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Table of Contents
Headlines
Florida Clinic Owner, Manager Convicted of Fraud
Beverly Settlement Announced
Beverly Name Change Announced
Louisiana Medical Center Settles Medicare Fraud Claims
USC Acts to Terminate Lease
Pharma Supply Company Charged with Medicaid Fraud
Regulatory News
CMS Updates and Notes
In the Federal Register
CMS Transmittals
Court Cases and Administrative Actions
From the OIG
This
Week’s Link
Acronym Library
Visit
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Headlines:
Florida Clinic Owner, Manager Convicted of Fraud
On August 23, News4Jax reported that “The former owner and the office manager of a walk-in medical clinic in Jacksonville were convicted Tuesday of 25 federal charges including health care and mail fraud and lying to cover it up.
Robert Brown, 63, was the owner and acting manager of RCB Inc. Medical Clinic and Laurette Hunter, 42, was his office manager. The two were accused of working together from March 2002 until September 2004 to bill private insurance companies $2 million in services never provided, according to United States Attorney Paul Perez. For more:
http://www.news4jax.com/news/9723663/detail.html
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Beverly Settlement Announced
On August 18, the US Department of Justice announced that Beverly Enterprises, Inc. has agreed to pay $20 million to settle allegations that its former wholly owned subsidiary, MK Medical, violated the civil False Claims Act.
The government alleged that MK Medical submitted false claims for payment to the Medicare and Medi-Cal programs from 1998 until 2002, while Beverly owned the company. MK Medical, a now-defunct wholesaler of durable medical equipment (DME), allegedly billed Medicare and Medi-Cal for DME provided to the programs’ beneficiaries without obtaining the proper claims and medical documentation.
“This agreement reflects the government’s determination to prevent fraud and abuse by ensuring that health care providers comply with program safeguards regarding critical documentation,” said Assistant Attorney General Peter D. Keisler of the Justice Department’s Civil Division.
Beverly has agreed to settle these allegations by paying $14,487,278 to the United States and $5,512,722 to the state of California. No action has been filed in court. The Medicare program is funded by the federal government, while the Medi-Cal program is jointly funded by the federal government and California.
For more: http://www.usdoj.gov/opa/pr/2006/August/06_civ_560.htm
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Beverly Name Change Announced
Also on August 18, the Arkansas Democrat Gazette reported that “The company that bought the former Beverly Enterprises Inc. announced a name change Thursday that will affect 78 percent of its nursing homes and assisted living centers nationwide.
“Golden Gate National Senior Care Holdings LLC is now Golden Horizons. Golden Gate completed a $ 2. 29 billion acquisition of Beverly in March.” For more: http://www.nwanews.com/adg/Business/163875/
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Louisiana Medical Center Settles Medicare Fraud Claims
On August 17, the US Department of Justice announced that Our Lady of Lourdes Regional Medical Center has agreed to pay the United States $3.8 million to settle claims that they defrauded Medicare, TRICARE and Medicaid from 1999 to 2003.
Today’s civil settlement resolves allegations that the Lafayette, La., facility violated the False Claims Act by submitting claims for medically unnecessary elective angiogram, medically unnecessary elective angioplasty, and medically unnecessary elective stenting procedures performed at the hospital by Dr. Mehmood Patel between from 1999 to 2003. For more: http://www.usdoj.gov/opa/pr/2006/August/06_civ_554%20.html
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USC Acts to Terminate Lease
On August 23, Associated Press reported that “The University of Southern California wants hospital operator Tenet Healthcare Inc. to give up control of its USC University Hospital, claiming Tenet's recent financial and legal troubles void the terms of its lease.
“USC filed a lawsuit Tuesday in Superior Court, asking a judge to enforce a notice sent to Dallas-based Tenet triggering a lease provision that forces Tenet to vacate the hospital and sell the buildings to USC.
