One of the lingering questions about the Health Insurance Marketplace created under the Affordable Care Act is whether plans on the Marketplace are considered part of a Federal health care program, thus opening up potential liability under the Anti-Kickback Statute. There was concern that the broad language defining a “Federal health care program” would apply to the Exchanges because of the federal tax subsidizes provided to individuals on the private market. Under 42 U.S.C. 1320a-7b(f)(1), a “Federal health care program” is defined as “any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government.” This presented the possibility that, by virtue of the inclusion of federal subsidy payments, even private insurance plans on the Marketplace and the state Exchanges would constitute Federal health care programs and necessitate compliance with the entire array of federal legal requirements. Continue reading
Medicare Payments for Zombies: OIG reveals that Medicare Advantage payments sometimes outlive beneficiaries
Just in time for Halloween, in a Medicare audit, the Office of the Inspector General of the Department of Health and Human Services has found that $23 million in Medicare expenditures in 2011 were paid inappropriately after the beneficiary had died. The vast majority of these overpayments, 86 percent, flowed from Medicare Part C, also known as Medicare Advantage, a program that allows private insurers to offer managed care plans for Medicare beneficiaries. The average payment for a deceased Part C beneficiary was $1,682.
In the scheme of total Medicare expenditures, these overpayments accounted for only a tiny fraction—less than one-tenth of one percent, according to OIG. Nonetheless, OIG recommended that CMS take actions that would more closely monitor claims made on behalf of beneficiaries after their dates of death, and to ensure that dates of death are properly documented.
The OIG’s press release in this matter may be viewed here: http://oig.hhs.gov/oei/reports/oei-04-12-00130.pdf
Caitlin Monjeau contributed this post.
The New York State Office of the Medicaid Inspector General announced on October 30 that it has recovered the single largest monetary recovery in its history, a sum of $211 million. The repayment stems from an investigation of payments made on behalf of dually-eligible individuals, who are eligible for both Medicaid and Medicare. The overpayments were identified within the Third Party Liability Home Health Care Demonstration Project, which targeted dual-eligible populations who received home health care.
Notably, the audit that led to this recovery was conducted using a sampling technique, rather than an individual, case-by-case analysis of each claim submitted. The audit indicated that in some cases, Medicaid was billed first for services rendered to the beneficiary and then Medicare was billed, rather than the other way around.
The OMIG’s press release in this matter may be viewed here: http://www.omig.ny.gov/latest-news/697-496-million
Caitlin Monjeau contributed this post.
Today, CMS issued a Press Release announcing that it is conducting a demonstration project with New York State known as the Fully Integrated Duals Advantage (FIDA) demonstration. Under this capitated demonstration, approximately 170,000 New Yorkers who are people eligible for Medicaid and Medicare in NYC, Long Island and Westchester County will be able to join a health plan that includes all the benefits of under Medicare (Parts A and B, and Part D) and Medicaid and additional support for care coordination and community living. Those who are eligible can opt in starting in July 2014 for community based individuals and October 2014 for individuals living in nursing homes. Continue reading
At a Managed Care Policy Meeting held last week with managed care plans, New York’s Medicaid Director, Jason Helgerson, spoke about the importance for plans to submit timely and accurate encounter data. He noted that managed long term care plan submissions are particularly late. He indicated that if the lack of reporting continues there is the possibility that Statements of Deficiencies (which can result in halting enrollments) will be issued and that the Department of Health will consider referrals to the OMIG for investigation and audit. The plans responded by explaining that the challenge, in part, is that they are not receiving the required information from the providers (home care, nursing facilities, adult day health care, etc). Continue reading
New York State Governor Andrew Cuomo has made three major appointments to top posts in the state’s health-related agencies. The Governor today announced that he has appointed Courtney Burke as the Deputy Secretary for the New York State Department of Health, Laurie Kelley as the Acting Commissioner of the Office for People with Developmental Disabilities (OPWDD), and Dr. Ann Sullivan as the Acting Commissioner of the Office of Mental Health (OMH). The Governor’s announcement indicated that he intended to nominate both Ms. Kelley and Dr. Sullivan as Commissioners of their respective agencies in the next legislative session.
If confirmed by the Senate, Ms. Kelley would replace Ms. Burke at OPWDD, while Dr. Sullivan would replace Kristin Woodlock, the current Acting Commissioner at OMH. Dr. Sullivan will take over at OMH in November of 2013; beginning at the end of July and until November, John Tauriello, Esq., will serve as Acting Commissioner for OMH.
The Governor’s release may be viewed here: http://www.governor.ny.gov/press/07192013-omh-opwdd-deputy-secretary-appts
The Medicaid Redesign Team (“MRT”) Affordable Housing Work Group has allocated $86 million in 2013-14 to fund various supportive housing initiatives throughout the state. The Notice of Funding Availability is available here. Of this amount, $36.376 million is targeted to expand supportive housing units for high cost Medicaid populations. These funding opportunities can be found on the MRT website, as well as on the HCR and OTDA websites. Continue reading
The Office of Children and Family Services announced that funding is available under the Federal Social Services Block Grant for health and human service providers impacted by Superstorm Sandy. In total, $200,034,600 in federal Superstorm Sandy Social Services Block Grant (Sandy SSBG) funding will be distributed through a solicitation for proposals. Sandy SSBG resources are dedicated to covering necessary expenses resulting from Superstorm Sandy, including social, health and mental health services for individuals, and for repair, renovation and rebuilding of health care facilities, mental hygiene facilities, child care facilities and other social services facilities. Continue reading
The managed care company WellPoint Inc. has reached a Resolution Agreement with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) to settle allegations that it violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules. WellPoint agreed to pay $1.7 million in connection with this settlement. The OCR enforces federal standards governing the privacy of individually identifiable health information, including the standards that cover the security of electronic individually identifiable health information. Continue reading
Following confirmation of Jeffrey Wise as the head of the Justice Center for the Protection of People with Special Needs (“Justice Center”), the Department of Health released a Dear Administrator Letter concerning new requirements that the Justice Center will enforce. The Department has indicated that it will communicate with covered facilities about compliance with the Justice Center’s new rules.
All custodians of people with special needs—which includes directors, operators, employees, volunteers of a facility or provider agency—must read and sign a Code of Conduct, which should have been sent to all affected institutions on June 11, 2013. Each custodian must read and sign the document by June 30, 2013, when they are hired or begin working for the facility, and once a year after that. The facility must retain copies if these signed documents on file.
The Justice Center will staff a 24-hour hot-line to receive reports about the safety of people with special needs. If the Justice Center receives a call, it will then contact the facility involved. If the administrator is not present in the facility, a responsible person must be designated to act on behalf of the operator during the administrator’s absence concerning the health, safety, comfort and well-being of residents. Although it is not clear from the law itself that this designated responsible person is the contact person for the Justice Center, it does seem clear from the DAL that covered facilities should expect that if the Justice Center calls when the administrator is not on site, they will expect a responsible person to know to field the call.
Posters concerning the hot-line were mailed to providers on June 21, 2013, and should be displayed prominently, replacing old Commission on Quality of Care and Advocacy for Persons with Disabilities (CQC) Helpline posters to avoid confusion. The hot-line posters must be displayed by July 1, 2013.