Vol. XIV, No.5 – February 3, 2012 | About HCCA | CCB Certification | Shop Online | Events | Career Opportunities | Read on Website

HCCAnet, HCCA's Compliance & Ethics Social Network: What’s Getting Talked About?

Headlines

Forecast is Brighter for Compliance and Ethics Professionals: Increase in Compliance Budgets, Greater Sense of Job Security, but only Slight Increase in Staffing
Justice Department Settles ADA Lawsuit with Michigan's Henry Ford Health System
DME Business Owner Lands in Federal Prison for 10 Years for Health Care Fraud and Identity Theft Scheme
Houston Concert Promoter Gets Federal Prison for Defrauding Medicare of Almost $10 Million
Former Hospice Owner Sentenced for Health Care Fraud
Patient Recruiter Pleads Guilty in Louisiana Health Care Fraud Scheme
Florida Halfway House Owner Sentenced to 28 Months in Prison for Participating in Medicare Fraud Kickback Scheme
Justice Department Celebrates 25th Anniversary of False Claims Act The Amendments of 1986
Rehabilitation Agency Owner in Detroit Found Guilty for Role in $2 Million Therapy Fraud Scheme
Four Individuals and Three Corporations Convicted for Roles in Wire Fraud Conspiracy at New York Presbyterian Hospital

This Week’s Links

Regulatory News

Health Reform Law Saves $2.1 Billion for 3.6 Million Americans with Medicare

Medicare Advantage Premiums Down 7 Percent on Average, Enrollment Up 10 Percent

CMS Update

In the Federal Register

CMS Transmittals

From the OIG

Acronym Library

Are you on HCCAnet?  Are you on Linkedin?  Enter the HCCAnet Profile Contest and win $100 American Express gift card or a free HCCA Web Conference Registration! For more information visit http://hcca-info.org/profile

HCCAnet, The official social network of HCCA: What’s Getting Talked About?

Group: HIPAA: Health Insurance Portability and Accountability Act Forum

Subject: Billing Errors

“This one happened to me personally, but as a compliance officer, it has gotten me thinking:

”I received a bill from a local hospital for services that I could not have possibly received as I was on an airplane leaving the state that day.  I called the telephone number provided on the bill and the first thing they asked for was the patient's date of birth.  I explained that I could not provide this as I did not know who the patient was and had not received services.  The person I was speaking with then gave me the patient's name.  It was not a name I recognized and told him so.  At this point they are investigating the registration process to see if there was a clerical error, but I'm wondering:

”Was there a breach when I was told the patient name?
  
”If I continue to receive bills, what information can/should the facility release to me? For example, the bill I received was not itemized. If I ask what services were provided or what the diagnosis was, should the hospital disclose this to me?”

Click here for more

(Note: you must already have an account on HCCAnet to participate in this discussion.)
To sign up for HCCAnet click here and click “Free Sign-up”, if you do not already have a HCCA username and password.  If you do already have a HCCA username and password, click “Login to see members only content”

***top***

Headlines

Forecast is Brighter for Compliance and Ethics Professionals: Increase in Compliance Budgets, Greater Sense of Job Security, but only Slight Increase in Staffing
The picture for compliance departments is getting brighter according to a recent survey conducted by the Society of Corporate Compliance and Ethics (SCCE) and the Health Care Compliance Association (HCCA). Economic conditions have improved. Compliance budgets are on the rise, and job security is less of a concern than it has been in the past. However, recent research indicates compliance and ethics professionals are experiencing great stress. So it is a grave concern that a brightening economic picture is not translating into more people to do the work and to relieve the stress of those already working in compliance. For more: Click here

***top***

Justice Department Settles ADA Lawsuit with Michigan's Henry Ford Health System
On February 1, 2012 the Justice Department announced it reached a settlement with the Henry Ford Health System to ensure effective communication with individuals who are deaf or hard of hearing in the provision of medical services. The agreement, under the Americans with Disabilities Act (ADA), resolves a complaint filed with the Department of Justice that alleged that the Henry Ford Health System failed to provide sign language interpreters to a deaf patient at one of its in-patient psychiatric facilities and to his family members who are also deaf and need interpreters to communicate effectively with health care providers. For more: Click here

***top***

DME Business Owner Lands in Federal Prison for 10 Years for Health Care Fraud and Identity Theft Scheme
Juan De Leon, 41, of Edinburg, Texas, and owner of United DME Inc. was sentenced today to 120 months in federal prison, without parole, for his role in a health care fraud and identity theft scheme, United States Attorney Kenneth Magidson and Texas Attorney General Greg Abbott announced February 2, 2012. For more: Click here

