Be Careful When Using Condition Code 42 When Transferring a Patient Back to Home Health

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MCare Solutions reviews large volumes of billed Medicare discharges for proper payment under the Transfer Payment Rule.  Generally speaking, the majority of these discharges are roughly split between home health and skilled nursing.  Lately we have noticed the frequent use of discharge status code 06 (transfer to home health) along with condition code 42 (CC42). (This combination of codes would be used when an acute care episode occurred in the middle of a home health episode and the patient was being transferred back to home health.)  Using CC42 indicates to CMS that the reason for the acute stay and the reason for receiving home health services are not related and that the acute provider should receive a full DRG payment.  Since there are no bill edits for this combination of codes, it is extremely important that the use of these codes be correct. 

What is the rule or guideline that the provider would use to properly determine whether acute and home health services are related?

MCare turned to our healthcare attorney at Arnall, Golden, Gregory to research the issue for us.  Their findings provide a concise course of action that our clients can follow to ensure that they are complying with CMS requirements in this matter.  MCare would like to share these findings with you.

ISSUE

Question:

When there has been a “Hospital Interlude”, must the hospital always consider the subsequent home health care “related” to the hospitalization? 

Response:   

No!  In fact, because patients who are admitted to hospitals during home health episodes may have multiple, distinct medical conditions, Hospital Interludes might actually be more likely to result in the appropriate use of condition code 42 than situations involving patients admitted to hospitals directly from home.  Condition code 42 asks whether the hospital’s continuing care plan at the time of discharge calls for the provision of services unrelated to the condition responsible for the patient’s admission to the hospital.  Patients who are admitted while in the middle of a home health care episode may require additional treatment after their hospital stay for the same medical issue that was being treated by home health care prior to their hospital admission, and this medical issue could be distinct from the condition responsible for the patient’s hospitalization.

For instance, if someone receiving home health care for mobility issues due to a hip fracture is admitted to an acute care facility for the treatment of pneumonia, and then is subsequently discharged to home health for mobility issues related to the hip fracture, then condition code 42 would be appropriate, as the pneumonia stay should not be subject to the post-acute transfer policy.   

Question:

If not, what criteria should be applied in determining whether condition code 42 is appropriate? 

Response:

Hospitals are responsible for deciding whether the home health care the patient is to receive as part of the hospital’s discharge plan is related to the condition responsible for the inpatient hospital admission.  In making that determination, the services called for in the hospital’s continuing care plan should be compared with the patient’s primary diagnosis – not the secondary diagnoses listed on the hospital bill.  If any of the services called for in the hospital’s discharge plan are related to the condition indicated by the hospital’s primary diagnosis, then condition code 42 should not be used. 

Hospitals are not expected to compare home health bills to hospital bills in order to determine relatedness between the two providers’ treatment.  However, whenever hospitals use condition code 42, they are expected to have documentation in the patient's record supporting their decision to use the condition code.

The Post-acute Transfer Policy Focuses on Hospitals’ Principal Diagnosis

Given that the post-acute care transfer policy is either applicable or inapplicable based on the hospital’s principal diagnosis code, the question of relatedness between the home health treatment and the prior hospital stay would also seem to be limited to the condition indicated on the principal diagnosis for the patient.  This is consistent with CMS’ use of the phrase “purpose of the inpatient hospital admission” when describing condition code 42 (since hospitals are instructed by coding rules to code as principal the condition that required the hospital admission), as well the fact that CMS’ overall discussion in the preamble to the post-acute transfer rule focuses on a hospital’s “principal” diagnosis.

CMS did not intend for the post-acute transfer policy to apply whenever any of the services provided during a home health episode are related to any of the services provided during the prior hospital stay.  Rather, CMS’ focus when it created the post-acute transfer policy was on the principal diagnosis and whether continued treatment related to that diagnosis is required upon discharge.

CONCLUSION

Condition code 42 can be used for Hospital Interludes.  CMS anticipates that Hospitals will look to the patient’s record (particularly the continuing care plan) to determine whether the hospital’s discharge plan called for services separate and distinct from the condition responsible for the patient’s hospitalization.  If the record demonstrates that the patient was discharged to home health for reasons unrelated to the condition responsible for her hospitalization, then condition code 42 is appropriate.

For a copy of the complete opinion, including cited references and examples of CC42 use, please click here.

http://www.mcare-solutions.com/be-careful-when-using-condition-code-42-when-transferring-a-patient-back-to-home-health

'No Show' Doctor Sentenced to 151 Months in Prison in Connection with $77 Million Medicare Fraud Scheme

Washington, DC--(ENEWSPF)--September 16, 2013.  Gustave Drivas, M.D., 58, of Staten Island, N.Y., was sentenced to serve 151 months in prison for his role as a “no show” doctor in a $77 million Medicare fraud scheme.  The State of New York revoked Dr. Drivas’s medical license earlier this year.

Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney Loretta E. Lynch of the Eastern District of New York, Assistant Director in Charge George Venizelos of the FBI’s New York Field Office and Special Agent in Charge Thomas O’Donnell of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) made the announcement.

