ICD-10, Two-Midnight Rule, RAC Audits, SGR Delayed

March 31, 2014 By

The Senate passed this evening the “Protecting Access to Medicare Act of 2014“, which creates a 12 month delay for pending Medicare cuts pursuant to Medicare’s sustainable growth rate (SGR) payment formula. This bill avoids the 24% Medicare cuts physicians were facing starting on April 1st (this will be the 17th delay of the SGR).  Another significant component of the Act includes the delay in ICD-10 implementation, until at least October 1, 2015.

In addition to these significant postponements, the Act also delays until March 2015 the implementation of the “two-midnight” rule and the recovery audits of unnecessary claims.

Filed Under: Medicare Tagged With: , , ,

Increased OIG Focus on Kwashiorkor Claims

March 10, 2014 By

In its recently released 2014 Work Plan, the OIG has announced that it will investigate hospital billing for Kwashiorkor.  Kwashiorkor is a form of severe protein malnutrition that generally affects children living in tropical and subtropical parts of the world during periods of famine or insufficient food supply. This syndrome is characterized by retarded growth, changes in skin and hair pigment, edema, and pathologic changes in the liver.

This extreme form of malnutrition, however, is very rare in the United States, which is why Kwashiorkor billing at hospitals is a target of the OIG. Because a diagnosis of Kwashiorkor on a claim also substantially increases a hospital’s reimbursement from Medicare, the OIG stated it would review Medicare payments based on Kwashiorkor claims to determine whether the diagnosis is adequately supported by documentation in the medical record.

Recently, for example, the OIG found that Wellspan York Hospital incorrectly billed Medicare inpatient claims with Kwashiorkor, resulting in overpayments of $204,000 over two years. The hospital attributed the errors to a misinterpretation of the coding guidelines for malnutrition because of a lack of clarity in the guidance.  Other hospitals, like Mercy Medical Center, have attributed Kwashiorkor errors to encoder software which incorrectly assign diagnoses of protein malnutrition to ICD-9-CM 260 (Kwashiorkor).

In light of the increased OIG focus on Kwashiorkor claims, hospitals should strengthen its controls to ensure that coding software and staff comply with Medicare billing requirements. Additionally, if there is in fact a Kwashiorkor diagnosis, hospitals should ensure that the medical record (e.g. discharge summary) substantiates the use of a Kwashiorkor diagnosis code.

For additional information regarding Kwashiorkor billing or the 2014 OIG Workplan please contact Adam Snyder or Jefferson Lin.

 

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

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: ,

OIG’s Report Highlights Enforcement Successes in 2014

December 30, 2013 By

The Office of Inspector General (OIG) recently published its Semiannual Report to the U.S. Congress. This Report summarizes the OIG’s enforcement activities from March, 2013 to September, 2013.

The Report highlights the OIG’s significant efforts in the enforcement of fraud and abuse laws.  For fiscal year (FY) 2013, the OIG is expecting total recoveries of $5.8 billion, consisting of nearly $850 million in audit receivables and about $5 billion in investigative receivables.

Additionally, for FY 2013, the OIG brought 960 criminal and 472 civil actions against individuals or entities that engaged in health-care-related offenses.   Compared with FY 2012, the number of criminal actions in FY 2013 rose by 182 cases, and the number of civil cases rose by 105 cases.

According to the OIG, these enforcement results are partially due to the successes of the Health Care Fraud Prevention and Action Team (HEAT).  HEAT is a partnership between Federal, State, and local law enforcement to identify fraudulent health care schemes.   The program combines sophisticated data analysis and investigative intelligence to move quickly against violators of fraud and abuse laws such as the False Claims Act.

There is no doubt that the OIG’s accomplishments in FY 2013 will motivate investigators to root out more health care fraud and overpayment schemes in FY 2014.  To avoid a costly investigation and potential prosecution, providers should take extra care that they are following Medicare and Medicaid laws and properly billing for services rendered to patients.

You can read the entire OIG Semiannual Report here.

For more information about health care fraud and abuse laws, please contact Casey Moriarty.

Filed Under: Compliance, Medicare, OIG

Want to Get Paid for Inpatient Admissions? Follow CMS Certification Requirements.

September 11, 2013 By

In its final regulations for the 2014 Inpatient Prospective Patient System, the Centers for Medicare and Medicaid Services emphasized the importance of physician certifications. Under the regulations, Medicare will only pay for an inpatient admission if a physician certifies the medical necessity for the stay. The first piece of such certification is for the physician to complete an inpatient order when he or she expects that the patient will require a stay that crosses at least two midnights.

In addition to the order, physician certification for the inpatient stay also must include the following information:

  • Certification that the inpatient services were ordered in accordance with the Medicare regulations governing the order;
  • The reasons for either: (1) hospitalization of the patient for inpatient medical treatment or medically required inpatient diagnostic study; or (2) special or unusual services for cost outlier cases under the inpatient prospective payment system;
  • The estimated time the beneficiary requires or required in the hospital;
  • The plans for post hospital care, if appropriate, and as provided in the Medicare regulations; and
  • For Critical Access Hospitals (CAHs), the physician must certify that the patient will reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH.

Physicians must complete all certification for the inpatient stay prior to patient discharge. In order to help ensure Medicare payment for inpatient admissions, hospitals should educate physicians on the importance of certifications, and provide assistance to physicians in gathering necessary documentation.

