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Vol. VIII, No. 39 – November 17, 2006 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Compliance Academy
Table of Contents
Headlines
Prior Steps Down in Face of Fraud Probe
Clinic Owner Charged with Medicare Fraud
Pharmaceutical Provider Settles
Health Care Company Owner Indicted
Survey: Public Trust Slipping
Cali Cartel Leaders Plead Guilty to Laundering Cocaine Proceeds through Pharmaceutical Drug Companies
Regulatory News
CMS Updates
Reports from the GOA
CMS Transmittals
From the OIG
This Week’s Links
Acronym Library
Visit
HCCA's Web site
HCCA
Headquarters - Contact Information
Headlines:
Prior Steps Down in Face of Fraud Probe
On November 15, Norfolk Eastern Daily Press (UK) reported that “Former MP David Prior has stood down as chairman of the Norfolk and Norwich University Hospital Trust following his arrest by police investigating fraud allegations.
“Mr. Prior announced his resignation in an email to staff and pledged to return to the post once he had proved his innocence. He had earlier been questioned under caution by Norfolk police following a dawn raid on his Swannington Manor home on Tuesday.
“The investigation centres on alleged financial irregularities at Cawston Park, an independent psychiatric hospital run by Norfolk-based company Chancellor Care, where Mr. Prior is non-executive chairman. For more:
http://new.edp24.co.uk/content/news/story.aspx?brand=
EDPOnline&category=News&tBrand=
edponline&tCategory=
news&itemid=NOED15%20Nov%20
2006%2020%3A24%3A49%3A030
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Clinic Owner Charged with Medicare Fraud
According to a November 12 report in the Los Angeles Daily News, “A Russian immigrant living in Agoura Hills has been charged with bilking Medicare out of more than $1.4 million in an elaborate scam in which he used Mother Teresa's personal physician to prey on homeless patients from Skid Row.
Rudik Avakyan, 55, in jail on $1.1 million bail, faces arraignment Monday on charges that he recruited Medi-Cal and Medicare card holders at Los Angeles's Union Rescue Mission for fraudulent billing at a clinic he owned and operated. For more: http://www.montereyherald.com/mld/
montereyherald/news/15994468.htm
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Pharmaceutical Provider Settles
According to a report in the November 15 issue of The Day, “A Kentucky pharmaceutical provider will pay the state nearly $3 million to settle allegations that it manipulated drug prescriptions distributed through four Connecticut pharmacies, including one in New London.
“Connecticut Attorney General Richard Blumenthal and Chief State's Attorney
Kevin T. Kane said Tuesday that Omnicare Inc., a leading provider of pharmaceuticals to the nation's elderly, agreed to a settlement that it overcharged the state's Medicaid program by switching prescriptions from tablets to capsules or capsules to tablets — whichever was more expensive.” For more:
http://www.theday.com/re.aspx?re=93adebf7-c750-46f3-8e8c-9bc40d84a62f
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Health Care Company Owner Indicted
On November 11, the Courier-Journal reported that “A federal grand jury in Louisville has indicted Anthony J. Conti and the company he owns, Conti Medical Concepts, on charges of falsifying Medicare and Medicaid billings.
“Conti and his eastern Jefferson County business pleaded not guilty.
“The indictment charged them with billing the two federal health-care programs for a more expensive back brace than the one actually provided for some patients.” For more:
http://www.courier-journal.com/apps/pbcs.dll/article?AID=/20061111/ BUSINESS/611110303/1003
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Survey: Public Trust Slipping
According to an article published in the November 16 issue of Modern Healthcare’s Daily Dose, “The public trusts hospitals less than previously but more than it trusts drugmakers, health insurers or managed-care companies, according to an annual poll by Harris Interactive. Across almost all 17 industries surveyed, the public’s level of trust has eroded in recent years. The percentage of respondents who perceived hospitals as generally trustworthy and honest fell to 28% in the latest survey, down from 34% in 2005. Hospitals ranked third out of the 17 industries for trustworthiness, behind supermarkets (34%) and banks (31%). Tobacco companies were considered the least trustworthy, scoring only 2%, followed by oil companies at 3% and managed-care companies at 4%. Both drugmakers and health insurers were rated as generally trustworthy by only 7% of the 2,010 adults surveyed. For the complete results:
http://www.harrisinteractive.com/news/ allnewsbydate.asp?NewsID=1120
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Cali Cartel Leaders Plead Guilty to Laundering Cocaine Proceeds through Pharmaceutical Drug Companies
Michael J. Garcia, the U.S. Attorney for the Southern District of New York, and R. Alexander Acosta, the U.S. Attorney for the Southern District of Florida, announced November 15, 2006 the guilty pleas of Gilberto Rodriguez-orejuela and Miguel Angel Rodriguez-Orejuela brothers and the leaders of the notorious Cali Cartel in Colombia, to money-laundering charges. Under the terms of a plea agreement with the United States Government, the RODRIGUEZ-OREJUELA brothers previously pleaded guilty to an Indictment filed in the Southern District of Florida (the "SDFL Indictment") charging them with importing tons of cocaine into the United States. The agreement also called for the brothers to plead guilty to an Indictment initially filed in the Southern District of New York (the "SDNY Indictment") charging them with money-laundering crimes. For more:
http://www.usdoj.gov/usao/fls/PressReleases/061115-01.html
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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
CMS: Open Enrollment for Medicare Health and Prescription Drug Plans
On November 16, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare beneficiaries have six weeks to change or add coverage to their current Medicare health and prescription drug plans. The Medicare annual Open Enrollment Period, which starts today, runs from November 15 through December 31, 2006. For more:
http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2047
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Competitive Acquisition Program
All physicians and physician groups who wish to participate in the Competitive Acquisition Program (CAP) during 2007 must submit a signed and completed Physician Election Agreement Form by mail to their local carrier. The form must be postmarked on or before November 15, 2006.
