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Compliance
News
The Department of Health and Human Services
(HHS or the Department) and the HHS Public Health Service (PHS),
proposes to amend its regulations on the Responsibility of Applicants
for Promoting Objectivity in Research for which PHS Funding is Sought
and Responsible Prospective Contractors. Since the promulgation ofthe
regulations in 1995, biomedical and behavioral research and the
resulting interactions among Government, research institutions, and the
private sector have become increasingly complex. This complexity, as
well as a need to strengthen accountability, have led to the proposal of
amendments that would expand and add transparency to investigator
disclosure of significant financial interests, enhance regulatory
compliance and effective institutional oversight and management of
investigators’ financial conflicts of interests, as well as
NIH’s compliance oversight. Click here for more
Interview with James G. Sheehan, New York
State Medicaid Inspector General
Introduction by Health Care Compliance
Association CEO Roy Snell:
The Board's role in regulatory and compliance
oversight is coming under scrutiny more than any other time in our
history. This role is important and can't be taken lightly. It weighs
heavily on the minds of countless Board members. Many Board members are
looking for guidance on how to fulfill this obligation and to do so
efficiently. James G. Sheehan is one of the most knowledgeable leaders
in this field. In the following interview, Jim shares his thoughts and
ideas regarding the Board's role in the oversight of compliance
programs. For more click here
Obama Administrations Healthcare Fraud Summit Webcast
Attorney General Eric Holder and Secretary Kathleen Sebelius,
Secretary of the Department of Health and Human Services
Video requires Real Media
Webcast of Morning Session
Webcast of Evening Session
[Federal Register: January 21, 2010 (Volume 75, Number 13)]
[Notices]
[Page 3525-3539]
From the Federal Register Online via GPO Access
[wais.access.gpo.gov]
[DOCID:fr21ja10-106]
UNITED STATES SENTENCING COMMISSION
Sentencing Guidelines for United States Courts
AGENCY: United States Sentencing Commission.
ACTION: Notice of proposed amendments to sentencing guidelines,
policy statements, and commentary. Request for public comment, including
public comment regarding retroactive application of any of the proposed
amendments. Notice of public hearing.
Click here for more
CMS Medicare Learning Network - Guidance on Using
Internet-based Provider Enrollment, Chain and Ownership System
(PECOS)
Click here
HHS Rescinds Medicaid Regulations
HHS Secretary Kathleen Sebelius today announced that the
administration will rescind all or part of three Medicaid regulations
that were previously issued and delay the enforcement of a fourth
regulation.
for
more click
here Click here for HHS press
release
Combating Fraud, Waste, and Abuse in Medicare and
Medicaid
Testimony of:
Daniel R. Levinson, Inspector General, Office of Inspector General,
U.S. Department of Health and Human Services
to the US Senate Special Committee on Aging
May 6, 2009
Click here
Testimony on Capitol Hill Supports Compliance
Programs
On April 22, 2009, Lewis Morris,
Chief Counsel, Office of Inspector General
Department of Health and Human Services and New York State Medicaid
Inspector General James G. Sheehan each promoted the use of compliance
programs as a means to thwart waste, fraud and abuse in Federal Health
Care Programs during testimony before the Senate Subcommittee on Federal
Financial Management, Government Information, Federal Services, and
International Security.
While outlining ways in which the
government could effectively combat fraud, waste and abuse in Federal
health care programs, Morris stated “Requiring health care
providers and suppliers to incorporate integrity safeguards and tools
into their organizations is an essential component of a comprehensive
antifraud strategy. In many sectors of the health care industry,
such as hospitals, compliance programs are widespread and often very
sophisticated; other sectors have been slower to adopt internal
compliance practices. Compliance programs benefit industry
stakeholders by improving their business practices, by fostering early
detection and correction of emerging problems, and by reducing the risk
that they will become the subject of a fraud prosecution.”
For Mr. Morris’ complete testimony click here
Specifically recommending
compliance programs as an effective means to combat health care fraud,
New York State Medicaid Inspector General James G. Sheehan stated
“We need to move to a system which makes program integrity a major
goal of oversight, investigative, and prosecutive efforts.
“First, require and support effective corporate compliance
programs and professional compliance officers. New York requires
by law that larger providers have an effective compliance program, with
eight elements. The Medicare program suggests model compliance
programs. We want health care providers to identify and resolve
issues themselves; the best already do.” For Mr. Sheehan’s
complete testimony, click here
Inspector General's "Open Letter
to Health Care Providers"
Announced March 24, 2009
On March 24, 2009 the U.S. Department of Health and Human Services
Office of Inspector General (OIG) released an Open Letter refining the
OIG’s Self-Disclosure Protocol. Click here
for the letter. Click here for a summary
New ‘Red Flag’
Requirements for Financial Institutions and Creditors Will Help Fight
Identity Theft
Identity thieves use
people’s personally identifying information to open new accounts
and misuse existing accounts, creating havoc for consumers and
businesses. Financial institutions and creditors soon will be required
to implement a program to detect, prevent, and mitigate instances of
identity theft. Click here for more
Fact Sheet: Department of
Justice Efforts to Combat Health Care Fraud and
Abuse
WASHINGTON, May 28
/PRNewswire-USNewswire/ -- The Department of Justice, in cooperation
with the Department of Health and Human Services, has guided the
enforcement efforts of the national Health Care Fraud and Abuse Control
Program (HCFAC) since its inception in 1997. The program was designed to
coordinate federal, state and local law enforcement on cases of health
care fraud and abuse as part of the Health Insurance Portability and
Accountability Act (HIPAA). Today, the Department's efforts to
investigate and prosecute the individuals and companies who commit
health care fraud are as strong as ever, thanks in large part to the
Department's many components working closely with partners at the
Department of Health and Human Services, and state and local law
enforcement.
Click here
for more
CMS Announces
Demo to Encourage Greater Collaboration and Improve
Quality
The Centers for Medicare
& Medicaid Services (CMS) announced on May 16, 2008 a new
demonstration for hospitals to test the use of a bundled payment for
both hospital and physician services for a select set of episodes of
care to improve the quality of care delivered through Medicare
fee-for-service. For more:
http://www.hcca-info.org/Content/NavigationMenu/ComplianceResources/
ComplianceNews/CMS_DemoEncourageCollaborationQualityBundledHospitalPayments.pdf
2008-2009 Office
of Medicaid Inspector General Work Plan
New York State Office of
the Medicaid Inspector General, SFY 2008-2009 OMIG Medicaid Work
Plan. Click here
for more
An Open Letter to
Health Care Providers, April 15, 2008
from Daniel
R. Levinson, Inspector General
Since the inception ofthe
Office ofInspector General (DIG) Provider Self-Disclosure Protocol (SDP)
in 1998, DIG has encouraged the health care provider community to help
ensure the integrity ofthe Federal health care programs by voluntarily
disclosing self-discovered evidence ofpotential fraud. In this spirit of
collaboration, we have responded to the provider community's suggestions
in the past for ways to improve the SDP. In my 2006 Dpen Letter, for
example, I encouraged providers to disclose improper arrangements under
the physician self-referral (Stark) law (42 U.S.C. § 1395nn) and
committed to settling liability under DIG's authorities generally for an
amount near the lower end of the damages continuum, i.e., a multiplier
ofthe value of the fmancial benefit conferred.
Click here for more
“Driving
for Quality in Long-Term Care: A Board of Directors
Dashboard”
Government-Industry Roundtable
A Report on the Office of
Inspector General and Health Care Compliance Association Roundtable on
Long-Term Care Board of Directors’ Oversight of Quality of
Care
Survey Results:
Top Risk Areas in Research Compliance
Research Billing, Effort Reporting, and Conflicts of Interest topped
the list of Risk Areas identified by Health Care Compliance Association
Research Compliance Conference attendees. The survey was conducted by
HCCA following the conference with approximately 85 responses. For
more, click here (PDF).
OIG Work Plan for FY
2008
On September 25, the U.S. Department of Health and Human Services
Office of Inspector General released its Work Plan for Fiscal Year 2008
Department Of Justice Files Complaint
Against Ex-Tenet General Counsel
On September 18, 2007, the government announced it had filed a
complaint alleging that the former general counsel of Tenet Healthcare
Corporation violated the False Claims Act, the Justice Department
announced today. The suit contends that in 1997 and 1998, Christi
Sulzbach submitted false certifications to the Department of Health and
Human Services which allowed Tenet to bill Medicare for millions of
dollars in claims that it was not entitled to receive. click here for the complaint.
August 21, 2007 –
CMS Announces Start of Participant Recruitment for Post Acute Care Payment Reform
Demonstration
The Centers for Medicare
& Medicaid Services (CMS) announced the start of participant
recruitment for the Post Acute Care Payment Reform Demonstration
(PAC-PRD). Participating providers include acute care hospitals and four
post-acute care (PAC) settings -- Long Term Care Hospitals (LTCHs), Inpatient
Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and
Home Health Agencies (HHAs). Click here
for more
August 1, 2007 –
CMS: Payment Reforms for
Inpatient
Hospital Services
in 2008
The Centers for Medicare
& Medicaid Services (CMS) today issued a final rule that takes
significant steps toimprove the accuracy of Medicare’s payment
under the acute care hospital inpatient prospective payment system
(IPPS),while providing additional incentives for hospitals to engage in
quality improvement efforts…….The rule implements a
provision of the Deficit Reduction Act of 2005 (DRA) that takes the
first steps toward preventing Medicarefrom giving hospitals higher
payment for the additional costs of treating a patient who acquires a
condition (including an infection) during a hospital stay.Already the
feature of many state health care programs, the DRA requires hospitals
to begin reporting secondary diagnosesthat are present on the admission
of patients, beginning with discharges on or after October 1, 2007.
Beginning in FY 2009, caseswith these conditions would not be paid at a
higher rate unless they were present on admission. In order to improve
the reliability of care inthe nation’s hospitals, the rule
identifies eight conditions, including three serious preventable events
(sometimes called “never events”) that meet the statutory
criteria.CMS will work to add an additional 3 conditions to the list
next year.
To read more on this rule
issued please click this URL for the IPPS
regulation:
http://www.cms.hhs.gov/AcuteInpatientPPS/Downloads/CMS-1533-FC%20TABLE.pdf
July 31, 2007 – CMS
Increases Payments to Inpatient Rehabilitation Facilities for FY
2008
Inpatient rehabilitation
facilities (IRFs) will receive approximately $6.4 billion in payments
from Medicare in fiscal year (FY) 2008, under a rule announced today by
the Centers for Medicare & Medicaid Services (CMS). The rule will
update payment rates and modify payment policies for services furnished
to Medicare beneficiaries for discharges occurring on or after October
1, 2007, through September 30, 2008. The rule's provisions are estimated
to increase Medicare payments to approximately 1,220 IRFs in FY 2008 by
approximately $150 million. For more
information please refer to the CMS IRF PPS web site which is http://www.cms.hhs.gov/InpatientRehabFacPPS/.
July 19, 2007 – CMS
Announces New Proposed
Clinical Research Policy The
Centers for Medicare & Medicaid Services (CMS) announced today the
reopening of its clinical trial policy (CTP) national coverage
determination (NCD) and is releasing a proposed decision memorandum for
public comment. The public comment period will last for 30 days
and a final decision will be released 60 days after that. Click here
for more
Details of the proposed coverage
policy are available at the CMS coverage website at http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=210.
July 16, 2007 - CMS
REVISES PAYMENT STRUCTURE FOR AMBULATORY SURGICAL CENTERS AND PROPOSES
POLICY AND PAYMENT CHANGES FOR HOSPITAL OPPS
The Centers for Medicare
& Medicaid Services (CMS) today issued a final rule revising the
payment system for services furnished to people with Medicare in
ambulatory surgical centers (ASCs) to better align payments for similar
services furnished in a hospital outpatient department (HOPD) or a
physician’s office. CMS also issued a proposed rule
that would update Medicare payment for services in HOPDs under the
Outpatient Prospective Payment System (OPPS) and would set new payment
rates for ASCs under the revised system effective for services in
calendar year (CY) 2008. Click here for more.
For the text of the ASC final revised
payment system rule see http://www.cms.hhs.gov/ASCPayment/
For the text of the
combined OPPS/ASC proposed rule, see:
http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp
OIG: Fiscal Year 2006 Annual
Report of the State Medicaid Fraud Control Units
(MFCU)
June 2007 - Corporate
Responsibility and Health Care Quality:
Resource for Health Care Boards of Directors
Click here
MEDICAID INTEGRITY PROGRAM
As presented by
Kimberly Brandt
Director
Program Integrity Group
Centers for Medicare and Medicaid Services
at the 2007 Compliance Institute, April 24, 2007
The Future of Medicaid Regulation and
Enforcement
Kimberly Brandt, Director of
Program Integrity, CMS
Brian Flood, Inspector General, Texas HHSC
Frank Sheeder, Partner, Jones Day
Lunch presentation Tuesday April
24, 2007 Compliance Institute.
March 2007 - CMS
provided additional guidance to State Medicaid
Directors on the "Employee Education" provisions found in Section 6032
of the Deficit Reduction Act of 2005(DRA). Section 6032 of the DRA
requires entities that receive $5 million or more in Medicaid funds per
year to have and disseminate certain policies and information to their
employees, contractors, and agents. The guidance is effective
immediately and covers 71 separate questions. This is the guidance
that States will use as they impose requirements on providers. CMS
also provided a summary of the Federal False Claims
Act prepared by the Department of Justice.
OIG Reports More
Than $38 Billion in Savings and Recoveries for FY
2006:
Press Release
OIG Work Plan for FY
2007
On September 25, the U.S. Department of Health and Human Services
Office of Inspector General released its Work Plan for Fiscal Year 2007
Essential links
to
August 23, 2006 -Proposed Rule - Hospital
Outpatient Prospective Payment System
Federal Register
Vol. 71, No. 163
Wednesday, August 23, 2006
Hospital Outpatient Prospective Payment System and CY 2007 Payment
Rates; CY 2007 Update to the Ambulatory Surgical Center Covered
Procedures List; Ambulatory Surgical Center Payment System and CY 2008
Payment Rates; Medicare Administrative Contractors; and Reporting
Hospital Quality Data for FY 2008 Inpatient Prospective Payment System
Annual Payment Update Program--HCAHPS[supreg] Survey,SCIP, and
Mortality
Centers for Medicare and Medicaid
Services – Hospital Outpatient PPS:Hospital Outpatient PPS
Overview links: http://www.cms.hhs.gov/HospitalOutpatientPPS/01_overview.asp
Hospital Outpatient Regulations and Notices http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage
Regulation No. CMS-1506-P
Title Proposed Changes to the Hospital Outpatient PPS and CY
2007 Rates;
Year 2007
Medicare Program: Proposed Changes to the
Hospital Outpatient PPS (OPPS) and CY 2007 Rates; Proposed CY 2007
Update to the ASC Covered Procedures List; and Proposed Changes to the
ASC Payment System and CY 2008 Payment Rates
http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS1185569
Draft AHA/AHIMA Guidelines with Suggested CMS
Revisions
June
2006 - The Government Accountability Office report on a year-long study
of not-for-profit health systems’ compensation, benefits and
governance
Click
here for report
MEDICARE
NEWS
FOR IMMEDIATE RELEASE
CMS Office of External Affairs
April 12,
2006
CMS PROPOSES PAYMENT AND POLICY
CHANGES FOR ACUTE CARE HOSPITAL SERVICES TO INPATIENTS
The Centers for Medicare & Medicaid
Services (CMS) today issued a notice of proposed rulemaking that would
begin the transition to the first significant revision of the Inpatient
Prospective Payment System (IPPS) since its implementation in
1983. When fully implemented, which is planned to occur by fiscal
year (FY) 2008 and potentially earlier, the revised IPPS would improve
the accuracy of payment rates for inpatient stays by basing the weights
assigned to Diagnosis Related Groups (DRGs) on hospital costs rather
than charges, and adjusting the DRGs for patient severity.
The estimated market basket increase of
3.4 percent in FY 2007 would increase payments to acute care hospitals
by $3.3 billion. Over 1000 hospitals in rural areas would see an
average increase of 6.7 percent.
