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
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 Office of the Inspector General (“OIG”) issued a 2014-2018 strategic plan including outlining the visions, goals, and priorities of that office for the upcoming several years. The plan sets forth four goals: 1. Fight fraud, waste and abuse; 2. Promote quality, safety, and value; 3. Secure the future; and 4. Advance excellence and innovation. Each goals is identified with several priority areas that support the stated goal. The report can be found at the OIG’s website http://go.us.gov/WdbV
Posted in Acute Care, Ambulance, Ambulatory Surgery Centers, Anti-Kickback, Assisted Living, Clinical Laboratory, Clinics, Community Based Care, Compliance Programs, Continuing Care, Diagnostic Testing, Disability, Durable Medical Equipment, Fraud and Abuse, General, Health Care, Health Care Providers, Health Care Workers, Health Information Privacy, HIPAA, Home Health, Hospice, Hospital, Intermediate Care Facility, Long Term Care, Long Term Care Hospital, Medicaid, Medicare, Mental Health, Nursing Home, Occupational Therapy, OIG, OIG Reports, OIG Work Plans, Out-Patient Care, Palliative Care, Pharmacy, Physicial Therapy, Physician Assistants, Physicians, Post Acute Care, Primary Care, Regulatory Compliance, Rehabilitation, Rehabilitation Hospital, Residential Care, Senior Housing, Skilled Nursing Facility, Supplier, Transportation
On October 30, 2013, the New York State Office of the Medicaid Inspector General (“OMIG”) issued a press release that New York recovered $211 million from the federal government out of an identified $496 million in Medicaid erroneous payments related to home care recipients who are dually eligible for both Medicare and Medicaid funds. On October 1, 2013, the New York State Department of Health’s Fiscal Group received the $211 million payment through the action of OMIG, which was the largest single monetary recovery in OMIG’s history.
These payments were recovered by New York State as part of a federal project, the Third-Party Liability Home Health Care Demonstration Project, which is reviewing home health care involving dual eligible recipients, and is being conducted in conjunction with the University of Massachusetts Medical School. Continue reading
Posted in DHHS, Health & Human Services, Health Care, Home Health, Long Term Care, Medicaid, Medicare, New York, Nursing Facility, Nursing Home, Participation, Participation, Payers, Reimbursement, Skilled Nursing Facility
Tagged Centers for Medicare and Medicaid Services, CMS, Home Health, Medicaid, Medicare, New York, Nursing Home, OMIG, Skilled Nursing Facility, SNF
The federal government has a wide array of sanctions it can levy against individuals and organizations that run afoul of the laws and regulations governing Medicare, Medicaid, and other federal healthcare programs.
One of its most effective tools is the ability to exclude persons convicted of certain criminal or civil violations from further participation in federal healthcare programs. Protecting your organization from individuals and entities that are excluded is an integral part of the operations of any organization that does business with federal health care programs.
Ari J. Markenson and Kelly Skeat discuss these issues in a recent article in the September issue of the Health Care Compliance Association’s Compliance Today magazine.
A copy of the article can be found here —> Protecting Your Organization From Exclusion Sanctions
Posted in Compliance Programs, Employee Background Checks, Exclusion, Fraud and Abuse, Health Care, Health Care Providers, Medicaid, Medicare, OIG, Payers, Program Integrity, Regulation, Regulatory Compliance
Covert video monitoring of care in long-term care facilities is becoming more and more pervasive. As a result, regulatory citations and investigations that are initiated by covert video monitoring are on the rise.
Janet Feldkamp discusses these issues in a recent article entitled “Cameras, Citations and Abuse Investigations” which appeared in the September 11, 2013 edition of Caring for the Ages.
You can find a copy of Janet’s article here —> Cameras, Citations and Abuse Investigations
Posted in Consumers, Fraud and Abuse, Health Care, Health Care Providers, Health Care Workers, Medicaid, Medicare, Nursing Facility, Nursing Home, Ohio, Patient Privacy, Senior Housing, Skilled Nursing Facility