Please remember that physicians must elect to participate in the CAP program annually; therefore physicians currently participating in the CAP must go through the election process in order to affirm their participation for 2007 or to leave the program at the end of 2006.
Additional information about the CAP physician election process for 2007 may be found at the following CMS website: http://www.cms.hhs.gov/CompetitiveAcquisforBios/
02_infophys.asp
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Power Mobility Devices
The Centers for Medicare & Medicaid Services (CMS) is making refinements to the new power mobility device (PMD) fee schedule issued on October 2, 2006. These changes are designed to improve the accuracy of Medicare pricing, support high quality and service, provide value for Medicare and its beneficiaries, and insure that Medicare beneficiaries who need mobility assistance receive the modern medical care they need.
Fee schedule amounts for the new codes were originally issued on October 2, 2006. The October 2 fee schedule was preceded by a posting in early August of MSRP information. CMS shared its data and calculations for the new fees with manufacturers and suppliers. After receiving comments and feedback, CMS has performed a comprehensive review of the data and decided to make several refinements to the calculations. The new codes and fee schedule amounts will be implemented on November 15, 2006.
For additional information regarding the fee schedule refinements, go to: http://www.cms.hhs.gov/DMEPOSFeeSched/
01a_Power_Mobility_Devices.asp
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CMS: New Medicare Learning Network Resources
The Centers for Medicare & Medicaid Services (CMS) recently announced it is making available a new Medicare Learning Network educational resource, “The Medicare Preventive Services PowerPoint Slide Presentation.” This PowerPoint Slide Presentation (including talking points for the speaker) has been developed to assist the Medicare fee-for-service provider community when they give education and training presentations about preventive services and screenings covered by Medicare. The presentation is designed so that speakers can pick and choose slides to meet the needs of various audiences, and covers the following topics:
- Overview of Preventive Services
- Preventive Benefits by Service
- Beneficiary Cost Sharing
- The Prevention Gap
- Medicare Prevention Demonstrations
- Prevention Activities for Beneficiaries
- Resources
You can navigate to the various sections within the document from Slide 6. A facilitator's guide is also provided for this slide presentation to further assist users who may not be as familiar with using PowerPoint features. Medicare Learning Network staff will regularly update the presentation to ensure that it contains the most current preventive services information.
The presentation can be downloaded from the CMS website at the following locations:
- The MLN Preventive Services Educational Products
http://www.cms.hhs.gov/MLNProducts/
35_PreventiveServices.asp - The CMS Prevention General Information/Provider Resources http://www.cms.hhs.gov/PrevntionGenInfo/
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From the GAO
Improper Payments: Agencies' Fiscal Year 2005 Reporting under the Improper Payments Information Act Remains Incomplete GAO-07-92, November 14, 2006
http://www.gao.gov/htext/d0792.html
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CMS Transmittals
General Information, Eligibility and Entitlement (PUB. 100-01)
Transmittal #42, Swing Bed Hospital Updates:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_01&u=mrpm10001r42gi&h=top1.html&t=80&s=twcc
Medicare Benefit Policy - Basic Coverage Rules (PUB. 100-02)
Transmittal #60, Outpatient Therapy Cap Clarifications:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_02&u=mrepm10002r60bp&h=top1.html&t=80&s=twcc
Transmittal #59, Inpatient Psychiatric Facility Prospective Payment System:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_02&u=mrepm10002r59bp&h=top1.html&t=80&s=twcc
Transmittal #57, Clarification/Update to Chapter 8, Pub. 100-02:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_02&u=mrepm10002r57bp&h=top1.html&t=80&s=twcc
Transmittal #56, 2006 Inpatient Psychiatric Facility Prospective Payment System:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_02&u=mrepm10002r56bp&h=top1.html&t=80&s=twcc
Medicare Claims Processing (PUB. 100-04)
Transmittal #1111, 2006 Clarification on Billing for Cryosurgery of the Prostate Gland:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1111cp&h=top1.html&t=80&s=twcc
Transmittal #1110, 2006 Release of a Separate File Containing the Payment Cap for the Technical Component of Imaging Procedures for Disclosure:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1110cp&h=top1.html&t=80&s=twcc
Transmittal #1108, 09/2006 Reporting of Taxonomy Codes to Identify Provider Subparts on Institutional Claims:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1108cp&h=top1.html&t=80&s=twcc
Transmittal #1107, 09/2006 Notification and Testing of an Integrated Outpatient Code Editor for the July 2007 Release:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004rr1107cp&h=top1.html&t=80&s=twcc
Transmittal #1106, 2006 Therapy Cap Clarifications:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1106cp&h=top1.html&t=80&s=twcc
