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E&M Services Now Under Review by the Recovery Audit Contractors (RACs)

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

In September 2012, the Centers for Medicare and Medicaid Services (CMS) made the decision to allow Recovery Audit Contractors (RACs) to begin reviewing the billing codes for office visits for healthcare providers. Those at issue are the codes referred to as evaluation and management (E&M) codes. These claims had previously been off-limits to RACS.

Connolly, Inc., the contractor for RAC audit services for 15 states and two U.S. territories, will sort through claims filed by doctors and hospitals from as far back as October 1, 2007. According to an article in American Medical News, the plan is to conduct limited reviews in those states and territories using statistical sampling to project how many physician claims that used the high-level, established patient evaluation and management code 99215 were paid correctly.

To read the entire article from American Medical News, click here.

American Medical Association (AMA) Says E&M Codes Are Too Complicated for RACs to Audit.

The American Medical Association (AMA) disagrees with the decision to allow RACs to review E&M codes. In a letter to CMS, the AMA requests the Medicare agency reconsider its decision. The AMA believes E&M services are complex and based on several components.

In the letter the executive vice president of the AMA stated, “Based on our historical experience with the RACs, and in light of the fact that the RACs are not required to have same-specialty physicians review RAC determinations, we have no confidence that the RACs will be up to the task of understanding these variables or their clinical relevance.”

Click here to read the entire letter from the AMA to CMS.

An Increased Use of Higher-Level E&M Codes by Physicians and Hospitals Led to Audit Approval.

The use of office visit codes by doctors and hospitals has been a topic of discussion lately. According to American Medical News, the Department of Health and Human Services (DHHS) Office of Inspector General (OIG) reported almost 442,000 physicians billed E&M services in 2010. Of those physicians, 1,669 were found to be consistently billing higher-level E&M codes, such as the 99215 code that Connolly will review.

A recent article in New York Times discusses the reason for the increase in billing could be the switch to electronic health records. The article states some of the programs will automatically generate detailed patient histories, or allow doctors to cut and paste the same examination findings for multiple patients, a practice called cloning. Cloning can make it appear the physician conducted a more extensive exam, than perhaps he or she actually did.

Click here to read the entire article from The New York Times.

15 States and Two U.S. Territories Face RAC Audits of E&M Services?

Physicians and other healthcare professionals in 15 states, including Florida, and two U.S. territories may face these audits. RACs within these states will be permitted to extrapolate their findings based on a statistical sample of claims.

The states and territories in Connolly’s jurisdiction are: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, Puerto Rico and the U.S. Virgin Islands.

What To Do If You Receive a Notification of a Medicare Audit.

When a physician, medical group or other healthcare provider receives a notice of an audit and site visit from Medicare, the Medicare Administrative Carrier (MAC) or the Zone Program Integrity Contractor (ZPIC), things happen fast with little opportunity to prepare. To help, read our checklist of what to do when notified of a Medicare or ZPIC audit. Click here for part one and click here for part two.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

As a healthcare provider, how to do feel about these audits? Please submit any thoughtful comments below.

Sources:

Abelson, Reed, Creswell, Julie and Palmer, Griff. “Medicare Bills Rise as Records Turn Electronic.” The New York Times. (September 21, 2012). From: http://www.nytimes.com/2012/09/22/business/medicare-billing-rises-at-hospitals-with-electronic-records.html?pagewanted=all

Fiegl, Charles. “Medicare Auditor Targets E&M Services for Review.” American Medical News. (October 1, 2012). From: http://www.ama-assn.org/amednews/2012/10/01/gvl11001.htm

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Strike Force Busts 89 People, Mostly Health Care Professionals, in Nationwide Crackdown on Medicare Fraud

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

In a nationwide takedown nearly 100 people, including doctors, nurses and other medical professionals, in eight cities were all allegedly charged in separate Medicare fraud schemes. These individual scams involved approximately $223 million in false billing, according to the Department of Justice (DOJ) and the Department of Health and Humans Services (DHHS). On May 14, 2013, more than 400 law enforcement officials with the Medicare Fraud Strike Force spread out between Miami, Detroit, Los Angeles, New York, New Orleans, Houston, Chicago and Tampa to make the arrests of these 89 people, according to the DOJ.

