Delay in Return of Overpayments Leads to False Claims Act Suit

July 23, 2014 By

The generally accepted wisdom is to move expeditiously to investigate and return federal health care program overpayments once you become aware of them.  Now we know the potential downside of failing to do so even when all overpayments are eventually returned.

Late last month the United States Attorney’s Office filed a false claims act complaint in intervention against Continuum Health Partners.  The complaint seeks treble damages, civil penalties and costs.

Relevant facts:

  • From early 2009 to late 2010, due to a computer glitch, defendant submitted improper claims to Medicaid for additional payments for services
  • September 2010  New York state comptroller notified defendant of a small number of these claims improperly billed to and paid by Medicaid
  • February 2011 defendant became aware of much larger batch of improper claims totally over $1,000,000 that may have been submitted to and paid by Medicaid
  • Defendant repaid improper claims in dribs and drabs eventually repaying everything by March 2013 – 300 improper claims were repaid only after the Government issued a Civil Investigative Demand to defendant regarding payment of these claims in June 2012

“Continuum thus intentionally or recklessly failed to take the necessary steps to timely identify the claims affected by the software issue or to timely reimburse DOH for those affected claims that resulted in overbilling to Medicaid.”

For more information about this case or for assistance with reporting overpayments please contact Greg Montgomery.

Filed Under: Medicaid, Overpayment

Medicare EHR Incentive Program Deadline Extended

February 12, 2014 By

CMS announced last week that it has extended the registration and attestation deadline for the Medicare EHR Incentive Programs to March 31, 2014 for eligible professionals.  This month long extension will aid eligible professionals in compiling their meaningful use data from 2013 and filling out the registration process (which can be time consuming).

In addition, CMS is offering to assist eligible hospitals who experienced difficulty with their attestation.  This assistance will allow eligible hospitals to submit their attestation retroactively to avoid the 2015 payment adjustment.  To do so, hospitals must contact CMS by March 15, 2014.  Eligible hospitals are instructed to contact CMS at EH2013Extension@Provider-Resources.com  no later than 11:59 PM EST on Marfch 15, 2014.

  1. Type “EH 2013 EXTENSION” in the subject line of the email note
  2. Include the following information:
    • CCN;
    • hospital name;
    • contact person name;
    • contact person email; and
    • contact person phone number.

CMS will then contact the designated individual to discuss the retroactive extension.

As a reminder, these extensions are for the Medicare EHR Incentive Program only, and do not apply to the Medicaid EHR Incentive Program.  In Washington, the deadline to apply for the Medicaid EHR Incentive Program remains February 28, 2014.

For more information about the EHR Incentive Programs or meaningful use generally please contact Elana Zana.

Filed Under: EHR, Health Information Technology, HITECH, Incentive Payments, Meaningful Use, Medicaid, Medicare Tagged With: ,

Washington Medicaid EHR Incentive Program Webinar

February 11, 2014 By

The Washington State Health Care Authority announced that it will be hosting a webinar to aid in the registration for the Medicaid EHR Incentive Program.  This will help providers who are registering and attesting to both adopt, implement and upgrade and meaningful use.

Topics Include: Navigating the WA ST EHR Attestation Application-eMIPP (MU Stage 1)

  • Attestation
  • Navigating the eMIPP application
  • How to get paid correctly
  • Live Q & A after presentation

To register click here.

The state of Washington has also published helpful tools for registration, including user guides and state specific worksheets (for example the .95 multiplier).

These webinars are very informative and it is recommended that all first time applicants (and those applicants that need a refresher) attend.

Also, note that though the Medicare EHR Incentive Program has extended registration through March 31, 2014, the Washington Medicaid EHR Incentive Program requires registration and attestation by February 28, 2014.

For assistance with registration and attestation for the Medicare or Medicaid EHR Incentive Program please contact Elana Zana.

 

Filed Under: EHR, Health Information Technology, HITECH, Incentive Payments, Meaningful Use, Medicaid, Washington Tagged With: , ,

OIG Okays Provision of Free Services to Uninsured and Underinsured Patients

October 21, 2013 By

On October 15, 2013, the Office of Inspector General (OIG) released an Advisory Opinion concerning a community health services organization’s provision of free dental care to financially needy uninsured and underinsured patients that are not covered by Medicaid.

The organization was concerned that the free services violated two aspects of the Medicaid law: (1) the Social Security Act prohibits providers from billing Medicaid charges for items or services substantially in excess of the provider’s “usual charges,” and (2) the Anti-Kickback Statute prohibits providers from offering remuneration to Medicaid patients to induce them to receive services from the provider.

In the Advisory Opinion, the OIG stated that when a provider calculates its “usual charges,” it need not consider free or substantially reduced charges to uninsured or underinsured patients with financial need.  Therefore, the OIG would not seek to exclude a provider from the Medicaid program for providing discounts to financially needy uninsured and underinsured patients.

