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 InterQual. In an effort to […]
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 query all hospitals at which […]
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 recovered more than $4 billion […]
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 (e.g., the Federal Stark law, […]
Last week, a lawsuit was filed in the Northern District of Texas federal court, challenging the validity of the aggregate annual cap for hospice reimbursement. Medicare provides reimbursement for hospice services rendered on a per beneficiary, per diem basis, subject to an aggregate annual cap. This cap is based upon the product of a per-beneficiary […]
The days are counting down to December 31 where certain New York providers and suppliers must certify that they have adopted and implemented “effective compliance programs” to be eligible to receive Medicaid payments (for a more detailed explanation of the requirements under the Medicaid Provider Compliance Programs can be found in our June 26, 2009 […]
Passed in the House and Senate and awaiting signature by the President, the Red Flag Program Clarification Act of 2010 limits the definition of “creditor” to include only those that use consumer reports, furnish information to consumer reporting agencies or advance funds to a person. Importantly, the definition does not include one who advances funds […]
On December 7, 2010, the U.S. District Court for the District of Kansas refused to dismiss False Claims Act (FCA) claims against a hospice provider. The defendant, Hospice Care of Kansas, Inc. (HCK), which was purchased by defendant Voyager Hospicecare, Inc. in 2004, provides hospice care to Medicare beneficiaries. The suit contends that the defendants […]
Representatives Dingell (D-Mich.), Pete Stark (D-Calif.), and other representatives have introduced legislation to extend the current physician Medicare reimbursement rates for 13 months as well as to provide a 1% update for this year and next year. We will continue to keep our readers apprised of any future developments. Continue Reading →
Following The HLP’s submission of numerous written inquiries and phone calls to representatives of CMS, National Government Services, Inc. (“NGS”) (the Medicare Affiliated Contractor), and CGI (the Medicare RAC for Region B), on November 8, 2010, CMS published a response to Frequently Asked Questions related to RAC reviews of Periodic Interim Payments (“PIP”). As described […]
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