Published on:

by

On July 14, 2011, the Department of Health and Human Services Office of Inspector General (OIG) issued a favorable advisory opinion regarding the use of a preferred hospital network as part of Medicare Supplemental Health insurance (Medigap) policies. Under the proposed arrangement, the requestors who offer Medigap insurance policies, would establish a preferred provider organization (PPO) comprised of certain hospitals. The PPO network would allow the requestors to receive discounts on Medicare inpatient deductibles for policyholders. Also under the proposed arrangement, the requestors would provide a $100 premium credit to policyholders who opt to use a network hospital for an inpatient stay. Any savings realized by the requestors would be filed with the state insurance departments accountable for regulating the premium rates charged by Medigap insurers.

The OIG determined that the proposed arrangement would implicate both the anti-kickback statute and Section 1128A(a)(5) of the Social Security Act which provides for the imposition of civil monetary penalties for providing remuneration to beneficiaries. However, because of several factors, the OIG concluded that the proposed arrangement would present a low risk of fraud and abuse. Although not directly on point, the OIG looked at the safe harbor for waivers of beneficiary coinsurance and deductible amounts, as well as the safe harbor for reduced premium amounts offered by health plans.

The OIG concluded that the discounts offered on inpatient deductibles by the network hospitals would present a low risk of fraud or abuse for the following reasons:

Continue reading
Published on:

by

According to a new report released by The Department of Health and Human Services Office of the Inspector General (HHS OIG), hospice companies have quickly expanded their services to patients residing in nursing homes. HHS OIG found that total Medicare spending for hospice care for nursing home residents had grown by nearly 70 percent between 2005 and 2009. In addition, the number of hospice beneficiaries in nursing facilities has increased by 40 percent during that same time period. The report also found that 263 hospices (nearly 8 percent of all hospices) had two-thirds or more of their Medicare beneficiaries residing in nursing homes, referred to in the report as “high-percentage hospices.” Moreover, high-percentage hospices were paid an average of $3,182 more per beneficiary by Medicare. Also, high-percentage hospice beneficiaries received hospice services nearly three weeks longer than beneficiaries served by hospices overall, and the costs to high-percentage hospices were much lower due to patients requiring less services because they are already receiving similar services from the nursing facilities.

In connection with the Inspector General’s recommendation, the Centers for Medicare and Medicaid Services (CMS) has announced that it is making an effort to reduce its Medicare payments for hospice patients residing in nursing facilities. As a result, hospice providers will likely see increased audits in this area, with a specific focus on skilled nursing facility referrals. If you are a hospice provider and need assistance in preparing or defending against an audit, or seek assistance with creating a compliance program to minimize audit risk, please contact a Wachler & Associates attorney at 248-544-0888.

Published on:

by

With the rise of the health-related mobile application market, the Food and Drug Administration (FDA) proposed its first-ever regulations on the industry. The regulations target three types of applications that require the FDA’s approval: an application that acts as an accessory to a regulated medical device, turns the mobile technology into a regulated medical device or makes recommendations pertaining to a patient’s treatment or diagnosis. The FDA believes that just because a medical device is used with a cellular phone, it should still face the same regulations as its traditional non-mobile counterpart.

The FDA plans to collect feedback over a 90 day period from manufacturers and other health care providers, and until this happens the regulations will not take effect. According to the Washington Post, some concerns have already surfaced in regards to the proposed regulations, such as the FDA’s ability to monitor the technology when the mobile industry faces such rapid changes. Another concern is the willingness of investors and companies to back these products when facing this sort of regulatory uncertainty. Jeff Shuren, director for the FDA’s Center for Devices and Radiological Health, said that the FDA will likely take a more subtle approach in reviewing the mobile applications due to the speeding change of the industry, such as focusing on the design of the product and eliminating the requirement of clinical trials.

If you have any questions relating to mobile application compliance with FDA regulations or any other compliance issues, please contact a Wachler & Associates attorney at 248-544-0888.

Continue reading
Published on:

by

The face-to-face requirements for Medicaid home health services will follow a similar timeframe to that set forth for Medicare. The timeframes were established by the Patient Protections and Affordable Care Act (PPACA), and CMS intends to enforce the regulation. A proposed rule creates the requirement that physicians document the existence of a face-to-face encounter with Medicaid beneficiaries within 90 days prior to the ordering of home health services. However, in circumstances where it is deemed not to be possible to meet the 90 day requirement, the face-to-face encounter would be satisfied by an encounter with the beneficiary occurring within 30 days after the start of home health services. Additionally, states that currently allow use of telehealth or telemedicine when delivering services under Medicaid will remain able to use these techniques to fulfill the face-to-face encounter.

If you have any questions pertaining to the Medicare or Medicaid face-to-face requirement, telemedicine rules or any other regulations under PPACA, please contact a Wachler & Associates attorney at 248-544-0888.

