Medicare Update

Medicare Recovery Audit Contractors: Don't Be Left in the Dark

The Centers for Medicare & Medicaid Services (CMS) intends to implement the permanent Medicare Recovery Audit Contractor (RAC) program in phases beginning in March 2009.  Medicare providers should become informed about the RAC program and prepare for its implementation.  In this post, aspects of the nationwide RAC program are highlighted to assist Medicare providers in understanding the program.

UPDATE: Senator Reid to Unveil Amendment to Senate Health Reform Legislation

According to The Hill, Senate Majority Leader Harry Reid may unveil the long awaited amendment to the Senate health care reform legislation shortly after the U.S. Senate votes on a 2010 defense appropriations bill (H.R.3326).  The Hill reports that the vote may occur around 7:30 a.m. on Saturday, December 19, 2009.

The amendment is expected to include proposed changes, which are intended to secure the votes of 60 Democratic Senators. The Hill also reports that Senator Reid may release the Congressional Budget Office's (CBO) cost estimate for the amendment on Saturday morning.

UPDATE: On December 19, 2009, Senator Reid unveiled a Manager's Amendment, which can be found here. The CBO's cost estimate can be found here.

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

Related Post: Senate Set to Vote on Bill Delaying 2010 Medicare Physician Payment Reductions

UPDATE: Senate Set to Vote on Bill Delaying 2010 Medicare Physician Payment Reductions

On December 18, 2009, the U.S. Senate voted 63-33 on a cloture motion for a 2010 defense appropriations bill (H.R.3326), which contains a provision that would delay the scheduled 21.2 percent Medicare payment reduction for physician services until March 2010.

The Senate cloture motion vote should clear the way for a final Senate vote on the bill, which many news organizations report will occur on Saturday, December 19, 2009.  On December 16, 2009, the U.S. House of Representatives voted 395-34 to pass the defense appropriations bill.

In the Final Rule updating the Medicare Physician Fee Schedule (MPFS) for calendar year 2010, the Centers for Medicare & Medicaid Services (CMS) adopted an update of -21.2 percent. MPFS rates are updated annually based on a formula that includes the sustainable growth rate (SGR) formula.  The SGR formula has resulted in negative updates since 2002. However, CMS has taken action or Congress has enacted legislation each year to avoid the negative updates.

UPDATE: The Hill reports that the Senate passed the defense appropriations bill in a vote of 88-10.

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

Related Post: House Votes to Delay 2010 Medicare Physician Payment Reductions

CMS to Hold Listening Session on 2011 Physician Quality Reporting Initiative

On December 18, 2009, the Centers for Medicare & Medicaid Services (CMS) published a Notice announcing that it will hold a Physician Quality Reporting Initiative (PQRI) listening session.  The listening session will take place from 10:00 a.m. - 4:30 p.m. (EST) on February 2, 2010.

According to CMS, the purpose of the listening session is to solicit input from stakeholders on:

• The individual quality measures and measures groups (e.g., suggestions for new measures groups or for the composition of existing measures group(s) being considered for possible inclusion in the proposed set of quality measures for use in the 2011 PQRI program); and
• Key components of the design of the PQRI program, such as possible reporting mechanisms, reporting periods, criteria for satisfactory reporting, the group practice reporting option, and public reporting of 2011 PQRI data.

See the Notice for information regarding deadlines, registration, location, submission of comments or statements, participation by telephone, and other instructions.

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

CMS to Host Open Door Forum on 2010 PQRI and E-Prescribing Incentive Programs

The Centers for Medicare & Medicaid Services (CMS) recently announced that it will host a Special Open Door Forum (ODF) on the 2010 Physician Quality Reporting Initiative (PQRI) and Electronic Prescribing (eRx) Incentive Programs.  The Special ODF will take place from 3:30 p.m. - 5:00 p.m. (ET) on January 14, 2010.

CMS reports that the Special ODF will focus on a new reporting option known as the Group Practice Reporting Option (GPRO).  During the Special ODF, CMS will provide information on GPRO eligibility, participation instructions, data submission, measures, and criteria for satisfactory reporting. Following the presentation, callers will have an opportunity to ask questions of CMS.

