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Vol. VIII, No. 40 – November 22, 2006 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Audit & Compliance
Compliance Academy
Table of Contents
Headlines
UMDNJ Places Doctor on Leave
Sioux Falls Resident Admits to Health Care Fraud
DOJ: $3.1 Billion Recovered in 2006
Call to Fire Hospital Chief and Board
Owner of Medical Supply Business Sentenced
Texas Nursing Home Operator Pleads Guilty to Fraud
Three U of Maryland Medical Center Employees Indicted
Regulatory News
CMS Updates
CMS Transmittals
From the OIG
This Week’s Links
Acronym Library
Visit
HCCA's Web site
HCCA
Headquarters - Contact Information
Headlines:
UMDNJ Places Doctor on Leave
On November 22, The Star-Ledger reported that “A world-renowned doctor at the University of Medicine and Dentistry of New Jersey has become the latest to fall victim to the widening repercussions over an illegal patient referral scheme now under investigation by the U.S. Attorney's Office.
“The university said it placed Jerrold Ellner, the chairman of medicine at UMDNJ's Newark campus, as well as Ronald Pittore, the second-in-command of its legal management department, on administrative leave while the school continues reviewing the referral program.“
For more: http://www.nj.com/search/index.ssf?/base/news-10/116417417527240.xml?starledger?ntop&coll=1
More UMDNJ News: On November 17, The Star-Ledger reported that “The state's medical university plans to fire two cardiologists who allegedly were given no-show faculty jobs as part of a scheme to boost referrals to its heart surgery program and plans to cut the salaries of nine other doctors, according to an internal memo from the university president.
“The cardiologist program, run by the University of Medicine and Dentistry of New Jersey, also is getting new work rules and will operate under far greater oversight to ensure that doctors are doing more for their salaries than simply referring patients, according to the memo obtained by The Star-Ledger.”
For more: http://www.nj.com/search/index.ssf?/base/news-10/1163744859307060.xml?starledger?ntop&coll=1
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Sioux Falls Resident Admits to Health Care Fraud
On November 21, the Argus Leader reported that “A 62-year-old man whose business handles contract work for psychological counseling admitted Monday in federal court that he filed insurance claims for services that were never provided.
Herbert Brooks Wettlin, 62, appeared in court in his former hometown of Sioux Falls, where he pleaded guilty to counts of health care fraud and mail fraud. Wettlin faces up to 20 years in prison and must pay $171,700 in restitution. He was accused of filing $218,400 in false claims with Blue Cross Blue Shield of Florida. For more: http://www.argusleader.com/apps/pbcs.dll/ article?AID=/20061121/NEWS01/611210318/1001/NEWS
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DOJ: $3.1 Billion Recovered in 2006
On November 21, 2006, The United States Department of Justice announced that, in the fiscal year ending Sept. 30, a record amount of more than $3.1 billion in settlements and judgments in cases involving allegations of fraud against the government was recovered. Previously, the department's largest recoveries totaled $2.2 billion for FY 2003. The largest of the FY 2006 settlements against two industry giants -- Tenet Healthcare Corporation and the Boeing Company -- comprised nearly half the total.
For more: http://www.usdoj.gov/opa/pr/2006/November/06_civ_783.html
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Call to Fire Hospital Chief and Board
On November 22, the Cambridge Evening News (UK) reported that “HEALTH watchdog is calling on Hinchingbrooke Hospital chief Jane Herbert to be fired along with the rest of the hospital's board.
Coun Geoff Heathcock, the chairman of Cambridgeshire County Council's health scrutiny committee, wants drastic action following the revelation Ms Herbert was directly involved in a waiting list fixing scandal in a previous job.
He has written to Keith Pearson, chairman of the East of England Strategic Health Authority, demanding Ms Herbert's head. For more: http://www.cambridge-news.co.uk/news/huntingdon/2006/11/22/73fe49e0-96cc-411c-940f-c0579a3297bf.lpf
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Owner of Medical Supply Business Sentenced
The News-Democrat reported on November 20 that “The owner of two Kansas City-area medical supply businesses was sentenced Monday to three years in prison without parole for his part in a scheme that bilked Medicare out of millions of dollars.
