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Vol. VIII, No. 38 – November 10, 2006 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Compliance Academy
Table of Contents
Headlines
Cancer Center Settlement Announced
New Jersey Chiropractor Admits Fraud
Texas Doctor Convicted of Health Care Fraud
Jury Convicts Defendant in Health Care Kickback Case
Clinic Manager, Dentist Arrested for Medicaid Fraud
Technology Helps Medicare Investigators
Secret Ruling Issued by Judge
Use of FCA by Government to Increase
Regulatory News
CMS Updates
In the Federal Register
CMS Transmittals
From the OIG
This Week’s Links
Acronym Library
Visit
HCCA's Web site
HCCA
Headquarters - Contact Information
Headlines:
Cancer Center Settlement Announced
On November 7, U.S. Attorney for the Central District of California Debra Wong Yang announced that Comprehensive Cancer Centers, Inc. (CCC) has agreed to pay the federal government $900,000 to settle allegations that it knowingly caused the Medicare program to pay too much for services rendered at CCC's outpatient cancer center located at Desert Regional Medical Center in Palm Springs.
The Los Angeles-based CCC paid $450,000 of the settlement on October 25, and it is required to pay the remaining $450,000, plus interest, by December 8.
For more: http://www.usdoj.gov/usao/cac/pr2006/153.html
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New Jersey Chiropractor Admits Fraud
On November 6, the U.S. Attorney for New Jersey announced that a Fort Lee Chiropractor pleaded guilty to defrauding Horizon Blue Cross Blue Shield and other insurers out of more than $688,000 by submitting bogus claims. For more;
http://www.usdoj.gov/usao/nj/press/2006releases.html
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Texas Doctor Convicted of Health Care Fraud
On November 6, U.S. Attorney for Southern District of Texas Don DeGabrielle announced that a federal jury convicted Dr. Ira Klein of 44 counts of mail fraud and health care fraud in connection with a scheme to defraud various insurance companies of $10 million. The guilty verdicts, announced late this morning, were followed by a forfeiture hearing and the jury’s finding that Klein should forfeit $10 million as proceeds of his illegal scheme.
Klein, indicted in February 2006, was a physician who specialized in treating patients diagnosed with Hepatitis C. He billed insurance companies for services not provided to patients and misrepresented services that were actually provided. The fraudulent scheme involved ordering large quantities of medications used to treat Hepatitis C and providing medications to patients to self administer at home and then billing the insurance companies as if the injections had been administered by him or his staff in his office. For more:
http://www.usdoj.gov/usao/txs/releases/November2006/061106-Klein_print.htm
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Jury Convicts Defendant in Health Care Kickback Case
On November 3, U.S. Attorney for the Southern District of Florida R. Alexander Acosta announced that on November 2, 2006, a jury convicted defendant Armando Jose Figueredo, an owner of National Medical Laboratory, Inc. and other health care companies of Florida of five counts of a federal Indictment, charging him with conspiracy to pay health care kickbacks, in violation of Title 18, U.S.C., Section 371, and payment of kickbacks and bribes involving the Medicare program, in violation of Title 42, U.S.C., Section 1320a-7b(b)(2)(A)-(B). For more: http://www.usdoj.gov/usao/fls/PressReleases/061103-01.html
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Clinic Manager, Dentist Arrested for Medicaid Fraud
On November 2, Florida Attorney General Charlie Crist announced that two Miami-Dade residents were arrested and charged with multiple counts of fraud and theft. Miami dentist Lorenzo Puentes and Francisco Torres, the owner of the dental clinic where both men worked, were arrested for their involvement in a scheme that defrauded the Medicaid program out of more than $20,000. A third individual was arrested in March and pled guilty to fraud in June. For more:
http://myfloridalegal.com/newsrel.nsf/ newsreleases/A85EC5FDC7F0E69C8525721A004E4575
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Technology Helps Medicare Investigators
On November 7, USA Today reported that Medicare investigators in Los Angeles, using sophisticated computer technology to sift through claims data, saw an unusual pattern: A single patient had apparently undergone a diagnostic rectal-probe procedure 118 times in a year — at 21 medical facilities.” For more:
http://www.usatoday.com/tech/news/computersecurity/2006-11-06-medicare-usat_x.htm?POE=TECISVA
Also published on November 7, in USA Today, “Computer sleuths trying to stop health care fraud say they have a new weapon: computer programs that can flag potential fraud even before medical claims are paid.
