medicare will not make separate payment for DMEPOS when a beneficiary is in the institution. The institution is expected to provide all medically necessary DMEPOS during a beneficiary’s covered Part A stay.
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The Centers for Medicare and Medicaid Services (CMS) recently announced it will release a national provider Comparative Billing Report (CBR) focused on Ordering Durable Medical Equipment: Diabetic Supplies. The CBRs will be released to 5,000 providers on August 29, 2011. CMS will make two additional CBR releases to 5,000 providers, which are currently slated for September 7, 2011 and September 15, 2011.

The CBRs are produced by Safeguard Services under contract with CMS and will provide comparative data to help show how these individual providers compare to other providers within the same field. These comparative studies are designed to help providers review their coding and billing practices and utilization patterns, and take proactive compliance measures. Providers should view CBRs as a tool, rather than a warning, as a way to aid them in properly complying with Medicare billing rules. It is also important to understand that CBRs do not contain patient or case-specific data, but rather only summary billing information as a method of ensuring privacy.

If you are a recipient of a CBR on Ordering Durable Medical Equipment: Diabetic Supplies, or are among the other provider types that have been identified to receive CBRs (i.e. physical therapists, chiropractors, ambulance, hospice, podiatry, and sleep studies), please contact a Wachler & Associates attorney at 248-544-0888 to discuss evaluating the CBR analysis and development of an appropriate compliance plan that will reduce audit risks.

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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.

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Additional Documentation Limits for Medicare Providers

Effective August 22, 2011, the Recovery Audit Contractors are permitted to request up to 35 records every 45 days from health care providers whose previous record request limit was set at 34 additional documentation requests or less. The limit is based on claim volumes only, and the type of claims do not factor into the limit. The maximum number of record requests remains at 300 within 45 days.

http://www.aha.org/aha/content/2011/pdf/11racadrlimits.pdf

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A new bill was recently introduced in the House of Representative in an effort to amend the Health Care Quality Improvement Act of 1996 (HCQIA) to require greater due process rights for health care professionals before any reports are made to the National Practitioner’s Data Bank (NPDB).

According to the Association of American Physicians and Surgeons, the bill, H.R. 2472, seeks to counter hospitals’ current practice of reporting adverse actions taken against physicians regardless whether the physician had been afforded a hearing or adequate notice about the investigation. According to supporters of the bills, rather than granting physicians an opportunity to defend themselves against these actions, hospitals have been bypassing these due process steps and reporting the actions to the NPBD. Reports to the NPBD have proven to be extremely detrimental to physicians and have resulted in a number of physicians losing their careers.

The bill amends 42 U.S.C. 11133(a) to prohibit a review entity from reporting to the NPDB while the physician is under investigation. Also, the bill would bar a hospital’s ability to submit a report to the NPDB before a physician is afforded a hearing and adequate notice of the adverse actions taken by the hospital. The amendment also seeks to change the current immunity power of a professional review body. The current HCQIA grants the professional review body immunity from actions taken against it even if the reviewer fails to follow the guidelines for adequate notice and hearing procedures described in the Act. The new bill may provide a means for a physician to bring a cause of action against a professional review body when the entity has failed to provide the required notice and hearing prior to filing a report to the NPBD or if the entity has conducted a “sham” peer review.

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On July 28, 2011, the U.S. Department of Health and Human Services, Office of Inspector General (OIG) issued an unfavorable advisory opinion regarding two proposals by a supplier of medical supplies, equipment and related services (Supplier) seeking to enter into a contract with a county-operated skilled nursing facility (SNF) to provide such items and services.

Supplier provides medical supplies and equipment to SNFs along with providing related services (e.g. emergency delivery of medical supplies, inventory control and customized packaging). Supplier bills Medicare directly for supplies and equipment covered by Medicare Part B (covered items). For items not covered by Medicare (non-covered items), Supplier bills the SNFs directly and includes a markup which covers the costs of related services, overhead and profit. Supplier acknowledged that the amount paid by Medicare Part B for the covered items is enough to cover the costs related to the services provided to the SNF in connection with the non-covered items.

The SNF solicited bids from suppliers to be the exclusive supplier of covered items and related services to the SNF. The SNF also required all bids to include pricing for the non-covered items and related services. The SNF proposed to purchase the non-covered items at its option. Supplier was one of the bidders and the OIG analyzed two proposed arrangements that Supplier sought to use in the bidding process.

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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.

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DCS Healthcare, RAC for Region A, added two new issues subject to medical necessity reviews to its CMS-approved issues list for providers in Maryland. DCS Healthcare also added four new issues for providers in all Region A states.

  • MS-DRG 286, 287 Cardiac Catheterization for Ischemic Heart Disease (All severity and risk of mortality levels) (Maryland only). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 286, 287 cardiac catheterization for ischemic heart disease.
  • MS-DRG 149 vertigo and other labyrinth disorders (All severity and risk of mortality levels) (Maryland only). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of MS-DRG 149 vertigo and other labyrinth disorders.
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The Centers for Medicare and Medicaid Services (CMS) recently announced it will release a national provider Comparative Billing Report (CBR) targeting Independent Physical Therapy Providers who practice in the outpatient setting and bill Medicare with the KX Modifier, which is the billing requirement used to show that the beneficiary has exceeded the therapy cap, but requires additional medically necessary physical therapy services. Last August, physical therapists were the first provider type to receive CBRs. The CBRs currently being issued to physical therapists will be distributed to 5,000 additional or different providers and will be centered on 2010 billing data.

The CBRs are produced by Safeguard Services under contract with CMS and will provide comparative data to help show how these individual providers compare to other providers within the same field. These comparative studies are designed to help providers review their coding and billing practices and utilization patterns, and take proactive compliance measures. Providers should view CBRs as a tool, rather than a warning, as a way to aid them in properly complying with Medicare billing rules. It is also important to understand that CBRs do not contain patient or case-specific data, but rather only summary billing information as a method of ensuring privacy.

If you are a recipient of a Physical Therapy CBR or are among the other provider types that have been identified to receive CBRs (i.e. physical therapists, chiropractors, ambulance, hospice, podiatry, and sleep studies), please contact a Wachler & Associates attorney at 248-544-0888 to discuss evaluating the CBR analysis and development of an appropriate compliance plan that will reduce audit risks.

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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.

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