Tag Archives: cms

OIG Criticizes CMS For Lack Of Adequate Fraud Detection Practices in Electronic Health Records

In early January, 2014, the Office of Inspector General (“OIG”) for the Department of Health and Human Services (“HHS”) issued a report criticizing HHS’s Centers for Medicare and Medicaid Services (“CMS”) for failing to adopt stronger integrity practices governing electronic health records (“EHRs”). “CMS And Its Contractors Have Adopted Few Program Integrity Practices To Address Vulnerabilities In EHRs,” oig.hhs.gov/oei/reports/oei-01-11-00571.pdf. Here are some of the OIG’s challenges and concerns: “…clues within the progress notes, handwriting styles, and other attributes that help corroborate the authenticity of paper medical records are largely absent in EHRs. Further, tracing authorship and documentation in an EHR may not be as straightforward as tracing in a paper record. Health care providers can use EHR software features that may mask true authorship of the medical record and distort information in the record to inflate health care claims.” Continue reading OIG Criticizes CMS For Lack Of Adequate Fraud Detection Practices in Electronic Health Records

Increased Spotlight on Emergency Department Facility Coding by CMS, HHS and DOJ

Although the professional component of coding for evaluation and management services (“E&M Services”) has been scrutinized over the years, until recently, little attention has been given to coding practices for the facility component of these services—including emergency department facility services. In a September 24, 2012, letter written by Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services (HHS); and Eric Holder, Jr., Attorney General, U.S. Department of Justice, to hospital leadership throughout the United States, HHS and the Justice Department expressed their concern that hospitals may be inappropriately coding E&M Services. Specifically, the letter notes that “CMS is initiating more extensive medical reviews to ensure that providers are coding evaluation and management services accurately.” In light of the recent attention on emergency department facility component coding practices, an area that so far has largely been overlooked by the regulators, any facility that has not reviewed its coding practices for the facility component of E&M Services may want to consider doing so at this time.

Click here to read the full Alert.

Research-Related Payments and the Physician Payment Sunshine Act: How Reporting Works and What Applicable Manufacturers Should Consider

The Centers for Medicare & Medicaid Services on February 1, 2013, published long-awaited rules (the “Rules”) detailing manufacturers’ and group purchasing organizations’ reporting requirements under Section 6002 of the Patient Protection and Affordable Care Act, otherwise known as the Physician Payment Sunshine Act. This Alert is the second in Duane Morris’ series of Alerts on the new Sunshine Act reporting requirements, and addresses the unique reporting requirements for applicable manufacturers’ making payments or transfers of value related to clinical research and pre-clinical research. The Rules contain different reporting requirements for these research-related payments, so applicable manufacturers may want to analyze their relationships now in preparation for the August 1, 2013, data collection start date.

Click here to read more about the Rules and what every applicable manufacturer should know about reporting research-related payments.

Medicare and Health Care Reform: Why Isn’t Real Time Data a Priority?

Last month, top health care investors and entrepreneurs came together with hospital, payor and government leaders at a conference sponsored by the University of Pennsylvania’s Wharton Healthcare Management Alumni Association to discuss the restructuring of the health care system. Jonathan Blum, CMS Deputy Administrator and Director of the Center of Medicare participated on a panel about about macro health care system changes and one of the key take aways was not surprisingly, that change in the health care system is all about the data. Continue reading Medicare and Health Care Reform: Why Isn’t Real Time Data a Priority?

CMS Awards Loans to First Seven CO-OPs

On February 21, 2012, CMS announced its first award of repayable loans to seven Consumer Operated and Oriented Plans (CO-OPs). The awards will help CO-OPs establish private, non-profit, consumer-governed health insurance companies with the goal of expanding health insurance options for consumers and small businesses. The CO-OPs will eventually operate in each states’ health insurance exchange under the Affordable Care Act, but will also offer plans outside of the exchange. Starting on January 1, 2014, the first seven CO-OPs will become operational in eight states.

Continue reading CMS Awards Loans to First Seven CO-OPs

CMS Finalizes Rules Regarding Eligibility for Medicare Prescription Drug Subsidy

On January 17, 2012 the Centers for Medicare & Medicaid Services (“CMS”) adopted as a final rule changing Medicare’s Extra Help Program. The Extra Help Program is a prescription drug coverage low-income subsidy created through the Affordable Care Act (“ACA”). Effective January 18, 2012, the final rule incorporates the ACA’s changes to the Extra Help Program by extending eligibility for one year after the death of a beneficiary’s spouse that would otherwise decrease or eliminate the subsidy. The final rule also implements changes to the Medicare Improvements for Patients and Provider Act of 2008 by excluding from a resource (for purposes of Extra Help eligibility) the value of life insurance policies or income for food, shelter, and certain household bills.

Read the full notice from the federal register here.

Proposed Physician Payment Disclosure Rule Published

The Centers for Medicare and Medicaid Services (“CMS”) released its proposed rule regarding the required reporting of device, biologics and pharmaceutical manufacturer payments to physicians on December 14, 2011. The proposed rule includes templates for physicians and manufacturers to use when logging payments and gifts.

Continue reading Proposed Physician Payment Disclosure Rule Published

CMS Issues Final Rule on ACA’s New Medical Loss Ratio

The Centers for Medicaid & Medicare Services (“CMS”) recently released a final rule establishing the new medical loss ratio requirements under the Affordable Care Act (“ACA”). Under the ACA, individual and small group market insurers are required to spend at least 80 percent of premium dollars on medical care and quality improvement, and large group market insurers must spend at least 85 percent of premium dollars on the same services. The final rule describes the technical process for calculating medical loss ratio and also provides details on insurers’ annual medical loss ratio reporting requirements, as well as the ACA’s requirement that insurers grant rebates to consumers in the event the insurer fails to meet the required medical loss ratio.

Read the full text of the rule here, or HHS’ fact sheet on the ACA’s changes to medical loss ratios here.

CMS Announces Coverage of Preventive Services to Reduce Cardiovascular Disease

Recently the Centers for Medicare and Medicaid Services (“CMS”) announced new coverage under the Medicare program for preventive services for the reduction of cardiovascular disease. CMS’ decision details that Medicare will now cover one-to-one cardiovascular disease risk reduction visits that may include three components: (1) encouraging aspirin use; (2) high blood pressure screening for adults 18 years or older, and (3) intensive behavioral counseling to encourage healthy diets.

The new coverage is part of a joint initiative between CMS and the Centers for Disease Control, the Million Hearts Initiative. Read more about the initiative here, and access CMS’ entire coverage decision here.

OIG’s 2012 Work Plan For Nursing Facilities: Same Fraud, Different Enforcement

Recently, the United States Department of Health and Human Services Office of Inspector General (“OIG”) published its Work Plan for fiscal year 2012 (“Work Plan”) and delineated focus points for nursing facilities and new enforcement in 2012. The Work Plan is not much different than previous work plans with the exception of increased areas of enforcement, as well as a few new areas to be looked at by OIG.

Continue reading OIG’s 2012 Work Plan For Nursing Facilities: Same Fraud, Different Enforcement