The OIG also stated that the organization’s provision of free services to financially needy uninsured or underinsured patients does not violate the Anti-Kickback Statute because the free services will not be provided to Medicaid patients.  The Anti-Kickback Statute would only be implicated if a provider used the free services as a means to induce Medicaid patients to order additional services that could be billed to the Medicaid program.

The bottom line is that providers may offer free services to uninsured or underinsured patients with financial hardship.  With that said, it is critical that providers have uniform eligibility criteria to determine whether such patients actually are financially needy.  In separate guidance released in 2004  the OIG outlined factors that providers should consider in determining financial need, including:

  • The local cost of living;
  • A patient’s income, assets, and expenses;
  • A patient’s family size; and
  • The scope and extent of a patient’s medical bills.

By applying these factors uniformly at all times, providers can ensure that their provision of free or discounted services meets OIG requirements.

If you would like more information please contact Casey Moriarty.

Filed Under: Anti-Kickback/Stark, Compliance, Medicaid, OIG Tagged With: , ,

Former Hospital CFO Blows Whistle On Effort To Buy Medicaid Referrals

August 1, 2013 By

Georgia recently joined a false claims act lawsuit alleging that Healthcare Management Associates, Inc. and Tenet Healthcare Corporation hospitals have been improperly paying for referrals for many years.  According to the complaint, the hospitals paid interpreter, management and other service fees to clinics in exchange for which the clinics referred pregnant, undocumented women to the hospitals for delivery and post-delivery care paid for, in part, from Medicaid funds available for emergency deliveries and post-delivery care of the newborn.  Georgia seeks to recover three times the dollar amount of false Medicaid claims plus civil penalties of between $11,000 and $15,000 for each false claim.

Tenet issued a statement to the effect that the agreements were legitimate and the hospitals were providing necessary healthcare services to women in underserved Hispanic communities served by the hospitals.  According to Tenet the services were designed to increase the likelihood of a safe birth and healthy baby.

The lawsuit was filed by Ralph Williams who served briefly as a CFO for one of the HMA hospitals before he was fired.  Among other things, the Complaint alleges:

  • Hospitals paid the clinics up to $15,000 to $20,000 a month for referrals
  • One hospital projected a 56.2% rate of return on its investment in a clinic’s “Hispanic Maternity Program”.
  • One clinic billed a hospital for in excess of 13 hours a day of interpreter services during June and July 2009 but Williams was unable to confirm that any clinic employee was on the hospital campus at any time during this period

Georgia brought its claims under its state false claims act based on the federal false claims act.  Washington has a virtually identical act applicable to Medicaid payments.

For more information please contact Greg Montgomery.

 

Filed Under: Compliance, False Claims Act, Medicaid

Private Payors Attempt to Apply 2% Sequester to Providers – CMS Says “No” (Mostly)

July 23, 2013 By

The recent sequester of federal spending triggered automatic, across the board cuts in the federal budget.  Included in these cuts is a 2% reduction in Medicare reimbursement to providers.  The cuts went into effect on April 1, 2013.

In the aftermath of sequestration, many private health insurance companies have attempted to reduce their reimbursement to providers for services provided to non-Medicare patients by the same 2% amount.  These insurers argue that the reimbursement rates in their contracts with providers are based on Medicare payment methodologies; therefore, they are entitled to implement the 2% cuts.  The truth is a bit more complicated.

According to Medicaid Administrative Contractors like Noridian the 2% payment reduction under sequestration is applied to claims only after determining the final  Medicare payment.   All fee schedules, prices, etc., are unchanged by sequestration – it is only the final payment amount that is reduced.

Therefore, if an insurer’s contract with a provider states that the insurer’s reimbursement is based on Medicare fee schedules, the insurer may have a difficult time arguing that it has a contractual right to reduce reimbursement by 2% based on sequestration.

Additionally, in a memo dated May 1, 2013, the Centers for Medicare and Medicaid Services addressed the impact of the sequestration cuts on Medicare Advantage Organizations (“MAOs”) and Medicare Part D sponsors.  According to CMS, the 2% cuts apply to reimbursement received by MAOs and Part D Sponsors, but such organizations can not pass on the cuts to contracted providers.   One exception to this rule is if the contract between the provider and the MAO or Part D sponsor has a specific provision that allows the organization to pass on sequestration cuts to providers.

Providers should carefully track their reimbursement rates to determine if private insurers are improperly taking advantage of sequestration’s Medicare cuts to lower their contractually required payments to providers.  If you would like assistance in protesting any private payor sequester related cuts please contact Casey Moriarty or Don Black.

Filed Under: Medicaid, Medicare Tagged With: , ,

CA Surgeon Stripped of Medicaid Funding for Failure to Treat HIV Positive Patient

July 22, 2013 By

On July 18th, the U.S. Department of Health and Human Services announced that a California surgeon who refused to treat a patient based solely on the patient’s condition as HIV positive would lose Medicaid funding.  The surgeon had refused to perform necessary back injury and a resulting investigation by the HHS Office of Civil Rights found the surgeon had discriminated against the patient in violation of federal laws.  The violation ultimately resulted in an action to ensure compliance with federal civil rights laws and eventually the surgeon’s loss of the federal funding.

