In reviewing certain inpatient hospital claims, the RAC for Region B (covering the Midwestern states), CGI, and its subcontractor, PRG Schultz, are now requesting that nursing notes not be included in response to additional documentation requests (“ADRs”). Note that this directive is not consistent across all ADRs, as other ADRs…
The Medical Group Management Association (“MGMA”) recently released the result highlights of the largest physician compensation survey in the United States. The survey is based on 2010 data from 60,000 providers in more than 150 specialties; the publically reported figures focus on 15 specialties. According to the selected specialties data,…
In addition to the multitude of auditing activities and programs that exist, the Medicare Carriers/Medicare Administrative Contractors also conduct medical reviews. Like many other auditing programs, these probe reviews are data driven and are conducted for the purpose of validating potential provider billing errors. The process may include either provider…
The Medical Payment Advisory Commission (MedPAC) plans to release a recommendation calling for a reduction in the use of imaging services, including MRIs, CT scans and nuclear medicine. MedPAC’s advisory opinion would require some physicians and their patients to obtain pre-approval from Medicare for advanced imaging services. The proposal, if…
On Friday, June 3, the American Medical Association (“AMA”) submitted its comments concerning the Accountable Care Organizations (“ACOs”) Proposed Rule (the “Proposed Rule”) to Donald Berwick, the Centers for Medicare and Medicaid Services (“CMS”) Administrator. The Proposed Rule was issued by CMS on March 31, 2011. In its comments, AMA…
On May 20, 2011, Ohio governor, John Kasich, signed Ohio House Bill 93 into law. The bill represents an effort by Ohio to strengthen the State’s regulatory framework relating to the prevention of prescription drug abuse. According to the Ohio Department of Health, since 2007, unintentional drug overdoses in the…
The national health care reform, the implementation of which effectively requires a shift of health insurer spending more heavily towards medical care, is projected to reduce insurance profit margins to approximately 3% to 5%. This is a substantial decline considering these margins historically averaged around 7% to 8%. As a…
A Florida radiology clinic, Midtown Imaging LLC, and its former owners–Midtown Imaging PA and PBC Medical Imaging–have agreed to pay $3 million to settle allegations that Midtown Imaging LLC submitted false claims to Medicare between 2000 and 2008. The allegations arose from Midtown Imaging LLC’s lease and professional services agreements…
Five U.S. senators requested an investigation by the Inspector General of the Department of Health and Human Services (“HHS”) into the legality of physician-owned distributorships (“PODs”). The legality of the PODs is being questioned under the federal Anti-kickback Statute and other fraud and abuse laws. Distributorships act as a link…
June 7, 2011, the Departments of Justice and Health and Human Services (“HHS”) announced that Reynel Betancourt, a 51 year-old Miami resident, was sentenced for his involvement in a $9 million Medicare fraud scheme originating in metro Detroit. His penalty includes 77 months in prison and three years of supervised…