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Vol. IX, No. 4 – January 26, 2007 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Table of Contents
Headlines
Florida Man Convicted in Identity Theft and Medicare Fraud Case
Former Mental Health Counselor Sentenced
Southern Radiology Services, LLC Settle
SCCI Health Services and Subsidiary Agrees to Pay U.S. $7.5 Million
Atlanta Physician Pleads Guilty of Medicaid Fraud
Former CEO and Physician Charged in Bribery and Kickback Conspiracy Case
Regulatory News
States Get Federal Backing to Build More Efficient, High Quality Medicaid Systems
This Week’s Links
Acronym Library
Visit
HCCA's Web site
HCCA
Headquarters - Contact Information
Headlines:
Florida Man Convicted in Identity Theft and Medicare Fraud Case
U.S. Attorney for the Southern District of Florida R. Alexander Acosta announced on January 24, 2007 that a Fort Lauderdale jury convicted defendant Fernando Ferrer Jr., of Naples, Florida, of all eight counts of a Superseding Indictment, which charged him with one count of conspiring to defraud the United States, one count of computer fraud, one count of wrongful disclosure of individually identifiable health information, and five counts of aggravated identity theft. For more: http://www.usdoj.gov/usao/fls/PressReleases/070124-02.html
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Former Mental Health Counselor Sentenced
On January 20, 2007, the Rutland Herald reported that “A former New Hampshire man was sentenced to more than a year in jail and ordered to pay $41,136 in restitution Thursday following a federal conviction of making false statements in a health care matter.
“Charles Gill, 71, who formerly lived in Hanover, N.H., was sentenced to 15 months in jail by Judge William K. Sessions III in federal court in Burlington.
“Gill was convicted of using a false date of birth and Social Security number to obtain a job at the Clara Martin Center in Randolph in August 2004. Gill provided counseling services at the center which provides mental health and substance abuse counseling services.
“He was later fired from the center when administrators there discovered that he had lied about his birth date and social security number to hide convictions in federal court dating back to 1996 when he was found guilty of federal mail fraud, wire fraud and false claims to the Medicare and Medicaid programs.”
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Southern Radiology Services, LLC Settles
Southern Radiology Services, LLC (SRS) has agreed to pay the United States $36,000 to settle civil claims arising out of charges SRS submitted to Medicare for services performed by unqualified technologists. The settlement agreement was announced on January 23, 2007 by Alice H. Martin, U.S. Attorney, Northern District of Alabama. For more: http://www.usdoj.gov/usao/aln/Docs/January%202007/ JANUARY%2023,%202007%20SOUTHERN%20 RADIOLOGY%20SERVICES.htm
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SCCI Health Services and Subsidiary Agrees to Pay U.S. $7.5 Million
Texas-based SCCI Health Services Corporation (SCCI) and its subsidiary, SCCI Hospital Ventures Inc., have paid the United States $7.5 million to settle allegations that the companies violated the Stark self-referral statute and the False Claims Act, the Justice Department announced January 5, 2007. SCCI, which was purchased by Triumph Hospital in 2005, operates long term acute care facilities across the United States.
The government complaint alleged that from November 1996 through at least 1999, SCCI entered into prohibited financial relationships with three physicians and paid these physicians illegal payments in violation of the Stark statute. The government further alleged that from November 1996 through at least 1999, SCCI either submitted or caused false claims to be submitted to the Medicare program, as a result of these prohibited financial relationships, in violation of the False Claims Act. For more: http://www.usdoj.gov/opa/pr/2007/January/07_civ_003.html
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Atlanta Physician Pleads Guilty of Medicaid Fraud
On January 5, 2007, U.S. Attorney for the Northern District of Georgia David E. Nahmias announced that Aaron M. Hurowitz, a doctor of osteopathic medicine and former owner and operator of “Midtown Medical Center, Atlanta, Georgia, pleaded guilty in federal district court to having perpetrated a scheme to defraud the State of Georgia Medicaid Program. For more: http://www.usdoj.gov/usao/gan/press/index.html#pdf
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Former CEO and Physician Charged in Bribery and Kickback Conspiracy Case
On January 16, 2007, U.S. Attorney for the Northern District of Illinois announced that Wendy Mamoon, former Chief Executive Officer at the shuttered Rock Creed Center in Lemont, IL and Dr. Roland Borassi, became the 3rd and 4th individuals charged in an ongoing federal investigation relating to the privately-owned psychiatric facility that closed in 2002. For more: http://www.usdoj.gov/usao/iln/pr/chicago/2007/index.html
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This week, MediRegs provided TWCC readers with the following Regulatory information: CMS Transmittals and From the OIG.
