DOJ files false claims case vs largest U.S. hospice provider

DOJ files false claims case vs largest U.S. hospice provider

5/6/2013

By Adam Kerlin

(Reuters) - The U.S. Department of Justice on Thursday charged the nation's largest for-profit hospice chain with inappropriately admitting patients and billing Medicare for unnecessary crisis care, highlighting the agency's ongoing battle to crack down on fraud in the hospice industry.

The Justice Department filed the False Claims Act complaint in district court in Kansas City, Missouri, alleging that Vitas Innovative Hospice Care, headquartered in Miami, paid employees bonuses tied to the number of patients they enrolled for unnecessary intensive services.

The complaint also alleged that the company's marketing intentionally misled patients into believing they qualified for "intensive comfort care" services, a level of care covered by Medicare only in the case of a short-term crisis and acute medical symptoms, and "to believe that the Medicare hospice benefit would routinely cover around the clock care for hospice patients."

"The Medicare hospice benefit is intended to provide patients nearing the end of life with pain management and other palliative care to make them as comfortable as possible," said Stuart Delery, Acting Assistant Attorney General for the Civil Division in a statement. "Too often, however, we hear reports of companies that abuse this critical service by using aggressive marketing tactics to push patients into services they don't need in order to get higher reimbursements from the government."

Vitas did not return calls for comment.

UPTICK IN 'UPCODING'

The case against Vitas is the latest in a series of actions by the Department of Justice against hospice and skilled nursing facilities for submitting inaccurate and fraudulent claims.

In January of this year, the department announced a settlement with a South Carolina hospice center that allegedly had submitted claims for patients who had not received a prognosis of six months or less to live, the standard that qualifies someone for hospice care. In March, the agency announced a $12 million settlement with Hospice of Arizona over similar allegations.

A November 2012 study by the Office of Inspector General showed that inappropriate payments to skilled nursing homes cost Medicare $1.5 billion in 2009. The majority of the claims from the nursing facilities were "upcoded" - where the facility charges for unnecessary Medicare claims that are reimbursed at a higher rate - and many of the claims were for ultrahigh therapy, the report said.

According to the government's complaint against Vitas, the company pushed its workers to bill for "crisis care" rather than "routine home care" because the daily reimbursement rates for crisis care was $742 more than for routine home care.

Incentivizing workers to comply with companywide false claims schemes is common in big cases, said Erika Kelton, an attorney at Phillips & Cohen who represents whistle-blowers in healthcare fraud cases.

"The more significant False Claims Act cases are schemes organized from the top of the organization and participation in them is encouraged," Kelton said. "It's a strategy for the companies to increase profits."

The case is USA v. Vitas Hospice Services, U.S. District Court for the Western District of Missouri, No. 13-449.

For the United States: Lucinda Woolery of the Justice Department.

For Vitas: Not immediately available.

J.P. Morgan’s Medicare Advantage endorsement lifts Humana shares

May 6, 2013, 11:34 AM

By Russ Britt

Shares of Humana Inc. got a lift Monday after J.P. Morgan declared membership in Medicare Advantage plans will keep growing despite pending reimbursement cuts.

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But brokerage analyst Justin Lake also targeted Louisville, Ky.-based Humana HUM +0.04% for upgrade, to “overweight” from “neutral.” He also raised his price target on Humana to $91 a share from $88 a share.

Shares of Humana led the sector into positive ground on an otherwise flat day for stocks, with the company up 3.5% to $76.52.

Lake noted that Humana will see 100 basis points of margin contraction in Medicare Advantage plans over the next two years, but will accelerate again in 2016. Humana has a high proportion of Medicare Advantage patients on its rolls.

“With the stock having underperformed peers meaningfully, we see an increasingly positive risk-reward profile over a multi-year period,” Lake wrote in a note to clients. He says his new price target assumes a price-to-earnings ratio of 11 off his earnings-per-share estimate for 2014.

Lake also gave UnitedHealth Group Inc. UNH +0.35%, another big Medicare Advantage carrier, an initial “overweight” rating. Lake had no rating on UnitedHealth prior to Monday. Shares were up 2% to $60.14.

“Our analysis indicates [UnitedHealth] is best-positioned in our coverage universe from a benefit standpoint heading into [health-care] reform with only 13% of membership ‘at risk’ by our definition,” Lake said.

Lake says that even though there will be reductions in Medicare Advantage reimbursements, those will be more than offset by growth in enrollment due to the value-added proposition that the plan offers seniors.

iBlueButton medical app is a portable health record for Medicare, Veterans & Medicaid patients

6 hours ago by Guido Giunti

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App Review mHealth

TEDMED is a multi-disciplinary community of innovators and leaders who share a common goal of creating a better future in health and medicine.

iMedicalApps was at its latest iteration. Among the many things that we saw at TEDMED 2013, one thing that really caught our eye wasiBlueButton, an app and service that was on display in the exhibition area.

iBlueButton is developed byHumetrix, an Information Technology (IT) company that uses smart portable devices (USB flash drives, smart cards or smartphones), to offer patient-centered, individually controlled connectivity and interoperability solutions to the health care environment.

