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Vol. IX, No. 1 – January 5, 2007 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Table of Contents
Headlines
University of Miami Settles, Agrees to Pay $2.2 Million
DOJ Files Appeal
Government Requires Employee Education on Fraud
Florida Doctor Indicted on Drug and Fraud Charges
Doctor Pleads Guilty to Securities and Health Care Fraud
Connecticut Doctor Settles, Agrees to Pay $160,000
Texas Dentist Permanently Excluded
Regulatory News
OIG Review of Prescription Drug Plan Sponsors’
Compliance Plans
CMS Updates
From the GAO
In the Federal Register
This Week’s Links
Acronym Library
Visit
HCCA's Web site
HCCA
Headquarters - Contact Information
Headlines:
University of Miami Settles, Agrees to Pay $2.2 Million
On December 21, 2006 the Miami Herald reported that “The University of Miami medical school agreed Thursday to pay $2.2 million to settle allegations that it overcharged Medicare patients from 1995 through 1999.“The alleged overbilling occurred when Donna Shalala, now UM's president, was head of U.S. Health and Human Services, the federal group that includes Medicare.” For more: http://www.miami.com/mld/miamiherald/16293003.htm
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DOJ Files Appeal
On January 3, 2007 Associated Press reported that “Federal authorities have asked the U.S. 9th Circuit Court of Appeals to overturn a ruling that prohibits them from viewing a legal file created on behalf of four heart surgeons suspected of defrauding Medicare and Medicaid.
“Federal agents, joined by the state Department of Justice's Medicaid Fraud Unit, have been investigating the Eugene-based practice of Drs. David Duke, Stanley Baldwin, Warren Glover and Richard Hicks since August 2003. Hicks is now retired, and the doctors sold the practice in 2004.
“Federal authorities want the appeals court to overturn U.S. District Judge Anna Brown's ruling that the doctors each retained individual attorney-client privilege over the file. The documents in question were created by a Boston lawyer the doctors hired before selling the practice.
“The U.S. Justice Department filed the appeal Dec. 29 in Portland.” For more: http://www.oregonlive.com/newsflash/regional/index.ssf?/ base/news-17/1167814546122940.xml&storylist=orlocal
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Government Requires Employee Education on Fraud and Abuse
The December 31, 2006 issue of The Tennessean reported that “Some hospitals, nursing homes and other businesses won't get paid by Medicaid in the coming year unless they teach workers how to blow the whistle on fraud.
“Under a law to take effect on Monday, companies that receive at least $5 million a year under the government health plan for poor people have to tell employees and contractors how to find fraud and report wrongdoing. Several health-care organizations throughout the state, including hospital systems, nursing home operators and BlueCross BlueShield of Tennessee, say they should have no trouble meeting Medicaid's new whistleblower rule. Medicaid is sponsored by the federal government but administered by the states. In Tennessee, it operates as TennCare.” For more:
http://www.thetennessean.com/apps/pbcs.dll/ article?AID=/20061231/BUSINESS01/612310393/1044
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Florida Doctor Indicted on Drug and Fraud Charges
On December 13, 2006, U.S. Attorney for the Northern District of Florida Gregory Miller announced that a Federal Grand Jury had returned an Indictment charging a Panama City physician and the office manager of his medical practice with conspiracy to commit fraud, health care fraud, mail fraud, conspiracy to distribute controlled substances, and unlawful dispensing of controlled substances.
