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
Posted in Acute Care, Anti-Kickback, Compliance Programs, Corporate Integrity Agreements, DHHS, Diagnostic Testing, Florida, Fraud and Abuse, General, Health & Human Services, Health Care, Health Care Providers, Medicaid, Medicare, New Jersey, New York, OIG, Physicians, Reimbursement, Self-Referral, Settlements
Tagged Ancillary Arrangements, False Claims Act, Medical Necessity, Radiology, Stark
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
Posted in Acute Care, DHHS, Health Care, Health Care Providers, Hospital, Integration, Medicaid, Medicare, New Jersey, New York, Pennsylvania, Physicians, Post Acute Care, Reimbursement
Tagged Cancer Centers, Managed Care Companies, Managed Care Contracting, Unwinding
Many senior care employers are losing sleep over healthcare reform, reimbursement cuts and changing consumer preferences. Balancing cost, compliance and competitive pressures with the quest to provide high quality care has put an increased focus on the workforce. What does quality staffing look like in 2014? A free McKnight’s webcast will sort through facts and myths to help providers better understand what they should be doing to keep themselves at the quality forefront. The featured speaker will be Janet K. Feldkamp, a partner with Benesch Friedlander Coplan & Aronoff. The event begins at 1 p.m. (Eastern Time).
To learn more or sign up for the free event, which is being sponsored by OnShift, click here.
If you have any questions concerning this topic please do not hesitate to contact a member of the Health Care Practice Group.
Janet K. Feldkamp at firstname.lastname@example.org or 614.223.9328
On February 4, 2014, the Centers for Medicare and Medicaid Services (CMS) issued in the Federal Register a notice of temporary moratoria on enrollment of new home health agencies (HHA) and ambulance suppliers and providers in certain geographic locations across the U.S. The moratoria were effective on January 30, 2014. CMS also extended existing moratoria noticed on July 31, 2013. Continue reading
Posted in Ambulance, Certification, Community Based Care, Florida, Fraud and Abuse, General, Health & Human Services, Health Care, Health Care Providers, Home Health, Illinois, Medicaid, Medicare, Michigan, New Jersey, Participation, Post Acute Care, Program Integrity, Provider Enrollment - Medicaid, Provider Enrollment - Medicare, Regulation, States, Texas, Transportation
The OIG recently made available its 2014 Work Plan. The Plan identifies OIG focus areas and priority projects for the coming year. This post provides a brief summary of many of the new OIG projects for fiscal year 2014 to assist providers in keeping abreast of the latest developments in health care fraud and abuse, compliance, reimbursement, and enforcement activities. Only a small part of the Plan is summarized here. For the entire document, please follow the link below. Continue reading
Posted in Acute Care, Community Based Care, Compliance Programs, Continuing Care, Durable Medical Equipment, Fraud and Abuse, Health Care, Health Care Providers, Hospice, Hospital, OIG, OIG Work Plans, Palliative Care
Ordinarily, the donation of Electronic Health Record (EHR) technology, services or training to a provider would raise fraud and abuse concerns and potentially implicate the Stark law and Anti-kickback Statute. In order to encourage the use of EHR technology, in August of 2006, CMS and OIG published companion rules creating an exception to the Stark law and a safe harbor for the Anti-kickback Statute that protects arrangements involving the provision of EHR technology, services, and training to providers. The rules were scheduled to expire on December 31, 2013.
A recent CMS news release reported that Affordable Care Act reforms are leading to lower hospital readmission rates for Medicare beneficiaries. Hospital readmission can be an indicator of poor care coordination or low-quality care. Readmission are also costly—CMS reports spending $17.8 billion a year on avoidable readmissions.