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Vol. VIII, No. 35 – October 20, 2006 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Table of Contents
Headlines
Doctor Receives 22 Year Jail Term
Texas Doctor Arrested
St. Louis Nursing Home CEO Guilty of Fraud
Oklahoma Doctor Faces 10 Year Prison Sentence
Regulatory News
CMS: Aggressive Oversight Account for Reduction in Medicare Improper Claims Payment
CMS Updates and Announcements
Medicare Hospital Inpatient PPS Information
PPS FY 2008 wage index cycle
First-Ever Medicare Survey Finds Overall Satisfaction in
Contractor-Provider Relationship
Power Mobility Device Updates
Medicare Learning Network News
In the Federal Register
CMS Transmittals
This
Week’s Link
Acronym Library
Visit
HCCA's Web site
HCCA
Headquarters - Contact Information
Headlines:
Doctor Receives 22 Year Jail Term
On Friday, October 6, 2006 the St. Petersburg Times reported that “Seven months after he was found guilty of falsely diagnosing dozens of people with cancer and subjecting them to unnecessary surgery, Michael Rosin apologized to the patients who put their trust in him.
"I'm terribly, terribly sorry," Rosin said during his sentencing hearing in U.S. District Court on Wednesday. "I hope before they make a final decision about me, they will be patient, they will be forgiving, and they will not be overly strict or harsh as they form their opinion."
“But Rosin's tearful apology didn't sway the victims who attended his final hearing or U.S. District Judge William Castagna, who sentenced the disgraced Sarasota dermatologist to 22 years in prison.” For more: http://www.theledger.com/apps/pbcs.dll/article?AID=/ 20061006/NEWS/610060393/0/FRONTPAGE
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Texas Doctor Arrested
On October 10, ABC12/WJRT reported that “A Midland doctor has been charged with more than 100 counts of fraud.
“Hamid Taaid, 45, was arrested this morning and arraigned in U.S. District Court in Bay City. He's charged with 119 counts of Medicare and Medicaid fraud. The federal investigation appears to have lasted a little more than a month, according to U.S. court records. No word on when Doctor Taaid will be back in court.”
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St. Louis Nursing Home CEO Guilty of Fraud
On October 10, Associated Press reported that “A St. Louis nursing home executive pleaded guilty Tuesday to conspiracy to defraud Medicare and Medicaid by collecting payments for services not provided, U.S. Attorney Catherine Hanaway said.
“Robert Wachter, 59, chief executive officer of American Healthcare Management Inc., will serve 18 months in prison under a plea agreement.” For more: http://www.belleville.com/mld/belleville/news/state/15724928.htm
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Oklahoma Doctor Faces 10 Year Prison Sentence
On October 12 the Insurance Journal reported that “An Alva, Okla., doctor faces up to 10 years in prison and a $250,000 fine after pleading guilty to defrauding Medicare out of $1 million. Gregory Glase Pinegar also will forfeit more than $400,000 as part of his plea agreement with federal prosecutors in Oklahoma City.
A federal grand jury indicted Pinegar, 42, in March on two counts of health care fraud for allegedly overbilling Medicare for prescription drugs used to treat anemia and arthritis.
Prosecutors also intended to present evidence of fraudulent billing by Pinegar to Medicaid and private insurance companies, according to court documents, but he pleaded guilty rather than take his case to trial. For more:http://www.insurancejournal.com/news/ southcentral/2006/10/12/73245.htm
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This week, MediRegs provided TWCC readers with the following Regulatory information: CMS Transmittals.
Regulatory News
CMS: Aggressive Oversight Account for Reduction in Medicare Improper Claims Payment
On October 12, 2006, The Centers for Medicare & Medicaid Services (CMS) Administrator Mark B. McClellan, M.D., Ph.D., announced that aggressive oversight and improvement efforts have resulted in a further reduction of the number of improper Medicare claims payments from 5.2 percent in 2005 to 4.4 percent in 2006; a $1.3 billion reduction in improper payments.