"Everyone is trying to see if they can catch the fraud before the check goes out the door," says Andrea Allmon, director of health care operations at Fair Isaac, a firm known for its credit card scoring model that also sells health fraud detection computer systems.
“That's because companies can save far more money by stopping claims before they are paid than trying to get fraudsters to pay back money.” For more:
http://www.usatoday.com/money/industries/health/2006-11-07-medicare-side-usat_x.htm
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Secret Ruling Issued by Judge
On November 6, The Register-Guard reported that “A U.S. District judge has issued a secret ruling on whether PeaceHealth has to turn over a legal file to federal authorities who are investigating four Eugene heart surgeons suspected of defrauding Medicare and Medicaid.
Judge Anna Brown filed her opinion and order last week in U.S. District Court in Portland, but it is a "sealed document," her courtroom deputy, Steve Minetto, said.
At issue is who gets possession of a legal file created on behalf of the heart surgeons when they were an independent practice. PeaceHealth, the parent corporation of Sacred Heart Medical Center, bought their practice, Cardiovascular Surgical Associates, in November 2004.” For more: http://www.registerguard.com/news/2006/11/06/ c1.cr.docs.1106.p1.php?section=nation_world
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Use of FCA by Government to Increase
On November 9, CCH reported that “The federal False Claims Act (FCA) is the primary government weapon in combating health care fraud since it covers a broad range of activities and includes huge penalties and settlement potential, according to John Brennan, a Partner at Crowell & Moring LLP. He spoke at a Crowell & Moring seminar on October 26-27, 2006 in Washington, D.C.
Since 1986, $17 billion has been recovered under the FCA, including $12.4 billion in HHS-related cases alone. In 2004, 80 percent of all FCA recoveries were via whistleblower cases, he noted. "Whistleblower cases are rising exponentially," he said.
False claims prosecutions will “follow the money,” said Brennan, adding that prosecutions will increasingly involve Part D participants, the pharmaceutical product marketplace, medical device manufacturers, and fiscal intermediaries and carriers.” For more: http://health.cch.com/news/medicare/110906a.asp
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This week, MediRegs provided TWCC readers with the following Regulatory information: CMS Transmittals and From the OIG.
Regulatory News
CMS Updates
Fix to Correct National Provider Identifier Information within the 837 Institutional
Crossover Claim Files
The Centers for Medicare & Medicaid Services (CMS) has learned that its October 2, 2006 Fiscal Intermediary Shared System (FISS) release introduced error conditions (zeroes being populated in the 2010AA and 2010AB segments for the national provider identifier (NPI)) that negatively impacted the volume of Part A 837 COB claims that should have crossed to the supplemental (next) payer(s) after Medicare. The error condition created non-compliant HIPAA transactions that, as of October 27, prevented up to 97% of the Part A 837 COB claims from crossing to the next payer. The CMS has aggressively pursued a fix to the problem within the FISS and has been informed that the fix to correct the issue has been successfully tested. The installation of the fix into production has occurred or will occur and will produce two outcomes: 1) upon installation date of the fix into production at the Fiscal Intermediary locations, all claims transmitted to CMS’ Coordination of Benefits Contractor (COBC) to be crossed over to the next payer will no longer contain the error condition and the Part A Medicare claims crossover process will return to normal; 2) all claims that “errored” out due to this problem will be repaired and retransmitted to the COBC to be crossed over. As a result of the fix being installed at most Fiscal Intermediaries, the error rate for Part A 837 COB claims that were transmitted to the COBC for crossover to the next payer has dropped to 47% as of 11/2/2006.
The CMS anticipates that the Medicare paid claims affected by the error condition from October 2, 2006 until the individual production date of the fix at each Fiscal Intermediary will be repaired & retransmitted to the COBC for crossover to the next payer by the week of November 6th at the latest.
All Fiscal Intermediaries have reported that they have installed the fix into production with the exception of the following list. It is anticipated that these Fiscal Intermediaries will move the fix into production no later than November 5, 2006, enabling the Part A Medicare claims crossover process to return to its regular schedule and to recover the claims that did not cross from October 2, 2006 through November 4, 2006.
