CMS contracts with Recovery Audit Contractors (“RACs”) to identify Medicare overpayments and underpayments made to health care providers. RACs will issue a demand letter to notify providers of overpayments identified during automated reviews. You can access the letters here: Region A; Region B; and Region C. Region D has not yet posted a sample letter. More information on the issues RACs will review is provided in the August 28 post below titled “Three RACs Posted CMS-Approved Audit Issues in August.”.
von Briesen Health Law Blog
August 31, 2009
August 28, 2009
CMS Issues EMTALA Guidance for H1N1 Flu
CMS recently issued a memo clarifying permissible options under the Emergency Medical Treatment and Labor Act for hospitals handling a surge in patients with H1N1 flu. This guidance was released in response to concerns from hospitals that they may have difficulty complying with the requirements of EMTALA based on projected surges in emergency department volumes.
According to CMS, hospitals may set up alternative screening sites on campus or at off-campus, hospital-controlled sites. Additionally, communities may set up screening clinics at sites not under the control of a hospital. The memo also notes that the law provides for waivers of certain EMTALA requirements in a declared public health emergency.
Click here for further guidance.
Three RACs Posted CMS-Approved Audit Issues in August
The fourth RAC has not yet posted an issues list. Some of the issues are only focused on outpatient services, others for inpatient services, and some for both. More detail on each list and the types of service affected is available at each RAC’s website. Below is a summary for the three RACs.
CGI Federal (Region B): CGI’s list, with more detail, is available here.
- Blood Transfusions
- IV-Hydration
- Bronchoscopy Services
States in Region B: IL, IN, OH, KY, MI, MN, WI. Only IN, MI and MN are currently targeted.
Connolly Healthcare (Region C): CH’s list, with more detail, is available here.
- Clinical Social Worker Services
- Blood Transfusions
- Untimed Codes
- IV-Hydration Therapy
- Bronchoscopy Services
- Once in a Lifetime Procedures
- Pediatric Codes Exceeding Age Parameters
- J2505: Injection, Pegfilgrastim, 6 mg.
States in Region C: AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV. Note: Only FL and SC are currently targeted, depending on the issue.
HealthDataInsights (Region D): HDI’s list, with more detail, is available here.
- Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit
- Once in a Lifetime Procedures
- Excessive Units — Untimed Codes
- Excessive Units — Blood Transfusions
- Excessive Units – Bronchoscopy
- Excessive Units – IV Hydration
- Neulasta (J2505)
States in Region D: AK, AZ, CA, HI, IA, ID, KS, MO, MT, ND, NE, NV, OR, SD, UT, WA, WY. Note: HDI is targeting all states in Region D.
August 24, 2009
Vice President Biden Announces Availability of Nearly $12 Billion in Grants to Help Hospitals and Doctors Use Electronic Health Records
The grants will be awarded under the American Recovery and Reinvestment Act of 2009 (ARRA) and will help health care providers qualify for new incentives that will be made available in 2010 to doctors and hospitals that “meaningfully use” electronic health records. Click here to read the press release. Click here for more information about applying.
To track the progress of HHS activities funded through the ARRA, visit www.hhs.gov/recovery. To track all federal funds provided through the ARRA, visit www.recovery.gov.
August 21, 2009
Provide Comments to Wisconsin DHFS to Improve Medicaid Managed Care Service Delivery
Wisconsin’s Medicaid program has been tasked with generating $625 million in savings over the next two years, to help battle Wisconsin’s $6.6 billion budget deficit for the 2009-2011 biennium. The Wisconsin Department of Health and Family Services convened advisory groups to help identify savings measures and ways to improve the Medicaid health care service delivery. In that effort, the Department is soliciting comments and suggestions to restructure the Medicaid managed care delivery system in southeast Wisconsin, including Milwaukee, Racine, Kenosha, Ozaukee, Washington and Waukesha counties. Comments and suggestions can be made online by clicking here through September 11, 2009.
