Articles Posted in Medicare

Time Magazine published an article on January 4 outlining the Federal Government’s increased measures to combat Medicare fraud.  The article outlined that although there is not an official figure on the cost of government health program fraud, the National Health Care Anti-Fraud Association estimates that it is at least $60 billion per year, approximately 10% of Medicare and Medicaid’s combined annual funding.  However, some experts believe this estimation is below the actual cost because most fraud goes undetected.

To decrease the amount of undetected fraud, the Federal government has enlisted the help of Medicare beneficiaries.  According to the Times article, there are 47 million Medicare beneficiaries and the number is expected to rise to 80 million by 2030.  The government intends to use Medicare beneficiaries for fraud detection.  Senior Medical Patrols (SMPs) are volunteers that have been spread across the country to spread the word to seniors about detecting Medicare fraud.  The government is requesting that seniors keep track of their Medicare Summary Notices (MSNs), which outline the services and equipment that a beneficiary has been provided through Medicare.  Seniors that thoroughly check their MSNs can likely detect if the statement includes a service or equipment that the beneficiary did not receive.  Although some complain that the MSNs are not user-friendly, Washington is trying to simplify them.  In addition, the government has considered switching from quarterly MSNs to monthly MSNs.  This would help the government detect fraud more quickly, before the money can change hands and the fraudulent practice closedown. 

Finally, even absent Medicare beneficiary’s involvement, the government hopes that the publicity on Medicare Fraud crackdowns will help inform doctors of the legal risks of being lured into Medicare scams.  However, criminal enterprises have begun to rely on identity theft to curtail the need of doctors at all.

Last week President Obama signed legislation that will delay Medicare payment cuts for one more year.  The reduction in pay, 25 percent, had been scheduled to begin on January 1, 2011.  The American Medical Association strongly advocated for the delay that is longer than the previous five delays over the past year.  Over the upcoming year, Congress will work to develop a long-term solution to the Medicare physician payment problem. 

For more information on Medicare payments or the physician fee cut, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888. 

President Obama signed the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010.” The law includes a provision that clarifies Medicare’s position for payment of hospital outpatient services provided on either the day of or the three days prior to an inpatient admission. The 3-day payment window policy is effective for services provided on or after June 25, 2010. Medicare may not reopen claims submitted prior to June 25, 2010 to require a separate bill for outpatient non-diagnostic services.

The 3-day payment window, which has been unofficially followed by Medicare since 1991, allows a hospital to charge for all diagnostic services and non-diagnostic services “related” to the inpatient stay that are provided during the 3-day payment window.

The law defines “other services related to the admission” as including services that are not diagnostic services (other than ambulance and maintenance renal dialysis services) for which payment may be made by Medicare that are provided to a patient by a hospital: (1) on the date of the patient’s inpatient admission; (2) during the 3 days immediately prior to the date of admission, unless the hospital shows that the services provided were not related to the admission.

The U.S. Department of Health and Human Services Office of Inspector General (OIG) issued Advisory Opinion 10-08 to address the provision of dietitian and social worker services at a freestanding radiation oncology center (Center) at no extra charge to the beneficiaries. The OIG determined that the proposed arrangement would not violate the Federal Anti-Kickback Statute and thus, the OIG would not impose administrative sanctions.

The proposed arrangement involved patients at the Center receiving dietitian and social worker services at no additional charge. The OIG addressed the arrangement as it affected Medicare beneficiaries. The services would not be advertised as “free” or “at no charge.” Patients would receive the dietitian services after being identified for risk of nutritional complications and social worker services would be provided during the patient’s treatment. Under the proposed arrangement, the services would not be separately billed, and the applicable cost sharing amounts for the Medicare beneficiaries would not be routinely waived.

The Centers for Medicare and Medicaid Services (CMS) informed the OIG that the dietitian and social worker services provided at the Center would fall within the reimbursement the Center received for the patients. Thus, the amounts that the Medicare beneficiaries pay to share the costs would be partially attributable to the costs of the dietitian and social worker services and the Center would not be provided the services free because of this reimbursement. If this form of reimbursement had not been factored into the proposed arrangement, then the services would not be part of the reimbursement and could implicate the Anti-Kickbac Statute.