Drivas was convicted by a jury on April 8, 2013, of health care fraud conspiracy and health care fraud after a seven-week trial.  He was acquitted of kickback conspiracy.  Including Drivas, 13 individuals have been convicted of participating in the massive fraud scheme, either through guilty pleas or trial convictions.  In addition to the prison term, U.S. District Judge Nina Gershon of the Eastern District of New York sentenced Drivas to three years of supervised release with a concurrent exclusion from Medicare, Medicaid and all Federal health programs, ordered him to forfeit $511,000 and ordered him to pay restitution in the amount of $50.9 million.

The evidence at trial showed that Drivas knowingly authorized his co-conspirators at a Brooklyn medical clinic to use his Medicare billing number to charge Medicare for more than $20 million in medical procedures and services that were never performed.  In return, he received more than $500,000 for his role in the scheme.  According to court documents, from 2005 to 2010, Drivas was the medical director of or a rendering physician at a clinic in Brooklyn that billed Medicare under three corporate names: Bay Medical Care PC, SVS Wellcare Medical PLLC and SZS Medical Care PLLC (collectively “Bay Medical clinic”).  The evidence established that Drivas was a “no show” doctor, who almost never visited the clinic except to pick up his check.  The evidence also showed that the clinic paid cash kickbacks to Medicare beneficiaries and used the beneficiaries’ names to bill Medicare for more than $77 million in services that were medically unnecessary and never provided.

The government’s investigation included the use of a court-ordered audio/video recording device hidden in a room at the clinic in which the conspirators paid cash kickbacks to corrupt Medicare beneficiaries.  The conspirators were recorded paying approximately $500,000 in cash kickbacks during a period of approximately six weeks from April to June 2010.  This room was marked “PRIVATE” and featured a Soviet-era poster of a woman with a finger to her lips and the words “Don’t Gossip” in Russian.  The purpose of the kickbacks was to induce the beneficiaries to receive unnecessary medical services or to stay silent when services not provided to the patients were billed to Medicare.

To generate the large amounts of cash needed to pay the patients, Drivas’s business partners and co-conspirators recruited a network of external money launderers who cashed checks for the clinic.  Clinic owners wrote clinic checks payable to various shell companies controlled by the money launderers.  These checks did not represent payment for any legitimate service at or for the Bay Medical clinic, but rather were written to launder the clinic’s fraudulently obtained health care proceeds.  The money launderers cashed these checks and provided the cash back to the clinic.  Clinic employees used the cash to pay illegal cash kickbacks to the Bay Medical clinic’s purported patients.

This case was investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Eastern District of New York.  The case is being prosecuted by Trial Attorney Sarah M. Hall of the Criminal Division’s Fraud Section and Assistant U.S. Attorneys William C. Campos and Shannon C. Jones of the Eastern District of New York. 

http://enewspf.com/latest-news/law-and-order/federal-and-international/46257-no-show-doctor-sentenced-to-151-months-in-prison-in-connection-with-77-million-medicare-fraud-scheme.html

The High Cost of Getting Paid - Physician's Expense Per Claim...

AMA: The administrative burden of being a physician

ARDIS D. HOVEN, MD | POLICY | SEPTEMBER 15, 2013

A guest column by the American Medical Association, exclusive to KevinMD.com.

The administrative burden of being a physician continues to fuel discontent among doctors. The unfulfilling interface with the insurance bureaucracy is a major contributor to physician dissatisfaction. But not all health insurers are equal when it comes to hassle factors imposed on physicians.

New data released by the American Medical Association (AMA) ranks major health insurers according to their administrative cost burdens for billing and paying medical claims.

The AMA’s new Administrative Burden Index (ABI), which was unveiled as part of its sixth annual National Health Insurer Report Card, shows that administrative tasks associated with avoidable errors, inefficiency and waste in the medical claims process resulted in an average ABI cost per claim of $2.36 for physicians and insurers.

Of the nation’s seven largest commercial insurers included in the report card, Cigna had the best ABI cost per claim of $1.25, or 47 percent below the commercial insurer average. HCSC had the worst ABI cost per claim of $3.32, or 41 percent above the commercial insurer average.

Overall administrative burden index

Payer	Overall rework cost per claim
HCSC	$3.32
Anthem	$2.65
Humana	$2.29
Regence	$2.28
United Healthcare	$2.13
Aetna	$1.68
Cigna	$1.25

When these rework costs are compounded by the thousands of medical claims filed by a typical medical practice in a month, the total burden can quickly drain time and resources from patient care. The AMA estimates that $12 billion a year could be saved if insurers eliminated unnecessary administrative tasks with automated systems for processing and paying medical claims. This savings represents 21 percent of total administrative costs that physicians spend to ensure accurate payments from insurers.