Transmittal #1105, Swing Bed Hospital Updates:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1105cp&h=top1.html&t=80&s=twcc
Transmittal #1104, Uniform Billing Implementation:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1104cp&h=top1.html&t=80&s=twcc
Transmittal #1103, Reporting and Payment of No-Cost Devices Furnished by Outpatient Prospective Payment System Hospitals:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1103cp&h=top1.html&t=80&s=twcc
Transmittal #1102, 2006 Ambulance Inflation Factor for CY 2007:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1102cp&h=top1.html&t=80&s=twcc
Transmittal #1101, Inpatient Psychiatric Facility Prospective Payment System:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1101cp&h=top1.html&t=80&s=twcc
Transmittal #1100, 2006 Jurisdiction for Ambulance Supplier Claims:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1100cp&h=top1.html&t=80&s=twcc
Transmittal #1099, Common Working File Duplicate Claim Edit for the Technical Component of Radiology and Pathology Laboratory Services Provided to Hospital Patients:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1099cp&h=top1.html&t=80&s=twcc
Transmittal #1098, 2006 Common Working File Duplicate Claim Edit for the Technical Component of Radiology and Pathology Laboratory Services Provided to Hospital Patients:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1098cp&h=top1.html&t=80&s=twcc
Transmittal #1083, Release of a Separate File Containing the Payment Cap for the Technical Component of Imaging Procedures for Disclosure:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1083cp&h=top1.html&t=80&s=twcc
Transmittal #1074, Calendar Year 2007 Participation Enrollment and Medicare Participating Physicians and Suppliers Directory Procedures:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1074cp&h=top1.html&t=80&s=twcc
Transmittal #1030, 2006 Policy Changes to the Fiscal Intermediary Calculation of Hospital Outpatient Payment System and Community Mental Health Center Cost to Charge Ratios:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1030cp&h=top1.html&t=80&s=twcc
Program Integrity (PUB. 100-08)
Transmittal #171, Outpatient Therapy Cap Clarifications:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08&u=mrpm10008r171pi&h=top1.html&t=80&s=twcc
Transmittal #170,Transition of Medical Review Educational Activities:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08&u=mrpm10008r170pi&h=top1.html&t=80&s=twcc
Transmittal #169:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08&u=mrpm10008r169pi&h=top1.html&t=80&s=twcc
CMS One-Time Special Notification (PUB. 100-20)
Transmittal #248, Optical Character Recognition Interface in the Fiscal Intermediary Standard System:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_20&u=mrepm10020r248otn&h=top1.html&t=80&s=twcc
Transmittal #247, Returning Paper Claims Received From Clearinghouses:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_20&u=mrepm10020r247otn&h=top1.html&t=80&s=twcc
National Coverage Analyses
Serum Iron Studies (Addition of Restless Leg Syndrome as a Covered Indication) (CAG-00263R) - Expected Completion Date: 11/07/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CAG00263R3&h=top1.html&t=80&s=twcc
Intracranial Stenting and Angioplasty (CAG-00085R2) - Expected Completion Date: 11/07/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca&u=CAG00085R23&h=top1.html&t=80&s=twcc
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From the OIG
Cahaba Government Benefit Administrators Final Cost Proposals for Fiscal Years 2002 Through 2004 (A-04-05-04012; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=40504012&h=top1.html&t=80&s=twcc
Review of Postretirement Benefit Costs Claimed by Blue Cross Blue Shield of Rhode Island, (A-07-06-00210; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=70600210&h=top1.html&t=80&s=twcc
Medicaid Payments for Skilled Professional Medical Personnel to Missouri School Districts (A-07-06-03075; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=70603075&h=top1.html&t=80&s=twcc
Audit of California's Section 1115 Medicaid Demonstration Project Extension for Los Angeles County (A-09-04-00038; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=90400038&h=top1.html&t=80&s=twcc
Review of Medicare Part A Pension Costs Claimed for Medicare Reimbursement by Blue Cross Blue Shield of Oregon for Fiscal Year 1996 (A-07-06-00214; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=70600214&h=top1.html&t=80&s=twcc
Review of Medicare Contractor's Pension Segmentation Requirements at Blue Cross Blue Shield of Oregon for the Period January 1, 1994, Through January 1, 1997 (A-07-06-00197; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=70600197&h=top1.html&t=80&s=twcc
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This Week’s Link:
JCAHO Q&A about Unannounced Surveys
http://www.jointcommission.org/AccreditationPrograms/SVNP/qa_uannounced.htm
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Acronym Library
| RHHI | Regional Home Health Intermediary |
| RHHIPEP | Regional Home Health Intermediary Performance Evaluation Program |
| RHIR | Resident Health Insurance Representative |
| RHP | Rebundling of Hospital Payment |
| RI | Regional Intermediary |
For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp
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