This Week in Corporate Compliance

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Headlines

Six Arrested In $47 Million Medicaid Scam
Nursing Home Executive Excluded from Federal Health Care Programs
Code of Conduct for Managed Care Gains Traction
New Jersey Surgeon Accused of Fraud
Alcohol Treatment Facility Operator Sentenced
Endoscopic Technologies to Pay U.S. $1.4 Million
Houston Area under Scrutiny for Medicare Fraud
Detroit-Area Chiropractor Sentenced
Bayer Ombudsman Urges Ethical Business Behavior
Regulators Urged to Better Police Health Care

Compliance & Ethics Social Network: What’s Getting Talked About

Regulatory News

CMS Update

From the GAO

HIPAA Info
CMS Transmittals
From the OIG

This Week's Link

Acronym Library

Visit HCCA's Web site
HCCA Headquarters Contact Information

Headlines:

Six Arrested In $47 Million Medicaid Scam
The July 16, 2009 Newsday reported that “A medical clinic operator barred from participating in New York's Medicaid program 12 years ago for filing false claims was charged Thursday with secretly scamming his way back into the system and orchestrating a new fraud that took in $47 million. For more: Click here

New York Attorney General Press Release: Click here

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Nursing Home Executive Excluded from Federal Health Care Programs
On July 13, 2009 the U.S. Department of Health and Human Services Office of Inspector General reported that president and chairman of the board of Pleasant Care Corporation, Emmanuel Bernabe, has agreed to be excluded permanently from Federal health care programs following an investigation of substandard care at nursing homes formerly operated by Pleasant Care. The exclusion of Emmanuel Bernabe is the result of an OIG investigation regarding allegations of substandard care provided at Pleasant Care nursing facilities between 2003 and 2007. For more: Click here

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Code of Conduct for Managed Care Gains Traction
On July 16, 2009 Insurance & Financial Advisor reported that “While Congress and President Barack Obama work on comprehensive health reform, an effort to force managed care companies to adhere to a code of conduct is gaining steam.” For more: Click here

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New Jersey Surgeon Accused of Fraud
According to a report in the July 15, 2009 Star-Ledger, A New Jersey “surgeon and his office manager have been charged with defrauding Medicaid, Medicare and private insurance companies out of more than $8.5 million, state officials announced yesterday.” For more: Click here

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Alcohol Treatment Facility Operator Sentenced
On July 14, 2009 the Wichita Business Journal reported that “A Wichita woman was sentenced Monday to two years in prison and was ordered to pay more than $3.7 million in restitution for health care fraud.”
Click here

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Endoscopic Technologies to Pay U.S. $1.4 Million
On July 14, 2009 the U.S. Department of Justice announced that Endoscopic Technologies Inc. (Estech), a medical device manufacturer, has agreed to pay the United States $1.4 million to resolve civil claims in connection with the alleged promotion of its surgical ablation devices, the Justice Department announced today. Surgical ablation devices use focused energy to create controlled lesions or scar tissue on a patient’s heart or other organs. For more: Click here

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Houston Area under Scrutiny for Medicare Fraud
On July 12, 2009 the Houston Chronicle reported that “When investigators recently raided a pain management clinic in the Clear Lake area, they found Dr. Arun Sharma seated in a chair facing a Medicare patient in a tiny room set aside for the copy machine. The clinic owner had four needles filled with colored liquids there ready for injection.

“The patient, who admitted being addicted to hydrocodone, came to the Webster clinic every two weeks for the past four years to obtain the narcotic painkiller, according to a sworn affidavit.” For more: Click here

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Detroit-Area Chiropractor Sentenced
On July 10, 2009 U.S. Attorney for the Eastern District of Michigan Terrence Berg announced that Geoffrey Ramseur, 52, of Rockledge, FL (formerly of Northville, MI), was sentenced yesterday to 20 months’ in prison and ordered to pay restitution in the amount of $121,000.00 after having been convicted on health care fraud charges. For more: Click here

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Bayer Ombudsman Urges Ethical Business Behavior
On July 12, 2009 the Pittsburg Post-Gazette published an interview it conducted with Bayer Ombudsman Melissa Cameron. For more: Click here

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Regulators Urged to Better Police Health Care
On July 16, 2009 the Wall Street Journal reported that the chairman of the Senate Commerce Committee, Sen. John Rockefeller, D-W.Va., “on Thursday said U.S. antitrust regulators have not done enough to police anti-competitive behavior in the health-care sector. “ For more: Click here

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Compliance & Ethics Social Network: What’s Getting Talked About

Subject: Court request to testify
Click here for more

Note: you must already have an account on the Social Network to access this discussion. To sign up for a free account, click here: Click here for more

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

Regulatory News

The American Hospital Association AHA News Now reported on Tuesday, July 14, 2009 that “The Centers for Medicare & Medicaid Services is accepting comments through Aug. 31 on proposed changes to the cost report form that hospitals must submit annually to Medicare. CMS is proposing the first major changes to the form since 1996. The proposed new form would apply to cost reporting periods beginning Feb. 1, 2010. The AHA is reviewing the form and plans to submit comments.

