The Centers for Medicare and Medicaid Services (“CMS”) recently published a final rule addressing termination of non-random prepayment complex medical review, which became effective January 1, 2009. The final rule implements Section 934 of the MMA, which required CMS to establish termination dates for non-random prepayment complex medical reviews performed by Medicare Administrative Contractors (“MACs”), […]
The Medicare Recovery Audit Contractor Program (“RAC”) program has been made permanent and is expanding nationwide, pursuant to Section 302 of the Tax Relief and Health Care Act of 2006. Medicare providers and suppliers in Michigan are some of the first in the country that will experience RAC audits and potential claim denials. Pursuant to […]
The Medicare Recovery Audit Contractor (“RAC”) program is being challenged by the two San Diego, California-based hospitals of Palomar Pomerado Health (“Palomar”). In a complaint filed against the Department of Health and Human Services (“HHS”) on March 27, 2009, Palomar alleged that PRG Schultz International, Inc. (“PRG Schultz”), the RAC operating in California during the […]
A recent Federal appeals court decision paved the way for a whistleblower to proceed with a False Claims Act (“FCA”) case involving allegations of Stark and Anti-kickback Statute violations regarding an exclusive anesthesia coverage agreement and pain management services arrangement. This case is important as it highlights how courts and enforcement officials may apply Stark […]
As part of the OIG 2008 Work Plan, the OIG reviewed Medicare payments for interventional pain management procedures in connection with Section 1862(a)(1)(A) of the Social Security Act, which requires that services must be medically necessary. The OIG noted that interventional pain management was a growing specialty and that Medicare paid almost $2 billion for […]
As the “Red Flag Rules” enforcement date of May 1, 2009 quickly-approaches, health care providers need to get prepared. The Red Flag Rules require financial institutions and “creditors” to develop and implement identity theft prevention programs that provide for identification, detection, and response to patterns, practices or specific activities (known as red flags) that could […]
According to the Office of Inspector General (“OIG”) 2009 Work Plan, “incident to” services continue to be an area of scrutiny. The OIG is currently reviewing this billing area and expects to issue a report of its findings in 2009. In summary, in order to bill “incident to” services, the services must be integral to […]
The Health Information Technology for Economic and Clinical Health Act (“HITECH Act” or the “Act”) included in the “Stimulus Bill” significantly expands HIPAA privacy and security provisions. Health care organizations and providers may be interested in some of the critical aspects of the HIPAA privacy and security portions as follows: • Required Notification for Information […]
New York Medicaid Inspector General Mandates Compliance Programs Although compliance programs have traditionally been viewed as voluntary, on January 14, 2009, the Office of Medicaid Inspector General issued proposed regulations mandating the establishment and maintenance of compliance programs for many Medicaid participating providers. In addition to applying to certain providers like hospitals and hospices, the […]
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