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Feds, state investigating St. Mary's pediatric heart surgery unit Print E-mail
Written by John Pacenti | Palm Beach Post   
Friday, 12 June 2015 17:03

The microscope on <West Palm Beach based> St. Mary's Medical Center's pediatric cardiac surgery program tightened its focus on Friday <6.5.15> with federal and state agencies saying they are investigating nine infant deaths at the hospital.

The federal Centers for Medicare & Medicaid Services said it was launching an investigation after CNN reported on Monday <6.1.15> that the mortality rate at St. Mary's 4-year-old program dwarfed the national average.

"We take these allegations very seriously. CMS is actively investigating these complaints," CMS spokesman Aaron Albright said.
CMS Releases Broad Data on Prescribing Patterns of Physicians & Providers Under Medicare Part D Print E-mail
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Friday, 22 May 2015 17:13

In a highly anticipated and scrutinized decision, the Centers for Medicare & Medicaid Services (CMS) released a new public data set on April 30, 2015, that includes detailed data regarding the prescribing patterns of physicians and other health care providers under the Medicare Part D Prescription Drug Program. Referred to as the Provider Utilization and Payment Data: Part D Prescriber Public Use File, the file comprises data relating to more than one million health care providers that prescribed $103 billion in prescription drugs across 36 million Medicare beneficiaries under the Part D program in 2013 (the Data Set). The decision reflects a growing effort by CMS to use data sharing to promote transparency and innovation, but users should be mindful of the context and limitations of the data, as cautioned by CMS.

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Last Updated on Saturday, 23 May 2015 09:28
CMS to Host Call re Hospital Inpatient Quality Reporting and Value-Based Purchasing Programs Print E-mail
Written by Jeff Cohen | Florida Healthcare Law Firm Blog   
Tuesday, 12 May 2015 11:03

CMS is hosting a call on May 12, 2015 to provide an overview of all Hospital Inpatient Quality Reporting and Value-Based Purchasing Programs.  The agenda items include...

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MEDCAC Meeting 7/22/2015 - Lower Extremity Peripheral Artery Disease Print E-mail
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Tuesday, 05 May 2015 10:18

On July 22, 2015, the Centers for Medicare & Medicaid Services (CMS) will convene a panel of the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC). The MEDCAC panel will examine the scientific evidence of existing interventions that aim to improve health outcomes in the Medicare population, and address areas where evidence gaps exist, related to lower extremity peripheral artery disease (PAD). For purposes of this MEDCAC, we will focus on three categories along the disease progression continuum (asymptomatic, intermittent claudication, and critical limb ischemia).

Clinical outcomes of interest to the Medicare program include reduction in pain; avoidance of amputation; improvement in quality of life and/or functional capacity including walking distance; wound healing; avoidance of cardiovascular events, including myocardial infarction, stroke, cardiovascular death, and all-cause mortality; and avoidance of harms from the interventions. By voting on specific questions, and by their discussions, MEDCAC panel members will advise CMS about the extent to which it may wish to use existing evidence as the basis for any future determinations about Medicare coverage for interventions related to lower extremity peripheral artery disease. MEDCAC panels do not make coverage determinations, but CMS often benefits from their advice.

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2015 Office of Inspector General (OIG) Work Plan Physicians and other Part B Providers Print E-mail
Written by Benjamin Frosch   
Tuesday, 16 December 2014 08:47
With the passage the Affordable Health Care Act (Health Care Reform) and the Medicare program in financial jeopardy, the OIG 2015 Work Plan is possibly more important than any of their previous work plans.  With a few thousand staff members throughout the United States, the Office of Inspector General (OIG) plans and performs audits, investigations, evaluations, and legal activities pertaining to the Department of Health and Human Services (HHS). With the Issuance of the 2015 OIG Work Plan there are a variety of important Medicare issues that they will evaluate pertaining to Medicare physicians and other health care providers.
With more federal agencies taking a closer look at Medicare fraud and abuse than ever before, it is very clear that there is a zero tolerance for Medicare fraud and abuse. The OIG for 2014 expects recoveries of over $4.9 billion and exclusions of 4,017 individuals and entities from participation in Federal healthcare plans, 971 criminal actions, and 533 civil actions. Therefore, this may be a good opportunity to evaluate compliance in your practice or entity with respect to these specific 2015 OIG issues listed below and to review the entire 2015 work plan. The following is a list of what I think are some of the hottest physician and other provider subjects targeted in the 2015 OIG Work Plan:
Home Health Services               
The OIG will evaluate compliance with various aspects of the home health PPS, including the documentation required in support of the claims paid by Medicare. They will review whether home health claims were paid in accordance with Federal laws and regulations. Past OIG reports found that one in four home health agencies had questionable billing. Since 2010, nearly $1 billion in improper payments and fraud has been identified relating to the home health benefit. 

