Helping Physicians Navigate The Healthcare Industry: May 2011

Tuesday, May 31, 2011

Review of Medicare Contractor's Pension Segmentation Requirements at National Heritage Insurance Company for the Period January 1, 2000, to January 1, 2008

National Heritage Insurance Company (NHIC), a Centers for Medicare & Medicaid Services (CMS) contractor-prepared a reasonable representation of the Medicare Administrative Services (MAS) segment initial asset as of January 1, 2000, and of the MAS and Medicare Administrative Contractors (MAC) contracts asset as of January 1, 2008. NHIC administered Medicare Part B operations, Durable Medical Equipment, and MAC contracts with CMS.

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at
http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Review of Medicare Payments to Arimed Orthotics and Prosthetics, Inc., for Lower Limb Prosthetic Services for the Period January 1, 2008, Through December 31, 2009

Medicare payments to Arimed Orthotics and Prosthetics, Inc., for lower limb prosthetic services were correct. As a result, this report contains no recommendations.

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at
http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Review of District of Columbia Medicaid Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Provider Enrollment Practices

We identified 10 District of Columbia (District) Medicaid providers whose Medicare supplier numbers were in revoked status. The Department of Health Care Finance (State agency) concurred with our recommendation to implement a procedure to check the status of providers' Medicare supplier numbers and to take the appropriate action in accordance with District regulations when the Centers for Medicare & Medicaid Services has revoked a Medicare supplier's number.

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at
http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Review of Medicaid Services to Incarcerated Juveniles in the State of South Carolina During Federal Fiscal Years 2004 and 2005

For Federal fiscal years 2004 and 2005, the South Carolina Department of Health & Human Services (the Medicaid agency) claimed $881,000 ($618,000 Federal share) in costs relating to non-inpatient medical services provided to juvenile inmates of public institutions. The Medicaid agency inappropriately claimed these costs because neither the South Carolina Department of Juvenile Justice nor the Medicaid agency had adequate controls to ensure that services to inmates of public institutions were excluded from Federal financial participation in compliance with Federal requirements.

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at
http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Review of Child Delivery Claims and Newborn Claims Included in the Kansas Medicaid Family Planning Program

None of the 2,781 family planning claims related to child delivery and newborn services that were submitted by providers and claimed by the Kansas Health Policy Authority (the State agency) at the enhanced 90-percent Federal financial participation rate (90-percent FFP rate) from July 1, 2005, through June 30, 2009, were allowable pursuant to Federal requirements. As a result, the State agency received approximately $2.4 million in unallowable Federal reimbursement. Federal requirements make provisions for various specified services, including family planning, to be reimbursed at higher rates of FFP.

We recommended that the State agency (1) refund $2.4 million to the Federal Government; (2) determine the amount of Federal Medicaid funds that were improperly reimbursed at the 90-percent FFP rate for child delivery and newborn services because they did not qualify as family planning services, both before and after our audit period, and refund that amount to the Federal Government; and (3) ensure that Medicaid Management Information System edits appropriately identify claims that are ineligible for reimbursement at the 90-percent FFP rate.

In written comments on our draft report, the State agency disagreed with our finding and first recommendation and described an alternative method that it used to calculate child delivery and newborn claims. The State agency did not respond to our second recommendation and described corrective actions that it implemented to address our third recommendation. After reviewing the State agency's method of calculating child delivery and newborn claims, we revised the amount of our finding and recommended refund to $2.4 million. We maintain that our findings and recommendations, as modified, remain valid.

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555 begin_of_the_skype_highlighting 1 888-428-2555 end_of_the_skype_highlighting, Ext. 200.