August 20, 2009
August 19, 2009
HITECH Breach Notification Regulations
The U.S. Department of Health and Human Services (HHS) issued new regulations today that require health care providers, health plans, and other entities covered by the Health Insurance Portability and Accountability Act (HIPAA) to notify individuals when their health information is breached.
The regulations require health care providers and other HIPAA covered entities to promptly notify affected individuals of a breach, and, in cases where a breach affects more than 500 individuals, to notify the HHS Secretary and the media.
August 18, 2009
A Recent OIG Report Examines “Incident to” Services
An August 2009 report by the Office of Inspector General (the “OIG”) revealed the results of a study aimed at identifying the prevalence and qualifications of non-physicians who provide “incident to” services. Physicians bill “incident to” services to Medicare Part B, although such services are provided by non-physicians (e.g. a nurse). Such services are payable by Medicare, provided certain conditions are met (e.g. direct physician supervision). The OIG, which focused on days for which Medicare allowed physicians more than 24 hours of service, found that:
- Non-physicians performed about half of non-invasive services and two-thirds of invasive procedures allowed for physicians on such days (physicians performed the rest);
- Unqualified non-physicians (e.g. lack of requisite licensure or training) performed 21% of the services provided by non-physicians, but allowed by Medicare for physicians, on such days.
Based on its findings, the OIG set forth the following three recommendations in its report:
- Revise the “incident to” rules to require physicians who bill for services they did not perform to ensure that only licensed physicians or qualified non-physicians (e.g. proper training, certification and licensure) personally perform the services;
- Require physicians to use a code modifier when billing for services they did not personally perform to enable CMS to monitor the appropriateness of any non-physicians’ qualifications;
- Take appropriate action to address claims that (i) were billed as “incident to” services but which did not meet the definition for “incident to” services; and (ii) were rehabilitation therapy services performed by non-physicians who lacked the requisite therapist training.
In a letter included with the OIG’s report, CMS agreed with the OIG’s first and third recommendations. CMS noted that it will provide guidance in its manuals for documenting the qualifications of non-physicians who perform “incident to” services. CMS will also instruct Medicare Administrative Contractors to consider the OIG’s report when they prioritize medical review strategies. CMS did not concur with the OIG’s second recommendation, citing operational difficulties for developing a definition for services that are not “personally performed” by a physician. CMS, however, stated that it would consider adding code modifiers for services provided exclusively by staff other than the physician identified as the rendering provider.
The OIG’s study was based on data from 2007 and the report may be accessed here.
August 17, 2009
FTC Issues Final Rule on PHR Security Breaches
The Federal Trade Commission published its final rule requiring vendors of web-based personal health records to notify consumers when security of their information has been breached. Impacted vendors include many that do not have to comply with HIPAA, such as occupational health vendors that host employee health records and vendors who sell devices that include an option to upload data to a personal record. The rule can be found on the FTC web site.
August 11, 2009
OIG Advisory Opinion Approves Free Blood Pressure Screenings
In an Advisory Opinion posted on August 10, the OIG said a hospital could provide free blood pressure screenings to walk-in visitors at the hospital without the threat of sanctions under certain circumstances.
The Opinion centered around an arrangement whereby a small critical access hospital provides free blood pressure checks to any visitor who enters requesting the service during daylight hours. The hospital does not advertise the free screening, and it is not conditioned on the visitor’s use of any other goods or services from the hospital or any other particular health care provider. Hospital staff responds to abnormal blood pressure readings obtained during a free check by advising the visitor to see his or her own health care professional.
In issuing its Opinion, the OIG found the arrangement met the preventive care exception of the Anti-Kickback Statute, which allows for the provision of a free non-covered screening as long as the screening is not tied to the provision of other hospital-provided services reimbursed in whole or in part by Medicare or an applicable state health care program.
The Opinion also reiterated previous guidance, which stated that similar arrangements that also involve the scheduling of appointments with hospital providers, discounting of additional covered services, or promotion of its programs may violate the prohibition on beneficiary inducements.
Providers contemplating similar screening services should carefully review and structure such arrangements to avoid improper ties to the provision of other services.