August 2010 Archives

August 17, 2010

CARE Act Would Create Credentialing Standards for Medical Imaging Personnel

A bill introduced in the Senate on August 5, 2010 would set forth minimum credentialing standards for medical personnel who "perform or plan" medical imaging or radiation therapy procedures. The Consistency, Accuracy, Responsibility and Excellence (CARE) in Medical Imaging and Radiation Therapy Act, introduced by Sen. Harkin (D-IA) and Sen. Enzi (R-WY) responds to concerns that procedures like x-rays, CT scans, and MRIs are increasingly being performed by personnel without adequate training, and would go into effect in 2013. Currently, standards vary from state to state; the CARE Act isn't meant to supplant or diminish more stringent standards that exist in some states. In addition, the Bill creates a grandfathering process for technicians who currently provide medical imaging or radiation therapy but don't meet the new education standards. It also establishes alternative standards for rural and underserved populations.

Given broad-based support, according to a press release from Sen. Harkin, the Bill is expected to pass this year.

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August 12, 2010

CMS Clarifies Timely Filing Requirements for Claims Including a Span of Time

CMS has issued new guidance expanding on the Fee-for-Service Reimbursement instructions detailed in CR 6960 (which HLP had blogged about here). The earlier change request explained the basic standards stemming from the Section 6404 of the Patient Protection and Affordable Care Act of 2010: services billed more than one year after they were provided would be considered untimely filed and would not be paid.

The new CR 7080, explained in the MLN Matters 7080, sets forth instructions for timely billing for claims that span dates of service (i.e., "from... through..."). In particular, for institutional services, the one-year deadline will be based on the "through" date (the final date included in the claim). For professional services, the one-year deadline will be calculated on the "from" date.

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August 12, 2010

RAC for Region D Posts New Anesthesia Care Package

As HLP reported, in April, CMS requested that the RAC for Region D remove an anesthesia care package it had posted to its website. Now, the issue has been re-posted, with some changes:

Under NCCI Edit rules, the anesthesia care package consists of preoperative evaluation, standard preparation and monitoring services, administration of anesthesia, and post-anesthesia recovery care. Anesthesia CPT codes 00100 to 01999 include Evaluation & Management (E&M) services rendered on the day of the anesthesia procedure. If the only service provided is management of epidural/subarachnoid drug administration, then an E&M service should not be reported in addition to CPT code 01996.

The above lacks clarity around two issues: (1) whether this refers to E&M services provided only on the day of the procedure and E&M services billed with 01996; and (2) whether this is being treated as automated or a complex review. As you may recall, CMS directed the removal of the issue when it was written more broadly to include all E&M services billed before and after anesthesia.

You can view the posting by clicking "next" to page 2 of this RAC Info page.

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August 12, 2010

Insurers Stepping in to Provide Technology to Doctors

As the Wall Street Journal reported on August 9th, health-insurance companies progressively are initiating programs to equip doctors with high-tech patient records. Even with all of the focus on electronic health records ("EHR"), an estimated 80% of U.S. physicians and 90%of hospitals continue to use paper records. As HLP has discussed in a number of blogs, during this past year, the Obama administration included $27 billion in federal stimulus money to provide incentives for physicians and hospitals to convert to EHR. EHR, which represent a digital platform for storing patients' medical data, differ greatly from the billing, claim-management and patient-scheduling systems that upon which substantial number of providers continue to rely.

From insurers' perspective, the deployment of EHR creates the opportunity to diversify their operations as the federal health overhaul presents new challenges to their business of collecting premiums and paying claims. The insurance companies' involvement has raised a number of questions among consumer advocates who question how patient information will be used. As one advocate observed, insurers "have a conflict of interest, since they want to know about you so they can better price products to you or deny you."

For providers, migrating to an EHR platform affords opportunities in the form of practice efficiency, as well as access to federal tax incentives. Nonetheless, it is not anomalous for physicians to experience challenges with the process of converting to EHR; in addition, it is imperative to be cognizant of the legal issues implicated by the use of EHR.

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August 5, 2010

NY AG investigating health care credit cards

Attorney General of New York, Andre Cuomo, initiated an investigation into health care credit cards after receiving a substantial number of complaints from consumers who were convinced by doctors and dentists to sign up for them.

The investigation will examine the financial incentives providers received from promoting the cards. Subpoenas have already been issued to 10 providers, while medical associations that endorse the card, including the American Dental Association and American Society of Plastic Surgeons, are being questioned as to the basis for their support. Cuomo also issued a subpoena to evaluate the operating structure of the three health care programs including: Chase Health Advance, Visa Health Benefits and Citibank Health Care.

According to Cuomo, providers have been inducing cardholders to finance procedures including dental work, veterinary services and cosmetic surgery not covered by insurance. In one example, CareCredit charged providers a fee to offer the card and gave rebates for part of the fee based on the amount of business providers get consumers to charge.

