On Monday, August 4, 2014, The Department of Justice announced that Community Health Systems (“CHS”), the nation’s largest operator of acute care hospitals, agreed to pay $98.15 million to settle nine whistleblower lawsuits alleging that the company violated the False Claims Act between January 2005 and December 2010. The whistleblowers alleged that CHS knowingly billed Medicare, Medicaid, and TRICARE for medically unnecessary inpatient admissions rather than the lower outpatient or observation rates at 119 hospitals. Additionally, allegations were made that services were rendered to patients at one of CHS’s hospitals in Laredo, Texas by a physician who was offered a medical directorship in violation of the physician self-referral law, known as the Stark Law.
Under the settlement, CHS entered into a five-year Corporate Integrity Agreement requiring it to retain independent review organizations to review the accuracy of the claims for inpatient services under federal health care programs, and to engage in significant compliance efforts over the next five years.
The allegations against CHS are particularly notable in light of new regulations such as the two-midnight rule, which took effect October 1, 2013. The two-midnight rule requires that physicians deem a patient’s condition as serious enough to require at least two overnight stays in order to qualify for Medicare reimbursement under inpatient rates. Patients who aren’t formally admitted may remain under outpatient or observation status. Emergency and internal medicine physicians often struggle to get the right designation and status for the patient. The federal government has delayed enforcement of the rule until March 31, 2015 at which time hospitals may face financial penalties if auditors determine the hospital could have met the patient’s needs in an outpatient setting.
For more information on the CHS settlement, the two-midnight rule, the Stark Law, the Anti-Kickback Statute, or related fraud and abuse issues, please feel free to contact Daniel Meier or any member of our health care practice group for a further discussion.
You can find a more extensive discussion about the CHS settlement, the impact of observation status on patients and the two-midnight rule in the following Client Bulletin.
Posted in Acute Care, Administration on Aging, Anti-Kickback, Compliance Programs, Corporate Integrity Agreements, DHHS, Fraud and Abuse, Health & Human Services, Health Care, Health Care Providers, Long Term Care, Medicaid, Medicare, Nursing Facility, OIG, Out-Patient Care, Regulatory Compliance, Self-Referral, Settlements, Tennessee
Tagged Admission, Investigation, Observation, Two Midnight Rule
Nursing homes, residential care facilities and county homes (“Homes”) in Ohio will soon have additional requirements related to the admission of a registered sex offender. House Bill 483, the Mid-Biennium Budget Review bill was signed by Governor Kasich on June 16, 2014 with an effective date in September 15, 2014. Rules are required to be written by the Ohio Department of Health (“ODH”) in the future for further guidance. Requirements for the Homes include checking the Ohio sex offender registry before admission of a registered sex offender. Facilities can include questions about a registered sex offender status on their admission applications. The Homes must check the potential resident’s name in the required database to determine if the potential resident is an Ohio registered sex offender. If a registerd sex offender is admitted, a care plan must be devleoped to protect other residents and provide a safe environment free of abuse. Also, the Homes must notify residents and their sponsors of the sex offender’s admission and provide a description of the plan of care for safety. Sex offender registry link: http://www.icrimewatch.net/index.php?AgencyID=55149
Posted in Adult Home, Assisted Living, Group Home, Health Care, Health Care Providers, Intermediate Care Facility, Long Term Care, Nursing Facility, Ohio, Regulatory Compliance, Residential Care, Senior Housing, Skilled Nursing Facility
The second annual Skilled Nursing Facility (“SNF”) Program for Evaluating Patterns and Electronic Reports (“PEPPERs”) are now available to be retrieved via the secure portal at PEPPERresources.org. These reports are accessible to a limited number of high level management personnel within your organization. The Centers for Medicare and Medicaid Services (“CMS”) contracted with TMF Health Quality Institute (“TMF”) for the development, preparation and distribution of the PEPPERs to SNFs, as well as other health care provider types. Continue reading
On April 25, 2014, the Centers for Medicare and Medicaid Services (“CMS”) issued revision 113 to the State Operations Manual (“SOM”) governing skilled nursing and nursing facility survey and enforcement processes. Specifically, CMS updated the SOM Chapter 7 with an effective date of January 1, 2012 as the modifications were mandated by section 6111 of the Affordable Care Act of 2010. The major provisions related to guidance on the independent informal dispute resolution process; escrow of civil money penalty funds pending a formal appeal; a reduction of fifty percent (50%) for facilities that promptly correct self-reported non-compliance and guidance on the use of civil money penalty funds for the state agencies. As of today, the online CMS manual system does not include the updated guidance.
This guidance is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R113SOMA.pdf.
Posted in CMS Transmittals, Health & Human Services, Health Care, Health Care Providers, Long Term Care, Medicare, Nursing Facility, Participation, Regulatory Compliance, Skilled Nursing Facility, Survey and Certification Letters