May 2011 Archives

May 31, 2011

The HLP Welcomes New Health Care Attorney

The Health Law Partners, P.C. ("The HLP") is pleased to announce a new addition to our growing team of health care lawyers. Attorney Timothy Burkhard, formerly of Foster, Swift, Collins & Smith, P.C. has joined The HLP. Mr. Burkhard focuses his practice on health care business transactions and corporate matters, licensure matters and health care litigation, including Civil False Claims Act and white collar criminal defense. The HLP is excited to welcome Mr. Burkhard to our team of lawyers who specialize in the business of health care.

May 31, 2011

New Pre-Op Guidance for ASCs

Earlier this month, Transmittals to the State Operations Manual for ASCs (Appendix L) implemented certain clarifications/changes to the anesthetic risk assessment, H&P and pre-surgical evaluation Conditions of Participation at ASCs, effective 5.13.11. The new standards from the Transmittal are set forth below, followed by the provisions in which these new standards of Appendix L have been incorporated.

1. Anesthetic Risk Assessment: When the comprehensive H&P assessment is performed in the ASC on the same day as the surgical procedure, the Transmittal indicates that the assessment of the patient's procedure/anesthesia risk must be conducted separately from the history and physical, including any update assessment incorporated into that history and physical.

2. H&Ps:

a. The H&P (conducted within 30 days of the scheduled surgery) must be comprehensive in order to allow assessment of the patient's readiness for surgery and, as clarified by the Transmittal, is required regardless of the type of surgical procedure.


b. While the comprehensive H&P may be performed in the ASC on the same day as the surgical procedure (provided that it is conducted by qualified personnel, is comprehensive, and the results of the H&P are placed in the patient's medical record prior to the surgical procedure), according to the Transmittal, it is not acceptable to conduct the H&P after the patient has been prepped and brought into the operating or procedure room. The rationale for this requirement is that the purpose of the H&P is to determine, prior to surgery, whether there is anything in the patient's overall condition that would affect the conduct of, or possibly require cancellation of, the planned procedure.

3. Pre-Surgical Assessment:

a. Independent of the H&P requirement discussed above, upon admission to the ASC each ASC patient must have a pre-surgical assessment by a physician to evaluate the risk of the anesthesia and of the procedure for that patient. The Transmittal notes that this component must be conducted by a physician, immediately prior to surgery, and must be performed in a manner consistent with the anesthetic risk assessment requirements discussed in paragraph 1 above.


b. In accordance with the Transmittal, if the H&P is performed on the day of the surgical procedure in the ASC, some, but not all, elements of the pre-surgical assessment may be incorporated into the H&P. However, the assessment of the patient's risk for the procedure and anesthesia (as discussed in paragraph 1 above) must still be conducted separately, by a physician and immediately prior to surgery.


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Below are the sections from the Transmittal in which each of the foregoing is discussed. The new clarification language is highlighted in red.


(Rev.71, Issued: 05-13-11, Effective: 5-13-11-Implementation: 05-13-11)

§416.42(A) STANDARD: ANESTHETIC RISK AND EVALUATION
(1) A physician must examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed.
Interpretive Guidelines: §416.42(a)(1)

The purpose of the exam immediately before surgery is to evaluate, based on the patient's current condition, whether the risks associated with the anesthesia that will be administered and with the surgical procedure that will be performed fall within an acceptable range for a patient having that procedure in an ASC, given that the ASC does not provide services to patients requiring hospitalization. The assessment must be specific to each patient; it is not acceptable for an ASC to assume, for example, that coverage of a specific procedure by Medicare or an insurance company in an ASC setting is a sufficient basis to conclude that the risks of the anesthesia and surgery are acceptable generically for every ASC patient. The requirement for a physician to examine the patient immediately before surgery is not to be confused with the separate requirement at 42 CFR 416.52(a)(1) for a history and physical assessment performed by a physician, although it is expected that the physician will review the materials from such pre-admission examination as part of the evaluation. Nevertheless, this requirement does constitute one component of the requirement at 42 CFR 416.52(a)(2) for a pre-surgical assessment upon admission. In those cases, however, where the comprehensive history and physical assessment is performed in the ASC on the same day as the surgical procedure, the assessment of the patient's procedure/anesthesia risk must be conducted separately from the history and physical, including any update assessment incorporated into that history and physical. See the interpretive guidelines for§§416.52(a)(1) & (2).

