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Vol. IX, No. 2 – January 12, 2007 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Table of Contents
Headlines
Tennessee Cardiologists Settle, Agree to Pay $2.9 Million
Massachusetts Man Gets Jail Term
Five Admit Guilt in Bogus Clinic Scam
Mississippi Doctor Settles Medicare Fraud Charges
HCCA Survey Reveals Members Concerns
Regulatory News
A Message for Medicaid Providers Regarding Section 6032 of the Deficit Reduction Act
CMS Announces Grant Awards
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:
Tennessee Cardiologists Settle, Agree to Pay $2.9 Million
According to the January 6, 2007 Mountain Press, “A group of 42 cardiologists with East Tennessee Heart Consultants (ETHC) has agreed to pay $2.9 million in restitution and settlement of a civil claim that they have kept overpayments from patients, federally-funded health care programs, and insurance companies since 1995, according to an announcement by the U.S. Attorney's Office.
ETHC has offices in Knox and surrounding counties, including an office at 681 Middle Creek Road in Sevierville. For more:
http://www.zwire.com/site/news.cfm?BRD=1211&dept_id= 169689&newsid=17673973&PAG=461&rfi=9
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Massachusetts Man Gets Jail Term
On January 11, 2007 the Westborough News reported that “A Westborough, Massachusetts man who committed Medicare fraud for more than a decade was sentenced yesterday in federal court to two and a half years in prison.
James Taylor, 67, of 77 Ruggles St., was also fined $6,000 and he has to pay more than $636,000 in restitution to go along with the $279,500 he has already paid. After his release, he will be supervised for two years.
Taylor admitted in September he never delivered expensive medical equipment he billed to Medicare or to Blue Cross/Blue Shield. In some cases, he delivered a less expensive version of the equipment, according to court records. For More: http://www.townonline.com/westborough/ homepage/8999010857782345727
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Five Admit Guilt in Bogus Clinic Scam
The January 11, 2007 issue of the Mercury News reported that “A group of Southern California health care providers pleaded guilty Wednesday to stealing nearly $1 million from the government by operating a bogus Milpitas medical clinic that targeted elderly patients from the Vietnamese community.
“The five defendants admitted carrying out a sophisticated health care fraud that involved recruiting hundreds of unwitting patients with the promise of free checkups and then billing the federal Medicare program for tests and procedures that were either unnecessary or never performed.” For more: http://www.mercurynews.com/mld/mercurynews/ living/16430234.htm
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Mississippi Doctor Settles Medicare Fraud Charges
WLBT 3 posted on January 11, 2007 the following Associated Press report “A Jackson psychiatrist has agreed to pay $216,000 to settle allegations of Medicare and Medicaid fraud after a multiyear investigation concluded.
The U.S. Attorney's Office alleges that Dr. Viacin Faeza Jones misused billing codes and billed Medicare and Medicaid for excessive numbers of patients per day.” For more: http://www.wlbt.com/Global/story.asp?S=5929046
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HCCA Online Survey Results
Recently, the Health Care Compliance Association asked its members to select topics from the Health and Human Services Office of Inspector General 2007 Work Plan that are most relevant. The following are the top 10 topics they selected:
- Medical appropriateness of Coding and Diagnosis-Related Group services
- Unbundling of hospital outpatient services
- Outpatient department payments
- Evaluation of “incident to” services
- “Inpatient only” services performed in an outpatient setting
- Physical and occupational therapy services
- Inpatient rehabilitation facility compliance and Medicare requirements
- Outpatient outlier and other charge-related issues
- Payments for observation services vs. inpatient admissions for dialysis
- Cardiography and echocardiography
For the complete results: http://www.hcca-info.org/Content/
NavigationMenu/ComplianceResources/ Surveys/
OIG-WorkPlan.htm
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This week, MediRegs provided TWCC readers with the following Regulatory information: CMS Transmittals and In the Federal Register.
Regulatory News
A Message for Medicaid Providers Regarding Section 6032 of the Deficit Reduction Act
The Centers for Medicare & Medicaid Services (CMS) understands the interest and concern over the implementation of Section 6032 of the Deficit Reduction Act, entitled “Employee Education About False Claims Recovery”. Further guidance will be forthcoming soon. In the interim, any questions or concerns may be directed to the following e-mail address: Medicaid_integrity_program@cms.hhs.gov. No questions will be answered individually prior to the issuance of additional guidance. However, CMS noted it will make every reasonable attempt to consider any questions or issues raised through an e-mail to that address.