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CMS Update

New from Medicare Learning Network
The publication titled ICD-10-CM/PCS Myths & Facts (June 2009), which presents correct information in response to some myths regarding the ICD-10-Clinical Modification/Procedure Coding System, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at Click here .

The Second in Series: General Equivalence Mappings – ICD-9-CM to and from ICD-10-CM and ICD-10-PCS Fact Sheet (May 2009), which provides basic information about the General Equivalence Mappings (GEM) including possible users of the GEMs, why the GEMs are needed, and how the GEMs files are formatted as well as Reimbursement Mappings information, is now available in print format from the Centers for Medicare & Medicaid Services Medicare Learning Network. To place your order, Click here , scroll down to “Related Links Inside CMS” and select “MLN Product Ordering Page.”

The revised Inpatient Psychiatric Facility Prospective Payment System Fact Sheet (May 2009), which provides general information about the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS), how payment rates are set, and the Rate Year 2010 update to the IPF PPS, is now available in print format from the Centers for Medicare & Medicaid Services Medicare Learning Network. To place your order, Click here , scroll down to “Related Links Inside CMS” and select “MLN Product Ordering Page.”

The Clinical Laboratory Improvement Amendment established quality standards for laboratories to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test is performed. The CLIA brochure contains information and links to a variety of CLIA resources including: CLIA regulations, CLIA enrollment, CLIA certificates, CLIA fee schedules, CLIA-approved accrediting organizations and CLIA State and Regional offices. To view the brochure, Click here .

Take Action Now to Prepare for the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program!

A Special Edition MLN Matters education article identifying steps suppliers should take in preparation for the DMEPOS Competitive Bidding Program to ensure successful bidder registration is available at Click here.

The article highlights specific sections of the CMS-855S, Medicare Enrollment Application, where the accuracy of the Authorized Official information and correspondence mailing address are critical for successful bidder registration. The Centers for Medicare & Medicaid Services (CMS) urges suppliers planning to bid in the 2009 bidding cycle to read this article and make sure their most recent CMS-855S submission is still current and accurate.

The Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) --- Competitive Bidding Program Round 1 Rebid Is Coming Soon!!

Summer 2009
• CMS announces bidding schedule/schedule of education events
• CMS begins bidder education campaign
• Bidder registration period to obtain user ID and passwords begins

Fall 2009 Bidding begins

If you are a supplier interested in bidding, prepare now – don’t wait!
--UPDATE YOUR NSC FILES: DMEPOS supplier standard # 2 requires ALL suppliers to notify the National Supplier Clearinghouse (NSC) of any change to the information provided on the Medicare enrollment application (CMS-855S) within 30 days of the change. DMEPOS suppliers should use the 3/09 version of the CMS-855S and should review and update:
• The list of products and services found in section 2.D;
• The Authorized Official(s) information in sections 6A and 15; and
• The correspondence address in section 2A2 of the CMS-855S.
This is especially important for suppliers who will be involved in the Medicare DMEPOS Competitive Bidding Program. These suppliers must ensure the information listed on their supplier files is accurate to enable participation in this program. Information and instructions on how to submit a change of information may be found on the NSC Web site (Click here) and by following this path: Supplier Enrollment/Change of Information/Change of Information Guide.

--GET LICENSED: Suppliers submitting a bid for a product category in a competitive bidding area (CBA) must meet all DMEPOS state licensure requirements and other applicable state licensure requirements, if any, for that product category for every state in that CBA. Prior to submitting a bid for a CBA and product category, the supplier must have a copy of the applicable state licenses on file with the NSC. As part of the bid evaluation we will verify with the NSC that the supplier has on file a copy of all applicable required state license(s).

