Thursday, November 7, 2013

Fighting Medicaid Fraud, Waste, and Abuse Through Education - Medicare Blog

By Ted Doolittle, CMS Deputy Director, Center for Program Integrity

Nov. 7, 2013 - The Centers for Medicare & Medicaid Services (CMS) wants everyone to join in the fight against fraud, waste, and abuse as part of our comprehensive strategy to protect federal health care programs and taxpayer dollars.  We are now making it easier than ever before for health care providers, managed care plans, and individuals and families with Medicaid benefits to use the education and training materials on the new Medicaid Program Integrity website.
Resources available on the website include videos, fact sheets, and checklists, made specifically for providers and beneficiaries.  These tools are national in scope, but some information can be personalized by your State of residence (or where you live) upon request. 
One of the key resources is a brochure on how people with Medicaid can protect themselves and the Medicaid program from fraud. You can also email for the state contact number for reporting fraud.
State program integrity professionals and counselors will also find valuable education and training materials on the site – all available at no cost.  We have developed toolkits to address hot issues and frequently asked questions about Medicaid program integrity, including beneficiary protections and compliance resources for dental professionals and managed care organizations. 
Take a moment to learn more about the CMS Medicaid Program Integrity education and training materials available by clicking on this link, that will take you to the website.
Click here to join our listserv to receive timely notices of new material as it becomes available. Listserv members are also notified when new training, education, or speaking events are scheduled.
We value your feedback, recommendations, questions, and requests and encourage you to e-mail the Education Medicaid Integrity Contractor at for further information.
Thank you for being a partner in Medicaid program integrity!
And for more information on CMS’s efforts to protect consumers in the Health Insurance Marketplace, please visit:

Mid-Hudson Medical Group to Pay $5 Million in Health Care Fraud Settlement

Mid-Hudson Medical Group to Pay $5 Million in Health Care Fraud Settlement
HUDSON VALLEY, N.Y. – The medical group that employed Spyros Panos, the Hopewell Junction surgeon who pleaded guilty last week to felony health care fraud, will pay the United States $5 million as part of a federal settlement agreement.
Preet Bharara, U.S. attorney for the Southern District of New York, said in a news release that the Mid-Hudson Medical Group (MHMG), which has offices throughout Dutchess and Putnam counties, received millions of dollars from two schemes to defraud Medicare, the New York State Insurance Fund, and other private health insurance providers. The settlement agreement was submitted to U.S. District Judge Vincent L. Briccetti Wednesday afternoon.
“The laws are clear and formidable when it comes to the bilking of health insurance providers: you cannot be permitted to keep and enjoy illicit proceeds of fraud,” Bharara said.
According to the complaint and other publicly filed documents, between at least 2006 and July 2011, Panos engaged in an unlawful scheme to defraud health insurance providers, where he and MHMG submitted fraudulent information regarding the nature and details of surgical procedures he performed. As a result, the insurance companies paid MHMG millions of dollars more than it was entitled to receive for the actual work that Panos performed.
On Oct. 31, Panos pleaded guilty to one count of engaging in a scheme to commit health care fraud.
Court documents also state that from approximately 2009 through June 2012, some employees at MHMG submitted requests to insurance companies that, in some cases, contained false information about patients. As a result the insurance companies paid MHMG more for MRI tests than the medical group was entitled to receive.
Under the terms of the settlement, MHMG is awarded credits for reimbursements it has already made to certain health insurance providers. The medical group is also required to transfer an additional $3.67 million to the United States in accordance with an agreed-upon schedule.
The settlement represents an estimate of the amount of proceeds MHMG obtained from health insurance providers as a result of the alleged fraud.
Panos faces up to 10 years in prison and owes millions of dollars after admitting to running a scheme that defrauded health insurance providers.

Outpatient coding and ICD-10-PCS

Initially, we thought that outpatient coders didn’t have to learn to code in ICD-10-PCS. They would still use CPT® codes to report physician services in the outpatient world.
question marksNow it looks like that might not be the case everywhere. During the AHIMA Conference in Atlanta October 26-30 the topic of outpatient coders using ICD-10-PCS came up repeatedly.
Some facilities now require coders to report ICD-9-CM procedure codes for outpatient services so they can compare data for inpatient and outpatient services, outcomes, etc. Some commercial payers also require ICD-9-CM procedure codes for outpatient services.
The jury is still out on what payers will do once we transition to ICD-10. But facilities should start to think about training outpatient coders on ICD-10-PCS. Outpatient coders are used to looking for information in the operative report that inpatient coders don’t need to see now. That should help outpatient coders in ICD-10-PCS.
However, what physicians need to document for CPT code assignment is not always the same as what they need to document for ICD-10-PCS. You knew it couldn’t be easy, right?
Having everyone code in ICD-10-PCS could be a good thing. We would get standardized data on all procedures, regardless of the setting. We would also have more coders who can fill in when someone is on vacation, out sick, or leaves the organization.
On the downside, training all coders on ICD-10-PCS costs money and takes time. It will also probably decrease productivity, which could result in a slowdown in reimbursement.
Weigh the pros and cons at your organization and talk to your payers. Then decide whether to bring the outpatient coders into the ICD-10-PCS world.
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Naples HMA to return $31 million in questionable incentive money

