Senate Finance Committee Seeks Feedback on Fighting Fraud & Abuse as They Look at ZPICs


Reposted from email blast received May 2, 2012.
FOR IMMEDIATE RELEASE
May 2, 2012
CONTACT:  Julia Lawless/Antonia Ferrier (Hatch)              (202) 224-4515
                            Communications Office (Baucus)                          (202) 224-4515 

HATCH, BAUCUS LEAD FINANCE COMMITTEE MEMBERS IN BIPARTISAN EFFORT TO COMBAT WASTE, FRAUD, & ABUSE IN
MEDICARE & MEDICAID PROGRAMS
In an open letter to members of the health care community Senators write, “Drawing on the collective wisdom and accumulated insights of thousands of professionals and individual experiences could offer a fresh perspective and potentially identify solutions that may have been overlooked or underutilized.”


WASHINGTON – Today, six members of the Senate Finance Committee, led by Ranking Member Orrin Hatch (R-Utah) and Chairman Max Baucus (D-Mont.), announced a bipartisan effort to begin soliciting ideas from interested stakeholders in the health care community regarding effective solutions to improve federal efforts to combat waste, fraud, and abuse in the Medicare and Medicaid programs. Joining Hatch and Baucus in the effort are:  Senators Tom Coburn (R-Okla.), Ron Wyden (D-Ore.), Chuck Grassley (R-Iowa), and Tom Carper (D-Del.).

In an open letter to members of the health care community, the Senators wrote, “We believe federal efforts would be strengthened by input from members across the health care community – providers, payers, health plans, contractors, non-profit entities, consumers, data analytics entities, governmental partners, and patients. Drawing on the collective wisdom and accumulated insights of thousands of professionals and individual experiences could offer a fresh perspective and potentially identify solutions that may have been overlooked or underutilized.”

This week, the lawmakers invited interested stakeholders to submit white papers offering recommendations and innovative solutions to improve program integrity efforts, strengthen payment reforms, and enhance fraud and abuse enforcement efforts. Submissions are due by June 29, 2012. A summary document highlighting key proposals will be compiled and released later this year.

The Senate Finance Committee has jurisdiction over the Medicare and Medicaid programs.

To view a signed copy of the letter click HERE.

Below is the full text of the letter:

May 2, 2012

To Members of the Health Care Community:

According to the Government Accountability Office (GAO), few programs are as much at risk for fraud, waste and abuse as the Medicare and Medicaid programs.  Estimates of the amount of fraud and misspending in these programs vary widely, from $20 billion to as much as $100 billion. Just this week, testimony before the Senate Finance Committee underscored the seriousness of this problem, as witnesses testified that while much has been accomplished in the fight against fraud and abuse, much more needs to be done.  As Senators and members of the Finance Committee, we have a duty to ensure that taxpayer funds are being spent wisely.

Combating fraud in Medicare and Medicaid has long been a challenge for the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services Inspector General (HHS OIG) and the Department of Justice (DOJ).  To date, numerous efforts have been made to reduce fraud, yielding a mixed record of successes and failures.  We believe federal efforts would be strengthened by input from members across the health care community – providers, payers, health plans, contractors, non-profit entities, consumers, data analytics entities, governmental partners, and patients. Drawing on the collective wisdom and accumulated insights of thousands of professionals and individual experiences could offer a fresh perspective and potentially identify solutions that may have been overlooked or underutilized.

Today we are announcing an effort to solicit ideas from all interested stakeholders in the health care community, regarding solutions and suggestions for how to better prevent and combat the multi-billion dollar problem of waste, fraud and abuse in the Medicare and Medicaid programs.  We invite you to submit white papers offering your best ideas, built on years of experience and insight.  We want to know what areas you see for improvement in current program integrity efforts, as well as additional solutions that we should consider. Working together, we hope to identify innovative solutions that will provide taxpayers with a better return on the investments being made to combat the overpayments in these federal health care programs.

Below are the general categories in which we seek input, though some recommendations may include multiple categories:

&#61623      Program Integrity Reforms to Protect Beneficiaries and Prevent Fraud and Abuse

&#61623      Payment Integrity Reforms to Ensure Accuracy, Efficiency and Value

&#61623      Fraud and Abuse Enforcement Reforms to Ensure Tougher Penalties Against Those Who Commit Fraud

 

Entities interested in submitting white papers should email a PDF or Microsoft Word document to ProgramIntegrityWhitePapers@finance.senate.gov by June 29, 2012.  Submissions should include summary information about the entity or individual submitting a white paper, as well as phone and email contact information. White papers should be as succinct and concrete as possible.  When possible, please include cost-benefit or potential savings information.  Our staff will review submissions and compile a summary document highlighting key proposals later this year.

We appreciate your submission of thoughtful and constructive solutions, as we work to conduct targeted oversight to improve federal efforts to reduce fraud and abuse in Medicare and Medicaid. Together, we believe we can improve program integrity and be better stewards of taxpayer dollars.

Sincerely,

BAUCUS
HATCH
COBURN
WYDEN
GRASSLEY
CARPER

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Date of Death Audits for DME & Inpatient Facilities


Beware, this is just one region that has published the date of death audit for DME and inpatient facilities such as rehab, hospital, LTC, SNF facilities.  This audit is done periodically and most suppliers are hit with a few thousand to upwards of $20K in overpayment refund requests.  Be prepared with a reserve of cash based on the size of your business.  At a minimum, I would suggest a set back of $5K even if you are outside of Region A.  Region A tends to publish this type of information earlier than other areas. These audits typically take place about every three years which is why the dollar amounts are so high.

