Archive for the ‘Compliance Issues’ Category

Chiropractic Services oig work plan 2014

Tuesday, April 1st, 2014

Chiropractic Billing and Payments

OIG Annual Work Plan 2014


We will compile the results of prior OIG audits, evaluations, and investigations of chiropractic services paid by Medicare to identify trends in payment, compliance, and fraud vulnerabilities and offer recommendations to improve detected vulnerabilities. Context—Prior OIG work identified inappropriate payments for chiropractic services that were medically unnecessary, were not documented in accordance with Medicare requirements, or were fraudulent. Medicare does not pay for items or services that are “not reasonable an d necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” (Social Security Act, § 1862(a)(1)(A).) Part B pays only for a chiropractor’s manual manipulation of the spine to correct a subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment. (42 CFR § 410.21(b).) CMS’s Medicare Benefit Policy Manual, Pub. No. 100- 02, ch. 15, § 30.5, states that chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable. Further, § 240.1.2 of the Manual establishes Medicare requirements for documenting chiropractic services. This planned portfolio document will offer new recommendations to improve Medicare chiropractic vulnerabilities detected in prior OIG work. (OAS; OIG-12-14-03; expected issue date: FY 2014; work in progress)
Chiropractic services—Part B payments for noncovered services
Billing and Payments. We will review Medicare Part B payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements. Context—Prior OIG work identified inappropriate payments for chiropractic services furnished during calendar year (CY) 2006. Subsequent OIG work (CY 2013) also identified unallowable Medicare payments for chiropractic services. Part B pays only for a chiropractor’s manual manipulation of the spine to correct a subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment. (42 CFR § 410.21(b).) Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable. (CMS’s Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15, § 30.5B.) Medicare will not pay for items or services that are “not reasonable and necessary.” (Social Security Act, § 1862(a)(1)(A).) (OAS; W-00-12-35606; W-00-13-35606; various reviews; expected issue date: FY 2014; work in progress)
hiropractic services—Questionable billing and maintenance therapy (new)
Billing and Payments. We will determine the extent of questionable billing for chiropractic services. We will also identify trends suggestive of maintenance therapy billing. Context—Previous OIG work has demonstrated a history of vulnerabilities relative to inappropriate payments for chiropractic services, including recent work that identified a chiropractor with a 93-percent claim error rate and inappropriate Medicare payments of about $700,000. Although chiropractors may submit claims for any number of services, Medicare reimburses claims only for manual manipulations or treatment of subluxations of the spine that provides “a reasonable expectation of recovery or improvement of function.” Moreover, Medicare does not reimburse for chiropractic maintenance therapy. (CMS’s Medicare Benefit Policy Manual, Pub. No. 100 02, ch. 15, § 30.5B.) (OEI; 01-14-00200; expected issue date: FY 2015, work in progress)

New Physician Assistant Supervision Requirements Effective March 1

Tuesday, March 11th, 2014

Wisconsin MEB Changes PA Supervision Requirements

The Wisconsin Medical Examining Board (MEB) recently approved several changes impacting physician supervision of physician assistants (PAs) in Wisconsin. These revisions are reflected in the Wisconsin Administrative Code Med 8 (Med 8) and became effective March 1, 2014. It is important that physicians be aware of the changes and the impact the revisions may have on their practice.

Here’s an overview of the key changes:

Supervising Physician to Ratio
A supervising physician may now simultaneously supervise four, rather than two, on-duty PAs. There is no limit to the number of PAs that a physician can supervise over time, and a PA may be supervised by more than one physician while on duty. A physician may still request authorization from the MEB to supervise additional PAs.

PA Prescribing
PA prescribing is simplified under Med 8. A PA may prescribe orders for drugs provided the PA’s prescriptive practices are initially reviewed, and at least annually reviewed after the initial review, by a supervising physician. Reviews must be documented and signed by the supervising physician, and the PA must be available to the MEB upon request.

Identifying the Supervising Physicians
Med 8 adds the requirement that the supervising physician must be readily identifiable by the PA. The rule does not require a specific manner of documentation—just that it is being documented.

