Tag Archives: Medicare

The Trouble with RACs

It seems the United States House of Representatives has taken aim at Medicare Recovery Audit Contractors (“RACs”). The RACs are private, non-governmental entities that are authorized by the Medicare program to conduct audits of Medicare providers and suppliers.

In December, 2013, the Office of Medicaid Hearings and Appeals (“OMHA”) sent a letter to providers with “a significant number of Medicare appeals currently pending” informing them that OMHA had temporarily suspended all Medicare claim and entitlement appeals “due to the rapid and overwhelming increase in claim appeals.” At the end of 2013, the number of appeal requests had grown to approximately 15,000 per week. The goal of the suspension was to “allow OMHA to adjudicate appeals involving almost 357,000 claims for Medicare services and entitlements already assigned to its 65 Administrative Law Judges.” The current wait time for a hearing to review the results of a RAC audit with an Administrative Law Judge is over two years. Continue reading

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Filed under Medicare

Attention Medicaid and Medicare Providers: US DOJ Sues Providers for Failing to Return Overpayments Within 60 Days

On June 27, 2014, in the case of United States ex rel. Kane v. Healthfirst, Inc., et al., No. 11-2325 (S.D.N.Y.), the United States Department of Justice (USDOJ), via the United States Attorney’s Office for the Southern District of New York, sued several Medicaid providers under the federal False Claims Act for failing to return Medicaid overpayments within 60 days of identifying them. Continue reading

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Filed under False Claims Act, Federal Case Updates, Fraud and Abuse, Medicaid, Medicaid Fraud, Medicare, Medicare Fraud

HHS OIG 2010 Medicare Audit: $6.7 Billion Misspent for Evaluation and Management Services

The United States Department of Health and Human Services Office of the Inspector General (“OIG”) has completed its audit of 2010 Medicare payments for Evaluation and Management (“E/M”) services. The audit report, available at  https://oig.hhs.gov/oei/reports/oei-04-10-00181.asp, states that the Medicare program overpaid providers $6.7 billion for E/M services that were incorrectly coded or lacked documentation in 2010. The claims error rate was 55% and the dollar value of the overpayments represented 21% of Medicare payments for E/M services that year.  The OIG audit found that 42% of claims for E/M services were incorrectly coded (upcoded, billed at a higher level than appropriate, and downcoded, billed at a lower level than appropriate) and 19% were lacking documentation. This equates to 61% of E/M services being incorrectly billed and/or documented in 2010.  Continue reading

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Filed under Medicare, Medicare Fraud

OMIG Posts Assisted Living Program Audit Protocols

The New York State Office of the Medicaid Inspector General (OMIG) has released its final audit protocols for Assisted Living Programs (ALPs). These protocols became effective November 22, 2013 and are the OMIG’s audit tool that they will use when conducting their audits of ALPs.  The protocols contain 22 areas of potential disallowances based upon various documentation requirements and timelines.

The protocols explain what will constitute an error to the OMIG and lead to the OMIG attempting to recoup money previously paid for Medicaid claims.  These protocols provide the best source of information as to what the OMIG will be looking for during an ALP audit, as well as what criteria ALP providers should be auditing themselves against. Click here to view the protocols. 

This post was written by David R. Ross, Shareholder of O’Connell and Aronowitz. Mr. Ross presented, along with Medicaid Inspector General James Cox, on OMIG ALP audits at the NYSHFA/NYSCAL Fall Conference last year in Troy, New York.

Mr. Ross served as General Counsel and Director of Audits and Investigations at the OMIG and was also the Acting Medicaid Inspector General under Governors Pataki and Spitzer. Please contact Mr. Ross for more information at dross@oalaw.com

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Filed under Long Term Care, Medicaid, New York State Agencies, NY Office of Medicaid Inspector General

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.

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Filed under Medicare

OMIG Highlights Errors in Home Health Payments

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.