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CMS Announces Grant Awards
On January 12, 2007 CMS announced that 17states will receive more than $23 million in grants for FY 07 and up to $900 million over five years for demonstration programs that will help build Medicaid long-term care programs to keep people in the community and out of institutions.
The awards, announced by Leslie Norwalk, acting administrator for the Centers for Medicare and Medicaid Services (CMS), are the first round of grants that will total $1.75 billion over five years (2007-2011) to help states shift Medicaid’s traditional emphasis on institutional care to a system offering greater choices for individuals and a full range of home- and community-based services. This Money Follows the Person (MFP) “rebalancing” initiative was included in the Deficit Reduction Act of 2005 (DRA) currently being implemented by CMS.
For more details about the New Freedom Initiative, of which this demonstration is part, visit the CMS web site at: http://www.cms.hhs.gov/newfreedom/. For the complete press release: http://www.cms.hhs.gov/apps/media/press/release.asp?
Counter=2074&intNumPerPage=10&checkDate=&checkKey=
&srchType=&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 Updates
Recently-Released MLN Matters Articles
-MM5332 – Instructions for the Coordination of Medicare Secondary Payer (MSP) claims for the Competitive Acquisition Program (CAP)
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/MM5332.pdf
-MM5478 – Outpatient Therapy Cap Exception Process for 2007
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/MM5478.pdf
-MM5486 – Payment by DME MACs and DMERCs for the Administration of Part D Vaccines
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/MM5486.pdf
-Revised: MM5459 – Emergency Update to the 2007 Medicare Physician Fee Schedule Database (MPFSDB)
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/MM5459.pdf
-Revised: MM4239 – Claims Submission Instructions for Institutional Providers Billing Vaccine Claims in Cases Where a National Provider Identifier (NPI) Is Not Available
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/MM4239.pdf
-SE0702 – Annual Medicare Contractor Provider Satisfaction Survey: Make Your Voice Heard!
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/SE0702.pdf
-MM5431 – Rules of Behavior Governing Medicare Eligibility Inquiries
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/MM5431.pdf
-MM5438 – 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)
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/MM5438.pdf
-MM5468 – Tax Relief and Health Care Act of 2006 Changes to Independent Laboratory Billing for the Technical Component (TC) of Physician Pathology Services
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/MM5468.pdf
NPI News from the Centers of Medicare and Medicaid Services:
-New MLN Matters Article Available
A new Special Edition MLN Matters article is now posted on the CMS website with important information for Medicare providers, as well as information that may be helpful for all health care providers. You can view this article by visiting http://www.cms.hhs.gov/MLNMattersArticles/ downloads/SE0679.pdf on the CMS website.
-WEDI NPI Readiness Survey Now Open
This is the last in a series of WEDI surveys to measure the healthcare industry's ability to meet the May 23, 2007 NPI implementation deadline. You can take the survey by visiting http://www.surveymonkey.com/s.asp?u=64993103585 on the web.
Please note that the survey is only open until Friday, January 19th.
-Upcoming WEDI Events
WEDI will host the WEDI NPI Industry Forum on February 12th and an audiocast on the impact of the NPI on standard transactions on February 28th. Visit the WEDI website for more details at http://www.wedi.org/npioi/index.shtml on the web. Please note that there is a charge to participate in WEDI Events.
Update Information Regarding Fix to Correct National Provider Identifier (NPI) Information within the 837 Institutional Crossover Claim File
-The Centers for Medicare & Medicaid Services (CMS) has been monitoring the progress of its Part A Medicare contractors and their associated Data Centers with respect to installation of the Fiscal Intermediary Shared System (FISS) fix to ensure that all future Part A 837 COB claims will be devoid of zero-filled NPI values. All Medicare contractors have installed the fix, with the majority having done so on or before November 11, 2006. CMS has also been closely monitoring the progress of its Part A Medicare contractors and their Data Centers with respect to the repair and retransmission of the Part A 837 COB claims that contained the non-compliant NPI values. Though a large number of Part A contractors have successfully repaired and retransmitted their 837 COB claims that had contained the NPI problem, the following contractors, representing the states indicated, have been unable to successfully repair and retransmit their problem NPI claims through the COBA process: Cahaba Government Benefits Administrator (Iowa and South Dakota #00011) Kansas Blue Cross/Wheatland Administrators (Kansas #00150 Nebraska Blue Cross (Nebraska #00260) Noridian Administrative Services (Arizona #03001, Montana #03201, Oregon/Idaho #00325, Utah #03501, and Wyoming #03061)
Palmetto Government Benefits Administrator (North Carolina #00382– only claims paid by Medicare on October 27, 2006, were repaired and transmitted to supplemental payers.)