There has been noticeable progress since the AMA launched the National Health Insurer Report Card in 2008 to lead the charge against unnecessary administrative waste in the health care billing and payment system, and this has helped physicians tremendously. In fact, health insurers’ constructive response to our call to improve the accuracy, efficiency and transparency of their claims processing is evident in the significant improvements found in this year’s report card, including:

• Error rates on claims paid by commercial insurers dropped from nearly 20 percent in 2010 to 7.1 percent in 2013.
• Medical claim denials dropped 47 percent after a sharp spike in 2012 among most commercial health insurers. The overall denial rate for commercial health insurers went from 3.48 percent in 2012 to 1.82 percent in 2013.
• Response times to medical claims improved by 17 percent from 2008 to 2013.
• The transparency of rules used to edit medical claims has improved by 37 percent from 2008 to 2013.

We’ve seen dramatic improvements this year, and while there is good reason to celebrate meaningful progress there is still more work to be done. The AMA is committed to helping physicians navigate this transformation era in health care and has made preserving professional satisfaction and practice sustainability for physicians a key pillar in our new strategic focus.

To learn more the National Health Insurer Report Card and the new Administrative Burden Index, please visit the National Health Insurer Report Card.

Ardis D. Hoven is president, American Medical Association. 

http://www.kevinmd.com/blog/2013/09/ama-administrative-burden-physician.html

NY health benefit exchange adds 3 more health insurers

New York's health benefit exchange opens Oct. 1 for enrollment, and uninsured individuals and small businesses will not only have more choices, they'll have new kinds of choices.

Three brand new health insurance companies will be plying their wares to the estimated 150,000 Long Islanders expected to enroll in the exchange.

North Shore-Long Island Jewish Health System, which is the first major health system in the state to form its own insurance company; Oscar, founded by three young, tech-savvy Harvard Business School graduates frustrated by their health insurance bills; and Health Republic, a new type of nonprofit health insurer -- created by the federal Affordable Care Act -- that will be directed by its customers.

The exchange, called NY State of Health, is a marketplace for health insurance plans for uninsured individuals and small-business owners with fewer than 50 employees as part of the federal Affordable Care Act. Beginning Oct. 1, people will be able to go online or work with trained "navigators" to compare prices and benefits for insurance coverage. Coverage can start Jan. 1, although people have until March 31, 2014, to enroll.

In Nassau, nine insurers are offering plans for individuals, in Suffolk, eight. Three insurers are offering plans to small businesses in both counties.

"Long Island is one of the markets around the country that is showing a true increase in choice," said Joseph Berardo, chief executive of MagnaCare, which manages plans for self-insured organizations in New York and New Jersey. "I think this is one of the most exciting and most competitive times in my 20-plus years in New York health care."

MagnaCare isn't participating directly on the exchange but is leasing parts of its network of 81,000 doctors and other health care providers to two of the newcomers: Oscar and Health Republic. The third, North Shore-LIJ CareConnect, will use its own 15 hospitals and 400 doctor and ambulatory care practices.

Benefits, costs still unclear

Each of the newcomers says it is offering a different approach to traditional health insurance. And the three are among the least costly of the plans being proffered. However, what benefits or doctors they provide or what deductibles and co-pays they and others require won't be clear until Oct. 1, when the exchange is open and people can examine each plan closely.

"Not all insurance is equal," said Janine Logan, spokeswoman for the Nassau-Suffolk Hospital Council, which the state has appointed to provide trained navigators at sites throughout Long Island. "It depends on what premiums you're willing to pay each month, how much coverage you want, and the provider networks the plan offers. Like anything else, you should comparison shop."

Depending on the level of care selected, the monthly premiums for individuals in the exchange can range from $284.50 to $1,019.18, the state has said.

North Shore-LIJ chief executive Michael Dowling said he decided to go into the health insurance business because it was a way to make money as the health care industry -- prompted by the Affordable Care Act -- undergoes a major shift in how hospitals will make money: from being paid for each service provided to being reimbursed for keeping people healthy and out of the hospital.

The health system has hired 60 people from the insurance industry and is building a storefront on Northern Boulevard in Manhasset.

Alan Murray, hired from United Health Care as chief executive of North Shore-LIJ CareConnect, said that the insurance exchange "really changes the landscape. It's a fundamental shift."

Now, he said, customers will have "a direct portal of entry" to compare health plans. And, he said, he knows that if their experience with North Shore-LIJ Connect is not good, "next year they can use their dollars and go elsewhere."

Nonprofit alternative

Health Republic is the product of a different approach: the cooperative. Freelancers Union, which started Freelancers Insurance Co. in 2009, is sponsoring nonprofit, member-driven health plans in some states.

These plans have been designated by the federal government as Consumer Operated and Oriented Plans (CO-OP). The federal government has allocated these health plans a $23.8 million start-up loan and $150.7 million loan to be used on an as-needed basis, both of which must be repaid.

Health Republic, which will be offered in New York City, Long Island, Westchester, Albany, Buffalo, Syracuse and Rochester, is the only CO-OP in New York and although a separate entity from Freelancers, uses the same model, said Health Republic chief executive Debra Friedman. "We're happy to provide alternative to traditional insurance models," she said.

