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2014 Regional Conference Prospectus Available


San Juan, PR Regional Conference
May 1-2, 2014
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May 9, 2014
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June 6, 2014
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June 20, 2014
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September 12th, 2014
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September 19th, 2014
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September 29th, 2014
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November Research Basic Compliance Academy
November 3 – 6, 2014
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Compliance Academies

June Basic Compliance Academy SOLD OUT
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August 4 – 7, 2014
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June Health Care Privacy Basic Compliance Academy
June 16 – 19, 2014
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National Conferences

Research Compliance Conference
June 1 – 4, 2014
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Clinical Practice Compliance Conference
October 12 - 14, 2014
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The Health Care Compliance Professional’s Manual

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The Health Care Privacy Compliance Handbook

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Compliance and Ethics: An Introduction for Health Care Professionals

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Web Conferences

Trends in Medicaid Compliance and Enforcement
April 21, 2014


Survival of the Fittest - Navigating the DMEPOS Jungle
April 24, 2014


Is Your Compliance Program Window Dressing or Effective?
April 29, 2014


A Compliance Program Makeover...From Good to Great
May 12, 2014


Mentoring Other Compliance Professionals
May 13, 2014


Importance of Population Health Management and Case & Care Management Applications
May 15, 2014


The Data Deep Dive
May 19, 2014


Integrating PEPPER into your IRF Compliance/Quality Program
May 20, 2014


Sunshine Act - Update
May 27, 2014


Manage Evaluate Assess Treat (MEAT): Monitoring ICD-9 and ICD-10 Coding to Detect Fraud
May 28, 2014


The PPACA Mandate for Effective Compliance Programs: a Primer for Non-Institutional Providers
May 29, 2014


Current Fraud and Abuse Issues for Home Health Providers
June 4, 2014


HIPAA Business Associate Satisfactory Assurances: What Do We Ask For?
June 5, 2014


Fraud, Abuse and Compliance Risks in Everyday Agreements
June 11, 2014


Medicare's Physician Supervision Requirements and the False Claims Act
June 16, 2014


Lessons Learned From OIG's Evolving Approach to Corporate Integrity Agreements
June 17, 2014


Counterfeit Medicine, Careful Compliance
July 29, 2014


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Vol. XVI, No. 16
April 18, 2014

 

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HCCAnet, HCCA’s Compliance & Ethics Social Network: What’s Being Talked About

This Week’s Headlines – April 18, 2014

Grassley announces plans to create Senate Whistleblower Caucus
Anchorage psychiatrist charged with Medicaid fraud
Lawyers start mining the Medicare data for clues to fraud
Tennessee substance abuse treatment facility agrees to resolve False Claims Act allegations for $9.25 million
Colleagues in cuffs: When employees steal patient records
Illinois-based Astellas to pay $7.3M settlement
Government intervenes in lawsuit against medical equipment supplier Orbit Medical Inc. and former vice president Jake Kilgore
Final two defendants sentenced in identity theft tax refund fraud scheme involving thousands of patients’ personal identity information
Cancer doctor and clinic agree to pay $2.9 million to settle federal whistleblower lawsuit

This Week’s Links

Regulatory News

CMS Proposes Adoption of Updated Life Safety Code

CMS Update

From the GAO

In the Federal Register

CMS Transmittals

From the OIG

Acronym Library


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Headlines

Grassley announces plans to create Senate Whistleblower Caucus
On April 10, 2014, U.S. Senator Chuck Grassley announced in a press release his “plans to create a Senate Whistleblower Protection Caucus.

“Grassley said he’s creating the caucus to build a coalition of like-minded Senators who can help bring attention to the need for ongoing whistleblower protections. Over the next six months, Grassley will be discussing the caucus with colleagues and encouraging them to join with an eye on an official start in the new Congress.

“‘Whistleblower protections are only worth anything if they’re enforced.  Just because we’ve passed good laws does not mean we can stop paying attention to the issue.  There must be vigilant oversight by Congress. The best protection for a whistleblower is a culture of understanding and respecting the right to blow the whistle,’ Grassley said. ‘I hope this whistleblower caucus will send the message that Congress expects that kind of culture.’” For more

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Anchorage psychiatrist charged with Medicaid fraud
On April 16, 2014, the Anchorage Daily News reported, “Authorities arrested an Anchorage physician Tuesday evening, alleging he billed Medicaid more than $300,000 for services he never provided.

