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Vol. IX, No. 11 – March 16, 2007 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Table of Contents
Headlines
Vermont Town Settles Dispute Over Ambulance Bills
New Jersey Hospital Settles, Agrees to Pay $7.5 M
Former Nursing Home Executives Indicted
Three Indicted in Texas in Wheelchair Fraud Case
Former Caregivers Face Fraud and Abuse Charges
HealthSouth and Portsmouth-Based Physicians Settle False Claims Allegations
New York Pharmacy Owner Arrested for Stealing from Medicaid
Former Fletcher Allen Employee Sentenced for His Role in Cost-Hiding Conspiracy
Regulatory News
CMS Update
Important Notice Regarding the Revised Form CMS-1500
This Week’s Links
Acronym Library
Visit
HCCA's Web site
HCCA
Headquarters - Contact Information
Headlines:
Vermont Town Settles Dispute Over Ambulance Bills
The Burlington Free Press reported on Tuesday, March 13, 2007
that “Colchester, VT, has agreed to pay $45,000 to settle a dispute with federal prosecutors over claims for Colchester ambulance transportation.” For more: http://www.burlingtonfreepress.com/apps/pbcs.dll/ article?AID=/20070313/NEWS02/70313010/1007 &theme=COLCHESTER
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New Jersey Hospital Settles, Agrees to Pay $7.5 M
On March 15, 2007, the U.S. Department of Justice announced that Raritan Bay Medical Center has agreed to pay the United States $7.5 million to settle allegations that it defrauded the federal Medicare program. The settlement resolves allegations that Raritan Bay, headquartered in Perth Amboy, N.J., improperly increased charges to Medicare patients in order to obtain enhanced reimbursement from Medicare.
In addition to its standard payment system, Medicare pays supplemental reimbursement to hospitals and other health care providers in cases where the cost of care is unusually high. These cases are known as “outliers.” Congress enacted the supplemental outlier payment system to ensure that hospitals possess the incentive to treat inpatients whose care requires unusually high costs.
The government alleged that, between January 1998 and August 2003, Raritan Bay purposefully inflated charges for inpatient and outpatient care to make these cases appear more costly than they actually were, and thereby obtained outlier payments from Medicare that it was not entitled to receive. For more: http://www.usdoj.gov/opa/pr/2007/March/07_civ_150.html
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Former Nursing Home Executives Indicted
On March 16, 2007, North Texas e-News reported that “Three former nursing home executives, one a lawyer, were charged yesterday in a federal indictment with various offenses related to their operation of nursing homes located in Texas and elsewhere, announced U.S. Attorney Richard B. Roper of the Northern District of Texas. A federal grand jury in Fort Worth returned the 29-count indictment charging Gary R. Trebert, Stephen Michael Ewing, a/k/a “Stephen Michaels,” and Larry Gordon May each with one count of conspiracy to defraud the Internal Revenue Service (IRS) and the U.S. Department of Health and Human Services (HHS), nine counts of tax evasion, five counts of mail fraud, seven counts of false statements to a government agency and seven counts of false statements relating to health care matters." For more:
http://www.ntxe-news.com/artman/publish/article_41267.shtml
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Three Indicted in Texas in Wheelchair Fraud Case
On March 9, 2007, U.S. Attorney for the Southern District of Texas Donald J. DeGabrielle, Jr. announced a 46-count health care fraud indictment charging Sandra Thurman Patino, also known as Sandra Thurman; Anthony D. Thurman; and Katrice Lashunn Oliver, also known as Katrice Warren, was unsealed today following the arrest of the three defendants. For more: http://www.usdoj.gov/usao/txs/releases/March2007/070309-Patino.htm
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Former Caregivers Face Fraud and Abuse Charges
On March 16, 2007, The Lebanon Daily News reported “Two former employees of a company that operates adult-care homes in Lebanon County have been charged in separate cases — one with abuse of a mentally retarded client, the other with fraud.