Noridian (Oregon, Idaho, North Dakota, Arizona, Utah, Wyoming, North Dakota)
Montana Blue Cross
Nebraska Blue Cross
Cahaba (Iowa, South Dakota)
AdminaStar Federal
Cooperativa de Seguros de Vida de Puerto Rico
Kansas Blue Cross
United Government Services
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Social Security Administration
Electronic Records Express “Embracing Technology to Deliver Benefits”
Technology is helping the Social Security Administration transform the disability decision-making process which will mean better service for Social Security disability benefit applicants across the country. You can help ensure more accurate and timely decisions for your patients by sharing your medical records electronically with Social Security and its partner agencies. This will also save you time and money copying and mailing medical records. If you would like to begin using the Social Security Administration’s secure website to send medical records or obtain more information about the options available for submitting records electronically, visit http://www.socialsecurity.gov/ere/, send an e-mail to electronic-records-express@ssa.gov or call 1-866-691-3061.
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CMS Convenes Medicare Coverage Advisory Committee on Clinical Trial Policy
The Centers for Medicare & Medicaid Services (CMS) will convene its Medicare Coverage Advisory Committee (MCAC) on December 13, 2006 at the CMS Headquarters in Baltimore, Maryland. The purpose of this meeting is to advise CMS on changes under consideration as the Agency re-visits Medicare’s Clinical Trial Policy.
Medicare has covered certain items or services provided in the context of clinical trials since 2000. The implementation of the Clinical Trial Policy has allowed CMS to increase access to cutting-edge medical technologies for Medicare beneficiaries who participate in clinical research studies. The Agency is seeking to update the policy to address some of the changes to the clinical research landscape that have occurred since 2000, as well as to answer some of the questions the beneficiary and provider communities have had in delivering items and services to Medicare study participants.
The Committee will call on the expertise of clinical research and methodological experts from private industry, academia, and other Federal agencies to review the standards Medicare uses to determine which studies should be eligible for Medicare coverage; recommend processes through which a trial is determined to meet these standards; and advise on the services that should be covered for the Medicare beneficiaries enrolled in these trials.
After the Committee meets in December, CMS will issue a proposed decision memorandum no later than April 2007, followed by a 30-day public comment period, and with a final policy expected 60 days after the close of the comment period.
For more information on the Clinical Trial Policy, including details about the December meeting, please visit the Coverage web site at http://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=186.
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The Hospice Payment System Fact Sheet, which is the second in the Medicare Learning Network’s (MLN) series of payment fact sheets, is now available in downloadable format on the MLN Products Page.
To access the fact sheet, visit http://www.cms.hhs.gov/MLNProducts/downloads/HospicePaymtSysfctsht.pdf. Print versions of the fact sheet will be available from the MLN in approximately six weeks (just in time for that perfect holiday gift!).
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In the Federal Register
November 9, 2006 – Final Rule
Medicare Program; Home Health Prospective Payment System Rate Update
for Calendar Year 2007 and Deficit Reduction Act of 2005 Changes to
Medicare Payment for Oxygen Equipment and Capped Rental Durable Medical
Equipment
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/06-9068.htm
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CMS Transmittals
Medicare Claims Processing (PUB. 100-04)
Transmittal #1095,Processing All Diagnosis Codes Reported on Claims Submitted to Carriers:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1095cp&h=top1.html&t=80&s=twcc
Transmittal #1094, Update To The Hospice Payment Rates, Hospice Cap, Hospice Wage Index and the Hospice Pricer For FY 2007:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1094cp&h=top1.html&t=80&s=twcc
Transmittal #1093,2006 Changes to the Laboratory National Coverage Determination Edit Software for January 2007:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1093cp&h=top1.html&t=80&s=twcc
Transmittal #1092, File Descriptions and Instructions for Retrieving the 2007 Fee Schedules and HCPCS through CMS Mainframe Telecommunication System:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1092cp&h=top1.html&t=80&s=twcc
Transmittal #1091, 2006 The Supplemental Security Income/Medicare Beneficiary Data for Fiscal Year 2005 for Inpatient Prospective Payment System Hospitals:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1091cp&h=top1.html&t=80&s=twcc
Transmittal #1090,Medicare Summary Notice Format Changes for Jurisdiction 3 A/B MAC Transition:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1090cp&h=top1.html&t=80&s=twcc
Transmittal #1089,Claim Status Category Code and Claim Status Code Update:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1089cp&h=top1.html&t=80&s=twcc