While at TEDMED, we had the pleasure to meet and talk with Dr. Bettina Experton, founder and CEO of Humetrix about their app.

Some of our readers might be familiar with Blue Button, the platform that allows patients to view and download their own personal health records. We briefly described iBlueButton after they came in first in the Blue Button Mash-up Challenge. This technology is in use at the Departments of Defense, Health and Human Services, Veterans Affairs as well as Medicare and Medicaid.

Data from Blue Button-enabled sites can be used to create portable medical histories that facilitate dialog among health care providers. However, such data is downloaded as a text file that’s hardly easy to read by humans. That’s where iBlueButton comes in.

The patient can use iBlueButton to connect and download their health records to their smartphone; the app itself parses the information and organizes it in a visual-friendly manner. What is the value of this technology for physicians? As Dr. Experton put it,

“Most Medicare patients usually see between 7 or 8 health providers per year on average and because of the lack of connectivity between individual EMRs, that means 7 or 8 different separate records for that same patient. The prime value of iBlueButton is that physicians get a complete useful history of their patients when they come as they get the information straight from the source.”

iBlueButton displays records of medications, visits and past surgeries. Everything is there for us to see at a glance. We even get suggested screening tests depending on our patient’s risk factors. Tapping on a medication shows a brief description of that drug from the National Institutes of Health’s Web Medline Plus.

The patient can also annotate whether they are experiencing any side effects from that drug or if they no longer take it. Patients can attach any kind of files to their health record and the app can also use the smartphone’s camera to take pictures.

Whenever we are dealing with medical information, privacy and security becomes an issue. Naturally, we asked Dr. Experton about this. He responded, “Since all of the patient information is stored inside the app, the medical records are only accessible through a password that uses the same type of encryption technology the military uses.”

As an added security measure, iBlueButton health records can only be shared in person and cannot be sent via e-mail. During a visit, QR codes can be generated so that patients share their chart with their physician; the QR code works as a record locator and encryption key so the information remains protected during this transmission.

iBlueButton is available for both Android and iOS. The app comes in two versions, a patient-facing app and a physician app dubbed iBlueButton Pro. While the apps themselves are free, the service is charged on the amount of downloaded records.

Physicians can use iBlueButton for free for up to 3 patients or can pay the full price of $39.99 for the app. Patients have 1 free download and can purchase packs of 5 downloads for $1.99 or 25 downloads for $7.99. Patients get record download credits every time they share their records with a physician. There is also a Veteran version of the app for free.

We found iBlueButton to be a very innovative application of mobile technology and we hope to see more initiatives like this appear as time goes by. In the words of Dr. Experton,

Use ICD-10 to tell a better story about the patient

Use ICD-10 to tell a better story about the patient

I love the ICD-10-CM external causes codes. I’m weird, I know, but I’m also a writer and I love telling good stories. When I first started coding, my boot camp instructor Peggy Blue, MPH, CPC, CCS-P, said coders tell the patient’s story using codes. ICD-10-CM allows coders to tell better stories about patients and detail what happened to them and how.

Some of the external causes codes are pretty funny and you’ll probably never report them. If you work in an urban setting, you’ll probably never report W61.4- (contact with turkey) unless someone is trying to kill his or her own Thanksgiving dinner.

If you don’t live near water, you likely won’t need V94.1 (bather struck by watercraft) or W56.2- (contact with orca). Well, you might need the orca, dolphin (W56.0-), and sea lion codes (W56.1-) if you work near Sea World. But let’s hope you don’t have cause to use them.

The ICD-10-CM external causes codes include codes for encounters with a variety of animals including, but not limited to:

• Alligator
• Crocodile
• Nonvenomous reptiles
• Parrot
• Macaw
• Chicken
• Goose
• Frogs
• Toads
• Squirrel
• Cow
• Dog
• Cat
• Mouse

The only thing missing seems to be an attacking partridge in a pear tree. Oh wait, that’s contact with other birds (W61.9-).

Those codes seem to get the most attention. In fact, Rep. Ted Poe, R-Texas, called out the turkey codes as a way to bolster his argument that the government should stop ICD-10 implementation. He’s even introduced a bill—H.R. 1701: Cutting Costly Codes Act of 2013—to that effect. Take two minutes and read the bill. Trust me, you’ll only need two minutes. It’s not very long.

Poe also mocked the codes for walking into a lamp post (W22.02-). I’ve made fun of that code too, mainly because I can’t image anyone actually admitting he or she walked into a lamp post. At least not sober.

Here’s something he didn’t consider though. How often does an abuse victim claim to have walked into a door or fallen down the stairs? So if a physician or nurse sees a patient who is always walking into things, the clinician might suspect abuse. Or that the patient has a problem with vision. That can be valuable information when forming a diagnosis and also to potentially support a criminal charge against an abuser. Or a bully.