***top***

Houston Concert Promoter Gets Federal Prison for Defrauding Medicare of Almost $10 Million
Aghaegbuna “Ike” Odelugo, 39, of Sugarland, Texas, has been sentenced to 72 months in federal prison for engaging in a conspiracy to commit health care fraud, committing health care fraud and money laundering, United States Attorney Kenneth Magidson announced January 30, 2012. U.S. District Judge Vanessa Gilmore handed down the prison sentence this morning and further ordered him to pay $9.9 million to Medicare in restitution and to forfeit $7.45 million in illegal proceeds. For more: Click here

***top***

Former Hospice Owner Sentenced for Health Care Fraud
On February 1, 2012 a federal judge sentenced Jackie Randolph Gist, a Muscle Shoals man, to 28 months in prison for taking part in a health care fraud totaling more than $3 million in connection to a hospice care program he operated, announced U.S. Attorney Joyce White Vance, FBI Special Agent in Charge Patrick Maley and Health and Human Services, Office of Inspector General, Special Agent in Charge Derrick Jackson. For more: Click here

***top***

Patient Recruiter Pleads Guilty in Louisiana Health Care Fraud Scheme
An Atlanta resident pleaded guilty January 31, 2012 for his role in a Louisiana-based Medicare fraud scheme involving fraudulent claims for unnecessary durable medical equipment (DME), announced the Department of Justice, the FBI, the Department of Health and Human Services (HHS) and the Louisiana State Attorney General’s Office. For more: Click here

***top***

Florida Halfway House Owner Sentenced to 28 Months in Prison for Participating in Medicare Fraud Kickback Scheme
The owner and president of a Fort Lauderdale, Fla.-area halfway house company was sentenced January 31, 2012 to 28 months in prison for her role in a kickback scheme that funneled patients to a fraudulent mental health provider, American Therapeutic Corporation (ATC), announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS). For more: Click here

***top***

Justice Department Celebrates 25th Anniversary of False Claims Act The Amendments of 1986
On January 31, 2012 The Justice Department celebrated the 25th anniversary of the 1986 amendments to the False Claims Act. The False Claims Act has been called the single most important tool that American taxpayers have to recover funds when false claims are made to the federal government, including health care fraud, mortgage fraud, and procurement fraud. For more: Click here

***top***

Rehabilitation Agency Owner in Detroit Found Guilty for Role in $2 Million Therapy Fraud Scheme
On February 2, 2012 the Department of Justice, FBI and the Department of Health and Human Services (HHS) announced that the owner of a rehabilitation agency in Dearborn, Mich., was convicted today by a federal jury in Detroit for his leading role in a fraudulent Medicare therapy scheme. For more: Click here

***top***

Four Individuals and Three Corporations Convicted for Roles in Wire Fraud Conspiracy at New York Presbyterian Hospital
On February 2, 2012 a Manhattan jury convicted four individuals and three corporations for their participation in an eight-year conspiracy, involving kickbacks in excess of $2 million, to defraud New York Presbyterian Hospital (NYPH), the Department of Justice announced. For more: Click here

***top***

This Week’s Links:

Reuters: Exclusive: Senate investigating HSBC for money laundering Click here

Philadelphia Inquirer: Tougher federal prosecution of health-care fraudClick here

GAO: Defense Health:  Coordinating Authority Needed for Psychological Health and Traumatic Brain Injury Activities.  GAO-12-154, January 25. Click here

***top***

This week, MediRegs provided TWCC readers with the following: CMS Transmittals and From the OIG.

Regulatory News

Health Reform Law Saves $2.1 Billion for 3.6 Million Americans with Medicare
3.6 million people with Medicare saved $2.1 billion on their prescription drugs in 2011 thanks to the Affordable Care Act according to data issued February 2, 2012 by the Department of Health and Human Services (HHS). Savings for people with Medicare will increase over time. According to a new report issued today from HHS, the average person with Medicare will save nearly $4,200 by 2021 because of the new law. For more: Click here

***top***

Medicare Advantage Premiums Down 7 Percent on Average, Enrollment Up 10 Percent
Medicare Advantage premiums have fallen by 7 percent on average and enrollment has risen by about 10 percent since this time last year, HHS Secretary Kathleen Sebelius announced February 1, 2012. For more: Click here

***top***

CMS Update

CMS announces the Prior Authorization of Power Mobility Devices (PMDs) Demonstration and the Recovery Audit Prepayment Review Demonstration  
On November 15, 2011 Centers for Medicare and Medicare (CMS) announced three demonstration projects that aim to strengthen Medicare by eliminating fraud, waste, and abuse.  Reductions in improper payments will help ensure the sustainability of the Medicare Trust Funds and protect beneficiaries who depend upon the Medicare program.