It's the only insurance company in the exchange that is member owned. Because the majority of board members will be health plan members, the company will have fewer administrative costs.

"Because we don't have public profit margins, members profit from lower premium prices," Friedman said. "We're able to be highly effective and efficient."

Changing consumers' experience with their health plan is the holy grail of Oscar's three co-founders. Joshua Kushner, 28, a Harvard College and Harvard Business School graduate and founder of a venture capital investment company, said he decided to start a health insurance company when he opened up his insurance bill "and I had no idea what it meant."

What he also found perplexing, he said, was the typical relationship of the health insurer with the customer. "They do everything to acquire customers and then do everything to avoid dealing with them," he said. "What if you took that relationship that is broken and made it simple and transparent?"

Like 'a doctor in the family'

That is the "grand vision" that is driving Kushner and two friends from Harvard Business School: Kevin Nazemi, 32, a graduate of MIT and Harvard Kennedy School and a former director at Microsoft, and Mario Schlosser, 35, a graduate of Stanford University and a former senior investment associate at a hedge fund.

The company is housed in a sixth-floor loft in SoHo and employs 35. The founders chose the name Oscar because they wanted to make the company seem like a person. "It's like having a doctor in the family," Nazemi said.

In fact, an Oscar customer -- Oscar will operate in New York City, Long Island and Westchester and Rockland counties -- will be able to call a number and get a personal call back within 20 minutes from a doctor, who can prescribe medicine if necessary, the founders said. Customers will also get free, unlimited "telemedicine" visits, free wellness checkups and no-cost generic prescriptions.

Whether the co-founders will be able to keep something as dauntingly complex as health care simple and affordable and make a profit is unclear. But as Kushner remarked: "Young people want to work on big problems."

PROVIDERS ON INSURANCE EXCHANGE

Here's a list of the health insurers on New York's health benefit exchange, to begin Oct. 1:

INDIVIDUAL MARKETPLACE

-- Affinity Health Plan

-- Empire BlueCross BlueShield

-- Fidelis Care

-- Health Republic

-- Health Insurance Plan of Greater New York (EmblemHealth)

-- Healthfirst New York (being offered in Nassau County only)

-- North Shore-LIJ CareConnect

-- Oscar Insurance

-- United Healthcare

SMALL-BUSINESS MARKETPLACE

-- Health Republic

-- North Shore-LIJ CareConnect

-- United Healthcare

http://www.newsday.com/news/health/ny-health-benefit-exchange-adds-3-more-health-insurers-1.6075340

New Medicaid system starts Sunday in Palm Beach County

Thousands of low-income seniors in Southwest Florida and areas of the East Coast are poised this weekend to become part of the state's long-debated shift to a Medicaid managed-care system.

The change, which will take effect Sunday, will involve an estimated 13,450 people in 12 counties — including Palm Beach County — who need long-term care, most of them seniors.

Approved by lawmakers and Gov. Rick Scott in 2011, the changes have long been controversial, with critics questioning the care Medicaid beneficiaries will receive. But Liz Dudek, secretary of the state Agency for Health Care Administration, said this week that state officials are trying to address questions and concerns through "outreach'' to service providers and through other efforts.

"The agency and its partners are committed to making the transition to statewide Medicaid managed care as seamless as possible,'' Dudek said in a prepared statement. "However, if there is a hiccup along the way, we have put a number of tools in place to fast-track those issues to the individuals who can make things right.''

The state has started the changes by planning to move roughly 90,000 people who need long-term care into the new system. That process started Aug. 1 in a four-county region of Central Florida and will continue until March 1, 2014. AHCA then plans to turn to enrolling the broader Medicaid population in managed care.

Lawmakers have divided the state into 11 regions to carry out the plan, with the long-term care changes taking effect Sunday in two of the regions. The counties in those two regions are Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota, Indian River, Martin, Okeechobee, Palm Beach and St. Lucie.

Under the system, AHCA sought bids from health plans in each region and awarded varying numbers of contracts. In the Southwest Florida counties, the available plans are American Eldercare, Sunshine State Health Plan and UnitedHealthcare of Florida. In the East Coast counties, the available plans are American Eldercare, Coventry Health Plan, Sunshine State Health Plan and UnitedHealthcare of Florida.

Many of the new managed-care enrollees already receive care in nursing homes. But a broad goal of the program is to use managed care to provide services to help other seniors remain in their residences or communities, instead of needing to move into nursing facilities.

Groups such as AARP Florida, however, have expressed skepticism about shifting seniors into managed-care plans and have questioned the oversight of the care they will receive.

AHCA officials said they have focused heavily on issues such as trying to prevent disruptions in where people live and in the relationships between Medicaid beneficiaries and service providers. As an example, in the Central Florida region, AHCA said only one assisted-living facility declined to participate in the new system, and 10 Medicaid beneficiaries were moved elsewhere before the managed-care changes took effect Aug. 1.