We know ICD-10 will change the way we code. We know it’s going to cost a lot of money and decrease productivity. But we also know (at least I hope we do) that ICD-10 will give us better data and a better clinical picture of the patient’s condition. That alone is a good reason to move forward with implementation.

Here are four other good reasons:

• ICD-9 is out of space
• We’ve already spent literally millions preparing for the change
• We can’t talk to the rest of the world about healthcare, diseases, and mortality rates
• We’re 15 years behind Canada

On a more serious note, we all hope we never have to use any of the codes under Y36.5 (war operations involving nuclear weapons).

 http://blogs.hcpro.com/icd-10/author/mleppert/

Medicare Seeks To Limit Number Of Seniors Placed In Hospital Observation Care - Kaiser Health News

Medicare Seeks To Limit Number Of Seniors Placed In Hospital Observation Care - Kaiser Health News

Medicare Seeks To Limit Number Of Seniors Placed In Hospital Observation Care

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TOPICS: AGING, MEDICARE, HOSPITALS, HEALTH COSTS

By Susan Jaffe

MAY 03, 2013

This KHN story was produced in collaboration with 

Medicare officials have proposed changes in hospital admission rules that they say will curb the rising number of beneficiaries who are placed in observation care but are not admitted, making them ineligible for nursing home coverage.

"This trend concerns us because of the potential financial impact on Medicare beneficiaries," officials wrote in an announcement April 26. Patients must spend three consecutive inpatient days in the hospital before Medicare will cover nursing home care ordered by a doctor.

Observation patients don't qualify, even if they have been in the hospital for three days because they are outpatients and have not been admitted. They also have higher out-of-pocket costs than admitted patients while in the hospital, including higher copayments and sometimes paying exorbitantcharges for non-covered drugs.

Under the proposed changes, with some exceptions, if a physician expects a senior will stay in the hospital for less than two days (or through two midnights), the patient would be considered an outpatient receiving observation care. If the physician thinks the patient will stay longer, the patient would be admitted. Setting deadlines for observation stays would also limit the growing length of time of observation visits, another trend officials said was troubling.

The reaction from patient advocates, doctors and hospitals has been swift and surprisingly unanimous: it’s a bad idea.

The number of observation patients has jumped 69 percent in the past five years, to 1.6 million in 2011, according to federal records. They also are staying in the hospital longer, even though Medicare suggests that hospitals admit or discharge them within 24 to 48 hours. Observation visits exceeding 24 hours has nearly doubled to 744,748.

Officials said the longer observation stays occur because hospitals are not sure Medicare will pay them if patients are admitted. The proposed changes are intended to address these questions.

The proposed admission changes are part of a 1,400-page annual hospital payment update released Friday. If adopted, the new admission rules would apply to more than 3,400 acute care hospitals, and Medicare estimates it will result in 40,000 more inpatient hospital stays. In order to offset the expected additional cost of $220 million, Medicare would cut hospital payments by 0.2 percent.

More From KHN

Advocates Head To Court To Overturn Medicare Rules For Observation Care

Joanna Kim, vice president for payment policy at the American Hospital Association, called the time factor "somewhat arbitrary." The association also objects to the pay cut, arguing that the projected inpatient increase is not certain.

"I can't imagine anyone is going to like this proposed rule because it makes time the determining factor in whether the services are provided on an inpatient or observation basis," said Toby Edelman, senior policy attorney at theCenter for Medicare Advocacy. "It is not about what the hospital is actually doing for you, what kinds of care you need and are receiving."

Edelman said the proposal does nothing to help observation patients because it keeps the three-inpatient-days requirement in place, doesn't require hospitals to tell patients when they are held for observation and doesn't give patients a right to appeal their observation status. The center is representing 14 seniors who have filed a lawsuit against the government to eliminate the observation care designation.

A federal judge is holding the lawsuit's first hearing Friday in Hartford, Conn., to consider the government's request to throw out the case because the seniors should have followed Medicare's lengthy appeals process before going to court. Three days ago, government lawyers submitted the proposed rule change to the judge to bolster its argument for dismissal, claiming that it clarifies "when we believe hospital inpatient admissions are reasonable and necessary, based on how long beneficiaries have spent or are reasonably expected to spend, in the hospital."

The American Medical Association is still reviewing the proposed changes, which don't include steps it asked Medicare to take last year: either drop the three-day policy or count observation days toward the requirement.

"This policy is of great concern to the physician community because it has created significant confusion and tremendous, unanticipated financial burden for Medicare patients," James Madara, the AMA's executive vice president, wrote to Medicare. He also criticized hospital's ability to overrule the physician’s decision to admit a patient, which creates more confusion when the physician bills Medicare for inpatient services and the hospital bills for observation services.

Contact Susan Jaffe at Jaffe.KHN@gmail.com