CCH Health NetNews
Home  |  Products  |  Health Law Blog  |  Contact Us November 13, 2013 Edition

Headlines

Dennis Barry's Reimbursement Advisor

Receivables Report


Headlines (from the Medicare Medicaid Guide):

CMS issues additional guidance for “two midnight” rule for inpatient hospital admissions

CMS issued additional guidance for the “Two Midnight Rule” that was included as part of the Final rule (CMS-1599-F) updating the inpatient hospital prospective payment system (IPPS) for fiscal year 2014. The two documents, titled “Reviewing Hospital Claims for Patient Status” and “Selecting Hospital Claims for Patient Status Reviews” contain CMS’ instructions for Medicare Administrative Contractors (MACs) regarding how to they are to review inpatient hospital admissions for payment purposes. The selected hospital claims will be reviewed and used during a “Probe and Educate” program for admissions that occur between October 1, 2013, and March 31, 2014. CMS also issued a Frequently Asked Questions document titled “Questions and Answers Relating to Patient Status Reviews” to help MACs answer common questions related to the two midnight inpatient admission guidance and patient status reviews.

CCH Chicago Bureau, November 1, 2013

Back to Top

Johnson & Johnson agrees to pay $2.2 billion to resolve criminal and civil claims regarding off-label drug uses

Johnson & Johnson (J&J) and its subsidiaries have agreed to resolve global allegations relating to its prescription drugs Risperdal, Invega and Natrecor by paying criminal fines and forfeitures totaling $485 million and $1.72 billion in civil settlements with the federal and state governments based on violations of the False Claims Act (FCA) (Integrity Agreement Between the Office of Inspector General of the Department of Health and Human Services and Johnson & Johnson, October 31, 2013). The allegations include claims that the drugs were promoted for unapproved off-label uses and the payment of kickbacks to physicians and the largest long-term care pharmacy provider in the nation. In addition to monetary penalties, the resolution will subject J&J to a Corporate Integrity Agreement (CIA) with the HHS Office of Inspector General (HHS-OIG).

CCH Chicago Bureau, November 4, 2013

Back to Top

CMS receives numerous comments on the potential release of Medicare physician data

In response to CMS’ August 6, 2013, request for public comments regarding the potential release of physician payment data, numerous organizations and individuals submitted letters to CMS detailing their particular reasons why this information should or should not be released. CMS received more than 130 comments from 300 organizations and individuals. Their letters were recently posted on CMS’ website and several organizations recognized CMS’ ongoing efforts towards greater transparency must be balanced against a physician’s privacy interests

CCH Chicago Bureau, November 1, 2013

Back to Top

Medicare paid $23 million on services for dead people in 2011: OIG

Medicare inappropriately paid $23 million in 2011 on services for people who were dead, according to a report from the OIG. The OIG noted that this figure is less than one tenth of a percent of total Medicare expenditures for that period. Part C accounted for 86 percent of these improper payments. Additionally, 11 percent of these improper payments resulted from missing or incorrect dates of death. The OIG also identified 251 providers and suppliers that had high numbers of paid and/or unpaid Part B claims with service dates after beneficiaries’ deaths. This, in turn, leads to further investigation.

OIG Report, No. OEI-04-12-00130, October 30, 2013, ¶60,999

Read IntelliConnect »  |  Not a Subscriber?

Back to Top

Facilities, not corporate parents, may remain liable for submitting false claims

While a false claims action against a nursing facility was able to proceed against the facility and its contractor, the claims did not reach to the corporate parents of the facility because no facts were sufficiently pled to support the claims against the corporate parents. The nursing facility was accused of submitting false claims for reimbursement under Medicare and the government intervened. Sufficient facts were not alleged against the corporate entities, however, to trigger direct liability against the corporate entities, nor was there enough evidence to pursue claims under a veil-piercing or alter-ego theory. The relator’s complaint did state a plausible claim for relief against the nursing facility and contractor, Aegis, based on their jointly-provided speech-therapy services because specific claims for reimbursement were presented.

U.S. ex rel. Lawson v. Aegis Therapies, Inc., S.D. Ga., October 29, 2013, ¶304,668

Read IntelliConnect »  |  Not a Subscriber?

Back to Top

Claims remaining after $9 million settlement deficient

The public disclosure bar required dismissal with prejudice of claims brought by relators who were not the original source of the information their qui tam action was based upon. Relators’ retaliation claims were also dismissed with prejudice for violating the statute of limitations; the remainder of their claims may be repleaded to cure the existing deficiencies.

U.S. ex rel. Tahlor v. AHS Hospital Corporation, D. N.J., October 31, 2013, ¶304,669

Read IntelliConnect »  |  Not a Subscriber?