--GET ACCREDITED: CMS would like to remind DMEPOS suppliers that time is running out to obtain accreditation by the September 30, 2009 deadline or risk having their Medicare Part B billing privileges revoked on October 1, 2009. Accreditation takes an average of 6 months to complete. DMEPOS suppliers should contact a CMS deemed accreditation organization to obtain information about the accreditation process and the application process. Suppliers must be accredited for a product category in order to submit a bid for that product category. CMS cannot contract with suppliers that are not accredited by a CMS-approved accreditation organization.

Further information on the DMEPOS accreditation requirements along with a list of the accreditation organizations and those professionals and other persons exempted from accreditation may be found at the CMS website: Click here .

--GET BONDED: CMS would like to remind DMEPOS suppliers that certain suppliers will need to obtain and submit a surety bond by the October 2, 2009 deadline or risk having their Medicare Part B billing privileges revoked. Suppliers subject to the bonding requirement must be bonded in order to bid in the DMEPOS competitive bidding program. A list of sureties from which a bond can be secured is found at the Department of the Treasury’s “List of Certified (Surety Bond) Companies;” the web site is located at: Click here.

Visit the CMS website Click here for the latest information on the DMEPOS competitive bidding program.

DMEPOS Supplier Accreditation and Surety Bond Requirement Deadlines Coming In October
Suppliers May Choose to Voluntarily Terminate Enrollment If They Do Not Plan To Comply

Medicare suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), unless exempt, must be accredited and obtain a surety bond by October 1, 2009 and October 2, 2009, respectively.

If you have made the decision not to obtain accreditation or a surety bond when required, you may want to voluntarily terminate your enrollment in the Medicare program before the implementation dates above. You can voluntary terminate your enrollment with the Medicare program by completing the sections associated with voluntary termination on page 4 of the Medicare enrollment application (CMS-855S). Once complete, you should sign, date, and send the completed application to the National Supplier Clearinghouse (NSC). By voluntarily terminating your Medicare enrollment, you will preserve your right to re-enroll in Medicare once you meet the requirements to participate in the Medicare program.

If you do not comply with the accreditation and surety bond requirements and do not submit a voluntary termination, your Medicare billing privileges will be revoked. A revocation will bar you from re-enrolling in Medicare for at least one year after the date of revocation.

Suppliers who do not plan to stay enrolled in Medicare are strongly encouraged to notify their beneficiaries as soon as possible so the beneficiary can find another supplier.

For additional information regarding DMEPOS accreditation or the provisions associated with a surety bond, Click here. Frequently Asked Questions (FAQs) on the surety bond requirement can be found on the NSC’s FAQ page Click here.

National Cancer Institute, AHRQ, and VA Publish New Resource
The National Cancer Institute (NCI), the Agency for Healthcare Research and Quality (AHRQ), and the Department of Veterans Affairs (VA) are pleased to announce the publication of Health Care Costing: Data, Methods, Future Directions, published July 2009, Volume 47, Issue 7, Supplement 1 in Medical Care. Accurate measurement of health care costs is critical for developing health care budgets, setting priorities for allocating funds, and making health care policy decisions. Estimates of these costs are key inputs to cost-effectiveness analyses and other economic evaluations. The supplement takes a careful look at diverse methodologic issues related to this timely and important topic.

Written by experts in health economics, epidemiology, health services research, and biostatistics, the papers discuss ways to improve and apply health care cost estimation methods and promote research in this area. The supplement was developed by scientists at the NCI, the AHRQ, the VA, and Emory University. It was based on a 2007 workshop sponsored by the NCI and the AHRQ. For more information about the supplement and the workshop, Click here.

Requests for one free copy of the supplement may be made to the AHRQ Publications Clearinghouse. Please order by specifying AHRQ publication number OM 09-0079: Medical Care supplement on health care costing. If more than one copy is needed, please describe the reason in your request.
    *    In the United States, call the toll-free number 800-358-9295, 24 hours a day, 7 days a week.
    *    Hearing impaired persons may call 888-586-6340 for the TDD service.
    *    Callers from outside of the United States only should use the telephone number (703) 437-2078.
    *    Written requests may be sent to: AHRQ Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547.
    *    Electronic requests may be made to: AHRQPubs@ahrq.hhs.gov.

