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Vol. IX, No. 8 – February 23, 2007 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Audit & Compliance
Quality of Care
Physician’s Practice Compliance Conference
Research Compliance Conference
Medicare Prescription Drug Part D Conference
Table of Contents
Headlines
Former Rock Creek Psychiatric Hospital CEO and Physician Charged
Surgeon, Chiropractors Charged with Health Care Fraud
Medical Center Settles Fraud Charges
Heart Procedures at UMDNJ Drop
Regulatory News
JCAHO Seeks Hand Hygiene Measurement Methods
JCAHO Awarded Robert Wood Johnson Foundation Grant to Test Nursing-Focused Quality of Care Measures
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:
Former Rock Creek Psychiatric Hospital CEO and Physician Charged
On February 16, 2007 U.S. Attorney’s Office for the Northern District of Illinois announced that the former Chief Executive Officer at the shuttered Rock Creek Center in Lemont, IL and an associated physician became the third and fourth 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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Guilty Pleas Anticipated
On February 22, Modern Healthcare reported that “Prosecutors with the U.S. Attorney’s Northern District of Illinois announced they anticipate that three individuals will plead guilty Feb. 27 to their part in an alleged fraud scheme that involved setting up a "sham joint venture" in order to satisfy minority contracting requirements for a $49.3 million radiology deal with Malvern, Pa.-based Siemens Medical Solutions and 460-bed John H. Stroger Jr. Hospital of Cook County, Chicago (then Cook County Hospital).
“Siemens already pleaded guilty Feb. 8 to a charge of obstruction of justice and agreed to pay a $1 million fine and more than $1.5 million in restitution to Cook County, Ill.
“Indictments for wire fraud, mail fraud and other charges were issued in January 2006 for Faust Villazan, chief executive officer of Faustech, Siemens USA attorney Ellen Roth and Siemens Medical Solutions (then Siemens Medical Systems) business administrator Daniel Desmond.” For more:
http://www.modernhealthcare.com/apps/pbcs
.dll/article?AID=/20070222/FREE/70221008/0/FRONTPAGE
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Surgeon, Chiropractors Charged with Health Care Fraud
On February 20, the Atlanta Business Journal reported “A federal grand jury handed down two separate health-care fraud indictments today, charging a total of five health-care providers with fraudulently billing approximately $6 million, principally for a back pain procedure.
“According to the U.S. Attorney's office, Howard Berkowitz, 59, of Atlanta; Arthur Hargraves, 66, of Douglasville; and Daniel Puffenberger, 51, of Kissimmee, Fla., were each charged with five counts of health care fraud that they allegedly committed as owners of the Associated Spinal Care Network in Douglasville. The indictment alleges that Berkowitz was an orthopedic surgeon and the medical director of Associated Spinal Care, while the two other defendants were chiropractors. The indictment alleges that Associated Spinal Care, at the direction of the three, billed Blue Cross/Blue Shield of Georgia for over $3 million relating to the procedure from 2001 through 2005.” For more: http://charlotte.bizjournals.com/atlanta/stories
/2007/02/19/daily11.html
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Medical Center Settles Fraud Charges
On February 21, The Moultrie Observer reported that “Colquitt Regional Medical Center (CRMC) agreed to pay the federal government $475,000 to settle fraud allegations.
“The federal whistleblower case, which was filed Aug. 17, 2004, remained sealed until Wednesday. It centered around a series of claims submitted for Medicaid and Medicare reimbursement by CRMC’s Home Care Services office in Sylvester from 2001 to 2005.” For more: http://www.moultrieobserver.com/
local/local_story_052225555.html
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Drug Firms Accused of Fraud
The Star-Ledger reported on February 18, that “The nation's big drugmakers have been systematically overcharging the Medicaid health-care program for the poor, reaping billions of dollars in illegal windfalls at the expense of the taxpayers, according to federal officials, members of Congress and a watchdog group.
“Drugmakers are required by law to provide Medicaid with the same discounts they offer to big managed-care plans and hospital chains, but they have been disguising those prices, Ronald Tenpas, a U.S. associate deputy attorney general, told the House Committee on Oversight and Government Reform earlier this month.” For more: http://www.nj.com/business/
ledger/index.ssf?/base/business-0/117177766697300.xml
&coll=1
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Heart Procedures at UMDNJ Drop
On February 23, the Courier News reported that “News of an illegal scheme involving referrals of heart patients has caused a sharp drop in procedures at the University of Medicine and Dentistry of New Jersey’s hospital here, and the university now expects a big financial loss as a result.
University spokeswoman Kaylyn Dines said Wednesday that the loss is expected to total $5.5 million from January through the end of the current fiscal year, June 30.
