Archive for the ‘Fraud and Abuse’ Category

Wisconsin Home Health Quality Regulations – HHA Attorney Wisconsin

Tuesday, February 14th, 2017

Wisconsin Home Health Quality Reporting Requirements-  OASIS Data Item Set 

The reporting of quality data by home health agencies (HHAs) is mandated by Section 1895(b)(3)(B)(v)(II) of the Social Security Act (“the Act”).  This statute requires that ‘‘each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this clause.’’

OASIS reporting is mandated in the Medicare regulations at 42 C.F.R.§484.250(a), which requires HHAs to submit OASIS assessments and Home Health Care Consumer Assessment of Healthcare Providers and Systems Survey (HH CAHPS) data to meet the quality reporting requirements of section 1895(b)(3)(B)(v) of the Act.

Home Health Quality Reporting Requirements

OIG Releases Annual Work Plan for 2017

Monday, January 23rd, 2017

OIG Annual Work Plan for 2017 – Topics Covered

The Health and Human services Office of Inspector General (OIG) recently released its 2017 Annual Work Plan.  Work planning is an ongoing project within the OIG.  Every year, the OIG publishes a work plan that consolidates the OIG audits and evaluations that are being conducted or planned within the organization.  The annual work plan has become a source that compliance officers look to as a tool for the identification of potential risk areas or areas of emphasis within their organization.  It is obviously not the only source for identifying compliance risk areas, but is certainly one reliable source that providers can draw on when setting their annual compliance priorities.

The 2017 OIG Work Plan can be download through the OIG site.

Ruder Ware’s health care group will continue to put out blogs and articles on various issues identified in the 2017 Annual Work Plan.  We will focus primarily on issues that were introduced for the first time in this year’s plan.

Employment Exceptions From Anti-kickback Statute

Tuesday, May 20th, 2014

By John Fisher, JD, CHC, CCEP

employment exception safe harbor regulations

How Broad is the Employee Exception 

Parameters of the Stark Law and Anti-kickback Statute Exception

Both the Anti-Kickback Statute and the Stark Law contain exceptions that apply to employer/employee relationships.  Recent developments in the health law area indicate that there may be limits on the employment exception that were not previously contemplated.  I posted an article on the Health Law Blog that discussed possible limited to compensation structures for employed physicians.

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Voluntary Self Disclosure Decisions Can Be Complicated

Tuesday, April 8th, 2014

By John Fisher, JD, CHC, CCEP

OIG Self Disclosure Decisions

Provider Self Disclosure Decisions – Voluntary Disclosure Process

The decision whether or not to voluntarily disclose to the government can be very difficult.  Not every case is clear.

Clearly not every situation where there has been a billing error amounts to fraud or wrongdoing requiring use of the self-disclosure protocol.  Many over-payments that are identified through audit can be dealt with at the intermediary level.  Where investigation raises questions about whether incorrect bills are “knowingly” submitted, the self disclosure process may provide some mitigation of potential loss.  Situations where the provider perhaps “should have known” raise more difficult issues of analysis.

The situation is also complicated because a potential whistle-blower may view a situation much differently than a provider who finds what it believes to be an innocent mistake through the audit process.  A provider may sincerely believe that there was no “wrongdoing” and that a simple mistake has been identified.  Finding such a mistake may actually be evidence that the provider’s compliance efforts are working.  On the other hand, there is a whole legal profession out there now that is advertising for people to come forward with these types of mistakes.  With potential recover under the False Claims Act of 3 times

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Auditing Physician Payments For Stark Law Compliance

Tuesday, April 8th, 2014

By John Fisher, JD, CHC, CCEP

One area of compliance that is often overlooked involves auditing of physician payments.  Physician contracts are often audited to determine whether they comply with a Stark Law exception.  Compliance should also work in the other direction, from payments that are made back to the existence of a contract that memorializes an applicable Stark Law exception.

Periodic monitoring of payments that are made to physicians should be undertaken.  Payments should be tracked to contracts to assure that the payment is covered by an applicable exception.  If there is no corresponding written agreement or if the written agreement has expired, there could be a potential Stark Law violation.  Further examination concerning the nature and purpose of the payment should be made.  If a Stark Law violation is found, self disclosure should be considered.

 

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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)

Power Mobility Devices OIG Annual Work Plan

Tuesday, April 1st, 2014
Power mobility devices—Add-on payment for face-to-face examination

From 2014 PIG Annual Work Plan

Billing and Payments. We will review Medicare Part B payments for PMD to determine whether the Medicare requirements for a face-to-face examination were met. Context—Medicare requires that the treating physician, when prescribing a PMD, conduct a face-to-face examination to determine the medical necessity of the PMD and write a prescription for the PMD. (42 CFR § 410.38(c)(2).) To receive compensation for conducting the face-to-face examination, the prescribing physician can bill for an evaluation and management (E/M) service and has the option of billing Medicare for an add- on payment for the sole purpose of documenting the need for the PMD. Prior OIG work found that when the prescribing physician did not bill the code for the add-on payment in addition to the evaluation and management (E/M) code, the resulting PMD claim was likely to be
unallowable. (OAS; W-00-14-35460; expected issue date: FY 2014; work in progress)

Home Health and Hospice Compliance Focus

Monday, December 16th, 2013

By John Fisher, JD, CHC, CCEP

Home Health and Hospice in the Crosshairs

Governmental Enforcement Actions Against Post Acute Care Providers

Home health agencies and hospices are seeing a rapidly accelerating level of scrutiny by federal and state regulatory agencies.  Post acute providers need to take note of increased enforcement action and examine their level of readiness to undergo audit and review.  These organizations need to brush off their compliance and audit programs and take steps necessary to avoid the disruption and financial exposure that inevitably occurs when the government discovers a problem.

Compliance programs should create a systematic process to identify areas of risk that are specific to the type of provider and the specific nature of their operations.  A good place for providers to begin the risk identification process is to review OIG annual work plans, recent enforcement actions, newly enacted legislation and other external indications of areas of concern to regulators.

HHS officials have publicly stated that home health and hospices are areas of concern.  Sources of increased scrutiny include state survey agencies, CMS program integrity review organizations, the Office of Inspector General, Department of Justice and a variety of other agencies.  Regulators are widely using statistical analysis to identify potential outlier billings that may require further

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