Click here to read the press release from the DOJ.

Medicare Schemes Could Not Have Happened Without the Help of Health Professionals.

According to an article in Reuters, one out of every four defendants in this crackdown was some type of health professional. Authorities say most of these allegedly complex scams could not have happened without the participation of a doctor signing off on a bogus service, or a nurse filling out false paperwork.

Click here to read the entire article from Reuters.

Florida Health Professionals Involved.

According to the DOJ, in Miami, a total of 25 people, including two nurses and a paramedic, were allegedly part of numerous Medicare scams, totaling about $44 million in false claims. In one case involving a home health agency, defendants allegedly bribed Medicare beneficiaries for their Medicare information, which was used to bill for home health services that were never rendered or not medically necessary. The DOJ believes the lead defendant spent a majority of the money from the scam on luxury cars.

Phony Health Care Clinics Set Up.

In Tampa, nine individuals were charged in a variety of schemes, ranging from pharmacy fraud to health-care related money laundering. According to the DOJ, in one case four individuals allegedly established four health care clinics. The individuals allegedly used these clinics to steal more than $2.5 million from Medicare for surgical procedures that were never performed.

This Marks the Sixth Time the Medicare Fraud Strike Force Has Executed a Nationwide Crackdown.

This crackdown marks the sixth time the Medicare Fraud Strike Force has taken nationwide action against Medicare fraud. To date, the Medicare Fraud Strike Force is credited with making more than 1,500 arrests on charges related to $5 billion in allegedly false Medicare claims since 2007. According to the DOJ, it’s believed Medicare fraud costs the program between $60 billion and $90 billion each year.

Medicare operates under a pay-and-chase system, but according to the Washington Post, authorities are beginning to use new technology that flags suspicious claims before Medicare makes a payment. To read the entire Washington Post article, click here.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

What do you think of these nationwide crackdowns on Medicare fraud? Do you think they work as a deterrent for others committing health care fraud? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Medicare Strike Force Charges 89 Individuals for Approximately $223 Million in False Billing.” Department of Justice. (May 14, 2013). From: http://www.justice.gov/opa/pr/2013/May/13-crm-553.html

Kennedy, Kelli. “Doctors and Nurses Among Nearly 100 Charged in $223 Million Medicare Fraud Busts in 8 Cities.” Washington Post. (May 14, 2013). From: http://www.washingtonpost.com/politics/health_care/doctors-nurses-among-nearly-100-charged-in-223-million-medicare-fraud-busts-in-8-cities/2013/05/14/fbb0de3a-bcbc-11e2-b537-ab47f0325f7c_story.html

Morgan, David. “U.S. Charges 89 People in $223 Million Medicare Fraud Scheme.” Reuters. (May 14, 2013). From: http://www.reuters.com/article/2013/05/14/usa-healthcare-fraud-idUSL2N0DV3GZ20130514

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Internal Medicine Specialists Should Be Aware of Impending Medicare Audits

6 Indest-2008-3Coming to a medical practice near you. . . It’s scary, it’s horrible, and it could cost you a lot of money!

It’s the dreaded Comprehensive Error Rate Testing (CERT) audit.

The Horror! The Horror!

First Coast Service Options, the Medicare contractor for Florida, announced a new prepayment audit program that will impact Internal Medicine Specialists. The prepayment program is focused on Initial and Subsequent Hospital Evaluation and Management Services, CPT Codes 99223 and 99233. The program is being launched due to the high CERT error rate associated with these codes.

The audits will start on October 21, 2014.

What is the CERT Program?

CMS created the CERT program to measure the paid claims error rate for Medicare claims submitted to Medicare administrative contractors, carriers, durable medical equipment regional carriers, and Medicare Administrative Contractors (MACs). CMS receives more than two billion claims annually. The CERT program randomly selects approximately 120,000 of these claims for review to determine whether the claims were properly paid.