HHS Agency for Healthcare Research and Quality Releases New Report
A new report by HHS' Agency for Healthcare Research and Quality, which found insufficient evidence to conclude that genetic testing for two gene mutations in adults with a history of deep-vein thrombosis (DVT) prevents reoccurrence or improves other outcomes, is now available. The report, a summary of which was published in the June 17, 2009 issue of JAMA, also failed to find any benefit from genetic testing of DVT patients' family members.
The report's authors, who were led by Jodi Segal, M.D., of the AHRQ-supported Johns Hopkins Evidence-based Practice Center in Baltimore, failed to find any studies that directly addressed the effect of genetic testing on patient outcomes, but they found research indicating that keeping patients who have a genetic tendency to develop blood clots on blood-thinning drugs such as warfarin reduces the chance of a future clot. This benefit appears to be similar to that seen in patients who do not have the genetic tendency to develop blood clots but who have a history of clots.

The authors also reviewed the evidence for the accuracy of the testing methods used to identify the FVL and prothrombin G20210A mutations, which can signal continued risk of blood clots. The evidence shows that tests for identifying the mutations have excellent analytic validity and that nearly all laboratories report accurate results.
AHRQ's report, Outcomes of Genetic Testing in Adults with a History of Venous Thromboembolism, is available Click here.

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Help Keep Your Medicare Patients Healthy This Summer. The Centers for Medicare & Medicaid Services (CMS) is asking the provider community to keep their patients with Medicare healthy by ensuring that they take advantage of Medicare-covered preventive services. Medicare covers a wide array of preventive services for eligible beneficiaries, including cancer screenings, glaucoma screenings, an initial preventive physical examination, and certain immunizations, among others.

What Can You Do?
As a health care professional who provides care to seniors and others with Medicare, you can help protect the health of your Medicare patients by educating them about their risk factors and reminding them of the importance of getting the preventive screenings covered by Medicare.
For More Information
CMS has developed several educational products related to Medicare-covered preventive services, including screenings for various forms of cancer:

The MLN Preventive Services Educational Products Web Page ~ provides descriptions and ordering information for Medicare Learning Network (MLN) preventive services educational products and resources for health care professionals and their staff. Click here
Quick Reference Information: Medicare Preventive Services ~ This double-sided chart provides coverage and coding information on Medicare-covered preventive services. Click here
Quick Reference Information: The ABCs of Providing the Initial Preventive Physical Examination (IPPE) ~ This double-sided chart provides a checklist of services included in the IPPE, as well as additional information on the IPPE benefit. Click here
Quick Reference Information: Medicare Part B Immunization Billing This double-sided chart provides coverage and coding information on Medicare-covered immunizations.

Please visit the Medicare Learning Network for more information on these and other Medicare fee-for-service educational products.

Open Door Forums
Use this Link to check for upcoming CMS Special Open Door Forums Click here

Special Open Door Forum:
Centers for Medicare and Medicaid Services (CMS) Acting Administrator Charlene Frizzera invites you to a special Webinar with CMS on the Competitive Bidding Round I Rebid for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). The Medicare DMEPOS Competitive Bidding Program Round I Rebid Is Coming Soon. Medicare's DMEPOS competitive bidding program will change the way some beneficiaries obtain certain medical equipment and supplies. An educational Webinar for DMEPOS referral agents (beneficiary advocacy groups and prescribers) will be held on Monday, July 20, 2009 at 2pmET. Participants will have the opportunity to ask questions of CMS policy experts. Please go to the following website to register: Click here. or Click here

Special Open Door Forum: Children's Health Insurance Program Reauthorization Act (CHIPRA) Outreach and Enrollment Grants- Cycle I will be held on Wednesday, July 22, 2009 from 2pm-4pmET. Click here

The next Rural Health ODF is scheduled for Tuesday, July 21, 2009 from 2-3pmET. Click here

The next Home Health, Hospice & DME Open Door Forum is scheduled for Wednesday, July 29, 2009 from 2-3pmET. Click here

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From the GAO
VA Health Care: Preliminary Findings on VA's Provision of Health Care Services to Women Veterans, by Randall B. Williamson, director, health care, before a joint hearing of the Subcommittee on Disability Assistance and Memorial Affairs and the Subcommittee on Health, House Committee on Veterans' Affairs. GAO-09-899T, July 16.Click here Highlights - Click here

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HIPAA Info
HIPAA - Security Standards
Overview: Click here

HIPAA - Administrative Simplification Enforcement
HIPAA Enforcement Statistics: Click here

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CMS Transmittals
Medicare National Coverage Determinations (National Coverage Decisions) (PUB. 100-03)
Transmittal #103, Date: July 10, 2009 Sleep Testing for Obstructive Sleep Apnea (OSA) (PDF):Click here