CMS is pleased to announce that the Prior Authorization of Power Mobility Devices (PMDs) Demonstration and the Recovery Audit Prepayment Review Demonstration which were delayed from their initial January 1, 2012 start date are expected to move forward on or after June 1, 2012.  For additional information on these demonstrations please visit Click here

These demonstrations will begin after receipt of a paperwork reduction act (PRA) Office of Management and Budget (OMB) control number. The CMS posted a PRA notification from these demonstrations on February 3, 2012 at Click here

The CMS significantly revised the Prior Authorization of PMDs demonstration in response to provider and supplier concerns. For more information on the adopted changes please visit Click here

The Part A to Part B Rebilling Demonstration began on January 1, 2012.

Click here to view Federal Register notice: Click here

National Provider Call:  Medicare Spending Per Beneficiary Measure – Registration Now Open -- Thu Feb 9; 1:30-3pm ET
CMS will host a National Provider Call on the Medicare Spending Per Beneficiary (MSPB) Measure, featuring CMS subject matter experts and a question & answer session.

Target Audience: Hospitals, Quality Improvement Organizations (QIOs), and Hospital Associations

Registration Information: In order to receive the call-in information, you must register for the call. 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.  For more details, including instructions on registering for the call, please visit Click here.

Presentation: The presentation for this call will be posted at least one day before the call at Click here. 

Care Innovation Summit Builds on Affordable Care Act; Highlights Private and Public Innovations to Improve Healthcare Quality and Lower Costs
Obama Administration officials and a breadth of representatives from across the healthcare system met in Washington on Thu Jan 26 for a day-long meeting to explore how they can collaborate and improve the quality of healthcare while at the same time lowering costs.

The Obama Administration also released a new report highlighting the success of the Center for Medicare & Medicaid Innovation.  Created by the Affordable Care Act, the Innovation Center has already worked to test and support innovative new healthcare models that can reduce costs and strengthen the quality of healthcare.  The CMS Innovation Center Year-in-Review report is available at Click here.

The summit showcased nearly half a dozen announcements of major new initiatives by leading healthcare organizations, including new “challenges” to reverse the trend of diabetes, advance the field of Alzheimer’s prevention and treatment, and bolster the battle against HIV/AIDS.  For more information on the Care Innovation Summit, visit Click here.

The full text of this excerpted HHS press release (issued Thu Jan 26) can be found at Click here.

Preservation of Resident Cap Positions from Closed Hospitals
On Mon Jan 30, CMS released the results of its decisions regarding which teaching hospitals are receiving increases to their direct Graduate Medical Education (GME) and Indirect Medical Education (IME) full time equivalent (FTE) resident caps under section 5506 of the Affordable Care Act.  Section 5506 of the Affordable Care Act directed CMS to develop a process to permanently preserve the Medicare funded residency slots from teaching hospitals that close. 

The provision directed CMS to create a pool based on the number of Medicare cap slots associated with the closed teaching hospital’s direct GME and IME caps.  This pool of direct GME and IME slots is then to be redistributed, giving priority to hospitals located in the same or contiguous CBSA (Core Based Statistical Area) as the closed hospital, and that met other criteria.  Applications requesting slots from the first round of section 5506 – that is, from the 14 teaching hospitals that closed between Sun Mar 23, 2008, and Tue Aug 3, 2010 – were due to CMS by Fri Apr 1, 2011. 

To see the list of hospitals reviewed under this first round of section 5506, visit Click here and look for the “Section 5506 Cap Increases Related to Applications Due April 1, 2011” file in the Downloads section of the page.

Only One Electronic Remittance Advice Recipient per NPI / Legacy ID beginning Sun Apr 1
Prior to the implementation of HIGLAS (the Healthcare Integrated General Ledger Accounting System), Medicare’s Multi-Carrier System (MCS) created just one check per sender, National Provider Identifier (NPI), or legacy ID.  Each sender / NPI / legacy ID was able to have multiple receivers of the electronic remittance; MCS would use the sender ID submitting each claim to aid in determining to whom the remit should be sent.  For each check that was created, MCS also created an electronic remittance advice (ERA), which accurately reported the payment amount for that ERA. 

