The recovery audit contractor (“RAC”) for Region B covering the Midwestern states, CGI Federal, Inc., is requesting additional documentation from providers regarding facet joint injections without reported imaging guidance (CPT codes 64470-64476). The requests for additional documentation acknowledge that CMS has not yet approved this issue for complex review and…
On February 2, 2011, the OIG published its findings from an audit conducted of Prescription Drug Event (PDE) records obtained from Medicare Part D sponsors for Schedule II drugs. A copy of the report can be found at: http://go.usa.gov/Ydd. A significant number of PDE records contained invalid prescriber identifiers which…
In an Office of Inspector General (OIG) press release, the OIG announced its first-ever Most Wanted Healthcare Fugitives List, which includes photos and profiles for each fugitive. According to the press release, “the 10 individuals on the Most Wanted Health Care Fugitives List have allegedly cost tax payers more than…
In light of recent campaign promises, Congressional Republicans have pushed to quash the Affordable Care Act, commonly known as the healthcare reform law or “Obamacare.” On January 20, the US House of Representatives voted 245-189 to repeal the Affordable Care Act while yesterday, Senate Democrats, by a 51-47 vote, defeated…
A report published in the February 2, 2011 edition of the Journal of the American Medical Association, compared the patient diagnoses, length of stay, and location of service for hospice patients receiving care from for-profit and not-for-profit hospices. The researchers found that for-profit hospices had a higher percentage of patients…
CMS has issued revised Interpretive Guidelines for the Hospital Conditions of Participation. The revised Interpretive Guidelines, which are effective immediately, contain significant changes affecting anesthesia providers, including the following: • Labor Epidurals. CMS removed language exempting labor epidurals from the physician supervision requirements. The revised Interpretive Guidelines note that, “there…
During the Recovery Audit Contractor (“RAC”) demonstration program, a significant number of the claims denied were denied for the reason that an inpatient hospital admission was not medically necessary. The RACs regularly based these denials not upon published Medicare guidance, but based upon the criteria of private companies, such as…
The New York regulations related to the credentialing of medical staff personnel have been revised, effective December 22, 2010. In particular, the regulations have been revised to reduce the required “look-back period” for medical staff credentialing from 10 years to five years. During this “look-back period,” hospitals are mandated to…
The FY 2010 Health Care Fraud and Abuse Control Program Report was issued on January 24, 2011 by the Office of Inspector General (“OIG”). This report summarizes the health care fraud prevention and enforcement efforts that yielded results during fiscal year (“FY”) 2010. According to the Report, the federal government…
The American Hospital Association (AHA) expressed its concerns with numerous regulations adversely impacting hospitals, by way of letter dated January 14, 2010 to Darrell Issa, the Chairman of the Committee on Oversight and Government Reform in the U.S. House of Representatives. Among numerous other regulations causing strife for hospital providers…