AHCA will wait until Nov. 1 to make the long-term care changes in the next two regions. Broward County makes up one of those regions, while the other involves 14 North Florida counties stretching from Bay County to Madison County and including Tallahassee.

http://touch.sun-sentinel.com/#section/-1/article/p2p-77222235/

State temporarily suspends doctor charged in Sacred Heart health care fraud case

The state has temporarily suspended the license of a doctor charged in the Sacred Heart Hospital Medicaid and Medicare fraud scandal after his attorneys asked a judge in Indiana to delay his unrelated trial there because he is was "medically unfit."

Dr. Subir Maitra, one of four doctors named in the alleged Sacred Heart conspiracy, faces trial in November in the Northern District of Indiana on similar fraud charges. This week his attorneys asked a judge to delay the start of that trial, saying the 73-year-old was physically frail, had suffered several medical setbacks recently and had lost the ability to concentrate for long periods.

That filing prompted the Illinois Department of Financial and Professional Regulation on Friday to temporarily suspend Maitra's license, saying the filing indicates he "may be "physically and/or mentally impaired" and his practice "presents an immediate danger to the safety of the public."

A hearing on the suspension is set for next week. Thomas Anthony Durkin, Maitra's attorney, declined to comment.

Maitra and three other doctors are charged along with hospital CEO Edward Novak and its chief financial officer, Roy Payawal, in a scheme that allegedly involved paying kickbacks for patient referrals and performing unnecessary procedures, including tracheotomies. Five deaths tied to tracheotomies performed at the hospital are under investigation as part of the probe.

Novak sought to last month have his unusually high $10 million cash bond reduced, based on what his attorneys said were emerging questions about the evidence against him. U.S. Magistrate Judge Daniel Martin on Thursday denied the request, saying it was not appropriate for him to weigh the evidence. He also noted Novak's extraordinary wealth.

"Mr. Novak's personal wealth is estimated at approximately three times the amount posted on his behalf," Martin wrote in his order. "He has set forth no argument demonstrating any type of financial difficulty suffered as a result of the cash amount posted."

http://my.chicagotribune.com/#section/-1/article/p2p-77397961/

Health Literacy Could Reduce Medicare Expenses

By Clara Ritger | Friday, September 13, 2013 | 1:09 p.m.Photo: AP Photo/Anja Niedringhaus

Patients – particularly minorities and those on Medicare – are not actively making decisions about their treatments and procedures because doctor-patient communication is poor, according to a study presented Thursday to MedPAC, the Congressional advisory committee on Medicare.

The result is a greater expense for Medicare and a lack of empowerment among patients.

"Once patients understand the risks and benefits of expensive procedures, they tend to opt for more conservative treatment options," said Rita Redberg, a MedPAC member and professor at the University of California San Francisco School of Medicine.

It's the reason physicians and hospitals are resisting training programs that would teach care providers to include patients in the decision-making process, Redberg said, because they lose money when patients choose less-costly options.

The deliberations of the 17 MedPAC members will be presented as recommendations to Congress and the Department of Health and Human Services.

Improving health literacy, or the ability of patients to understand their health care and make informed decisions, is a stated priority for HHS Secretary Kathleen Sebelius.

It's a priority that could come with significant financial implications for the United States. In 2007, a team of researchers estimated that low health literacy costs the U.S. between $106 and $236 billion annually. A number of factors account for those costs, including a patient's inability to find the best provider, treatment and services for his or her condition. The researchers argue the savings would be enough to insure all of the more than 47 million patients who were uninsured in the U.S. in 2006.

There's room to grow – only 22 percent of Americans are reported to be "proficient" when it comes to their understanding of health care costs and services, according to a U.S. Department of Education study.

Low-income adults are disporportionally affected. Health literacy was lower on average for adults living below the poverty level than those living above, the DOE's 2003 National Assessment of Adult Literacy found. As income increased, so did health literacy.

Racial and ethnic minorities had lower average health literacy scores than White adults, the study showed. Forty-one percent of Hispanic adults and 24 percent of Black adults had below basic levels of health literacy, compared with 9 percent of White adults.

Those numbers complement MedPAC's findings that Hispanic and Black patients report poorer communication with providers than Whites and the 2012 National Healthcare Disparities Report which found that Hispanic and Black patients were less likely to be asked their preferences in treatment decisions.

The health literacy problem also poses a challenge for the success of the Affordable Care Act. Once the exchanges open on Oct. 1, the millions of new patients added to the system in the coming years are expected to have high rates of health illiteracy, as many of them may not have had health insurance before.

How to inform patients – and who to hold accountable for health information – remains controversial. Some MedPAC members argued that health literacy wasn't only the responsibility of the patient, but also the provider, to explain health options in ways patients can understand.

"What if patients were treated with dignity and respect?" said George Miller, a MedPAC member and CEO of CommUnityCare in Austin, Tex. "Maybe then they'd feel empowered."

The consensus among the group was that patient engagement was an important issue that needs to be addressed, but they were unsure how Medicare would play a role.

"Health literacy is a responsibility of the Medicare program in that we should be paying for care that supports shared decision-making," said Mary Naylor, MedPAC member and a professor at the University of Pennsylvania School of Nursing.

