Author Archive for: Compliance Monitor
Court approves Medicare freeze on payments to Miami home healthcare companies
December 1st, 2008 
Medicare will continue to suspend payments to Miami home healthcare agencies suspected of fraud, according to a November 24 Miami Herald article.
A federal judge ruled Medicare’s refusal to pay reimbursement to companies suspected of overcharging for diabetic and other services, which began in October, is reasonable and appropriate.
A home healthcare company sued Medicare following the initial announcement claiming that the program was beyond Medicare’s scope of authority.
According to the article, Medicare estimates it spends $1.3 billion of its $16.5 billion national home healthcare budget on companies based in Miami-Dade County.
Click here to read the Miami Herald article.
Tip: Submission of claims for laboratory services
November 20th, 2008
A hospital should ensure all claims for clinical and diagnostic laboratory testing services are accurate and correctly identify the services ordered by the physician (or other authorized requestor) and performed by the laboratory. The OIG recommends a hospital’s written policies and procedures require:
- The hospital bill for laboratory services only after they are performed
- The hospital bill only for medically necessary services
- The hospital bill only for tests actually ordered by a physician and provided by the hospital laboratory
- The CPT or HCPCS code used by the billing staff accurately describe the service ordered
- The coding staff only submit diagnostic information obtained from qualified personnel
- The coding staff contact the appropriate personnel to obtain diagnostic information when the individual who ordered the test has failed to provide such information
- The hospital document receipt of diagnostic information obtained from a physician or the physician’s staff after receiving the specimen and request for services
- The hospital conduct routine audits to assess billing compliance with the regulations
This tip was adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, click here.
CMS releases display copy of CY 2009 MPFS, seeks comments on Stark exception
November 6th, 2008
On October 30, CMS released a display copy of the Medicare Physician Fee Schedule (MPFS) final rule for calendar year 2009 (CY 2009). The final rule will be published in the November 19 issue of the Federal Register.
According to the document, CMS received 55 public comment letters in reference to the proposed Stark Law exception for incentive payment and shared savings programs. CMS said the majority of commenters supported separate exceptions for incentive payment and shared savings programs, but wanted CMS to make modifications before each became part of the final rule.
Despite receiving several constructive comments on arrangements affected by the potential exception, CMS decided to reopen the comment period for 90 days in hopes commenters will agree on an exception broad enough to apply to as many parties as possible, but still prevent abuse.
CMS is seeking comments that:
-
Define the terms “incentive payment program” and “shared savings program”
-
Determine whether the terminology “incentive payment” and “shared savings” programs are appropriate or whether different terminology would better describe the range of nonabusive programs CMS intends to cover under the proposed exception(s)
-
Identify with specificity which conditions should be made applicable to incentive payment programs (and why)
-
Identify which conditions need not or should not be made applicable to incentive payment programs (and why)
-
Indicate why it would not be necessary to impose on both types of programs the same safeguards against program or patient abuse
-
Determine whether a program involving cost savings measures that also improve quality should be treated as an incentive payment or shared savings program
To read the display copy of the MPFS, click here
For more information on Stark Law updates, join us December 11 for the “Stark Law Update: Analysis of Recent Changes to Phase III” audio conference. Click here to register for the event.
Tip: Retention of records
October 23rd, 2008
Hospital compliance programs should provide guidance to the organization for the implementation of a records system. Such a system should establish policies and procedures regarding the creation, distribution, retention, storage, retrieval, and destruction of documents. The two types of documents developed under this system include:
- All records and documentation, including clinical and medical records and claims documentation, required either by federal or by state law for participation in healthcare programs
- All records necessary to protect the integrity of the hospital’s compliance process and to confirm the effectiveness of the program, including documentation that employees were adequately trained, reports from the hospital’s hotline (including the nature and results of any investigation conducted), modifications to the compliance program, self-disclosure, and the results of the hospital auditing and monitoring efforts.
This tip was adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, click here.
News: Six Nevada doctors pay to settle Medicare fraud claims
October 23rd, 2008
Six Las Vegas area doctors agreed to collectively pay over $600,000 for their role in a Medicare fraud scheme, according to a report issued by KTNV, a Las Vegas news station.
The six doctors, Robert Shreck, MD, Tony Q.F. Chin, MD, Craig M. Jorgensen, MD, Wen Liang, MD, Mohammed Najmi, MD, and Edmund Pasimio, MD, allegedly referred patients to a nurse practitioner, Greg Martin, for medically unnecessary procedures.