Monday, May 30, 2011

Review of Select Medicare Conditions of Participation and Costs Claimed at Richards Memorial Hospital from October 1, 2004, Through September 30, 2007

Our review found that Richards Memorial Hospital (the hospital) was noncompliant with a Medicare Condition of Participation (CoP), reported unallowable costs in its Medicare cost reports, and did not properly disclose related-party rental costs. Contrary to Federal regulations, the hospital did not comply with a Medicare CoP because it did not maintain current and active network agreements with other hospitals during our audit period. The hospital also reported approximately $1 million of unallowable costs in its FYs 2005, 2006, and 2007 Medicare cost reports. Specifically, the hospital reported $804,000 in unsupported costs, $198,000 in unallocable costs, and $58,000 in costs unrelated to patient care. Additionally, the hospital did not properly disclose $213,000 in related-party rental costs in its Medicare cost reports.

We recommended that the hospital (1) establish and maintain network agreements with other hospitals; (2) revise and resubmit its FYs 2005, 2006, and 2007 Medicare cost reports to properly reflect the exclusion of the $1 million of unallowable costs and the disclosure of $213,000 of related-party rental costs; and (3) ensure that it reports only allowable costs and properly discloses related-party transactions in future Medicare cost reports. In written comments on our draft report, the hospital disagreed with our first recommendation, did not specifically address our second recommendation, and concurred with our third recommendation.

Review of Medicare Payments to Prescription Drug Plans on Behalf of Deceased Enrollees

Our review found that the Centers for Medicare & Medicaid Services (CMS) made approximately $3.61 million of unallowable payments on behalf of deceased Medicare enrollees to prescription drug plan sponsors for coverage periods after the enrollees' months of death. CMS made improper payments for 1,500 of the 2.7 million deceased enrollees (far less than 1 percent of the enrollees who died). As of January 31, 2010, $3.61 million in improper payments remained uncollected. CMS's systems categorized these enrollees as alive or as having different dates of death than those listed in the Social Security Administration's death master file. Although CMS had correctly stopped payments for the vast majority of deceased enrollees, its systems did not always identify and prevent the improper payments. In addition, CMS did not always recover payments made on behalf of deceased enrollees on a timely basis.

We recommended that CMS (1) recoup the $3.61 million in payments for deceased Medicare enrollees, (2) recover improper payments in a timely manner, and (3) implement system enhancements to prevent and detect future improper payments for deceased enrollees. CMS concurred with our recommendations but said that it believed it had recovered the $3.6 million in payments made for deceased Medicare enrollees. Nothing in CMS's comments caused us to change our findings or recommendations. As of January 2010, CMS had not recouped the payments.

Head Start Recipient Capability Audit of Pinellas Opportunity Council, Inc.

Our review found that Pinellas Opportunity Council, Inc. (POC), was financially viable. However, we identified certain issues concerning Pinellas Opportunity Council's capacity to manage and account for Federal funds and to operate its Head Start program in accordance with Federal regulations. The issues pertained to loans to related parties and improper use of Head Start funds, direct versus indirect costs, personal expenses, and conflicts of interest and family favoritism. We conducted this review because the American Recovery and Reinvestment Act of 2009 awarded additional funds to the Head Start program.

Results of Limited Scope Review at Central Oklahoma Community Action Agency, Inc.

We reviewed the financial condition of Central Oklahoma Community Action Agency, Inc. (COCAA), as part of a nationwide series of reviews of Community Action Agencies that have received funding under the American Recovery and Reinvestment Act of 2009.

Based on our assessment, COCAA has the ability to manage and account for Federal funds and is capable of operating its Community Services Block Grant (CSBG) program in accordance with Federal regulations. However, COCAA has weaknesses related to its accounting system, cost allocation plan, cost shifting, safeguarding of Federal assets, board of directors composition, financial management systems, and policies and procedures.

We recommended that the Administration for Children and Families consider the information presented in this report in assessing COCAA's ability to operate a CSBG program in accordance with Federal regulations. In written comments on our draft report, COCAA agreed with our findings and described actions it had taken to address them.

