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Vol. IX, No. 10 – March 9, 2007 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Table of Contents
Headlines
Florida Leader in Medicaid Fraud Referrals
Crozer-Keystone Health System Settles with Government
Physical Therapy Clinics Owner Admits to Medicare Fraud
Medicaid Fraud Cases Could Dramatically Increase
Kentucky Dentist Found Guilty of Medicaid Fraud
Chiropractor Arrested on Theft and Insurance Fraud Charges
Regulatory News
CMS: Physician Quality Reporting Initiative (PQRI) PowerPoint Presentation- Module One Available
In the Federal Register
CMS Transmittals
This Week’s Links
Acronym Library
Visit
HCCA's Web site
HCCA
Headquarters - Contact Information
Headlines:
Florida Leader in Medicaid Fraud Referrals
On March 8, 2007, All Headline News reported that “A recent report issued by the United States Department of Health and Human Services named Florida as one of only three states that referred more than 100 fraud cases to the state Attorney General's office last year. Florida led the nation with 197 referrals.” For more: http://www.allheadlinenews.com/articles/7006680384
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Crozer-Keystone Health System Settles with Government
U.S. Attorney for the Eastern District of Pennsylvania Pat Meehan announced a settlement with Crozer-Keystone Health System, on March 5, 2007, regarding services provided at its Crozer-Chester Medical Center in Upland, PA. The settlement includes the payment of $549,663 to the Medicare program.
From July 1, 1999 to June 30, 2004 Crozer-Keystone, through its subsidiary Health Access Network, employed four physicians who specialized in Physical and Rehabilitation Medicine. During that period, the four doctors, Dennis Ivill, M.D., Patrick Murphy, D.O., Jyothi Chinta, M.D., and Lynn W. Yang, M.D., overcharged Medicare for outpatient visits, hospital admissions, hospital discharges, and inpatient consultations. For more: http://www.usdoj.gov/usao/pae/News/Pr/2007/mar/crozer.html
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Physical Therapy Clinics Owner Admits to Medicare Fraud
On March 5, 2007, U.S. Attorney for New Jersey Christopher J. Christie announced that the owner of two physical therapy clinics admitted defrauding Medicare of approximately $3.8 million. For more: http://www.usdoj.gov/usao/nj/press/2007releases.html
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Medicaid Fraud Cases Could Dramatically Increase
On March 5, 2007, the Nashville Business Journal reported that “A newly active health care regulation encouraging whistleblowing for Medicaid fraud has Tennessee investigators anticipating a jump in their case loads, meaning more money recovered from providers and given to TennCare.
Starting this year, every entity receiving or making $5 million or more in Medicaid (TennCare) payments is required to have written policies and procedures concerning false claims - how to find and report fraud - and the protections and rewards for whistleblowers. Those policies must be distributed to all employees, contractors and agents.
The statute, part of the Deficit Reduction Act of 2005, is designed to increase the number of whistleblowers to help reduce Medicare/Medicaid spending by $11 billion over five years.
Peter Coughlan, senior counsel at the Tennessee Attorney General's office, says the requirement should create an "explosion" of fraud cases for the state.
The reason, he says, is because the policies will be in the hands of so many people - managed care contractors, hospitals, nursing homes, billing agencies, coding vendors and more. And within those policies is the incentive that those who tattle on Medicaid overbilling get to keep 15 percent to 25 percent of any money recovered.
The state's false claims act provides for damages equal to triple the amount of the false claim, plus $5,000 to $25,000 per claim. Under the new law, the state will keep 46 percent of any recovery (instead of the previous 36 percent) giving it more incentive to go after fraud cases, Coughlan says.
Federal statistics show the average Medicaid fraud recovery is $10 million, with the whistleblower's share at $1.7 million. Last year, Tennessee recovered $3.5 million from health care fraud cases.
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Kentucky Dentist Found Guilty of Medicaid Fraud
Kentucky Attorney General Greg Stumbo announced March 8, 2007, Peter Robert Ciampa, an oral surgeon who practiced in Paducah, Kentucky, was found guilty of defrauding the Kentucky Medicaid Program. A McCracken County jury convicted Ciampa, age 49, of fraudulently billing the Kentucky Medicaid Program and double-billing for services. He is charged with three counts of devising or engaging in a scheme to defraud the Kentucky Medical Assistance Program (KMAP, commonly known as Medicaid) out of nearly $10,000 between January, 2001 and November, 2004. Late Wednesday, March 7th, the jury recommended a sentence of one year on each count to run concurrently. Final sentencing by the trial judge is scheduled for April 30, 2007. For more:
http://ag.ky.gov/news/peterrobertciampa.htm
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Chiropractor Arrested on Theft and Insurance Fraud Charges
Pennsylvania Attorney General Tom Corbett announced March 5, 2007, that agents from the Attorney General's Insurance Fraud Section have filed criminal charges against a Bucks County chiropractor accused of submitting $90,000 in false insurance claims.
