Georgia's Trusted Healthcare
& Medical Provider Attorneys

CIS Recoupments Begin – Still Time To Appeal

CIS Recoupment ClaimsThe first Special Remittance Advices (“RA”) pursuant to the Department of Community Health’s CIS Claims Reprocessing were issued this week.  Claims originally processed between November 1, 2010, through June 30, 2012, that billed specific CPT codes are subject to this special reprocessing based on the CMS National Correct Coding Initiative mandated by the Affordable Care Act.

Early reports are that the Special RA’s detailing the voided claims have been several hundred pages long with recoupments reported from $5000 to $100,000.

Some providers have indicated that DCH may be willing to enter into payment plans with providers to space-out the recoupment amount and that the Department may also allow denied claims to be re-billed with the proper CPT modifiers to allow for payment.

Section 202 of DCH’s Part I:  Policies and Procedures Manual requires that claims be received within six (6) months after the month in which service was rendered to be reimbursed unless certain exceptions are met.  It is unclear whether DCH considers the Special Reprocessing as meeting the exception requirements.  If it does not, then providers may be limited to six (6) months for re-billing claims.

If you think the Department’s determination of recoupment is incorrect, you can still appeal the determination as described in Part I of this article. It is extremely important that you satisfy all of the appeal requirements and meet all deadlines.  Failing to do so means that you waive your appeal rights and may not be able to challenge the DCH action.

If you’ve received notice that your practice is subject to the reprocessing recoupment and need help or if you need to appeal DCH’s decisions, Jeyaram & Associates can help. Contact DJ Jeyaram at DJ@Jeylaw.com or 678.325.3872.

Jeyaram & Associates and Parker, Hudson, Rainer & Dobbs File Class Action Law Suit Against the State

Class Action Law Suit Against GeorgiaJeyaram & Associates and Parker, Hudson, Rainer & Dobbs have filed suit against the state for withholding millions of tax funds earmarked for severely disabled individuals.

Family members representing people with severe disabilities and a group of their health care providers today filed a class action law suit against the Georgia Department of Behavioral Health and Developmental Disabilities and the Georgia Department of Community Health for withholding funds that were designated for the care of those individuals contrary to controlling law.

United Cerebral Palsy of Georgia, Inc., Coastal Center for Developmental Services, Inc., Hope Haven of Northeast Georgia and Creative Community Services, Inc. as well as four families representing nearly 12,000 individuals in the State seek the return of hundreds of millions of dollars that should have been used to care for those individuals since 2008.  The exact amount will be determined at trial.

The families filing suit represent clients who depend on vital services from these healthcare providers every single day. These clients are some of the most vulnerable members of our communities.  Their daily lives have been negatively impacted in real and tangible ways, as have those of their families and caregivers.

“My daughter Tammy wants and needs activity.  Sitting in front of a TV set is counterproductive for her,” says Angela Tulloh of Kennesaw.

Marilyn Harvill worries about the ongoing and future care of her son, 53 year old Matt Windham.  “Matt has severe brain damage and needs 24 hour one-on-one care.  I am worried about the services Matt will receive in the future because I wasn’t given any notice of the cuts.”

None of the families affected was notified by the state of the pending cuts and none was given any recourse.

Additionally, an undetermined number of other individuals requiring new services have been turned away due to the improper budget cuts.

Those organizations filing suit are designated Medicaid providers. The two state agencies being sued have failed to reimburse the plaintiffs for services provided under contract to clients with profound intellectual and developmental disabilities. That has led to severe financial harm to these providers. The state has very specific rules and procedures it must follow before reducing already agreed upon payments to providers and families.  None of those procedures has been followed.

These cuts in Medicaid funds were not tied to the recent economic downturn; rather the funds were allocated by the state legislature and simply not paid in full to the providers and clients who depend on them.

“We have gone through our financial resources to keep serving our existing clients, but we have had to turn away other people with severe developmental, medical and behavioral needs.  I don’t know what happens to those people,” says Sally Buchanan, CEO of Creative Community Services of Norcross.