The ASC must have approved policies and procedures to assure that the assessment of anesthesia-related and procedural risks is completed just prior to every surgical procedure. (Ideally, the ASC would conduct such an assessment prior to the patient's admission as well as immediately prior to surgery, but this is not specifically required by the regulations.)

The ASC‟s policies must address the basis or criteria used within the ASC in conducting these risk assessments, and must assure consistency among assessments.
The regulations do not specify the content or methodology to be employed in such assessments. As an illustrative example, an ASC might choose to incorporate consideration of a patient's ASA Physical Classification into its criteria. Although the American Society of Anesthesiologists did not create its ASA Physical Status Classification System for the purpose of predicting operative risk, this system has nevertheless been found to be useful in predicting morbidity and mortality in surgical patients1 and has been used by surgical facilities as a standard tool. This system classifies patients‟ physical status in 6 levels:

ASA PS I - Normal healthy patient;
ASA PS II - Patient with mild systemic disease;
ASA PS III - Patient with severe systemic disease;
ASA PS IV - Patient with severe systemic disease that is a constant threat to life;
ASA PS V - Moribund patient who is not expected to survive without the operation; and
ASA PS VI - Declared brain-dead patient whose organs are being removed for donor purposes.

As the ASA PS level of a patient increases, the range of acceptable risk associated with a specific procedure or type of anesthesia in an ambulatory setting may narrow. An ASC that employed this classification system in its assessment of its patients might then consider, taking into account the nature of the procedures it performs and the anesthesia used, whether it will accept for admission patients who would have a classification of ASA PS IV or higher. For many patients classified as ASA PS level III, an ASC may also not be an appropriate setting, depending upon the procedure and anesthesia.

If a State establishes licensure limitations on the types of procedures an ASC may perform that are based on patient classifications and would permit ASCs to perform fewer procedures than they would under the CfCs, then the ASC must conform to those State requirements. However, State requirements that would expand the types of procedures an ASC may offer beyond what is permitted under the CfCs are superseded by the Federal CfC requirements.
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(Rev. 71, Issued: 05-13-11, Effective: 5-13-11-Implementation: 05-13-11)

§416.52(A) STANDARD: ADMISSION AND PRE-SURGICAL ASSESSMENT
(1) Not more than 30 days before the date of the scheduled surgery, each patient must have a comprehensive medical history and physical assessment completed by a physician (as defined in section 1861(r) of the Act) or other qualified practitioner in accordance with applicable State health and safety laws, standards of practice, and ASC policy.
Interpretive Guidelines §416.52(a)(1)

The purpose of a comprehensive medical history and physical assessment (H&P) is to determine whether there is anything in the patient's overall condition that would affect the planned surgery, such as a medication allergy, or a new or existing co-morbid condition that requires additional interventions to reduce risk to the patient, or which may even indicate that an ASC setting might not be the appropriate setting for the patient's surgery. The H&P must be comprehensive in order to allow assessment of the patient's readiness for surgery and is required regardless of the type of surgical procedure. The H&P
should specifically indicate that the patient is cleared for surgery in an ambulatory setting.

The H&P must be completed and documented for each ASC patient no more than 30 calendar days prior to date the patient is scheduled for surgery in the ASC.
In cases where the patient is scheduled for two surgeries in the ASC within a short period of time, the same H&P may be used so long it is completed no more than 30 calendar days before each surgery. For example, if a patient has two surgeries for cataracts scheduled, one eye on May 3rd, and the other eye on May 18th, and H&P performed on April 20th could be used for both surgeries.