“Dr. Shubhranjan Ghosh, the 39-year-old founder and sole practitioner at Ghosh Psychiatric Services, was charged by the state with medical assistance fraud, scheme to defraud and evidence tampering. He primarily treats children, according to a charging document filed in the case.

“The arrest comes after a string of charges connected to Medicaid in what the state is calling a continuing "crackdown" on billing fraud. Since October 2012, the Alaska Medicaid Fraud Control Unit has charged 77 individuals with Medicaid fraud, abuse or neglect, compared to about 30 people the decade before, said Andrew Peterson, assistant attorney general.”
For more | Alaska Department of Law Press Release

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Lawyers start mining the Medicare data for clues to fraud
On April 14, 2014, Reuters reported, “Within hours of the U.S. government's unprecedented release last week of a trove of Medicare billing data, a small fraternity of lawyers who specialize in representing whistleblowers in healthcare fraud cases began to mobilize.

“These lawyers earn their living bringing cases on behalf of employees at drug companies and healthcare providers who believe their bosses or colleagues may be cheating the federal Medicare system by bribing doctors to prescribe certain drugs, for example, or inflating bills.

“A whistleblower who prevails gets up to 30 percent of whatever the government recovers, and 40 percent of that reward typically goes to the whistleblower's lawyer.

“Whistleblower cases can result in huge settlements, such as the $3 billion GlaxoSmithKline paid in 2012 to resolve claims that it promoted drugs for unapproved uses and failed to report certain safety data.” For more

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Tennessee substance abuse treatment facility agrees to resolve False Claims Act allegations for $9.25 million
On April 17, 2014, Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery announced, “CRC Health Corp. (CRC) has agreed to pay $9.25 million to the federal government and the state of Tennessee to settle allegations that CRC knowingly submitted false claims by providing substandard treatment to adult and adolescent Medicaid patients suffering from alcohol and drug addiction at its facility in Burns, Tennessee. CRC, based in Cupertino, California, is a nationwide provider of substance abuse and mental health treatment services.”

According to the government press release, “CRC owns and operates a residential substance abuse treatment facility in Burns, Tenn., called New Life Lodge.  The government alleged that, between 2006 and 2012, New Life Lodge billed the Tennessee Medicaid program (TennCare) for substance abuse therapy services that were not provided or were provided by therapists who were not properly licensed by the state of Tennessee.  The government also alleged that New Life Lodge failed to make a licensed psychiatrist available to patients at the facility, as required by the state’s regulations; failed to maintain patient-staffing ratios required by Tennessee Department of Mental Health regulations and billed for Medicaid patients in excess of the state-licensed bed capacity at the facility.  In addition, the government alleged that New Life Lodge double-billed Medicaid for prescription substance abuse medications given to residents at the facility.  New Life Lodge currently is not treating Medicaid patients at its facility.” For more

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Colleagues in cuffs: When employees steal patient records
On April 7, 2014, Information Week reported, “The Queens, N.Y., district attorney recently charged two employees of Jamaica Hospital Medical Center with illegally accessing emergency room patients' medical records and personal identification information, and selling that data to individuals who then solicited services such as outpatient care or legal assistance -- sometimes while patients were still in the ER.

“‘These defendants are accused of blatantly violating their HIPAA obligations and illegally trolling through confidential patient records. Their alleged actions led to patients who were seeking treatment for injuries unwittingly being victimized again with the illegal release of their personal information and medical records,’ said DA Richard Brown, in a statement.