Martin allegedly billed Medicare for the procedures and, upon receiving payment, split the amount with the referring physician.
To read the full KTNV story, click here
News: Louisiana Hospital pays $3.3 million to resolve Medicare fraud charges
October 23rd, 2008
West Jefferson Medical Center, a New Orleans area hospital, agreed to pay $3.3 million to resolve allegations of Medicare fraud, according to a Department of Justice (DOJ) press release.
The charges alleged West Jefferson Medical Center lied about its ability to provide critical care services at its pediatric intensive care unit. The alleged lie caused the hospital to receive overpayments from Medicare between March 1998 and October 2003.
Leslie Klemm, a former nurse at the hospital, filed the qui tam suit and will receive $627,000 as her share of the state and federal recovery.
To read the full DOJ press release, click here
Eight indicted in South Florida AIDS/HIV infusion scheme
October 20th, 2008
Federal and state Medicare Strike Force agents indicted eight individuals – Juan A. Marrero, a/k/a Tony Marrero; Orlando Pascual Jr.; Belkis Marrero; Dr. David Rothman; Luz Borrego; Dr. Keith Russell; Eda Milanes; and Jorge L. Pacheco – in the Miami area for alleged involvement in a scheme to defraud Medicare.
According to the Department of Justice press release, the scheme involved two Miami medical clinics—Medcore Group LLC and M&P Group of South Florida Inc. Tony Marrero, Pascual, and Belkis Marrero controlled day-to-day operations for those clinics.
According to the indictment, medical assistants Borrego, Pacheco, and Milanes administered unnecessary treatments and paid cash to patients. Rothman and Russell allegedly performed cursory examinations and signed the appropriate documentation to make it appear the infusions were medically necessary.
The indictment also alleges the defendants laundered a portion of the proceeds to pay the patients for their participation in the scheme.
To read the DOJ press release click here
News: McKesson charged with Medicare fraud scheme
October 10th, 2008
The Department of Justice joined a whistleblower suit accusing McKesson, North America’s largest durable medical equipment (DME) supplier of creating a sham DME company that submitted false claims and paid kickbacks to a nursing facility company.
Federal prosecutors allege McKesson created and managed a phony DME company named CERES Strategies Medical Services Inc. (CSMS) which was an affiliate of Beverly Enterprises, Inc., a nursing facility company.
According to prosecutors, CSMS billed Medicare for DME supplies and made it appear as though Beverly supplied its own DME. McKesson allegedly supplied those services and the two parties shared the higher reimbursement received from Medicare. In exchange for the arrangement Beverly referred all its Medicare supply needs to McKesson.
To read the DOJ press release click here
Tip: Guidelines for documenting screening treatment
October 10th, 2008
Use the following guidelines when documenting screening treatment, to ensure you are compliant with Emergency Medical Treatment and Active Labor Act (EMTALA):
- For potential emergency conditions, include all medically indicated screenings, tests, mental status evaluations, impressions, and diagnoses (supported by a history and physician examination, laboratory, or other test results).
- For pregnant women, the medical records should show the screening examination included ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of the membranes, (e.g., ruptured, leaking, intact).
- For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempts, or risk; disorientation; or assaultive behavior that indicates danger to self or others.
This tip was adapted from A Practical Guide to EMTALA Compliance. For more information about the book or to order your copy click here
NJ Hospital pays $3.85M to settle Medicare fraud charges
October 2nd, 2008
Cooper University Hospital in Camden, N.J., agreed to pay the federal government $2.85 million plus interest to resolve allegations it illegally increased charges to Medicare beneficiaries to obtain higher reimbursement from the program, according to a Department of Justice (DOJ) press release.
Between 2001 and 2003, Cooper allegedly inflated the cost of certain inpatient and outpatient stays in order to qualify for more lucrative outlier payments.
Whistleblower Anthony Kite will receive $654,500 for bringing the case to the government’s attention, according to the release.
To read the full DOJ press release click here.
A federal judge ruled Medicare’s refusal to pay reimbursement to companies suspected of overcharging for diabetic and other services, which began in October, is reasonable and appropriate.
A home healthcare company sued Medicare following the initial announcement claiming that the program was beyond Medicare’s scope of authority.
According to the article, Medicare estimates it spends $1.3 billion of its $16.5 billion national home healthcare budget on companies based in Miami-Dade County.