Curt Harrison, Associate Executive Director of United Cerebral Palsy Georgia and South Carolina, says

“So many people rely on us and we’re doing the best we can.  But development of new services and additional employee training have really suffered.  However, we don’t think it’s morally appropriate to cut services.”

 To view this story on Channel 46: http://www.cbsatlanta.com/story/23086886/exclusive-lawsuit-filed-against-state-of-georgia-alleges-funds-withheld-for-disabled

Georgia to Hire Private For Profit Company to Oversee Medical Care of Foster Children

Streamlined Managed CareThe state is planning to streamline the medical care of children in foster care, adoption assistance or the juvenile justice system by transitioning to a managed care model.

Currently, the change in the living situation of these children may result in a change in doctors and incomplete medical records, which can ultimately result in complications when doctors are not aware of medical history or allergies.

Under the managed care model, the children will have one primary care physician and their records will be stored electronically, allowing for continuity of care and access to information regardless of where the child is living.

In addition to potentially saving the state $27.5 million over five years, the move to managed care may result in healthier children. Other states using the managed care model for foster children have reported decreases in the use of psychotropic medication and increases in health risk screenings.

Georgia plans to hire one of the three for-profit care management organizations in the state that currently oversee the provision of care to children and pregnant women who receive Medicaid.

Further, a quarterly oversight committee will be established that is comprised of representatives from several agencies to monitor the progress under the managed care model.

The managed care model for children in foster care, adoption assistance or the juvenile justice system may potentially provide less confusion for physicians and a greater continuity of care for children.

Medicare Trustees Report Includes Promising News for Healthcare Providers and Beneficiaries

Healthcare Cost SavingsThe Medicare Trustees recently released their 2013 Report, and it contained some promising news for the Medicare Hospital Insurance Trust Fund.  The Fund will be able to cover its obligations until 2026, which is an extension of last year’s projection by two years.

The increased solvency of the Trust Fund is good news for both healthcare providers and beneficiaries because it points to the positive financial impacts of current efforts to reduce healthcare spending.  Additional good news for beneficiaries included a preliminary estimate of the Part B premium for 2014, which is unchanged from 2013.

The CMS Administrator attributes the increased solvency of the Trust Fund to the Affordable Care Act; however, the Report cites numerous contributing factors, such as lower 2012 Part A spending and potentially lower Medicare Advantage costs.

Opponents of health care reform stress that crediting the Affordable Care Act for the increase in solvency may be premature because the numbers depend on a range of factors, none of which are fully predictable at this stage of implementation.

The actual impact of the Affordable Care Act provisions remains to be seen as does the implications to the Trust Fund.  Providers should stay informed about the potential financial impacts of healthcare reform as provisions are implemented in the coming months.

Jeyaram & Associates to Host Free Legal Seminars: Healthcare, Corporate, Administrative and Education Law

Jeyaram & Associates Free Legal SeminarsTell us what you want!

We’re putting together a schedule of *free* legal seminars hosted by Jeyaram & Associates for this fall, and we want to hear what you want you want to learn about!

Past seminars have included:
* “How to Prepare for a Payor Audit”
* “The Do’s and Dont’s of Physician Contracts”
* “Recovery Audit Contractor (RAC) Appeals”
* “Tips on How to Prepare for an IEP”

….and more

But we want to know what’s on your mind and what you need!

We’ll send invites later this summer for the free seminars.

Let us know your healthcare, corporate, administrative, and legal education needs!

Is it O.K. to Waive Medicare and Medicaid Beneficiary Co-Pays?

AntiKickback Medicaid MedicareThe answer is sometimes.  However, providers must be very careful to consider the implications of waiving beneficiary co-pays.  Primarily, waiving co-pays may trigger The Anti-Kickback Statute.

The Anti-Kickback Statute provides in relevant part:

Whoever knowingly and willfully offers or pays any remuneration (including any kickback, bribe, or rebate) directly or indirectly…, in cash or in kind, to any person to induce such person to refer an individual [for] any item or service for which payment may be made … under a Federal health care program, … shall be guilty of a felony.42 U.S.C. § 1320a-7b(b).