“Bobbi Sue Cessna, 26, formerly of 105 E. Washington Ave., Myerstown, was charged in state court with nine counts, including neglect of a care-dependent person, aggravated assault, conspiracy, reckless endangerment and theft by deception. If convicted, she could face three to 41⁄2 years on the aggravated assault charge alone.” For more: http://www.ldnews.com/news/ci_5452303
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HealthSouth and Portsmouth-Based Physicians Settle False Claims Allegations
On March 7, 2007, U.S. Attorney for New Hampshire Tom Colantuono announced that HealthSouth Corporation, Robert E. Eberhart, M.D., Jonathan Holzaepfel, M.D., Thomas King, M.D., Seacoast Trust and Seacoast Trust, L.L.P. have paid over $1 million to settle allegations that they violated the federal False Claims Act by submitting claims to Medicare based upon referrals that were tainted by an improper financial relationship.
For more: http://www.usdoj.gov/usao/nh/march07.html
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New York Pharmacy Owner Arrested for Stealing from Medicaid
On March 1, 2007, U.S. Attorney for the Southern District of New York announced that licensed pharmachist and owner of MLK Pharmacy in Manhattan Dinesh Dayabhai Shah, was arrested on charges they he systematically defrauded the Medicaid Program of at least $1.2 Million over the past four years by buying drug prescriptions from Medicaid beneficiaries in exchange for cash merchandise. For more: http://www.usdoj.gov/usao/nys/pressreleases/index.html
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Former Fletcher Allen Employee Sentenced for His Role in Cost-Hiding Conspiracy
On March 9, 2007, U.S. Attorney’s Office for Vermont announced that David Demers of Shelburne was sentenced to two years probation, 200 hours of community service, and a $25,000 fine, for conspiring to make false statements and conceal information relating to the costs of the Fletcher Allen Health Care (FAHC) Renaissance Project, a charge to which he had previously pled guilty. Chief Judge William K. Sessions, III, presided over the sentencing hearing which occurred in federal court in Burlington. For more: http://www.usdoj.gov/usao/vt/press/2007/mar/demers.html
March 10, 2007 Report in the Burlington Free Press: http://www.burlingtonfreepress.com/apps/pbcs.dll/ article?AID=2007703100309
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This week, MediRegs provided TWCC readers with the following Regulatory information: From the GAO, CMS Transmittals, and From the OIG.
Regulatory News
Medicare Reviewing Erythropoiesis Stimulating Agents (ESAS) Policies in Response to FDA’s Recent Black Box Warning and Public Health Advisories
On March 14, 2007, The Centers for Medicare & Medicaid Services (CMS) announced it is closely reviewing all Medicare policies related to the administration of Erythropoiesis Stimulating Agents (ESAs) in light of the Food and Drug Administration (FDA) recent issuances of new warnings regarding the use of ESAs. For more: http://www.cms.hhs.gov/apps/media/press/release.asp?
Counter=2090&intNumPerPage=10&checkDate=&checkKey
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&numDays=3500&srchOpt=0&srchData
=&keywordType=
All&chkNewsType
=1%2C+2%2C+3%2C+4%2C+5&intPage=
&showAll=&pYear=&year=&desc=&cboOrder=date
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CMS Update
Important Notice Regarding the Revised Form CMS-1500
In July 2006, the Form CMS-1500 (12-90) was revised by the National Uniform Claim Committee (NUCC) predominantly for the purpose of accommodating the National Provider Identifier. Since that time, the industry has been preparing for the implementation of the revised Form CMS-1500 (08-05). In September 2006, Medicare announced that it would implement the revised Form CMS-1500 (08-05) on January 1, 2007 with dual acceptability of both versions until March 31, 2007. Medicare further announced that beginning April 1, 2007, the only acceptable version of the form would be the Form CMS-1500 (08-05) and that the prior version, Form CMS-1500 (12-90), would be rejected.
It has recently come to our attention that there are incorrectly formatted versions of the revised form being sold by print vendors, specifically the Government Printing Office (GPO). After reviewing the situation, the GPO has determined that the source files they received from the NUCC’s authorized forms designer were improperly formatted. This resulted in the sale of both printed forms and negatives which do not comply with the form specifications.