Audit of the Indian Health Service's Internal Controls Over Monitoring of Recipients' Compliance With Requirements of the Indian Health Professions Scholarship Program

Our review found that the Indian Health Service (IHS) did not have adequate internal controls to monitor recipients' compliance with certain requirements of the Indian Health Professions Scholarship program. IHS did not always follow its policies and procedures to verify that recipients completed approved education programs and that recipients were fulfilling their required service obligations. As a result, IHS could not ensure that all recipients were in compliance with program requirements. The Indian Health Professions Scholarship program provides scholarship grants (scholarships) to Indians who are enrolled full or part time in appropriately accredited schools and pursuing courses of study in the health professions. Each recipient of funds must sign a contract with IHS in which he or she agrees to complete an approved education program and fulfill a minimum active duty service obligation of 2 years.
We recommended that IHS follow its policies and procedures to verify that recipients of Indian health professions scholarships complete approved education programs and fulfill required service obligations. IHS concurred with our recommendation and described actions that it had taken or planned to take to address the recommendation.

Sunday, May 29, 2011

Audit of the Indian Health Service's Internal Controls Over Monitoring of Recipients' Compliance With Requirements of the American Indians Into Psychology Program

Our review found that IHS did not have adequate internal controls to monitor recipients' compliance with certain requirements of American Indians Into Psychology Program (Psychology Program) scholarships. IHS did not have policies and procedures to monitor whether recipients had completed their approved education programs or were fulfilling required service obligations. As a result, IHS could not ensure that all recipients were in compliance with Psychology Program scholarship requirements. Under the Psychology Program, IHS provides grants to colleges and universities to develop and maintain psychology career recruitment programs to encourage American Indians to enter the mental health field. Each recipient must maintain full-time or part-time enrollment until completion of the approved education program and fulfill a minimum service obligation.
We recommended that IHS develop and implement policies and procedures for monitoring recipients' fulfillment of education requirements and service obligations for Psychology Program scholarships. IHS concurred with our recommendation and described actions that it had taken or planned to take to address the recommendation.

To learn more about Atlantic Financial Consulting you may visit their website at

http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Modification of OIG Advisory Opinion No. 10-07

http://oig.hhs.gov/fraud/docs/advisoryopinions/2011/AdvOpn11-07.pdf

To learn more about Atlantic Financial Consulting you may visit their website at

http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Healthcare Common Procedure Coding System (HCPCS) collection instrument published in Federal Register Notice for a 60-day comment period

The Centers for Medicare & Medicaid Services (CMS) would like to inform you that the Healthcare Common Procedure Coding System (HCPCS) collection instrument has been published in the Federal Register Notice for a 60-day comment period as part of the Paperwork Reduction Act (PRA) process. You can access this publication at http://edocket.access.gpo.gov/2011/pdf/2011-10366.pdf. To obtain copies of the supporting statement and any related forms for the HCPCS collection, access CMS' Website at http://www.cms.gov/PaperworkReductionActof1995. If you have comments regarding the proposed revision of this paperwork collection please follow the instructions in the Federal Register Notice. To be assured consideration, comments and recommendations must be submitted by May 31, 2011.

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at
http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Verification of Hillcrest Baptist Medical Center's Refund of Place-of-Service Overpayments for Calendar Years 2007 Through 2009

We determined that Hillcrest Baptist Medical Center (the Hospital) submitted claims with overpayments totaling $122,000 for physician services for calendar years 2007 through 2009. The Hospital, billing on behalf of its physicians, incorrectly coded these claims by using nonfacility place-of-service codes for services that actually were performed in one of the Hospital’s outpatient facilities.

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at
http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555 , Ext. 200.