Place of Service Errors
The OIG has and will continue to review physician coding on Medicare Part B claims for services performed in Ambulatory Surgical Centers (ASC) and hospital out-patient departments to determine whether they are coded properly with the correct place of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed.  Medicare pays a physician a higher amount when a service is performed in a non-facility setting, such as a physician office, than it does when a service is performed in hospital outpatient department or, with certain exceptions, in an Ambulatory Surgical Centers.  

PART B Imaging Services
The OIG will continue to evaluate Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices.  Physicians are paid for services pursuant to the Medicare Fee Schedule, which covers the major categories of cost, including the physician professional cost component, malpractice cost, and practice expenses. Practice expenses are those such as office rent, wages of personnel, and equipment. For selected imaging services, the OIG will focus on the practice expense components, including the equipment utilization rate. 
Diagnostic Radiology-Medical Necessity of High Cost tests
The OIG will also review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and to determine the extent to which use has increased for these tests. Medicare will not pay for items that are not medically reasonable and necessary.

Chiropractic Services
The OIG will be taking a hard look at Part B payments for non-covered services and questionable billing practices. Previous OIG reviews have demonstrated a history of vulnerabilities relative to inappropriate payments for chiropractic services, including a recent audit that identified a chiropractor with a 93 percent claim error rate and inappropriate payments of about $700,000. Part B only reimburses for chiropractic manual manipulation of the spine to correct a subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment. Chiropractic maintenance therapy is not considered to be medically reasonable and necessary and is therefore not payable. 

Anesthesia Services
The OIG will review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. They will also determine whether Medicare payments for anesthesia services reported on claims with the “AA” modifier were appropriate. Physicians report the appropriate anesthesia modifier to denote whether the service was personally performed or medically directed. Reporting an incorrect modifier on the claim as if services were personally performed by an anesthesiologist when they were not will result in Medicare’s paying a higher amount.  

Sleep Disorder Clinics- High use of sleep-testing procedures
The OIG will examine Medicare payments to physicians, hospital outpatient departments, and independent diagnostic testing facilities for sleep–testing procedures to determine the appropriateness of Medicare payments for high-use sleep-testing procedures to determine if they meet Medicare rules, regulations, and guidelines. A past analysis of 2010 Medicare payments for certain sleep disorder CPT codes totaling $415 million, showed high utilization associated with these procedures.
Outpatient Physical Therapy Services
The OIG will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. In the past, the OIG has identified claims for therapy services provided by independent physical therapists that were not, medically reasonable and necessary, or properly documented. The OIG will focus on independent therapists who have a high utilization rate for outpatient physical therapy services because of their concern that they may not be medically reasonable and necessary.
Clinical Laboratories Services
The OIG will take a look at Medicare payments to independent clinical laboratories to determine their compliance with certain billing requirements. The OIG will use the results of these reviews to identify clinical laboratories that routinely submit improper claims. In the past these reviews and investigations have identified independent clinical laboratory areas at risk for non-compliance with Medicare billing requirements.  

Ophthalmologists-Inappropriate and questionable billing
The OIG will examine Medicare claims data to identify potentially inappropriate and questionable billing services provided in 2012.They will use this data to determine the locations and specialties of providers with questionable billing. In 2010, Medicare allowed more than $6.8 billion for services provided by ophthalmologists.

End-stage renal disease facilities-Payment system for renal dialysis and drugs
The OIG will review Medicare payments for and utilization of renal dialysis services and related drugs pursuant to the new bundled end-stage renal disease prospective payment system. The OIG will compare facilities acquisition costs for certain drugs to inflation –adjusted cost estimates and determine how costs for the drugs have changed. Past OIG reviews found that data did not accurately measure changes in facilities acquisition costs for high dollar drugs.  

Ambulatory Surgical Centers
The OIG will review the appropriateness of Medicare’s methodology for setting ambulatory surgical center payment rates under the revised payment system. The OIG  will determine whether a payment disparity exists between ASC and hospital outpatient department payment rates for similar surgical procedures provided in both settings.

Mr. Frosch is the President of Frosch Medical Consultants in Plantation, FL.  Got a Question for Ben?  Click Ask Ben.

Last Updated on Tuesday, 16 December 2014 09:23
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