For more: http://www.usdoj.gov/usao/ fln/press%20releases/2006/dec/durfey.htm
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Doctor Pleads Guilty to Securities and Health Care Fraud
On December 27, U.S. Attorney for the Southern District of Florida R. Alexander Acosta announced the guilty plea of defendant Clark Mitchell before United States District Judge Paul C. Huck in Miami. Clark Mitchell, a medical doctor once associated with Mutual Benefits Corp. (MBC), pled guilty to securities fraud in connection with his role in a viatical and life settlement scheme in which 28,000 investors lost approximately $956 million, in violation of 15 U.S.C. §§ 78j(b) and 78ff(a), 17 C.F.R. §240.10b-5, 18 U.S.C. § 2. Mitchell also pled guilty to conspiracy to commit health care fraud in connection with his employment at Community Healthcare/CenterOne, Inc (CenterOne), a South Florida AIDS clinic, in violation of 18 U.S.C. §371. For more: http://www.usdoj.gov/usao/fls/PressReleases/061227-01.html
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Connecticut Doctor Settles, Agrees to Pay $160,000
On December 21, 2006 the U.S. Attorney for the District of Connecticut announced that Juan Fica, of Waterbury, Connecticut, has entered into a civil settlement agreement with the Government to resolve allegations that he violated the False Claims Act by submitting false claims to the Medicare and Medicaid programs.The Government alleged that, from 1996 through 2003, Fica employed an individual named Elie Nakouzi to work at Fica’s medical practice, located at 1389 West Main Street in Waterbury. Although Nakouzi was not licensed to practice medicine, Nakouzi treated patients in Fica’s medical practice. During this time, Fica and Nakouzi referred to Nakouzi as “Doctor Nakouzi,” and Nakouzi signed Fica’s initials on prescriptions and medical records that Nakouzi had written. Fica then billed insurance companies for services that were rendered by Nakouzi, representing them as services rendered by Fica. To settle allegations under the False Claims Act, FICA agreed to pay double damages, in the amount of $160,000. The False Claims Act provides for treble damages and penalties of $5,500 to $11,000 per false claim submitted to the Government. For more:
http://www.usdoj.gov/usao/ct/Press2006/20061221-2.html
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Texas Dentist Permanently Excluded
On December 21, U.S. Attorney for the Southern District of Texas Don DeGabrielle announced that Dr. Roberto Ramirez, Jr. paid the United States $30,000 in damages for violations of the federal False Claims Act, and he will be permanently prohibited from participating in Medicare, Medicaid and any other federally funded health care programs. The fine was paid on Nov. 2, 2006, and the settlement agreement was fully executed on Dec. 21, 2006.
Dr. Ramirez owned and operated Family Night Dentistry, a dental clinic based in McAllen, Texas. Ramirez contracted with the Texas Department of Health as a Medicaid provider for dental services to Texas Medicaid recipients. In November 2000, he came under the scrutiny of National Heritage Insurance Company, (NHIC), which at the time was the claims administrator for the Texas Medicaid program. As of Jan. 1, 2004, the claims administrator for the program is Texas Medicaid Health Care Partnership (TMHP). For more: http://www.usdoj.gov/usao/txs/releases/December2006/061221-Ramirez.htm
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This week, MediRegs provided TWCC readers with the following Regulatory information: CMS Transmittals and From the OIG.
Regulatory News
OIG Review of Prescription Drug Plan Sponsors’ Compliance Plans
On January 4, 2007, the OIG released a report—Prescription Drug Plan Sponsors’ Compliance Plans. It found that while all Prescription Drug Plan sponsors had compliance plans, 72 of the 79 did not address all CMS requirements regarding the eight compliance plan elements. For more: http://www.hcca-info.org/Content/NavigationMenu/ ComplianceResources/ComplianceNews/ OIG_DrugPlanSponsorCompliance.pdf
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CMS Updates
CMS to Hold Briefing on Employee Education about False Claims Recovery
On Thursday, January 11, 2007, at 1:00 p.m. eastern time, the Centers for Medicare & Medicaid Services (CMS) will host a briefing to respond to providers’ questions regarding section 6032 of the Deficit Reduction Act of 2005 (P.L. 109-171) (DRA), Employee Education About False Claims Recovery.The following is a link to guidance on section 6032 that was issued to State Medicaid Directors on December 13, 2006:
http://www.cms.hhs.gov/SMDL/SMD/itemdetail.asp?filter Type=none&filterByDID=0&sortByDID=1&sortOrder= descending&itemID=CMS1190449&intNumPerPage=10
Call Leader: Aaron Wesolowski
Date: Thursday, January 11, 2007
Time: 1 PM ET
Call duration: 90 minutes
Toll Free #: 1-888-677-1819
Password:
ProviderParticipants will be required to know the PASSCODE and the CALL LEADER’S NAME to gain access to the conference.