Published on:

by

According to a Boston Globe article, Tufts Medical Center and one of its primary care doctors are being sued by a patient whose privacy rights were allegedly violated when her medical history was sent to a fax machine at her workplace without her consent. The patient, Kimberly White, was recovering from a hysterectomy this past December. While recovering, she asked Dr. Kimberly Schelling to fax a form to White’s employer that was required to receive disability payments. Instead, medical records were allegedly sent to a shared fax machine in the office, which resulted in White’s medical records being viewed by at least two co-workers. White claimed that this disclosure has caused her extreme embarrassment and the inability to show her face at work again. Tufts has not yet filed a response to the complaint, but the hospital maintains that they were in full compliance with the patient’s request to share the medical information.

The HIPAA Privacy Rule allows information to be disclosed pursuant to a patient’s authorization or as otherwise permitted by the HIPAA Privacy Rule. The Office of Civil Rights (OCR) has issued guidance stating that the use of fax machines are permissible so long as reasonable safeguards are taken to protect the information from unauthorized or impermissible disclosure. If you have questions regarding patient privacy or assistance with HIPAA compliance policies and procedures, please contact a Wachler & Associates attorney at 248-544-0888.

Published on:

by

A Miami resident and Detroit clinic owner, Arnaldo Rosario, was recently sentenced to 27 months in prison for his role in recruiting patients to three clinics in the Detroit area. According to the FBI, the Medicare fraud scheme involved remuneration to Medicare beneficiaries for visiting the clinics and fraudulently representing that they had received treatments that were either not provided or not medically necessary. The services were then billed to Medicare and the beneficiaries would receive cash kickbacks for their role in the scheme. Rosario was responsible for obtaining cash from the clinics to pay the kickbacks to the beneficiaries and also to other co-defendants for their role in recruiting and paying Medicare patients. Over a span of one year, Medicare had paid approximately $10.8 million to the clinics based on the fraudulent claims. This case was brought as part of the Medicare Fraud Strike Force, which in its four years of operations, has already discovered more than $2.3 billion worth of allegedly fraudulent Medicare claims. Both Miami and Detroit are cities targeted by the Medicare Fraud Strike Force and providers in these cities should be aware of this heightened scrutiny.

If you have any questions regarding the Anti-Kickback Statute, inappropriate remuneration to beneficiaries, medical necessity issues, or any other compliance issues relating to Medicare fraud or allegations of Medicare fraud, please contact a Wachler & Associates attorney as 248-544-0888.

Published on:

by

The Centers for Medicare and Medicaid Services (CMS) has posted a summary of the Medicare Fee for Service RAC recoveries for the 3rd quarter of fiscal year 2011. The summary displays the amount of each region’s overpayments, underpayments and total corrections, as well as the nationwide totals. In addition to these quantitative findings, CMS has also identified the top issues for each region.

Click here to view the summary posted by CMS.

Review of these issues is helpful for providers wishing to develop a compliance program that will alert them to potential RAC issues prior to a RAC audit. The issues identified by CMS should be a key focus area for providers developing compliance programs to prepare for and hopefully avoid RAC audits. If you need assistance in preparing for, or defending against a RAC audit through the Medicare appeals process, or for assistance implementing a compliance program geared toward identifying and correcting potential risk areas related to RAC audits, please contact a Wachler & Associates attorney at 248-544-0888.

Published on:

by

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.

Published on:

by

Despite the large number of Medicare and Medicaid audits and investigations currently being conducted by government contractors, the Government Accountability Office (GAO) recently released a report stating that the federal government’s systems for analyzing Medicare and Medicaid data to detect fraud are “inadequate and underused.”

In 2009, CMS enacted new $150 million systems intended to be a one-stop database accessible to all CMS staff and contractors, law enforcement, and state agencies. However, the report finds that the “share systems data” and other tools to identify and prevent payment of fraudulent claims are still missing. The federal government believes the technology is crucial to curtailing the $60 billion to $90 billion in fraudulent claims paid each year.

The GAO report noted that the current systems don’t even include Medicaid data. Further, only 41 of the 639 analysts charged with using the new detection system have been trained so far. The systems are meant to replace CMS’ “pay and chase” method, which allows criminals to flea before CMS can analyze their claim. The new systems detect fraudulent Medicare and Medicaid claims in real time and deny the claim prior to payment.

Continue reading
Published on:

by

The Centers for Medicare and Medicaid Services (CMS) recently announced it will release a national provider Comparative Billing Report (CBR) this July. CMS will release 5,000 CBRs to physicians ordering spinal orthotic devices billed to Medicare. 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 spinal orthotic 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.

Click Here to view a Spinal Orthotic CBR sample

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

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 – 2026, Wachler & Associates, P.C.
JUSTIA Law Firm Blog Design