Guest Blog: Fraud and Abuse Tied to MD Face-to-Face Encounters

The following is a guest blog post on fraud and abuse issues by Robert W. Markette, Jr., CHC, Of Counsel for
Benesch Friedlander Coplan & Aronoff LLP. Mr. Markette’s primary areas of practice are health law and litigation and his wide range of health care clients includes home health, hospice and private duty providers.

Mr. Markette is also responsible for assisting the Home Care Alliance with its “Keeping it Legal in Home Care” resources on patient choice.

To view the entire article, click the link after the introduction:

As home health and hospice care continue to become more and more competitive and reimbursement continues to decline, referral sources are discovering new ways to leverage this for their own benefit. Two new examples include physicians requesting “administrative fees” to complete face to face paperwork and referral sources seeking “donations” from providers to defray the cost of capital equipment and other improvements. Providers need to understand the risks in these arrangements in order to avoid entering into arrangements that place them in violation of the Anti-Kickback Statute and/or the Stark Law.

The entire article from Mr. Markette is available here.

 

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Avoid Denied Claims-Follow Medicare’s Provider Enrollment Guidelines.

As reported in the HCA’s Update last week, CMS published in the Federal Register  “Medicare and Medicaid Programs: Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreement.”

This final rule finalizes several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare.

To receive payment for home health services, any Medicare-enrolled Home Health Agency must file claims containing the name and National Provider Identifier (NPI) of the physician who ordered the service.

The ordering physician must be enrolled in PECOS. The NPI used must be for an individual physician (cannot be a group or organizational NPI) and the individual physician must be of a specialist type that is eligible to order; Doctors of Medicine or Osteopathy, Doctors of Podiatric Medicine

Failure to meet the requirements mentioned above will result in denied claims once the automatic edits are activated.  The Medicare Learning Network’s “Medicare Enrollment Guidelines for Ordering/Referring Providers” is an excellent fact sheet if you need more information

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Challenged with Teaching New Staff OASIS

When home care agencies hire clinicians with little to no home care experience it certainly is a challenge to orient new staff to all the home care policies, procedures, regulations and OASIS. A tremendous amount of time and resources are needed for the opportunity to education the clinician. CMS created four training videos that are related to OASIS-C and process measure items. These videos may be a good resource for home care orientation.

They are available on YouTube as follows:

The Process Based Quality Improvement (PBQI) process.

Accurately Responding to Process Items: Intervention Synopsis (M2400)

Accurately Responding to Process Items: Plan of Care Synopsis (M2250)

Accurately Responding to Process Items: Fall Risk Assessment (M1910)

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Keeping It Legal, Part 2: Patient Choice

Building on a previous document called “Keeping It Legal” that focuses on what providers need to know when referring patients to home health care, the Home Care Alliance is releasing a series of documents on other legal issues related to the industry.

This new document in the series focuses on “Patient Choice” and what rights a patient has under the Medicare and Medicaid programs.

See the article: Respecting Patient Choice and the Rights of Medicare Patients

Drafted by Robert Markette, Jr., CHC – Of Counsel for Benesch Friedlander Coplan & Aronoff LLP, the Home Care Alliance is pleased to make this series of resource documents available. Agencies are encouraged to pass these documents along to partnering providers and pertinent agency staff to ensure that they are aware of the rules and regulations.

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HHAs Must Ensure Physician Enrollment in Medicare

 CMS Releases:  Ordering and Referring Physician Final Rule

On Tuesday, CMS posted for public inspection the final rule “Medicare and Medicaid Programs: Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreement” This document was published in the Federal Register on 04/27/2012.

This rule requires enrollment of physicians ordering home health and other services to be enrolled in the Provider Enrollment, Chain, and Ownership System (PECOS). Work is underway to transition all physicians enrolled in other systems, such as the Legacy system, to PECOS. This process is being expedited by CMS through physician Medicare re-validation.

Home health agencies should  begin checking every physicians Medicare enrollment status in the Ordering and Referring Physician report. Through this report CMS has made available the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI).
A new file will be made available periodically that will replace the posted file; at any given time, only the most recent file will be available. It can also be used to search for a particular physician or non physician practitioner by NPI number or by name.
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FYI: “Home Health Prospective Payment System” Fact Sheet Revised

The Medicare Learning Network has recently released the revised “Home Health Prospective Payment System” fact sheet and is now available in downloadable format. It includes the following information: background, consolidated billing requirements, criteria that must be met to qualify for home health services, coverage of home health services, elements of the HH PPS, updates to the HH PPS, and healthcare quality. This can be used as a handy tool for new employees to home health care!