Basically, the statute prohibits giving anything of value in order to induce referrals for business covered by Medicaid and other federally funded health care programs, and may apply to any transaction between providers and program beneficiaries.

However, the statue does not apply if a health care provider acts without any intent to induce improper referrals. In addition, the provider must know about the law, and act “with the specific intent to violate the law.” Hanlester Network v. Shalala, 51 F.3d 1390 (9th Cir. 1995).

Thus, actions taken in good faith for the benefit of patients or program beneficiaries without any improper intent to generate referrals or violate the law do not implicate Anti-Kickback.

The Department may examine any transaction that could generate improper referrals, especially those in which a provider offers free or discounted items or services to program beneficiaries, or those that would otherwise promote over-utilization or create a risk of fraudulent claims. See OIG Special Advisory Bulletin, Offering Gifts and Other Inducements to Beneficiaries (8/02).

Copays and deductibles help discourage unnecessary services and lower the cost of government programs. A provider’s routine waiver of copays and deductibles may create an incentive to over-utilize program resources and violate the Anti-Kickback Statute. See OIG Special Fraud Alert (12/94).

The OIG has set out some safe harbor guidelines.  Waiving Medicaid and Medicare copays or deductibles does not violate the Anti-Kickback Statute if:

  • the waiver is not offered as part of any advertisement or solicitation;
  • the provider does not routinely waive coinsurance or deductibles; and
  • the provider waives the coinsurance and deductibles after determining in good faith that the individual is in financial need or reasonable collection efforts have failed.

The beneficiary’s “financial need” will depend on the individual’s circumstances.  Providers should have a written policy and guidelines in place showing consideration of factors such as the local cost of living, the patient’s income, assets and expenses, and the scope and extent of the patient’s medical bills. The documentation of financial need should be placed in that patient’s file to prove that the analysis was undertaken and the policy was followed.  In addition, collection should always be attempted.

By taking these factors into consideration, a Provider may greatly reduce the risk of being flagged for fraudulent waiver of copays.

For more information, contact DJ Jeyaram at DJ@Jeylaw.com or  678.325.3872.

How To Request The Georgia Special Needs Scholarship – What You Need To Know

IEP Education LawIf you have a child whom receives special education services in Georgia and meets certain eligibility requirements, you have the right to transfer your child to:

  1. another public school within your district of residence, or
  2. another public school outside your district of residence, or
  3. one of three state schools for the blind or deaf, or
  4. a private school authorized to participate in the scholarship program

if you believe your child would be better served.

If you are interested in offsetting the costs of sending your child to a private school, you must select a private school that participates in the Georgia Specials Needs Scholarship (GSNS) Program.  To qualify for the GSNS Program, your child must meet the following requirements:

  1. A student must have a parent/guardian who currently lives in Georgia and has been a resident for at least one calendar year.
  2. A student was enrolled and attended a Georgia public school (grades K-12) the entire 2012-2013 school year. Pre-school special education students do not quality. A student must complete a full year in kindergarten before he/she can be eligible.
  3. A student was reported by a school district(s) during mandatory student counts conducted in October 2012-2013 and March 2013 by public schools.
  4. A student does not need to have an Individualized Education Program (IEP) for the entire school year to qualify for the scholarship program. A student *must* have received special education services at some point during the 2012-2013 school year under an IEP. A student must be reported by a school district(s) in either the October 2013 or March 2013 student counts or in final student record as a student receiving special education services by the end of the school year.

Scholarship funds received through the GSNS Program can only be used to offset tuition and fees at a private school authorized by the State Board of Education. Funds *cannot* be used to offset the costs of out of district tuition, charter schools or other options available under public school choice.

The deadline to have a student enrolled in a private school through the GSNS Program for the 2013-2014 school year is September 16, 2013. No exceptions.

For more information about the scholarship program or if you need assistance with your child’s IEP , please contact DJ@Jeylaw.com at Jeyaram & Associates.