“U.S. District Judge Gary A. Fenner also ordered Godwin Iloka, 39, of Lee's Summit, to forfeit his home, three vehicles and all the funds in two bank accounts. For more: http://www.belleville.com/mld/belleville/news/state/16060753.htm
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Texas Nursing Home Operator Pleads Guilty to Fraud
On November 15, the U.S. Attorney for the Western District of Texas Johnny Sutton announced that a former nursing home operator pleaded guilty to health care fraud and money laundering charges. For more: http://www.usdoj.gov/usao/txw/press_releases/index.html
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Three U of Maryland Medical Center Employees Indicted
The U.S. Attorney for Maryland announced on November 3 that A federal grand jury has indicted Paula Anderson, age 39, her mother Carlet Clemons, age 59, and Michael Venable, age 31, all of Baltimore, in a scheme to defraud the University of Maryland Medical Center’s Employee Referral Program, announced United States Attorney for the District of Maryland Rod J. Rosenstein. The indictment was returned yesterday and unsealed today upon the arrest of the defendants. For more: http://www.usdoj.gov/usao/md/Public-Affairs/ press_releases/press06/UMMC%20Fraud%20scheme.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
Over 1.4M National Provider Identifiers (NPIs) have been issued. Do you have yours?
Think you don’t need an NPI? Think again, and be sure. If you are a health care provider who bills for services, you probably do need an NPI. If you bill Medicare for services, you definitely do!
The bad news is that as of November 23rd, only six months remain until the NPI compliance date. The implementation of the NPI is a complex process that will impact all business functions of your practice, office or institution including: billing, reporting and payment. This is why providers are urged to get, share, and use their NPI NOW to avoid a disruption in cash flow.
If you don’t have an NPI, get one. If you have one, start the testing process with your health plan and use it on your claims and other transactions.
CMS continues to urge providers to include legacy identifiers on their NPI applications. This information is critical for health plans and health care clearinghouses in the development of crosswalks to aid in the transition to the NPI.
Key NPI Facts
The Centers for Medicare and Medicaid Services (CMS) along with the Workgroup for Electronic Data Interchange (WEDI) and other industry health plans would like to remind providers of the following key NPI facts:
- Every covered health care provider must get and use the NPI; and even if a health care provider is an individual and is not conducting electronic transactions and is, therefore, not a covered provider, he or she may be required by health plans or employers to obtain an NPI.
- The NPI is not just a number. It does affect internal and external business and systems operations and can affect the appropriate payment of claims in a timely manner.
- It is estimated that use of the NPI can require a transition period of no less than 120 days.
- Providers should begin to test and use their NPIs in electronic health care transactions no later than January 31, 2007.
- May 23, 2007 is not when the process starts, but when the process must be completed.
- Providers may be requested to communicate their NPIs to health plans, clearinghouses, and other providers well before the compliance date.
- A health care provider who is a sole proprietor is considered an individual and can only have ONE NPI.
Sharing NPIs
Once providers have received their NPIs, they should share their NPIs with other providers with whom they do business, and with health plans that request it. In fact, as outlined in current regulation, all providers must share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes -- including designation of ordering or referring physician. Providers should also consider letting health plans, or institutions for whom they work, share their numbers for them.
NPIs are FREE!
Health care providers should know that getting an NPI is free. You do not need to pay an outside source to obtain your NPI for you. All CMS education on the NPI is also free. CMS does not charge for its education or materials.