CMS has prepared a guidance document about hospital inpatient admission orders and certification. For more information about inpatient admission certification, please contact Casey Moriarty.

Filed Under: Medicare Tagged With: , ,

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: , ,

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: , , ,

Tacoma Physician Group Pays $14.5 Million To Settle Medicare Over-Billing Allegations

July 7, 2013 By

Sound Physicians, a Tacoma-based, national physician group that employs more than 700 hospitalists, paid $14.5 million to settle claims that it over-billed Medicare.  Former Sound Physicians’ employee Craig Thomas filed a whistleblower lawsuit under the qui tam provisions of the False Claims Act.  The lawsuit alleges that the company knowingly submitted inflated claims where documentation did not support the level of service billed.  Qui tam relators are generally entitled to 15 – 30 percent of the government’s recovery; Thomas will receive $2.7 million, or approximately 18.6%, of the $14.5 million settlement.  The settlement represents one of several recent settlements between the government and health care providers under the False Claims Act.

To read the Department of Justice press release click here.

To read qui tam Relator Craig Thomas’ statement click here.

For more information about government investigations, Medicare compliance, or the False Claims Act, please contact Adam Snyder.

Filed Under: Compliance, False Claims Act, Medicare, Washington Tagged With: ,

Deadline for Avoiding the eRx Payment Adjustment Approaching at End of the Month

June 18, 2013 By

The June 30, 2013 deadline to participate in the Electronic Prescribing Incentive Program (“eRx”) and avoid the 2014 eRx payment adjustment is fast approaching.  Eligible Professionals (“EP’) looking to avoid the 2% payment adjustment in 2014 (payment adjustment means that EPs will only receive 98% of his/her Medicare Part B Physician Fee Schedule amount for covered professional services),  must either participate in the eRx program, fall under the exclusion criteria, or file for a hardship exemption by June 30, 2013.  Information regarding participation in the eRx program can be found here.

Exclusions

The following EPs will not be subject to the 2014 eRx payment adjustment if any one of the following applies:

  1. EP successfully participates in the eRx program during the 2012 12-month reporting period (1/1/12 – 12/31/12).
  2. EP is not an MD, DO, podiatrist, Nurse Practitioner or Physician Assistant.
  3. EP does not have at least 100 Medicare Part B PFS cases containing the encounter code in the measure’s denominator between 1/1/2013-6/30/2013.
  4. EP does not have 10% or more of their charges as Medicare Part B PFS allowable charges for encounter codes in the measure’s denominator during between 1/1/2013-6/30/2013.
  5. EP does not have prescribing privileges and reported GT8644 on a payable Medicare Part B service on at least once on a claim between 1/1/2013-6/30/2013.
  6. EP submits at least 10 eRx and reports the G-code G8553 between 1/1/2013-6/30/2013.
  7. EP achieves Meaningful Use under the Medicare or Medicaid EHR Incentive Program during 2012 or between 1/1/2013-6/30/2013 (and attests before 6/30/2013).
  8. EP demonstrates by registration of their intent to participate in the Medicare or Medicaid EHR Incentive Program during the 1/1/13-6/30/13 reporting period.
  9. EP submits one hardship exemption G-code via any payable Medicare Part B PFS claim between 1/1/2013-6/30/2013.
  10. EP request and CMS approves a hardship exemption.

Hardship Exemptions

EPs may be exempted from the payment adjustment if it is determined that compliance would result in a significant hardship.  Hardship exemptions must be submitted by June 30, 2013.  Such exemptions include:

  1. EP’s inability to electronically prescribe due to state, federal or local law or regulation. (Submit using the Communication Support Page)
  2. EP prescribes fewer than 100 prescriptions in a six month payment adjustment reporting period.  (Submit using the Communication Support Page)
  3. EP practices in a rural area without sufficient high speed internet access .  (Submit using the Communication Support Page or use G8642 in at least one claim between 1/1/13-6/30/13)
  4. EP practices in an area without sufficient available pharmacies for eRx.  (Submit using the Communication Support Page or use G8643 in at least one claim between 1/1/13-6/30/13)
  5. EP achieves Meaningful Use under the Medicare or Medicaid EHR Incentive Program.
  6. EP demonstrates their intent to participate in the Medicare or Medicaid EHR Incentive Program during the 1/1/13-6/30/13 reporting period.
  7. EP does not have prescribing privileges between 1/1/2013-6/30/2013.  (File at least one claim with G8644 on a payable Medicare Part B service between 1/1/13-6/30/13)

Requesting a Hardship Exemption

To submit a hardship request, EPs must access the Communication Support Page located here (look at upper-left hand corner once on the site).  CMS suggests that when submitting a hardship, EPs should provide detailed justifications for the hardships.

Those hardships with G-codes may also be submitted by EPs on a claim with a payable Medicare Part B service during the six-month reporting period (1/1/13-6/30/13).

EPs that achieve Meaningful Use under the Medicare or Medicaid EHR Incentive Program or demonstrate their intent to participate in the Medicare or Medicaid EHR Incentive Program during the 1/1/13-6/30/13 reporting period will be determined by CMS through review of the EHR Incentive Program Attestation and Registration system.  CMS will automatically determine if these exemptions apply.

Group practices participating in 2013 eRx GPRO must indicate hardship exemptions during self-nominations/registration or submit an exemption request via the Communication Support Page (listed above).

For more information on eRx or other incentive programs please contact Elana Zana.

 

Filed Under: e-Prescribing, EHR, Medicare 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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