The RAC for Region C, Connolly Healthcare, has added 20 new DRG Validation issues to the list of CMS-approved audit issues. In addition, earlier this month several issues were approved for Region C providers in Virginia and West Virginia.
If you need assistance with a RAC or third party payor audit or for more information, please visit www.racattorneys.com or contact a Wachler & Associates attorney at 248-544-0888.
The Patient Protection and Affordable Care Act (PPACA), also referred to as the Healthcare Reform Legislation, made significant changes for Medicare providers. One change found in Section 6404 of the PPACA reduces the Medicare Parts A and B claims filing deadline to one (1) calendar year after the date of service furnished on or after January 1, 2010. The Section also gives the Secretary of the Department of Health and Human Services discretion to specify “exceptions” to the filing deadline. However, the PPACA did not specify the exceptions and it will be necessary to wait until the Centers for Medicare and Medicaid Services (CMS) begins the rulemaking process to implement the new filing deadlines. Regardless of the lack of specification of the exceptions to the filing deadlines, the new timely filing deadlines are self-executing.
It is also important to note that Section 6404 of the PPACA alters the timely filing deadline for claims under Medicare Parts A and B with dates of service prior to January 1, 2010. Claims with dates of service prior to January 1, 2010 must be filed by December 31, 2010.
For more information on health law issues, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.
In the same vein as the Healthcare Reform legislation’s vendor-providing reporting requirements known as the “sunshine law,” several leading professional medical organizations have adopted the new ethics codes, including: the American College of Physicians, the American College of Cardiology, and the American Society of Clinical Oncology. The ethical codes require the professional organizations to publicly post any industry support the group receives, decline industry funding for developing medical practice guidelines, disclose financial ties that leaders and board members have with companies, and ban company or product names and logos form pens, bags and other gifts at conferences. The goal of the ethical codes is to make financial ties more transparent.
For more information on health law issues, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.
On April 15 a bipartisan bill, the Health Information Technology Extension for Behavioral Health Services Act of 2010, was introduced in the House. The bill extends the Health Information Technology for Economic and Clinical Health (HITECH) Act’s electronic health records incentives to mental health professionals. Currently the HITECH Act provides incentives for qualifying healthcare professionals to demonstrate a “meaningfuluse” of electronic health records. However, the HITECH Act did not expand this incentive to mental health professionals. The proposed legislation would extend the incentives by ensuring the eligibility of certain behavioral and mental health professionals, psychiatric hospitals, behavioral and mental health treatment facilities, and substance abuse treatment facilities.
One supporter of the legislation, Congressman Tim Murphy(R-PA) reemphasized the importance of electronic health records for promoting quality health care. “To best diagnose and treat patients, mental health professionals need complete, up-to-date medical histories…Electronic health records ensure that physicians and mental health professionals are working together and delivering the best possible treatments.”
For more information on health law issues, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.
On April 15 President Obama signed H.R. 4851 into law, blocking the 21% reduction in Medicare physician payments through May 31. The original Senate bill delayed the cuts until April 30, but was passed with an amendment that pushed the date to May 31. Although the 21% cuts toMedicare reimbursement technically took effect on April 1, the Centers for Medicare and Medicaid Services (CMS) has withheld processing claims.
The American Medical Association (AMA) continues to react against the repeated delays and uncertainty behind the congressional action. The AMA urges Congress to find a permanent fix to the currently used sustainable growth rate (SGR) formula. “Congress must now turn toward solving this problem once and for all through repeal of the broken payment formula…Fixing the Medicare physician payment problem is essential to the security and stability of Medicare.”
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The Health Reform bill, also known as the Patient Protection and Affordable Care Act, includes amendments to the Anti-Kickback Statute (AKS), including a relaxation of the “specific intent” requirement. The Health Reform bill amended Section 1128B of the Social Security Act to add the following statement: “with respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section.” The change rejects previous interpretations of the AKS that required the government to prove that an individual “knowingly and willfully” violated the statute. This amendment in the health care reform bill will make it much easier for federal prosecutors to prove the requisite intent in AKS cases.
The Health Reform bill also amended the AKS to expressly state that a claim billed pursuant to an arrangement that violates the statute is a false or fraudulent claim under the false claims act, a position that was previously taken by some courts.
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The Healthcare Reform legislation includes vendor-provider reporting requirements, also known as the “sunshine law.” The law requires manufacturers of drugs, medical devices, medical supplies, and biologics to report financial arrangements with certain “covered recipients.” “Covered recipients” include physicians or teaching hospitals. The manufacturer must make the report to the U.S. Department of Health and Human Services (HHS). Then HHS must disclose the information on a public website.
The purpose of the reporting and disclosure requirements is to promote transparency of these financial arrangements. The goal is to encourage the avoidance of conflicts of interest that can compromise clinical care, biomedical research, and medical education, and potentially lead to violations of federal anti-fraud statutes.
The federal sunshine law generally preempts state sunshine laws with the exception of state laws that require disclosure of information not required under the federal legislation or excluded by the federal legislation, by any person or entity other than an applicable manufacturer or a covered recipient, or reporting of information to a Federal, State, or local government agency for public health surveillance, investigation, or other public health purpose. Manufacturers practicing in states with sunshine laws must now be attentive to both the federal and state law requirements to ensure compliance to both requirements.
The College of American Pathologists (CAP) recently announced that it is changing its accreditation checklist for CLIA accreditation in response to an interpretation communicated by the Centers for Medicare and Medicaid Services (CMS) with regard to the qualifications for “processing” personnel. Previously CAP treated “processing” personnel different from “grossing” personnel and did not require “processing” personnel to meet the requirements for “high complexity testing.” Laboratory providers who previously relied upon the distinction of “processing” vs. “grossing” must now ensure that all personnel who perform macroscopic tissue examinations meet the educational requirements of 42 CFR §493.1489 or are grandfathered pursuant to 42 CFR §493.1489 or 42 CFR §493.1491. If personnel meet the requirements to be “grandfathered”, additional supervision requirements may apply.
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A proposed bill, the Medicare Fraud Enforcement and Prevention Act, introduced in the House on Tuesday would double penalties for Medicare fraud. Sentences for Medicare fraud would be increased from 5 to 10 years and fines from $25,000 to $50,000. In addition, it would create a new crime for distributing patients’ Medicare or Medicaid IDs or billing information. That new crime would carry a maximum 3-year sentence.
The bill was introduced by two representatives from Florida, Ileana Ros-Lehtinen (R-Miami) and Ron Klein (D-Boca Raton). The bill, one of the first bipartisan efforts since the passage of the federal healthcare reform is a rebuttal to the increase in fraud despite the efforts of a federal health care fraud task force that prosecuted more than 800 people and identified more than $2.5 billion in fraudulent claims since 2006. According to law enforcement officials, Medicare fraud is an estimated $60 billion annual crime and is now more lucrative than drug dealing.
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Providers and suppliers that receive request letters from Recovery Audit Contractors (RACs) should ensure the following:
Wachler & Associates Health Law Blog