Medicare Claims Processing (PUB. 100-04)
Transmittal #1770, Date: July 10, 2009 Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) (PDF): Click here
Transmittal #1769, Date: July 10, 2009 ESRD: Placement of a List of Diagnostic Tests that are Considered End Stage Renal Disease (ESRD) (PDF): Click here
Transmittal #1768, Date: July 10, 2009 Update to Pub 100-04, Chapter 24, Section 40.7 of the Claims Processing Manual (PDF): Click here
Transmittal #1767, Date: July 10, 2009 IOM Chapter 25 Revenue Code 076X Description Change (PDF): Click here
Transmittal #1766, Date: July 10, 2009 Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2009 (PDF): Click here
Transmittal #1765, Date: July 10, 2009 2009 Durable Medical Equipment Prosthetics, Orthotics, and Supply Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List (PDF): Click here

State Operations Manual (PUB. 100-07)
Transmittal #50, Date: July 10, 2009 Revisions to Chapter 5, Complaint Procedures (PDF): Click here

Program Integrity (PUB. 100-08)
Transmittal #296, Date: July 10, 2009 Provider Enrollment Verification Activities (PDF): Click here
Transmittal #293, Date: June 12, 2009 Review of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) **Rescinded 07/02/09**(PDF): Click here

CMS One-Time Special Notification (PUB. 100-20)
Transmittal #515, Date: July 10, 2009 2009 Reminder for Roster Billing and Centralized Billing for Influenza and Pneumococcal Vaccinations (PDF): Click here
Transmittal #511, Date: July 1, 2009 Standard Paper Remittance (SPR) Update for Health Insurance Portability and Accountability Act (HIPAA) Version 005010 (PDF): Click here

National Coverage Analyses
Magnetic Resonance Imaging (MRI) (CAG-00399R) - Expected Completion Date: 9/28/2009:Click here

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From the OIG
List of Excluded Individuals/Entities
OIG 06/09 Cumulative Sanction Report-Reinstatements for June 2009 (Excel):Click here
OIG 06/09 Cumulative Sanction Report-Update for June 2009 (Excel):Click here

Audit Reports
Review of Palmetto GBA, LLC Medicare Payments to Providers Terminated From January 1, 2003, Through January 31, 2007 (A-05-09-00012) (06/22/09)(PDF): Click here
Review of High-Dollar Payments for Inpatient Services Processed by Wisconsin Physicians Service for Calendar Years 2004 Through 2006–Hospitals With Fewer Than Five High-Dollar Payments (A-05-08-00061) (06/17/09) (PDF): Click here
Review of Place-of-Service Coding for Physician Services Processed by Medicare Part B Carriers During Calendar Years 2005 and 2006 (A-01-08-00528) (06/17/09) (PDF): Click here
Review of Retiree Drug Subsidy Plan Sponsor Commonwealth of Pennsylvania for Plan Year Ended December 31, 2006 (A-03-08-00013) (06/17/09) (PDF): Click here
Review of High-Dollar Payments for Louisiana Medicare Part B Claims Processed by Pinnacle Business Solutions, Inc., for the Period January 1 Through December 31, 2005(A-06-08-00037) (06/12/09) (PDF): Click here
Review of Medicaid Outpatient Drug Expenditures in Texas for the Period October 1, 2003, Through September 30, 2005 (A-06-07-00092) (06/04/09) (PDF): Click here

Evaluation and Inspection Reports - Centers for Medicare and Medicaid Services
Medicare Part B Billing for Ultrasound (PDF) (OEI-01-08-00100) (07/2009) (PDF): Click here
Variation in the Clinical Laboratory Fee Schedule (PDF) (OEI-05-08-00400) (07/2009) (PDF): Click here

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This Week’s Link:
Office of Counsel to the Inspector General, Department of Health and Human Services, seeks experienced attorneys for its Administrative and Civil Remedies Branch. Click here

Collaborative Effort to Identify Overlapping Claims for Dual-Eligible Beneficiaries Receiving Medicare Part A and Medicaid Long-Term-Care Services in Texas Click here

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Acronym Library

SADMERC	Statistical Analysis Durable Medical Equipment Regional Carrier
SAEP	State Agency Evaluation Plan

For more from CMS Acronyms: Click here

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NOTE: HCCA Members, please contact April Kiel at Click here if you have not received your password. This new 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, without faxing, emailing and other time-consuming activities.HCCA's Web site also offers E-Communities, 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.

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HCCA Headquarters Contact Information
Your HCCA Office is located at:
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Minneapolis, MN 55435
HCCA Toll-Free Phone: 888-580-8373
Fax: 952-988-0146
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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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