Statistical samples are selected and the CERT documentation contractor (CDC) submits documentation requests to those providers who submitted affected claims. Once the requested documentation has been received, the information is forwarded to the CERT review contractor (CRC) for review. The CRC will review the claims and supporting documentation to measure compliance with Medicare coverage, coding and billing rules. Click here to read my previous blog on the CERT Program.

How Internal Medicine Specialists Can Avoid CERT Audits.

First Coast is only targeting Internal Medicine Specialists as their data analysis suggests the specialty is the primary contributor to an elevated CERT error rate. Errors are normally cause by insufficient documentation to justify the service.

Healthcare providers designated as Internal Medicine with First Coast Service Options need to pay special attention to this audit program and the documentation requirements for billing 99223 and 99233 codes. If you find yourself or your practice the target of a CERT audit, click here for tips on how to respond.

Our Thoughts on the CERT Program.

In working with the CERT Program, we have been pleasantly surprised when our personal phone calls to the CERT auditors have been answered and actual accurate information provided, as well as letters and documents we provided being promptly acknowledged. Like with any other audit, however, we urge those being audited to seek the advice of an experienced health law attorney who may be able to assist in heading off and avoiding a more serious investigation or a large repayment demand.

Comments?

Have you heard of CERT audits? Has your practice encountered a CERT audit? Please leave any thoughtful comments below.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2014 The Health Law Firm. All rights reserved.

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 fine was based on incorrect accounting by a Medicare Administrative Contractor (MAC) for the DHHS. The contractor reviewed “a small sample of claims and determined that many did not meet Medicare coverage criteria.”

The actual overpayment on those claims was $10,764, which was determined to be an error rate of fifty-one percent (51%). The error rate was then used to extrapolate and obtain the $2.65 million figure which was demanded from the ambulance company.

Ambulance Company Files Administrative Appeal.

Upon administrative appeal, the ambulance company said most of its claims were determined to be appropriate, yet the error rate was never recalculated and the company was still stuck with a large bill.

Disputes of payments included bills for transporting dialysis patients by ambulance. The DHHS said those trips were not valid because they were not emergencies. The ambulance company refuted this contending that the trips did not have to be emergencies because they were ordered by a doctor.

Click here to read the entire lawsuit.

What You Should Know About the Use of Statistical Sampling and Extrapolation Formulas.

In both state Medicaid audits and in Medicare audits, we have experienced increased reliance by the auditing agency on use of mathematical extrapolation formulas to estimate the amount that should be repaid. The formula used usually takes the overpayment that has actually been found and, based on several factors, multiplies it out to many times the actual overpayment amount, as is the example in this case. We have seen ratios of as high as 1 to 150 (or 150 times the actual disallowed claims amount) calculated.

Things you should know about this are as follows:

1.  Neither the Medicare program nor the state Medicaid programs should use an extrapolation formula, unless:

  a. There is a “high” error rate in the claims that have been submitted; or

  b. There have been prior educational efforts or prior audits of the provider, and the provider

has failed to correct the problems in claims submission previously found.

2.  The states each have different guidelines, rules or regulations on when they will apply the statistical formula. Some do not use it at all. Some use a higher percentage error rate to prompt use of the formula and some lower. For example, North Carolina uses one of the lowest percentage error rates we have encountered; an error rate of more than five percent (5%) will prompt its Medicaid agency to apply the statistical extrapolation to the recovery amount.


Two Parties Settle.

On May 25, 2012, the United State District Court announced the ambulance company and the DHHS had settled and compromised. The lawsuit was dismissed against the DHHS without prejudice for a period of ninety (90) days.

Click here to see the order of dismissal.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.
The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Sources:

Nashville Business Journal. “Ambulance Company Sues Over $2.65M Bill.” Nashville Business Journal Online. (March 15, 2012). From: http://www.bizjournals.com/nashville/stories/2010/03/15/daily2.html

First Call Ambulance Service, Inc., v. Department of Health and Human Services, Case Number 3:10-0247, Order of Dismissal, May 25, 2012 available at: http://www.thehealthlawfirm.com/uploads/First%20Call_Dismissal.pdf

First Call Ambulance Service, Inc., v. Department of Health and Human Services, Case Number 3:10-cv-0247, First Call Ambulance Service, Inc., Sues Department of Health and Human Services Over $2.65 Million, March 20, 2010 available at: http://www.thehealthlawfirm.com/uploads/First%20Call%20Case.pdf

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2012 The Health Law Firm. All rights reserved.

