Helping Physicians Navigate The Healthcare Industry: July 2011

Sunday, July 31, 2011

Health Care Reform, part 3 The Solution

Uploaded by WAPolicyCenter on Jul 29, 2009
As our government considers a serious overhaul of our health care system and even a public insurance plan, it is essential that the public understands how more government involvement will impact accessibility, affordability, and quality. Under the direction of Dr. Roger Stark, a retired surgeon with over thirty years of medical experience, Washington Policy Center has launched its 2009 Federal Health Care Reform Project. As part of this project, WPC created these three short, informative health care videos detailing the current state of health care in the U.S., Congress proposed reforms, and practical solutions to the health care crisis. Health care reform is far too important of an issue to be settled outside of the public light. Please forward these videos to your friends and all those who are interested in true health care reform. Consider embedding/linking these videos on your website. We must keep patients in charge of their own health care!

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.

2010-2011 Influenza Season Week 29 ending July 23, 2011

All data are preliminary and may change as more reports are received.

U.S. Virologic Surveillance:

WHO and NREVSS collaborating laboratories located in all 50 states and Washington, D.C. report to CDC the number of respiratory specimens tested for influenza and the number positive by influenza type and subtype.

http://www.cdc.gov/flu/weekly/?source=govdelivery

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, July 30, 2011

What Does Health Care Reform Mean for You

Uploaded by plannedparenthood on Apr 22, 2010
Health care reform is now law. But what exactly does it mean for you? Julianne Moore explains what's in the law and how it advances women's health care.

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.

Friday, July 29, 2011

Comparison of Fourth-Quarter 2010 Average Sales Prices and Average Manufacturer Prices: Impact on Medicare Reimbursement for Second Quarter 2011 (OEI-03-11-00360)

We identified 30 Healthcare Common Procedure Coding System (HCPCS) codes with average sales prices (ASP) that exceeded average manufacturer prices (AMP) by at least 5 percent in the fourth quarter of 2010. Of these 30 HCPCS codes, 15 had complete AMP data (i.e., AMP data for every drug product that CMS used to establish reimbursement amounts). If reimbursement amounts for all 15 codes with complete AMP data had been based on 103 percent of the AMPs during the second quarter of 2011, we estimate that Medicare expenditures would have been reduced by $1.3 million in that quarter alone.

By law, OIG must notify the Secretary of Health & Human Services if the ASP for a particular drug exceeds the drug's AMP by a threshold of 5 percent. If that threshold is met, the Secretary may disregard the ASP for the drug when setting reimbursement and shall substitute the payment amount with the lesser of either the widely available market price or 103 percent of the AMP.

This is OIG's 22nd report comparing ASPs to AMPs. OIG has consistently recommended that CMS develop a price substitution policy and subsequently lower reimbursement for drugs that exceed the 5-percent threshold. Although CMS has yet to make any changes to Part B drug reimbursement as a result of these studies, the agency published a proposed rule in July 2011 that, among other things, specifies the circumstances under which AMP-based price substitutions would occur. CMS plans to implement its price substitution policy beginning in the first quarter of 2012.

If CMS's proposed price substitution policy had been in effect, reimbursement amounts for 5 of the 15 drugs would have been reduced, saving an estimated $554,000. The remaining 15 of 30 HCPCS codes also met the 5-percent threshold in the fourth quarter of 2010 but did not have AMP data for every drug product that CMS used when calculating reimbursement. Although CMS's proposed price substitution policy would not apply to codes with partial AMP data, price reductions for 5 of the 15 HCPCS codes may be legitimately warranted because missing AMPs likely had little influence on the pricing comparison results for these codes. We could not compare ASPs and AMPs for an additional 61 HCPCS codes because AMP data were not submitted for any of the drug products that CMS used to calculate reimbursement. Manufacturers for 17 percent of those drug products had Medicaid drug rebate agreements and were therefore generally required to submit AMPs.

http://oig.hhs.gov/oei/reports/oei-03-11-00360.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, Ext. 200.

CMCS Special Assistant Job Postings

CMCS is currently hiring for two Special Assistant jobs working with Center Director Cindy Mann (in the DC office) and Deputy Center Director Penny Thompson (in the Baltimore office). We are looking for smart, committed individuals to come join us.

The job involves:
· Ensuring that the Center Director/Deputy Director is briefed and prepared for the events of each day
· Facilitating problem solving for the Director/Deputy Director as critical issues emerge
· Completing quick turnaround research and data assignments and requests for information and/or comments
· Ensuring follow-up on Center Director/Deputy Director priorities
· facilitating and monitoring calendar requests
· Coordinating and completing special projects on behalf of the Center Director/Deputy Director
· Preparing briefing papers, talking points, slides and other materials for the Center Director/Deputy Director
· Monitoring and briefing the Center Director/Deputy Director on press and research reports relating to the work of the Center
· Serving as liaison to other CMS and HHS components
· Working closely with other Office of the Center Director staff

The posting is available at:

http://jobview.usajobs.gov/GetJob.aspx?JobID=100823720&JobTitle=Health+Insurance+Specialist&rad_units=miles&brd=3876&pp=25&sort=rv%2c-dtex&jbf574=HE70&jbf785=&vw=b&re=134&FedEmp=N&FedPub=Y&caller=advanced.aspx&AVSDM=2011-07-15+07%3a36%3a00
Applications must be submitted by Thursday, July 28, 2011.

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.

2010-2011 Influenza Season Week 28 ending July 16, 2011

http://www.cdc.gov/flu/weekly/?source=govdelivery

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.

Thursday, July 28, 2011

National Provider Call: Medicare and Medicaid EHR Incentive Programs: Understanding Meaningful Use – Register Today

Thursday, August 18; 1:30-3pm ET

Registration is now open for a CMS National Provider Call on the Medicare
and Medicaid EHR Incentive Program meaningful use requirements. Providers
have received more than $273 million in Medicare and Medicaid EHR incentive
payments. You may be eligible for a payment, too.

Agenda:

* Defining “Meaningful Use”
* The requirements for Stage 1 of Meaningful Use (2011 and 2012)
* Attestation for Meaningful Use
* Goals of the Meaningful Use Objectives Specification Sheets

* Stage 1 EHR Meaningful Use Specification Sheets for Eligible
Professionals
<https://www.cms.gov/EHRIncentivePrograms/Downloads/EP-MU-TOC.pdf>
* Stage 1 EHR Meaningful Use Specification Sheets for Eligible
Hospitals
<https://www.cms.gov/EHRIncentivePrograms/Downloads/Hosp_CAH_MU-TOC.pdf>

* A question and answer session

Registration Information – In order to receive the call-in information, you
must register for the call. Registration will close at 1:30pm on Wednesday,
August 17 or when available space has been filled; no exceptions will be
made, so please register early. For more details, including instructions on
registering for the call, please visit
http://www.eventsvc.com/palmettogba/081811
<http://www.eventsvc.com/palmettogba/081811> .

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.

Grants.gov Quarterly Webcast Features Presentation on Grants Fraud Prevention - July 2011

In the July 2011 Grants.gov quarterly webcast, Ken Dieffenbach, Senior Special Agent, U.S. Department of Justice, Office of the Inspector General, Fraud Detection Office and Special Agent Brandon Trice, U.S. Department of Health and Human Services, Office of Inspector General, give a special presentation on grants fraud prevention that highlights three areas of interest; conflicts of interest, misuse of funds, and embezzlement. The session runs one hour and three minutes and includes discussion with audience questions.

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.

2011 Physician Quality Reporting System & Electronic Prescribing Incentive Program National Provider Call to be held on August 16, 2011

Tuesday, August 16; 1:30-3pm ET

The Centers for Medicare & Medicaid Services (CMS) will host a national provider call on the Physician Quality Reporting System & Electronic Prescribing Incentive Program. A question and answer session will follow the presentation. Agenda:Overview of the 2010 Incentive Payments and Feedback Reports for Physician Quality Reporting System; Overview of the 2010 Incentive Payments and Feedback Reports for Electronic Prescribing Incentive Program; andQuestion & Answer Session. Registration Information – Will be made available soon, and will be shared via listserv announcement and at http://www.cms.gov/PQRS/04_CMSSponsoredCalls.asp on the CMS website. Presentation: The presentation will be posted at least one day before the call at: http://www.cms.gov/PQRS/04_CMSSponsoredCalls.asp in the “Downloads” section on the CMS website.

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.

Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) Meetings

9/21/2011 - Anti-VEGF Treatment of Diabetic Macular Edema
Announced meeting
http://www.cms.gov/medicare-coverage-database/details/medcac-meeting-details.aspx?MEDCACId=59

Medicare Approved Facilities/Trials/Registries

Bariatric Surgery
Updated list
http://www.cms.gov/MedicareApprovedFacilitie/BSF/list.asp#TopOfPage

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 Reform - Affording Health Care

Uploaded by ZocDocVideo on Feb 23, 2010
The ZocDoc interns went on a mission to find out just how much health care costs, and what you can do to afford it.

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.

Centers for Medicare & Medicaid Services (CMS) Cms.hhs.gov- Electronic Health Records Demonstration Update

http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1204776

Now available! As part of the independent evaluation of the EHR Demonstration, CMS' contractor, Mathematica Policy Research (MPR), has written a report on the first year's implementation of the EHR demonstration. Scroll down to the bottom of the page to the "Related Links Inside CMS" section and click on the link for the report.

Electronic Health Records Demonstration Summary

The Secretary of the Department of Health and Human Services has directed the Centers for Medicare & Medicaid Services to develop a new demonstration initiative using Medicare waiver authority to reward the delivery of high-quality care supported by the adoption and use of electronic health records (EHR). The goal of this demonstration is to foster the implementation and adoption of EHRs and health information technology (HIT) more broadly as effective vehicles to improve the quality of care provided and transform the way medicine is practiced and delivered. Adoption of HIT has the potential to provide significant savings to the Medicare program and improve the quality of care rendered to Medicare beneficiaries. This demonstration is designed to leverage the combined forces of private and public payers to drive physician practices to widespread adoption and use of EHRs.

As part of this new demonstration, all participating primary care physician practices will be required to have a Certification Commission for Healthcare Information Technology (CCHIT)-certified EHR by the end of the second year. (CCHIT is the recognized certification authority for EHRs and their networks.) Physician practices must, as part of the demonstration, be utilizing the EHR to perform specific minimum core functionalities that can positively impact patient care processes, (e.g., clinical documentation, ordering of lab tests, recording lab tests, and recording of prescriptions). However, the core incentive payment will be based on performance on the quality measures, with an enhanced bonus based on the degree of HIT functionality used to manage care.

The Electronic Health Record demonstration will be operational for a 5-year period. The first operational year of the demonstration will provide payments to participating practices based on CCHIT-certified EHR functionalities used to manage the care of patients, with higher payment for more sophisticated HIT use (e.g., use of the EHR to facilitate care management activities, sharing of records among providers of care, etc.). Payments will be determined by a practice's score on the Office Systems Survey (OSS), which will be administered annually to track the status of EHR implementation at the practice level, and the specific EHR functions employed by each participating practice to support the delivery of care. Higher scores on the OSS will result in increased incentive payments to participating practices.

During the second operational year of the demonstration, payments will be made to participating physician practices that are using CCHIT-certified EHRs and reporting clinical quality measures, again with additional payments based on EHR functionalities employed by the practice. During years 3 to 5 of the demonstration, payments to participating practices will be based on performance on the designated clinical quality measures, with an added bonus each year based on the degree to which the practice has used the EHR to change and improve the way it operates.

The Centers for Medicare & Medicaid Services (CMS) solicited partners interested in working with CMS to implement the Electronic Health Records (EHR) Demonstration in their communities. The role of the community partner is to assist CMS with outreach activities, education and recruitment of eligible primary care physician practices in their defined communities. Community partners will also collaborate with CMS on an ongoing basis in an effort to assist us in achieving our goal of leveraging the combined forces of private and public payers to drive physician practices to widespread adoption and use of EHRs. CMS sought strong organizational entities that have the necessary infrastructure and a clear commitment to advancing the adoption of EHRs and are capable of supporting CMS in these activities

Status

On June 10, 2008 CMS announced the selection of 12 community partners in defined sites to help CMS implement this demonstration. The approved community partners in each site represent diverse collaborations of organizations including, but not limited to: varied HIT stakeholder collaborations, medical societies, primary care professional organizations and health departments. The demonstration was initially planned to be implemented in two phases. Phase I includes the following 4 sites: Louisiana, Southwest Pennsylvania, South Dakota (and some counties in bordering states), and Maryland and the District of Columbia. Phase 2 included 8 additional sites and was scheduled to follow one year later. Recruitment of physician practices in the four Phase I sites was initiated on September 2, 2008, and the enrollment period closed on November 26, 2008. Over 800 eligible applications were received from interested practices in the four Phase I sites.

On April 7, 2009 CMS announced that, as a result of the incentive provisions for physicians to encourage the adoption of health information technology in the American Recovery and Reinvestment Act 0f 2009 (ARRA), CMS would change its plans for implementing the EHR Demonstration. Specifically, we decided to continue implementation of Phase I of the EHR Demonstration but discontinue Phase II of the EHR demonstration, which originally was planned to begin operations in mid-2010. Phase 1 of the demonstration began as scheduled on June 1, 2009 and will continue through May 31, 2014.

