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& Medical Provider Attorneys

Court Finds DCH’s Handling of Mass Reprocessing “Inconsistent and Misleading”

DCHIn a decision last week, the Office of State Administrative Hearings (OSAH) reversed the Department of Community Health’s (DCH) denial of a Request for Administrative Review by a group of Children Intervention Services (“CIS”) providers. The CIS providers had requested a review of recoupment actions that stemmed from two 2014 Mass Reprocessings by the Department, one involving NCCI edits that included claims dating back to 2010.  The Department argued that the providers missed the 30 day deadline to file a Request for Administrative Review.

Attorney Kimberly Sheridan of Jeyaram & Associates represented the group of CIS providers in the administrative hearing and argued that the providers should be granted a review because they followed all the instructions specific to the mass reprocessing posted by the Department in several banner messages and emails, as well as in-person conversations. Through the banner and email message instructions, the Department departed from its standard deadlines in its policy manuals.  The Court found that the Department’s position was “illogical and wholly unfair,” and that its instructions to the providers after the mass reprocessing were “inconsistent and misleading.” The Court also said the providers had justifiably relied on these instructions and could not now be penalized for their reliance.

At this time, the Department has not made it known if it will appeal the decision.

If you are a provider subject to a recoupment and need help, or if you need to appeal DCH’s decisions, Jeyaram & Associates has extensive experience and success with these cases. Contact Kimberly Sheridan at ksheridan@Jeylaw.com or 678.325.3872.

Healthcare Providers Need To Examine Billing Practices To Ensure Compliance

healthcare fraudLast month, the Department of Health and Human Services released its annual report for the Health Care Fraud and Abuse Control Program. According to the report, in 2014 more than 900 new criminal health care fraud investigations were opened by the Department of Justice. There was a slight increase in the number of criminal cases and convictions from last year, with 496 cases and 735 defendants convicted of criminal health care fraud. Civil cases alone resulted in $2.3 Billion in settlements and judgments.

The government’s press release reiterated that detecting and eliminating fraud and abuse continues to be a top priority. The government attributes its high recoveries to a change in strategy which uses real-time data analysis to detect fraud more quickly. The Centers for Medicare and Medicaid currently uses advanced analytics on Medicare fee-for-service claims. The goal of this is to detect aberrant and suspicious billing patterns which would then trigger an investigation or enforcement action by the government.

Now is the time to for Medicare and Medicaid providers to review their billing practices and financial relationships to ensure that they are compliant with federal laws. Charges against providers were made under the False Claims Act, as well as Anti-Kickback Statute, the Stark Law (Physician Self-Referral Law), and other federal laws.

The full annual report is available at www.oig.hhs.gov/publications/hcfac.asp.

If you have any questions about the legality of your billing practices or financial relationships, please contact DJ Jeyaram at DJ@jeylaw.com or Danielle Hildebrand at dhildebrand@jeylaw.com.

 

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.

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.

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. 

 

 

Fiscal Cliff Compromise Impacts Healthcare Providers’ Bottom Line

Fiscal Cliff Impacts Healthcare ProvidersLast week, the President and Congress reached a last-minute compromise regarding the much-discussed “fiscal cliff.” The compromise was signed into law by the President and has several provisions that affect the healthcare industry.

1. A reduction in Medicare payment rates to physicians was postponed for an additional year; however, the avoidance of a rate cut is offset by cuts to other providers such as dialysis centers and hospitals.

2. Adjustments will be made resulting in a reduction in Medicare payments to hospitals over the next 10 years.

3. For therapy providers, payments for multiple therapy services provided on the same day will be reduced by 50% instead of 25% beginning in April.

Check back in with the Jeyaram & Associates blog to learn more about the effects of the new law.

Medical Group Management Association: Governmental/Third Party Payer Forum This Friday

Stop by our booth this Friday, November 9th, at the Medical Group Management Association (MGMA) Governmental/Third Party Payer Forum to learn more about how Jeyaram & Associates can help medical practice managers with issues such as Medicaid and Medicare audits, reimbursement disputes, litigation and appeals and how Jeyaram & Associates can serve as your in-house counsel.

https://m360.gmgma.com/event.aspx?eventID=58989&instance=0

Healthcare Providers Could See an Increase in Centers for Medicare and Medicaid Services Audits

On June 2012, the Department of Justice (DOJ) issued a report from its study of Home and Community Based Services (HCBS) waiver programs.  Seven of 25 states reviewed were found to have systems that were lacking in their ability to provide quality care to waiver program recipients.  In addition, the study found that the Centers for Medicare and Medicaid Services (CMS) did not use all means available to monitor the states’ programs.  As a result, the DOJ recommended that CMS implement additional requirements to ensure quality care.

Going forward, states may see more involvement and oversight on the part of CMS in enforcing compliance with the requirements of the HCBS waiver programs.  The increased attention paid by CMS could mean more site visits, audits, and compliance initiatives aimed at providers.  As with any audit or proposed adverse action, it is always to the provider’s benefit to consult with an experienced healthcare attorney immediately upon receipt of notice of an upcoming audit, audit results or overpayment demand letters.  The attorneys at Jeyaram & Associates have in-depth audit experience and are available for consultation.