“Tenet has struggled with lawsuits, federal investigations and criminal charges over the past several years. In June, the company agreed to a $900 million settlement of charges it bilked Medicare. That came a month after Tenet agreed to pay $21 million to settle charges of making illegal kickbacks to doctors in San Diego.
“The USC lawsuit claims that Tenet's troubles have hurt the company's ability to invest in patient care. The company's declining reputation has also hurt its ability to recruit and retain top doctors and have caused patients to seek care elsewhere, the lawsuit alleges.
“Tenet said it has poured hundreds of millions of dollars into new equipment and facilities, including a 10-story tower scheduled to open later this year. The company said it had not yet seen the lawsuit.
“’Today is the first we've heard about any formal notice to terminate,’ Tenet spokesman Steven Campanini said Tuesday. ‘It appears to be an unfortunate negotiating tactic which is better left to the arbitration provisions in our agreement.’”
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Pharma Supply Company Charged with Medicaid Fraud
On August 22, the Detroit News reported that “The owner of a Livonia pharmaceutical supply company stood mute Monday at his arraignment on 148 counts of Medicaid fraud, the largest case of its kind in state history, according to Attorney General Mike Cox.
Daniel Edward Lohmeier, 43, of South Lyon, president of Specialized Pharmacy Services Inc., waived his right to a 14-day pretrial hearing during a brief appearance before Judge David Jordan in 54B District Court in East Lansing.Afterward, neither Lohmeier nor his attorney, David DuMouchel of Detroit, would comment on the charges.
According to Cox, Lohmeier from 1999 through 2005 bilked the state out of at least $5 million through Medicaid fraud, including the billing for prescriptions allegedly dispensed to 20 deceased people.”***top***
This week, MediRegs provided TWCC readers with the following Regulatory information: CMS Transmittals, From the OIG, and Court Cases and Administrative Actions.
Regulatory News
Centers for Medicare and Medicaid Services (CMS) Updates and Notes:
Nine-Day Hold on Medicare Payments in September
This is a reminder for all providers and physicians who bill Medicare contractors for their services. A brief hold will be placed on Medicare payments for all claims during the last 9 days of the Federal fiscal year (September 22 through September 30, 2006). These payment delays are mandated by section 5203 of the Deficit Reduction Act of 2005. No interest will be accrued and no late penalties will be paid to an entity or individual by reason of this one-time hold on payments. All claims held during this time will be paid on October 2, 2006.
This policy only applies to claims subject to payment. It does not apply to full denials, no-pay claims, and other non-claim payments such as periodic interim payments, home health requests for anticipated payments, and cost report settlements.
Please note that payments will not be staggered and no advance payments will be allowed during this 9-day hold.
For more information, please view the MLN Matters Article at
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/MM5047.pdf
***
End Date for Non HIPAA-Compliant ERAs
REMINDER!! Effective October 1, 2006, Medicare will only generate Health Insurance Portability and Accountability Act (HIPAA)-compliant Electronic Remittance Advice (ERA) transactions (transaction 835 version 004010A1) to all electronic remittance advice receivers.
Current figures indicate that 99% of all ERA receivers, (providers and other entities that receive the ERA on behalf of providers), are receiving a HIPAA compliant ERA format. Further, the overall compliance rate for all Medicare providers in May, 2006, was 96%.
Therefore, CMS announces that, effective October 1, 2006, it will end the contingency plan for the remittance advice transaction. After that date, your carriers, FIs, DMERCs, DME MACs, and RHHIs will send only HIPAA-compliant remittance advice (transaction 835) to all electronic remittance advice receivers. In doing so, Medicare will stop sending electronic remittance advice in any version other than the standard HIPAA version (835 version 004010A1), or in any other format (e.g., NSF).