Contact

For additional information, please contact the following mailbox resource: EHR_Demo@cms.hhs.gov

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 the Pension Segmentation Requirements for the Local 153 Pension Plan at Group Health Incorporated for the Period of April 1, 1987, to January 1, 2009 (A-07-11-00358)

Group Health Incorporated (GHI), an EmblemHealth Company and Centers for Medicare & Medicaid Services (CMS) contractor, overstated the Medicare segment pension assets by $12.6 million for the period of April 1, 1987, to January 1, 2009. GHI administered Medicare Part B operations under cost reimbursement contracts with CMS.

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.

Wednesday, July 27, 2011

Review of Medicaid Administrative Costs Claimed for the Pennsylvania Department of Aging's Healthy Steps Program (A-03-10-00205)

The State did not comply with Federal requirements when it claimed Medicaid administrative costs for the Healthy Steps for Older Adults program (Healthy Steps). The claimed costs were for Department of Aging payments for services to help older adults remain active and not for the administration of the Medicaid program. Accordingly, the State's claims of $2.4 million ($1.2 million Federal share) in Healthy Steps costs for State fiscal years 2007 through 2009 were unallowable.

Federal law permits States to claim Federal reimbursement for Medicaid administrative costs. These costs must be "for the proper and efficient administration of the State plan." In a December 1994 letter to State Medicaid directors, the Centers for Medicare & Medicaid Services (formerly the Health Care Financing Administration) clarified its position on State claims for administrative costs, stating that "allowable claims must be directly related to the administration of the Medicaid program."

We recommended that the State (1) refund $1.2 million in Federal funds for unallowable Healthy Steps costs, (2) refund the Federal share of unallowable Healthy Steps costs claimed after our audit period, and (3) discontinue all future claims for Healthy Steps costs. The State did not comment on our recommendations.

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 Fee-for-Service Payments Made by Palmetto Government Benefit Administrators for Medicare Advantage Enrollees During Calendar Years 2007 and 2008 (A-07-11-05012)

Medicare fee-for-service payments made by Palmetto Government Benefit Administrators (Palmetto), a Centers for Medicare & Medicaid Services contractor, to hospitals for inpatient services furnished to Medicare Advantage enrollees did not always comply with Federal regulations. Palmetto made $978,000 in unallowable payments to hospitals for inpatient claims for beneficiaries who were enrolled in Medicare Advantage plans.

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 Fee-for-Service Payments Made by TrailBlazer Health Enterprises, LLC, for Medicare Advantage Enrollees During Calendar Years 2007 and 2008 (A-07-11-05013)

Medicare fee-for-service payments made by TrailBlazer Health Enterprises, LLC (TrailBlazer), a Centers for Medicare & Medicaid Services contractor, to hospitals for inpatient services furnished to Medicare Advantage enrollees did not always comply with Federal regulations. TrailBlazer made $472,000 in unallowable payments to hospitals for inpatient claims for beneficiaries who were enrolled in Medicare Advantage plans.

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.

2010 health care law

Uploaded by expo20111 on Feb 24, 2011
video on the constitutionality of the 2010 Health Care Reform Law

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 Administrative Costs Claimed for the Pennsylvania Department of Aging's Direct Care Worker Initiative (A-03-10-00206)

The State did not comply with Federal requirements when it claimed Medicaid administrative costs for the Direct Care Worker Initiative (Initiative). The claimed costs were supplemental to payments to direct care workers for direct medical services and included training and other nonadministrative expenses. These costs were not incurred to operate the Medicaid program, and the Centers for Medicare & Medicaid Services specifically prohibits claiming them as administrative costs. Accordingly, the State claims totaling $3.5 million ($1.7 million Federal share) in unauthorized Initiative costs for State fiscal years 2007 through 2009 were unallowable.

We recommended that the State (1) refund $1.7 million in Federal funds for unallowable Initiative costs, (2) refund the Federal share of unallowable Initiative costs claimed after our audit period, and (3) discontinue all future claims of Initiative costs. The State did not directly address our recommendations.

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.

