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Regulations Update

Medicare Fraud Strike Force Charges 91 Individuals for Approximately $430 Million in False Billing
Published on line 10/04/2012
Medicare Fraud Strike Force operations in seven cities have led to charges against 91 individuals – including doctors, nurses and other licensed medical professionals – for their alleged participation in Medicare fraud schemes involving approximately $429.2 million in false billing. More than 500 law enforcement agents from the FBI, HHS-OIG, multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies participated in the takedown.

Dozens of charged individuals were arrested or surrendered in the last 24 hours as indictments were unsealed across the country.   Together, those indictments charge more than $230 million in home health care fraud; more than $100 million in mental health care fraud and more than $49 million in ambulance transportation fraud; and millions more in other frauds.

HHS also suspended or took other administrative action against 30 health care providers following a data-driven analysis and based upon credible allegations of fraud.  Under the Affordable Care Act, HHS is able to suspend payments until the resolution of an investigation.

The defendants charged are accused of various health care fraud-related crimes, including conspiracy to commit health care fraud, health care fraud, violations of the anti-kickback statutes and money laundering.   The charges are based on a variety of alleged fraud schemes involving various medical treatments and services such as home health care, mental health services, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and ambulance services.  

The cases announced today are being prosecuted and investigated by Medicare Fraud Strike Force teams comprising attorneys from the Fraud Section of the Justice Department’s Criminal Division and from the U.S. Attorneys’ Offices for the Southern District of Florida, the Southern District of Texas, the Northern District of Texas, the Central District of California, the Middle District of Louisiana, the Northern District of Illinois, and the Eastern District of New York, and agents from the FBI, HHS-OIG and state Medicaid Fraud Control Units, with assistance from the Justice Department’s Civil Division and the IRS.

To read the entire article, please click on Medicare Strike Force

To learn more about HEAT, go to: www.stopmedicarefraud.gov

Additionally - In a two minute segment, Inspector General Daniel R. Levinson speaks at the October 4, 2012 press conference on the Medicare Fraud Strike Force operations in seven cities that led to charges against 91 individuals - including doctors, nurses and other licensed medical professionals - for their alleged participation in Medicare fraud schemes involving approximately $429.2 million in false billing. To listen to the press conference, please click on Inspector General

HHS & DOJ Highlight Health Reform Tools to Combat Medicare Fraud
Published on line 04/10/2012
The Health Human Services Secretary and the Attorney General hosted the Seventh Regional Health Care Fraud Prevention Summit on April 4, 2012. At this Chicago summit highlighting a new high-tech war against healthcare fraud, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder discussed how the Affordable Care Act and the Obama Administration’s Health Care Fraud Prevention and Enforcement Action Team (HEAT) are helping fight Medicare fraud.

The regional summits bring together a wide array of public and private partners, and are part of the HEAT partnership between HHS and the Department of Justice (DOJ) to prevent and combat healthcare fraud. The Obama Administration’s HEAT efforts have resulted in record-breaking healthcare fraud recoveries. In FY2011, for the second year in a row, the departments’ anti-fraud activities resulted in more than $4 billion in recoveries, an all-time high.

New tools provided by the Affordable Care Act are strengthening the Obama Administration’s efforts to fight healthcare fraud. As a result of Affordable Care Act provisions:

  • Criminals face tougher sentences for healthcare fraud, 20-50 percent longer for crimes that involve more than $1 million in losses

  • Contractors that police the Medicare program for waste, fraud, and abuse will expand their work to Medicaid, Medicare Advantage, and Medicare Part D programs

  • Government entities, including states, CMS, and law enforcement partners at the Office of the Inspector General (OIG) and DOJ, have greater abilities to work together and share information so that CMS can prevent money from going to bad actors by using its authority to suspend payments to providers and suppliers engaged in suspected fraudulent activity

On April 4, 2012, the Obama Administration also announced more progress from its anti-fraud efforts, beyond the nearly $4.1 billion recovered last year:

  • In the early phase of revalidating the enrollment of providers in Medicare, 234 providers were removed from the program because they were deceased, debarred, or excluded by other federal agencies, or were found to be in false storefronts or otherwise invalid business locations