“The hospital payment reforms we are proposing today will
mean payments for hospital inpatient services will more accurately
reflect the costs of providing the services,”said CMS Administrator Mark B. McClellan, M.D.,
Ph.D. “We are taking important
steps to make payments fairer to hospitals and to assure beneficiary
access to services in the most appropriate setting.”
“This proposed rule will be shaped
by the public comment process,” Dr. McClellan added. “We
look forward to comprehensive feedback from hospitals, suppliers, and
other stakeholders that will help to refine and improve the final
version of the rule.”
The proposed changes reflect
recommendations from the Medicare Payment Advisory Commission (MedPAC),
and respond to some Congressional concerns that the existing system may
create incentives for certain hospitals to “cherry-pick”
more profitable cases. The reforms will significantly affect
payments to specialty hospitals – hospitals that typically are
owned, in whole or in significant part, by physicians who serve as
referral sources. The growth in specialty hospitals has been
slowed temporarily by statute or regulation since the Medicare
Modernization Act was signed in December 2003.
CMS is considering a two-step process of
transformation. The first step, set out in the proposed rule,
would assign weights to DRGs based on hospital costs, rather than
hospital charges. This would eliminate biases in the current DRG
system arising from the differential markup hospitals assign for
ancillary services among the DRGs. The new DRG weights would go
into effect October 1, 2006.
A second step, currently
scheduled for FY 2008, would replace the current 526 DRGs with either
the proposed 861 consolidated severity-adjusted DRGs or an alternative
severity adjusted DRG system developed in response to the public
comments CMS is soliciting on this issue. CMS is also considering ways
of improving recognition of severity in the current DRG system by FY
2007. When the two steps are fully implemented, hospitals can
expect more accurate payment for their services.
CMS is proposing to increase the outlier
threshold for FY 2007 to $25,530, up from $23,600 in 2006. This
proposed increase is based on data suggesting a consistent pattern of
inflation in hospital charges which affect hospital cost-to-charge
ratios used in determining eligibility for outlier payment. The
proposed FY 2007 threshold is expected to keep aggregate hospital
outlier payments within the target of 5.1 percent of total payments
under the IPPS.
In addition to accurate payment for
existing technologies, CMS is committed to ensuring that Medicare
beneficiaries have rapid access to new technologies by providing for
temporary add-on payments for appropriate technologies. In order
to be eligible for additional reimbursement, a product must
be:
- New – that is, less than two to
three years old;
- Expensive – that is, it must meet
a defined cost threshold in relation to the underlying DRG;
and
- A substantial clinical improvement for
the Medicare patient population.
CMS has received three applications for
new technology add-on payments in FY 2007. CMS is soliciting
comments on whether these technologies meet the criteria for the
temporary add-on payments. CMS is also proposing to continue new
technology payments for two of the three technologies that were approved
for payment in FY 2006.
The proposed rule will be published in the April 25,
2006Federal Register. Comments will be
accepted until June 12, 2006, and a final rule will be published later
this year.
April 6, 2006
- Lewis Morris, Chief Counsel to the Inspector
General, before the Subcommittee on Health of the U.S. House Committee
on Ways and Means on issues regarding health care information
technology. Click here for more.
February 8, 2006 -
Deficit Reduction Act of 2005, Signed by President Bush
“This new law contains a number of provisions about which
compliance professionals must be aware. It will also require
providers to modify some aspects of their compliance programs and, in
particular, the education element that is one of the seven components of
an effective compliance program. The compliance-related provisions
become effective January 1, 2007. The Act requires entities that receive
more than $5 million in Medicaid reimbursement to include their
compliance program information in employee training.” From an
article written by Frank Sheeder and to be published in the March issue
of Compliance Today.
Chapter 3 (page 69) --
ELIMINATING FRAUD, WASTE, AND ABUSE IN
MEDICAID of the “Act” (See SEC. 6032, page 70, EMPLOYEE
EDUCATION ABOUT FALSE CLAIMS RECOVERY to review the Employee Education
Provisions of the “Act”)
Deficit Reduction Act of 2005
(Medicaid begins on page 51, Medicaid
Fraud & Abuse see page 69)
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