Tuesday, July 26, 2011

Review of Medicaid Expenditures for Medicare Part A and Part B Premiums in Missouri (A-07-10-03158)

The Missouri Department of Social Services (State agency) overclaimed $2.1 million ($1.5 million Federal share) in Medicaid expenditures for Medicare Part B premiums during fiscal year 2009. Specifically, the State agency made calculation errors when completing Form CMS-64, Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64 report). The CMS-64 report is an accounting statement that the State agency must submit to CMS within 30 days after the end of each quarter. The expenditures reported on the CMS-64 report and its attachments must represent actual expenditures for which all supporting documentation, in readily reviewable form, has been compiled and that is available at the time the claim is filed. In addition, the State agency must maintain an accounting system and supporting fiscal records to assure that claims reported on the CMS-64 report are in accordance with applicable Federal requirements. The State agency claimed the Medicaid expenditures for Medicare Part A premiums pursuant to Federal requirements

We recommended that the State agency (1) refund $1.5 million to the Federal Government for overclaimed Medicaid expenditures for Medicare Part B premiums and (2) strengthen internal controls to ensure that all Medicaid expenditures claimed for Federal reimbursement are in accordance with Federal requirements. The State agency agreed with our recommendations and described corrective actions that it had taken.

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.

Pemiscot County Woman Pleads Guilty In Medicaid Fraud Case

Jefferson City, Mo.— Attorney General Chris Koster said today that Kristi M. Smith, a provisionally licensed professional counselor in Caruthersville, has pleaded guilty to one count each of Medicaid fraud, forgery, and stealing by deceit. Each of the charges is a class C felony.

Smith admitted that she submitted claims for payment to Medicaid for children’s counseling services she did not perform. Smith also admitted that she presented documents with forged signatures as genuine in order to support the fraudulent claims. The Honorable Fred Copeland accepted the plea and set sentencing for September 20.

Koster said his Medicaid Fraud Control Unit investigated the case and found that between November 2009 and September 2010, Smith billed the state for more than $3,264 in false claims.

"One of my top priorities as Attorney General is to prosecute those who are cheating Missouri's Medicaid system," Koster said. “This kind of illegal conduct denies medical resources that would otherwise be directed to truly needy Missourians. Those who would steal from Missouri's Medicaid system should understand this conduct will no longer be tolerated."

Koster said Smith is charged with three Class C felonies, punishable by up to seven years imprisonment and fines for each count. The court also may order restitution to the state of the amount defrauded and reimbursement of the costs of bringing the prosecution, plus civil penalties and damages.

Koster said citizens should report suspected Medicaid provider fraud or abuse and neglect to his Medicaid Fraud Hotline toll free at 800-286-3932, e-mail the complaint to attorney.general@ago.mo.gov or complete a complaint form at the Attorney General’s Medicaid Fraud Website athttp://www.ago.mo.gov/divisions/medicaid-fraud-control-unit-faqs.htm.

Koster commended Assistant Attorneys General Justine Finney Guyer and Arvids Petersons for their work on the case.

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.

EMREHR Medicare Incentives in the HITECH Act

Uploaded by TheFoxGroup on Oct 19, 2009
Point by point overview for physician practices regarding the incentives, eligibility rules, and deadlines in the HITECH Act.

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.

Usman Added to the Most Wanted Fugitives List

This Web page contains information about OIG's most wanted health care fugitives. In all, we are seeking more than 170 fugitives on charges related to health care fraud and abuse.

Click any of the photos below for more information about the fugitives or view captured fugitives.

http://oig.hhs.gov/fraud/fugitives/

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.

Last Chance to Register for theICD-10 Implementation Strategies for Physicians National Provider Call

Join Us: Wednesday, August 3, 2011 from 1-3 pm ET Is your office preparing for a smooth transition to ICD-10 on October 1, 2013? The Centers for Medicare & Medicaid Services (CMS) will host a National Provider Call on "ICD-10 Implementation Strategies for Physicians." CMS subject matter experts will discuss ways that physician offices can prepare for the change to ICD-10 for medical diagnosis and inpatient procedure coding. In addition to this presentation for Medicare fee-for-service (FFS) providers, there will also be an update on national ICD-10 implementation issues affecting all providers. A question and answer session will follow the presentations. Agenda:· ICD-10 requirements and resources overview· Implementation strategies for physician offices· Update on coverage conversion activities· National ICD-10 implementation issues· Update on bill processing, including claims that span the implementation date· Update on Home Health Agency Home Health Resource Grouper Target Audience: Physicians, physician office staff, provider billing staff, medical coders, health records staff, vendors, educators, system maintainers, laboratories, and all Medicare FFS providers. Registration:To register for this informative session, please go to http://www.cms.gov/ICD10/Tel10/itemdetail.asp?itemID=CMS1249632&intNumPerPage=10 on the CMS website. Registration will close on Tuesday, Aug 2nd at 1pm ET or when available space has been filled. No exceptions will be made. Please register early.