Click here to read the Miami Herald article.
Tip: Submission of claims for laboratory services
November 20th, 2008
A hospital should ensure all claims for clinical and diagnostic laboratory testing services are accurate and correctly identify the services ordered by the physician (or other authorized requestor) and performed by the laboratory. The OIG recommends a hospital’s written policies and procedures require:
- The hospital bill for laboratory services only after they are performed
- The hospital bill only for medically necessary services
- The hospital bill only for tests actually ordered by a physician and provided by the hospital laboratory
- The CPT or HCPCS code used by the billing staff accurately describe the service ordered
- The coding staff only submit diagnostic information obtained from qualified personnel
- The coding staff contact the appropriate personnel to obtain diagnostic information when the individual who ordered the test has failed to provide such information
- The hospital document receipt of diagnostic information obtained from a physician or the physician’s staff after receiving the specimen and request for services
- The hospital conduct routine audits to assess billing compliance with the regulations
This tip was adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, click here.
CMS releases display copy of CY 2009 MPFS, seeks comments on Stark exception
November 6th, 2008
On October 30, CMS released a display copy of the Medicare Physician Fee Schedule (MPFS) final rule for calendar year 2009 (CY 2009). The final rule will be published in the November 19 issue of the Federal Register.
According to the document, CMS received 55 public comment letters in reference to the proposed Stark Law exception for incentive payment and shared savings programs. CMS said the majority of commenters supported separate exceptions for incentive payment and shared savings programs, but wanted CMS to make modifications before each became part of the final rule.
Despite receiving several constructive comments on arrangements affected by the potential exception, CMS decided to reopen the comment period for 90 days in hopes commenters will agree on an exception broad enough to apply to as many parties as possible, but still prevent abuse.
CMS is seeking comments that:
-
Define the terms “incentive payment program” and “shared savings program”
-
Determine whether the terminology “incentive payment” and “shared savings” programs are appropriate or whether different terminology would better describe the range of nonabusive programs CMS intends to cover under the proposed exception(s)
-
Identify with specificity which conditions should be made applicable to incentive payment programs (and why)
-
Identify which conditions need not or should not be made applicable to incentive payment programs (and why)
-
Indicate why it would not be necessary to impose on both types of programs the same safeguards against program or patient abuse
-
Determine whether a program involving cost savings measures that also improve quality should be treated as an incentive payment or shared savings program
To read the display copy of the MPFS, click here
For more information on Stark Law updates, join us December 11 for the “Stark Law Update: Analysis of Recent Changes to Phase III” audio conference. Click here to register for the event.
Tip: Retention of records
October 23rd, 2008
Hospital compliance programs should provide guidance to the organization for the implementation of a records system. Such a system should establish policies and procedures regarding the creation, distribution, retention, storage, retrieval, and destruction of documents. The two types of documents developed under this system include:
- All records and documentation, including clinical and medical records and claims documentation, required either by federal or by state law for participation in healthcare programs
- All records necessary to protect the integrity of the hospital’s compliance process and to confirm the effectiveness of the program, including documentation that employees were adequately trained, reports from the hospital’s hotline (including the nature and results of any investigation conducted), modifications to the compliance program, self-disclosure, and the results of the hospital auditing and monitoring efforts.
This tip was adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, click here.
News: Six Nevada doctors pay to settle Medicare fraud claims
October 23rd, 2008
Six Las Vegas area doctors agreed to collectively pay over $600,000 for their role in a Medicare fraud scheme, according to a report issued by KTNV, a Las Vegas news station.
The six doctors, Robert Shreck, MD, Tony Q.F. Chin, MD, Craig M. Jorgensen, MD, Wen Liang, MD, Mohammed Najmi, MD, and Edmund Pasimio, MD, allegedly referred patients to a nurse practitioner, Greg Martin, for medically unnecessary procedures.
Martin allegedly billed Medicare for the procedures and, upon receiving payment, split the amount with the referring physician.
To read the full KTNV story, click here
News: Louisiana Hospital pays $3.3 million to resolve Medicare fraud charges
October 23rd, 2008
West Jefferson Medical Center, a New Orleans area hospital, agreed to pay $3.3 million to resolve allegations of Medicare fraud, according to a Department of Justice (DOJ) press release.
The charges alleged West Jefferson Medical Center lied about its ability to provide critical care services at its pediatric intensive care unit. The alleged lie caused the hospital to receive overpayments from Medicare between March 1998 and October 2003.
