Medicare

Published on: October 27, 2010

Joint Commission Announces Accreditation Standards for Patient-Centered Medical Homes

In September the Joint Commission announced that it will begin to accredit patient-centered medical home models for physicians by July 2011. A medical home model is a method to deliver care that is based on the ability to demonstrate evidence-based protocols, self-management education and care coordination with specialists and other facilities. The Joint Commission’s final standards will be available in March 2011 and on-site surveys will begin in July 2011.

The American Medical Association supports patient-centered medical homes, but stated to American Medical News that it will continue to work with the Joint Commission to ensure that proposed accreditation standards will focus on patient safety and access to physician care. Currently, some of these practices follow the standards published by a Washington D.C.-based organization, National Committee for Quality Assurance (NCQA). NCQA argues that more accreditation or recognition bodies will complicate the accrediting landscape and will cause confusion among providers.

For more information on patient centered medical homes or other health care reform concepts, please contact a Wachler & Associates attorney at 248-544-0888.

Published on: September 23, 2010

CMS Publishes Proposed Rule Implementing Affordable Care Act Provisions

by Wachler & Associates, P.C.

The Centers for Medicare and Medicaid Services (CMS) published a proposed rule implementing provisions of the Patient Protection and Affordable Care Act (PPACA) that help tackle Medicare and Medicaid fraud. According to Peter Budetti, the Director of the new anti-fraud office at CMS, the proposed rules will provide federal authorities the power to identify fraud and reduce improper payments by an estimated $55 billion.

According to CMS, the proposed rule is essential to the implementation of healthcare reform since the expansion of healthcare coverage relies upon saving money on fraud and abuse in the healthcare systems. Specifically, the rules will provide increased scrutiny to $900 billion in annual spending in federal Medicare, and the state-federal Medicaid and Children’s Health Insurance Program (CHIP), but it is unknown how much money the proposed rules will actually save.

Increased scrutiny over Medicare and Medicaid Programs will include the following measures:

Published on: September 15, 2010

CMS Publishes a New Rule Affecting DME Providers

by Wachler & Associates, P.C.

The Centers for Medicare and Medicaid Services (CMS) recently published a new rule affecting Durable Medical Equipment (DME) providers. The rule, effective September 27, 2010, strengthens Medicare’s standards for marketing and solicitations and expands enrollment requirements for DMEPOS providers.

Important highlights from the rule include:

– DME providers will be required to remain open to the public for at least 30 hours per week, except for physicians or licensed non-physician practitioners furnishing services to their own patients as part of their professional service and DME providers working with custom orthotics and prosthetics.

Published on: August 23, 2010

The OIG Publishes Reports Targeting IRFs

by Wachler & Associates, P.C.

The Office of Inspector General (OIG) published two reports targeting inpatient rehabilitation facilities (IRF). Most notable, however, is the CMS response to the OIG reports. The first report reviewed IRF transmission of patient assessment instruments for calendar years (CY) 2006 and 2007. This report showed that IRFs failed to timely submit patient assessment data and this could reduce the case-mix group payment. Based upon the OIG findings, CMS concluded that fiscal intermediaries (FI) overpaid IRFs approximately $20.2 million in CY 2006 and 2007. Additionally, FIs may have overpaid $19 million because of a lack of clarity in the regulations regarding data for claims originally submitted within the 27-day timeframe, but then later resubmitted to correct errors outside the 27-day timeframe.

The second report addressed the issue of whether proper status codes were used on IRF claims. When a patient is discharged to his or her home, Medicare pays the full prospective rate. In contrast, if a patient is transferred from the IRF (to another IRF, a short-term, acute care prospective payment hospital, a long-term hospital or a nursing home that qualifies for Medicare or Medicaid payments), Medicare pays a reduced amount. The OIG review found that out of 220 claims sampled, 213 claims were improperly coded as discharges. This resulted in an overpayment of approximately $1.2 million. For the four year period ending in September 2007, CMS determined the overpayments for this issue totaled approximately $34 million. Of particular importance to IRFs is the fact that CMS has indicated that it will share the OIG audit information with the Recovery Audit Contractors (RACs) and encourage them to utilize the findings in their reviews.

For more information on Medicare audits, or for assistance with an audit, please visit www.racattorneys.com or contact a Wachler & Associates attorney at 248-544-0888.

Published on: August 18, 2010

OIG Publishes Report Showing Overpayments to DME Suppliers

by Wachler & Associates, P.C.