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.

Two Corporate Integrity Agreements Added to CIA List

http://oig.hhs.gov/compliance/corporate-integrity-agreements/cia-documents.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, Ext. 200.

Nebraska Medicaid Payments for Personal Care Services (A-07-10-03152)

Based on our random sample and the results of our computer data match, we estimated that Nebraska improperly claimed a total of $275,000 ($169,000 Federal share) in Medicaid reimbursement for personal care services (PCS) from January 1, 2007, through June 30, 2009. In addition, based on the potentially unallowable portion of the claims that we identified in our random sample, we estimated that the State agency claimed $7.4 million ($4.5 million Federal share) for PCS that may not have been allowable in accordance with Federal and State requirements.

Of the 100 paid claims in our random sample, portions of 11 claims were not allowable because of inaccurate or missing documentation, and portions of 87 claims may have been unallowable because providers' billing documentation differed significantly from the beneficiaries' Service Needs Assessment/Plans. In addition, our computer data match identified 464 instances in which providers billed for PCS during the beneficiaries' inpatient hospital stays, contrary to Federal and State requirements.

We recommended that Nebraska (1) refund $169,000 to the Federal Government; (2) work with the Centers for Medicare & Medicaid Services to determine whether payment and service documentation fully complied with Federal and State requirements and, if not, determine what portion of the $4.5 million (Federal share) in set-aside costs should be refunded to the Federal Government; and (3) strengthen controls by developing policies and procedures for more substantive documentation and prepayment and postpayment claim review to ensure that PCS claims are reviewed and paid in accordance with Federal and State requirements. In written comments on our draft report, Nebraska described corrective action that it had taken or planned to take.

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 Fee-for-Service Payments Made by National Government Services, Inc., for Medicare Advantage Enrollees During Calendar Years 2007 and 2008 (A-07-11-05010)

Medicare fee-for-service payments made by National Government Services, Inc. (NGS), a Centers for Medicare & Medicaid Services contractor, during calendar years 2007 and 2008 to hospitals for inpatient services furnished to Medicare Advantage enrollees did not always comply with Federal regulations. NGS made $133,000 in unallowable payments to hospitals for inpatient claims for beneficiaries who were enrolled in Medicare Advantage plans.

http://oig.hhs.gov/oas/reports/region7/71105010.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, Ext. 200.

Monday, July 25, 2011

Medicare Compliance Review of Cape Cod Hospital for Calendar Years 2008 and 2009 (A-01-10-00530)

Cape Cod Hospital (the Hospital) complied with Medicare billing requirements for 178 of the 382 claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for selected inpatient and outpatient claims in other areas. Specifically, of 382 sampled claims, 204 claims had errors in overpayments totaling $379,000 for calendar years 2008 and 2009. Overpayments occurred primarily because the Hospital did not have adequate controls to prevent incorrect billing of Medicare claims and did not fully understand Medicare billing requirements.

http://oig.hhs.gov/oas/reports/region10/11000530.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, Ext. 200.

Replacing Average Wholesale Price: Medicaid Drug Payment Policy (OEI-03-11-00060)

Of the 45 States that used average wholesale price (AWP) to set reimbursement for prescription drugs in the first quarter of 2011, 20 States did not have definitive plans for prescription drug reimbursement after First DataBank stops publishing AWPs in September 2011.

Federal regulations require that Medicaid reimbursement amounts for prescription drugs not exceed the lower of (1) the estimated acquisition cost plus a dispensing fee or (2) the provider's usual and customary charge to the public for the drug. CMS allows States flexibility in determining the estimated acquisition cost. Most States estimated the acquisition cost based on AWP; many of these States obtained AWP data from the pricing compendium published by First DataBank. Following a lawsuit, First DataBank decided to stop publishing AWPs no later than September 26, 2011. We sent surveys that asked States to describe how they intend to set reimbursement after First DataBank stops publishing AWPs and to describe the role they would prefer CMS play in developing Medicaid reimbursement methodologies. We also interviewed CMS staff to determine whether the agency had provided guidance to all States regarding recent AWP issues.