Leslie Klemm, a former nurse at the hospital, filed the qui tam suit and will receive $627,000 as her share of the state and federal recovery.
To read the full DOJ press release, click here
Eight indicted in South Florida AIDS/HIV infusion scheme
October 20th, 2008
Federal and state Medicare Strike Force agents indicted eight individuals – Juan A. Marrero, a/k/a Tony Marrero; Orlando Pascual Jr.; Belkis Marrero; Dr. David Rothman; Luz Borrego; Dr. Keith Russell; Eda Milanes; and Jorge L. Pacheco – in the Miami area for alleged involvement in a scheme to defraud Medicare.
According to the Department of Justice press release, the scheme involved two Miami medical clinics—Medcore Group LLC and M&P Group of South Florida Inc. Tony Marrero, Pascual, and Belkis Marrero controlled day-to-day operations for those clinics.
According to the indictment, medical assistants Borrego, Pacheco, and Milanes administered unnecessary treatments and paid cash to patients. Rothman and Russell allegedly performed cursory examinations and signed the appropriate documentation to make it appear the infusions were medically necessary.
The indictment also alleges the defendants laundered a portion of the proceeds to pay the patients for their participation in the scheme.
To read the DOJ press release click here
News: McKesson charged with Medicare fraud scheme
October 10th, 2008
The Department of Justice joined a whistleblower suit accusing McKesson, North America’s largest durable medical equipment (DME) supplier of creating a sham DME company that submitted false claims and paid kickbacks to a nursing facility company.
Federal prosecutors allege McKesson created and managed a phony DME company named CERES Strategies Medical Services Inc. (CSMS) which was an affiliate of Beverly Enterprises, Inc., a nursing facility company.
According to prosecutors, CSMS billed Medicare for DME supplies and made it appear as though Beverly supplied its own DME. McKesson allegedly supplied those services and the two parties shared the higher reimbursement received from Medicare. In exchange for the arrangement Beverly referred all its Medicare supply needs to McKesson.
To read the DOJ press release click here
Tip: Guidelines for documenting screening treatment
October 10th, 2008
Use the following guidelines when documenting screening treatment, to ensure you are compliant with Emergency Medical Treatment and Active Labor Act (EMTALA):
- For potential emergency conditions, include all medically indicated screenings, tests, mental status evaluations, impressions, and diagnoses (supported by a history and physician examination, laboratory, or other test results).
- For pregnant women, the medical records should show the screening examination included ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of the membranes, (e.g., ruptured, leaking, intact).
- For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempts, or risk; disorientation; or assaultive behavior that indicates danger to self or others.
November 6th, 2008
On October 30, CMS released a display copy of the Medicare Physician Fee Schedule (MPFS) final rule for calendar year 2009 (CY 2009). The final rule will be published in the November 19 issue of the Federal Register.
According to the document, CMS received 55 public comment letters in reference to the proposed Stark Law exception for incentive payment and shared savings programs. CMS said the majority of commenters supported separate exceptions for incentive payment and shared savings programs, but wanted CMS to make modifications before each became part of the final rule.
Despite receiving several constructive comments on arrangements affected by the potential exception, CMS decided to reopen the comment period for 90 days in hopes commenters will agree on an exception broad enough to apply to as many parties as possible, but still prevent abuse.
CMS is seeking comments that:
-
Define the terms “incentive payment program” and “shared savings program”
-
Determine whether the terminology “incentive payment” and “shared savings” programs are appropriate or whether different terminology would better describe the range of nonabusive programs CMS intends to cover under the proposed exception(s)
-
Identify with specificity which conditions should be made applicable to incentive payment programs (and why)
-
Identify which conditions need not or should not be made applicable to incentive payment programs (and why)
-
Indicate why it would not be necessary to impose on both types of programs the same safeguards against program or patient abuse
-
Determine whether a program involving cost savings measures that also improve quality should be treated as an incentive payment or shared savings program
To read the display copy of the MPFS, click here
For more information on Stark Law updates, join us December 11 for the “Stark Law Update: Analysis of Recent Changes to Phase III” audio conference. Click here to register for the event.