“Defendants Maritza Amador, 44, and Dache Prawl, 45, were registrars at the Queens, N.Y., hospital's ER. Allegedly the duo illegally accessed personal information, including Social Security numbers and medical data, and passed that information to people who falsely represented themselves as representatives of the hospital to patients. These individuals offered transportation to outpatient therapy, attorney services related to car accident injuries, and follow-up medical treatment, the DA charges. They were released without bail and their next court date is May 20, the Queens County DA's office told InformationWeek.For more

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Illinois-based Astellas to pay $7.3M settlement
On April 16, 2014, the Miami Herald reported, “The U.S. Justice Department announced Wednesday that an Illinois-based pharmaceutical company will pay $7.3 million to resolve allegations involving the marketing of the drug Mycamine (MY'-kuh-meen).

“Northbrook-based Astellas Pharma US Inc. manufactures and sells Mycamine, which is used to treat invasive fungus infections.

“The Justice Department investigated Astellas for alleged off-label promotion of the drug for children between 2005 and 2010. The company has denied the allegation.” For more | DOJ Press Release

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Government intervenes in lawsuit against medical equipment supplier Orbit Medical Inc. and former vice president Jake Kilgore
On April 14, 2014, Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery announced, “The government has intervened in a False Claims Act lawsuit against Orbit Medical Inc. and Jake Kilgore alleging that Orbit Medical’s sales representatives boosted power wheelchair and accessory sales by altering and forging physician prescriptions and supporting documentation. Orbit Medical is a durable medical equipment supplier based in Salt Lake City, Utah. Jake Kilgore is the former vice president and sales manager at Orbit Medical for the Western region of the United States.”

According to the government press release, “Medicare pays for power wheelchairs for beneficiaries who cannot perform mobility- related activities of daily living in their home using other mobility assistance equipment, such as a cane, walker or power scooter. To qualify for reimbursement, a physician must conduct a face-to-face examination of the beneficiary and provide the supplier with a written prescription for a power wheelchair within 45 days of such an encounter, along with documentation that supports the medical necessity of the device. The prescription must be completed by the physician who performed the exam and must include the beneficiary’s name, the exam date, the diagnoses and conditions the wheelchair is expected to accommodate, the length of need and the physician’s signature.” For more

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Final two defendants sentenced in identity theft tax refund fraud scheme involving thousands of patients’ personal identity information
On April 11, 2014, U.S. Attorney for the Southern District of Florida Wifredo A. Ferrer announced, “Michael Ali Bryant, Sr., 41, and his wife, Latina Rashawn Bryant, 43, both of Lauderdale Lakes, were sentenced for their participation in a stolen identity tax refund scheme. Michael Bryant was sentenced to 144 months in prison, to be followed by three years of supervised release. Latina Bryant was sentenced to 48 months in prison, to be followed by three years of supervised release.

“Both defendants previously pled guilty to one count of aggravated identity theft, in violation of Title 18, United States Code, Section 1028A. Michael Bryant also previously pled guilty to one count of possession of fifteen or more unauthorized access devices, in violation of Title 18, United States Code, Section 1029(a)(3); and Latina Bryant previously pled guilty to one count of using an unauthorized access device, in violation of Title 18, United States Code, Section 1029(a)(2).”
For more

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Cancer doctor and clinic agree to pay $2.9 million to settle federal whistleblower lawsuit
On April 15, 2014, the Kansas City Star reported, “As a cancer specialist, Raj Sadasivan did some of his most lucrative work altering medical records with a paper cutter and scissors, some of his former employees contend.

“It was those records at the Hope Cancer Institute in Kansas City, Kan., that became the key to an alleged fraud to bilk Medicare and other government programs out of millions of dollars — the largest federal health fraud case in the Kansas City area in recent years.

“Sadasivan and his clinic have agreed to pay $2.9 million to settle a federal whistleblower suit alleging that for years he faked claims to inflate the doses of the costly chemotherapy drugs he gave his patients and to make it appear he was spending more time consulting with patients than he actually did.” For more | DOJ Press Release

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This Week’s Links

Reuters: “Exclusive - U.S. weighs $5 million fine against ex-MoneyGram compliance chief.” For more

eNCA: “Credit bureau breaches medical records regulation” For more

Miami Herald: “Medicare fraud “tourism” hits Miami” For more

The Observer: “Former HealthSouth whistleblower addresses ethics” For more

CMS: Comprehensive ESRD Care Model Fact Sheet For more

OIG: Advisory Opinion 14-04 For more

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MediRegs is a pioneer in Ethics, Compliance and Regulatory Information Management. With more than 500 organizations using MediRegs already, you can confidently empower your team with our ADVantage ArchitectureSM.This week, MediRegs provided TWCC readers with the following: From the GAO, In the Federal Register, CMS Transmittals, and From the OIG.