Of the 45 States with AWP-based reimbursement methodologies, 3 had developed plans to replace AWP with average acquisition cost, 12 to replace AWP with wholesale acquisition cost, and 10 to use AWP from a source other than First DataBank. Most States (44 of 51) would prefer that CMS develop a single national benchmark to set Medicaid reimbursement rates, and 24 of these States specifically wanted a benchmark based on pharmacy acquisition costs. Based on our interview with CMS staff, the agency has not yet provided uniform guidance about options for Medicaid reimbursement after AWPs are no longer available from First DataBank, but is taking steps to address this issue and plans to provide guidance to States in the future.

First DataBank's plan to cease publication of AWPs has forced many States to reevaluate how they will pay for prescription drugs and presents them with the opportunity to move to new reimbursement methodologies that could better reflect pharmacy acquisition costs. Therefore, we recommend that CMS develop a national benchmark that accurately estimates acquisition cost and encourage States to consider it when determining Medicaid reimbursement for prescription drugs. CMS concurred with our 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.

Podcast: Medicare Hospices That Focus on Nursing Facility Residents

July 19, 2011 Podcast
Jodi Nudelman, Region II Inspector General for Evaluation and Inspections in New York, is interviewed by Roberta Baskin, OIG Director of Media Communications

http://oig.hhs.gov/newsroom/podcasts/index.asp#nudelman

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.

Medicare Hospices That Focus on Nursing Facility Residents (OEI-02-10-00070)

Medicare spending on hospice care for nursing facility residents has grown nearly 70 percent since 2005. Additionally, hundreds of hospices had a high percentage of their beneficiaries residing in nursing facilities, and most of these hospices were for-profit. Compared to hospices nationwide, these high-percentage hospices received more Medicare payments and served beneficiaries who spent more time in care. High percentage hospices typically enrolled beneficiaries whose diagnoses required less complex care and who already lived in nursing facilities before they elected hospice care.

Medicare currently pays hospices the same rate for care provided in nursing facilities as it does for care provided in other settings, such as private homes. Unlike private homes, nursing facilities are staffed with professional caregivers and are often paid by third party payers, such as Medicaid. These facilities are required to provide personal care services, which are similar to hospice aide services that are paid for under the hospice benefit.

Some hospices may be seeking beneficiaries with particular characteristics, including those with conditions associated with longer but less complex care. Such beneficiaries are often found in nursing facilities. By serving these beneficiaries for longer periods, the hospices receive more Medicare payments, which can contribute to larger profits.

We recommend that CMS (1) monitor hospices that depend heavily on nursing facility residents and (2) modify the payment system for hospice care in nursing facilities. CMS concurred with both of our recommendations. It also agreed that the current payment structure may provide incentives for hospices to seek out beneficiaries in nursing facilities, who often receive longer but less complex care.

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.

Spotlight on Hospice Care Claim Problems

The goal of hospice care is to help terminally ill beneficiaries continue life with minimal disruption and to support beneficiaries' families and caregivers throughout the entire process. It includes pain control, symptom management, and counseling for beneficiaries and their families in an effort to make the last days of a beneficiary's life as comfortable as possible. Clearly, this type of care is both important and personal, yet hospice care in the Medicare program does not escape the problems of fraud, waste, and abuse. This spotlight page highlights this issue and the Office of Inspector General's (OIG) efforts to eliminate it.

What is the Medicare hospice benefit?

To be eligible for Medicare hospice care, a beneficiary must be entitled to Part A of Medicare and be certified as having a terminal illness with a life expectancy of 6 months or less. The hospice care may be provided in various settings, including the home or a nursing facility. This care is palliative—improving quality of life—rather than curative—curing the illness.

What is the status of the Medicare hospice benefit?

A nurse checks an elderly man's heartrate

Medicare is paying more and more each year for hospice care. Between 2005 and 2009, hospice payments increased 53 percent. Payments for hospice care in nursing facilities rose even faster: nearly a 70-percent increase over the same years.

There are also more hospices providing care to Medicare beneficiaries, and an ever greater percentage are for-profit hospices. In 2009, more than half of Medicare hospices (56 percent) were for-profit, up from 13 percent in 1992.

In addition, there are compliance issues with hospice claims and Medicare requirements. Eighty-two percent of hospice claims for beneficiaries residing in nursing facilities did not meet Medicare coverage requirements in 2009, totaling $1.8 billion. (

Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance With Medicare Coverage Requirements) Sixty-three percent of Medicare hospice claims did not meet the plan-of-care guidelines, which state that hospices must establish a plan of care for each beneficiary describing what is supposed to be done, by whom, at what time, and for what purpose.