The Affordable Care Act Offers the Government New Tools to Fight Healthcare Fraud

By Catherine T. Hollis, J.D., The Health Law Firm

In 2013, the government reported recovery of a record-breaking $10.7 billion in healthcare fraud in the past three years, according to the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ). The HHS credits the Affordable Care Act’s tough stance on fraud for improving the efforts to fight Medicare fraud.

The increase in fraud recovery is attributed in part to the Act’s proactive approach to preventing fraud. The Act contains several initiatives that address Medicare fraud, resulting in increased fraud-fighting tools available to the government. The joint effort between the HHS, the DOJ and the Health Care Fraud Prevention and Enforcement Action Team has been a primary driving force in seeking out fraud and securing recoveries. The HHS and DOJ’s website highlights some of the Act’s “powerful steps” toward fighting fraud, waste and abuse. Click here to read more from www.stopmedicarefraud.gov.

Tougher Punishment.

The Act increases federal sentencing guidelines for healthcare fraud by twenty percent (20%) to fifty percent (50%) for crimes that involve more than $1 million in losses. The Act also establishes penalties for obstructing a fraud investigation or an audit.

Stricter Screening for Enrollment and Revalidation.

According to the HHS, the new screening procedures include licensure checks and site visits for all providers and suppliers. In addition, the Act imposes higher scrutiny on providers and suppliers who may pose a higher risk of fraud or abuse. High risk providers and suppliers can be subject to unscheduled site visits and fingerprint-based criminal background checks.

The Center for Medicare & Medicaid Services (CMS) has started to revalidate the enrollment of all 1.5 million existing Medicare providers and suppliers, using the new screening requirements set forth by the Act. Thousands of enrollments have already been deactivated or revoked as the result of this effort. There is a blog on our website about the devastating and far reaching effects of being excluded from the Medicare program. Click here to read that blog.

New Detection Technology.

CMS is using the Fraud Prevention System to screen all fee-for-service Medicare claims. This system uses advanced predictive technology, similar to that used by credit card companies, to analyze claims prior to payment. It also scans for suspicious billing patterns. Claims identified by the Fraud Prevention System as suspect are reviewed by CMS for possible fraud.

Increased Resources.

The Act provides an additional $350 million over ten years (2011 through 2020) through the Health Care Fraud and Abuse Control Account.

These steps represent a more proactive approach to Medicare fraud. The government is focusing on preventing fraud before it happens, rather than paying fraudulent claims and seeking reimbursement after the fact. The tools contained in the Act, as implemented by CMS and HHS, further the goal of the Act to reduce fraud, waste and abuse in the Medicare system. To read a summary of the anti-fraud provisions in the Affordable Care Act, click here.

Anti-Fraud Provisions At Work.

On May 14, 2013, the HHS and DOJ announced the arrest of 89 people, including doctors, nurses and other medical professionals, in eight cities. These people are allegedly charged in separate Medicare fraud schemes. According to the DOJ, the scans involve approximately $223 million in false billing. Click here to read a blog on these arrests. To read more blogs on Medicare and Medicaid fraud, visit our website.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Do you think the Affordable Care Act will help cut down on healthcare fraud? Why or why not? Please leave any thoughtful comments below.

