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Compliance National & Local News |
The
Office of Inspector General and other government agencies continue
to actively investigate areas of reported non-compliance. Being
aware of government auditing trends is beneficial in determining
areas for the OU Billing Compliance Office to focus on during
in-house audits. The findings of government investigations are
published on-line for public viewing.
AAMC Urges Ban on Medical Giveaways
Published on line 05/01/08
The Association of American Medical Colleges (AAMC) has proposed a ban on drug and device companies offering free food, gifts, travel and ghost-writing services in all 129 of the nation's medical colleges, This proposed ban is the result of a two-year effort by the AAMC, to create a model policy governing interactions between the medical schools and industry.
Rob Restuccia, executive director of the Prescription Project, a nonprofit group dedicated to eliminating conflicts of interest in medicine, said the report would transform medical education. "Most medical schools do not have strong conflict-of-interest policies, and this report will change that," Mr. Restuccia said.
Drug companies spend billions in wooing doctors - more than they spend on research or consumer advertising. Medical schools, packed with prominent professors and impressionable trainees, are particularly attractive marketing targets. So companies have for decades provided faculty and students with free food and gifts, offered lucrative consulting arrangements to top-notch teachers and even ghost-wrote research papers for busy professors.
Such forms of industry involvement tend to establish reciprocal relationships that can inject bias, distort decision-making and create the perception among colleagues, students, trainees and the public that practitioners are being 'bought' or 'bribed' by the industry, according to the AAMC report. A group of influential doctors decried these practices in a 2006 article in The Journal of the American Medical Association, and said that medical schools should put bans on the industry. In the wake of the article, the AAMC created a task force to review the matter. The report from the task force stated in addition to the gift, food, and travel bans, medical schools should "strongly discourage participation by their faculty in industry-sponsored speakers' bureaus," in which doctors are paid to promote drug and device benefits. t is recommended that schools set up centralized systems for accepting free drug samples or "alternative ways to manage pharmaceutical sample distribution that do not carry the risks to professionalism with which current practices are associated."
But this year's graduating class of doctors at the University of Pittsburgh School of Medicine will not be allowed to accept any gifts and the daily pizza lunches brought by drug companies are gone as well, said Dr. Arthur S. Levine, dean of Pittsburgh School of Medicine. Dr. Levine said when he graduated from the medical school in 1964, Eli Lilly gave him his first doctor's bag. Roche gave him an Omega watch for being valedictorian and he still has the watch.
However, not all in the medical industry have the same opinion as the AAMC. Ken Johnson of the Pharmaceutical Research and Manufactures of America has taken a different view. "Providing physicians - and medical students - with timely, accurate information about the medicines they prescribe clearly benefits patients and advances healthcare throughout the United States," said Mr. Johnson. He also stated his group would review the report. Dr. Vagelos, formerly of Merck, said that the report's recommendations were certain to face resistance among faculty who liked the present system. "The outcome of this for the industry is that those companies that are strong in science will always be welcome at medical colleges and others won't," Dr. Vagelos said.
To access the AAMC task force report, please click on Industry Funding of Medical Education
Psychiatrist to Pay $1.1M to Settle False Claims Case
Published on line 04/03/08
A consent judgment was entered against a Cleveland psychiatrist in the amount of $1.1 million to resolve claims against her in a joint lawsuit brought by the United States and the State of Tennessee in January 2007.
A Cleveland psychiatrist submitted more than 6,000 false claims to Medicare and the Tennessee Medicaid (TennCare) programs according to a Department of Justice (DOJ). The claims were for violations of the federal False Claims Act and the Tennessee Medicaid False Claims Act during 2000 to 2005 which resulted in a lose of $267,253 to the Medicaid program
The psychiatrist submitted false billing to Medicare and Medicaid for services under two separate codes under her name when the services were performed by a nurse who did not have the required psychiatric training. She also billed for over 200 separate days for face-to-face time-based psychotherapy services she did not perform. Also the complaint stated that on a number of days the psychiatrist claimed to have performed time-based services well in excess of 24 hours.
The psychiatrist was, previously charged with certain criminal violations involving false billing for psychiatric services performed by her nurse, pled guilty in United States District Court and was sentenced on July 7, 2006, to two years probation and ordered to pay restitution of $3775 and a $5000 fine for the federal criminal conviction. As a result of the criminal conviction, the psychiatrist has been excluded from participating in the Medicare and Medicaid programs. To access the complete report from the Department of Justice, please click on Cleveland Psychiatrist.
CEO Sentenced for Upcoding
Published online 04/04/08
The former CEO of a medical clinic in Plainview, Texas, was sentenced to 30 months in prison and pay $370,657 in restitution for upcoding claims submitted to Medicare, Medicaid, and private insurance companies stated the U.S. Attorney's Office for the Northern District of Texas. The former CEO admitted that from January 2002 through August 2005, she caused upcoded and improperly coded claims and diagnosis codes to be submitted to Medicaid, Medicare, and private insurers in order to receive higher payments than what was authorized.