The anticipated loss was disclosed Tuesday night at the monthly meeting of the university’s board of trustees and reported Wednesday by The Star-Ledger of Newark. For more:
http://www.c-n.com/apps/pbcs.dll/article?
AID=/20070221/FRONT01/70221051
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This week, MediRegs provided TWCC readers with the following Regulatory information: In the Federal Register, CMS Transmittals, Court Cases and Administrative Actions, and From the OIG.
Regulatory News
JCAHO Seeks Hand Hygiene Measurement Methods
On February 16, 2007, the Joint Commission announced it is seeking comprehensive, innovative and cost effective hand hygiene measurement methods that address adherence to hand hygiene guidelines to share with health care organizations throughout the world, as part of its Consensus Measurement in Hand Hygiene (CMHH) project. For more: http://www.jointcommission.org/NewsRoom/
NewsReleases/nr_021607.htm
JCAHO Awarded Robert Wood Johnson Foundation Grant to Test Nursing-Focused Quality of Care Measures
On February 20, the Joint Commission will begin a comprehensive test of nursing-focused performance measures to determine whether they can be used nationally to identify opportunities to improve the quality of patient care provided by nurses. The project is being funded by a grant from the Robert Wood Johnson Foundation. For more: http://www.jointcommission.org/NewsRoom/
NewsReleases/nr_02_20_07.htm
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CMS Update
NPI Information
There are less than 90 days left between today and the NPI compliance date of May 23, 2007. It is estimated that it may take at least this much time to implement the NPI into your business practices. Failure to prepare could result in a disruption in cash flow. Will you be ready to use your NPI? Time is running out!
Updating National Plan and Provider Enumeration System (NPPES) Information
All health care providers, including Medicare providers, should include their legacy identifiers, as well as associated provider identifier type(s), on their NPI applications. If a provider has already completed an application and did not submit a legacy identifier, this provider should go back and update its information in NPPES. A provider can easily do so by using the web (https://nppes.cms.hhs.gov). While doing so, providers should also validate other data in NPPES, such as address, contact person information, etc. and update anything that has changed.
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 their NPIs. In fact, as outlined in current regulation, providers must share their NPI with any entity that may need it for billing purposes -- including those who need it for designation of ordering or referring physician. Providers should also consider letting health plans, or institutions for whom they work, share their NPIs for them.
New Frequently Asked Questions (FAQs) Posted
CMS has posted new NPI FAQs on its website.
Questions include:
- For Medicare provider enrollment purposes, will group practices need to submit new CMS-855R’s for every member of the group practice in order to let Medicare know their NPIs?
- Will health plans link the National Provider Identifiers (NPIs) of group practices to the NPIs of the health care providers who are members of the group practices?
- Who needs an NPI – who is not eligible to apply for an NPI - what if I have a Drug Enforcement Administration (DEA) number – what if I only bill on paper – what if I do not submit claims to Medicare?
- Can my office Employer Identification Number (EIN) be used instead of a National Provider Identifier (NPI)?
- When do I need to use my National Provider Identifier (NPI)?
- Is a corporation that owns pharmacies that have National Provider Identifiers (NPIs) required to have an NPI in order to receive payments on behalf of the owned pharmacies?
To view these FAQs, please go to the CMS dedicated NPI webpage at www.cms.hhs.gov/NationalProvIdentStand and click on Educational Resources. Scroll down to the section that says “Related Links Inside CMS” and click on Frequently Asked Questions. To find the latest FAQs, click on the arrows next to “Date Updated”.
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 Info for Medicare Providers
Sharing NPIs with Medicare
In addition to updating critical data and legacy identifiers in the NPPES, Medicare providers should include both their NPIs and their Medicare legacy numbers in their Medicare claims. This will help Medicare build its NPI crosswalk by enabling Medicare to link providers’ NPIs to their Medicare legacy identifiers. Also, when Medicare providers make changes to their Medicare enrollment information, they are now required to furnish their NPIs when making those changes. Providers applying for Medicare enrollment must furnish their NPIs on their enrollment applications. These actions inform Medicare of providers’ NPIs.
There are no additional actions that Medicare providers need to take to inform Medicare of their NPIs.
Need More Information
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 1-800-465-3203.
New From MLN
The Acute Inpatient Prospective Payment System Fact Sheet, which provides general information about the Acute Inpatient Prospective Payment System (IPPS) and how IPPS rates are set, is now available in print format from the Medicare Learning Network. To place your order, visit www.cms.hhs.gov/mlngeninfo, scroll down to “Related Links Inside CMS,” and select “MLN Product Ordering Page.” Remember that all Medicare Learning Network products are free of charge!