Sources:

Sjoerdsma, Donald. “The Affordable Care Act Bolstered, Didn’t Drive Medicare Anti-Fraud Efforts.” The Medicare Newsgroup. (March 22, 2013). From: http://medicarenewsgroup.com/context/understanding-medicare-blog/understanding-medicare-blog/2013/03/22/the-affordable-care-act-bolstered-didn-t-drive-medicare-anti-fraud-efforts

“The Affordable Care Act and Fighting Fraud.” U.S. Department of Health & Human Services and U.S. Department of Justice. From: http://www.stopmedicarefraud.gov/aboutfraud/aca-fraud/index.html

 

Health Benefits ABCs. “Summary of Anti-Fraud Provisions in the Affordable Care Act.” U.S. Administration on Aging, Department of Health and Human Services. From: http://www.smpresource.org/Content/NavigationMenu/ConsumerProtection/HealthCareReform/Anti-Fraud_Provisions_in_Health_Care_Reform.docx

“New Tools to Fight Fraud, Strengthen Federal and Private Health Programs, and Protect Consumer and Taxpayer Dollars.” U.S. Department of Health & Human Services. (March 15, 2011). From: http://www.healthcare.gov/news/factsheets/2011/03/fraud03152011a.html

About the Author: Catherine T. Hollis is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Phony Medical Equipment Supplier will Spend 30 months in Prison for Medicare Fraud

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

A Los Angeles medical equipment supplier will spend 30 months in prison for submitting nearly $1 million in false claims to Medicare. The claims were almost all for expensive, high-end power wheelchairs. The man was sentenced on October 5, 2012.

To see the press release from the Department of Justice (DOJ), click here.

Man Owned and Operated a Phony Durable Medical Equipment Supply Company.

In February 2012, the defendant in this case pleaded guilty to owning and operating a fake durable medical equipment (DME) supply company, which he used to submit false claims to Medicare. He would allegedly pay kickbacks to co-conspirators for prescriptions and other documents needed to pull off the fraud. About ninety-five percent (95%) of all of his claims were for power wheelchairs. The wheelchairs were allegedly supplied to Medicare beneficiaries who were illegally solicited by recruiters.

Feds Taps the Brakes on Wheelchair Medicare Fraud.

In September of 2012, power wheelchair suppliers voiced their concerns over a new government program called the Power Mobility Devices (PMDs) Demonstration. Durable Medical Equipment Suppliers (DMES) protested the program because it requires advanced approval prior to the delivery of a power wheelchair to the consumer.

Federal health officials argue that 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, according to the government. That error rate means more than $492 million of improper payments.

I recently wrote on blog on this hot-button topic, click here to read it.

Beware of Patient Recruiters.

We have seen several big cases recently involving prosecution for Medicare fraud in which patient recruiters were involved. It would probably be a good idea, if you are a legitimate Medicare provider, to have nothing to do with patient recruiters. If you are not a legitimate Medicare provider, you don’t care about this anyway.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare Issues Now.
The attorneys of The Health Law Firm represent durable medical equipment (DME) suppliers and health care providers in Medicare audits, ZPIC audits, MAC audits and RAC audits throughout Florida and across the U.S. They also represent DME suppliers, physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions, termination from the Medicare or Medicaid Program and administrative hearings.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

What do you think about this story? Please leave any thoughtful comments below.

Sources:

U.S. Department of Justice. “Los Angeles Medical Equipment Supplier Sentenced to 30 Months in Prison for Medicare Fraud Scheme.” FBI. (October 5, 2012). Press Release. From: http://www.justice.gov/opa/pr/2012/October/12-crm-1213.html

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Health Care Professionals and Providers Beware: The Health Care Fraud Prevention and Enforcement Action Team (HEAT) Is Catching Fire

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

In May 2009, the Department of Health and Humans Services (HHS) and the Department of Justice (DOJ) created the Health Care Fraud Prevention and Enforcement Action Team (HEAT). HEAT’s mission is to focus its efforts on preventing and deterring fraud and to enforce current anti-fraud laws around the country. To date, almost 1,400 individuals have been charged in connection with schemes involving more than $4.8 billion in fraudulent billings in these HEAT takedown operations.

To learn more about HEAT, click here to visit the website.

The Success of the HEAT Team.

According to the website, between 2008 and 2011, HEAT actions led to a seventy-five percent (75%) increase in individuals charged with criminal health care fraud. So far there have been six nationwide HEAT sting operations.

In 2011, HEAT agents led the largest-ever federal health care fraud takedown involving $530 million in fraudulent billing. To read more on this sting, click here.