“We have been increasing our efforts to reduce improper Medicare claims payments, and for the second year in a row, it’s paying off,” said CMS Administrator Mark B. McClellan, M.D., Ph.D. “Because we are able to measure the accuracy of payments more closely now, we are able to target our efforts more effectively with Medicare contractors and providers.”
The Medicare fee-for-service (FFS) error rate has declined from 14.2 percent in 1996, when the Medicare improper payment rate was first reported, to the current 4.4 percent in 2006. The recent error rate reductions have led to approximately $11 billion less in improper payments over the past two years. CMS pays more than 1 billion fee-for-service claims each year.
CMS conducted detailed reviews of randomly sampled Medicare FFS claims submitted between April 1, 2005 and March 31, 2006. Approximately 160,000 claims spanning all types of Medicare FFS payments were included in the Medicare error rate testing program. By providing accurate statistical information to its personnel and contractors, CMS can identify where problems exist and target improvement efforts to address the problems. For more: http://www.cms.hhs.gov/apps/ media/press/release.asp?Counter=2031
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CMS Updates and Announcements
Medicare Hospital Inpatient PPS Information
In the FY2007 IPPS final rule (71 FR 48024), CMS explained that, for certain hospitals, the wage index value that is effective October 1, 2007 will change for the second half of FY 2007 (that is, from April 1 through September 30, 2007), due to the March 31, 2007 expiration of reclassifications under section 508 of Pub. L. 108-173. Table 2 in the final notice (CMS-1488-N, displayed at http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/cms-1488-N.pdf) and on CMS’s Acute Inpatient web page (at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/ itemdetail.asp?filterType=keyword&filterValue= table%202&filterByDID=0&sortByDID=3&sortOrder= ascending&itemID=CMS061712 ) shows a single FY 2007 wage index value for each hospital that reflects a 50-50 blend of the hospital’s first half and second half wage indices. In a new file posted October 6, “Supplemental Table 2 for FY 2007”, CMS has included two additional columns on Table 2 to show hospitals’ wage indices for each of the first and second half of FY 2007.
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PPS FY 2008 wage index cycle
Friday, October 6, 2006 marked the beginning of the Medicare hospital Inpatient PPS FY 2008 wage index cycle. On Friday October 6, 2006, CMS posted 3 excel files: one with preliminary Worksheet S-3 wage data from FY 2004 cost reports, and two files with preliminary first quarter and second quarter Calendar Year 2006 occupational mix survey data, respectively. In addition, CMS will be posting a document called The FY 2008 Hospital Wage Index Development Timetable. Please go to CMS’s wage index website at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/ list.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending to verify your hospital’s S-3 wage and occupational mix data. Hospitals have until December 4, 2006 to request revisions to their S-3 wage data and first quarter and second quarter occupational mix survey data (along with supporting documentation) as included in these October files. FIs must receive the revision requests and supporting documentation by December 4, 2006.
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First-Ever Medicare Survey Finds Overall Satisfaction in Contractor-Provider Relationship
CMS recently unveiled the results of the first Medicare Contractor Provider Satisfaction Survey (MCPSS). According to the survey, the vast majority of Medicare health care providers are satisfied with the customer service, claims processing and educational activities provided by the Medicare fee-for-service (FFS) contractors.
The MCPSS is designed to garner objective, quantifiable data on provider satisfaction with the 42 FFS contractors that process and pay more than $280 billion in Medicare claims each year. The survey focuses on the seven business functions of the provider-contractor relationship – provider communications, provider inquiries, claims processing, appeals, provider enrollment, medical review, and provider audit and reimbursement.
The MCPSS was sent in early 2006 to more than 25,000 randomly selected providers, including physicians, suppliers, health care practitioners and institutional facilities that serve Medicare beneficiaries across the country. Respondents were asked to rate their contractors using a scale of 1 to 6 on each of the business functions, with “1” representing “not at all satisfied” and “6” representing “completely satisfied.” The MCPSS revealed that 85 percent of respondents rated their contractors between 4 and 6 on a 6-point scale.