Corbett identified the defendant as Jonathan Paul Wiktorchik, 55, of 1445 Churchville Rd., Southampton, Bucks County.
Corbett said Wiktorchik allegedly submitted insurance claims for phantom visits billed under the name of several of his patients. From Feb. 21, 2003 to Aug. 13, 2004, Dr. Jonathan Wiktorchik allegedly submitted $90,000 worth of insurance claims to Highmark and Independence Blue Cross for more than 1,800 procedures that were not performed. For more:
http://www.attorneygeneral.gov/press.aspx?id=2273
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This week, MediRegs provided TWCC readers with the following Regulatory information: In the Federal Register and CMS Transmittals.
Regulatory News
CMS: Physician Quality Reporting Initiative (PQRI) PowerPoint Presentation- Module One Available
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that a PowerPoint Presentation on the 2007 Physician Quality Reporting Initiative (PQRI) is now available.
On December 20, 2006, President Bush signed the Tax Relief and Health Care Act of 2006 (TRHCA). TRHCA Section 101 authorizes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible professionals, who chose to participate and successfully report on a designated set of quality measures for services paid under the Medicare Physician Fee Schedule and provided between July 1 and December 31, 2007, may earn a bonus payment of 1.5% of their charges during that period, subject to a cap. CMS has titled the statutory program the 2007 Physician Quality Reporting Initiative (PQRI).
To access the PowerPoint Presentation, visit http://www.cms.hhs.gov/PQRI on the CMS website and click on the Educational Resources tab.
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CMS Update
Commenting on a Revised Advance Beneficiary Notice
A notice was published in the Federal Register on February 23, 2007 on a revised version of the general ABN (CMS-R-131). Public comments are requested during the 60-day comment period and will be considered as part of finalizing the revised ABN.
As required by Section 1879 of the Social Security Act, the ABN is used to inform beneficiaries of potential financial liability, except in home health care and inpatient hospital settings. Formerly, CMS maintained two versions of the ABN, a general and lab-test specific version, but with this revision, CMS proposes to combine these two versions of the ABN into a single notice meeting both needs. Other proposed changes are described in the website posting. Physicians, practitioners, providers and suppliers already required to use ABNs will continue to use the currently approved ABN until the revised notice is finalized and approved.
To view the announcement and requirements for submitting comments in the Federal Register, go to: http://www.gpoaccess.gov/fr/advanced.html
On this page, under “Search by Issue Date”, on the “Specific Date”: line, select “On” and enter “02/23/2007” in the date field. After “Search:” in the next line, enter “CMS-R-131”. The announcement should appear first if multiple items are found.
To obtain copies of the ABN and supporting documents, go to:
http://www.cms.hhs.gov/PaperworkReductionActof1995.
On the menu on the left side of this page, click on “PRA Listing”, then scroll down or search for “CMS-R-131”. Alternatively, you may email your request including your name, address, phone number, OMB control number (0938-0566) and CMS document identifier (CMS-R-131) to Paperwork@cms.hhs.gov, or call the Reports Clearance Office on (410) 786-1326. [Note both sites may be down briefly. Please try multiple times if you encounter a problem.]
In order to be accepted, comments must be sent to:
CMS, Office of Strategic Operations and Regulatory Affairs,
Division of Regulations Development – C
Attention: Bonnie L. Harkless
Room C4-26-05,
7500 Security Blvd.
Baltimore, Maryland 21244-1850
These comments must be received by 5 p.m. on April 24, 2007.
Use of the UB-04 and UB-92
Discussion on the web page below addresses the issue raised during the open Q&A portion on the February 15, 2007 Skilled Nursing Facility-Long Term Care Open Door Forum regarding use of the UB-04 and UB-92 prior to the date the UB-92 will no longer be accepted by CMS (after May 22, 2007).