Also, OIG found that in 46% of all hospices surveyed, health deficiencies were cited most often in regard to patient care quality and planning.

Why are some hospices seeking out nursing facility residents?

A recent OIG report (Medicare Hospices That Focus on Nursing Facility Residents, OEI-02-10-00070) found that hundreds of hospices had more than two-thirds of their beneficiaries residing in nursing facilities in 2009. These "high-percentage hospices" typically served beneficiaries who required less complex care than other beneficiaries but required hospice care for longer periods. By serving beneficiaries for longer periods, these hospices billed Medicare more per beneficiary, on average, which can mean larger profits. The numbers reflect this; compared to the overall pool of hospices, high-percentage hospices are more likely to be for-profit.

What does OIG recommend to address this issue?

This report shows that the current payment structure provides incentives for hospices to seek out beneficiaries in nursing facilities, who often receive less complex care but receive it for longer periods. Accordingly, OIG recommends that the Centers for Medicare & Medicaid Services (CMS):

monitor hospices that depend heavily on nursing facility residents and
reduce Medicare payments for hospice care provided in nursing facilities.

CMS concurred with these recommendations. For more information, see the full report.

What other work has OIG done related to hospice care?

A nurse checks an elderly man's breathing

OIG's work in the hospice care area is not new. For example, in 1999, OIG issued compliance guidance for hospices. In 2001, an advisory opinion was posted concerning a payment arrangement between a Medicare-certified hospice and certain nursing facilities for services provided to residents of such facilities who are eligible both for Medicaid and Medicare hospice benefits ("dually eligibles").

Earlier this year, OIG published an audit regarding Medicare hospice payments made by the Massachusetts Executive Office of Health and Human Services, pointing out various errors totaling $1.7 million in overpayments.

Also, several enforcement actions have been related to hospices. Examples are highlighted below:

SouthernCare Inc. , an Alabama-based company, and its shareholders allegedly submitted false claims to the Government for hospice patients who were not eligible for such care. In 2009, SouthernCare Inc. agreed to pay a total of $24.7 million to settle allegations and enter into a corporate integrity agreement (CIA) with OIG.
Roberto Ruiz, M.D., and his company, Southwest Internal Medicine Group, P.C., entered into an integrity agreement with OIG in 2009 to resolve charges of submitting false claims to Medicare for hospice services. The agreement requires written policies, employee education, and annual audits. He also paid $525,000 to resolve his civil liability.
In 2008, Solaris Hospice, Inc. , formerly Home Hospice of North Texas, and its two owners agreed to pay $500,000 plus interest to resolve allegations that Solaris submitted improper claims for hospice-related items and services. The improper claims included, for example, alleged misrepresentation to Medicare of the medical conditions of patients to ensure that they would be or continue to be hospice patients. Also, Solaris Healthcare, the parent company of Solaris, agreed to enter a 5-year CIA with OIG.

What does OIG plan to do from here?

OIG will continue to monitor hospice care in the Medicare program and take action against those who break the rules. OIG also has some forthcoming reports planned, including:

investigating the business relationships between high-percentage hospices and nursing facilities and the way hospice services are marketed and
assessing the appropriateness of hospices' general inpatient care claims and hospice beneficiaries' drug claims under Part D.

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.

National Provider Call on Medicare and Medicaid EHR

Incentive Programs: Understanding Meaningful Use

Thu Aug 18; 1:30-3pm ET

Providers have received more than $273 million in Medicare and Medicaid EHR
incentive payments. You may be eligible for a payment, too. Join CMS for a
National Provider Call on the Medicare and Medicaid EHR Incentive Program
meaningful use requirements.

Agenda:

* Defining “Meaningful Use”
* The requirements for Stage 1 of Meaningful Use (2011 and 2012)
* Attestation for Meaningful Use
* Goals of the Meaningful Use Objectives Specification Sheets

* Stage 1 EHR Meaningful Use Specification Sheets for Eligible
Professionals
<https://www.cms.gov/EHRIncentivePrograms/Downloads/EP-MU-TOC.pdf>
* Stage 1 EHR Meaningful Use Specification Sheets for Eligible
Hospitals
<https://www.cms.gov/EHRIncentivePrograms/Downloads/Hosp_CAH_MU-TOC.pdf>

* A question and answer session

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.

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What is the Medicare hospice benefit?

What is the status of the Medicare hospice benefit?

Why are some hospices seeking out nursing facility residents?

What does OIG recommend to address this issue?

What other work has OIG done related to hospice care?

What does OIG plan to do from here?