NPI Questions
CMS continues to update our Frequently Asked Questions (FAQs) to answer many of the NPI questions we receive on a daily basis. Visit the following link to view all NPI FAQs:
http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?p_sid= Qjr3YRYh&p_lva=&p_li=&p_page=1&p_cv=&p_pv=&p_prods= 0&p_cats=&p_hidden_prods=&prod_lvl1=0&p_search_text= NPI&p_new_search=1&p_search_type=answers.search_nl
Providers should remember that the NPI Enumerator can only answer/address the following types of questions/issues:
- Status of an application
- Forgotten/lost NPI
- Lost NPI notification letter
- Trouble accessing NPPES
- Forgotten password/User ID
- Need to request a paper application
- Need clarification on information that is to be supplied in the NPI application
Providers needing this type of assistance may contact the enumerator at 1-800-465-3203.
Upcoming WEDI Events
WEDI has several NPI events scheduled in the upcoming month. Visit http://www.wedi.org/npioi/index.shtml to learn more about these events. Please note that there is a charge to participate in WEDI events.
Important Information for Medicare Providers
Communicating NPIs to Medicare
Medicare providers should know that there is no “special process” or need to call to communicate NPIs to the Medicare program. NPIs can be shared with the Medicare program in three different ways, as part of the following standard procedures:
- Medicare providers should use their NPI, along with appropriate legacy identifiers, on their Medicare claims
- For new Medicare providers, an NPI must be included on the CMS-855 enrollment application
- Existing Medicare providers must provide their NPIs when making any changes to their Medicare enrollment information
Still Uncertain?
Not sure what an NPI is and how you can get it, share it and use it? As always, 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 can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 800/465-3203.
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CMS Transmittals
Medicare Benefit Policy - Basic Coverage Rules (PUB. 100-02)
Transmittal #58, Swing Bed Hospital Updates - Updates Chapter 8, Section 10.3:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_02&u=mrepm10002r58bp&h=top1.html&t=80&s=twcc
Medicare Claims Processing (PUB. 100-04)
Transmittal #1113, Implementation of an Ultrasound Screening for Abdominal Aortic Aneurysms - Rescinds and replaces Transmittal 1014:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1113cp&h=top1.html&t=80&s=twcc
Transmittal #1109, Skilled Nursing Facility Consolidated Billing Common Working File Edit Bypass Instructons for Hospital Emergency Room Services Spanning Multiple Service Dates - Clarifies instructions in Transmittal 881 titled "Outpatient Prospective Payment System Emergency Room Services Exceeding 24 Hours" and updates CWF SNF CB edits to bypass those services related to an ER encounter performed on subsequent dates when the ET (emergency services) modifier is appended to those line items:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04&u=mrepm10004r1109cp&h=top1.html&t=80&s=twcc
Program Integrity (PUB. 100-08)
Transmittal #174, Date: November 17, 2006 Transition of Medical Review Educational Activities - Rescinds and replaces Transmittal 170.
:http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08&u=mrpm10008r174pi&h=top1.html&t=80&s=twcc
Transmittal #173, Update to Chapter 10 Medicare Provider/Supplier Enrollment - Updates several items in Chapter 10.:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm_100_08&u=mrpm10008r173pi&h=top1.html&t=80&s=twcc
CMS One-Time Special Notification (PUB. 100-20)
Transmittal #250, PECOS to FISS Interface Via Extract File (PDF--3mg) - Advises that an extract file of provider enrollment data that has been input via the FI contractors will be generated out of PECOS and available for the FISS datacenters to load into the FISS claims system to populate the claims provider files so claims can be processed:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_20&u=mrepm10020r250otn&h=top1.html&t=80&s=twcc
Transmittal #249, Claims Submitted With Only a National Provider Identifier During the Stage 2 NPI Transition Period - Supplies instructions to the contractors to educate providers regarding submission of provider identifiers during the Stage 2 NPI transition period:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_20&u=mrepm10020r249otn&h=top1.html&t=80&s=twcc
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From the OIG
Corporate Integrity Agreements