But that, commission members said, leaves the question of how MedPAC would measure success, and providing financial incentives for patient-inclusion appeared contentious.

The commission will wrap up its meeting Friday at the Ronald Reagan Building, International Trade Center in the Horizon Ballroom.

http://mobile.nationaljournal.com/congress/health-literacy-could-reduce-medicare-expenses-20130913

Fla. hospitals and clinics to pay $3.5 million

PENSACOLA, Fla. -- Radiation oncology providers in Pensacola will pay $3.5 million to the federal government and the state of Florida to resolve allegations they improperly billed government health-care programs.

The U.S. Department of Justice announced Friday that the providers — which included Sacred Heart Health System and West Florida Medical Center Clinic — had been accused of improperly billing Medicare, Medicaid and the health care program used by uniformed military.

The allegations included billing for services that were performed while doctors were on vacation as well as billing twice for the same services.

The improper billing is alleged to have taken place between 2007 and 2011 at locations in Pensacola and Destin. The allegations were first raised in a whistleblower lawsuit.

The whistleblower, Richard Koch, will receive nearly $610,000.

http://www.miamiherald.com/2013/09/14/3626034/fla-hospitals-and-clinics-to-pay.html

Read more here: http://www.miamiherald.com/2013/09/14/3626034/fla-hospitals-and-clinics-to-pay.html#storylink=cpy

Humana IT systems down Friday

Health care and insurance benefits provider Humana Inc. (NYSE: HUM) experienced some significant technical problems Friday, including problems with its online systems for customers.

A statement on the company’s website says:

“Humana.com is currently experiencing intermittent issues. We’re working hard to resolve all issues as soon as possible. We apologize for any inconvenience.”

In an email, Humana’s vice president for corporate communication Tom Noland said Humana also has been experiencing technical difficulties regarding its ability to receive inbound communications, such as telephone calls and emails.

“Connectivity is now being restored, and we are doing everything we can to complete this work as quickly as possible,” he said. “We apologize for any inconvenience anyone may have experienced.”

It is unclear whether the problems are limited to Humana's Louisville operations.

Humana provides insurance products and health and wellness services nationwide. In 2012, the company had revenue of $39.13 billion. Nationwide, the company has more than 43,000 employees. Locally it has more than 11,000 workers.

http://m.bizjournals.com/louisville/news/2013/09/13/humana-it-systems-down-friday.html?r=full

Ga. doctor finds simple way to pay for health care

Saturday, September 07, 2013, 7:22am

(NECN/NBC News: Lauren Walsh, Augusta, Ga.) - A Georgia doctor has a much simpler way of paying for health care.

He doesn't accept health insurance, Medicare, or Medicaid. Instead, his unique practice offers patients unlimited visits for a flat monthly rate.

Unlike most doctor's visits, Aubrielle Mills' parents aren't paying a copay or towards their deductible, and they say it's eliminating a lot of questions.

"Do we really want to sit in the waiting room? Do we really want to have that expense of being seen? Is it worth just trying to fix it on our own?"asked Nathan Mills, the patient's father.

Like all of Dr. Robert Lamberts' patients, the Mills pay a flat monthly rate for unlimited primary care.

"It is very nice to know each month that this is the amount we pay for our medical bills," said Aubrielle's mother, Meredith Mills.

Lamberts, who left his 18-year career in traditional medicine, admits his new business model is a learning process.

"If I can make each week just a tiny bit of progress, in a month, we've got a moderate amount of progress, and in a year we've got a whole lot of progress if we just keep turning in that direction," explained Dr. Lamberts.

Although all of Lamberts' patients visit him for their primary care, half of them still carry their own health insurance.

Many wonder what happens in case of emergency for those who choose not to have insurance with Lamberts' plan.

"That's where people say, well, then I'll just drop my insurance and take you. I say, you don't want to do that," suggests Lamberts. "You need to have some sort of insurance to cover if you do have those emergencies, or if you do have those problems."

Lamberts believes his patients are less likely to have one of those emergencies because his goal is to keep each of them healthy and out of the doctor's office. It's a concept that benefits his office financially, so that he can add new patients and gain new monthly payments.

"What is our purpose in health care? It's not to give medicines. It's not to draw lab tests. It's to get people healthy."

His latest challenge is selling that concept to patients and the medical community.

"And that's actually, to some extent, a hard sell to patients sometimes because I'm saying, it's not necessary to treat that, or we don't need to do all of those lab tests. Because truthfully, they don't show us anything to make you feel better or make you live longer," said Lamberts.

It's a new kind of thought process, at a time when our nation's health care laws are drastically changing. Lamberts thinks the Affordable Care Act may actually boost his business.

"That says that people can have a direct contract with a physician, along with a high deductible health care plan and that can qualify them for that type of insurance that they're actually covered," Lamberts said.

He believes this could incentivize businesses to offer his service to their employees.

