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Vol. IX, No. 6 – February 9, 2007 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Table of Contents
Headlines
Kentucky Is Paid $4.3 Million by Schering-Plough
Jury Says PwC Should Pay $10 Million
Connecticut Plastic Surgeon Sentenced
Former Madigan Army Medical Center Employee Charged
Two Florida Nurses Arrested, Charged with Neglect
Nursing Home Administrator Convicted in Resident’s Death
Regulatory News
CMS Reports Generic Drug Use on the Rise
This Week’s Links
Acronym Library
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HCCA's Web Site
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Headquarters Contact Information
Headlines:
Kentucky Is Paid $4.3 Million by Schering-Plough
Kentucky Attorney General Greg Stumbo announced on February 5, 2007, that pharmaceutical manufacturer Schering-Plough Corporation, of Kenilworth, New Jersey, has paid $4.3 million in civil damages, fines and penalties for offenses against the Medicaid and Medicare programs. A large portion of the settlement was paid to the federal government, but $1,398,035.06 was paid directly to the Commonwealth.
The settlement arose out of illegal sales and marketing activities that defrauded the Kentucky Medicaid program and the federal Medicare program. Those activities included reporting fraudulent prices to the federal government to avoid paying Medicaid rebates, making illegal payments to physicians to induce them to prescribe Schering-Plough drugs and illegally promoting Schering drugs for “off-label” uses that had not been approved by the FDA. For more:
http://ag.ky.gov/news/schering-plough.htm
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Jury Says PwC Should Pay $10 Million
According to a February 7, 2007 report published on Law.com “A Cobb County, Ga., jury Tuesday dunned PricewaterhouseCoopers $10 million for negligent misrepresentation but rejected civil allegations of fraud and racketeering against the accounting firm.
“The jury also rejected claims including racketeering, fraud, breach of fiduciary duty and negligent misrepresentation against a PricewaterhouseCoopers partner and three former executives of a Boston-based nursing home conglomerate.” For more:
http://www.law.com/jsp/article.jsp?id=1170756166535
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Connecticut Plastic Surgeon Sentenced
U.S. Attorney for Connecticut Kevin J. O’Connor announced on February 2, 2007 that Steven Herman, MD, age 63, of 295 Saugatuck Avenue, Westport, Connecticut, was sentenced by United States District Judge Janet C. Hall in Bridgeport to 20 months of imprisonment, followed by two years of supervised release. On September 18, 2006, Herman waived indictment and pleaded guilty to charges of tax evasion, illegal structuring of financial transactions, and health care fraud. In addition to the imposed term of imprisonment, Judge Hall ordered Herman to pay a fine in the amount of $60,000, to pay approximately $150,000 in restitution to the Oxford Insurance Company for his health care fraud offense, and to forfeit $236,117 to the Government for his financial structuring offense.
Also, Herman has paid more than $800,000 in a civil settlement with the Internal Revenue Service. For more: http://www.usdoj.gov/usao/ct/Press2007/20070202-2.html
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Former Madigan Army Medical Center
Employee Charged
On February 2, 2007, Luis Cruz, of Lakewood, Washington, was charged in U.S. District Court in Tacoma with Theft of Honest Services, and Accepting a Bribe to Aid in the Commission of a Fraud on the United States. Cruz was employed as a Tool and Parts Attendant at the U.S. Army’s Madigan Medical Center until he was fired in April 2005, for drug use. Following his dismissal, an investigation revealed that he had been using his government issued credit card to pay for services never ordered or received by the military. Working with a co-conspirator who processed the charges, Cruz and the co-conspirator pocketed more than $50,000 in cash for which they had falsely billed the government. For more:
http://www.usdoj.gov/usao/waw/press/2007/feb_2007.html
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Two Florida Nurses Arrested, Charged with Neglect
Florida Attorney General Bill McCollum announced on February 6, 2007, that two Suwannee County nurses were arrested on charges they failed to administer required medication to residents of the nursing facility where the women were formerly employed. Ashley Dawn Fralick and Melissa Elaine Bowen will be charged with multiple counts of neglecting an elderly person. For more:
http://myfloridalegal.com/newsrel.nsf/newsreleases
/A7A86FF9B45FD3EF8525727A006FB36B
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Nursing Home Administrator Convicted
in Resident’s Death
On February 9, the Pittsburgh Post-Gazette reported that “A jury yesterday convicted former nursing home administrator Martha F. Bell and the facility she operated on all of the charges they faced in the death of former resident Mabel Taylor.