Even though she knew that only medical providers were authorized to make diagnoses and determine the level of patient visits for payment purposes, the CEO personally changed bills submitted by the providers. She also taught her billing staff to routinely change the bills by submitting claims for visits that were marked at higher levels than the ones indicated by the providers and by adding diagnoses and procedures to the claims.
As a result of her actions, health care payors, including Medicare, Medicaid, and commercial insurance companies, paid the medical clinic $370,657 for fraudulent billing. Subsequently, from her actions, the medical clinic is now in bankruptcy. The CEO must surrender to the Bureau of Prisons on April 18, 2008 to start serving her sentence.
U.S. Department of Justice Hits County Hospital for Improper Physician Referrals
Published online 04/04/08
The U.S. Department of Justice announced that a county hospital in Texas has agreed to pay the U.S. a total of $398,230.56 to resolve allegations that it violated the civil False Claims Act. The hospital allegedly violated the Act by submitting improper claims for payment to the Medicare program for health care items and services provided to patients as a result of improper physician referrals. The US DOJ concluded the hospital was paid substantial sums by the Medicare program for health care items and services referred to the hospital by a physician who had received free rental of office space by the hospital. As part of the settlement, the hospital entered into a three-year Corporate Integrity Agreement (CIA) with the Office of Inspector General. The CIA requires the hospital to adhere to certain policies and procedures to ensure compliance with applicable statues and regulations that govern the use of federal health care funds.
Kickback Inquiry in the Orthopedic Device Industry Now Focuses on Doctors
Published online 04/04/08
A long running federal investigation into the orthopedic device industry's suspected kickback payments to hip and knee surgeons now has the doctors in the spotlight. Settlements have been reached with the five leading makers of artificial joints last year over the payments, the government has been focusing on the many doctors who received money as the companies' paid consultants.
The government has not argued that any of the kickbacks led to unnecessary knee or hip surgery or maltreatment of nay patients. Nor has it established a direct link to higher Medicare costs. Switching a patient from one company's device to another would not change the amount Medicare pays hospitals for an implant. But kickbacks might raise the overall cost of health care. Doctors can be convicted of violating Medicare's antifraud statutes simply for submitting a bill for a procedure linked to a kickback, whether or not the procedure was necessary.
Each company site posted a deferred prosecution agreement which details their involvement with the investigation. In addition to paying fines totaling $310 million collectively, all five companies were required to disclose on their web sites cash payments last year to each doctor or medical group they dealt with, as well as the compensations paid each doctor or medical group in the form of plane tickets, lodging, food, and gifts.
The government investigators have appointed monitors, overseers whom the companies pay monthly retainers plus up to $895 an hour, screen every payment the companies make to doctors who help with training or with developing new products. The settlements also set a $500-an-hour ceiling for most consulting agreements. The companies must operate for 18 months under stricter federal scrutiny to avoid prosecution.
CMS Identifies $371.5 Million In Improper Medicare Payments
Published online 03-03-2008
The Centers for Medicare & Medicaid Services (CMS) announced that $371.5 million in improper Medicare payments has been collected from or repaid to health care providers and suppliers as part of a demonstration program using recovery audit contractors (RACs) in California, Florida and New York in 2007. Nearly $440 million has been collected since the program began in 2005.
The RAC demonstration program, created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), is designed to find and correct improper Medicare payments paid to health care providers participating in fee-for-service Medicare. Medicare processes more than 1.2 billion Medicare claims annually, submitted by more than one million health care providers, including hospitals, skilled nursing facilities, physicians and medical equipment suppliers. Errors in claims submitted by these health care providers for services provided to Medicare beneficiaries can account for billions of dollars in improper payments each year.
Implementation of the RAC program has been guided by reports from the Department of Health and Human Services Office of Inspector General and the Government Accountability Office. Based on the recommendations included in these reports and experience gained from their work conducting audits of Medicaid and the private sector health care claims, in 2007, the RACs in the three-state pilot returned a total of $247 million to the Medicare Trust Funds after taking into account the dollars repaid to health care providers, the money overturned on appeal and the costs of operating the RAC demonstration program.
Similar to what was found through the CERT program, most of the improper payments that the RACs identified occurred when health care providers submitted claims that did not comply with Medicare’s coverage or coding rules. More than 85 percent of the overpayments collected by RACs and almost all underpayments refunded by the RACs were from claims submitted by inpatient hospitals.
The RAC demonstration was authorized in the MMA by Congress and was required to be a permanent part of Medicare in the Tax Relief and Healthcare Act of 2006. CMS will enter into new contracts as the national program is implemented before January 1, 2010.
The RAC expansion schedule for Oklahoma is set for October 2008. To view the schedule, please click on Map
To view the entire article, please click on Press Release
For more information on the program, please click on RAC Program
To view the FY 2007 Status Document, please click on RAC Status 2007
Trailblazer Audit Template for E/M
Published online 2/19/08
As you know, Trailblazer will become our Part A and Part B Medicare carrier on March 1, 2008. Available on the Trailblazer Medicare web site is the audit form they use to audit E/M services. The Billing Compliance office has been comparing the form to the other more well known E/M forms as noted above. The Trailblazer form has several significant differences specifically in the history section and the medical decision making section. Thus a question was posed to Trailblazer during a recent audio conference regarding the differences.