The H&P is still required in those cases where the patient is referred to the ASC for surgery on the same day as the referral and the referring physician has indicated it is medically necessary for the patient to have the surgery on the same date. The H&P may be performed by the referring physician, if the ASC‟s policies permit this, or qualified personnel in the ASC. If there are elements of the H&P that are essential to the performance of the physician assessment required under §416.42(a) or under this requirement at §416.52(a)(1), based on the type of procedure to be performed as well as applicable State health and safety laws, standards of practice, or ASC policy, and those elements cannot be completed prior to the scheduled time of the surgical procedure, then it is questionable whether the case is suitable for that ASC.

The H&P may be performed on the same day as the surgical procedure, and may be performed in the ASC, as long as it is conducted by qualified personnel, is comprehensive, and the results of the H&P are placed in the patient's medical record prior to the surgical procedure (see §416.52(a)(3). It is not acceptable to conduct the H&P after the patient has been prepped and brought into the operating or procedure room, since the purpose of the H&P is to determine before the surgery whether there is anything in the patient's overall condition that would affect the conduct of the planned procedure, or which may even require cancellation of the procedure.

The medical history and physical examination must be completed and documented by a physician (as defined in Section 1861(r) of the Act) or other qualified licensed individual practitioner in accordance with State law, generally accepted standards of practice, and ASC policy.

Section 1861(r) defines a physician as a:

doctor of medicine or osteopathy;
doctor of dental surgery or of dental medicine;
doctor of podiatric medicine;
doctor of optometry; or a
chiropractor.

In all cases the practitioners included in the definition of a physician must be legally authorized to practice within the State where the ASC is located and providing services within their authorized scope of practice.

Other qualified licensed individuals are those licensed practitioners who are authorized in accordance with their State scope of practice laws or regulations to perform an H&P and who are also formally authorized by the ASC to conduct an H&P. Other qualified licensed practitioners could include nurse practitioners and physician assistants.
More than one qualified practitioner can participate in performing, documenting, and authenticating an H&P for a single patient. When performance, documentation, and authentication are split among qualified practitioners, the practitioner who authenticates the H&P will be held responsible for its contents.
In the case of an ASC the H&P is typically completed by the patient's primary care practitioner rather than a member of the ASC‟s medical staff. The ASC‟s policy on H&Ps should address submission of an H&P prior to the patient's scheduled surgery date by a physician who is not a member of the ASC‟s medical staff and should indicate whether it will accept H&Ps performed by a qualified licensed individual who does not practice at the ASC but is acting within his/her scope of practice under State law or regulations.

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(Rev. 71, Issued: 05-13-11, Effective: 5-13-11-Implementation: 05-13-11)

§416.52(A) STANDARD: ADMISSION AND PRE-SURGICAL ASSESSMENT
(2) Upon admission, each patient must have a pre-surgical assessment completed by a physician or other qualified practitioner in accordance with applicable State health and safety laws, standards of practice, and ASC policy that includes, at a minimum, an updated medical record entry documenting an examination for any changes in the patient's condition since completion of the most recently documented medical history and physical assessment, including documentation of any allergies to drugs and biologicals.

Interpretive Guidelines: §416.52(a)(2)

Each ASC patient upon admission to the ASC must have a pre-surgical assessment. The requirement at §416.42(a)(1) for a physician to examine the patient immediately before surgery to evaluate the risk of the anesthesia and of the procedure for that patient is one component of the requirement at 42 CFR 416.52(a)(2). This component must be conducted by a physician, immediately prior to surgery, and must be performed in a manner consistent with the requirements at §416.42(a)(1). (See the interpretive guidelines for §416.42(a)(1). Other elements of the assessment may be conducted by a licensed practitioner who is credentialed and privileged by the ASC to perform an H&P. In all cases, the update must take place prior to the surgery.

If the H&P required under §416.52(a)(1)is performed on the day of the surgical procedure in the ASC, some, but not all, elements of the pre-surgical assessment may be incorporated into the H&P. However, the assessment of the patient's risk for the procedure and anesthesia required under §416.42(a)(1) must still be conducted separately, by a physician and immediately prior to surgery.