Tip: Retention of records
October 23rd, 2008
Hospital compliance programs should provide guidance to the organization for the implementation of a records system. Such a system should establish policies and procedures regarding the creation, distribution, retention, storage, retrieval, and destruction of documents. The two types of documents developed under this system include:
- All records and documentation, including clinical and medical records and claims documentation, required either by federal or by state law for participation in healthcare programs
- All records necessary to protect the integrity of the hospital’s compliance process and to confirm the effectiveness of the program, including documentation that employees were adequately trained, reports from the hospital’s hotline (including the nature and results of any investigation conducted), modifications to the compliance program, self-disclosure, and the results of the hospital auditing and monitoring efforts.
This tip was adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, click here.
News: Six Nevada doctors pay to settle Medicare fraud claims
October 23rd, 2008
Six Las Vegas area doctors agreed to collectively pay over $600,000 for their role in a Medicare fraud scheme, according to a report issued by KTNV, a Las Vegas news station.
The six doctors, Robert Shreck, MD, Tony Q.F. Chin, MD, Craig M. Jorgensen, MD, Wen Liang, MD, Mohammed Najmi, MD, and Edmund Pasimio, MD, allegedly referred patients to a nurse practitioner, Greg Martin, for medically unnecessary procedures.
Martin allegedly billed Medicare for the procedures and, upon receiving payment, split the amount with the referring physician.
To read the full KTNV story, click here
News: Louisiana Hospital pays $3.3 million to resolve Medicare fraud charges
October 23rd, 2008
West Jefferson Medical Center, a New Orleans area hospital, agreed to pay $3.3 million to resolve allegations of Medicare fraud, according to a Department of Justice (DOJ) press release.
The charges alleged West Jefferson Medical Center lied about its ability to provide critical care services at its pediatric intensive care unit. The alleged lie caused the hospital to receive overpayments from Medicare between March 1998 and October 2003.
Leslie Klemm, a former nurse at the hospital, filed the qui tam suit and will receive $627,000 as her share of the state and federal recovery.
To read the full DOJ press release, click here
Eight indicted in South Florida AIDS/HIV infusion scheme
October 20th, 2008
Federal and state Medicare Strike Force agents indicted eight individuals – Juan A. Marrero, a/k/a Tony Marrero; Orlando Pascual Jr.; Belkis Marrero; Dr. David Rothman; Luz Borrego; Dr. Keith Russell; Eda Milanes; and Jorge L. Pacheco – in the Miami area for alleged involvement in a scheme to defraud Medicare.
According to the Department of Justice press release, the scheme involved two Miami medical clinics—Medcore Group LLC and M&P Group of South Florida Inc. Tony Marrero, Pascual, and Belkis Marrero controlled day-to-day operations for those clinics.
According to the indictment, medical assistants Borrego, Pacheco, and Milanes administered unnecessary treatments and paid cash to patients. Rothman and Russell allegedly performed cursory examinations and signed the appropriate documentation to make it appear the infusions were medically necessary.
The indictment also alleges the defendants laundered a portion of the proceeds to pay the patients for their participation in the scheme.
To read the DOJ press release click here
News: McKesson charged with Medicare fraud scheme
October 10th, 2008
The Department of Justice joined a whistleblower suit accusing McKesson, North America’s largest durable medical equipment (DME) supplier of creating a sham DME company that submitted false claims and paid kickbacks to a nursing facility company.
Federal prosecutors allege McKesson created and managed a phony DME company named CERES Strategies Medical Services Inc. (CSMS) which was an affiliate of Beverly Enterprises, Inc., a nursing facility company.
According to prosecutors, CSMS billed Medicare for DME supplies and made it appear as though Beverly supplied its own DME. McKesson allegedly supplied those services and the two parties shared the higher reimbursement received from Medicare. In exchange for the arrangement Beverly referred all its Medicare supply needs to McKesson.
To read the DOJ press release click here
Tip: Guidelines for documenting screening treatment
October 10th, 2008
Use the following guidelines when documenting screening treatment, to ensure you are compliant with Emergency Medical Treatment and Active Labor Act (EMTALA):
- For potential emergency conditions, include all medically indicated screenings, tests, mental status evaluations, impressions, and diagnoses (supported by a history and physician examination, laboratory, or other test results).
- For pregnant women, the medical records should show the screening examination included ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of the membranes, (e.g., ruptured, leaking, intact).
- For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempts, or risk; disorientation; or assaultive behavior that indicates danger to self or others.
October 23rd, 2008
Six Las Vegas area doctors agreed to collectively pay over $600,000 for their role in a Medicare fraud scheme, according to a report issued by KTNV, a Las Vegas news station.
