May 2012 Archives

May 31, 2012

CMS to Release Comparative Billing Reports for Evaluation and Management Services

CMS (Centers for Medicare & Medicaid Services) expects to publish Comparative Billing Reports (CBRs) on Evaluation and Management (E/M) Services on June 4, 2012.

Since 2010, CMS, through Safeguard Services (SGS), has produced national comparative billing reports in select fields. These comparative studies are designed to help providers review their coding and billing practices and utilization patterns, and take proactive compliance measures. A CBR outlines the provider's billing patterns and compares those patterns to other similar entities. Pursuant to Safeguard Services website, E/M services CBRs will be given to providers that meet the following criteria:

  • Filed Medicare Part B final claims with dates of service from January 1 to December 31, 2011;
  • Claims were retrieved from the Integrated Data Repository (IDR) on April 13, 2012;
  • The provider is a specialty primary care provider (General Practice, Family Practice, Internal Medicine, Nurse Practitioner, Multispecialty Clinic or Group Practice, Preventive Medicine, or Physician Assistant);
  • Billed CPT codes 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215;
  • Place of service was in the office (11);
  • Allowed charges greater than $0; and
  • Provided greater than or equal to 100 total units for the combination of the aforementioned CPT codes.

The sole intent of conducting CBRs is to educate providers as to potential fraud and abuse; they are not punitive. Providers should view CBRs as a tool, rather than a warning, as a way to aid them in properly complying with Medicare billing rules. It is also important to understand that CBRs do not contain patient or case-specific data, but rather only summary billing information as a method of ensuring privacy.

E/M services are specifically targeted because they are susceptible to fraud and abuse. From 2001 to 2010 Medicare payments for E/M Services increased by 48 percent. CMS will publish CBRs that analyze Medicare Part B final claims data from January 1, 2011 through December 31, 2011. Collective trends in the individual CBRs will be published for the nation to inspect.


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May 29, 2012

Knowledge of Illegality Not Required For Criminal Charges Under HIPAA

On May 10, 2012 the United States Court of Appeals for the Ninth District decided that criminal charges under the Health Insurance Portability and Accountability Act (HIPAA) do not require that an individual have knowledge that their actions are illegal. The case, United States of America v. Zhou, is the first such case to establish that the knowledge requirements of a criminal HIPAA violation apply only to the fact that the information accessed was protected health information, and not that obtaining the information was in violation of HIPAA.

Under the statute, HIPAA provides that a criminal penalty applies to a person who knowingly and in violation of the statute, uses, obtains, or discloses protected health information. Zhou argued that the statute requires knowledge that the information obtained was protected health information, as well as knowledge that obtaining it was illegal. The court rejected the argument and determined that the language of HIPAA is plain. The court found that the word "and" unambiguously indicates that there are two elements of a violation, and that knowingly applies only to obtaining the protected health information, and not to the fact that obtaining the protected health information was illegal.

The statute at issue in the decision is 42 U.S.C ยง1320d-6a, which reads as follows:

(a) Offense
A person who knowingly and in violation of this part--
(1) uses or causes to be used a unique health identifier;
(2) obtains individually identifiable health information relating to an individual; or
(3) discloses individually identifiable health information to another person,
shall be punished as provided in subsection (b) of this section. For purposes of the previous sentence, a person (including an employee or other individual) shall be considered to have obtained or disclosed individually identifiable health information in violation of this part if the information is maintained by a covered entity (as defined in the HIPAA privacy regulation described in section 1320d-9 (b)(3) of this title) and the individual obtained or disclosed such information without authorization.

Penalties for violations of the statute can include fines of up to $250,000, imprisonment for up to 10 years, or both.

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May 14, 2012

CMS Provides List of Providers Who Need to Revalidate Their Medicare Enrollment

As part of healthcare reform, Section 6401(a) of the Affordable Care Act requires all providers and suppliers who enrolled in the Medicare program prior to March 25, 2011 to revalidate their provider enrollment under the new screening criteria. Providers and suppliers who enrolled after March 25, 2011 do not need to revalidate at this time as they have already been screened.

Medicare Administrative Contractors (MACs) will be sending revalidation notices to individual providers and suppliers between now and March 23, 2015. Providers and suppliers must complete the enrollment forms within 60 days of receiving the request from the MACs. If a provider fails to submit the provider enrollment forms after receiving the request, it may lead to a suspension of the provider's Medicare billing privileges.

Providers and suppliers may not revalidate their provider enrollment until they have received a revalidation notice from their MAC. The CMS website provides a list of all the providers and suppliers to whom revalidation notices have been sent (See "download" section). The notices are listed according to the month in which the revalidation notice has been sent, and CMS updates these lists on a bimonthly basis. In case a revalidation notice has been sent but never received, every provider is encouraged to check the list to determine whether or not they are currently expected to revalidate. If you are listed, but have not received the request, you should contact your Medicare contractor.

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May 8, 2012

CMS Delays Implementation of Physician Payments Sunshine Act

On May 3, 2012, the Centers for Medicare and Medicaid Services (CMS) announced, via the CMS blog, that CMS will not require data collection by applicable manufacturers and group purchasing organizations under the Physician Payments Sunshine Act (PPSA) before January 1, 2013. The announcement indicates that the final rule will be released later this year and that the additional time will allow CMS to address operational and implementation issues and provide time for organizations to prepare for data submission.

The PPSA was a section of the Affordable Care Act of 2010 intended to provide transparency in requiring reporting of payments or gifts to physicians, and physician ownership and investment interests. The proposed rule implementing the PPSA was released December 19, 2011, and the announced delay is partly a result of the comments received from stakeholders during the 60 day comment period. The final rule was originally scheduled to be released for implementation on January 1, 2012.

The proposed rule requires that applicable manufacturers that sell or distribute a covered drug, device, biological, or medical supply disclose certain payments or other transfers of value to covered recipients. A covered recipient is a physician, other than a physician who is an employee of the applicable manufacturer, or a teaching hospital. The rule also requires the disclosure of payments or transfers of value to the immediate families of covered recipients.

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