Health care giant promises more diligent oversight

Health Management Associates Inc. is repaying $31 million in technology incentives it improperly collected through federal and state programs and will tighten its financial controls as it restates financial results dating back to 2010, the Naples-based hospital company reported.
HMA disclosed that 11 of its hospitals collected the $31 million through the Medicare and Medicaid Health Information Technology program, but made an error in applying the requirements of the program. The program is intended to encourage health care providers to upgrade their electronic records systems.
HMA did not name the hospitals involved and did not return calls seeking additional information on Wednesday.
In a press release, HMA said it has notified the Centers for Medicare and Medicaid Services and has repaid “the majority of the funds” and is still working to pay back some state agencies that participate in the programs.
HMA operates 71 hospitals in 15 states, including Lehigh Regional Medical Center in Lehigh Acres; two Physicians Regional Healthcare System hospitals in the Naples area; Bayfront Health Port Charlotte; and Bayfront Health Punta Gorda.
The $31 million recorded as income from the program was consistently less than 2 percent of earnings before interest, taxes, depreciation and amortization in each impacted quarter, said analyst Sheryl Skolnick, analyst with CRT Capital Group.
“As these kinds of restatements go, it is fairly minor,” Skolnick said. “The degree of overstatement is not huge, but it is not acceptable. It’s the material failure of the controls that raises the level of seriousness.”
Skolnick said HMA will likely get some leniency for reporting the problem itself, but the Securities and Exchange Commission may investigate the company’s controls further.
HMA already faces whistle-blower suits alleging Medicaid and Medicare fraud, federal investigations from the Department of Justice and the Securities and Exchange Commission and class-action suits from shareholders saying the company isn't acting in their best interest.
In August, Glenview Capital Management — HMA's largest shareholder — replaced the company's board and put its own directors in place.
On July 30, Franklin, Tenn.-based Community Health Systems Inc. announced it intended to buy HMA for cash and stock valued at about $13.78 a share, or about $7.6 billion, including $3.7 billion in debt. That deal is expected to close in the first quarter, HMA said in its statement.

Miami-Dade community health centers win government grants

More than a dozen Florida community health centers — including seven in Miami-Dade County — were awarded $8.3 million in grants Thursday to expand their practices and hire more physicians, nurses, dentists, psychologists and other providers in an effort to increase Americans’ access to healthcare under the Affordable Care Act, federal officials announced.
The grants from the U.S. Department of Health and Human Services are part of a national effort by the federal government, which awarded about $150 million to 236 health centers in 43 states, including 16 centers in Florida.
Seven centers in Miami-Dade will share more than $3.9 million, with the largest single amounts awarded to Borinquen Health Care Center in Miami and the Center for Family and Child Enrichment in Miami Gardens. Each received grants of $775,000.
Altogether, Florida’s grants will help deliver healthcare to approximately 73,000 Floridians who otherwise may not have had access to care. Florida has 48 health centers that served 1.1 million patients in 2012, with about 44 percent of them uninsured, according to HHS.
Mary Wakefield, a registered nurse and administrator for the Health Resources and Services Administration, an agency within HHS, said the grants were written into the healthcare reform law. She said the ACA set aside $11 billion to be awarded over five years, beginning in 2011, to support the expansion of community health centers. Total grants to be awarded for 2014, including the ones announced Thursday, will total $2.2 billion.
“All of us in the Obama administration are working hard to make sure that Americans who aren’t in the healthcare system finally get in,’’ Wakefield said.
Wakefield added that community health centers can use the grants to hire more providers or to rent new healthcare delivery sites, but not for the construction of new clinics. They can also use the funds to purchase medical equipment.
But the emphasis, Wakefield said, will be on providing more primary care services that will help individuals manage chronic diseases and prevent illnesses.
Nationwide about 1,200 community health centers operate more than 9,000 delivery sites that provide care to more than 21 million patients in every state, according to HHS.
Thursday’s grants are the latest round to be awarded to community health centers as part of the ACA. In July, HHS awarded 46 grants totaling $8 million to 46 Florida health centers to hire about 160 outreach workers who would help uninsured individuals obtain health coverage through the federally run online marketplace, or exchange.
“Today’s investment,’’ Wakefield said, “is about expanding service capacity.’’

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