The six doctors, Robert Shreck, MD, Tony Q.F. Chin, MD, Craig M. Jorgensen, MD, Wen Liang, MD, Mohammed Najmi, MD, and Edmund Pasimio, MD, allegedly referred patients to a nurse practitioner, Greg Martin, for medically unnecessary procedures.
Martin allegedly billed Medicare for the procedures and, upon receiving payment, split the amount with the referring physician.
To read the full KTNV story, click here
News: Louisiana Hospital pays $3.3 million to resolve Medicare fraud charges
October 23rd, 2008
West Jefferson Medical Center, a New Orleans area hospital, agreed to pay $3.3 million to resolve allegations of Medicare fraud, according to a Department of Justice (DOJ) press release.
The charges alleged West Jefferson Medical Center lied about its ability to provide critical care services at its pediatric intensive care unit. The alleged lie caused the hospital to receive overpayments from Medicare between March 1998 and October 2003.
Leslie Klemm, a former nurse at the hospital, filed the qui tam suit and will receive $627,000 as her share of the state and federal recovery.
To read the full DOJ press release, click here
Eight indicted in South Florida AIDS/HIV infusion scheme
October 20th, 2008
Federal and state Medicare Strike Force agents indicted eight individuals – Juan A. Marrero, a/k/a Tony Marrero; Orlando Pascual Jr.; Belkis Marrero; Dr. David Rothman; Luz Borrego; Dr. Keith Russell; Eda Milanes; and Jorge L. Pacheco – in the Miami area for alleged involvement in a scheme to defraud Medicare.
According to the Department of Justice press release, the scheme involved two Miami medical clinics—Medcore Group LLC and M&P Group of South Florida Inc. Tony Marrero, Pascual, and Belkis Marrero controlled day-to-day operations for those clinics.
According to the indictment, medical assistants Borrego, Pacheco, and Milanes administered unnecessary treatments and paid cash to patients. Rothman and Russell allegedly performed cursory examinations and signed the appropriate documentation to make it appear the infusions were medically necessary.
The indictment also alleges the defendants laundered a portion of the proceeds to pay the patients for their participation in the scheme.
To read the DOJ press release click here
News: McKesson charged with Medicare fraud scheme
October 10th, 2008
The Department of Justice joined a whistleblower suit accusing McKesson, North America’s largest durable medical equipment (DME) supplier of creating a sham DME company that submitted false claims and paid kickbacks to a nursing facility company.
Federal prosecutors allege McKesson created and managed a phony DME company named CERES Strategies Medical Services Inc. (CSMS) which was an affiliate of Beverly Enterprises, Inc., a nursing facility company.
According to prosecutors, CSMS billed Medicare for DME supplies and made it appear as though Beverly supplied its own DME. McKesson allegedly supplied those services and the two parties shared the higher reimbursement received from Medicare. In exchange for the arrangement Beverly referred all its Medicare supply needs to McKesson.
To read the DOJ press release click here
Tip: Guidelines for documenting screening treatment
October 10th, 2008
Use the following guidelines when documenting screening treatment, to ensure you are compliant with Emergency Medical Treatment and Active Labor Act (EMTALA):
- For potential emergency conditions, include all medically indicated screenings, tests, mental status evaluations, impressions, and diagnoses (supported by a history and physician examination, laboratory, or other test results).
- For pregnant women, the medical records should show the screening examination included ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of the membranes, (e.g., ruptured, leaking, intact).
- For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempts, or risk; disorientation; or assaultive behavior that indicates danger to self or others.
October 20th, 2008
Federal and state Medicare Strike Force agents indicted eight individuals – Juan A. Marrero, a/k/a Tony Marrero; Orlando Pascual Jr.; Belkis Marrero; Dr. David Rothman; Luz Borrego; Dr. Keith Russell; Eda Milanes; and Jorge L. Pacheco – in the Miami area for alleged involvement in a scheme to defraud Medicare.
According to the Department of Justice press release, the scheme involved two Miami medical clinics—Medcore Group LLC and M&P Group of South Florida Inc. Tony Marrero, Pascual, and Belkis Marrero controlled day-to-day operations for those clinics.
According to the indictment, medical assistants Borrego, Pacheco, and Milanes administered unnecessary treatments and paid cash to patients. Rothman and Russell allegedly performed cursory examinations and signed the appropriate documentation to make it appear the infusions were medically necessary.
The indictment also alleges the defendants laundered a portion of the proceeds to pay the patients for their participation in the scheme.