“After hearing testimony for more than four weeks, the Allegheny County Common Pleas Court jury found Mrs. Bell and the nursing home guilty of neglect of a care-dependent person, involuntary manslaughter and reckless endangerment.”
For more: http://www.post-gazette.com/pg/07040/760735-57.stm
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This week, MediRegs provided TWCC readers with the following Regulatory information: CMS Transmittals and From the OIG.
Regulatory News
CMS Reports Generic Drug Use on the Rise
Recently released data indicate that more Americans are cutting their prescription drug costs by switching to generic medications. New data from the Centers for Medicare & Medicaid Services (CMS) find that generic use is especially high among those in the new Medicare drug benefit, with generics accounting for nearly 60 percent (59.6 percent) of the drugs dispensed to people in Medicare Prescription Drug Plans (PDPs) and Medicare Advantage (MA) plans through the third quarter of 2006. For more:
http://www.cms.hhs.gov/apps/
media/press/release.asp?Counter=
2081&intNumPerPage=10&checkDate=
&checkKey=&srchType=&numDays=3500&srchOpt=
0&srchData=&keywordType=All&chkNews
Type=1%2C+2%2C+3%2C+4%2C+5&intPage
=&showAll=&pYear=&year=&desc=&cboOrder=date
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CMS Transmittals
Results From a Hospital Value-Based
Purchasing Demonstration Project
GROUNDBREAKING MEDICARE PAYMENT DEMONSTRATION RESULTS IN SUBSTANTIAL IMPROVEMENT FOR HOSPITAL PATIENT CARE
Second-year results from a groundbreaking hospital value-based purchasing demonstration project show substantial improvement in quality of care, leading to incentive payments totaling $8,690,447 to 115 top-performing hospitals, the Centers for Medicare & Medicaid Services (CMS) recently announced.
Participants in the Premier Hospital Quality Improvement Demonstration reported significant improvement in quality of care across five clinical focus areas measured by more than 30 nationally standardized and widely accepted quality indicators. To view the entire press release, click here: http://www.cms.hhs.gov/apps/media/press_releases.asp
A Medicare Proposal to Expand Coverage of Angioplasty
of the Carotid Artery Concurrent with Stenting
MEDICARE PROPOSES EXPANDED COVERAGE OF
ANGIOPLASTY OF THE CAROTID ARTERY CONCURRENT WITH STENTING
The Centers for Medicare & Medicaid Services (CMS) announced that it is proposing to expand its coverage policy for carotid artery stenting (CAS).
A proposed National Coverage Determination (NCD) posted February 2, 2007, includes a coverage expansion that reflects the latest evidence on the effective use of stenting, a procedure that reduces the occurrence of stroke in the Medicare population. Stroke is the third leading cause of death in the United States and the leading cause of serious, long-term disability. Approximately 70 percent of all strokes occur in people age 65 and older. To view the entire press release, click here:
http://www.cms.hhs.gov/apps/media/press_releases.asp
Notice from CMS
Due to a problem associated with CMS CR 5250, “Coordination of Benefits Agreement (COBA) Eligibility File Claims Recovery Process,” 835 Remittance Advice (RA) associated with claims processed as of January 2, 2007 were missing the remark code “MA18” for TRICARE crossover claims produced by their Medicare carriers. That missing remark is the statement that says that the claim has been crossed over by Medicare. CMS has verified that the claims have in fact crossed over so there is no need to send paper RA to TriCare.
A coding correction has been sent to the contractors; however, only those claims received on or after February 5, 2007 will have the remark code present on the RA.