To participate in the Special ODF, one must dial (800) 837-1935 and reference conference ID 45243499.  CMS will also post an audio recording and transcript of the call on the Special Open Door Forums page of the CMS website, which will be accessible for download beginning on or around January 27, 2010.

For more information, see the announcement.

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

House Votes to Delay 2010 Medicare Physician Payment Reductions

A number of news organizations (including Modern Healthcare) report that the U.S. House of Representatives voted 395-34 to pass a fiscal 2010 defense appropriations bill that includes a provision that would delay the scheduled 21.2 percent Medicare payment reduction for physician services until March 2010.

In the Final Rule updating the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2010, the Centers for Medicare & Medicaid Services (CMS) adopted an update of -21.2 percent.

MPFS rates are updated annually based on a formula that includes the sustainable growth rate (SGR) formula.  The SGR formula has resulted in negative updates since CY 2002. However, CMS has taken action or Congress has enacted legislation each year to avoid the negative updates. 

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

Related Post: Physician Organizations Advocate for Repeal of Medicare Sustainable Growth Rate Formula

Physician Organizations Advocate for Repeal of Medicare Sustainable Growth Rate Formula

On December 15, 2009, a number of national physician organizations (including the American Medical Association) and state medical societies sent a letter to Senator Harry Reid stressing the "urgency of establishing a pathway for a permanent repeal of Medicare's sustainable growth rate (SGR) formula."

In the letter, the physician organizations and state medical societies advocate for a permanent repeal of the SGR formula and oppose "any proposal that would implement another short-term, one- or two-year patch to postpone the 2010 Medicare payment cuts."

However, in the interest of patients, they state that they would "support a very short postponement of the imminent cuts for a period of 30-45 days, so that Congress has enough time to pass Medicare physician payment reform legislation that will be signed into law."

In the Final Rule updating the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2010, the Centers for Medicare & Medicaid Services (CMS) adopted an update of -21.2 percent.

MPFS rates are updated annually based on a formula that includes the SGR formula.  The SGR formula has resulted in negative updates since CY 2002. However, CMS has taken action or Congress has enacted legislation each year to avoid the negative updates.

On October 21, 2009, the U.S. Senate voted 47-53 to defeat a cloture motion for the Medicare Physician Fairness Act of 2009 (S.1776), which would eliminate the 21.2 percent Medicare payment rate reduction for physician services in 2010 and sunset the SGR formula.

However, on November 19, 2009, the U.S. House of Representatives voted 243-183 to pass the Medicare Physician Payment Reform Act of 2009 (H.R.3961), which would repeal the now 21.2 percent Medicare payment rate reduction for physician services in 2010 and restructure the SGR formula.

So, the SGR formula and its impact in 2010 remains unresolved at this time.

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

Medicare Fraud Strike Force Efforts Trigger Arrests in 3 States

Today, the Department of Health and Human Services (HHS) and Department of Justice (DOJ) announced that 30 individuals in 3 states have been charged for their alleged roles in Medicare fraud schemes to submit more than $61 million in false Medicare claims.

The charges announced today arise from Medicare Fraud Strike Force (Strike Force) operations in Miami, Detroit and Brooklyn. According to a DOJ Press Release, the defendants allegedly participated in various criminal schemes, including conspiracy to defraud the Medicare program, conspiracy to launder money, money laundering, criminal false claims, making false statements and receiving kickbacks.

As part of today's announcement, the HHS and DOJ also announced that the Strike Force is expanding its operations to include Brooklyn, Tampa and Baton Rouge. The Strike Force is already operating in Miami, Los Angeles, Houston and Detroit.

The Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques.

The Strike Force efforts are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), which is a joint HHS and DOJ effort to reduce and prevent Medicare fraud. 

Since the inception of Strike Force operations (in March 2007), the Strike Force has obtained indictments of more than 400 individuals and organizations (involving more than $1 billion in Medicare claims).

For more information, see the DOJ Press Release.