"And I think from my standpoint, that's one of the real opportunities."

http://www.necn.com/09/07/13/Ga-doctor-finds-simple-way-to-pay-for-he/landing_mobile.html?blockID=851703&feedID=11106

South Florida Doctors Seek New Practice Options to Offset Rising Expenses

Individually and in groups, South Florida doctors are trying new business models for their practices that can reduce costs but may increase their risk.

Palm Beach County neurologist James Goldenberg says his practice is weighing a "risk" model where government or managed-care providers pay doctors a flat sum to care for patients. The doctors make money if they control their costs.

In Broward County, Dr. Brian Polner reduced the cost of business operations 20 percent after forming HealthwoRx, a group of cardiovascular, internal medicine and family practice physicians who share a testing lab and other expenses.

"We're seeing more doctors forming groups, or they're going to work for the hospitals," said Cynthia Peterson, executive vice president for the Broward County Medical Association. Nearly half of doctors who responded to a recent survey by the Florida Medical Association said they would pursue alternatives that included trimming their hours, retiring early, providing "concierge" care to a limited number of well-heeled patients, seeking hospital employment, or cutting back on the patients they see.

The trend "bears watching because it could negatively affect Florida patients' access to health care," the state group said.

Goldenberg said physicians are frustrated with ever-changing regulations, lower reimbursements for their services, and bureaucracy that often gets in the way of patient care.

To diagnose a diabetic for nerve damage, for example, he conducts a common test. But insurers and Medicare are reimbursing doctors at a rate 30 percent lower today than in previous years.

Goldenberg said his 75-doctor group, Medical Specialists of the Palm Beaches, is considering "all options" to offset declining reimbursements while maintaining quality care. That includes a model that would encourage doctors to think twice about ordering an expensive test — or assume the financial responsibility if they proceed.

"I think that's going to be a very important model in the future," he said.

Polner, chief executive of HealthwoRx, helped found the 20-doctor Broward County practice in 2005. The goal: to improve patient care through collaboration, which also helps lower costs for the doctors.

"You reduce the redundancy of testing, improve patient compliance by following up with doctors in the group, and have better control of medical records," he said.

By year-end, HealthworRx's number of doctors will double after it forms a new multispecialty model, he said.

But even a larger practice isn't enough to curb spiraling health care costs. A year ago, Polner launched PremierMD, an independent physicians association that contracts with major insurers to reduce costs. If the cost-cutting is a success, the group shares profits with the insurer. The physicians remain independent but benefit from the power of group purchasing for medical and office equipment and supplies.

So far, 80 local doctors have joined the association.

In January, PremierMD will introduce a group that will collect data with the goal of reducing Medicare costs.

"Doctors, especially in South Florida, are afraid of being in a group practice because they're afraid of losing their autonomy. But they want to collaborate with other doctors," Polner said.

Dr. Octavio "Tony" Prieto, who has been practicing family medicine for more than 30 years, is feeling the pinch as a solo practitioner. The Plantation doctor said insurance companies pay less — or nothing at all in some case — while patients cut back on visits to save on co-pays.

At one point, he considered selling his practice to a corporation, but "they couldn't come up with the money to buy my practice," he said.

So Prieto presses on, but has reduced his practice from 14 workers to six. He's also considering eliminating in-office X-rays because they cost more than insurers will pay.

South Florida patients, many who've lost jobs and employer insurance, try to talk their doctors into reducing their bills. "People arm-wrestle you for the $10 co-pay," he said.

Meanwhile, Prieto, 65, said he loves his work too much to give it up.

But someday, "If I can afford it, I will cut down my hours," he said.

http://touch.sun-sentinel.com/#section/-1/article/p2p-77089126/

Ambulance Company Owners Sentenced to Prison for Fraud Scheme

The two men have also been ordered to repay more than $3 million in restitution for their health care fraud scam that used falsified reports to bilk money out of the federal Medicare program.

The owners of a Feasterville-based ambulance company have been sentenced to federal prison after they pled guilty to 41 counts of health care fraud, wire fraud and related charges, according to a press release from the Department of Justice.

Aleksandr N. Zagorodony, 39, of Upper Southampton, was sentenced to 78 months in prison for a fraud scheme involving MedEx Ambulance Inc., located in Feasterville. Zagorodny was the president and a founder of MedEx Ambulance. 

MedEx Ambulance was ordered to be dissolved after it has been excluded from participation in Medicare and its assets are transferred to the government to satisfy restitution and forfeiture obligations. Each defendant had pleaded guilty to all counts in a 41-count indictment including health care fraud, false statements in connection with health care matters, wire fraud, and conspiracy to commit health care fraud and wire fraud.His 36 year-old brother, Sergey Zagorodny, from Philadelphia, the former vice-president and co-owner of the company, was sentenced to 60 months in prison for his involvement in the health care fraud scheme. 

Defendant MedEx Ambulance and its owners transported patients who were able to walk and could travel safely by means other than ambulance and who were not eligible for ambulance transportation under Medicare requirements. 

Falsified reports made it appear that the patients needed to be transported by ambulance when the defendants and their employees knew otherwise. The defendants billed for the ambulance services as if those services were medically necessary. The Medicare program was bilked out of more than $3.4 million through this fraud.