On May 14, 2013, the DOJ announced that more than 400 law enforcement officials with HEAT spread out between eight cities including Miami and Tampa Bay to arrest 89 people accused of false billing. A majority of these arrests were allegedly of health care professionals. Click here to read a blog with more information on this takedown.

HEAT Captures One of Medicare’s Most-Wanted Fugitives.

On June 1, 2013, a former Los Angeles physical therapy clinic owner, and one of Medicare’s most-wanted fugitives, was arrested by HEAT agents at the Los Angeles International Airport on his return flight. According to a Los Angeles Times article, the clinic owner was an acupuncturist who billed Medicare for $2.1 million in false claims and was paid about $1.2 million. To read more from the Los Angeles Times, click here.

Expanding the Medicare Fraud Strike Force Efforts.

HEAT is a multi-agency team of federal, state and local investigators who combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing.

The Affordable Care Act has given HEAT additional tools to preserve Medicare by expanding the team’s authority to suspend Medicare payments and reimbursements when fraud is suspected.

To better combat fraud, the government has established HEAT in a number of cities, such as Los Angeles, Miami, Tampa Bay, Houston, Dallas, Chicago, Brooklyn, Baton Rouge and Detroit.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Have you heard of HEAT? Do you think the team’s efforts are curbing Medicare fraud around the country? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Medicare Fraud Strike Force Charges 89 Individuals for Approximately $223 Million in False Billing.” Department of Justice. (May 14, 2013). From: http://www.justice.gov/opa/pr/2013/May/13-crm-553.html

Terhune, Chad. “One of Medicare’s Most-Wanted Fugitives is Arrested in L.A.” Los Angeles Times. (June 3, 2013). From: http://www.latimes.com/business/money/la-fi-mo-medicare-most-wanted-fugitive-arrest-20130603,0,7474342.story

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Revised Readmission Penalties are Coming Due to Calculation Errors

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

Back in August of 2012, I wrote that lower Medicare reimbursement rates were coming to more than 2,000 hospitals around the country due to excessive readmission rates. To see that blog, click here.

In October of 2012, the Centers for Medicare and Medicaid Services (CMS) announced it has discovered errors in its initial calculations. This means, 1,422 hospitals with high readmission rates will lose slightly more money than first expected, according to Kaiser Health News.

Click here to read the entire article from Kaiser Health News.

Hiccup  in Medicare’s Hospital Readmission Reduction Program.

According to Kaiser Health News, the revisions were relatively small, averaging two-hundredths of a percent of a hospital’s regular Medicare reimbursements. Florala Memorial Hospital in Alabama will see the largest increase in its reimbursements, from 0.62 to 0.73 percent.

Originally, Medicare said it would base the penalties on the readmission rates for patients who were discharged from July 2008 through June 2011. According to a notice the CMS published, the mistake happened because the agency accidentally included claims before July 1, 2008, in its evaluations. Click here to see the notice from the CMS.

Program Initiated to Lower Hospitals’ Readmission Rates.

According to CMS, nearly one out of five Medicare patients will return to the hospital within a month of being discharged, these readmissions cost the government $17.5 billion in 2010. Medicare has estimated, with this program, it will recoup about $280 million from hospitals where too many patients return.

To see an updated list of hospital penalties, click here.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

What do you think about this story? Does this error by the CMS leave you jaded about the program? Leave any thoughtful comments below.


Sources:

Rau, Jordan. “Medicare Revises Hospitals’ Readmissions Penalties.” Kaiser Health News. (October 2, 2012). From: http://www.kaiserhealthnews.org/Stories/2012/October/03/medicare-revises-hospitals-readmissions-penalties.aspx

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Cardiologists Face Higher Scrutiny by CMS

Lance Leider headshotBy Lance O. Leider, J.D., The Health Law Firm

As the U.S. population ages and heart disease continues to be a leading cause of health issues, cardiologists and cardiology practices are finding themselves billing Medicare for more and more visits and procedures.

Along with that increase in reimbursement from Medicare comes an increase in scrutiny.  According to the Centers for Medicare and Medicaid Services (CMS), more than sixteen percent (16%) of total Medicare spending in 2010, was for cardiovascular care.