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CMS Announces Annual Medicare Contractor Provider Satisfaction Survey
The Centers for Medicare and Medicaid Services recently announced that in January 2007 it would begin dissemination of the Medicare Contractor Provider Satisfaction Survey (MCPSS) to a new sample of Medicare providers. The survey is designed to garner quantifiable data on provider satisfaction levels with key services performed by the fee-for-service contractors (FFS) that process and pay more than $280 billion in Medicare claims each year.Providers selected to participate in the survey will be notified by mail during the first week of January 2007. The survey is designed so that it can be completed in about 15 minutes and providers can submit their responses via a secure Web site, mail, fax, or over the telephone. CMS will ask providers to respond by February 2007.The views of each provider in the survey are important because they represent many other organizations similar in size, practice type and geographical location. If you are one of the 35,000 providers randomly chosen to participate in the 2007 MCPSS implementation, you have an opportunity to help CMS improve service to all providers.
Survey Article
http://www.hcca-info.org/Content/NavigationMenu/ ComplianceResources/ComplianceNews/
ProviderSurveyArticle.pdf
Press Release
http://www.hcca-info.org/Content/NavigationMenu/
ComplianceResources/ComplianceNews/
ContractorSurvey121906.pdf
Survey Sample
http://www.hcca-info.org/Content/NavigationMenu/ ComplianceResources/ComplianceNews/surveysample2007.pdf
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HIPAA Security Guidance for Remote Use of Electronic Protected Health Information
CMS recently published the” Security Guidance for Remote Use of Electronic Protected Health Information”. This document is intended to provide HIPAA covered entities with general information on the risks and possible mitigation strategies for remote use of Electronic Protected Health Information (EPHI). As you may know, CMS has delegated authority to enforce the non-privacy provisions of the HIPAA Regulations, to include HIPAA Security. This guidance document sets forth CMS’ minimal compliance expectations for covered entities seeking to safeguard EPHI that is accessed, stored or transported offsite. Please note however that this document does not seek to provide a comprehensive list of risks and mitigation strategies but rather a general list of suggestions for organizations that require remote use of sensitive health information. For more information please go here and click downloads: http://www.cms.hhs.gov/SecurityStandard/
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From the GAO
Medical Devices: Status of FDA's Program for Inspections by Accredited Organizations. GAO-07-157, January 5.
http://www.gao.gov/cgi-bin/getrpt?GAO-07-157
Highlights - http://www.gao.gov/highlights/d07157high.pdf
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In the Federal Register
January 5, 2007 - Correction Notice
Medicare Program; Changes to the Hospital Inpatient Prospective
Payment Systems and Fiscal Year 2007 Rates; Final Fiscal Year 2007 Wage
Indices and Payment Rates After Application of Revised Occupational Mix
Adjustment to the Wage Index; Corrections
http://a257.g.akamaitech.net/7/257/2422/01jan20071800/ edocket.access.gpo.gov/2007/06-9976.htm
December 22, 2006 – Proposed Rule/ Medicaid Program; Prescription Drugs
This proposed rule would implement the provisions of the
Deficit Reduction Act of 2005 (DRA) pertaining to prescription drugs
under the Medicaid program. The DRA requires the Secretary of Health
and Human Services to publish a final regulation no later than July 1,
2007. In addition, we would add to existing regulations certain
established Medicaid rebate policies that are currently set forth in
CMS guidance. This rule would bring together existing and new
regulatory requirements in one, cohesive subpart.