U.S. District Court Judge Berle M. Schiller also ordered restitution to Medicare in the amount of $3,418,358.81, a special assessment of $4,100 for each individual defendant and $16,400 for the corporation, and a three-year term of supervised release for the individuals and five years of probation for the corporation. 

The court ordered the forfeiture of four ambulances that had been purchased for more than $200,000, as well as forfeiture of bank accounts worth more than $40,000, and entered a money judgment against the defendants for $3,418,358.81. 

In connection with the sentencing, the company agreed to sell its base of operations and to provide the proceeds of that sale to the government in partial satisfaction of the defendants’ restitution obligations. The defendants and their wives also pledged to sell their family homes, as well as additional property, and to provide the proceeds of the sale of those assets to partially satisfy the defendants’ restitution obligations.

http://lowersouthampton.patch.com/groups/police-and-fire/p/ambulance-company-owners-sentenced-to-prison-for-health-care-fraud-scheme

Blue Cross Blue Shield of Texas Creates New Accountable Care Organization Alliance

Richardson-based Blue Cross and Blue Shield of Texas announced a new strategic alliance Thursday that it hopes will deliver improved, sustainable patient care while better managing healthcare costs, beginning in mid-2014.

The partnership—with Memorial Hermann Accountable Care Organization—is aiming to improve patients’ health while reducing costs through avoiding unnecessary hospital admissions, readmissions, emergency room visits, and duplication of services.

“This is a paradigm shift in paying for medical services,” Shara McClure, BCBSTX vice president for network management, said in a statement. ”The arrangement begins to move reimbursement away from fee for service to fee for value. In addition, the arrangement enables MHACO to harness clinical data to help drive medical care decision-making, enhance patient safety, and improve quality of care—all supporting the goals of better health and improved outcomes for BCBSTX members.”

The ACO model of healthcare delivery is designed to improve outcomes in three  categories: quality of care, patient experience and satisfaction, and cost efficiency. BlueCross will reach those goals by pursuing:

— Early identification of disease and illness through coordination of patient care

— Use of advanced technology and support services to make more informed decisions and facilitate transitions in care

— the implementation of an alternative or non-fee-for-service payment arrangement

— lower cost trends by increasing coordination among payers and providers

“Our relationship with Blue Cross Blue Shield of Texas around accountable care activities is consistent with Memorial Hermann’s commitment to quality outcomes and cost management,” said Chris Lloyd, CEO of MHACO. “The efforts we will undertake together will continue to advance the health of the populations we serve.”

BCBSTX is entering the ACO game just as another prominent North Texas healthcare organization is leaving it. Plus ACO—the accountable care organization comprised of Texas Health Resources and North Texas Specialty Physician— indicated to CMS in July that it intended to withdraw from the Pioneer ACO program, due to unmet financial goals.

“We look forward to working with CMS in other areas, and we will continue to support the accountable care framework’s fundamental components—reducing costs, improving patient outcomes through enhanced quality of care and care coordination across the continuum,” THR spokesman Wendell Watson said in an email to D Healthcare Daily in July.

Watson said Plus ACO was on track to save $10 million annually, yet was anticipating that it could be liable for a penalty between $6 million and $9 million at the end of the year. Watson said the group will continue to work with commercial plans to implement accountable care programs.

http://healthcare.dmagazine.com/2013/09/06/blue-cross-blue-shield-of-texas-creates-new-accountable-care-organization-alliance/

OIG: Medicare's Recovery Audit Program Generally Accurate

Medicare's recovery audit program is more accurate than critics claim, although it could detect more fraud, according to a report by HHS' Office of Inspector General, Modern Healthcare reports.

In 2006, Congress ordered Medicare to hire four private contractors -- known as recovery auditors -- to oversee Medicare payments and find cases in which providers and suppliers were being overpaid. The auditors have encountered criticism from the hospital industry, which claims that the companies are overly aggressive. Hospitals point to hospital-reported surveys that indicate at least 40% of all payments denials are appealed and 70% of those appeals are successful. Bills in the House and Senate to temper the auditors have garnered support from the American Hospital Association.

However, HHS OIG's report found that of the 1.1 million cases in 2010 and 2011 in which an auditor recommended denying Medicare reimbursements, just 6% were ever appealed and only 44% of those appeals were successful.

The report stated that CMS is falling short on investigating the leads it receives and does not provide enough training or regular updates to help generate new fraud leads. Further, the report noted that although CMS made 28 changes to its billing rules to close "vulnerabilities" found through examination of overpayment data, the department never measured the success of those changes.

In response, CMS Administrator Marilyn Tavenner said measuring the efficacy of such changes is challenging, because some require multiple steps over long periods. She added, "Some are implemented within a few months, while others take significantly longer, hindering CMS' ability to draw conclusions about the effectiveness of a specific corrective action"(Carlson, Modern Healthcare, 9/4).

http://www.californiahealthline.org/articles/2013/9/4/oig-medicares-recovery-audit-program-more-accurate-than-believed