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Filed under Medicaid, Medicare, NY Office of Medicaid Inspector General

New York and CMS Announce Partnership to Coordinate Care for Medicare-Medicaid Dual Enrollees

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

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Filed under Long Term Care, Medicaid, Medicare, Nursing Homes

Proposed Rule to Extend and Amend the Exception to Donate Electronic Health Records Items and Services

The Office of Inspector General for the Department of Health and Human Services (OIG) and the Centers for Medicare and Medicaid Services (CMS) published on April 10, 2013 proposed rules to extend and amend the Electronic Health Records (EHR) donation exceptions under the Anti-Kickback Statute and Stark Law, respectively.

The proposed rules would extend the exceptions until the end of 2016, but both the OIG and CMS are seeking comments on extending the sunset date to December 31, 2021, which corresponds to the end of the EHR Medicaid incentives program.  Under the current law, both exceptions are set to sunset on December 31, 2013 .

In addition, the OIG and CMS propose to amend the conditions of the EHR donation exceptions by removing the electronic prescribing requirement and redefining (i.e. limiting) the type of entities that can donate.   The current EHR donation exceptions permit donations by any individual or entity that provides patients with health care items or services covered by a Federal health care program, based on a public policy initiative to expedite adoption and use of EHR systems.  The proposed rules would remove, among other entities, clinical laboratories and pharmacies from the definition of a protected donor.

Finally, the OIG and CMS propose to address a critical issue identified as “data and referral lock-in,” in which EHR technology that appears to support the interoperable exchange of information on its face, in practice restricts the recipient provider to transmit data and communicate only with the donor entity to control referrals.  In response, the OIG and CMS propose to require that the donated EHR software is certified in accordance with the definition of Certified EHR Technology applicable on the date of the donation. Under the current law, both exceptions require only that the EHR software is interoperable.

Comments on the proposed rules will be accepted for 61 days from the date of publication, which is June 10, 2013.

This post is contributed by Charles Dunham.

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Filed under Anti-Kickback Statute, Electronic Health Records, False Claims Act, Fraud and Abuse, Laboratories, Medicaid, Medicaid Fraud, Medicare Fraud, Stark Law

Quest’s Competitors File Lawsuit for Prohibited Arrangements with National Health Plans

Over the past several years, some commercial insurers have made a concerted effort to reduce costs associated with laboratory services, which physicians have increasingly relied upon in diagnosing and treating patients. In particular, insurers are concerned with the rise in laboratory services being performed out-of-network and the increased costs associated with such claims. Despite the imposition of higher premiums for out-of-network benefits, insurers are attempting to do indirectly – what they cannot do directly – to restrict the ability of health plan members to receive laboratory services from out-of-network providers.

A federal complaint was filed on November 14, 2012, in the Northern District of California that highlights the extent of such activities alleged to have been taken by Aetna, Inc., Blue Shield of California, and Blue Cross and Blue Shield Association in violation of federal and state law, and charges that such efforts are being initiated in concert with Quest Diagnostics Incorporated, the largest clinical laboratory provider in the nation. Rheumatology Diagnostics Lab., Inc. et al v. Blue Shield of Cal. Life & Health Ins. Co. et al, Case No. 12-5847 (November 14, 2012).

In short the complaint alleges that Aetna and Blue Shield, in order to receive capitated rate discounts on laboratory services, have conspired with Quest to direct all laboratory testing business to Quest by controlling referrals and reducing competition by the following: Continue reading

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Filed under Uncategorized

CMS Issues Section 1135 Waivers for New York and New Jersey

The Centers for Medicare and Medicaid Services (CMS) approved waivers for New York and New Jersey under Section 1135 of the Social Security Act.  The waivers ease certain legal requirements on healthcare providers who are serving those impacted by Sandy.  The Section 1135 waiver for New York is available here.  The waivers relax the rules for providers in areas like recordkeeping, patient relocation and billing in order to ensure that individuals enrolled in federal programs like Medicare and Medicaid receive the health care items and services that they need.  New York’s waiver is retroactive to Oct. 27. Continue reading

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Filed under Announcements, Medicaid