Given the circumstances, CMS has decided to extend the acceptance period of the Form CMS-1500 (12-90) version beyond the original April 1, 2007 deadline while this situation is resolved. Medicare contractors will be directed to continue to accept the Form CMS-1500 (12-90) until notified by CMS to cease. At present, we are targeting June 1, 2007 as that date. In addition, during the interim contractors will be directed to return, not manually key, any Form CMS-1500 (08-05) forms received which are not printed to specification. By returning the incorrectly formatted claim forms back to you, we are able to make you aware of the situation which will allow you to begin communications with your form supplier.
The following will help you to properly identify which form is which. The old version of the form contains “Approved OMB-0938-0008 FORM CMS-1500 (12-90)” on the bottom of the form (typically on the lower right corner) signifying the version is the December 1990 version. The revised version contains “Approved OMB-0938-0999 FORM CMS-1500 (08-05)” on the bottom of the form signifying the version is the August 2005 version. The best way to identify if your CMS-1500 (08-05) version forms are correct is by looking at the upper right hand corner of the form. On properly formatted claim forms, there will be approximately a ¼” gap between the tip of the red arrow above the vertically stacked word “CARRIER” and the top edge of the paper. If the tip of the red arrow is touching or close to touching the top edge of the paper, then the form is not printed to specifications. Questions may be directed to Brian Reitz at Brian.Reitz@cms.hhs.gov .
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Medicare Now Provides Coverage for a One-time Ultrasound Screening for Abdominal Aortic Aneurysms as Part of the Initial Preventive Physical Examination
The Centers for Medicare & Medicaid Services (CMS) invites you to join with us in promoting awareness of abdominal aortic aneurysms (AAA) and the new screening benefit for the early detection of this disease. Three in four aortic aneurysms are AAAs. Aortic aneurysms account for about 15,000 deaths in the United States annually; of these 9,000 are AAA-related. Men are 5 to 10 times more likely than women to have an AAA and the risk increases with age. Although AAAs may be asymptomatic for years, as many as 1 in 3 eventually rupture if left untreated. Early diagnosis allows for more effective treatment and cure. Diagnosis of an AAA can be done painlessly with a simple ultrasound scan. Medicare now provides coverage for this screening service for eligible beneficiaries.
Medicare Coverage ~ Effective for dates of service on or after January 1, 2007, Medicare will pay for a one-time ultrasound screening for AAA for beneficiaries who are at risk (has a family history of AAA or is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime). Eligible beneficiaries must receive a referral for the screening as a result of their initial preventive physical examination (IPPE) also referred to as the Welcome to Medicare physical exam. There is no Part B deductible. The coinsurance/copayment applies.
IMPORTANT NOTE: Only Medicare beneficiaries who receive a referral for the AAA ultrasound screening as part of the Welcome to Medicare physical exam will be covered for the AAA benefit.
How Can You Help? As a trusted source, your recommendation is the most important factor in increasing the use of preventive services and screenings. CMS needs your help to ensure that patients new to Medicare receive their Welcome to Medicare physical exam within the first six months of their effective date in Medicare Part B and those beneficiaries at risk for AAA receive a referral for the ultrasound screening as part of their Welcome to Medicare physical exam. It could save their lives!
For More Information about Medicare’s coverage of the AAA benefit, refer to MLN Matters article MM5235 (2006), Implementation of a One-Time Only Ultrasound Screening for Abdominal Aortic Aneurysms (AAA), Resulting from a Referral from an Initial Preventive Physical Examination, located at http://www.cms.hhs.gov/MLNMattersArticles/ downloads/MM5235.pdf on the CMS website.
