OIG Issues Report on Limited Compliance with Medicare’s Face-to-Face Requirement for Home Health Services

On April 9, 2014, the US Department of Health and Human Services Office of the Inspector General’s (OIG) Office of Evaluation and Inspections (OEI) issued a report (OEI-01-12-00390) entitled “Limited Compliance With Medicare’s Home Health Face to Face Documentation Requirements.”

The Center for Medicare and Medicaid Services (“CMS”) requires physicians to physically see and evaluate patients for home health services. The Patient Protection and Affordable Care Act requires the physicians to document this face-to-face visit as a condition of payment. The face-to-face requirement was implemented to help prevent fraud in home health. The idea is that requiring physicians to document the specifics of a face-to-face visit with a Medicare beneficiary will help prevent fraud by ensuring the physician actually saw and assessed the beneficiary before certifying the patient as eligible for home health services. Continue reading

N.Y. Budget Includes Private Equity Healthcare Pilot Project

New York ‘s 2014-2015 budget legislation opens the door for a two-year pilot program allowing private equity firms to own and operate healthcare facilities in the state. The proposed plan would allow for the participation of up to five for-profit corporations with affiliations with at least one academic medical center or teaching hospital, while publicly traded entities and private corporations with more than thirty-five stockholders would be prohibited from participating. The move would represent a shift away from the state’s traditional regulations, which have created a system where almost all hospitals have been operated by non-profit entities.

HHS DAB Upholds Revocation of Clinic’s Medicare Provider Number

On February 20, 2014, the US Department of Health and Human Services, Departmental Appeals Board upheld CMS’ revocation of the Medicare provider number of a clinic/group practice.

In Advanced Care Medical Center v CMS (Docket No. C-13-1383/Decision No. CR3124), the DAB, Civil Remedies Division upheld CMS’ revocation of Advanced Care’s Medicare provider number.

The matter began with an investigation by the Office of the Inspector General which revealed that Advanced Care entered into a contract with a doctor, allowing him to bill for services under it’s billing number in exchange for a set reimbursement, and the doctor submitted bills under Petitioner’s billing number.   Continue reading

OIG 2014 Work Plan – Hospice

This article represents another installment of a series of articles that will outline the OIG’s activities, as discussed in the 2014 work plan, for a specific industry sector – hospice.

For 2014, the OIG’s activities relating to hospices are focused on the provision of hospice services in assisted living facilities, and quality of care.

Hospice in Assisted Living Facilities

Pursuant to the Affordable Care Act, CMS is required to reform the hospice payment system, collect data relevant to revising hospice payments, and develop quality measures for hospices. Hospice care is currently provided in a variety of settings, including private residences, skilled nursing facilities, and assisted living facilities. Continue reading

OIG 2014 Work Plan – Skilled Nursing Facilities

Recently, the Department of Health and Human Services Office of the Inspector General (the “OIG”) released its work plan for 2014. The work plan provides stakeholders in the health care industry with a broad overview of the OIG’s activities in the coming year as they relate to its enforcement priorities and issues it will review and evaluate during the year. This article is one in a series of articles that will outline the OIG’s activities, as discussed in the 2014 work plan, for a specific industry sector – skilled nursing facilities.

For 2014, the OIG’s activities relating to skilled nursing facilities are focused on billing and payments and quality of care. Continue reading

Long Island Radiology Group Settles FCA Allegations That It Billed Medicaid And Medicare For Unnecessary Tests For $15.5M

A company operating diagnostic testing facilities in New York has agreed to pay $13.65 million to the federal government and $1.85 million to New York and New Jersey for a total of $15.5 million in penalties to settle claims it falsely billed federal and state health care programs for tests that were not performed or not medically necessary and for paying kickbacks to physicians. The company denies liability for the allegations that are part of the settlement.

The settlement resolves allegations that between 1999 and 2010 the radiology group submitted false claims to Medicare and state Medicaid programs in New Jersey and New York for Three Dimensional reconstructions of CT scans that, according to the complaint, were medically unnecessary, were not ordered by the treating physicians, and in some cases were never actually performed or interpreted.  These scans are often used in orthopedic, cardiovascular and neurologic imaging, including to visualize complex fractures, tumors in the lungs or soft tissues, and cardiac issues.  In addition, the group allegedly submitted false billings for expensive imaging services, including retroperitoneal ultrasounds, Doppler scans, transrectal ultrasounds and pelvic x-rays.  These imaging services allegedly resulted in a total of more than 40,000 false claims made to the New York Medicaid program. Continue reading

The UPMC – Highmark Dispute: The Beginning of the End of Medical Practices Using Hospitals’ Managed Care Contract Rates?

Recent trends across the country have health systems buying out private physician practices and reclassifying them as hospital-outpatient departments.  There are a number of motivations behind these transactions, the greatest being managed care contracting.  Typically, the physician practice will reassign its Medicare NPI Number to the Hospital and the Hospital will then bill exclusively under that NPI number.  The Hospital will also submit claims to the third party payor and receive payments based on the hospital’s negotiated contract rates and fee schedule.

Critics, including a number of insurers, have claimed that this practice allows the hospital to bill higher rates for the same service at the same location.  For this reason, on February 26, 2014, Highmark, a  Blue Cross Blue Shield company based in Pittsburgh, stated that it would stop reimbursing health systems at higher hospital-outpatient rates for cancer treatment performed in physician offices.  Highmark explained that this move would save patients’ money by reducing out-of-pocket costs for deductibles and co-insurance. Continue reading