The patient must be assessed for any changes in his/her condition since the patient's H&P was performed that might be significant for the planned surgery. Patients may have had a change in health status after the H&P, but may not recognize the significance for their planned surgery. Any changes in health and medication can have an impact on the patient's ability to tolerate the surgery or anesthesia, and the post-admission pre-surgical assessment is designed to identify these changes and take appropriate action, up to and including postponing or cancellation of the surgery. In addition, the pre-surgical assessment must identify and document any allergies the patient may have to drugs and biologicals, or indicate that the patient has no known allergies to drugs and biologicals.

Further, if the practitioner finds that the H&P done before admission is incomplete, inaccurate, or otherwise unacceptable, the practitioner reviewing the H&P, examining the patient, and completing the update may disregard the existing H&P, and conduct and document in the medical record a new H&P prior to the surgery.
The patient's medical record must include documentation that the patient was examined prior to the commencement of surgery for changes since the H&P. The physician or qualified licensed individual uses his/her clinical judgment, based upon his/her assessment of the patient's condition and co-morbidities, if any, in relation to the patient's planned surgery to decide the extent of the update assessment needed as well as the information to be included in the update note in the patient's medical record.

If, upon examination, the licensed practitioner finds no change in the patient's condition since the H&P was completed, he/she may indicate in the patient's medical record that the H&P was reviewed, the patient was examined, and that "no change" has occurred in the patient's condition since the H&P was completed. Likewise, any changes in the patient's condition must be documented by the practitioner in the update note prior to the start of surgery.

Continue reading "New Pre-Op Guidance for ASCs" »

May 30, 2011

MGMA's Physician Starting Salary Survey Released

According to the Medical Group Management Association ("MGMA"), physicians enjoyed an employee's market in 2010. Based on MGMA survey data, 56% of first-year physicians accepted paid relocation packages and signing bonuses last year. Also, 12% of first-year doctors obtained loan-forgiveness packages.

The MGMA survey also found that first-year specialists in multispecialty practices earned 7.5% more than similar physicians in single-specialty practices in 2010 (median salaries of $258,677 and $240,596, respectively). Among primary-care doctors, however, the situation was reversed. New primary-care doctors in single-specialty practices earned 4.5% more than their peers in multispecialty practices (median salaries of $172,400 and $165,000, respectively).

The MGMA survey is based on data from 4,295 providers and starting salaries of 1,986 physicians directly following residency or fellowship.

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May 27, 2011

ACO Proposed Rule's Program Integrity Includes Mandatory Compliance Plans

In its proposed rule for accountable care organizations ("ACOs"), the Centers for Medicare and Medicaid Services ("CMS") includes mandatory compliance plans as an element of its ACO-program integrity efforts. The compliance plan must include at least the following elements:

• A designated compliance officer who is not legal counsel to the ACO and who reports directly to the ACO's governing body

• Mechanisms for identifying and addressing compliance problems related to the ACO's operations and performance

• A method for employees or contractors of the ACO or ACO providers/suppliers to report suspected problems related to the ACO

• Compliance training of the ACO's employees and contractors

• Requirement to report suspected violations of the law to an appropriate law enforcement agency.


Since the Patient Protection and Affordable Care Act's enactment, adoption of compliance plans--both for ACOs and generally--has become mandatory for participation in Medicare, Medicaid and the Children's Health Insurance Program.

Continue reading "ACO Proposed Rule's Program Integrity Includes Mandatory Compliance Plans" »

May 26, 2011

Pain Clinic Zoning Ordinance Passed in South Florida Town

May 10, 2011, the Miami Lakes, Florida council passed a zoning ordinance requiring pain clinics in its town to obtain a special permit. A pain clinic's grand opening advertisement featuring the words "pain" and "opiates" put a Miami Lakes councilman in fear of potential pill-mill activity coming to town and prompted the council's efforts to pass the ordinance.

The fear is not completely ungrounded. South Florida has been called the "national epicenter" of the funneling of illegal prescription drugs, and law enforcement officials' recent raids have targeted the area. Broward County, located only a few miles from Miami Lakes, in particular has significantly contributed to the nation's pill-mill problem.