When a MAC transitions to HIGLAS, only one check can be produced per NPI/legacy ID.  The old MCS system logic, which took the sender information into account when generating the remit, was not changed when MACs began their transition to HIGLAS; in some instances, the result was a remittance advice that did not contain all of the claims processed in a given cycle or a remittance advice containing payments that did not total to the EFT/check amount.

In order to accurately produce electronic remittance advices to match the EFT/check amount, MCS will be changing their logic effective Sun Apr 1, 2012 – and will no longer consider the sender information when creating the ERA files.  MACs will allow only one receiver of an electronic remittance per NPI/legacy ID regardless of whether the provider submits their inbound files under different sender IDs.  Your respective MAC will be contacting you if you are set up on their files for multiple receivers of the ERA, in which case you will need to select one receiver for your electronic remittance.

Envelope Control / Reference Number Matching for Version 5010 Claim Transitions
With the implementation of Accredited Standards Committee (ASC) X12 Version 5010 transactions for acknowledgements (TA1, 999, and 277CA), Medicare Fee-for-Service is recommending the use of unique numbering for several enveloping control / reference numbers built into the Version 5010 claims transitions.  Using unique numbering for the IAS13, ST02, and BHT03 data elements on the inbound 837 Institutional and Professional claims will allow Medicare trading partners to easily match submitted claims with the acknowledgement transactions.

Examples of those pairing include:

• 837 ISA13 is mapped to the TA1 response transaction and located in the TA101 data element
• The implementation guide for the TA1 (ASC X12 TA1 TR3) states for TA101:  “This is the value in ISA13 from the interchange to which this TA1 is responding.”
• 837 ST02 is mapped to the 999 response in the 2000.AK202 data element
• The implementation guide for the 999 (ASC X12 999 TR3) states for AK202:  “Use the value in ST02 from the transaction set to which this 999 transaction set is responding.”
• 837 BHT03 is mapped to the 277CA response in the 2200B.TRN02 data element
• The implementation guide for the 277CA (ASC X12 277CA TR3) states for TRN02:  “This element contains the value submitted in the BHT03 data element from the 837.”

From MLN Matters:

“The Guide to Medicare Preventive Services: Errata Sheet to the Fourth Edition” Fact Sheet Released
“The Guide to Medicare Preventive Services: Errata Sheet to the Fourth Edition” Fact Sheet (ICN 907802) has been released and is available in downloadable format.  This errata sheet reflects the changes to “The Guide to Medicare Preventive Services,” and includes updates such as information on newly-covered benefits, updated codes, and resources.

“Guidelines for Teaching Physicians, Interns, and Residents” Fact Sheet Revised
The “Guidelines for Teaching Physicians, Interns, and Residents” fact sheet (ICN 006347) has been revised and is now available in downloadable format.  It includes information about payment for physician services in teaching settings, general documentation guidelines, and evaluation and management documentation guidelines.

“Swing Bed Services” Fact Sheet Revised
The “Swing Bed Services” fact sheet (ICN 006951) has been revised and is now available in downloadable format.  It includes information on background, requirements that apply to hospitals and Critical Access Hospitals, and swing bed services payments.

“Additional Provider and Supplier Enrollment Requirements for Fixed-Wing and Helicopter Air Ambulance Operators” MLN Matters Article Revised
MLN Matters Article #MM7363, “Additional Provider and Supplier Enrollment Requirements for Fixed-Wing and Helicopter Air Ambulance Operators,” has been revised is now available in downloadable format.  This article is designed to provide education on the enrollment requirements for fixed-wing and helicopter air ambulance operators, as outlined in Change Request (CR) 7363.  It includes information from the final rule that was published on Mon Nov 29, 2010.  The article was revised to provide additional clarification on the licensure and certification requirements contained on the CMS-855B enrollment application.

Medicare Learning Network is Looking for Physician Volunteers to Pilot Test Continuing Education Activities
The Medicare Learning Network offers official CMS information for Medicare Fee-For-Service providers, designed to help increase understanding of the Medicare program and stay current on program policy changes, and to provide the information needed to bill correctly.  MLN pilot testers are unpaid volunteers whose feedback and comments help us to evaluate our activities and determine the average learning time for credit calculations.