Regulatory News

CMS Proposes Adoption of Updated Life Safety Code
On April 14, CMS announced a proposed rule on the adoption of an updated life safety code (LSC) that CMS would use in its ongoing work to ensure the health and safety of all patients, family and staff in every provider and supplier setting. The updated code contains new provisions that are vital to the health and safety of all patients and staff.

The proposed rule was published in the April 16, 2014 Federal Register. The deadline to submit comments is June, 16, 2014.Full text of this excerpted CMS fact sheet (issued April 14).

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CMS Update

Dates & Times of Upcoming National Provider Calls
Registration Opening Soon for the following CMS Calls:
- Tuesday, April 22; 1:30-3pm ET - Medicare Shared Savings Program ACO Application Process
- Monday, May 19; 2-3:30pm ET - Individualized Quality Control Plan for CLIA Laboratory Non-Waived Testing  
- Tuesday, May 20; 1:30-3:00pm ET - National Partnership to Improve Dementia Care in Nursing Homes

To register- To receive call-in information, you must register for calls on the CMS Upcoming National Provider Calls registration website. Space may be limited, register early. Registration will close at 12pm on the day of the call or when available space has been filled; no exceptions will be made, so please register early.

The presentation for calls will be posted on the FFS National Provider Calls web page. A link to the slide presentation will be emailed to all registrants on the day of the call.

Visit the Continuing Education Credit Notification web page for continuing education information

Special Open Door Forum: Suggested Electronic Clinical Template for Home Health - Conference Call Only
Tuesday, April 22; 3-4pm ET
Special Open Door Participation Instructions:

  • Participant Dial-In Number: 800-837-1935; Conference ID # 20361722
  • Note: TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.

SNF Consolidated Billing: Exclusion of HCPCS Code G0463 for Certain Outpatient Hospital Clinic Visits
Effective January 1, 2014, CMS recognized Healthcare Common Procedure Coding System (HCPCS) code G0463 (Hospital outpatient clinic visit for assessment and management of a patient) for payment under the Outpatient Prospective Payment System (OPPS) for outpatient hospital clinic visits. Effective January 1, 2014, Current Procedural Terminology (CPT) codes 99201-99205 and 99211-99215 are no longer recognized for payment under the OPPS.

For Skilled Nursing Facility (SNF) consolidated billing (CB) purposes, these CPT code ranges represent a hospital’s facility charge for clinic services of a hospital-based physician and are excluded from SNF CB. Therefore, HCPCS code G0463 is also excluded from SNF CB for outpatient clinic visits effective January 1, 2014. Medicare Administrative Contractors (MACs) were recently instructed to bypass this code when billed on outpatient hospital claims. If you previously received a SNF CB rejection for HCPCS G0463, you should contact your MAC to verify if you can adjust or resubmit your previously processed claim.

CMS is currently updating the claims processing internet-only manual, Chapter 6 “Inpatient Part A Billing and SNF Consolidated Billing,” section 20.1.1.2, “Hospital’s ‘Facility Charge’ in Connection with Clinic Services of a Physician” to include HCPCS code G0463.

Hold on CAH Claims for Non-Patient Specimen Analysis
Critical Access Hospital (CAH) claims for Type of Bill 14X with Date of Service on or after April 1, 2013 and Reason Code 39910 will be held starting April 1, 2014 until May 12, 2014. A fix will be applied on May 12, 2014 and held claims will be processed as normal. No action is required by the CAHs.

Hold on Some Part B Claims Following April Inpatient Payment Policy Update
CMS implemented Part B inpatient payment policies in April, 2014. See MLN Matters® Article MM8445. After implementation of the April 2014 Quarterly Release on April 7, 2014, issues were identified, and claims with the following Reason Codes will be held until the system is fixed on April 28, 2014.