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

Senator Grassley Seeks Action Against Health Care Providers With Tax Delinquencies

On December 14, 2009, Senator Charles Grassley wrote the Internal Revenue Service (IRS) requesting information on the collection activities against (and possible criminal investigation of) 90 health care providers with unpaid Federal taxes.

Senator Grassley's request follows a series of reports and testimony from the U.S. Government Accountability Office (GAO) about Medicare and Medicaid providers with unpaid Federal taxes. 

The GAO reports and testimony even highlight the results of the audits and investigations of the 90 (above referenced) providers with high tax debts.  According to the GAO, much of the unpaid Federal taxes consist of payroll taxes (including taxes used to fund the Medicare program).

Medicare providers and suppliers should also be aware of a little known tax provision, which is intended to address the tax delinquencies of government contractors and could impact their practices.

Specifically, Section 511 of the Tax Increase Prevention and Reconciliation Act of 2005 (TIPRA) requires that federal, state and local governments temporarily withhold 3 percent of their payments to certain persons providing goods or services. Payments made by the Medicare program to providers and suppliers fall within the withholding requirement.

However, on December 5, 2008, the IRS published a Proposed Rule for the purposes of implementing Section 511 of the TIPRA.  The Proposed Rule contains "transition relief," which would exempt certain written contracts in effect on the later of the effective date of Section 511 or the date that is 6 months after the publication of a final rule on the matter (unless a contract is materially modified).

At the time that the Proposed Rule was published, the withholding requirement was to apply to payments made after December 31, 2010. However, the American Recovery and Reinvestment Act of 2009 subsequently extended the effective date to payments made after December 31, 2011.

A number of trade and professional associations that oppose the tax provision have formed the Government Withholding Relief Coalition to work to repeal the 3 percent withholding requirement.  Information on the Coalition's efforts and pending legislation that may repeal the withholding requirement can be found here.

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

GAO Reports:

• Thousands of Medicare Part B Providers Abuse the Federal Tax System (March 2007) 
• Thousands of Medicaid Providers Abuse the Federal Tax System (November 2007) 
• Thousands of Medicare Providers Abuse the Federal Tax System (June 2008)

CMS Warns Medicare DMEPOS Bidders About Federal Antitrust Violations

The Centers for Medicare & Medicaid Services (CMS) has issued a bidder alert (Alert) in conjunction with the Medicare durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) competitive bidding program.

In the Alert, CMS warns bidders and contract suppliers that they must comply with applicable Federal and State laws, including Federal antitrust laws. The Alert even warns that any supplier suspected of violating Federal antitrust laws (by engaging in price fixing, bid rigging or other collusion) will be referred to the Department of Justice for investigation and is subject to having its bid rejected.

Based on the Alert (and its Q&As), it appears that CMS may be concerned that some bidders may be using consulting services that are comparing a supplier's bid with the bid of other suppliers and advising the supplier to submit identical or substantially identical bid prices.  

In addition, the Alert reminds suppliers that bidders must certify that their bids are true, accurate and complete and that the bidder understands that any omission, misrepresentation or falsification of information may be punishable by criminal, civil or other administrative actions.

For more detailed information, see the Alert, which can be found here.

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

Region A Medicare Recovery Audit Contractor Adds New CMS Approved Audit Issue

DCS Healthcare (DCS), the Medicare recovery audit contractor (RAC) for Region A, recently posted a new CMS approved audit issue for automated RAC review on its website.

The new CMS approved audit issue is titled "Clinical Social Worker (CSW) Services" and applies to CSW providers in the states of Massachusetts, Maine, New Hampshire, Rhode Island and Vermont. On the DCS website, the new audit issue is described as:

"CSW services rendered during an inpatient acute care or skilled nursing facility stay are not separately payable under Medicare Part B, instead they are included in the facility's Prospective Payment System (PPS) payment. CSW providers are expected to render services under arrangement with the facility. Therefore, an issue may exist when a beneficiary received CSW services during an inpatient stay, which have been billed and reimbursed under Medicare Part B."

Region A includes Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

For more information, see the CMS approved audit issues for Region A, which can be found here.

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.