Please see: http://www.cms.hhs.gov/ElectronicBillingEDITrans/15_1450.asp
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Listening Session #2 on Design Issues for the Medicare Hospital Value-Based Purchasing Plan
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the posting of the Federal Register Notice for Listening Session #2 that is part of the development of the Medicare Hospital Value-Based Purchasing Plan authorized by Section 5001(b) of the Deficit Reduction Act of 2005. The purpose of this Listening Session is to solicit comments on the Draft Plan for Medicare Hospital Value-Based Purchasing. The Draft Plan will be posted on Thursday, March 22, 2007 on the CMS website, Hospital Center, under Spotlights at: http://www.cms.hhs.gov/center/hospital.asp.
CMS will conduct Listening Session #2 on Thursday, April 12, 2007 from 10 AM to 5 PM in the CMS Baltimore auditorium. Attendees will have the opportunity to present verbal comments on the draft Plan. A dial-in number will be provided for those who cannot attend, and limited time will be allocated for comments from telephone participants.
All interested parties are encouraged to participate in the Listening Session, including, but not limited to hospitals and other health care providers, purchasers, employers, consumers, and representatives of these stakeholders. Registration is required for both on-site and teleconference participation. Registration information is available at: http://registration.intercall.com/go/cms2. Confirmation of registration is provided. Registration closes Monday, April 9, 2007 at 5:00 PM EDT.
Written comments on the draft Medicare Hospital Value-Based Purchasing Plan will be accepted until April 19, 2007 at 5:00 PM EDT and may be sent by e-mail to cmshospitalVBP@cms.hhs.gov. Comments may also be sent by FAX to 410-786-0330 or mailed to Robin Phillips, Medicare Feedback Group, Centers for Medicare & Medicaid Services, Mail Stop C4-13-07, 7500 Security Blvd., Baltimore, MD 21244-1850.
For more information about the Listening Session, please view the Federal Register Notice (CMS-1383-N2) at http://a257.g.akamaitech.net/7/257/2422/01jan20071800/ edocket.access.gpo.gov/2007/pdf/E7-3048.pdf
The Centers for Medicare & Medicaid Services (CMS) will administer its annual Medicare Contractor Provider Satisfaction Survey (MCPSS) in January 2008. The MCPSS is designed to measure provider satisfaction with and perceptions about the services provided by Medicare Fee-for-Service (FFS) claims-payment contractors. The survey gives providers the opportunity to rate their Contractor(s) on seven business functions: provider outreach and education, provider inquiries, claims processing, appeals, medical review, provider enrollment, and provider reimbursement.
CMS has requested clearance from the Office of Management and Budget (OMB) for the administration of the 2008 MCPSS. The reasons for this OMB submission is to 1) increase sample size, 2) make some minor changes to the survey instrument, and 3) address research and development activities needed to continuously improve the study. To obtain copies of the supporting statement and any related forms, you may access CMS' Paperwork Reduction Act website at http://www.cms.hhs.gov/PaperworkReductionActof1995, select PRA Listing and view CMS Form Number CMS-10097, or E-mail your request, including your address, phone number, OMB number, and CMS document identifier, to Paperwork@cms.hhs.gov, or call the Reports Clearance Office on (410) 786-1326.
Comments and recommendations for this collection of information must be received at the address below, no later than 5 p.m. on April 24, 2007:
CMS, Office of Strategic
Operations and Regulatory Affairs
Division of Regulations Development—C
Attention: Bonnie L Harkless
Room C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850.
For additional information about the MCPSS, please visit: http://www.cms.hhs.gov/mcpss/.
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NPI: Only 74 more days until the National Provider Identifier (NPI) compliance date!
For more: http://www.cms.hhs.gov/NationalProvIdentStand/
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Upcoming CMS Open Door Forums
-The next Home Health, Hospice, and DME Open Door Forum is scheduled for Wednesday, March 14, 2007
http://www.cms.hhs.gov/OpenDoorForums/ 17_ODF_HHHDME.asp#TopOfPage
- The next Rural Health Open Door Forum (ODF) is Tuesday, March 27, 2007.
http://www.cms.hhs.gov/OpenDoorForums/ 24_ODF_RuralHealth.asp#TopOfPage
- The next Skilled Nursing Facilities / Long-Term Care Open Door Forum is Wednesday, March 28, 2007.
http://www.cms.hhs.gov/OpenDoorForums/ 25_ODF_SNFLTC.asp#TopOfPage
The next Physicians, Nurses, and Allied Health Professionals Open Door Forum is Tuesday, April 17, 2007.
