Vol. XII, No. 9 – March 5, 2010 | Please direct all comments to subscriptions@hcca-info.org.
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Miami-Dade County HHA Owner Arrested for Defrauding Medicaid out of More Than $76,000 Former Medical Center Employee Pleads Guilty to Embezzling over $1 Million Dollars Two Large Nursing Home Chains and Their Principals Pay $14 Million to Settle False Claims Act Case DME Owner Pleads Guilty to Health Care Fraud and Aggravated Identity Theft Swindlers Adapt to Crackdown on Health Care Fraud Raleigh Man Sentenced to 90 Months for Medicare Fraud Two Former Executives of Medical Manager Found Guilty in Securities Fraud Scheme KV Pharmaceutical Subsidiary Pleads Guilty to Two Felonies Regarding Oversized Drugs U.S. Files Complaint Against Virginia Medicaid Providers California AG Subpoenas Health Plans over Claims Denials and Rate Hikes HHS Posts Medical Record Privacy Breaches Affecting 500 or More Individuals Shands Notifies Patients of Laptop Theft Health Care System in Delaware Pays $3.3 Million This Week’s Link: Testimony of Daniel R. Levinson, HHS Inspector General Compliance & Ethics Social Network: What’s Getting Talked About? Regulatory News CMS Suspends Marketing and Enrollment for Fox Insurance Company Drug Plan Headlines Miami-Dade County HHA Owner Arrested for Defrauding Medicaid out of More Than $76,000 Owner of Hialeah Health Care Facilities Sentenced to 112 Months for Threatening Investigators and Defrauding Medicare Former Medical Center Employee Pleads Guilty to Embezzling over $1 Million Dollars Two Large Nursing Home Chains and Their Principals Pay $14 Million to Settle False Claims Act Case DME Owner Pleads Guilty to Health Care Fraud and Aggravated Identity Theft Swindlers Adapt to Crackdown on Health Care Fraud Raleigh Man Sentenced to 90 Months for Medicare Fraud Two Former Executives of Medical Manager Found Guilty in Securities Fraud Scheme KV Pharmaceutical Subsidiary Pleads Guilty to Two Felonies Regarding Oversized Drugs U.S. Files Complaint Against Virginia Medicaid Providers California AG Subpoenas Health Plans over Claims Denials and Rate Hikes HHS Posts Medical Record Privacy Breaches Affecting 500 or More Individuals Shands Notifies Patients of Laptop Theft Health Care System in Delaware Pays $3.3 Million This Week’s Link Compliance & Ethics Social Network: What’s Getting Talked About
Regulatory News CMS Suspends Marketing and Enrollment for Fox Insurance Company Drug Plan CMS Update *** The therapy caps are determined on a calendar year basis, so all patients began a new cap on January 1, 2010. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1,860. For occupational therapy services, the limit is $1,860. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached. Some therapy providers have been holding claims for services furnished on or after January 1, 2010, for patients who exceeded the cap but qualified for an exception under previous law. These providers may submit those claims to Medicare effective immediately. Therapy providers, who submitted claims which were denied, for services furnished on or after January 1, 2010, for patients who exceeded the cap but whose services now qualify for an exception, should contact their Medicare contractor to request that their claim be adjusted to add the KX modifier and ensure the appropriate exception applies. A small number of therapy providers continued to submit claims with the KX modifier for services furnished on or after January 1, 2010, even though the exceptions process had expired on December 31, 2009. Medicare contractors held these claims and will now begin to release them for processing. These providers do not need to take any action on the claims that were held. Providers who charged beneficiaries for services that exceeded caps, which are now payable under the exception process, should refund the beneficiary’s cost, less the appropriate amount of deductible and co-insurance. Affected claims should be either submitted or, if already submitted, the provider should contact their contractor for an adjustment. *** Protect Your Privacy: Physicians and non-physician practitioners need to take steps to ensure that their Medicare enrollment information does not get into the hands of people who can use that information to commit fraud. (See the document titled, “Medicare Physicians and Non-Physician Practitioners - Protecting Your Privacy, Protecting Your Medicare Enrollment Record.” This document can be found here.) Organizations Must Be Enrolled Before Individuals: Before a physician or non-physician practitioner can reassign their benefits to a medical group or clinic other than the one they solely own, the medical group or clinic must have an approved enrollment record in PECOS. Initial Enrollment Application for an Individual: Physicians and non-physician practitioners who have not enrolled or updated their Medicare enrollment since November 2003 will need to complete an initial enrollment application. PECOS does not contain information for physicians and non-physician practitioners enrolled before November 2003 who have not updated their enrollment record since that time. Using Internet-based PECOS: We suggest you use Internet-based PECOS because it is faster and more efficient than the paper enrollment application process. Before you begin to use Internet-based PECOS, you should: Internet-based PECOS Limitations: While Internet-based PECOS supports most Medicare enrollment application actions, there are some limitations. A physician or non-physician practitioner cannot use Internet-based PECOS to: -Change his/her name or Social Security Number, -Reassign benefits to another supplier if that supplier does not have an approved enrollment