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A Republican Senator out of Iowa, Chuck Grassley, has introduced a new bill to the Senate.  This bill, which is entitled the Strengthening Program Integrity and Accountability in Health Care Act of 2011, seeks to amend the Social Security Act in a way that prevents improper billing, either through fraud or abuse, and waste in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).  These amendments would serve to bolster and expand upon the prevention measures implemented in last year’s Patient Protection and Affordable Care Act.

This Proposed legislation, which is part of a larger trend towards eliminating fraud and abuse in the health care arean, highlights the importance of providers maintaining up to date and comprehensive compliance programs.  To discuss new and existing compliance requirements and ways to meet these requirements, please contact a Wachler & Associates attorney at 248-544-0888. 

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The Department of Health and Human Service’s Office for Civil Rights will be conducting a series of workshops to help educate and train state Attorney Generals in enforcing the Health Insurance Portability and Accountability Act of 2009 (HIPAA).  These workshops will include reviews of HIPAA and state privacy laws and the new enforcement role of the Attorney Generals as promulgated under the Health Information Technology for Economic and Clinical Health Act (HITECH).

These workshops are part of a larger plan to increase awareness about HIPAA compliance and enforcement.  Experts anticipate an increase in HIPAA related enforcement activity in the coming months.  To discuss possible improvements to your current compliance program, or to develop a new program, contact a Wachler & Associates Attorney at 248-544-0888.

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The Government Accountability Office released a report on March 2, 2011, which concludes that inefficiencies and duplication in Government Programs are costing taxpayers billions every year.  This report, entitled “Opportunities to Reduce Potential Duplication in Government Programs, Save Tax Dollars and Enhance Revenue,” was issued to aid lawmakers in setting the federal budget.  The report claims that 10% of all Medicare payments are either fraudulent or otherwise improper and that these payments cost the federal government roughly $48 billion.  The report goes on further to specifically call on CMS and HHS to reign in these, and other health care related costs.  Reports such as this will undoubtedly increase audit activity from CMS contractors in an already aggressive audit environment.  If you are the subject of an audit from a RAC, ZPIC, MAC or other Medicare or CMS contractor, please contact a Wachler & Associates attorney.

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The Justice Department is seeking clarification on a ruling made by U.S. District Court Judge Roger Vinson.  Judge Vinson, in his ruling on the implementation of the Patient Protection and Affordable Care Act, suggested that the government was enjoined from implementation of the Act.  The DOJ now wants the Judge to clarify whether or not there is an injunction on the implementation of the Act.  This injunction would only be applicable to the 26 states that were a party to the suit.

The ruling on this case could have a significant impact on individuals and providers in the affected states and should be carefully watched.  For information on health care reform and compliance with the various provisions, please contact a Wachler & Associates attorney. 

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CGI, the Recovery Audit Contractor (RAC) for Region B, recently removed four DRG validation issues from its list.  This means that providers in Region B will no longer be subject to RAC audits on these particular procedures.

Connolly has added several new RAC issues to its CMS approved list.  One issue, Duplicate Claims, has been added for outpatient hospital claims.  Twelve issues have been added to DRG validation claims, and twenty-four issues have been added for medical necessity claims.  Providers in Region C need to be aware and prepared for these new issues being audited.

Some examples of the new medical necessity issues include: Skin graft and/or debridement DRG 577; Endocrine, nutritional and metabolic disorders DRG 639; Acute inpatient admission, MS-DRG 491.  For a full list of the new issues in Region C, please visit Connolly’s website.

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Effective February 14, 2011, CMS has limited the number of records RACs may request when reviewing Medicare claims from Physicians and other practitioners.  These requests for medical records, which are used in connection with complex claims reviews, will be limited based on the size of the group/office being audited.

If you have any questions regarding RAC, Medicare or other third party payor audits, please contact a Wachler & Associates attorney at 248-544-0888 or www.Wachler.com.

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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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