Substitute Supervising Physicians
Substitute supervising physicians no longer need to be reported to the MEB.

On-Site Visit and Review of PA Practice Locations
A supervising physician is no longer required to make a monthly visit and on-site review of each facility where the PA practices.

The full text of Med 8 is available online. Physicians who supervise PAs should be conscious of the new requirements and adjust their practices accordingly to ensure compliance.

Payment Suspension Fraud and Abuse – End To Pay and Chase

Monday, May 27th, 2013

Payment Suspension – Moving Away from Pay and Chase

CMS now has the authority to suspend further payments to a provider following receipt of any “credible allegation of fraud.”  Allegations are deemed to be credible when they have an “indication of reliability.”  The allegation can come from a number of possible sources such as employee complaints, whistleblower claims, provider audits, false claims allegations, or virtually any other source as long as CMS deems the allegation to be credible.  The suspension of payment may last up to eighteen (18) months or longer if a referral is made for further administrative action.

Suspension of payment is an extremely draconic remedy which can threaten the financial existence of some providers.  The remedy is available even before there is solid proof that fraud has been committed.  The possibility of having payment suspended is yet another reason for providers of all types to adopt sensible, scaled compliance programs.  An effective compliance program is the provider’s best proactive defense to the potentially devastating impact of having payment suspended.

Overpayment Demands and Collections CMS Medicare Overpayment

Friday, March 22nd, 2013

CMS Overpayment Demands and Collections Matters

The Affordable Care Act affirmatively requires a health care provider who has received an overpayment to return such amount within 60 days after it has been identified. Returning an overpayment past the 60 day notice period becomes a violation of the Federal False Claim Act. An “overpayment” includes any amount that a person returns or receives under Medicare of Medicaid that is not entitled.

The normal procedure that is followed by CMS is to recoup overpayments against future payments that are due to the provider. If CMS initiates the process, it will normally start with the issuance of a demand letter. Outstanding overpayment obligations may be referred to the Department of Treasury for collection following written notice to the provider. In some cases, private collection firms might also be used.

Providers can often work out extended repayment plans with private collection agencies, treasury, or directly with CMS. There are also opportunities to compromise some overpayment claims.

There is no statute of limitation for recoupment or offset of claims. There is a 6-year statute of limitations on affirmative actions to collect on overpayment.

In some cases, providers can be liable for the overpayment liabilities of entities that the purchase under the theory of successor liability. Medicare does not change a high rate of interest on overpayments that remain outstanding.

When Does HIPAA Override State Medical Privacy Laws

Thursday, March 14th, 2013

HIPAA Preemption of State Law

The HIPAA Privacy Rule provides a Federal floor of privacy protections for individuals’ individually identifiable health information where that information is held by a covered entity or by a business associate of the covered entity. State laws that are contrary to the Privacy Rule are preempted by the Federal requirements, unless a specific exception applies. These exceptions include if the State law:

  • relates to the privacy of individually identifiable health information and provides greater privacy protections or privacy rights with respect to such information
  • provides for the reporting of disease or injury, child abuse, birth, or death, or for public health surveillance, investigation, or intervention, or
  • requires certain health plan reporting, such as for management or financial audits. In these circumstances, a covered entity is not required to comply with a contrary provision of the Privacy Rule.

Additional areas that permit State law to have an exception from the Federal preemption rules can be created by formal request from the State if certain requirements are met.  The Department of Health and Human Services (HHS) may, following request from a State, determine that a provision of State law which is “contrary” to the Federal requirements – as defined by the HIPAA Administrative Simplification Rules – and which meets certain additional criteria, will not be preempted by the Federal requirements. The Secretary of HHS must determine that one of the following criteria apply before granting and exception from the HIPAA preemption rules. These criteria require a showing that the state law at issue:

  1.  is necessary to prevent fraud and abuse related to the provision of or payment for health care,
  2. is necessary to ensure appropriate State regulation of insurance and health plans to the extent expressly authorized by statute or regulation,
  3. is necessary for State reporting on health care delivery or costs,
  4. is necessary for purposes of serving a compelling public health, safety, or welfare need, and, if a Privacy Rule provision is at issue, if the Secretary determines that the intrusion into privacy is warranted when balanced against the need to be served; or
  5. has as its principal purpose the regulation of the manufacture, registration, distribution, dispensing, or other control of any controlled substances (as defined in 21 U.S.C. 802), or that is deemed a controlled substance by State law.