Fiscal Year 2010 Statistical Chart

Fiscal Year 2010 Statistical Chart (XLS)
http://links.govdelivery.com/track?type=click&enid=bWFpbGluZ2lkPTEzNjYwNjQmbWVzc2FnZWlkPVBSRC1CVUwtMTM2NjA2NCZkYXRhYmFzZWlkPTEwMDEmc2VyaWFsPTEyNzY2MzE5ODYmZW1haWxpZD1tYXJrc3VhbnNpbmdAZ21haWwuY29tJnVzZXJpZD1tYXJrc3VhbnNpbmdAZ21haWwuY29tJmZsPSZleHRyYT1NdWx0aXZhcmlhdGVJZD0mJiY=&&&105&&&http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/expenditures_statistics/fy2010-statistical-chart.xlsx

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Saturday, May 28, 2011

State Medicaid Fraud Control Units Fiscal Year 2010 Grant Expenditures And Statistics

In fiscal year (FY) 2010, the combined Federal and State grant expenditures for the State Medicaid Fraud Control Units (MFCU) totaled $205.5 million, of which Federal funds represented $153.8 million. The 50 MFCUs employed 1,827 individuals.

Collectively, in FY 2010, the MFCUs reported conducting 13,210 investigations, of which 9,710 were related to Medicaid fraud and 3,500 were related to patient abuse and neglect, including patient funds cases.¹ Investigations resulted in 1,603 individuals' being indicted or criminally charged: 1,048 for fraud and 555 for patient abuse and neglect. In total, 1,329 convictions were reported in FY 2010, of which 839 were related to Medicaid fraud and 490 were related to patient abuse and neglect.

In FY 2010, States reported $1.8 billion in recoveries for both civil and criminal cases handled by the 50 MFCUs.² In addition to other significant accomplishments of the MFCUs in prosecuting patient abuse and detecting and deterring fraud, this translates to a return on investment (ROI) of $8.98 per $1 expended by the Federal and State governments for operation of the MFCUs.³ The total number of civil judgments and settlements for the fiscal year was 1,077.

The MFCUs refer to OIG a significant number of cases for possible exclusion from participation in Medicare, Medicaid, and other Federal health care programs. In FY 2010, 942 of the 3,340 OIG exclusions were based on referrals made to OIG by MFCUs.

With the exception of the MFCU grant expenditures and exclusion information, which are maintained by OIG, these totals are based on information supplied by the MFCUs and have not been independently verified by OIG.

Areté Sleep to Pay the United States $650,000 to Resolve False Claims Act Allegations

WASHINGTON – Areté Sleep LLC, Areté Sleep Therapy LLC and Areté Holdings LLC have agreed to pay the United States $650,000 to settle allegations that their sleep medicine and durable medical equipment facilities in Arizona and Texas submitted false claims to Medicare, the Justice Department announced today.

Today’s settlement resolves False Claims Act allegations that, from Nov. 1, 2002, through Dec. 31, 2009, Areté made false claims to Medicare for diagnostic sleep tests performed by technicians lacking the licenses or certifications required by Medicare rules and regulations. The settlement also resolves related allegations that Areté made false claims to Medicare for medical devices resulting from these same technicians’ tests.

On Jan. 26, 2011, Areté filed voluntary petitions for relief under Chapter 11 of the Bankruptcy Code in the U.S. Bankruptcy Court in the District of Arizona. Areté has agreed to pay the False Claims Act settlement from the proceeds of the sale of its assets.

“The Department of Justice is committed to preventing waste, fraud and abuse in the Medicare program and ensuring that these funds are not spent on care that does not meet Medicare’s standards,” said Tony West, Assistant Attorney General for the Justice Department’s Civil Division.

“Cheating Medicare harms not only the health care of others but all taxpayers,” said Dennis K. Burke, U.S. Attorney for the District of Arizona. “This settlement demonstrates the ongoing efforts of our office to recover taxpayer dollars for the Medicare program.”

All three Arete entities were named as defendants in a whistleblower lawsuit brought under the False Claims Act, which permits private citizens, known as “relators,” to bring lawsuits on behalf of the United States and receive a portion of the proceeds of any settlement or judgment awarded against a defendant. Relator Amanda Drews will receive $107,250 as her share of the recovery.