The Miami Lakes zoning ordinance would allow the town two to three months to review a pain clinic's application. The ordinance also prohibits anyone operating or owning a pharmacy in town from running a pain clinic, requires special zoning approval to establish a new pain clinic within 500 feet of another clinic, and requires all current town medical offices, labs, and clinics to register with the town and provide detailed information within six months.

The existence of some pain mills places all pain physicians under greater scrutiny. As such, it is vital for well-intentioned pain management physicians to proactively protect themselves.

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May 25, 2011

HEAT Provider Compliance Training Materials Now Available

In order to assist individuals interested in learning more about the fundamentals of health care compliance and help answer questions about what to do when compliance issues arise, the Office of Inspector General recently posted the HEAT Provider Compliance Training slide presentation and written materials which accompany its compliance training webcast. The webcast focuses on Medicare fraud and the implementation of an effective health care compliance program.

The presentation materials may be viewed here. A video of the training webcast will also be available beginning May 31, 2011 at the same webpage.

Continue reading "HEAT Provider Compliance Training Materials Now Available" »

May 19, 2011

Potential ACOs Reluctant to Participate Under Proposed Rule

During late March, the Centers for Medicare and Medicaid Services ("CMS") proposed a rule regarding Accountable Care Organizations ("ACOs") and the Medicare Shared Savings Program, which will make payments of shared savings to ACOs ("Proposed Rule"). The Proposed Rule describes the amount of financial risk the participants will face and the type of data the providers will be expected to collect under CMS' current vision for the program. Many believe in the ACO concept of higher quality care at reduced costs. However, the complaints regarding the actual Proposed Rule are numerous and multi-faceted. Even the high-profile health care centers such as the Cleveland Clinic, the Mayo Clinic, and Intermountain Healthcare, which were used as inspirations for the Medicare Shared Savings Program and its ACOs, are hesitant to participate. Among other obstacles, the financial investment that providers will need to dedicate to participate in the Medicare Shared Savings Program under the Proposed Rule (e.g., to add technology and staff necessary to track the quality data to be collected) may prove to be a barrier to their participation. CMS officials are aware of the issues raised by the Proposed Rule. Dr. Donald Berwick, the Administrator of CMS, has expressed CMS' desire and commitment to cooperate with health care providers to work out the problems.

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May 18, 2011

New Medicare Compliance Newsletter Released

The Centers for Medicare & Medicaid Services ("CMS") released the latest edition of its Medicare Compliance Newsletter. The publication contains examples of Medicare billing errors and guidance on how to avoid such mistakes. The newsletter may be viewed here.

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May 16, 2011

A Route to Quality Medicare Reform - Insight by CMS' Donald Berwick

It is often instructive to review the thinking of health care decision-makers as a tool to acquire insight on the direction of health care policy. In this regard, Dr. Donald Berwick, the administrator of the Centers for Medicare & Medicaid Services ("CMS"), recently authored an Op-Ed in the Wall Street Journal outlining his view of Medicare reform. In light of the fluidity of the debate on the direction of the federal health care program, we, at The Health Law Partners, have summarized the central principles in Dr. Berwick's piece. While Dr. Berwick's perspective is, by no means, devoid of the partisanship that has become so endemic in the health care debate, his article nonetheless demonstrates that the Administration intends to pursue the reform path enacted with the passage of the Patient Protection and Affordable Care Act ("PPACA") in 2010. It is noteworthy that, subsequent to the publication of this article, Dr. Berwick has acknowledged that the negative reception of the proposed ACO rules by the provider community inevitably will result in modifications to those rules.

Medicare reform may be a crucial building block toward a brighter economic future for the country because, among other benefits, successful reform could reduce the country's deficit and debt. The task, however, requires balancing the growing costs of Medicare with the enormous financial burden medical costs impose on families. A plan proposed by Republicans in Congress would shift the costs of healthcare to seniors and the disabled. The plan would eliminate guaranteed Medicare benefits, limit the choice of doctors and hospitals, and burden the average senior with $6,400 of insurance costs. Although Medicare spending might be reduced as a result, the overall cost of healthcare would continue to climb under this plan.