Regulatory News
States Get Federal Backing to Build More Efficient, High Quality Medicaid Systems
On January 25, 2007, HHS Secretary Mike Leavitt awarded $103 million to 27 states across the nation to fund implementation of new ways to improve Medicaid efficiency, economy and quality of care.
States will use the funds to implement innovative systems to get more value out of the money they spend providing health care to their low-income elderly, children and disabled citizens.
Congress approved a total of $150 million for these Medicaid “transformation grants” in the Deficit Reduction Act of 2005 (DRA) to be distributed over fiscal years 2007 and 2008. Today’s award of the first $103 million will be followed later in the year with a second solicitation for the remaining $47 million. States will receive the funds over the next two years. For more: http://www.hhs.gov/news/press/2007pres/20070125.html
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CMS Update
NPI Readiness
To date, over 1.6M providers have obtained an NPI. Now, only 120 days are left to implement the NPI into business practices prior to the compliance date. A recent survey of the health care industry, conducted by the Workgroup for Electronic Data Interchange (WEDI), indicates that providers should have already obtained an NPI and be focusing on implementation and testing with health plans and clearinghouses. If you have not obtained your NPI by now you should do so immediately so that you can begin the implementation and testing process
Reminder to Supply Legacy Identifiers on NPI Application
CMS continues to urge providers to include legacy identifiers, as well as associated provider identifier type(s), on their NPI applications. This will help all health plans, including Medicare, to get ready for May 23, 2007. If reporting a Medicaid legacy number, include the associated State name. If providers have already been assigned NPIs, CMS asks them to go back into the NPPES and update their information with their legacy identifiers if they did not include those identifiers when they applied for NPIs. Providers should make sure that these legacy identifiers are the ones used to bill for services and should be sure that the NPPES is updated with this information for all health plans. This information is critical for health plans and health care clearinghouses in the development of crosswalks to aid in the transition to the NPI.
New MLN Matters Article Available
A new Special Edition MLN Matters article is now posted on the CMS website with important implementation 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.
Upcoming WEDI Events
WEDI will host the WEDI NPI Industry Forum on February 12th, an audio cast on the impact of the NPI on standard transactions on February 28th, as well as a question and answer session on March 21st. 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.
NPI Questions
More information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers may also apply for an NPI online at https://nppes.cms.hhs.gov or may call the NPI enumerator to request a paper application at 1-800-465-3203.
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From the GAO
Medicaid Outpatient Prescription Drugs: Estimated 2007 Federal Upper Limits for Reimbursement Compared with Retail Pharmacy Acquisition Costs. GAO-07-239R, December 22.