Transmittal #1088,Instructions for the Coordination of Medicare Secondary Payer claims for the Competitive Acquisition Program:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1088cp&h=top1.html&t=80&s=twcc
Transmittal #1087, 2006 Remittance Advice Remark Code and Claim Adjustment Reason Code Update:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1087cp&h=top1.html&t=80&s=twcc
Medicare Secondary Payer (PUB. 100-05)
Transmittal #57, Instructions for the Coordination of Medicare Secondary Payer claims for the Competitive Acquisition Program:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_mr_mspm&u=mremrmspmr57msp&h=top1.html&t=80&s=twcc
Financial Management (PUB. 100-06)
Transmittal #111, Status Codes for Financial Reporting of Debts Once the MMA Section 935 Appeal Process Has Been Completed:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_6&u=mrpm10006r111fm&h=top1.html&t=80&s=twcc
Program Integrity (PUB. 100-08)
Transmittal #168, DMEPOS Transcutaneous Electrical Nerve Stimulators Certificate of Medical Necessity for Purchases: Form CMS-848:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08&u=mrpm10008r168pi&h=top1.html&t=80&s=twcc
Demonstrations (PUB. 100-19)
Transmittal #50, Laboratory Competitive Bidding Demonstration (Second Phase of Implementation):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_mr_pm_100_19&u=mremrpm10019r50demo&h=top1.html&t=80&s=twcc
CMS One-Time Special Notification (PUB. 100-20)
Transmittal #245, Department of Veterans Affairs Medicare-equivalent Remittance Advice Project: Continued Use of Professional Legacy Provider Numbers After National Provider Identifiers Are Fully Implemented:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_20&u=mrepm10020r245otn&h=top1.html&t=80&s=twcc
Transmittal #244, New Contractor Numbers for Part A for the States of Montana, North Dakota, South Dakota, Utah, and Wyoming in Jurisdiction 3 Part AB Medicare Administrative Services Workload:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_20&u=mrepm10020r244otn&h=top1.html&t=80&s=twcc
DMERC - Region C - Palmetto DMEPOS Supplier Manual
Autumn Supplier Manual (3791 kb PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_d_palm_sm&u=autumn2006&h=top1.html&t=80&s=twcc
Revised Pages (2533 kb PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_d_palm_sm&u=autumn2006revised&h=top1.html&t=80&s=twcc
National Coverage Analyses
Clinical Trial Policy (CAG-00071R) - Expected Completion Date: 07/09/07:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CAG00071R3&h=top1.html&t=80&s=twcc
Medicare Coverage Advisory Committee Meetings - 10/30/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=mcacmeetings2&h=top1.html&t=80&s=twcc
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From the OIG
OIG Advisory Opinion No. 06-19 - Concerning a pharmaceutical company's proposal to establish a patient assistance program to provide outpatient prescription drugs to financially-needy Medicare Part D enrollees entirely outside of the Part D benefit:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=hc_ig_ao&u=ao0619&h=top1.html&t=80&s=twcc
OIG Advisory Opinion No. 06-18 - Concerning a volunteer services program for the provision of specialty medical care and professional development in rural areas, through which volunteers' travel costs would be covered:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=hc_ig_ao&u=ao0618&h=top1.html&t=80&s=twcc
Oversight and Evaluations of the Fiscal Year 2006 Hospital Payment Monitoring Program (A-03-06-00010; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=30600010&h=top1.html&t=80&s=twcc
Oversight and Evaluation of the Fiscal Year 2006 Comprehensive Error Rate Testing Program (A-03-06-00011; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=30600011&h=top1.html&t=80&s=twcc
Review of Subaward Costs Claimed Under University Of Massachusetts Medical School Prime NIH Grant Number 5 P01 HL56920-05 From February 1, 2001, Through August 31, 2002 (A-01-06-01501; 08/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_nih&u=10601501&h=top1.html&t=80&s=twcc
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This Week’s Links:
Advisory Opinion 06-20 concerning a durable medical equipment supplier’s practice of providing patients with free home oxygen until the patients qualify for Medicare coverage of oxygen, as well as the supplier’s proposed arrangement to provide patients with a free overnight oximetry test)
Important Announcement: The Office of Inspector General (OIG) will
discontinue publication of monthly exclusion actions in the Federal
Register in 1 month.
FR Nov. 7, 2006 - Program Exclusions: October 2006
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/E6-18758.htm
Advisory Opinion 06-21 PDF(concerning a pharmaceutical company’s proposal to establish a patient assistance program to provide outpatient prescription drugs to financially-needy Medicare Part D enrollees entirely outside of the Part D benefit) http://oig.hhs.gov/fraud/docs/advisoryopinions/2006/AdvOpn06-21.pdf
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Acronym Library
| PARD | Provider Audit & Reimbursement Department |
| PARL | Physician/Supplier Assignment Rate List |
| PART A | Medicare Hospital Insurance |
| PART B | Medicare Supplementary Medical Insurance |
For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp
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