The OIG recently published a report showing that from 2006 to 2008, Medicare allowed $2.2 million for routine maintenance and servicing of capped rental durable medical equipment (DME) with rental periods. These payments were erroneously made because the Deficit Reduction Act of 2005 (DRA) dramatically limited, if not eliminated, routine maintenance and servicing for beneficiary-owned DME with rental periods that began after January 1, 2006. During the same time period, OIG found that Medicare allowed nearly $4.4 million for repairs for beneficiary-rented capped rental DME. Medicare has never allowed payments for repairs of beneficiary-rented capped dental DME as the cost for repairs are already included in the monthly rental payments to suppliers.

As a result of its discoveries, the OIG is recommending that the Centers for Medicare and Medicaid Services (CMS) establish an edit to deny claims for routine maintenance and services of capped rental DME periods beginning after January 1, 2006 and for claims for repair of beneficiary-rented capped rental DME. In addition, the OIG urges CMS to enhance the enforcement of existing payment requirements for beneficiary-owned capped rental DME, to begin to track repair costs for capped rental DME and to take appropriate action on erroneously allowed claims for maintenance and servicing, repair and payment errors.

DME suppliers should expect to see audit activity from CMS contractors on this issue and may want to consider conducting self-audits as part of their compliance programs.

Published on: August 17, 2010

OIG Report Identifies Overpayments to Physicians for Incorrect Place of Service Codes

by Wachler & Associates, P.C.

The Department of Health and Human Services Office of Inspector General (OIG) published a report finding that Medicare contractors overpaid physicians an estimated $13.8 million for services provided during calendar year 2007 with incorrect place of service codes. The OIG report reminded physicians that they must identify the place of service on health insurance claim forms submitted to Medicare contractors. This is because physicians are reimbursed at different rates depending on where the services are performed.

In addition to its identification of common billing errors, OIG recommended that the Centers for Medicare and Medicaid Services (CMS) instruct its Medicare contractors to recover the overpayments found from the services OIG sampled for its report. OIG also encouraged the CMS to reopen nonsampled services to recover any overpayments and to continue its effort to educate physicians and billing services on the importance of identifying the place of service in Medicare billing records.

Providers should ensure that their billing practices follow the Medicare requirements, including proper place of service codes.

Published on: June 28, 2010

Codification of the Hospital 3-Day Payment Window

by Wachler & Associates, P.C.

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.

Published on: June 23, 2010

The OIG Releases an Advisory Opinion Regarding the Dietitian and Social Worker Services Provided at a Freestanding Radiation Oncology Center

by Wachler & Associates, P.C.

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.

Published on: June 22, 2010

The Senate Passes a Plan to Fix Medicare Physician Payment for Another Six Months

by Wachler & Associates, P.C.

On June 18 the U.S. Senate passed a six-month plan to prevent the Medicare physician 21 percent payment cut. The measure, which will cost $6.4 billion, was pushed through with the concern that the steep payment cut would raise the possibility that medical providers would turn away patients covered by Medicare. It will delay the cuts until November 30, 2010 while Congress tries to create a long-term plan. The plan was passed unanimously and lawmakers attribute its passage to the efforts to offset its attributed costs.

Almost immediately after the U.S. Senate announced the passage of the plan, Medicare announced that it would process Medicare claims received for June at the lower rate. This is because the U.S. House of Representatives will not be able to consider the plan until next week. However, there are indications that the bill’s success in the House may be complicated. House Speaker Nancy Pelosi announced that the House will not pass the Senate bill until the Senate agrees to act on job-creation legislation. If the bill does pass in the House, Medicare providers will have the burden to resubmit their claims to be made whole.

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.

Published on: May 23, 2010

CMS Releases MLN Matters Article Explaining Additions to the Medicare Program Integrity Manual

by Wachler & Associates, P.C.

On May 14, 2010, the Centers for Medicare and Medicaid Services (CMS) released an MLN Matters article explaining Change Request (CR) 6954. CR 6954 adds Section 3.14 to the Medicare Program Integrity Manual. This section clarifies language regarding clinical review judgments. It requires Medicare claim review contractors to instruct their clinical review staffs to use the clinical review judgment process when making complex review determinations about a claim. The clinical review judgment involves two steps:

(1) The synthesis of all medical record information to create a longitudinal clinical picture of the patient; and

(2) The application of the clinical picture to the review criterial to determine whether the clinical requirements in the relevant policy are met.