Other health care providers subpoenaed include: Allcare Dental Management Inc. of Buffalo; American Laser Centers of Farmington Hills, Mich.; Aspen Dental Management Inc. of East Syracuse; East Syracuse Family Dental Arts; Laser Cosmetica of New York City; Lifestyle Lift of Troy, Mich.; Northern Lights Chiropractic of Watertown; S & Y Diamond Dental P.C. of Brooklyn; Sunshine Dental of Watertown, and Toothsavers of New York City.

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August 4, 2010

OIG Advisory Opinion No. 10-11: The OIG Favorably Reviews a Company's Proposal to Encourage Health Care Providers to Use its Online Program to Schedule Meetings by Providing Charitable Donations in the Health Care Providers' Names

On July 30, the OIG released advisory opinion no 10-11 (the "Opinion") which favorably reviewed a company's proposal to encourage health care providers to use its online program for scheduling meetings with manufacturer representatives by offering the health care provider an opportunity to select a public charity to which the company would make a monetary, charitable contribution in the health care provider's name.

Under the proposed arrangement, the company is not a health care provider or supplier but offers marketing services to pharmaceutical, medical, and diagnostic product manufacturers. According to the Opinion, the company has developed an online scheduling website, which pharmaceutical, medical, and diagnostic product manufacturers can use to schedule time with health care providers to educate them about new products. Under the proposed plan, manufacturers would pay a fee to enroll in the program and a fee for every five minute intervals of time scheduled with each health care provider. The company would then encourage health care providers to participate in its scheduling program by offering them the opportunity to designate a public charity to which the corporation would make a charitable contribution "in the name of" the health care provider. Further, under the proposed program, the health care provider would not be entitled to a tax deduction as a result of the donation.

The Opinion recognized the importance of charitable contributions from health care providers and suppliers and expressed caution in the exercise of enforcement in this area. However, the OIG also listed several examples of potentially problematic contributions (e.g., contributions to charities that provide free or below market value rate office space to a referral source) which are nothing more than disguised kickbacks intended to induce referrals. With respect to the proposed arrangement, however, the OIG found that the program was not problematic as it was structured to prevent health care providers from receiving any actual or expected economic benefit from the charitable donations (i.e., the donations would be made directly to the public charities), the health care providers would not be entitled to tax deductions, the charities would be 501(c)(3) organizations that are public charities, and would meet the public support test under section 509 (a) of the IRC, the charity would have sole discretion in the use of the donated funds, the funds would not be restricted or earmarked, and the health care providers would have to provide certificates that they (or an immediate family member) are not employees or board members of the charity. Additionally, the company's proposed arrangement would not be determined by a health care provider's prescribing choices, thus preventing any potential link between the selected charity and health care provider's referrals.

Accordingly, the OIG concluded that the charitable contributions would not constitute prohibited "remuneration . . . directly or indirectly . . . in cash or in kind" to the health care providers within the meaning of the anti-kickback statute.

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August 2, 2010

Medicare Strike Force Rounds Up 94 People in $251 Million False Billing Scheme

As the HLP had previously reported, on July 16, the HHS Medicare Fraud Strike Force announced charges against 94 individuals for their alleged participation in schemes that collectively submitted more than $251 million in false claims to Medicare.

The charges are based on a variety of schemes including: physical therapy and occupational therapy schemes, home healthcare schemes, HIV infusion fraud schemes, and durable medical equipment (DME) schemes.

Of note, in Brooklyn, 22 defendants were charged for fraud which involved false billing for physical and occupational therapy and DME, while in Detroit, 11 defendants were charged for their alleged roles in schemes to submit fraudulent claims to Medicare for home health services, nerve conduction tests, and injection and infusion therapy sessions.

With these arrests, U.S. Attorney General Eric Holder announced that "Health care fraud is no longer a safe bet. The federal government is working aggressively--and collaboratively--to pursue health care criminals around the country and to bring these offenders to justice."

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August 2, 2010

CMS Solicits Proposals For Participation In Medicare Imaging Demo

On July 23, CMS published a notice in the Federal Register, soliciting proposals in a new imaging demonstration created under the Medicare Improvements for Patients and Providers Act of 2008.

The two-year Medicare Imaging Demonstration (MID) will test whether the use of decision supports systems (DSSs) can improve quality of care and reduce unnecessary radiation exposure and utilization by promoting appropriate ordering of advanced imaging services.

CMS would like to use "conveners" to reach eligible physicians interested in participating in the demonstrations. Conveners will be responsible for recruiting physician practices, deploying a DSS that incorporates medical specialty society guidelines for the selected procedures, ensuring the DSS remains current with those guidelines, collecting and transmitting data, and distributing payments to practices for reporting data. Accordingly CMS specifically would like the proposals from conveners to involve a diverse mix of physician practice sizes and types, medical specialties, and geographic areas. Applications to participate are due to CMS by September 21.

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