“Every Medicare dollar is precious, so we expect the program will only be billed for properly provided services,” said Glenn R. Ferry, Special Agent in Charge, Los Angeles Region, Office of Inspector General (OIG) of the Department of Health & Human Services (HHS). “Maintaining the integrity of Medicare is a top OIG priority.”

The investigation and settlement were the result of a coordinated effort among the U.S. Attorney’s Office for the District of Arizona, the Commercial Litigation Branch of the Justice Department’s Civil Division and HHS-IG.

“This resolution is part of the government’s emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and HHS Secretary Kathleen Sebelius in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $5.7 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $7.3 billion.”

Houston Federal Jury Convicts Patient Recruiter of Medicare Fraud Involving Claims of Hurricane Damage to Power Wheelchairs

To Date, Six Individuals Guilty of Federal Crimes for Roles in Scheme

WASHINGTON – Marion Beverly Metoyer, a patient recruiter for a Houston durable medical equipment (DME) company, was convicted today by a Houston federal jury of health care fraud related to a power wheelchair fraud scheme, the Departments of Justice, Health and Human Services (HHS) and the FBI announced.

After a four-day trial, Metoyer, 57, of Dayton, Texas, was convicted on one count of conspiracy to commit health care fraud, three counts of health care fraud, one count of conspiring to receive illegal kickbacks for referring Medicare beneficiaries, and two counts of receiving illegal kickbacks for referring Medicare beneficiaries.

According to evidence presented at trial, Helen Etinfoh was the owner and operator of Luant & Odera Inc., a Houston-area DME company doing business as Tonni Medical Equipment & Supplies. Metoyer was a recruiter for Luant who was paid kickbacks in exchange for providing the company with beneficiaries in whose names bills could be submitted to Medicare. Etinfoh and other co-conspirators submitted false and fraudulent claims to Medicare for medically unnecessary DME, including power wheelchairs, wheelchair accessories and motorized scooters.

Evidence at trial showed that, based on representations from Metoyer and other recruiters, Luant would bill Medicare under a special code that designated the power wheelchairs as replacements for wheelchairs lost during hurricanes that hit the Houston area in fall 2008. In fact, the hurricanes did not damage the wheelchairs. Certain beneficiaries testified that they did not even have a power wheelchair before receiving the ones provided to them by Luant. Luant used the hurricane code because it allowed the company to submit claims to Medicare without a doctor’s order.

At trial, beneficiaries in whose names claims were submitted to Medicare testified that recruiters whom they had never met, including Metoyer, came to their homes and offered them free power wheelchairs in exchange for their Medicare information. The power wheelchairs were often billed to Medicare at more than $6,000 per chair.

Etinfoh was previously convicted by a federal jury of health care fraud in April 2010, and was sentenced to 41 months in prison. Paula Whitfield, a patient recruiter for Luant, was also convicted by a federal jury in April 2010, and was sentenced to 21 months in prison. Melvin Barnes, Johnnie Lee Andrews and Monica Rene Perry, each a patient recruiter for Luant, pleaded guilty to conspiracy to commit health care fraud and await sentencing.

At sentencing, Metoyer faces maximum penalties of 10 years in prison for the health care fraud conspiracy; 10 years in prison for committing health care fraud; five years in prison for conspiring to receive illegal kickbacks for referring Medicare beneficiaries; and five years in prison for receiving an illegal kickback for referring a Medicare beneficiary. A sentencing date has not been set.

Today’s guilty jury verdict was announced by Assistant Attorney General Lanny A. Breuer of the Criminal Division; U.S. Attorney José Angel Moreno of the Southern District of Texas; Acting Special Agent-In-Charge Russell D. Robinson of the FBI’s Houston Field Office; Special Agent-in-Charge Mike Fields of the Dallas Regional Office of HHS’s Office of the Inspector General (HHS-OIG), Office of Investigations; and the Texas Attorney General’s Medicaid Fraud Control Unit (MFCU).