 

ICD-10 Deadline for Healthcare Providers Fast Approaching – Jeyaram & Associates Can Help

ICD DeadlineThe October 1, 2014 deadline to switch to the ICD-10 codes set is less than five months away. This mandatory requirement replaces the ICD-9 codes set used to report medical diagnoses and inpatient procedures.

All healthcare providers covered by the Health Insurance Portability Accountability Act (HIPAA) must adhere to this new requirement. Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.

All healthcare practices currently using the ICD-9 codes must transition to the new codes. The transition to the new codes set will take several months. If you have not started the transition, we strongly urge to begin now. 

ICD consists of two parts:

1. ICD-10-CM for diagnosis coding
2. ICD-10-PCS for inpatient procedure coding 

ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.

ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10­ PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

The Centers for Medicare and Medicaid Web site provides detailed check lists to help healthcare providers make the transition. However, if you have questions or need help with the transition to the ICD-10 codes set, Jeyaram & Associates can help. Contact DJ Jeyaram at DJ@Jeylaw.com or 678-708-4705.

 

Center for Medicaid & Medicare Services Shows Georgia Hospital Charges Vary

Center for Medicare & Medicaid ServicesA new study released by the Center for Medicaid and Medicare Services demonstrates that hospital charges for in-patient surgical and life threatening procedures vary greatly – including those in Georgia. The report looks at hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the Medicare Severity Diagnosis Related Group (MS-DRG) for Fiscal Year (FY) 2011. These DRGs represent almost 7 million discharges or 60 percent of total Medicare IPPS discharges.

Discrepancies for in-patient services in Georgia include:

Joint replacement or reattaching a limb:

  • Saint Josephs: up to $28,000
  • Northside: on average $62,000
  • Grady: up to $85,000

Treatment of pneumonia or pleurisy:

  • Grady: up to $19,000
  • Atlanta Medical Center: up to $41,000
  • North Fulton Regional in Roswell: up to $55,000

Admissions and treatment for life threatening conditions such as heart failure and stroke:

  • DeKalb Medical Center: up to $15,000
  • Atlanta Medical Center: up to $40,000
  • North Fulton: up to $58,000

The Center for Medicaid and Medicare Services issued the report in response to President Obama’s efforts to make the country’s health care system more affordable and accountable. To review the Center’s findings in Excel, click here. 

 

 

Office of Inspector General’s 2013 Work Plan Increases Focus on Hospital Billing and the Affordable Care Act

Last month the Office of Inspector General (“OIG”) released its Work Plan for Fiscal Year 2013 (“FY 2013 Work Plan”).  The FY 2013 Work Plan focuses on many of the same areas as the prior year; however, there are two areas that received extra attention:  hospital billing and payment issues and implementation of the Affordable Care Act (“ACA”).

For Medicare purposes, the OIG has added new reviews including:

  • the efficiency of edits to identify hospital claims that were billed as discharges when they should have been billed as transfers
  • costs resulting from inpatient hospital claims for canceled surgical procedures
  • savings resulting from new payments for swing-bed services at critical access hospitals

One area of increasing focus in the Medicaid arena is prescription drugs.  In FY 2013, the OIG intends to explore alternative payment methods for home blood-glucose test strips.  The cost-saving means include rebates and competitive bidding, both of which have been successful at reducing net payment rates in some states.

Finally, the OIG will continue to monitor the ongoing implementation of the ACA.  Actions that the OIG intends to take in FY 2013 include the following:

  • reviewing compliance of home health agencies with the ACA requirement that physicians or other certain practitioners have face-to-face contact with beneficiaries
  • exploring cost savings associated with rental rather than purchase of power mobility devices
  • planning the frequency of on-site visits as part of the Medicare enrollment or re-enrollment process

 
As the OIG begins to implement its FY 2013 Work Plan, providers should continue to monitor what Medicare and Medicaid areas receive increased attention.  Additionally, providers should be proactive as the deadlines approach for implementation of parts of the ACA.