The full results of the 2006 survey are now available at: http://www.cms.hhs.gov/MCPSS/.
In January 2007, the next MCPSS will be distributed to a new sample of Medicare providers. 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 providers randomly chosen to participate in the 2007 MCPSS implementation, you have an opportunity to help CMS improve service to all providers.
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Power Mobility Device Updates
The PMD fee schedule ceiling amounts are now available on the CMS website at: http://www.cms.hhs.gov/DMEPOSFeeSched/ .
The fee schedule amounts for all States were available as of October 3, 2006, in a public use file available at:
http://www.cms.hhs.gov/DMEPOSFeeSched/ LSDMEPOSFEE/list.asp
Tthe new PMD codes, fee schedule amounts and local coverage determinations (LCDs) were originally scheduled to take effect on October 1, 2006. In order to allow for additional time to prepare for implementation of the fee schedule amounts and LCDs, these changes will be effective on November 15, 2006.
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Medicare Learning Network News
Updates to the Medicare Physician Guide & Companion Facilitator’s Guide
Revised errata sheets and downloadable versions of the Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals and the Facilitator’s Guide – Companion to Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals have been posted on the Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network. To access these publications, visit www.cms.hhs.gov/MLNProducts/MPUB/list.asp on the CMS website
Acute Inpatient Prospective Payment System (IPPS) Web-Based Training Course
The Acute Inpatient Prospective Payment System (IPPS) web-based training course is now available. This course provides an overview of the Acute Hospital Inpatient Prospective Payment System (IPPS) and is designed to present a basic explanation of inpatient hospital coverage, billing and payment under this payment system. This course can be accessed through the web-based training modules link under the ‘Related Links Inside CMS’ section at www.cms.hhs.gov/MLNProducts .
The Skilled Nursing Facility Consolidated Billing Web-Based Training Course is now available on the Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network (MLN). The course provides general information about Skilled Nursing Facilities (SNF), SNF Consolidated Billing, and “under arrangement” agreements between SNFs and other providers or suppliers. To access the course, visit www.cms.hhs.gov/mlngeninfo/01_overview.asp, scroll down to “Related Links Inside CMS,” and select “Web-Based Training Modules.”
The Skilled Nursing Facility Prospective Payment
System Fact Sheet, which is the first in an upcoming series of payment fact sheets, is now available in downloadable format on the CMS MLN. To access the fact sheet, visit www.cms.hhs.gov/MLNProducts/downloads/snfprospaymtfctsht.pdf. The fact sheet will be available for ordering through the MLN in approximately six weeks.
The revised Understanding the Medicare Learning Network fact sheet is now available in downloadable format on the MLN Publications Page located at www.cms.hhs.gov/MLNproducts/downloads/Fact_Sheet_6JUN2006.pdf. This fact sheet explains the MLN web pages within the CMS website and provides an overview of the MLN and where to access information and education resources that are available through the MLN. Hard copies will be available in approximately six weeks.
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In the Federal Register
October 12, 2006
Notice
Privacy Act of 1974; Report of a Modified or Altered System of
Records
In accordance with the Privacy Act of 1974, we are proposing
to modify or alter an existing SOR, ``Medicare Managed Care Beneficiary
Reconsideration (RECON) System,'' System No. 09-70-4003, last published
at 67 Federal Register 48179 (July 23, 2002).
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/E6-16852.htm
October 11, 2006
Notice
CMS: Hospital Inpatient Prospective Payment Systems and
Fiscal Year 2007 Rates
This notice contains tables listing the final occupational mix
adjusted wage indices, hospital reclassifications, payment rates,
impacts, and other related tables as a result of the application of the
occupational mix adjustment to 100 percent of the wage index effective
for fiscal year (FY) 2007.