A CMS Review of Payments Made for Single Source Drugs and Biologics
After carefully examining Section 1847A of the Social Security Act, as established in the MMA, the Centers for Medicare & Medicaid Services (CMS) is conducting a review to ensure that separate payment is made for single source drugs and biologics as required by this section of the Act. In order to facilitate separate payment, it may be necessary to create unique HCPCS level II codes for certain products. As part of this effort, we will also review how we have operationalized the terms ‘single source drug,’ ‘multiple source drug,’ and ‘biological product’ in the context of payment under section 1847A to identify the potential need to make any changes to our assignment of National Drug Codes to billing codes for payment purposes. In the coming months, we will post additional information along with a preliminary list of drugs and biologics potentially affected.
So that we can implement any necessary changes during 2007, CMS will use its internal process for modifying the code set. While internally generated code requests are not part of the HCPCS public meeting process, CMS will consider any comments on potentially affected drugs and biologics and input to conventions for code descriptors and units of measure. Comments can be sent to HCPCS@cms.hhs.gov.
Information on Physician Performance to Be Given to Medicare Beneficiaries
Medicare to Provide Beneficiaries with Information on Physician Performance As Part of Value-Driven Health Care Initiative
The Centers for Medicare & Medicaid Services (CMS) announced that the Delmarva Foundation for Medical Care (Delmarva), one of its quality improvement organizations, has entered into subcontracts with four regional collaboratives, as part of the Better Quality Information to Improve Care for Medicare Beneficiaries (BQI) Project.
These regional collaboratives will combine Medicare data with data from other insurers to produce information on the performance of health care providers for the benefit of Medicare beneficiaries.
To view the entire press release, please click here:
http://www.cms.hhs.gov/apps/media/press_releases.asp
Upcoming CMS Open Door Forums
The next Rural Health Open Door Forum (ODF) is Wednesday, February 28, 2007
http://www.cms.hhs.gov/OpenDoorForums/24_
ODF_RuralHealth.asp#TopOfPage
The next Physicians, Nurses, and Allied Health Professionals Open Door Forum is Tuesday, March 6, 2007
http://www.cms.hhs.gov/OpenDoorForums/23_
ODF_PNAHP.asp#TopOfPage
The next Hospital Open Door Forum is scheduled for Thursday, March 8, 2007. For more:
http://www.cms.hhs.gov/OpenDoorForums/18_
ODF_Hospitals.asp
The next Home Health, Hospice, and DME Open Door Forum is scheduled for Wednesday, March 14, 2007
http://www.cms.hhs.gov/OpenDoorForums/17_
ODF_HHHDME.asp#TopOfPage
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In the Federal Register
Veterans Affairs Proposes Rule on Reasonable Charges for Medical Care or Services
On February 13, 2007, the Department of Veteran Affairs proposed revisions to the medical regulations concerning "reasonable charges" for medical care or services provided or furnished by VA to certain veterans for nonservice-connected disabilities. VA proposed changing the process for determining interim billing charges when a new Diagnosis Related Group code or Current Procedure Terminology/ Healthcare Common Procedure Coding System code identifier is assigned to a particular type or item of medical care or service and VA has not yet established a charge for the new identifier. This process is designed to provide interim billing charges that are very close to what the new billing charges would be when the charges for the new identifiers are established in accordance with the regulations.
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_fr69_
va&u=0702134&h=top1.html&t=80&s=twcc
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CMS Transmittals
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=
CALCAG00372N2&h=top1.html&t=80&s=twcc
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From the OIG
List of Excluded Individuals/Entities
OIG 01/07 Cumulative Sanction Report-Reinstatements for January 2007 (Excel):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_
fed_gov_oig_csr&u=0701rein&h=top1.html&t=80&s=twcc
OIG 01/07 Cumulative Sanction Report-Update for January 2007 (Excel):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_
fed_gov_oig_csr&u=0701up&h=top1.html&t=80&s=twcc
Evaluation and Inspection Reports - Centers for Medicare and Medicaid Services
Medicare Part B Services for Nursing Home Residents: 2002 PDF (OEI-05-06-00240; 01/2007) (PDF):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_
oig_oei_cms&u=oei050600240&h=top1.html&t=80&s=twcc
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Court Cases and Administrative Actions
CMS Advisory Opinions
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre
_cms_ao&u=CMSAO200601&h=top1.html&t=80&s=twcc
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This Week’s Link:
KPMG’s Healthcare Industry Report-2006
http://www.us.kpmg.com/news/index.asp?cid=2292
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Acronym Library
| CDI | Catastrophic Drug Insurance (Trust Fund) |
| CDM | (Hospital) Charge Description Master (Files) |
| CDOC | Covered Days of Care |
For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp
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