In a press release issued September 27, 2011, the United States Department of Justice, the Department of Health and Human Services, and the FBI announced that two Miami-area residents pled guilty for their roles in a $25 million home health Medicare fraud scheme. Both defendants pled guilty to conspiracy to…
Medicare Part A and Part B providers and suppliers appealing Medicare audit decisions at the administrative law judge (“ALJ”) level or through a judicial review must meet an amount in controversy (“AIC”) threshold amount pursuant to regulation at 42 CFR 405.1006(b) and (c). The regulations require the Secretary of the…
As many already know, when a review contractor (e.g., Recovery Audit Contractors (“RACs”), Medicare Administrative Contractors (“MACs”), the Comprehensive Error Rate Testing (“CERT”) contractor, the Program Error Rate Measurement (“PERM”) contractor, and Zone Program Integrity Contractors (“ZPIC”)) identifies an improper payment, the review contractor requests medical documentation from the provider…
On September 14, 2011, the Centers for Medicare and Medicaid Services (“CMS”) published in the Federal Register a proposed rule amending the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”) and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) to specify that, upon request, a patient may gain access…
On February 2, 2011, the Centers for Medicare and Medicaid Services (“CMS”) issued its final rule regarding the new provider and supplier enrollment screening criteria for Medicare, Medicaid and Children’s Health Insurance Program (“CHIP”) pursuant to Section 6401(a) of the Patient Protection and Affordable Care Act (“PPACA”). Included in the…
In July, the HEALTH LAW ATTORNEY BLOG reported on five U.S. Senators asking the Office of Inspector General (“OIG”) and the Centers for Medicare and Medicaid Services (“CMS”) to issue guidance on physician owned distributorships (“PODs”) (or, sometimes referred to as physician owned intermediaries (“POIs”)). The OIG and CMS have…
Section 6411 of the Patient Protection and Affordable Care Act (“PPACA”) requires states to establish a Medicaid recovery audit contractor (“Medicaid RAC”) program similar to the existing Medicare RAC program. Like Medicare RACs, Medicaid RACs will be tasked with auditing claims to identify overpayments and underpayments and will be compensated…
This month, the Centers for Medicare and Medicaid Services (“CMS”) published a revised recovery audit contractor (“RAC” or “Auditors”) statement of work (“SOW”) which is, as CMS described, a “contract” between CMS and the Auditors to support CMS in its mission to “reduce Medicare improper payments through the efficient detection…
On August 29, 2011, the Department of Health and Human Services Office of Inspector General (“OIG”) issued Advisory Opinion 11-12 in which an operating division of a non-profit corporation (“Requestor”) was seeking an opinion from the OIG regarding its “proposal to enter into arrangements to provide neuro emergency clinical protocols…
Wisconsin Physician Services (WPS)–the Part B Medicare Administrative Contractor (MAC) for Iowa, Kansas, Missouri and Nebraska and the Legacy Medicare Carrier for Michigan, Illinois, Wisconsin and Minnesota–regularly conducts Service-Specific Probes (Probes) “to validate potential systematic problems with billing, utilization, and or/documentation of a specific service.” In a recent Probe, 99213–the…