Providers that would have billed claims to one of these Medicare Part A contractors during the period from October 1, 2006, to November 11, 2006, and that have not received reimbursement on these claims from their patients’ supplemental insurers/payers (including Medicaid) should now bill them for supplemental payment.
Since Cahaba GBA for Iowa and South Dakota apparently did not install the fix to correct the NPI problem until approximately November 25, 2006, providers that would have billed claims to Cahaba GBA for Medicare reimbursement from October 1, 2006, to November 25, 2006, and have not received reimbursement on these claims from their patients’ supplemental insurers/payers should now bill them for supplemental claim payment (claims submitted to Cahaba GBA from October 1, 2006, to November 25, 2006).
Importance of Keeping Supplier Information Current
DMEPOS supplier standard # 2 requires ALL supplies to notify the NSC of any change to the information provided on the CMS 855S application form within 30 days of the change. This is especially important for suppliers who will be involved in the Medicare DMEPOS Competitive Bidding Program. These suppliers must ensure the information listed on their supplier files is accurate to enable participation in this program.
The Medicare DMEPOS Competitive Bidding Program will be phased in beginning in 2007.
Suppliers must understand the importance of keeping their supplier information current. Information and instructions on how to submit a change of information may be found on the NSC Web site (www.palmettogba.com/nsc) and by the following this path: Supplier Enrollment/Change of Information/Change of Information Guide. For more information on the Medicare DMEPOS Competitive Bidding Program please visit the CMS Competitive Bidding Web site (www.cms.hhs.gov/CompetitiveAcqforDMEPOS/).
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From the GAO
Prescription Drugs: An Overview of Approaches to Negotiate Drug Prices Used by Other Countries and U.S. Private Payers and Federal Programs GAO-07-358T, January 11, 2007
Abstract Highlights-PDF PDF Accessible Text
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In the Federal Register
HHS Proposes Rescinding Its Rules on Shipment of Etiologic Agents
On January 3, 2007, HHS proposed removing its regulations governing the interstate shipment of etiologic agents, because the Department of Transportation already has in effect a more comprehensive set of regulations applicable to the transport in commerce of infectious substances. The DOT regulations are in harmony with international standards adopted by the United Nations Committee of Experts on the Transport of Dangerous Goods for the classification, packaging, and transport of infectious substances. Rescinding the rule will eliminate duplication of the more current DOT regulations that cover intrastate and international, as well as interstate transport.
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_fr69_hhs&u=0701038&h=top1.html&t=80&s=twcc
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CMS Transmittals
Medicare Benefit Policy - Basic Coverage Rules (PUB. 100-02)
Transmittal #63, Outpatient Therapy Cap Exceptions Process for Calendar Year 2007:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm _100_02&u=mrepm10002r63bp&h=top1.html&t=80&s=twcc
Medicare Claims Processing (PUB. 100-04)
Transmittal #1146, Payment by DME MACs and DMERCs for the Administration of Part D Vaccines:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm _100_04&u=mrepm10004r1146cp&h=top1.html&t=80&s=twcc
Transmittal #1145, Outpatient Therapy Cap Exceptions Process for Calendar Year 2007:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm _100_04&u=mrepm10004r1145cp&h=top1.html&t=80&s=twcc
Transmittal #1144, Elimination of CMS-1491 and CMS-1490U Forms:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm _100_04&u=mrepm10004r1144cp&h=top1.html&t=80&s=twcc
Financial Management (PUB. 100-06)
Transmittal #112, Chapter 7, Internal Control Requirements Update:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm _100_6&u=mrpm10006r112fm&h=top1.html&t=80&s=twcc
Program Integrity (PUB. 100-08)
Transmittal #181, Outpatient Therapy Cap Exceptions Process for Calendar Year 2007:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm _100_08&u=mrpm10008r181pi&h=top1.html&t=80&s=twcc
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From the OIG
Audit Reports
Review of Associated Hospital Service Payments to Long-Term Care Hospitals in Massachusetts From January 1, 2003, Through April 30, 2004
http://oig.hhs.gov/oas/reports/region1/10600506.htm
Review of Additional Reimbursement for Distinct-Part Nursing Facilities of Public Hospitals in California
http://oig.hhs.gov/oas/reports/region9/90500050.htm
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This Week’s Link:
OIG’s recent Criminal Enforcement Actions
http://oig.hhs.gov/fraud/enforcement/criminal/06/1206.htm
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Acronym Library
| BSR | (Part B) Bill Summary Records |
| BSRS | Benefit Savings Reporting System |
| BSS | Beneficiary Satisfaction Survey |
For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp
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