American Medical Response, Inc. - Greenwood Village, CO - 09/14/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia&u=amr06&h=top1.html&t=80&s=twcc
Batipps, Gerald, M.D. - Washington, DC - 07/31/0:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia&u=batipps&h=top1.html&t=80&s=twcc
Bhat, Krishna, M.D. - Johnstown, PA - 09/29/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia&u=bhat&h=top1.html&t=80&s=twcc
Inova VNA Home Care - Falls Church, VA - 08/22/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia&u=inovavnahome&h=top1.html&t=80&s=twcc
Omnicare, Inc. - Covington, KY - 11/09/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia&u=omnicare1106&h=top1.html&t=80&s=twcc
Pediatrix Medical Group, Inc. - Sunrise, FL - 09/20/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia&u=pediatrix&h=top1.html&t=80&s=twcc
Shasta County (Department Of Mental Health) - Redding, Ca - 3/15/2001 - CLOSED: 10/18/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia&u=shasta&h=top1.html&t=80&s=twcc
Woodbine Healthcare and Rehabilitation Centre - Gladstone, Mo - 12/13/2002 - CLOSED: 10/16/2006:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cia&u=woodbine&h=top1.html&t=80&s=twcc
List of Excluded Individuals/Entities
OIG 10/06 Cumulative Sanction Report-Reinstatements for October 2006:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_fed_gov_oig_csr&u=0610rein&h=top1.html&t=80&s=twcc
OIG 10/06 Cumulative Sanction Report-Update for October 2006:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_fed_gov_oig_csr&u=0610up&h=top1.html&t=80&s=twcc
Audit Reports
Review of Potential Duplicate Payments Identified by a Centers for Medicare & Medicaid Services Recovery Audit Contractor (A-03-06-00004; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=30600004&h=top1.html&t=80&s=twcc
Nationwide Review of Inpatient Rehabilitation Facility Claims Coded as "Discharged to Home with Home Health Agency Services" (A-04-04-00013; 11/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=40400013&h=top1.html&t=80&s=twcc
Review of Fee-for-Service Payments for Medicare Beneficiaries Enrolled in Managed Care Risk Plans (A-07-05-01016; 11/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas_cms2005&u=70501016&h=top1.html&t=80&s=twcc
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This Week’s Link:
U.S. Department of Justice Fact Sheet: Significant Recoveries in Fiscal Year 2006
http://releases.usnewswire.com/GetRelease.asp?id=76676
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Acronym Library
| SACP | (AHA) Society for Ambulatory Care Professionals |
| SAD | Service Area Directory (SSA) |
For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp
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Compliance Today Call for Authors
If you would like to submit an article on one or more of the following topics for publication in HCCA's monthly magazine - Compliance Today - please contact Margaret Dragon margaret.dragon@hcca-info.org – Tel: 781/593-4924):
* Compliance Program Basics (articles should be geared to the new compliance officer)
* Identifying and addressing conflicts of interest
* Long-Term Care, Home Health, and Hospice compliance issues
* Developing effective compliance program education programs
* Research Compliance
* Conducting a risk assessment
* Clinical trials and the FDA
* Human Subjects Protections
* Clinical trial billing compliance
* How to audit Compliance with Federal Grant Requirements
* Issues involved with Medicare Part D Compliance
* Deficit Reduction Act Compliance
* Compliance with the NPI
If you have other topics you'd like to explore, please send them along to Margaret.
In addition, we would like to receive news on the ways you celebrated 2006 National Corporate Compliance and Ethics Week. The information you submit will be published in the March issue of Compliance Today, so please e-mail margaret.dragon@hcca-info.org with your news by January 2, 2007.
Upcoming Compliance Today Deadlines:
* February Issue - December 1, 2006
* March Issue – January 2, 2007
* April Issue – February 1, 2007
* May Issue – March 1, 2007
* June Issue – April 2, 2007
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Visit http://www.hcca-info.org
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HCCA Headquarters
- Contact Information Your HCCA Office
is located at:
6500 Barrie Road, Suite 250
Minneapolis, MN 55435
The HCCA Toll-Free
888/580-8373,
Fax number - (952)
988-0146
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(952) 988-0141
Email - info@hcca-info.org Contact: Margaret
Dragon, Editor
This Week in Corporate Compliance (781) 593-4924
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