To read the DOJ press release click here
News: McKesson charged with Medicare fraud scheme
October 10th, 2008
The Department of Justice joined a whistleblower suit accusing McKesson, North America’s largest durable medical equipment (DME) supplier of creating a sham DME company that submitted false claims and paid kickbacks to a nursing facility company.
Federal prosecutors allege McKesson created and managed a phony DME company named CERES Strategies Medical Services Inc. (CSMS) which was an affiliate of Beverly Enterprises, Inc., a nursing facility company.
According to prosecutors, CSMS billed Medicare for DME supplies and made it appear as though Beverly supplied its own DME. McKesson allegedly supplied those services and the two parties shared the higher reimbursement received from Medicare. In exchange for the arrangement Beverly referred all its Medicare supply needs to McKesson.
To read the DOJ press release click here
Tip: Guidelines for documenting screening treatment
October 10th, 2008
Use the following guidelines when documenting screening treatment, to ensure you are compliant with Emergency Medical Treatment and Active Labor Act (EMTALA):
- For potential emergency conditions, include all medically indicated screenings, tests, mental status evaluations, impressions, and diagnoses (supported by a history and physician examination, laboratory, or other test results).
- For pregnant women, the medical records should show the screening examination included ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of the membranes, (e.g., ruptured, leaking, intact).
- For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempts, or risk; disorientation; or assaultive behavior that indicates danger to self or others.
October 10th, 2008
Use the following guidelines when documenting screening treatment, to ensure you are compliant with Emergency Medical Treatment and Active Labor Act (EMTALA):
- For potential emergency conditions, include all medically indicated screenings, tests, mental status evaluations, impressions, and diagnoses (supported by a history and physician examination, laboratory, or other test results).
- For pregnant women, the medical records should show the screening examination included ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of the membranes, (e.g., ruptured, leaking, intact).
- For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempts, or risk; disorientation; or assaultive behavior that indicates danger to self or others.
This tip was adapted from A Practical Guide to EMTALA Compliance. For more information about the book or to order your copy click here
NJ Hospital pays $3.85M to settle Medicare fraud charges
October 2nd, 2008
Cooper University Hospital in Camden, N.J., agreed to pay the federal government $2.85 million plus interest to resolve allegations it illegally increased charges to Medicare beneficiaries to obtain higher reimbursement from the program, according to a Department of Justice (DOJ) press release.
Between 2001 and 2003, Cooper allegedly inflated the cost of certain inpatient and outpatient stays in order to qualify for more lucrative outlier payments.
Whistleblower Anthony Kite will receive $654,500 for bringing the case to the government’s attention, according to the release.
To read the full DOJ press release click here.
Recent
Unapproved drugs still sold
December 1, 2008
by: Patient Access Weekly Advisor • Medicaid, e-Newsletters
Court approves Medicare freeze on payments to Miami home healthcare companies
December 1, 2008
by: Compliance Monitor • Billing and reimbursement, Medicare compliance, e-Newsletters
Hospitals receive different reimbursements for identical procedures
December 1, 2008
by: Case Management Weekly • Billing and reimbursement, e-Newsletters
Cope with a new MAC
December 1, 2008
by: Medicare Weekly Update • Billing and reimbursement, Coding, Medicare compliance, e-Newsletters
2009 OPPS/ASC final rule published in Federal Register
December 1, 2008
by: Medicare Weekly Update • Billing and reimbursement, Medicare compliance, e-Newsletters
Popular
Revenue Cycle Institute’s RAC Readiness Summit faculty announced
November 7, 2008
by: Andrea Kraynak, CPC-A • Billing and reimbursement, Medicare compliance, Popular, RACs
CMS delays RAC permanent program
November 5, 2008
by: Lori Levans • Auditing and assessment, Billing and reimbursement, Medicare compliance, Popular, RACs
News: Six Nevada doctors pay to settle Medicare fraud claims
October 23, 2008
by: Compliance Monitor • Billing and reimbursement, Medicare compliance, Popular, e-Newsletters
News: Louisiana Hospital pays $3.3 million to resolve Medicare fraud charges
October 23, 2008
by: Compliance Monitor • Billing and reimbursement, Medicare compliance, Popular, e-Newsletters
Hospitals absorb costs of treating uninsured immigrants
October 20, 2008
by: Case Management Weekly • Billing and reimbursement, ED, Popular, e-Newsletters
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