The case was tried by Trial Attorney Laura Cordova and Assistant Chief Sam S. Sheldon of the Criminal Division’s Fraud Section. The case was brought as part of the Medicare Fraud Strike Force, supervised by the U.S. Attorney’s Office for the Southern District of Texas and the Criminal Division’s Fraud Section.

Since their inception in March 2007, Strike Force operations in nine locations have obtained indictments of 1,000 individuals who collectively have falsely billed the Medicare program for more than $2.3 billion. In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to: www.stopmedicarefraud.gov .

CMS Announces Proposed Rule for the Electronic Prescribing (eRx) Incentive Program

Overview
The Centers for Medicare & Medicaid Services (CMS) today proposed changes to the Medicare Electronic Prescribing (eRx) Incentive Program.

Background
Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended the Social Security Act to require the Secretary to establish a new reporting program that offers a combination of financial incentives and payment adjustments to eligible professionals to encourage electronic prescribing. Section 1848(m)(3)(B) of the Social Security Act (the Act), as added and amended by MIPPA, sets forth the requirements for being a successful electronic prescriber.

Although the Electronic Prescribing Incentive Program has similarities in structure and processes to the Physician Quality Reporting System (formerly the Physician Quality Reporting Initiative or PQRI), the Electronic Prescribing Incentive Program is a standalone program with distinct reporting requirements and associated incentive payments and payment adjustments.

Under the eRx Incentive Program, eligible professionals who are successful electronic prescribers can receive a 1-percent incentive payment for program years 2011 and 2012, and 0.5 percent for 2013. In addition to incentive payments, MIPPA requires a Medicare Physician Fee Schedule (PFS) payment adjustment, beginning in 2012, for eligible professionals who are not successful electronic prescribers. For the 2012 electronic prescribing payment adjustment, the fee schedule amount for covered professional services furnished by such professionals during the year shall be 1.0 percent less than the PFS amount that would otherwise apply. The PFS reductions for eligible professionals who are not successful electronic prescribers in the future are as follows: 1.5 percent for 2013 and 2.0 percent for 2014.

Provisions of the 2012 eRx Payment Adjustment Established in the 2011 MPFS Final Rule
In addition to setting forth the requirements for reporting the electronic prescribing quality measure for the 2011 eRx incentive, the calendar year (CY) 2011 Medicare Physician Fee Schedule (PFS) Final Rule, published in the Federal Register on November 29, 2010, established the program requirements for reporting the electronic prescribing quality measure for the 2012 eRx payment adjustment.

For individual eligible professionals, the 2012 eRx payment adjustment is not applicable if one of the following applies:

-          The eligible professional is not a physician (MD, DO, or podiatrist), physician assistant, certified registered nurse anesthetist, or certified nurse midwife as of June 30, 2011. This determination is based on the primary taxonomy code in the National Plan and Provider Enumeration System (NPPES);
-          The eligible professional does not have prescribing privileges and reports g-code G8644 (defined as not having prescribing privileges) at least one time on an eligible claim prior to June 30, 2011;
-          The eligible professional does not have at least 100 cases containing an encounter code in the electronic prescribing measure’s denominator;
-          The eligible professional’s total 2011 Medicare Part B PFS allowed charges for all such covered professional services submitted for the electronic prescribing measure’s denominator codes are less than 10 percent;
-          The eligible professional reports a significant hardship code and CMS determines that the hardship code applies (see “Significant Hardship Exemptions” section below); OR
-          The eligible professional is a successful electronic prescriber by reporting the electronic prescribing measure via claims for at least 10 unique electronic prescribing events for patients in the denominator of the measure between January 1, 2011 and June 30, 2011.