For more information on Ending the Contingency for Remittance Advice, see:
http://www.cms.hhs.gov/MLNMattersArticles/ downloads/SE0646.pdf
If you have any questions, please contact your Medicare contractor at their toll free number, which may be found at: http://www.cms.hhs.gov/MLNProducts/downloads/ CallCenterTollNumDirectory.zip
***
NPI: August 23rd marked 9 months remaining until the National Provider Identifier (NPI) compliance date. Over 1 million NPIs have been issued so far --- do you have your NPI yet?
CMS will hold an NPI Roundtable on September 26, from 2-3:30 PM Eastern Time. To participate, you may call 1-877-203-0044, pass code 4795739
During this Roundtable CMS will address common questions related to Medicare’s guidance on Subparts. While CMS will only address questions from a Medicare perspective, this information may be helpful to all providers.
Medicare providers, who have questions, should select the appropriate e-mail below and send in questions by Friday, September 8th. Questions received after this date will not be considered.
--Medicare providers who bill a Fiscal Intermediary should send questions to: NPIQuestionsfromFIBillers@cms.hhs.gov
--Medicare providers who bill a Carrier should send questions to:
NPIQuestionsfromCarrierBillers@cms.hhs.gov
--Medicare providers who bill a Durable Medical Equipment Regional Carrier (DMERC) should send questions to: NPIQuestionsfromDMERCBillers@cms.hhs.gov
***
CMS has developed a variety of educational products and resources to help health care professionals and their staff become familiar with coverage, coding, billing, and reimbursement for preventive services covered by Medicare.
--The MLN Preventive Services Educational Products Web Page provides descriptions and ordering information for all provider specific educational products related to preventive services. The web page is located at www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp on the CMS website.
--The CMS Website provides information for each preventive service covered by Medicare. Click on www.cms.hhs.gov, select “Medicare”, and scroll down to “Prevention”.
For products to share with your Medicare patients, visit www.medicare.gov on the Web.
***top***
In the Federal Register
August 23
Proposed Rule
Medicare: Hospital Outpatient Prospective Payment System and CY 2007 Payment Rates
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/ edocket.access.gpo.gov/2006/06-6846.htm
Notice
Medicare Program; Senior Risk Reduction Demonstration
This notice informs interested parties of an opportunity to
apply to participate in a risk reduction/health management
demonstration project.
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/ edocket.access.gpo.gov/2006/06-7120.htm
***
August 22
Proposed Rule
Medicare Program; Revisions to Payment Policies Under the Physician
Fee Schedule for Calendar Year 2007 and Other Changes to Payment Under Part B -
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/ edocket.access.gpo.gov/2006/06-6843.htm
***
August 18
Final Rule
Revision to Hospital Inpatient Prospective Payment Systems--2007 FY
Occupational Mix Adjustment to Wage Index
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/ edocket.access.gpo.gov/2006/06-6692.htm
***
Medicare Program; Inpatient Rehabilitation Facility Prospective Payment
System for Federal FY 2007; Provisions Concerning Competitive
Acquisition for Durable Medical Equipment, Prosthetics, Orthotics, and
Supplies (DMEPOS); Accreditation of DMEPOS Suppliers
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/ edocket.access.gpo.gov/2006/06-6694.htm
***top***
CMS Transmittals
Medicare Claims Processing (PUB. 100-04)
Transmittal #1036, Updates to Chapter 10 of the Medicare Claims Processing Manual:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1036cp&h=top1.html&t=80&s=twcc
Transmittal #1035, Updating Publication 100-04, Chapter 30 Regarding the CD ROM Initiative for the Annual "Dear Doctor" Mailing:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1035cp&h=top1.html&t=80&s=twcc
Transmittal #1034, Competitive Acquisition Program - Claim Processing for Not Otherwise Classified Drugs:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1034cp&h=top1.html&t=80&s=twcc
Transmittal #1033, Revise Chapters 22 and 24 to delete references to free downloads of X12 implementation guides adopted as HIPAA standards from Washington Publishing Company:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1033cp&h=top1.html&t=80&s=twcc