Upcoming Open Door Forums
February
The next Ambulance Open Door Forum is scheduled for Wednesday, February 15, 2012 from 2pm-3pmET. lick here

The next Hospital Open Door Forum is scheduled for Wednesday, February 22, 2012 from 2pm-3pmET. Click here

The next Home Health, Hospice & DME Open Door Forum is scheduled for Wednesday, February 29, 2012 from 2pm-3pmET Click here

March
The next Skilled Nursing Facility (SNF)/Long Term Care (LTC) Open Door Forum is scheduled for Thursday, March 1, 2012 from 2pm-3pmET. Click here

The next Physician, Nurses and Allied Health Professionals Open Door Forum is scheduled for Tuesday, March 6, 2012 from 2pm-3pmET. Click here

***top***

CMS Transmittals

Medicare National Coverage Determinations (National Coverage Decisions) (PUB. 100-03)

• Transmittal #141, Date: January 26, 2012 Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs (ICD-10) (PDF): Click here

Medicare Claims Processing (PUB. 100-04)

• Transmittal #2396, Date: January 26, 2012 April 2012 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (PDF): Click here
• Transmittal #2395, Date: January 26, 2012 Multiple Procedure Payment Reduction (MPPR) for Physician Services for Certain Diagnostic Imaging Procedures in Critical Access Hospitals (CAH) (PDF): Click here
• Transmittal #2394, Date: January 25, 2012 CWF Editing for Autologous Cellular Immunotherapy Treatment of Metastatic Prostate Cancer (PROVENGE) (PDF): Click here
• Transmittal #2393, Date: January 25, 2012 Inpatient Rehabilitation Facility (IRF) No-Pay Billing for Medicare Advantage (MA) Patients Update (PDF): Click here
• Transmittal #2388, Date: January 20, 2012 Update to Pub 100-04, Medicare Claims Processing Manual, Chapter 3: Inpatient Hospital Billing (PDF): Click here

State Operations Manual (PUB. 100-07)

• Transmittal #79, Date: January 20, 2012 Revised Exhibit 286, Hospital/CAH Database Worksheet(PDF): Click here

Program Integrity (PUB. 100-08)

• Transmittal #404, Date: January 20, 2012 General Update to Chapter 15 of the Program Integrity Manual (PIM) - Part I (PDF): Click here
• Transmittal #403, Date: January 20, 2012 Claims against Surety Bonds for Suppliers of Durable Medicare Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) (PDF): Click here

CMS One-Time Special Notification (PUB. 100-20)

• Transmittal #1024, Date: January 26, 2012 Common Edits and Enhancements Modules (CEM) Code Set Update (PDF): Click here
• Transmittal #1017, Date: January 24, 2012 Instructions to Teaching Hospitals for Reporting the Internal Revenue Service (IRS) Refund of Medical Resident FICA Taxes **Rescinds and Replaces Transmittal #1014, dated January 6, 2012**(PDF): Click here

***top***

From the OIG

Audit Reports
Review of Controls at SilverScript Insurance Company to Ensure Adherence to Formularies (A-07-11-06029) (1/18/12) (PDF): Click here
Review of Resident Data Reported in the Intern and Resident Information System for Medicare Cost Reports Submitted to Highmark Medicare Services, Inc. (A-02-09-01019) (1/5/12) (PDF): Click here
Review of Oklahoma Collections for the Medical Assistance Program for Calendar Years 2004 Through 2009 (A-06-10-00057) (1/5/12) (PDF): Click here

Evaluation and Inspection Reports
Public Health Preparedness for Radiological and Nuclear Incidents (OEI-04-10-00250) (01/12): Click here

Lack of Data Regarding Physicians Opting Out of Medicare (OEI-07-11-00340) (01/2012) (PDF): Click here
Nationwide Program for National and State Background Checks for Long-Term-Care Employees-Results of Long-Term-Care Provider Administrator Survey (OEI-07-10-00421) (01/2012) (PDF): Click here

***top***

Acronym Library

Click here for more from CMS Acronyms

***top***

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
Your HCCA Office is located at:
6500 Barrie Road, Suite 250
Minneapolis, MN 55435
HCCA Toll-Free Phone: 888-580-8373
Fax: 952-988-0146
Minnesota Phone: 952-988-0141
Email: service@hcca-info.org
Contact: Margaret Dragon, Editor, This Week in Corporate Compliance: 781-593-4924

To subscribe to TWCC, click here