Also: This message is to inform you that the proposed rule issued by the Centers for Medicare & Medicaid Services (CMS), “Medicare Program; Prospective Payment System for Long Term Care Hospitals RY 2008: Proposed Annual Payment Rate Updates, and Policy Changes; and Proposed Hospital Direct and Indirect Graduate Medical Education Policy Changes” (CMS-1529-P), which was published in the Federal Register on February 1, 2007, incorrectly states that the 60-day public comment period will close on April 2, 2007 (72 FR 4776). A correction notice will be issued shortly to specify that comments on CMS-1529-P must be received no later than 5 p.m. on March 26, 2007 to be assured consideration.
New Products from the Medicare Learning Network
The Medicare Physician Fee Schedule Fact Sheet, which provides general information about the Medicare Physician Fee Schedule, is now available in downloadable format from the Medicare Learning Network at www.cms.hhs.gov/MLNProducts/downloads/
MedcrePhysFeeSchedfctsht.pdf. Print versions of the fact sheet will be available in approximately six weeks.
The Skilled Nursing Facility (SNF) Spell of Illness Quick Reference Chart, which provides Medicare claims processing information related to SNF spells of illness, is now available in downloadable format from the Medicare Learning Network at www.cms.hhs.gov/MLNProducts/downloads/snfspellillnesschrt.pdf.
MLN Matters article MM 5498 has been posted to the Centers for Medicare & Medicaid Services (CMS) website. This article describes additional changes to the 2007 Medicare Physician Fee Schedule Database. To view the article, click on http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5498.pdf.
The related CMS Manual instruction is posted at http://www.cms.hhs.gov/transmittals/downloads/R1161CP.pdf.
The Physician Fee Schedule National Payment Amount Files are located at http://www.cms.hhs.gov/PhysicianFeeSched/
PFSNPAF/list.asp#TopOfPage (View calendar year 2007)
In the Federal Register
On February 7, 2007 CMS published a correction to
A proposed rule: Long-term care hospitals; prospective payment system; annual payment rate updates, policy changes, and clarifications: http://a257.g.akamaitech.net/7/257/2422/01
jan20071800/edocket.access.gpo.gov/2007/C7-392.htm
CMS Transmittals
Medicare Benefit Policy - Basic Coverage Rules (PUB. 100-02)
Transmittal #65, Date: January 26, 2007 Inpatient Hospital Therapeutic Services (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm
_100_02&u=mrepm10002r65bp&h=top1.html&t=80&s=twcc
Medicare Claims Processing (PUB. 100-04)
Transmittal #1168, Date: January 26, 2007 Direct Billing and Payment for Non- Physician Practitioner Services Furnished to Hospital Inpatients and Outpatients (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=
mre_pm_100_04&u=mrepm10004r1168cp&h=top1.html&t=80&s=twcc
Transmittal #1167, Date: January 26, 2007 Use of 9-Digit ZIP codes for Determining the Correct Payment Locality for Services Paid Under the Medicare Physician Fee Schedule (MPFS) and Anesthesia Service (PDF): http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm
_100_04&u=mrepm10004r1167cp&h=top1.html&t=80&s=twcc
Transmittal #1166, Date: January 26, 2007 the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) Pricer (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_
pm_100_04&u=mrepm10004r1166cp&h=top1.html&t=80&s=twcc
Transmittal #1165, Date: January 26, 2007 Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm
_100_04&u=mrepm10004r1165cp&h=top1.html&t=80&s=twcc
Transmittal #1164, Date: January 26, 2007 Coding Change for Lumbar Artificial Disc Replacement (LADR)(PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm
_100_04&u=mrepm10004r1164cp&h=top1.html&t=80&s=twcc
Transmittal #1163, Date: January 26, 2007 Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Update (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm
_100_04&u=mrepm10004r1163cp&h=top1.html&t=80&s=twcc
Financial Management (PUB. 100-06)
Transmittal #115, Date: January 26, 2007 Clarification of the Protocol for Estimating Allowance for Uncollectible Accounts Form CMS-H/M751A/B, Status of Accounts Receivable (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm
_100_6&u=mrpm10006r115fm&h=top1.html&t=80&s=twcc
Transmittal #114, Date: January 26, 2007 Reporting Requirements for Crossover Claims Transmitted to the Coordination of Benefits Contractor (COBC) under the Coordination of Benefits Agreement (COBA) Process (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_
pm_100_6&u=mrpm10006r114fm&h=top1.html&t=80&s=twcc
State Operations Manual (PUB. 100-07)
Transmittal #24, Date: January 27, 2006 Sunset of the Policies for Provider Nominations for an Intermediary and the Provider Requests for a Change of Intermediary (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm
_100_07&u=mrpm10007r24som&h=top1.html&t=80&s=twcc
Program Integrity (PUB. 100-08)
Transmittal #188, Date: January 26, 2007 Accrediation Quality Standards for Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm
_100_08&u=mrpm10008r188pi&h=top1.html&t=80&s=twcc
Transmittal #187, Date: January 26, 2007 Implementation of New Compliance Standards for Independent Diagnostic Testing Facilities (IDTFs) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm
_100_08&u=mrpm10008r187pi&h=top1.html&t=80&s=twcc
Transmittal #186, Date: January 26, 2007 Durable Medical Equipment Medicare Administrative Contractors (DME MACs) Adoption or Rejection of Local Coverage Determinations (LCDs) Recommended by Durable Medical Equipment Program Safeguard Contractors (DME PSCs) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm
_100_08&u=mrpm10008r186pi&h=top1.html&t=80&s=twcc
Transmittal #185, Date: January 26, 2007 Updating Financial Reporting Requirements for Workload and Cost Associated With the Return of Demand Bills (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm
_100_08&u=mrpm10008r185pi&h=top1.html&t=80&s=twcc
Transmittal #184, Date: January 26, 2007 Revisions for MACs and PSCs (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mr_pm
_100_08&u=mrpm10008r184pi&h=top1.html&t=80&s=twcc
CMS One-Time Special Notification (PUB. 100-20)
Transmittal #262, Date: January 26, 2007 Invalid Managed Care Informational Unsolicited Responses (MCIURs) from CWF (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm
_100_20&u=mrepm10020r262otn&h=top1.html&t=80&s=twcc
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From the OIG
OIG Advisory Opinion - 07-01 - Concerning a Hospital's Proposal to Provide Free Dialysis Services to Chronic Dialysis Patients unable to obtain Dialysis in their Community:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=
hc_ig_ao&u=ao0701&h=top1.html&t=80&s=twcc
Audit Reports - Centers for Disease Control and Prevention
Emergency Response to Hurricanes Katrina and Rita: Audit of Centers for Disease Control and Prevention’s Award Process for a Commercial Purchase Order to McKesson Drug Company PDF (A-04-06-01031; 01/2007) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oas
_cdc&u=40601031&h=top1.html&t=80&s=twcc
Evaluation and Inspection Reports -
Centers for Medicare and Medicaid Services
Preadmission Screening and Resident Review for Younger Nursing Facility Residents With Serious Mental Illness (OEI-05-05-00220; 01/2007) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oei_
cms&u=oei050500220&h=top1.html&t=80&s=twcc
Preadmission Screening and Resident Review for Younger Nursing
Facility Residents With Mental Retardation (OEI-07-05-00230; 01/2007) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_oig_oei_cms&u=oei070500230&h=top1.html&t=80&s=twcc
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This Week’s Link:
NCQA - Public Comment Opens With HEDIS® Specifications for Physician Measurement
http://www.ncqa.org/
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Acronym Library
| CBR | Cost Based Reimbursement |
| CBS | Current Beneficiary Survey (by OACT) |
| CBSR | Cost Benefit Savings Report |
| CBSS | Customer Billing Services System |
For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp
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Contact Margaret
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This Week in Corporate Compliance
(781) 593-4924
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