Transmittal #1032, Correction to Skilled Nursing Facility Consolidated Billing Coding File:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1032cp&h=top1.html&t=80&s=twcc
Transmittal #1031, Remittance Advice Remark Code and Claim Adjustment Reason Code Update:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1031cp&h=top1.html&t=80&s=twcc
Transmittal #1029, Schedule for Completing the Calendar Year 2007 Fee Schedule Updates and the Participating Physician Enrollment Procedures:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1029cp&h=top1.html&t=80&s=twcc
Transmittal #1028, Downloading the Medicare Zip Code File:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1028cp&h=top1.html&t=80&s=twcc
Transmittal #1027, Clarifications and Additions to Chapter 19, Indian Health Services:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1027cp&h=top1.html&t=80&s=twcc
Transmittal #1026, Medicare Telehealth Services:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1026cp&h=top1.html&t=80&s=twcc
Transmittal #1025, Revised Home Health Advance Beneficiary Notice:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1025cp&h=top1.html&t=80&s=twcc
Financial Management (PUB. 100-06)
Transmittal #104, Updated Procedures for AC Communication with RAC:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_6&u=mrpm10006r104fm&h=top1.html&t=80&s=twcc
Program Integrity (PUB. 100-08)
Transmittal #156, Date: August 18, 2006 Evidence of Medical Necessity: Wheelchair and Power-Operated Vehicle Claims (Clarification of CR 3952, Transmittal 128, Dated October 28, 2005):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08&u=mrpm10008r156pi&h=top1.html&t=80&s=twcc
CMS One-Time Special Notification (PUB. 100-20)
Transmittal #235, Correction of Business Requirement 4320.19:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_20&u=mrepm10020r235otn&h=top1.html&t=80&s=twcc
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Court Cases and Administrative Actions
CMS Departmental Appeals Board Appellate Division Decisions
DAB(APP) 07/25/06 - 2036 - Clinical Immuno Diagnostic Lab, Inc. vs. CMS - revocation of CLIA certificate:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mms_dec_dabap&u=dab2036&h=top1.html&t=80&s=twcc
DAB(APP) 07/11/06 - 2035 - Lake Park Nursing and Rehabilitation Center vs. CMS - failure to comply and CMP's:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mms_dec_dabap&u=dab2035&h=top1.html&t=80&s=twcc
DAB(APP) 06/22/06 - 2034 - Renaissance III - compliance with CDC cooperative agreements:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mms_dec_dabap&u=dab2034&h=top1.html&t=80&s=twcc
DAB(APP) 06/20/06 - 2033 - Russell Mark Posner vs. Inspector General - program exclusion:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mms_dec_dabap&u=dab2033&h=top1.html&t=80&s=twcc
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From the OIG
Evaluation and Inspection Reports - Centers for Medicare and Medicaid Services
Nursing Home Emergency Preparedness and Response During Recent Hurricanes (OEI-06-06-00020; 08/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oei_cms&u=oei060600020&h=top1.html&t=80&s=twcc
Medicare Advantage Marketing Materials for Calendar Year 2005 (OEI-01-05-00130; 08/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oei_cms&u=oei010500130&h=top1.html&t=80&s=twcc
Evaluation and Inspection Reports - Food and Drug Administration
The Food and Drug Administration's National Drug Code Directory (OEI-06-05-00060; 08/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oei_fda&u=oei060500060&h=top1.html&t=80&s=twcc
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This Week’s Links:
Publication of OIG's Guidelines for Evaluating State False Claims Acts
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/E6-13749.htm
eHealth Initiative’s New State Legislation Tracking Center http://ccbh.ehealthinitiative.org/communities/community.aspx?Section=288
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Acronym Library
| MMAP | (AARP) Medicare/Medicaid Assistance Program |
| MMCITS | Medicaid Managed Care Information Tracking System |
| MMCQI | Medicare Managed Care Quality Improvement |
| MMCS | Medicare Managed Care System |
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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