Dr. Debra Patterson, Medical Director for Trailblazer Medicare, discussed the issues we had. Dr. Patterson stated E/M services topped the list of problems seen by their auditors with an error rate two to three times higher than other services. Therefore, E/M services were reviewed more frequently. One issue addressed was history of present illness (HPI) elements and review of system (ROS) elements could not be counted twice, i.e. in each section of the history. This would count as double dipping to the Trailblazer auditor. So a fever mentioned in the HPI, for example, could not be counted again as a constitutional finding under the ROS section.
Also discussed was the verbiage "all other [systems] negative" in the ROS section. Dr. Patterson stated this was not acceptable to their auditors and no credit would be given for such a notation in the documentation. She stated the negative systems should be documented as well as the positive systems in order to achieve a complete 10 ROS. Dr. Patterson stated while CMS may have left this issue vague in the guidelines, Trailblazer has not.
Our office will continue to address this issue with Trailblazer for further clarification. The goal is to know exactly what is expected of us by Trailblazer as they become our Medicare carrier due to the closure of the Oklahoma City office. We will pass along any additional information to our faculty and staff.
Trailblazer has a computer based training module on E/M services. Users can log on and review the module at their convenience. To access the training, please click on Comprehensive E/M CBT. Also is the audit form used by Trailblazer Medicare. This form can be accessed by clicking on Audit Sheet. To view documentation related to Trailblazer teleconferences and J4 conversion, please click on Publications.
OIG Workplan FY 2008 Update
Published online 11-19-2007
The Office of Inspector General (OIG) workplan for fiscal year 2008 lists the targeted areas to be investigated. Some of the focus reviews will be:
- E/M Services During Global Surgery Periods
- "Incident To" Services
- Psychiatric Services
- Pain Management Procedures
- Place of Service Errors
- Assignment Rules for Medicare Providers
To access the complete report, please click on Workplan 2008.
Stryker Corp. & Associates Hit for False Claims to Federal Health Care Programs
Published online 11-19-07
Stryker Corporation and it's former outpatient therapy division, Physiotherapy Associates, Inc., have agreed to pay $16.6 million to settle allegations of false claims to Medicare and other federal health care programs, as announced by the Justice Department on November 14, 2007.
The investigation stemmed from two qui tams, or whistleblower suits filed against Stryker and Physiotherapy by former employees. The settlement resolved allegations that Physiotherapy submitted claims for services to Medicare, Medicaid, and Tricare for falsely billed as one-on-one services and improperly retained excess or duplicate payments it received from federal health care programs. The resolution of these two cases was achieved by the Justice Department's Civil Division, Commercial Litigation Branch, and the U.S. Attorney's Offices for the District of Massachusetts and the Western District of Tennessee.
"Submitting false claims to our nation's health care programs is tantamount to stealing from the American taxpayer," said Peter D. Keisler, Assistant Attorney General for the Civil Division. "Today's settlement sends a strong signal that the government aggressively pursues those who engage in such conduct and makes them pay a steep price for their misdeeds."
"The settlement is a reflection of our office's commitment to protecting the integrity of the Medicare system," said Michael J. Sullivan, U.S. Attorney for the District of Massachusetts. "The conduct in this case, which included billing for services not covered, and retaining overpayment from federal health care programs, is unacceptable."
"The case underscores the commitment of this office to vigorously investigate and prosecute qui tam suits, said David F. Kustoff, U.S. Attorney for the Western District of Tennessee. "The amount paid to settle this litigation should serve as a deterrent to other health care providers who seek to defraud federal health care programs."
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Alva Physician Convicted Under False Claims Act
Published online 12-6-07
An Alva physician has been convicted of both criminal and civil Medicare fraud under the false claims act. The physician is now serving a 33-month federal prison term after pleading guilty in the billing scheme. In addition to the prison sentence, the physician was ordered to pay $473,881 in restitution to Medicare and $69,685 in restitution to Blue Cross/Blue Shield of Oklahoma under the criminal case.
In addition to the criminal conviction, the physician was hit with a $1.5 million civil judgment against him which was the result of a whistleblower case brought by a former employee. The employee stated the physician overbilled Medicare for the administration of the drugs Procrit and Remicade from 2000 to 2005. The employee said the physician altered billing forms to cover the charges to Medicare. Those charges were for the administration of 19.75 million units of Procrit but no more than 7.4 million units of the drug were ordered from suppliers. In addition to the Procrit, the physician billed for 112,110 milligrams of Remicade but ordered no more than 49,600 milligrams from the suppliers.
As part of the guilty plea in the criminal case, the physician surrendered his medical license with the understanding that if the license is later restored, he will be forever excluded from future Medicare billing.
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