The determination underscores the need for health care providers to make best efforts to ensure patients and prospective patients who fall within protected classes receive the same treatment and standards of care as any other patient.  Failing to do so can jeopardize federal funding and also expose the provider to a range of potential claims for violations of federal and state workplace laws.

The fundamental steps to help avoid claims and liability are:

●             Have effective policies:  Providers should have written policies prohibiting discrimination and harassment.  Having an effective policy notifies all employees that discrimination and harassment will not be tolerated, and helps set a tone for conduct in the workplace.

●             Train up supervisors and staff:  All supervisors and staff should be fully aware of workplace discrimination and harassment laws and how to respond to potential problems.  Training helps prevent claims, allows problems to be identified and addressed early on, and provides vital potential evidence that the employer took reasonable steps to prevent improper behavior.

●             Familiarize yourself and staff with Medicaid rules:  Washington State Medicaid provider requirements obligate participating providers to provide all services without discriminating on the grounds of “race, creed, color, age, sex, sexual orientation, religion, national origin, marital status, the presence of any sensory, mental or physical handicap, or the use of a trained dog guide or service animal by a person with a disability.”  In addition, WA Medicaid allows termination of a provider relationship for discriminating in furnishing health care services as prohibited by federal statute.

For more information regarding avoiding such liability please contact Patrick Pearce.

Filed Under: Compliance, Medicaid Tagged With: ,

OIG Launches New Online Submission Process for the Self-Disclosure Protocol

July 9, 2013 By

On July 8th, the Office of Inspector General (OIG) launched a new online submission process for the Self-Disclosure Protocol (SDP).  The SDP allows health care providers to voluntarily identify, disclose, and resolve instances of potential fraud involving federal health care programs, including Medicare and Medicaid.   The OIG has stated that individuals and entities that utilize the SDP will pay a lower amount of damages for violations than would normally be required in resolving a government-initiated investigation.

You can access the online submission process here.

The OIG hopes that the online submission tool for the SDP will streamline the process for providers that want to resolve violations without the time and expense of a government-directed investigation.  With that said, we suggest that providers have an attorney analyze any potential SDP issues prior to completing the online form.  As always, the health law attorneys at OMW are happy to help.

For more information about the SDP online submission process please contact Casey Moriarty.

Filed Under: Compliance, Medicaid, Medicare, OIG, Overpayment Tagged With: , , ,

Medicaid Disallows Reimbursement, Requires Reporting for Provider Preventable Conditions

June 28, 2013 By

Starting  July 1, 2013, the Washington Medicaid program will not pay a provider for the health care costs of treating conditions that the provider could have prevented.  The rule, WAC 182-502-0022, contains a long list of such conditions and adds a few more acronyms to health care speak, including:

(1) PPC – provider preventable conditions that include hospital and non-hospital acquired conditions;

(2) OPPC – other provider preventable conditions that are a PPC subset of conditions identified in WAC 246-302-030, and;

(3) HCAC – health care acquired conditions that are also a PPC subset occurring in an inpatient hospital setting.

Providers, including inpatient hospitals, must report any PPC to the Health Care Authority even if there is no intent to bill for services related to the PPC.  Health care professionals or designees responsible for or associated with a PPC involving a Medicaid patient must notify the Health Care Authority within forty-five (45) calendar days of confirming the PPC.

A similar reporting requirement applies to hospitals for OPPC.  And, of course, Medicaid patients are not liable for payment of an item related to a HCAC or an OPPC and must not be billed for any item or service related to a PPC.

For information about this new rule or Medicaid reimbursements please contact Greg Montgomery.

Filed Under: Compliance, Hospitals, Medicaid, Washington Tagged With: ,

EHR Incentive Program Meaningful Use Stage 1 Updated

June 11, 2013 By

CMS has recently published a tip sheet consolidating for eligible professionals and hospitals the revisions made to the Stage 1 meaningful use measures that are effective in 2013.  These changes modify the following meaningful use objectives:

  • Public Health Reporting Objectives
  • Electronic Exchange of Key Clinical Information
  • Computerized Physician Order Entry (CPOE)
  • Record and Chart Changes in Vital Signs
  • Electronic Prescribing
  • Electronic Copy of and Electronic Access to Health Information (changes only applicable starting in 2014)

Some of the changes in the measures are required, while others are optional for 2013 but become required for 2014.  To view the Stage 1 changes tip sheet click here.

At the same time CMS also revised its Stage 1 Meaningful Use table of contents and tip sheets for each objective/measure for eligible professionals and hospitals/CAH.

If you have questions regarding the Medicare or Medicaid EHR Incentive Programs or meaningful use generally please contact Elana Zana.

Filed Under: EHR, Health Information Technology, HITECH, Hospitals, Medicaid, Medicare Tagged With: ,
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