On May 12th, the Office of the Inspector General of the Department of Health and Human Services (OIG) issued a proposed rule which would amend the federal civil monetary penalty (CMP) regulations addressing new CMP authorities created under the Affordable Care Act. The revised regulations would allow for civil penalties, assessments, and exclusion from Medicare for :
- Failure to grant OIG timely access to records;
- ordering or prescribing while excluded;
- making false statements, omissions, or misrepresentations in an enrollment application;
- failure to report and return an overpayment; and
- making or using a false record or statement that is material to a false or fraudulent claim.
Comments on the proposed regulations can be submitted up until July 11, 2014. The proposed rule and instructions for submitting comments can be viewed here—> Proposed CMP Regulatory Revisions
For more information on the revisions to the CMP regulations, Fraud and Abuse, Compliance, Medicare Program Integrity initiatives or related issues, please feel free to contact Ari Markenson or any member of our health care practice group for a further discussion.
Posted in Civil Monetary Penalty, Compliance Programs, Fraud and Abuse, Health Care, Health Care Providers, Medicaid, Medicare, OIG, Program Integrity, Proposed Rule, Regulation, Regulatory Compliance
In a recently released MLN Matters (Number: SE1417), CMS announced that it is implementing the enhanced enrollment screening provisions of the Affordable Care Act (ACA) by requiring finger print based background checks for certain so called “high risk” providers. Currently this means that for newly enrolling Durable Medical Equipment, Prosthetic, Orthotic and Supplies (DMEPOS) suppliers and Home Health Agencies, individuals with a 5% or greater ownership interest in the provider or supplier will be subject to criminal background checks based on fingerprint identification. The procedure will also apply to providers that CMS has elevated to the high risk category pursuant to regulations. Affected providers will be notified by their MAC and be given 30 days to comply. The notification will identify contact information for the Fingerprint Based Background Check Contractor (FBBC). Continue reading
Posted in Community Based Care, Compliance Programs, Durable Medical Equipment, Employee Background Checks, Fraud and Abuse, General, Health & Human Services, Health Care, Health Care Providers, Health Reform, Home Health, Medicare, MLN Matters, Participation, Program Integrity, Provider Enrollment - Medicare, Regulation, Regulatory Compliance
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
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
Posted in Certification, Community Based Care, Compliance Programs, DAB Decisions, DHHS, Fraud and Abuse, Health & Human Services, Health Care, Health Care Providers, Medicare, Out-Patient Care, Participation, Physicians, Program Integrity, Provider Enrollment - Medicare, Regulatory Compliance
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
Posted in DHHS, Fraud and Abuse, Health Care, Health Care Providers, Long Term Care, Medicaid, Medicare, Nursing Facility, Nursing Home, OIG, OIG Work Plans, Post Acute Care, Program Integrity, Skilled Nursing Facility
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
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