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According to a Department of Health and Human Services news release issued on Thursday, February 17, 2010, the Medicare Strike Force has indicted 111 health care providers for allegedly billing false claims to Medicare.  HHS called this the “largest ever federal health care fraud takedown.”

21 defendants were arrested in Detroit for allegations of billing false claims including home health care, nerve conduction tests, psychotherapy, physical therapy and podiatry.  Arrests were also made in Florida, New York, Texas, California, Louisiana and Illinois.

HHS also announced that it is expanding Strike Force operations to two additional cities – Chicago and Dallas.  Cities already under scrutiny of the Strike Force include Detroit, Miami, Houston, Brooklyn, Tampa and Baton Rouge.

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Connolly Healthcare, the region C RAC, recently posted 77 new issues eligible for review.  Twenty-three of these new issues involve Medical Necessity reviews, several of which include reviews of acute inpatient admissions to validate the medical necessity of short stay admissions.  These new approved issues implicate a variety of MS-DRGs, which will involve reviews for the medical necessity of the services and whether the MS-DRGs, which will involve reviews for the medical necessity of the services and whether the MS-DRG at issue was billed correctly.

DCS Healthcare, the RAC for region A, posted 7 new issues for review.  The new approved issues involve MS-DRG validation.  The issue description provided by DCS Healthcare indicates that the reviews require that diagnostic and procedural information and the discharge status of the beneficiary, as coded on the claim, matches the attending physician’s description and the patient’s medical record.

If you are facing a RAC audit or would like more information about a RAC related issues, please contact a Wachler & Associates attorney at (248) 544-0888 or visit www.Wachler.com.

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Physicians should take note of the fact that Medicare’s electronic prescribing program, while offering incentives now, will soon be changed to a penalty system for those who do not adopt e-prescribing.  Early adopters are currently being rewarded with a percentage of their total Medicare payments refunded to them.  In 2011 and 2012 the amount of the refund is 1% and it drops to .5% in 2013.  Penalties for those who do not adopt e-prescribing will begin in 2012 and will be 1% of Part B earnings in 2012 for those eligible physicians who do not meet e-prescribing criteria in at least 10 Medicare office visits from January 1, 2011 to June 30, 2011.

Physicians should also be aware of the fact that incentives will not be available from both the Medicare e-prescribing and Medicare EHR incentive programs simultaneously, i.e. those physicians receiving EHR incentives will not also be eligible for e-prescribing incentives, since e-prescribing is part of the “meaningful use” criteria.

If you have questions regarding applying for and qualifying for the e-prescribing programs or meeting the meaningful use criteria for the EHR incentive programs, please contact a Wachler & Associates attorney at 248-544-0888 or www.Wachler.com. 

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The OIG recently issued a favorable opinion concerning (1) the waiver of patient cost sharing amounts, without regard to patient need and (2) providing limited lodging and transportation for all patients of a network of pediatric charity hospitals.  The requestors were pediatric non-profit charity hospitals which currently provide free services to very sick and injured children.

The Requestors have not billed for their services in the past, but were seeking a favorable determination so that they could begin to bill on an “insurance only” basis without billing the patients or families for copayments, deductibles or other cost sharing amounts.  They would also continue to provide free services to uninsured patients and would not make decisions as to which families could receive the service based on insured status.

The OIG concluded that the Insurance-Only Billing would not lead to a risk of improper billing since the hospitals historically have not charged the patients or their families for services.

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CVS recently settled a suit with the US Attorney’s office for allegedly having a disqualified pharmacist fill prescriptions in their New York and New Jersey stores.  The settlement was for just under one million dollars.  The pharmacist had been excluded from participating in federal programs and CVS failed to pick up on this fact through its current system of background checking prospective employees.

This situation highlights the importance of thorough background checks for all healthcare employees.  These background checks should specifically check the status of the employee with respect to exclusion from any federal programs.  It can be a costly mistake to have an excluded employee bill for otherwise reimbursable services.

Whether you want to review your current compliance protocol, or construct an entirely new compliance program, one of our attorneys can help you navigate the labyrinth of complex healthcare compliance regulations.  Contact a Wachler & Associates attorney at 248-544-0888 or at www.Wachler.com.  

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The Affordable Care Act requires that all home health and hospice services be initiated by an in-person encounter with the patient and their physician in order to be covered under Medicare.  This requirement began January 1, 2011, but CMS has announced that it will not begin enforcing the requirement until April 1, 2011.  CMS has further stated that the delay in enforcement will not be further extended beyond April 1, 2011.

If you have any questions or concerns about complying with these new regulations, or any other regulations, please contact one of our attorneys at 248-544-0888 or www.Wachler.com. 

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The final rule changed several elements from the proposed rule.  One changed feature under the final rule is that one entity will be responsible for testing EHRs, and another entity will be responsible for certifying the EHRs.  No single entity will be allowed to perform both activities.

Other changes involve the process for accrediting the testing and certifying entities.  Those entities that were approved to test and certify records under the temporary program will not automatically be accredited under the permanent program and will have to meet any criterion required under the permanent program.  The permanent program is scheduled to begin January 12, 2012.

If you have any questions or concerns regarding certification of EHRs, or any compliance issues, please contact one of our attorneys at 248-544-0888 or visit www.Wachler.com for more information. 

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Due to confusion surrounding whether an IDTF was considered a “mobile” or “fixed-base” delivery structure, the DAB has explicitly stated that there are two types of mobile IDTFs.  Mobile IDTFs can either be “portable units” or a “mobile facility or unit.”  The difference between the two definitions is that a “portable unit” is one that transfers equipment to different fixed locations for diagnostic testing, while a “mobile facility or unit” is a vehicle that travels to different locations to treat patients inside the vehicle.

The DAB further clarified that rules on shared practice space between IDTFs and another Medicare enrolled provider.  These entities may share a location, but there is a clear distinction between clinical and non-clinical space.  The DAB specified that the sharing of common hallways, waiting rooms, and reception areas is permissible.  But the sharing of clinical space or diagnostic equipment is still strictly prohibited.

If you have any question or concerns regarding compliance with current CMS regulations, please contact one of our attorneys at 248-544-0888 or visit www.Wachler.com for more information.  

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The Adminstration has increased fraud prevention spending to $1.7 billion during the past fiscal year, a substantial increase from previous years.  This increase has been used to combat the estimated $60 billion lost to fraud in any given year.  The funds are going towards new law enforcement intra-agency teams called HEAT strike forces (Health Care Fraud Prevention and Enforcement Action Teams).  These teams are focused on seven cities, including Detroit, Houston, Los Angeles and Miami.  The goal is to expand these teams to 20 cities in the near future.

If you are facing any fruad or complaince related matters, please contact a Wachler and Associates attorney at 248-544-0888 or www.Wachler.com.

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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.

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