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/06-8471.htm
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CMS Transmittals
Medicare Benefit Policy - Basic Coverage Rules (PUB. 100-02)
Transmittal #55, Psychological and Neuropsychological Tests:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_02&u=mrepm10002r55bp&h=top1.html&t=80&s=twcc
Medicare Claims Processing (PUB. 100-04)
Transmittal #1067, Fiscal Year 2007 Inpatient Prospective Payment System, Long Term Care Hospital PPS, and Inpatient Psychiatric Facility PPS Changes:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1067cp&h=top1.html&t=80&s=twcc
Transmittal #1069, Reopenings and Revisions of Claim Determinations and Decisions:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1069cp&h=top1.html&t=80&s=twcc
Transmittal #1068, 2007 Annual Update of HCPCS Codes for Skilled Nursing Facility Consolidated Billing for the Common Working File, Medicare Carriers and Fiscal Intermediaries:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1068cp&h=top1.html&t=80&s=twcc .
Program Integrity (PUB. 100-08)
Transmittal #164, Update the Common Working File Duplicate Edits, Utilization Error Codes, Paid Claims History List and Part B Claims Screens to Use National Provider Identifiers in Place of Unique Physician Identification Numbers:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08&u=mrpm10008r164pi&h=top1.html&t=80&s=twcc
CMS One-Time Special Notification (PUB. 100-20)
Transmittal #238, Instructions for Fiscal Intermediary Standard System and Multi-Carrier System Healthcare Integrated General Ledger Accounting System Changes:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_20&u=mrepm10020r238otn&h=top1.html&t=80&s=twcc
Transmittal #239, Communications Infrastructure Testing:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_20&u=mrepm10020r239otn&h=top1.html&t=80&s=twcc
National Coverage Analyses
Infrared Therapy Devices (CAG-00291N) - Expected Completion Date: 10/24/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CAG00291N4&h=top1.html&t=80&s=twcc
Extracorporeal Photopheresis (CAG-00324R) - Expected Completion Date: 01/02/07:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CAG00324R2&h=top1.html&t=80&s=twcc
Prothrombin Time (Addition of ICD-9-CM V58.83, Encounter for therapeutic drug monitoring, as a covered indication) (CAG-00339N) - Expected Completion Date: 10/24/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CALCAG00339N2&h=top1.html&t=80&s=twcc
Partial Thromboplastin Time (PTT) (Addition of ICD-9-CM V58.83, Encounter for therapeutic drug monitoring, as a covered indication) (CAG-00338N) - Expected Completion Date: 10/24/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CALCAG00338N2&h=top1.html&t=80&s=twcc
Thyroid Testing (Addition of ICD-9-CM 783.0, Anorexia, as a covered indication) (CAG-00337N) - Expected Completion Date: 10/24/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CALCAG00337N2&h=top1.html&t=80&s=twcc
Hepatitis Panel/Acute Hepatitis Panel (Addition of ICD-9-CM 790.5, Other nonspecific abnormal serum enzyme levels, as a covered indication) (CAG-00335N) - Expected Completion Date: 10/24/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CALCAG00335N2&h=top1.html&t=80&s=twcc
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From the OIG
Advisory Opinion 06-16 concerning a proposed arrangement for a durable medical equipment (DME) manufacturer to provide advertising assistance and reimbursement consulting services to some of its customers
Audit Reports
Duplicate Medicare Payments to Cost-Based Health Maintenance Plan Scott & White Health Plan for the Fiscal Years 2002, Through 2004
http://oig.hhs.gov/oas/reports/region5/50600031.htm
Report on the Medicare Drug Discount Card Program Sponsor a Claim, Inc.
http://oig.hhs.gov/oas/reports/region6/60600014.htm
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This Week’s Link:
OIG Exclusions and Reinstatements for the month of September 2006
http://oig.hhs.gov/fraud/exclusions.html
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Acronym Library
| NCCLS | National Council of Clinical Laboratory Services |
| NCCNHR | National Citizen's Coalition for Nursing Home Reform |
| NCCR | National Colorectal Cancer Roundtable |
| NCD | National Coverage Determination |
| NCGME | National Council on Graduate Medical Education |
For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp
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