Only State laws that are “contrary” to the Federal requirements are eligible for an exemption determination. In order to be considered “contrary”  it must be impossible for a covered entity to comply with both the State and Federal requirements, or that the provision of State law is an obstacle to accomplishing the full purposes and objectives of the Administrative Simplification provisions of HIPAA.

Mandatory Compliance Programs For Nursing Facilities

Sunday, February 17th, 2013

Nursing Facilities Are The First to Require Compliance Programs

The Patient Protection and Affordable Care Act of 2010 (PPACA) mandates compliance programs for most providers and requires the Secretary of Health and Human Services to publish regulations that establish the core elements for compliance programs.

Nursing facilities are the first providers to be mandated and must comply in 2013. However, CMS missed its statutory deadline of March 23, 2012 for issuing detailed regulations for nursing facility compliance programs. It is expected that these regulations and the requirements for other providers will be forthcoming now that the Supreme Court has opened the way for enforcement.  In the meantime, nursing facilities do not have precise guidance on compliance program requirements. 

Even though final detailed regulations have not been issued, providers should not wait to step up their compliance efforts.  There are many sources for guidance on how compliance should operate.  Providers will be required to certify that their compliance programs are effective in preventing and detecting criminal, civil, and administrative violations and in promoting quality of care.  Simply having a program in place is not enough.  The program must have sufficient operating history to demonstrate that it is “effective.”  Effectiveness reviews should be periodically performed to support the required certifications.

Effective Dental Practice Compliance Cycles

Saturday, February 2nd, 2013

Establishing Effective Dental Practice Compliance Cycles

Dental practices normally focus their compliance efforts on regulations of the Occupational Safety & Health Administration (OSHA) and the Health Information and Portability Act of 1996 (HIPAA).  Until recently, dental practices have avoided many of the fraud and abuse enforcement activities that have been directed toward medical practices.  The environment for dental practices is beginning to change and we are seeing more governmental auditors and private contractors turn more attention toward review of dental claims.

Penalties for failure to follow billing rules can be very significant; particularly when a governmental health program is the reimbursement source.  For example, failure to return overpayments to a governmental program within 60-days following identification can result in liability of three times the amount of the overpayment, plus up to $11,000 per claim.  When discovery of an overpayment leads to other incorrectly submitted claims due to a systematic billing error, the penalties add up quickly.  Errors that are not discovered by the provider but could have been discovered through an “effective” compliance program will be deemed to have been “identified” and subject to penalty if discovered by a governmental or private auditor on review.

Because of the increased enforcement efforts, dental practices are beginning to recognize the need to establish systematic compliance programs that extend beyond the usual OSHA and HIPAA issues.  The Medicare Office of Inspector General has recognized that dental practices need to establish systematic compliance programs that include identification of potential legal risk areas and systematic audits of high risk areas.  “Off the shelf” form policies will not be  adequate to create a compliance program that is “effective” and in fact will often create additional risk.  Every clinic is unique and a “one-size-fits all” plan will not likely meet the government’s standards for “effectiveness.”


Using “form” policies may give you a sense of security, but shortcut the important step of going through the institutional process of identifying risk areas and creating compliance cycles that are unique to your specific organization.  A compliance program must be viewed much more as a process that must be continually operated rather than a set of policies.  It is important to create a “compliance cycle” which involves a continued process of risk identification, auditing and monitoring, training of personnel, corrective actions and appropriate plan revisions.  Attempting to shortcut the process necessary to create an organic compliance cycle will not result in an “effective” program and will not likely withstand governmental scrutiny.

John H. Fisher, CHC, CCEP is a healthcare attorney with Ruder Ware in Wausau, Wisconsin.  John is certified in healthcare compliance by the Health Care Compliance Association.  He is also certified in corporate compliance and ethics by the Society for Corporate Compliance and Ethics.  John is an active blogger on healthcare and compliance issues at