DOJ Annual Report on Health Care Fraud

The Department of Health and Human Services and the Department of Justice released the Health Care Fraud and Abuse Control Program Annual Report for FY 2012.  During Fiscal Year 2012 the Federal government won on negotiated over $3 billion in health care fraud judgments and settlements.  For FY 2012 the Federal government actually collected $4.2 billion from current and prior year settlements. 

In FY 2012, the Department of Justice (DOJ) opened 1,131 new criminal health care fraud investigations involving 2,148 potential defendants.  A total of 826 defendants were convicted of health care fraud-related crimes during the year.  They also opened 855 new civil health care fraud investigations and had 1,023 health care fraud matters pending at the end of the fiscal year.  In FY 2012, the Federal Bureau of Investigation health care fraud investigations resulting in the operational disruption of 329 criminal fraud organizations, and dismantlement of the criminal hierarchy of more than 83 criminal enterprises engaged in health care fraud.

In FY 2012 the HHS Office of Inspector General excluded 3,131 individuals and entities from federal health care programs. 

For more information please utilize the following link.

https://oig.hhs.gov/publications/docs/hcfac/hcfacreport2012.pdf

OIG Report on Medicare Payments to Unlawful Beneficiaries

The Office of Inspector General performed a study to determine if CMS data systems were adequate to prevent Medicare payments for unlawfully present beneficiaries. The study found that Medicare payments totaling $91,620,548 were made for 2,575 unlawfully present beneficiaries during FY 2009 to 2011.  It found that CMS did not have policies and procedures to review unlawful presence information on a post payment basis that would have detected improper payment that the prepayment edit could not prevent.  Consequently, CMS did not notify the Medicare contractors to recoup any of the $91,620,548 in improper payments. 

CMS released a MLN Matter Number: MM8009 on November 1, 2012 to perform new Informational Unsolicited Response (IUR) process to identify previously paid claims for services furnished to Medicare beneficiaries classified as “Unlawfully Present” in the United States.  The IUR process shall be initiated when there is an automatic update to the beneficiary’s record in the CWF via an EDB transaction which indicates a change to the beneficiary’s “unlawfully present” start or end date or when there is a manual update to the beneficiary’s record in CWF which indicate a change to the beneficiary’s “unlawfully present” start date or end date.  Upon receiving the IUR Medicare contracts will initiate overpayment recovery procedures to recoup any Medicare Part A and Part B payments.

For more information on OIG Study please utilize the following link.

https://oig.hhs.gov/oas/reports/region7/71201116.pdf

For more information on Future Medicare Learning Network Article please utilize the following link.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/mm8009.pdf

CMS New Patient Location & Other Requirements

Beginning July 1, 2013 home health agencies will have to utilize new Q codes to report were the home health services were provided.  The definitions of the Q codes are listed below:

• Q5001: Hospice or home health care provided in patient’s home/residence
• Q5002: Hospice or home health care provided in assisted living facility
• Q5009: Hospice or home health care provided in place not otherwise specified

HHAs must report when there are changes/additions to the plan of care by a physician other than the certifying physician using a modifier to indicate changes/additions to the plan of care by a physician other than the certifying physician.  Modifier XX must be appended to the HCPCS G code describing any visited added to the plan of care by that physician. 

Revisions to the definitions of the Q codes above will be published in the HCPCS update on March 31, 2013.  Modifier XX is a placeholder value.  The actual modifier and it final definition will also be published in the HCPCS update.

For more information please utilize the following link.

www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2650CP.pdf

Vermont Class-Action Settlement – Provides Coverage For Certain Home Health Patients

Many Medicare Administrative Contractors (MAC) have policies that home health patients must have a likelihood of improvement or they would not be covered for home health, nursing home or therapy.  The chief judge of Vermont’s federal district court approved a settlement with the Federal government to change the Medicare rules to cover services if they are needed to maintain the patient’s current condition or to slow any further deterioration.  The Federal government has agreed to make changes to the Medicare manual to show coverage of nursing and therapy is not based on the presence or absence of a patient’s potential for improvement, but would be based on the patient’s need for skilled care. 

CMS must make changes to the Medicare Benefit Policy Manual and other policy, guidelines and instructions.  This will include educating the Medicare Administrative Contractors who currently are making coverage decisions.  The actual settlement is effective now, but we encourage home health agencies to proceed cautiously.  Look for future updates from CMS and from you Medicare Administrative Contractor.

CMS Request Information on Hospice Consumer Assessment (CAHPS)

CMS published a request for information to aid in the design and development of a survey regarding patient and family member or friend experiences with hospice care on January 25, 2013.  CMS has previously implemented national surveys called Consumer Assessment of Healthcare Providers and Systems (CAHPS) for various health care providers such as hospitals, home health agencies, nursing homes and other entities.  The planned CMS Hospice Survey differs from other CMS patient experience surveys because the target population for the Hospice Survey is bereaved family members or close friends of patients who died in hospice care.  Once this survey is developed and implemented in a final rule, the survey results will be make available to the general public.  Hospices are encouraged to submit recommendations for items to be included in the survey.

For more information please utilize the following link.

http://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01299.pdf

Final HIPAA Privacy Rules Published By Health & Human Services

On January 25, 2013 the Department of Health and Human Services published the 138 page final rule on HIPAA Privacy, Security, Enforcement and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act, and other Modifications to the HIPAA Rules.  It makes final modifications to the HIPAA rules.  It makes business associates of covered entities directly liable for compliance with certain of the HIPAA Privacy and Security Rules’ requirements.  It strengthens the limitation on the use and disclosure of protected health information for marketing and fundraising purposes, and prohibits the sale of protected health information without individual authorization. It expands individuals’ rights to receive electronic copies of their health information and to restrict disclosures to a health plan concerning treatment for which the individual has paid out of pocket in full.  It requires modifications to, and redistribution of, a covered entity’s notice of privacy practices.  It modifies the individual authorization and other requirements to facilitate research and disclosure of child immunization proof to schools, and to enable access to decedent information by family members or others. It adopts the additional HITECH Act enhancements not previously adopted in the October 30, 2009 interim final rule. 

The final rule adopts changes to the HIPAA Enforcement Rule to incorporate the increased and tiered civil money penalty structure provided by the HITECH Act. It replaces the breach notification rule’s “harm” threshold with a more objective standard and supplants the interim final rule published on August 24, 2009.  It prohibits most health plans from using or disclosing genetic information for underwriting purposes.

For more information please utilize the following link.

http://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdf