Category Archives: Reimbursement

GAO Report – Medicare Program Integrity – CMS Continues Efforts to Strengthen the Screening of Providers and Suppliers

Posted on April 26, 2012 by | Comments Off

On April 10, 2012, the GAO released a report (GAO-12-351) entitled Medicare Program Integrity – CMS Continues to strengthen the Screening of Providers and Suppliers. The report focusses on many of the ongoing Medicare program integrity initiatives that CMS has been implementing and that are required by the Patient Protection and Affordable Care Act (“PPACA”).

The GAO specifically looked at  Medicare provider enrollment procedures. The GAO report focused on: (1) how CMS and its contractors use provider and supplier enrollment information to prevent improper payments and factors that may affect the usefulness of this information, and (2) the extent to which CMS has implemented new provider and supplier enrollment screening procedures since the enactment of PPACA.  Continue reading →

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Posted in Certification, Compliance Programs, DHHS, Fraud and Abuse, Health & Human Services, Health Care, Health Care Providers, Health Reform, Medicare, Participation, Program Integrity, Provider Enrollment - Medicare, Regulatory Compliance, Reimbursement

OIG Report finds that HHAs are largely compliant with Medicare Coverage Requirements

Posted on April 10, 2012 by | Comments Off

In recent years, home health agencies (“HHAs”) have been under a tremendous amount of scrutiny due to perceived concerns involving fraud and abuse. To that end, CMS assigned newly enrolling HHAs to the high-risk screening level in 2011, and the OIG responded by significantly increasing its focus on HHAs, as evidenced by the numerous OIG initiatives targeting HHAs contained within the OIG’s 2012 Work Plan. Many news outlets have also been critical of HHAs, particularly with respect to compliance with Medicare coverage requirements.

In a new report (the “Report”) issued by the OIG in March of 2011, however, the OIG released data which indicates that HHAs are doing a fairly good job in complying with Medicare coverage requirements. Continue reading →

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Posted in Community Based Care, Fraud and Abuse, Health Care, Health Care Providers, Home Health, Medicare, OIG, Participation, Program Integrity, Regulatory Compliance, Reimbursement

OIG Report – Questionable Billing Patterns of Portable X-Ray Suppliers

Posted on January 26, 2012 by | Comments Off

A new report (OEI-12-10-00190) entitled Questionable Billing Patterns of Portable X-Ray Suppliers was issued by the Department of Health and Human Services, Office of the Inspector General (“OIG”). The report concluded that twenty portable x-ray suppliers exhibited questionable billing patterns. The study was conducted as part of the Health Care Fraud Prevention and Enforcement Action Team (“HEAT”) initiative, and is another prime example of the increased scrutiny facing health care providers.

Continue reading →

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Posted in DHHS, Fraud and Abuse, Health Care, Health Care Providers, Long Term Care, Medicare, Nursing Facility, Nursing Home, OIG, Physicians, Post Acute Care, Program Integrity, Regulatory Compliance, Reimbursement, Skilled Nursing Facility

CMS Demonstration Project to Require Prior Authorization for Certain Medical Equipment

Posted on November 22, 2011 by | Comments Off

Begining in January of 2012, a CMS demonstration program will start requiring prior authorization for certain medical equipment before Medicare beneficiaries can recieve the equipment. CMS is initiating a three-year demonstration program as a program integrity initiative in states that CMS believes have higher instances of fraud and error-prone providers. The initial seven states are – CA, FL, IL, MI, NY, NC and TX

The demonstration will be implemented in two phases. During the first phase (the first three to nine months), the Medicare Administrative Contractors will conduct prepayment reviews on certain medical equipment claims. The second phase, for the remainder of the three-year demonstration, will implement prior authorization,  as a mechanism to prevent improper payments and deter the fraudulent provision of items or services. 

A CMS Fact Sheet on this demonstration and other program integrity intiatives can be found here —-> CMS Fact Sheet

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Posted in Durable Medical Equipment, Fraud and Abuse, Health Care, Health Care Providers, Health Insurance, Participation, Payers, Program Integrity, Regulatory Compliance, Reimbursement