In the alternative, the Medicare system could follow the example set by other fields (e.g., the computer industry) and focus on lowering costs and improving efficiency. The groundwork for such an approach was laid out by the PPACA. Up to $1 billion will be invested by the Partnership for Patients to aid healthcare providers in improving the safety of care. This partnership will not only elevate the quality of health care delivery, but will reduce Medicare costs by an estimated $50 million. In another effort, CMS recently introduced a Proposed Rule for Accountable Care Organizations ("ACOs"). Under this rule, ACOs will coordinate patient care and facilitate better communication among providers to reduce duplicate tests and procedures which should result in decreased healthcare costs. According to Dr. Berwick, improving the quality of healthcare may prove to be the best route to successful Medicare reform and a brighter economic future for the country.

Continue reading "A Route to Quality Medicare Reform - Insight by CMS' Donald Berwick" »

May 12, 2011

Social Media for Healthcare Providers

Healthcare providers are more frequently utilizing social media to market their practices and to dispense health information. In order to protect the patient-physician relationship and ensure a continued positive internet presence for healthcare providers, the American Medical Association ("AMA") adopted recommendations for physician use of social media. The guidelines recommend that physicians utilize privacy settings on social media websites and develop appropriate mechanisms to monitor their internet presence for accuracy and appropriateness. The AMA also suggests that healthcare providers maintain proper boundaries when interacting with patients on the internet and exercise good faith efforts to protect their clients' privacy and confidentiality. Finally, the AMA cautions physicians to be mindful of the potential negative implications arising from the use of social media on their reputations and professional careers.

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May 11, 2011

Erroneous Medicare Payments for Radiology Services in Hospital Emergency Departments Exceed the $30 Million Mark in 2008

Based on a recent report from the Office of Inspector General ("OIG"), Medicare permitted $38 million of improper claims for interpretation and reports of radiology services based on insufficient documentation in hospital emergency departments in 2008. This includes a 19 percent erroneous allowance of claims for interpretation and reports for magnetic resonance imaging ("MRI") and computed tomography ("CT") and a 14 percent allowance of similar x-ray claims.

Lack of physicians' documented orders (12 percent of MRI/CT claims, 8.6 percent of x-ray claims) and documentation verifying that interpretation and reports were performed (12 percent of MRI/CT claims, 8.2 percent of x-ray claims) were among the problems encountered. In some instances, overlapping documentation errors (5 percent of MRI/CT claims, 3 percent of x-ray claims) were found. Interpretation and reports claims were also allowed after the patients left the emergency department in a significant number of cases (12 percent of CT and MRI claims, 16 percent of x-ray claims).

In an effort to prevent the erroneous Medicare expenditure, the OIG recommended that the Centers for Medicare and Medicaid Services ("CMS") educate healthcare providers regarding the documentation maintenance requirement for submitted claims, create a consistent policy that services of interpretation be contemporaneous with diagnosis or treatment or classify situations in which noncontemporaneous services are beneficial, and take proper action for wrongful claims identified in the report.

According to the OIG Office of External Affairs, CMS agreed with the first and third recommendations but rejected the uniform policy suggestion.

The OIG report may be viewed here.

Continue reading "Erroneous Medicare Payments for Radiology Services in Hospital Emergency Departments Exceed the $30 Million Mark in 2008" »

May 10, 2011

CMS' RAC Recoveries Accelerate

The Centers for Medicare and Medicaid Services ("CMS") overpayment recovery through its Recovery Audit Contractor ("RAC") program is on the rise. CMS recovered in excess of $313 million in Medicare overpayments since October 2009, and almost half of that amount ($162 million) was collected during the first three months of 2011. In comparison, only $75.8 million was collected from October to December 2010, and $75.4 million was recovered from October 2009 to September 2010. The majority of overpayments alleged during FY 2010 through March 2011 involved incorrect coding. The CMS report may be viewed here.

