September 2009 Archives

September 25, 2009

America's Healthy Future Act of 2009

On September 22, 2009, the U.S. Senate's Chairman's Mark released a draft legislation regarding the future of healthcare in the United States. Some notable points include:
- Limiting physician referrals only to permit hospitals that meet certain exemption requirements, which would be more stringent than the current Medicare requirements;
- Establishing a process to update HIPAA standards periodically;
- Increasing transparency in the physician-manufacturer relationship involving payments and transfers of value and physician ownership or investment interests in manufacturers;
- Including in the in-office ancillary exception, for designated health services, that the referring physician inform the patient that s/he is not required to obtain services from the referred physician or a physician affiliated with the referring physician;
- Screening all providers and suppliers prior to the Secretary granting Medicare billing privileges;
- Expanding and consolidating provider databases with a "national patient abuse/neglect registry into a centralized sanctions data system;"
- Imposing a compliance program for Medicare and Medicaid providers as a condition of participation;
- Requiring Medicare and Medicaid providers and suppliers to repay overpayments when identified through an internal audit;
- Establishing a self-disclosure protocol allowing providers to voluntarily disclose instances or potential instances in which s/he has violated the physician self-referral law; and
- Expanding the RAC program the Medicare Part C, Medicare Part D, and Medicaid.

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September 24, 2009

Arizona Heart Hospital Settles with the HHS and the OIG

Arizona Heart Hospital agreed to settle with the Department of Health and Human Services (HHS) and the Office of Inspector General (OIG) for $675,000 for 10 instances of filing false claims with Medicare. According to the OIG and HHS, between July 2005 and March 2007, physicians at Arizona Heart Hospital submitted claims for carotid artery stenting procedures, a procedure not covered by Medicare. The physicians allegedly billed Medicare under a comparable billing code.

Dr. Edward Diethrich, the medical director of Arizona Heart Hospital, contends that the purpose of the stent procedure "did not coincide with the protocol or labeling for the stent," being used for a purpose not approved by the Food and Drug Administration (FDA). Diethrich further claimed that because there are so few of these atypical cases, it is not economically justifiable for a stent manufacturer to obtain FDA approval.

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September 13, 2009

OIG Releases Reports Regarding Hospice Claims and Medicare Coverage Requirements

OIG released two reports examining the hospice benefit for residents of a nursing care facility. The first report, "determined the extent to which hospice claims for beneficiaries in nursing facilities met Medicare coverage requirements." According to Section 418 of Title 42 of the Code of Federal Regulation, to receive Medicare coverage for delivering hospice care services, Medicare requires that
- The services be reasonable and necessary;
- Hospice care is elected pursuant to the applicable regulations;
- Prior to delivering any hospice services, a plan of care is established;
- The hospice services provided are within that established plan of care; and
- The patient has a certification that the illness is terminal.

The OIG's report revealed that a large percentage of hospice claims do not meet these requirements. More specifically, the report found that 82% of hospice claims did not meet at least one of the aforementioned requirements, resulting in Medicare paying $1.8 billion for these claims. Of this 82%, 63% of the claims failed to meet the requirement that a plan of care be established; 31% of the claims did not provide the services detailed in the plan of care; and 4% of the claims failed to meet the requirement that the patient's illness be terminal.

As a result of this study, the OIG has recommended that CMS develop better methods of educating hospices and providing them guidance on Medicare coverage requirements for hospice care services. Furthermore, the OIG recommends that CMS increase its monitoring of hospice care claims to "effectively use targeted medical reviews and other oversight mechanisms to improve hospice performance and compliance with Medicare requirements...." CMS agreed with all of the recommendations.

The second report OIG released pertaining to hospices examines hospice care services in nursing facilities. The study found that the percentage of hospice beneficiaries in nursing facilities increased by 3% from 2005 to 2006. In 2006, Medicare paid $2.59 billion for such services, averaging $960 per week per beneficiary (this does not include the physician services). Furthermore, the OIG found that the services hospices most commonly furnished included nursing services (96% of claims), home health aide (73% of claims), and medical social services (68% of claims). For these services, combined, the OIG found that hospices provided an average of 4.2 visits per week.

The purpose of this report was to raise awareness to CMS. The OIG did not have any recommendations or opinions on its findings.

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