Some experts predict that this number will increase as cardiologists continue to adopt state-of-the-art technology and procedural techniques when treating their patients.

All of this means that whistleblowers, Recovery Audit Contractor (RAC) auditors, Zone Program Integrity Contractor (ZPIC) auditors, and CMS’s data mining services are going to be more incentivized to come after cardiovascular reimbursements.

To read more on the high scrutiny cardiologists face, click here to read an article on Modern Healthcare.

The Audits Are Coming.

Cardiology physicians and practices need to understand that just because they are doing things the “right way” does not mean that they will not be the subject of an audit. Auditing can be triggered by any number of things ranging from disgruntled employees, competing practices, dissatisfied patients, random audits, above average billing for certain codes, etc. None of these triggers means that a practice is doing anything wrong, but it will have to face an audit nonetheless.

Being prepared before an audit happens can be the most effective defense.  Review some of these prior articles and blogs we have written for tips in establishing audit protocols and handling audits in general:

–  Self Audit Now to Save Your Practice Later
–  Responding to a Medicare Audit – Practice Tips
–  Checklist on What to Do When Notified of a ZPIC or Medicare Audit and Site Visit – Part 1
–  Checklist on What to Do When Notified of a ZPIC or Medicare Audit and Site Visit – Part 2

The Best Defense for an Audit is to be Prepared Before an Audit Happens.

So long as CMS employs a “pay and chase” method of reimbursement, audits will be a permanent part of the healthcare landscape.  Every medical practice should consult with an attorney experienced in handling Medicare, Medicaid and other third party audits in order to develop effective policies and procedures.  By preparing for an audit prior to its occurrence a practice is in the best position to avoid any kind of sanction or overpayment demand.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Do you think cardiologist and cardiology practices are under a higher amount of scrutiny? Please leave any thoughtful comments below.

Sources:

Carlson, Joe. “Cardiologists Enmeshed in High-Scrutiny Climate.” Modern Healthcare. (July 8, 2013). From: http://www.modernhealthcare.com/article/20130708/BLOG/307089995/cardiologists-enmeshed-in-high-scrutiny-climate

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999. Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Responding to a Medicare Audit – Practice Tips

Although you may speak of a “routine” Medicare audit, there is really no such creature. This is like saying you have a “routine IRS audit.”  The fact is that there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused you or your practice to be audited.

Having too many claims for level five CPT codes might, for example, cause you to be audited.  Having multiple claims submitted for the same date of service, may cause you to be audited.  Submitting claims for CPT codes outside of your medical speciality area, might cause you to be audited.  Having the dollar amount of claims greater than the average for a similar health practitioner in the same geographical area of the country, may cause you to get audited.  Having a greater number of claims submitted than the average for a similar health practitioner in the same geographical area of the country, may cause you to get audited.  Filing claims for services that are on the Office of Inspector General’s (OIG) annual work list may cause you to be audited.

“Routine” audits, those that do not involve some suspicion of false billings or fraudulent activities, should, nevertheless, be treated extremely seriously and the physician, group or health provider being audited should give the matter personal attention.  Examples of some contractors that may be involved in “routine” audits include DelMarva Foundation, Palmetto GBA, Cigna GBA, or First Coast Service Options, Inc.

However, if the audit letter or audit notice is from a Zone Program Integrity Contractor (ZPIC), such as SafeGuard Services, LLC, or AdvanceMed, the matter is very serious and should not be treated as a routine audit.  If the “audit” comes in the form of a subpoena, then it is extremely serious.  If any FBI agent or OIG special agent is involved in it, then it is extremely serious.  In any of these three cases, an experienced health attorney should be retained immediately.

Even on a “routine” audit, given the possible consequences, we recommend you immediately retain the services of an experienced health attorney to guide you through the audit process, to communicate with the auditors, and to be prepared if it is necessary to challenge the audit findings.

These are some of the items actions we recommend you take and which we take in representing a physician or other health provider in responding to a Medicare audit.

1. All correspondence from Medicare, or the Medicare contractor, should be taken seriously.  Avoid the temptation to consider the request from Medicare, or the Medicare contractor, just another medical records request.  Avoid the temptation to delegate this as a routine matter to an administrative employee.