http://www.cms.hhs.gov/OpenDoorForums/ 23_ODF_PNAHP.asp#TopOfPage
The next Ambulance Open Door Forum is Tuesday, April 24, 2007.
http://www.cms.hhs.gov/OpenDoorForums/ 10_ODF_Ambulance.asp#TopOfPage
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In the Federal Register
Proposed Rule on Appeals of CMS or Contractor Determinations Regarding Billing Privileges
On March 2, 2007, CMS proposed a rule that would establish an appeals process for providers and suppliers whose applications for enrollment or renewal of enrollment were denied. The rule would also grant providers and suppliers the right to a hearing by an ALJ after an adverse decision at the reconsideration level when a provider or supplier's enrollment application is denied. It would also establish timeframes for deciding enrollment appeals by an ALJ or the DAB. Finally, the proposed rule would implement a section of the MMA, which specifies the timeframes in which contractors must process all provider and supplier enrollment actions.
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_fr69_cms &u=0703024&h=top1.html&t=80&s=twcc
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CMS Transmittals
Medicare Benefit Policy - Basic Coverage Rules (PUB. 100-02)
Transmittal #66, Date: February 23, 2007 Services Not Provided Within United States (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_02 &u=mrepm10002r66bp&h=top1.html&t=80&s=twcc
Medicare National Coverage Determinations (National Coverage Decisions) (PUB. 100-03)
Transmittal #65, Date: February 23, 2007 INDEPENDENCE iBOT 4000 Mobility System (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_03 &u=mrepm10003r65ncd&h=top1.html&t=80&s=twcc
Medicare Claims Processing (PUB. 100-04)
Transmittal #1189, Date: February 28, 2007 Differentiating Mass Adjustments From Other Types of Adjustments and Claims for Crossover Purposes and Revising the Detailed Error Report Special Provider Notification Letters **Rescinds Transmittal #1179, dated February 2, 2007**(PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1189cp&h=top1.html&t=80&s=twcc
Transmittal #1188, Date: February 26, 2007 April Update to the 2007 Medicare Physician Fee Schedule Database (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1188cp&h=top1.html&t=80&s=twcc
Transmittal #1187, Date: February 23, 2007 Revisions to Incomplete or Invalid Claims Instructions Necessary to Implement the Revised Health Insurance Form CMS-1500(8/05) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1187cp&h=top1.html&t=80&s=twcc
Transmittal #1186, Date: February 23, 2007 Changes to Chapter 30 - Updates to Amount in Controversy Requirement and Correction of Appeals Terminology (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1186cp&h=top1.html&t=80&s=twcc
Transmittal #1185, Date: February 23, 2007 Ambulance Fee Schedule - Medical Conditions List - Manualization Revisions (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1185cp&h=top1.html&t=80&s=twcc
Program Integrity (PUB. 100-08)
Transmittal #190, Date: February 23, 2007 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08 &u=mrpm10008r190pi&h=top1.html&t=80&s=twcc
National Coverage Analyses
Ultrasound Diagnostic Procedures (CAG-00309R) - Expected Completion Date: 05/27/07:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CAG00309R2&h=top1.html&t=80&s=twcc
Bariatric Surgery Facilities - 02/23/07:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca &u=bariatricsurglist3&h=top1.html&t=80&s=twcc
Percutaneous Transluminal Angioplasty (PTA) and Stenting of the Renal Arteries (CAG-00085R4) - Expected Completion Date: 11/24/07:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CAG00085R4&h=top1.html&t=80&s=twcc
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From the OIG
Partnership Review -- Oklahoma Health Care Authority's Report on Hospice Covered Drugs for Dually Eligible Beneficiaries
http://oig.hhs.gov/w-new.html
Tenet Choices 65's Adjusted Community Rate Proposal Modifications for Contract Year 2004
http://oig.hhs.gov/w-new.html
Administration on Aging’s Resolution of Audit Recommendations
http://oig.hhs.gov/w-new.html
Exclusions and Reinstatements for the month of February 2007
http://oig.hhs.gov/fraud/exclusions.html
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This Week’s Link:
Testimony of Daniel R. Levinson, Inspector General, before the U.S. House of Representatives Ways and Means Subcommittees on Health and Oversight on Medicare Program Integrity
http://oig.hhs.gov/w-new.html
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Acronym Library
| CPPC | Cost Plus Percentage of Cost |
| CPQC | Claims Processing Quality Control |
For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp
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This Week in Corporate Compliance (781) 593-4924
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