We all know that payment after date of death will never be paid; however accidents will happen.  Ensure your billing staff doesn’t just “resubmit” claims without working the denial, this can cause a fraud audit even if you are not getting paid!  Likewise, if payment does occur it is usually less than 90 days from date of death when family fail to contact suppliers because they think the equipment belongs to the patient.  It could be a pick up ticket was not entered or a facility span date was not stopped at date of death instead of the full episode.  Note these are being audited by the RAC!

Republished:
NHIC, Corp.
DME MAC A ListServe
For Immediate Release
August 12, 2010

CMS Approved Audit Issues Posted for Region A Recovery Audit Contractor

DCS, the Medicare Recovery Audit Contractor (RAC) for Region A, recently posted new CMS approved audit issues for RAC review.

The new CMS approved audit issues are listed below and apply to the states of Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

* Date of Death – DME
* Date of Death – Inpatient

See the CMS approved audit issues at DCS’ RAC website: http://www.DCSRAC.com for more information.

Region A includes the states of Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

Health Care Reform: Compliance Programs, Reduce Filing Limits, Limited Ownership


The Health Care and Education Reconciliation Act of 2010 signed March 23, 2010, has made significant changes to health care providers and claims filing requirements.  Remember, CMS will have to publish written notification and post implementation deadlines; however, it will make your life easier to start educating staff and changing practice now.

*  Mandatory Effective Compliance Program for ALL health care providers that bill Medicare, Medicaid, and other federally funded program from hospital to mental health and everyone in between.

A compliance program has been required for providers collecting $5 million or more per year in Medicaid funds collectively since 2006.

http://www.cms.gov/smdl/downloads/SMD121306.pdf

New York Office of Inspector General implemented state requirement for effective compliance program 10/1/2009. http://www.omig.state.ny.us/data/content/view/79/1/

An effective compliance program contains 7 elements which includes Compliance Officer, Compliance Committee, Code of Conduct (approx 70 pages), Policies & Procedures (50+ depending on practice), Minimum of 5 hours of training per year on specific relationship and billing topics, Auditing and Monitoring Function, Reporting Options without fear of retaliation, and a few others that are embedded in these items.  It takes at least 12 months to roll out a compliance program and about 18 months to see effectiveness.  As a note, accreditation policies typically do not include most of the elements likewise the audits typically are not coverage criteria based or risk based.

*  Physicians must have a Face to Face with patients prior to ordering DME (durable medical equipment) and HHA (Home Health) Services effective 2/23/10.  This should be taking place now; however, if not, do not wait until CMS publishes an effective date.  This is good business practice and should be implemented immediately.

*  Physicians must be a Medicare provider as of July 1 2010, if they order DME and HHA that will be billed for Medicare reimbursement.

*  Physicians must provider medical record documentation to support referral orders or be subject to a revoked Medicare supplier number for a period not greater than one year **ADDED**

*  Claim submission filing limit has been reduce from 18 months to 12 months.  Until CMS publishes an effective date, you will have 18 months.  Be on the look out.  Announced 5/14/2010

*  Expanded Stark Law regulations will limit physician ownership in hospitals as of 12/31/2010.

*  Must provide patient choice when you have diagnostic equipment in your office such as MRI, PET, CAT.

*  Stark & Anti-kickback violations will also receive penalties until Federal False Claims Act.

*  Overpayments must be refunded to Medicare/Medicaid within 60 days whether you identify the overpayments or the refund is requested.  Failure to do so is likely to result in a revoked provider number and sanction from participating with the Medicare and Medicaid programs.  This was actually part of the Patient Affordable Care Act.  CMS announced 10/15/2010 see also Cynthia Stamer’s Blog.  This announcement also has language on Self Disclosure of Self Referral practices that have taken place.

*  Have heard from several people, that Oxygen will be reduced from 36 months to 13 months.  However, I have searched the full text and amendment and cannot find it. **ADDED**

*  It will require insurance payers to reimburse preventative services at 100% with no co-pay.  Please note, this has not been published with an implementation date so continue to file claims as normal.  Patients cannot expect to receive free preventative services until their payer publishes this change!

*  It appears to me that only companies with 50 or more employees will be required to provide health insurance for all W-2 employees.  I will be interested in seeing how this turns out.   It also appears that in 2018, you will have to use the government health care program or loose tax credits of 25-35% of the premiums.  I wish I had one of this money trees in my back yard!

This covers many of the highlights that impact provider billing, but there are so many more points.  Read over the information so your are prepared.  If you find you need your compliance program reviewed and developed remember to find a consultant that focuses on ALL aspects of compliance not just a compliance program.  They need to understand billing and operations and we are one of the companies that offers an all encompassing solution to health care providers.

You can reference the full text http://www.cbsnews.com/htdocs/pdf/Senate_health_care_bill.pdf and amendments http://www.cbsnews.com/htdocs/pdf/House_reconciliation_package_031810.pdf as well as a blog from Looper, Reed, & McGraw http://www.lrmlaw.com/pdf/ALERT-Healthcare-Reform-Alert.pdf.  Search the document for key words used in bullet points.  I have also included a Timeline link that has many items bullet pointed except the ones that apply to providers and reimbursement for Medicare services http://docs.house.gov/energycommerce/TIMELINE.pdf

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria.  Ms. Miller is very experienced with Medicare & Payer audits.  Ms. Miller ran a very successful compliance program for over 5 years for the largest HME/Pharmacy provider in the US at the time.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back-end collections. You can visit our website at Medical Auditing Solutions LLC.