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How does Massachusetts Compare to National Results from HHCAHPS?

Results from the CMS national survey, Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Survey, that asks patients about their experiences with Medicare-certified home health agencies, are now available on Quality Care Finder website.

Massachusetts scored better or the same compared to national results for 4 out of 5 survey items. “Percent of patients who reported that their home health team gave care in a professional way” was the survey result where Massachusetts scored 1% less than the national level. See how specific agencies in your local area compare to the state and national results.

HHCAHPS will be updated every four months with new survey data and will complement the clinical measures available on the “Home Health Compare” website. This survey collects feedback on topics that patients have identified as important to them in determining which home health agencies provide high-quality care. Ratings include an overall rating of home health care and a patient’s willingness to recommend the agency to someone else.

For more information on the survey, visit https://homehealthcahps.org.

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HHCAHPS to be Posted on Home Health Compare Tomorrow

The Centers for Medicare & Medicaid Services (CMS) plans to begin publicly reporting results from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Survey on April 19, 2012. HHCAHPS Survey results will be reported for a Medicare-certified home health agency based on 12 months worth of HHCAHPS Survey data. These customer survey results will be posted on Home Health Compare.

The survey results will be refreshed each calendar quarter, with data from the oldest quarter being replaced by data from the most recent quarter of the HHCAHPS Survey.

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New Web Resource Available on Dual Eligible Demonstration Projects

Massachusetts is leading the charge with a plan to integrate care for dually eligible individuals and most other states have plans to improve care for that population under an Affordable Care Act Program.

A new web resource has been made available from the National Senior Citizens Law Center (NSCLC) that is a one-stop shop for all information about all the states involved in creating a new service delivery plan for the dually eligible.

The new website is dualdemoadvocacy.org and it consists of recommended background reading, state profiles, and advocacy tools. All of these resources are meant to promote the position of NSCLC, but they are general views that are in the best interests of the individual receiving services. Additionally, those views are in line with preventing unnecessary hospital admissions and keeping people in the community whenever possible.

The site also allows people to comment on NSCLC’s specific recommendations.

The Home Care Alliance is continuing its advocacy on the Massachusetts proposal and will provide more information as it becomes available.

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CMS Announces New Accountable Care Organizations in Massachusetts

Two out of the first 27 accountable care organizations (ACO’s) in CMS’ new Shared Savings Program reside in Massachusetts and will be online with its counterparts from across the country this month.

According to a press release by CMS, “The selected organizations have agreed to be responsible for improving care for nearly 375,000 beneficiaries in eighteen states through better coordination among providers.”

The CMS statement continues that all ACOs that succeed in providing high quality care may share in the savings to Medicare, as long as their performance reduces the cost of care and is sufficiently rated on 33 quality measures. The quality measures relate to, among other things, care coordination and patient safety, use of appropriate preventive health services, improved care for at-risk populations, and the patient experience of care.

The Massachusetts ACO’s include Jordan Community ACO and Physicians of Cape Cod AC. CMS provides summaries of each ACO and the Massachusetts initiatives are described here:

• The Jordan Community ACO is a not-for-profit organization based in Plymouth, Massachusetts and founded in 2012. The Jordan Community ACO consists of more than 100 physicians from Plymouth Bay Medical Associates, Jordan Physician Associates, and a number of specialty physicians from Jordan Hospital. Together, the Jordan Community ACO physicians coordinate the healthcare of more than 6,000 Medicare beneficiaries in Plymouth and Barnstable Counties. This approach ensures that patients receive the right care from the right provider at the right time, making it possible to identify and address problems early, before hospital care becomes necessary.
• Physicians of Cape Cod ACO has been coordinating care for beneficiaries through a managed care program for 10 years, and intends to bring the expertise developed in that program to the ACO model for fee-for-service beneficiaries. It is expected to serve approximately 5,000 beneficiaries living in Cape Cod, Massachusetts.

Five of the 27 ACO’s are also participating in the Advance Payment ACO program, although none of them are in Massachusetts. One project is located in northern New Hampshire and called the North Country ACO. These 27 ACO’s join the 32 “Pioneer ACO’s” that have 5 projects in Massachusetts.

CMS revealed they are reviewing 150 additional applications for the Medicare Shared Savings Program, of which more than 50 are aiming to be in the Advance Payment Model.

More information is available in CMS’ announcement.

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