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/ edocket.access.gpo.gov/2006/06-9792.htm
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CMS Transmittals
Medicare Benefit Policy - Basic Coverage Rules (PUB. 100-02)
Transmittal #62, Date: December 22, 2006 22/2006 Private Contracting- Definition of Physician/Practitioner (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_02&u=mrepm10002r62bp&h= top1.html&t=80&s=twcc
Medicare Claims Processing (PUB. 100-04)
Transmittal #1143, Emergency Update to the 2007 Medicare Physician Fee Schedule Database (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_04&u=mrepm10004r1143cp&h= top1.html&t=80&s=twcc
Transmittal #1142, DMERC Claim Modifiers for Upgrades (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_04&u=mrepm10004r1142cp&h= top1.html&t=80&s=twcc
Transmittal #1135, Correction of Instructions for Calculating IRF Compliance Percentage Threshold (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_04&u=mrepm10004r1135cp&h= top1.html&t=80&s=twcc
Transmittal #1131, Legislative Change to the Update Factor for the 2007 Medicare Physician Fee Schedule (MPFS) and Extension of the Participating Enrollment Period **Previously communicated as Sensitive**(PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_04&u=mrepm10004r1131cp&h= top1.html&t=80&s=twcc
Transmittal #1140, December 22, 2006 Preadministration-Related Services Associated with IVIG Administration-Payment Extended through CY 2007 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_04&u=mrepm10004r1140cp&h= top1.html&t=80&s=twcc
Transmittal #1139, January 2007 Update of the Hospital Outpatient Prospective Payment System (OPPS): Summary of Payment Policy Changes and OPPS PRICER Logic Changes and Instructions for Updating the Outpatient Provider Specific File (OPSF) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_04&u=mrepm10004r1139cp&h= top1.html&t=80&s=twcc
Transmittal #1137, 2006 Inpatient Rehabilitation Facility (IRF) Teaching Status Adjustment (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_04&u=mrepm10004r1137cp&h= top1.html&t=80&s=twcc
Transmittal #1136, Revisions to Procedure to Establish Good Cause and Qualified Independent Contractor Jurisdictions (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_04&u=mrepm10004r1136cp&h= top1.html&t=80&s=twcc
Program Integrity (PUB. 100-08)
Transmittal #180, 2006 Sources of Data for PSCs (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mr_pm_100_08&u=mrpm1000r180pi&h=top1.html&t= 80&s=twcc
CMS One-Time Special Notification (PUB. 100-20)
Transmittal #258, Payment Amounts and Policies in the 2007 Medicare Physician Fee Schedule and the Telehealth Originating Site Facility Fee Payment Amount (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_20&u=mrepm10020R258otn&h= top1.html&t=80&s=twcc
Transmittal #256, 2006 Payment Allowances for the Influenza Virus Vaccine (CPT 90655, 90656, 90657, and 90658) and the Pneumococcal Vaccine (CPT 90732) When Payment is Based on 95 Percent of the Average Wholesale Price (AWP) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_20&u=mrepm10020r256otn&h= top1.html&t=80&s=twcc
Transmittal #255, 2006 Provider Migration (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_20&u=mrepm10020r255otn&h= top1.html&t=80&s=twcc
Transmittal #254, 12/22/2006 Provision of Data for the Care Management for High Cost Beneficiaries Demonstration from Selected FIs, Carriers, and DME MAC Contractors (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_pm_100_20&u=mrepm10020r254otn&h= top1.html&t=80&s=twcc
National Coverage Analyses
Pulmonary Rehabilitation (CAG-00356N) - Expected Completion Date: 09/27/07:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_nca&u=CAG00356N&h=top1.html&t=80&s=twcc
Blood Brain Barrier Disruption (BBBD) Chemotherapy (CAG-00333N) - Expected Completion Date: 04/11/07:http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_nca&u=CAG00333N2&h=top1.html&t=80&s=twcc
Ventricular Assist Devices as Destination Therapy (CAG-00119R) - Expected Completion Date: 04/10/07:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_nca&u=CAG00119R2&h=top1.html&t=80&s=twcc
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From the OIG
Audit Reports
Review of Postretirement Benefit Costs Claimed by First Coast Service Options for Medicare Reimbursement for Fiscal Years 2002 Through 2005 (A-07-06-00213; 12/2006) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_oig_oas_cms2005&u=70600213&h= top1.html&t=80&s=twcc
Review of Segmented Postretirement Benefit Assets at First Coast Service Options from January 1, 2002 to January 1, 2005 (A-07-06-00225; 12/2006) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_oig_oas_cms2005&u=70600225&h= top1.html&t=80&s=twcc
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This Week’s Link:
Federal Register - 2007: http://www.access.gpo.gov/su_docs/fedreg/frcont07.html
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Acronym Library
| BLUES | Blue Cross/Blue Shield associations |
| BMA | BioMedical Applications |
| BMACS | Part B Medicare Automated Claims Systems |
For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp
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