  • In 2011, HHS revoked 4850 Medicaid providers and suppliers and deactivated 56,733 Medicare providers and suppliers as HHS took steps to close vulnerabilities in the Medicare program

  • In 2011, HHS saved $208 million through pre-payment edits that stop implausible claims before they’re paid

  • Prosecutions are up:the number of individuals charged with fraud increased from 797 in FY2008 to 1430 in FY2011 – nearly a 75 percent increase

  • In the first few weeks of enhanced site visits required under the Affordable Care Act screening requirements, HHS found 15 providers and suppliers whose business locations were non-operational and terminated their billing privileges

  • Through outreach and engagement efforts, more than 49,000 complaints of fraud from seniors and people with disabilities reported to 1-800-MEDICARE were referred for further evaluation

  • A recent redesign of the quarterly Medicare Summary Notices received by Medicare beneficiaries makes it easier to spot and report fraud

To read the entire press release, please click on Medicare Fraud

Merging of NCCI Edits for Mutually Exclusive Services
Published on line 03/19/2012
Since 1996 the Medicare NCCI procedure to procedure edits have been assigned to either the Column One/Column Two Correct Coding edit file or the Mutually Exclusive edit file based on the criterion for each edit.  The Mutually Exclusive edit file included edits where two procedures could not be performed at the same patient encounter because the two procedures were mutually exclusive based on anatomic, temporal, or gender considerations.  All other edits were assigned to the Column One/Column Two Correct Coding edit file.  There are important upcoming changes to these files described below. 

In order to simplify the use of NCCI edit files, CMS will consolidate the two edit files into the Column One/Column Two Correct Coding edit file.  Separate consolidations will occur for the two practitioner NCCI edit files and the two NCCI edit files used for OCE.  This change will occur for practitioner NCCI edits in NCCI version 18.1 scheduled for April 1, 2012.  After these changes occur, it will only be necessary to search the Column One/Column Two Correct Coding edit file for active or previously deleted edits.  Effective April 1, 2012, CMS will no longer publish a Mutually Exclusive edit file on its website for either practitioner or outpatient hospital services since all active and deleted edits will appear in the single Column One/Column Two Correct Coding edit file on each website.  The edits previously contained in the Mutually Exclusive edit file are NOT being deleted but are being moved to the Column One/Column Two Correct Coding edit file. 

Practitioner NCCI - In NCCI version 18.1 for practitioners scheduled for April 1, 2012, all edits in the Mutually Exclusive edit file will be moved to the Column One/Column Two Correct Coding edit file with the same implementation and, if relevant, deletion date as the edits have in the mutually exclusive edit file.  These edits are not being deleted from NCCI but are being moved to the Column One/Column Two Correct Coding edit file.  The net result will be that the NCCI version 18.1 Column One/Column Two Correct Coding edit file will contain all active NCCI edits and deleted NCCI edits that previously were contained in the Mutually Exclusive and Column One/Column Two Correct Coding edit files.  The CMS website will have a single Column One/Column Two Correct Coding edit file for practitioner NCCI.

Outpatient NCCI used in OCE - Effective April 1, 2012 the change will be implemented on the CMS website where a single Column One/Column Two Correct Coding edit file will appear which will contain all active NCCI edits and deleted NCCI edits that previously were contained in the OPPS Mutually Exclusive and Column One/Column Two Correct Coding edit files.  These edits are not being deleted from the OCE NCCI files but are being moved to the Column One/Column Two Correct Coding edit file. 


Extension of HIPAA 5010 Transaction Standards
Published on line 03/16/2012
On March 15, 2012 the Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services (OESS) announced that it will not initiate enforcement action for an additional three (3) months, through June 30, 2012, against any covered entity that is required to comply with the updated transactions standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA): ASC X12 Version 5010 and NCPDP Versions D.0 and 3.0.

Health plans, clearinghouses, providers, and software vendors have been making steady progress: the Medicare Fee-for-Service (FFS) program is currently reporting successful receipt and processing of over 70 percent of all Part A claims and over 90 percent of all Part B claims in the Version 5010 format. Commercial plans are reporting similar numbers. State Medicaid agencies are showing progress as well, and some have made a full transition to Version 5010.