For a group practice participating in the eRx group practice reporting option (GPRO), the 2012 eRx payment adjustment is not applicable if:

-          The group practice reports a significant hardship code in the group practice’s 2011 self-nomination letter for participation in the Physician Quality Reporting System and the eRx Incentive Program as a group practice (see “Significant Hardship Exemptions” section below) and CMS determines that the hardship exemption applies; OR
-          The group practice is a successful electronic prescriber. Depending on the group practice’s size, the group practice is a successful electronic prescriber if the group practice reports the electronic prescribing measure via claims for at least 75–2,500 unique electronic prescribing events for patients in the denominator of the measure between January 1, 2011 and June 30, 2011.

Significant Hardship Exemption Categories. Section 1848(a)(5)(B) of the Act provides that the Secretary may, on a case-by-case basis, exempt an eligible professional from the application of the payment adjustment, if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship. In the CY 2011 PFS Final Rule, CMS established the following two significant hardship exemption categories in the form of g-codes for the 2012 eRx payment adjustment:

-          The eligible professional practices in a rural area without sufficient high speed internet access (report code G8642);
-          The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing (report code G8643).

In order to request a significant hardship exemption from the 2012 eRx payment adjustment via one of the two significant hardship g-codes mentioned above, the eligible professional or group practice must report the g-code at least one time on a claim between January 1, 2011 and June 30, 2011.

Proposed Changes to the Medicare eRx Incentive Program
Since publication of the CY 2011 PFS Final Rule, CMS has received requests to better align the eRx Incentive Program with the Medicare and Medicaid EHR Incentive Programs, as well as suggestions that we expand the significant hardship exemption categories. To address these concerns, the proposed rule announced today would do the following:

Modify the existing 2011 electronic prescribing measure to address the technological requirements of the Medicare eRx Incentive Program: The description statement of the existing 2011 electronic prescribing measure (the electronic prescribing quality measure used for certain reporting periods in 2011) would be revised to also recognize as certified electronic health record (EHR) technology as defined at 45 CFR 170.102 as a “qualified” eRx prescribing system. This proposed change to the 2011 electronic prescribing measure provides eligible professionals and groups participating in the eRx Incentive Program with the option of adopting either a qualified eRx system or certified EHR technology.

Provide additional significant hardship exemption categories for the 2012 e-Rx payment adjustment: The eligible professional or group practice would need to, in its significant hardship exemption request, demonstrate that one of these situations applies to the respective practice:

-          Eligible professionals who register to participate in the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program and adopt certified EHR technology;
-          Inability to electronically prescribe due to local, state, or federal law;
-          Limited prescribing activity; or
-          Insufficient opportunities to report the electronic prescribing measure due to limitations of the measure’s denominator.

Extend the deadline to request a significant hardship exemption for the two hardship exemption categories finalized in the CY 2011 MPFS final rule to October 1, 2011. This deadline would apply to the two significant hardship exemption categories established in the CY 2011 MPFS Final Rule, as well as to the proposed additional significant hardship exemption categories.

Allow submission of significant hardship exemption requests for the 2012 eRx payment adjustment via a web-based tool (if CMS is able to develop such a tool) or a mailed letter.

CMS’ proposed rule may be viewed at: http://www.ofr.gov/OFRUpload/OFRData/2011-13463_Pl.pdf

A news release sheet on the proposed rule may be viewed here: http://www.cms.hhs.gov/apps/media/press_releases.asp
.

Updated Criminal and Civil Enforcement Actions

http://oig.hhs.gov/fraud/enforcement/criminal/index.asp

To learn more about Atlantic Financial Consulting you may visit their website at http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555 begin_of_the_skype_highlighting 1 888-428-2555 end_of_the_skype_highlighting, Ext. 200.

Friday, May 27, 2011

8.25.2009: NBC 4 Connolly will not hurt Medicare

Uploaded by RepConnolly on Aug 26, 2009

Congressman Connolly addressed over 400 Greenspring residents at his recent health care forum. Congressman Connnolly assured his constituents that he will not vote for any health care bill that will harm Medicare.

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Tuesday, May 31, 2011

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Friday, May 27, 2011