Upcoming CMS Open Door Forums
- The next Rural Health Open Door Forum (ODF) is Tuesday, March 27, 2007.
http://www.cms.hhs.gov/OpenDoorForums
/24_ODF_RuralHealth.asp
- 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
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
The next Ambulance Open Door Forum is Tuesday, April 24, 2007.
http://www.cms.hhs.gov/OpenDoorForums /10_ODF_Ambulance.asp
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From the GAO
Veterans' Disability Benefits: Processing of Claims Continues to Present Challenges, by Daniel Bertoni, acting director, education, workforce, and income security issues, before the Subcommittee on Disability Assistance and Memorial Affairs, House Committee on Veterans' Affairs. GAO-07-562T, March 13.
http://www.gao.gov/cgi-bin/getrpt?GAO-07-562T
Highlights - http://www.gao.gov/highlights/d07562thigh.pdf
DOD and VA Health Care: Challenges Encountered by Injured Service members during Their Recovery Process, by Cynthia A. Bascetta, director, health care, before the Subcommittee on Oversight and Investigations, House Committee on Veterans' Affairs. GAO-07-606T, March 8.
http://www.gao.gov/cgi-bin/getrpt?GAO-07-606T
Highlights - http://www.gao.gov/highlights/d07606thigh.pdf
Veterans' Disability Benefits: Long-Standing Claims Processing Challenges Persist GAO-07-512T, March 7, 2007 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_gao_cms &u=d07512t&h=top1.html&t=80&s=twcc
Medicare Spending: Preliminary Findings Regarding an Approach Focusing on Physician Practice Patterns to Foster Program Efficiency GAO-07-567T, March 6, 2007 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_gao_cms &u=d07567t&h=top1.html&t=80&s=twcc
Medicare: Improvements Needed to Address Improper Payments for Medical Equipment and Supplies GAO-07-59, January 31, 2007 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_gao_cms &u=d0759&h=top1.html&t=80&s=twcc
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CMS Transmittals
Medicare Benefit Policy - Basic Coverage Rules (PUB.100-02)
02/23/07 Transmittal #66 Services Not Provided Within United States (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_02 &u=mrepm10002R66BPBUSREQ&h=top1.html&t=80&s=twcc
Medicare Claims Processing (PUB. 100-04)
Transmittal #1192, Date: March 2, 2007 Payment and Billing for Islet Isolation Add-On in National Institutes of Health (NIH) Clinical Trial (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1192cp&h=top1.html&t=80&s=twcc
Transmittal #1191, Date: March 2, 2007 Type of Service (TOS) Corrections (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1191cp&h=top1.html&t=80&s=twcc
Program Integrity (PUB. 100-08)
02/23/07 Transmittal #190 General Background Information on Certified Providers and Certified Suppliers (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08 &u=mrpm10008r190pibusreq&h=top1.html&t=80&s=twcc
DMERC - Region C - Palmetto DMEPOS Supplier Manual
Revised Pages (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_d_palm_sm &u=spring2007revised&h=top1.html&t=80&s=twcc
Replacement Chart (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_d_palm_sm &u=spring2007replacmentchart&h=top1.html&t=80&s=twcc
DMEPOS Supplier Manual - Spring 2007 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_d_palm_sm &u=spring2007&h=top1.html&t=80&s=twcc
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From the OIG
List of Excluded Individuals/Entities
OIG 02/07 Cumulative Sanction Report-Reinstatements for February 2007 (Excel):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_fed_gov_oig_csr &u=0702rein&h=top1.html&t=80&s=twcc
OIG 02/07 Cumulative Sanction Report-Update for February 2007 (Excel):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_fed_gov_oig_csr &u=0702up&h=top1.html&t=80&s=twcc
Partnership Review -- Oklahoma Health Care Authority's Report on Hospice Covered Drugs for Dually Eligible Beneficiaries
http://oig.hhs.gov/oas/reports/region6/60600102.htm
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This Week’s Link:
OIG’s Recent Criminal Enforcement Actions
http://oig.hhs.gov/fraud/enforcement/criminal/07/0207.htm
OIG Advisory Opinion 07-02 PDF (concerning a hospital’s proposal to subsidize the cost of ambulance transportation for patients transported to the hospital from outside the hospital’s local area)
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Acronym Library
| CSTE | Council of State & Territorial Epidemiologists |
| CSTP | Carrier System Testing Project (or Program) |
| CTC | Certified Transplant Center |
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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