http://www.gao.gov/cgi-bin/getrpt?GAO-07-239R
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CMS Transmittals
Medicare Claims Processing (PUB. 100-04)
Transmittal #1156, Date: January 12, 2006 Revised Medicare Zip Code File to Download (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1156cp&h=top1.html&t=80&s=twcc
Transmittal #1155, Date: January 12, 2006 January 2007 Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) Specifications Version 8.0 **Rescinds Transmittal #1130, dated December 15, 2006**(PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1155cp&h=top1.html&t=80&s=twcc
Transmittal #1154, Date: January 12, 2006 Healthcare Provider Taxonomy Codes (HPTC) Update (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1154cp&h=top1.html&t=80&s=twcc
Transmittal #1153, Date: January 12, 2006 Claim Status Category Code and Claim Status Code Update (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04 &u=mrepm10004r1153cp&h=top1.html&t=80&s=twcc
Program Integrity (PUB. 100-08)
Transmittal #182, Date: January 12, 2007 Medicaid State Agencies (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08 &u=mrpm10008r182pi&h=top1.html&t=80&s=twcc
CMS One-Time Special Notification (PUB. 100-20)
Transmittal #260, Date: January 12, 2007 Enhance MCS to Avoid Duplicate Payments When a Full Claim Adjustment is Performed. This CR rescinds and fully replaces CR 3878 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_20 &u=mrepm10020r260otn&h=top1.html&t=80&s=twcc
National Coverage Analyses
Human Chorionic Gonadotropin (Addition of ICD-9-CM Code 158.9, Malignant Neoplasm of Peritoneum, Unspecified) (CAG-00372N) - Expected Completion Date: 04/12/07:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca &u=CAL00372N&h=top1.html&t=80&s=twcc
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From the OIG
Corporate Integrity Agreements
Al-Shalchi, Najah, M., M.D. San Antonio TX 9/16/2002 (AND Addendum to the IA) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia &u=1015&h=top1.html&t=80&s=twcc
Dialysis Clinic, Inc - Nashville, TN - 11/20/2006 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia &u=dialysisclin&h=top1.html&t=80&s=twcc
Oregon Imaging Center - Springfield, OR - 12/12/2006 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia &u=oregonimag&h=top1.html&t=80&s=twcc
Tokars, Roger P., M.D. - Pittsburgh, PA; McMurray, PA - 11/21/2006 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia &u=tokars&h=top1.html&t=80&s=twcc
Catholic Healthcare West; Mercy Healthcare Sacramento; Mercy San Juan Hospital; Mercy General Hospital; Mercy American River Hospital; Woodland Memorial Hospital; Methodist Hospital Of Sacramento; Mercy Hospital Of Folsom; Woodland Healthcare; Woodland Clinic Medical Group; and MedClinic San Francisco Ca - 6/3/2002 - CLOSED: 12/07/06 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia &u=1093&h=top1.html&t=80&s=twcc
Lifepoint Hospitals, Inc. - Brentwood, TN - 12/21/2000 - CLOSED: 12/14/06 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia &u=lifepoint&h=top1.html&t=80&s=twcc
Nan Travis Memorial Hospital (ITS Lessor, East TX Medical Center-Jacksonville) -Jacksonville, TX - 5/22/2001 - CLOSED: 12/07/06 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia &u=nantravis&h=top1.html&t=80&s=twcc
National Healthcare Corporation - Murfreesboro, Tn - 11/15/2000 - CLOSED: 12/27/06 (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia &u=1312&h=top1.html&t=80&s=twcc
List of Excluded Individuals/Entities
OIG 12/06 Cumulative Sanction Report-Reinstatements for December 2006 (Excel):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_fed_gov_oig_csr &u=0612rein&h=top1.html&t=80&s=twcc
OIG 12/06 Cumulative Sanction Report-Update for December 2006 (Excel):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_fed_gov_oig_cs r&u=0612up&h=top1.html&t=80&s=twcc
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This Week’s Link:
List of Provider Reimbursement Review Board (PPRB) Decisions
http://www.cms.hhs.gov/PRRBReview/PRRBD/list.asp
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Acronym Library
| CASPER | Certification and Survey Provider Enhanced Reporting |
| CASPRO | Clinical Area Support PRO |
For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp
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Email - info@hcca-info.org Contact: Margaret
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This Week in Corporate Compliance (781) 593-4924
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