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May 9, 2011

Hospice Wage Index to Rise in FY 2012 under CMS' Proposed Rule

The Centers for Medicare & Medicaid Services ("CMS") recently proposed a rule regarding the hospice wage index for the fiscal year ("FY") 2012 ("Proposed Rule"). The rule would result in a 2.3 percent increase in Medicare payments to hospices for FY 2012 and implement a new quality reporting system as required by the Affordable Care Act.

In addition, the Proposed Rule includes key changes for the hospice cap calculations (based upon the recent lawsuits successfully challenging the hospice cap calculation methodologies) and revisions to the hospice face-to-face encounter requirements.

Under federal law, CMS must impose limits on the aggregate Medicare payments received yearly by hospice organizations. Beginning with the 2012 cap year, the Proposed Rule would modify how the cap is calculated by changing the way hospice patients are counted. The law would also allow for retroactive calculations under the new methodology in some circumstances. Hospice providers would be permitted to elect to continue using the current counting method under the Proposed Rule. See also Ruling CMS-1355-R, mirroring provisions of the Proposed Rule.

Lastly, the Proposed Rule includes revisions to the hospice face-to-face requirement. Under the Proposed Rule, the hospice physician who performs the face-to-face encounter would not necessarily be the same physician who certifies the patient's terminal illness.

The Proposed Rule may be viewed here. Comments on the rule will be accepted by CMS until June 27, 2011.

Continue reading "Hospice Wage Index to Rise in FY 2012 under CMS' Proposed Rule" »

May 9, 2011

CMS Issues Final Rule for Credentialing for Telemedicine Services

On May 5, the Centers for Medicare and Medicaid Services (CMS) published in the Federal Register its final rule for telemedicine credentialing and privileging for hospitals and critical access hospitals (CAHs). Beginning July 5, 2011, hospitals and CAHs, will have the option of proxy credentialing distant-site physicians and practitioners pursuant to a written agreement. Currently, hospitals and CAHs must credential distant-site physicians and practitioners in the same manner as their on-site staff.

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May 5, 2011

OIG Report: Review of Medicaid High-Dollar Payments for Inpatient Services in Michigan from January 1, 2007 Through March 31, 2009

The Office of Inspector General (OIG) released a report in April entitled Review of Medicaid High-Dollar Payments for Inpatient Services in Michigan from January 1, 2007 Through March 31, 2009 that reviewed whether certain high-dollar Medicaid payments (defined as payments of $200,000 or more) "made to hospitals for inpatient services were based on accurate charges and adequate documentation." The OIG audit of 204 high-dollar payments revealed that 25% of the payments made were based on inaccurate charges or inaccurate documentation, consisting of 52 overpayments totaling $641,184 and one underpayment totaling $682,537. 151 payments were based on accurate charges and documentation. As a result, the OIG recommended the Michigan Department of Community Health monitor Medicaid expenditures more closely by:

• Using the results of the OIG audit in its provider education activities related to data entry procedures and proper documentation; and


• Periodically review high-dollar Medicaid payments to hospitals.

Continue reading "OIG Report: Review of Medicaid High-Dollar Payments for Inpatient Services in Michigan from January 1, 2007 Through March 31, 2009" »

May 3, 2011

ASA Posts FAQs on Accountable Care Organizations (ACOs)


In an effort to better educate the anesthesia community with regard to the impact of Accountable Care Organizations ("ACOs") on the specialty, the ASA Ad Hoc Task Force on ACOs has been carefully analyzing the March 31, 2011 ACO proposed regulations. As a preliminary step, at the end of April 2011, the ASA released 21 FAQs relative to ACOs. The ASA also plans to continually update the FAQs as new information emerges. The ASA FAQs can be accessed here.

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May 1, 2011

Signature Requirements Fact Sheet Now Available

Our attorneys are seeing an increase in Medicare claim denials resulting from the lack of valid practitioner signatures. A new publication from the Medicare Learning Network® titled "Comprehensive Error Rate Testing (CERT) Signature Requirements" provides the guidance necessary to avoid such denials. The fact sheet aims to educate health care providers on signature and supporting documentation requirements relating to claims submitted to Medicare. The fact sheet may be downloaded here.

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