Hospices:
1. Due to the high number of hospices that were overdue in their certifications and due to the almost 50% of hospices having health deficiencies, the OIG recommends that CMS adopt statutory or regulatory changes to establish requirements for the frequency of certifications for hospice performance and for enforcing the remedies for a hospice's poor performance.
2. The OIG recommends that CMS strengthens its monitoring practices of hospice claims to ensure that they are properly submitted.
Home Health Agencies:
1. Due to the high levels of medically unnecessary care and fraudulent billing, the OIG recommends that CMS revise its regulations to require physicians to examine Medicare beneficiaries prior to ordering home health services.
2. For those HHAs performing poorly, the OIG recommends that CMS adopt and impose sanctions (besides termination from Medicare) to improve the quality of care.
Laboratory and Imaging Services:
1. To prevent over-utilization of laboratory testing, the OIG recommends that CMS reinstate beneficiary co-insurance and deductibles for lab tests.
2. The OIG recommends that CMS pursue legislation to set accurate and reasonable payment rates for lab tests as the carrier rates for nearly all lab tests varied.
3. Because few counties account for a large percentage of the Part B spending on ultrasound and because 20% of claims raised concern about whether or not they were appropriate, OIG recommends that CMS continue to monitor ultrasound claims to reduce Medicare's vulnerability to questionable ultrasound claims.
Again, these are merely recommendations and have not been implemented. However, they are useful in seeing where the OIG is looking to make changes and what kinds of changes we can expect from CMS in the future. We will continue to keep you apprised of any updates and regulatory changes as they develop.
OCR intended to issue new HIPAA regulations to meet the HITECH requirements prior to enforcement, and says it still hopes to issue the regs soon enough that a final rule could be issued during 2010. OCR also has not explicitly stated that it will be delaying enforcement--likely to encourage regulated entities to pursue good faith compliance efforts in the meanwhile--though spokesman Mike Robinson has been quoted saying, "It is not correct to characterize an 'effective date' for a legislative provision (which is what the Feb.17, 2010, date is for certain provisions of the HITECH Act) as the 'enforcement date.'"
OCR has also been clear that there will be no delay in enforcing the breach notification rule, which was effective last September.
]]> For more information regarding the HITECH Act and/or HIPAA, please contact Abby Pendleton, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510.]]>- On January 22, 2010, the St. Mary Medical Center of Long Beach, California paid nearly $500,000 for allegedly violating the CMP statute for paying remunerations in the form of administrative services and leased space.
- On February 2, 2010, Maria Aloise, the president and owner of Atenas Medical Equipment, Inc. (Atenas), was convicted on ten counts of healthcare fraud. Between the summer of 2006 and spring of 2007, Aloise submitted nearly $1.5 million in fraudulent claims to Medicare seeking reimbursement for DMEs by using forged prescriptions, certificates of medical necessity, and delivery receipts.
- On February 4, 2010, Yasmanny Benavides of Lacary Medical Services Equipment, Inc. (Lacary Medical) of Miami, Florida was found guilty by a federal jury for committing healthcare fraud and conspiracy to commit healthcare fraud. Lacary Medical provides durable medical equipment (DME) to Medicare beneficiaries. Between July and December of 2003, Lacary Medical submitted almost $5 million worth of false and fraudulent claims seeking reimbursement for DME items and services not prescribed by physicians. Further, Benavides controlled and operated Lily Orthopedic, Inc. (Lily Orthopedic), which also provided DMEs to Medicare beneficiaries in Miami. Between December 2003 and August 2004, Benavides and her co-conspirator Reinaldo Guerro, on behalf of Lily Orthopedic, caused for almost $15 million in false and fraudulent claims to be submitted to Medicare seeking reimbursement for DME items and services not prescribed by physicians.
- On February 8, 2010, Garden State Imaging (GSI) of New Jersey paid over $80,000 for allegedly violating the CMP statute for verbally agreeing to split the proceeds of mobile diagnostic imaging services provided to patients at a medical center between GSI and the owners of the medical center.
- On February 16, 2010, Dr. Harvey Montijo of Florida paid $650,000 for allegedly violating the CMP statute for soliciting and receiving remunerations "in the form of consulting payments from two medical device manufacturers in exchange for using their orthopedic hip and knee products.
This should be a reminder to everyone that the OIG continues to highly enforce and scrutinize healthcare professionals for violations of federal statutes. Please be sure to revisit your compliance programs and polices to ensure that they align with the most recent laws.
This certification is required by CMS for providers to receive payments in an incentive program created by CMS in January for the "meaningful use" of EHR technology.
ONC hopes to issue the final rule regarding temporary certification by the time that HHS issues final rules regarding meaningful use standards and certification criteria. Both are expected this fall.
The permanent certification program, with a longer comment period, will later replace the temporary program.
]]> For more information, contact Jessica L. Gustafson, Esq. at (248) 996-8510.]]>This week, CMS issued additional guidance regarding billing for those services that would previously been coded as consultations. This guidance includes a Questions and Answers on Reporting Physician Consultation Services and Revisions to Consultation Services Payment Policy.
The "Questions and Answers" document includes a wide range of information, including how to bill for services that don't fit classification by a CPT E/M code, how this change affects the definition of transfer of care, how to define new versus existing patients, and whether providers can bill patients for services denied by Medicare for the reason that the incorrect CPT code was billed.
]]> For more information, contact Abby Pendleton, Esq. at (248) 996-8510.]]>If an HHA submitted a CMS-855A ownership change that was received by the Medicare contractor prior to January 1, 2010, the contractor will not apply the 36-month policy found in 42 CFR 424.550(b). As such, if the contractor received a change of ownership or change of information which resulted in a change of owners (e.g., asset sale/stock transfer) prior to January 1, 2010 and the HHA was adversely affected by the contractor's application of the policies found in 424.550(b), the HHA should send a letter to the contractor formally requesting that its ownership change be processed. This letter should include:]]> For more information, please contact Robert Iwrey, Esq. or Adrienne Dresevic, Esq. at (248) 996-8510.]]>
*The seller's name, taxpayer identification number, national provider identifier, and the date on which the ownership change was submitted to the contractor.
Contractors will process these pre-January 1, 2010 Medicare enrollment applications under the policies in place prior to January 1, 2010.
While we always encourage providers and suppliers to discuss and resolve enrollment issues with the Medicare contractor, if a HHA encounters a processing problem, we will review it.
The Health Law Partners, P.C. ("The HLP") will continue to keep you apprised as updates occur.
]]> For more information, please call Adrienne Dresevic, Esq., Carey Kalmowitz, Esq., or Jessica Gustafson, Esq. at (248) 996-8510 or visit The HLP's website.]]>However, because a vote did not occur prior to the expiration of the physician payment freeze existing in February, triggering the 21% reduction in Medicare reimbursement beginning March 1, if payments were to be made under the cuts, and if the cuts are subsequently repealed, physicians would have to file new claims to recoup lost amounts, creating an administrative burden to both the provider community and Medicare claims processors. According to a recent AP report (3/2, Alonso-Zalvidar), the Obama Administration expects "the Senate will act soon to stave off the cuts," and has "directed Medicare billing contractors to hold off processing claims for 10 business days." Jonathan Blum, director of CMS' Center for Medicare Management, has stated that, CMS' "No. 1 goal is to avoid disrupting payments to physicians during this time."
The HLP will continue to keep you apprised of future developments.
]]> For more information, please contact Adrienne Dresevic, Esq. or Carey F. Kalmowitz, Esq. at (248) 996-8510 or visit The HLP website.]]>