Compliance with Conditions of Participation Necessary for Reinstatement of Terminated Medicare Billing Privileges or Revoked Medicare Provider Number and Participation Agreement

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

We have recently experienced an alarming increase in the number of Medicare providers receiving notices that their Medicare billing privileges are being terminated.  These include home health agencies (HHAs), independent diagnostic testing facilities (IDTFs), ambulance and emergency transport providers, physicians, pharmacies, durable medical equipment (DME) providers, medical groups, physical therapists and therapy providers.  In most cases, this is because the health care provider has failed to update its address with the Medicare Program.  To see a prior article we wrote on this, click here.

Most often this occurs when a site visit by the Medicare administrative contractor (MAC) (previously called the carrier or fiscal intermediary) arrives at the business location on file with Medicare and finds the provider’s business […]

Power Wheelchair Suppliers Voice Concerns over New Government Program

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On September 19, 2012, power wheelchair suppliers voiced their concerns over a new government program called the Power Mobility Devices (PMDs) Demonstration at a Senate Special Committee on Aging. Durable Medical Equipment Suppliers (DMES) protested the program because it requires the permission of a Medicare Administrative Contractor (MAC) prior to the delivery of a power wheelchair to the consumer.

To see the Power Mobility Devices (PMDs) Demonstration operational guide from the Centers for Medicare and Medicaid Services (CMS), click here.

Wheelchair Claims Have High Error Rates.

Federal health officials believe these changes are necessary because eighty percent (80%) of the power wheelchair claims that were submitted in 2011 to Medicare did not meet program requirements. That error […]

Ambulance Company in Tennessee Settles A $2 Million Overpayment Lawsuit

George F. Indest III, Board Certified by The Florida Bar in Health Law

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law and Dr. Thu Pham, O.D., Law Clerk, The Health Law Firm Attorney

A Tennessee ambulance company and the U.S. Department of Health and Human Services (DHHS) announced a settlement in a case over a post payment audit for more than two million dollars in May 2012. Back in March of 2010, the Nashville ambulance company sued the DHHS after being sent a $2.65 million overpayment demand, according to the Nashville Business Journal.

To see the Nashville Business Journal article on the lawsuit, click here.

Huge Fine Found Using Error Rate Extrapolation Formula.

According to the lawsuit, the ambulance company claimed that the […]

Medicare Put the Hospice Industry Under the Microscope

Patricia's Photos 013By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

It’s no surprise to anyone that Medicare is cracking down on hospices around the country. According to a report by the Office of Inspector General (OIG), eighty-two percent (82%) of hospices’ claims did not meet Medicare coverage requirements. That is why Medicare is investigating the industry as a whole. Specific details on what Medicare is looking for can be found in the 2013 OIG Work Plan. Click here to read the 2013 OIG Work Plan.

So far, Medicare has kept true to its word. During the week of January 7, 2013, the federal government announced it is suing a Central Florida hospice for Medicare fraud, according to the Orlando Sentinel. (Click here to read the […]

You Must Challenge Overpayment Demands from Medicare and Medicaid Audits

6 Indest-2008-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

We have recently received numerous communications from health care professionals, including physicians, physical therapists, occupational therapists, mental health counselors, durable medical equipment (DME) providers, assisted living facilities (ALFs), group homes, and psychologists, who have been placed on prepayment review after failing to challenge Medicare or Medicaid audit results. The problem is that these providers, once placed on prepayment review, have their payments held up for many months and are often forced out of business. Sometimes it appears that this may actually be the goal of the auditing contractor or agency.

What Happens on Prepayment Review.

Failing to challenge, follow-up on, and appeal any adverse audit determinations can be very detrimental. An error rate in excess of fifteen percent (15%) will usually result in the provider being […]

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