2. Read the audit letter carefully and provide all the information requested in the letter.  In addition to medical records, auditors often ask for invoices and purchase orders for the drugs and medical supplies dispensed to patients for which Medicare reimbursed you.

3. Include a copy of the complete record and not just those from the dates of service requested in the audit letter.  Include any diagnostic tests and other documents from the chart that support the services provided.  Many practices document the medications and immunizations given to the patient in a separate part of the chart and not in the progress notes; all documents, the complete record, should be provided to the auditor.  Remember that even other physicians records obtained as history, including reports, consultants and records from other physicians or hospitals, should also be included.  Consent forms, medical history questionnaires, histories, physicals, other physicians’ orders, all may be a crucial part of the record and should be included.  If hospital or nursing home discharge orders or other orders referred the patient to you, obtain these to provide to the auditors.

4. Make sure all the medical records are legible and legibly copied.  If the record is not legible, have the illegible record transcribed and include the transcription along with the hand-written or illegible records.  Make sure than any such transcriptions are clearly marked as a transcription with the current date it is actually transcribed.  Label it accurately.  Do not allow any room for there to be any confusion that the newly transcribed part was part of the original record.

5. If your practice involves taking or interpreting x-rays or other diagnostic studies, include these studies.  They are part of the patient’s record.  If the x-rays are digital, they can be submitted on a compact disc (CD).

6. Never alter the medical records after a notice of an audit.  However, if there are consults, orders, test reports, prescriptions, etc., that have not been filed into the chart, yet, have these filed into it, as you normally would, so that the record is complete.  Altering a medical record can be the basis for a fraud claim including criminal penalties.

7. Make sure each page of the record is copied correctly and completely.  If the copy of the record has missing information because it was cut off, the original needs to be recopied to ensure it includes all the information.  Don’t submit copies that have edges cut off, have bottom margins cut off, are copied slanted on the page, or for which the reverse side is not copied.  Reduce the copied image to 96% if necessary to prevent edges and margins from being cut off.

8. Make color copies of medical records when the original record includes different colored ink of significance.  Colors other than blue and black rarely copy well and may be illegible on standard photocopiers.

9. Include a brief summary of the care provided to the patient with each record.  The summary is not a substitute for the medical records, but will assist an auditor that may not be experienced in a particular specialty or practice area.  Make sure that any such summaries are clearly marked as summaries with the current date they are actually prepared.  Label it accurately.  Do not allow any room for there to be any confusion that this new portion was part of the original record.

10. Include an explanatory note and any supporting medical literature, clinical practice guidelines, local coverage determinations (LCDs), medical/dental journal articles, or other documents to support any unusual procedures or billings, or to explain missing record entries.  See item 9 immediately above.

11. When receiving a notice of a Medicare audit, time is of the essence.  Be sure to calendar the date that the records need to be in to the auditor and have the records there by that date.  Note: the due date is not the last date on which you can mail the records but rather is the date that the records must be at the auditor’s office.

12. Any telephone communication with the auditor should be followed up with a letter confirming the telephone conference.

13. Send all communications to the auditor by certified mail (or express mail), return receipt requested so you have proof of delivery.

14. Properly each copy of each medical record you provide and page number everything you provide the auditors, by hand, if necessary. Medical record copies often get shuffled or portions lost or damaged during copying, storage, scanning or transmission.

15. Keep complete, legible copies of all correspondence and every document you provide.  When we provide records to a Medicare auditor, we make a complete copy for the auditor, for the client, for us (legal counsel) and two for your future expert witnesses (to challenge any audit results) to use.

16. Consult an experienced health law attorney early in the audit process to assist in preparing the response.

The above check list is by no means comprehensive.  Nor do we mean to suggest that you should respond on your own.  The above is illustrative of the many actions that should be taken to help protect your interests when you are subjected to a Medicare audit.

Visit our website at www.TheHealthLawFirm.com for more information on Medicare audits, ZPIC audits, health care subpoenas, Medicare and Medicaid search warrants and Medicare and other federal administrative hearings.

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