record in PECOS, -Change in non-physician practitioner specialty type, or -Change an existing business structure. For example: o A sole owner of an enrolled Professional Association, Professional Corporation, or LLC cannot change the business structure to a sole proprietorship; or o An enrolled sole proprietorship cannot be changed to a solely-owned Professional Association, Professional Corporation, or LLC. Finalizing Submission and Responding to Development Request: After submitting an enrollment application via Internet-based PECOS, you: -Must print, sign and date (blue ink recommend) the Certification Statement(s) and mail the Certification Statement(s) and supporting documentation to the appropriate Medicare contractor. The Medicare contractor will not begin to process your enrollment application until it receives a signed and dated Certification Statement. -May be asked to make corrections or submitted additional documents by the Medicare contractor. In order for your application to be processed, you must submit this information. Reporting Responsibilities: Physicians and non-physician practitioners enrolled in the Medicare program have reporting responsibilities. See the download section found here for information about your reporting responsibilities. More Information: For more information about Internet-based PECOS, including contact information for the External User Services (EUS) Help Desk, click here and select the “Internet-based PECOS” tab on the left side of screen. EUS Help Desk provides assistance physicians and non-physician practitioners if they encounter an application navigation or systems problem with Internet-based PECOS. A navigation problem occurs when a practitioner is unable to determine how to use Internet-based PECOS. Physicians and non-physician practitioners who have problems with their User Ids or password should contact the NPI Enumerator at 1-800-465-3203. *** The PQRI is voluntary quality reporting program that provides an incentive payment to identified individual eligible professionals (EPs), and beginning with the 2010 PQRI, group practices who satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-For-Service (FFS) beneficiaries. The PQRI was first implemented in 2007 as a result of section 101 of the Tax Relief and Health Care Act of 2006 (TRHCA), and further expanded as a result of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA), and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). The eRx Incentive Program is an incentive program for eligible professionals initially implemented in 2009 as a result of section 132(b) of the MIPPA. The eRx Incentive Program promotes the adoption and use of eRx systems by individual eligible professionals (and beginning with the 2010 eRx Incentive Program, group practices). Following a few program announcements and updates, the lines will be opened to allow participants to ask questions of CMS PQRI and eRx subject matter experts. Educational products are available on the PQRI dedicated web page located here, on the CMS website, in the Educational Resources section, as well as educational products are available on the eRx dedicated web page located here on the CMS website. Registration will close at 1:30 p.m. EST on March 9, 2010, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time.
For those of who will be unable to attend, a transcript of the call will be available at least one week after the call here on the CMS website. If you require services for the hearing impaired please send an email to: Medicare.TTT@PalmettoGBA.com. *** When and Where: The Centers for Medicare & Medicaid Services (CMS) will be hosting a meeting with the Program Advisory and Oversight Committee (PAOC) on March 17, 2010 to discuss the Round 1 Rebid and upcoming Rounds of the Medicare DMEPOS Competitive Bidding Program. The agenda for the meeting is available on the CMS website here. Registration for the meeting is now open. To register, please click here. Registrations must be received no later than 5:00 p.m. Eastern Standard Time on March 12, 2010. Meeting attendees should allow plenty of time to ensure access to the CMS facility. CMS security procedures require that all visitors are subject to a vehicular search and can only gain access through the Central Building Main Lobby. All visitors must also be in possession of a valid, government-issued form of photo identification, such as a driver's license, age of majority card, passport or visa. *** The next Home Health, Hospice & DME Open Door Forum is scheduled for Wednesday, March 10, 2010 from 2pm-3pmET. Click here The next Skilled Nursing Facilities (SNF)/Long Term Care (LTC) Open Door Forum is scheduled for Thursday, March 11, 2010 from 2-3pmET. Click here ***top***From the GAO CMS Transmittals From the OIG Advisory Opinions Corporate Integrity Agreements List of Excluded Individuals/Entities Acronym Library Visit Our Website at www.hcca-info.org NOTE: HCCA Members, please contact April Kiel at Click here if you have not received your password. The Web site allows members and visitors to register for conferences, order products, or join HCCA online. HCCA Members can update membership information and search for compliance resources online in a secure environment. HCCA's Web site also offers Compliance Social Network HCCAnet, which allow regional and industry specific information to be shared through a discussion forum and list-serve. Members can view and respond to documents, tools, forms, policies and other information posted by Regional and Compliance Focus Group leaders! Visit www.hcca-info.org and see for yourself. ***top*** HCCA Headquarters Contact Information To subscribe to TWCC, click here
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