  • Reason Code 34910 assigns incorrectly for Type of Bill (TOB) 13X
  • Reason Codes 31795 and 31797 assign incorrectly for TOB 13X with a Statement To date on or after 10/01/13 and the Receipt date is on or after 04/01/14 with A/B Rebilling in the first treatment authorization field without a W2 Condition Code.
  • Reason Code 31796 assigns incorrectly for claims with the Receipt date on or after 04/01/14 with an Admit date greater than or equal to 10/01/13 and A/B Rebilling is in the first treatment authorization field with a W2 Condition Code.
  • Reason Code 39015 assigns incorrectly for TOB 12X, Admit date prior to 10/01/13 with a Receipt date on or after 04/01/14 or TOB 13X with statement To date prior to 10/01/13 and Receipt date is on or after 04/01/14.
  • Reason Codes 39011 and 39012 will assign incorrectly for TOB 12X when the Admit date is equal to 10/01/13 or greater and the Receipt date is greater than one year from the 10/01/13 date.
  • Reason Code 31818 will assign incorrectly for TOB 13X when non-covered Part B services are identified on the Part B Rebilled 12X TOB for Claims when the Admit date is on or after 10/01/13 and Receipt date on or after 04/01/14.

Once the fix is installed, these claims will be released. No action is required by providers.

New from MLN
“Certifying Physicians and the Phase 2 Ordering and Referring Denial Edits for Home Health Agencies (HHAs)” MLN Matters® Article — Released

 “Implementation of Fingerprint-Based Background Checks” MLN Matters® Article — Released

 “Medicaid Program Integrity: What Is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs?” Fact Sheet — Released

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From the GAO

  • MEDICARE: Second Year Update for CMS's Durable Medical Equipment Competitive Bidding Program Round 1 Rebid GAO-14-156: Published: Mar 7, 2014. Publicly Released: Apr 8, 2014 (PDF): For more
  • MEDICARE: Certain Physician Feedback Reporting Practices of Private Entities Could Improve CMS's Efforts GAO-14-279: Published: Mar 26, 2014. Publicly Released: Mar 26, 2014 (PDF): For more
  • VETERANS' HEALTH CARE: Oversight of Tissue Product Safety GAO-14-463T: Published: Apr 2, 2014. Publicly Released: Apr 2, 2014 (PDF): For more

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In the Federal Register

HHS

  • Rule: Occupational Safety and Health Investigations of Places of Employment 19835 [2014-07988]:
    For more
  • Proposed Rule: Occupational Safety and Health Investigations of Places of Employment 19848-19849 [2014-07987]: For more
  • Notice: Draft Guidance for Industry, Researchers, Patient Groups, and Food and Drug Administration Staff on Meetings.. 19623-19626 [2014-07908]: For more

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CMS Transmittals

2014 Transmittals and MLN Matters:
For more

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From the OIG

Podcasts, Spotlight Articles, Videos and Related Materials

  • OIG Podcasts about Reports - Last Updated: 04/10/2014: For more

Audit Reports

  • Oakwood Hospital and Medical Center Incorrectly Billed Medicare Inpatient Claims With Kwashiorkor (A-03-13-00032) (4/3/14) (PDF): For more
  • CMS Generally Met Requirements in the Durable Medical Equipment Competitive Bidding Round 1 Rebid Program (A-05-12-00067) (4/7/14) (PDF): For more

Evaluation and Inspection Reports

  • Limited Compliance With Medicare's Home Health Face to Face Documentation Requirements (OEI-01-12-00390) (4/2014) (PDF): For more
  • Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420) (4/2014) (PDF): For more
  • Iowa Has Shifted Medicare Cost-Sharing for Dual Eligibles to the Federal Government (OEI-07-13-00480) (4/2014) (PDF): For more

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Acronym Library

IOC Inspection of Care
IP/SNF Inpatient SNF
IPRP Interim Payment Review Program  
IPS  Institutional Provider of Service

Click here for more from CMS Acronyms

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Email: service@hcca-info.org
Contact: Margaret Dragon, Editor, This Week in Corporate Compliance: 781-593-4924

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