Given that OESS will not initiate enforcement actions through June 30, 2012, industry is urged to collaborate more closely on appropriate strategies to resolve remaining problems. OESS is stepping up its existing outreach to include more technical assistance for covered entities. OESS is also partnering with several industry groups as well as Medicare FFS and Medicaid to expand technical assistance opportunities and eliminate remaining barriers. Details will be provided in a separate communication.

The Medicare FFS program will continue to host separate provider calls to address outstanding issues related to Medicare programs and systems. The Medicare Administrative Contractors (MAC) will continue to work closely with clearinghouses, billing vendors, or healthcare providers requiring assistance in submitting and receiving Version 5010 compliant transactions.

The Medicaid program staff at CMS will continue to work with individual States regarding their program readiness. Issues related to implementation problems with the States may be sent to Medicaid5010@cms.hhs.gov.

OESS strongly encourages industry to come together in a collaborative, unified way to identify and resolve all outstanding issues that are impacting full compliance, and looks forward to seeing extensive engagement in the technical assistance initiative to be launched over the next few weeks.

To access the official CMS announcement, please click on 5010 Delay

Fraud Prevention Efforts Result In Record-Breaking Recoveries
Published on line 02/17/2012
On February 14, Attorney General Eric Holder and HHS Secretary Kathleen Sebelius released a new report showing that the government’s healthcare fraud prevention and enforcement efforts recovered nearly $4.1 billion in taxpayer dollars in FY2011. This is the highest annual amount ever recovered from individuals and companies who attempted to defraud seniors and taxpayers or who sought payments to which they were not entitled.

These findings, in the annual Health Care Fraud and Abuse Control Program (HCFAC) report, are a result of President Obama making the elimination of fraud, waste, and abuse a top priority in his administration. The success of this joint Department of Justice and HHS effort would not have been possible without the Health Care Fraud Prevention & Enforcement Action Team (HEAT), created in 2009 to prevent fraud, waste, and abuse in the Medicare and Medicaid programs, and to crack down on the fraud perpetrators who are abusing the system and costing American taxpayers billions of dollars.

The departments also continued their successes in civil healthcare fraud enforcement during FY2011. Approximately $2.4 billion was recovered through civil healthcare fraud cases brought under the False Claims Act (FCA). This marked the second year in a row that more than $2 billion has been recovered in FCA healthcare matters and, since January 2009, the department has used the FCA to recover more than $6.6 billion in federal healthcare dollars.

The HCFAC annual report can be found at http://oig.HHS.gov/publications/hcfac.asp. More information on the fraud prevention accomplishments under the Affordable Care Act can be found at http://www.Healthcare.gov/news/factsheets/2012/02/medicare-fraud02142012a.html.

The full text of this excerpted HHS press release (issued Tue Feb 14) can be found at http://www.HHS.gov/news/press/2012pres/02/20120214a.html.

Medicare Quarterly Provider Compliance Newsletter
Published on line 01/30/2012
The Medicare Learning Network® (MLN) has developed a new educational tool, the Medicare Quarterly Provider Compliance Newsletter, to advise physicians, suppliers, and other FFS providers about how to avoid common billing errors and other erroneous activities when dealing with the Medicare Program.  The newsletter will be issued on a quarterly basis and highlight the “top” issues of that particular quarter as identified through a variety of sources.  In this first edition, a number of issues that impact a variety of provider types are presented in order to introduce the newsletter to a wide audience of providers. 

To view all of the current and previous newsletters, please click on CMS Provider Compliance

Supervising Physicians in Teaching Settings
CMS revised the Medicare Claims Processing Manual to clarify the documentation requirements for evaluation and management (E/M) services billed by teaching physicians. This information is located in the Claims Processing Manual - 100-04,Chapter 12,  section 100 of the Medicare Internet-Only Manuals.  The revised language makes it clear that for E/M services, teaching physicians need not repeat documentation already provided by a resident. In addition, the revisions clarify policies for services involving students and other issues and updated regulatory references. 

To access the manual, please click on Claims Processing Manual, Chapter 12


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