Reimbursement

A recent report by the Office of Inspector General for the Department of Health and Human Services (OIG) concluded that in Fiscal Year 2010, 61% of Medicare providers that appealed CMS payment decisions were fully successful in their respective appeal.  In other words, these providers persuaded the Administrative Law Judge (ALJ) handling the appeal to completely overturn previous adverse payment decisions made by CMS and its contractors.  Notably, of the 61% of providers that were successful, those appealing Part A and B claims had the most success, 67% and 59% respectively.

The Medicare overpayment appeal process consists of four levels.  At the first level of appeal, which is available after an initial overpayment determination, the individual or entity (appellant) appeals the overpayment decision to CMS’s Medicare Administrative Contractor.  If the appellant is unsuccessful, the next appeal is administered by CMS’s Qualified Independent Contractor (QIC).  The third level of appeal is administered by the ALJ, and the fourth level is administered by the Medicare Appeals Council.  OIG’s report contrasted the high success rate at the ALJ level to the low 20% success rate at the QIC level.  While there are many reasons for the difference, OIG’s report found that the main reason is that ALJs tend to view Medicare’s reimbursement and coverage policies less strictly than CMS’s contractors.  OIG also found that CMS participated in only 10% of all ALJ appeals, which resulted in the ALJ overturning CMS’s decision in 60% of these cases.

The heads of both the Department of Justice (DOJ) and Department of Health and Human Services (HHS) sent a joint letter on Monday, September 24, to five hospital industry groups, including the American Hospital Association, threatening to prosecute providers that use electronic health records (EHR) to “game” the system and improperly obtain federal monies for…

In less than two weeks, CMS will begin reducing a hospital’s Medicare reimbursements by as much as 1% if the hospital’s readmission rates are too high.  This reduction is part of a program authorized by the Affordable Care Act called the Hospital Readmissions Reduction Program.  You can read more about the program CMS’s website.

Nearly 1…

In August, the Office of Inspector General (OIG) of the U. S. Department of Health and Human Services released a report describing inappropriate and questionable billing by home health agencies.  The OIG conducted the study because recent investigations and studies showed that home health agencies are vulnerable to fraud, abuse, and waste.  The OIG identified inappropriate claims by examining claims data from home health, inpatient hospital, and skilled nursing facilities.  The OIG also looked at HHAs that billed unusually high amounts according to at least one of its six measures of questionable billing.  The report determined that Medicare inappropriately paid $5M for home health claims with three specific errors in 2010.  To read the report, click here.

Attorney Elizabeth Hogue prepared a concise, helpful summary of the report as follows:

The OIG issued Report OEI-04-11-00240 in August, 2012, entitled “Inappropriate and Questionable Billing by Medicare Home Health Agencies.” Unlike some other guidance published the OIG, this Report provides detailed information about inappropriate and questionable billing practices by home health agencies (HHA’s). Specifically, the OIG concluded that HHA billing is questionable or unusually high on the six measures below, if greater than the 75th percentile plus 1.5 times the interquartile range. The six measures are as follows:

 1. High average outlier payment amounts per beneficiary

According to the OIG, HHA’s with outlier payments above $403 per beneficiary have unusually high outlier payments and are likely engaging in questionable billing practices.

Earlier this month, the US Dept. of Health and Human Services Office of inspector General (OIG) issued a report regarding suspicious billing practices by community mental health clinics (CMHCS).  OIG scrutiny of CMHCs, particularly with respect to partial hospitalization programs (PHPs), is probably not a surprise to those in the Texas mental health provider community…

A client recently asked me to review its fall policies and procedures as they relate to the standard of care.   Because that project was on my mind, the new training modules for nurse aides in long term care that were recently published by the Agency for Healthcare Research and Quality (AHRQ) caught my eye.  The three published modules are:

  1. Module 1: Detecting Change in a Resident’s Condition
  2. Module 2: Communicating Change in a Resident’s Condition; and
  3. Module 3: Falls Prevention and Management

Each module has an instructor’s guide and a student workbook that includes training materials, summaries and “Pearls and Pitfalls” to help staff become more aware of residents’ needs.   For example, the module on falls includes a mnemonic checklist “HEAR ME” to help prevent falls in the facility:

  • Hazards in the environment.
  • Educate residents.
  • Anticipate residents’ needs.
  • Round frequently.
  • Materials and equipment.
  • Exercises and ambulation.

Module 1 notes that the elderly do not exhibit the same signs and symptoms of illness that are seen in younger persons.  Therefore, identification of subtle changes can alert staff to a serious illness.  The AHRQ notes the top 12 changes in residents are:

A.  Physical Changes: Walking; Urination and bowel patterns; Skin; Level of weakness; Falls; and Vital signs.

B.   Non- Physical Signs: Demeanor, Appetite, Sleeping, Speech, Confusion or agitation, complaints of pain.

Our Insight. Your Advantage.   Much of the material will not be new to many providers.  However, use of the training modules developed, and following the steps advocated, by the AHRQ will provide strong evidence that the provider’s care was within the standard of care.   Long term care facilities that incorporate the AHRQ’s training standards into their care will be ahead of the game in number of areas such as:

  1. Regulatory compliance;
  2. Limiting exposure to civil malpractice;
  3. Reimbursement matters.

HHS and DOJ today announced that Federal law enforcement is teaming up with private insurance organizations in the fight against health care fraud.  While the details of how this partnership will work are unclear, the press releases issued by both DOJ and HHS indicate that the private and public sectors will share information with each other…

As many may already know, CMS is transiting most Texas providers from Trailblazer to Novitas Solutions, Inc. (Novitas) as part of the MAC JH transition.  With this transition, Novitas requires new Electronic Funds Transfer (EFT) form (CMS-588) be completed and submitted for ALL practices and providers.  A notice should arrive to the providers during the…

On July 10, 2012, two members of the Husch Blackwell Healthcare Group, Kate Mihalevich and Cori Turner, presented a webinar on ACO strategic physician alignment billing compliance.  The webinar:

  • highlighted compliance risks associated with ACOs and other physician alignment models; and
  • provided practical suggestions for evaluating and addressing risk in these areas.

To watch…