Back to Top

Payments made on behalf of unlawfully present beneficiaries cost millions

In a review of payments made on behalf of unlawfully present beneficiaries in Medicare Part D, the Office of Inspector General (OIG) found that between 2009 and 2011, unlawfully present beneficiaries received millions in prescription drug benefits. Out of the $227 billion final prescription drug event (PDE) records submitted to CMS by Part D sponsors, OIG found that CMS inappropriately accepted 279,056 PDE records with unallowable gross drug costs totaling $28,990,718 on behalf of 4,139 unlawfully present beneficiaries and used those records to make its final payment determinations to sponsors. Unlawfully present beneficiaries are not among those eligible for federal health benefits. Lack of policies regarding unlawfully present beneficiaries may be to blame for the problem

OIG Report, No. A-07-12-06038, October 30, 2013, ¶61,000

Read IntelliConnect »  |  Not a Subscriber?

Back to Top

ACO growth slowing, lack of proven model possibly to blame

The growth of ACOs has slowed, according to the journal Health Affairs, which reports that only 35 new ACOs have been announced since the end of January of this year. Considering an increase from 42 ACOs to nearly 500 between the end of 2010 and September 2013, this year’s slowdown raises questions about the reasons for the halt in growth and the repercussions on the changing health care system.

CCH Chicago Bureau, October 31, 2013

Back to Top

Confusion found in “grades” for hospital quality standard report card organizations

Despite promotion as a means to improve the overall quality of care and help people make well-informed decisions about health care, the widespread use of publicly available reports that rate the quality of health care in hospitals results in confusion, according to findings in a Report on Report Cards developed by the Healthcare Association of New York State (HANYS).

CCH Chicago Bureau, November 4, 2013

Back to Top

Community health centers rapidly increase use of EHR

Community health centers (CHCs) are progressing towards full implementation and use of electronic health records (EHR), according to a recent study released by Peter Shin and Jessica Sharac of George Washington University. Almost 70 percent of CHCs had full or partial EHR adoption at the time of the survey as opposed to 25 percent in 2006. Although 262 CHCs across 39 states have already received $72 million in EHR incentives, Shin and Sharac’s findings indicate CHCs may require not only more assistance in fully understanding and implementing the technical and technological requirements for demonstrating meaningful use (MU), but also more time to adapt their training and practices accordingly.

CCH Chicago Bureau, October 30, 2013

Back to Top

Location and vendor influence doctors’ use of EHR functionalities

A study in the American Journal of Managed Care revealed that physicians’ progress toward meaningful use of electronic health records (EHR) varies widely. The authors surveyed physicians about their use of electronic communications to exchange information in 2011. They found that the most significant predictors of use of EHR to exchange information appear to be location and the identity of the vendor. The authors anticipate that usage will increase as the stage 2 requirements of the EHR incentive programs become effective.

CCH Chicago Bureau, October 23, 2013

Back to Top

Record numbers of hospitals achieve Top Performer status

One-third of hospitals accredited by the Joint Commission (TJC) are Top Performers, representing a 77 percent increase from last year, according to TJC’s annual report on hospital safety and quality. Overall, 1099 hospitals received the Top Performer designation in the report, which is based on reported data for 2012. Another 20 percent of TJC-accredited hospitals only missed the Top Performer standard by one measure.

CCH Chicago Bureau, October 30, 2013

Back to Top

Dennis Barry's Reimbursement Advisor

Changes to Inpatient Admission Standards - Two-midnight rule raises unanswered questions

In the fiscal year (FY) 2014 inpatient prospective payment system (IPPS) final rule, the Centers for Medicare and Medicaid Services (CMS) adopted its proposals for inpatient admission guidance and medical review criteria, the so-called "two-midnight rule."

Read IntelliConnect »  |  Not a Subscriber?

Back to Top

Receivables Report

Claim Denials Likely to Increase with ICD-10

With the looming ICD-10 conversion, health care organizations are struggling to improve clinical documentation, coding accuracy, compliance, and workflow management. Most providers are expecting cash flow to diminish due to an increased level of claim denials. Much will depend on the ability of physicians and other clinicians to get acquainted with new reimbursement documentation requirements and guidelines, but just as much will depend on the readiness of the payers with whom providers contract.

Read IntelliConnect »  |  Not a Subscriber?

Back to Top


You are subscribed to NetNews, sponsored by Wolters Kluwer Law & Business. Click here to unsubscribe. To manage your newsletter preferences or subscribe, click here.

To unsubscribe via postal mail, please contact us at: Wolters Kluwer Law & Business, Attn: Business Compliance Marketing, 2700 Lake Cook Rd., Riverwoods, IL 60015. Please include the email address you have been contacted with.

© CCH, Incorporated. All Rights Reserved.

Quick Links

Featured Products

Health Reform Toolkit

A suite of electronic Smartcharts that help you gain quick knowledge on how these laws impact your organization by breaking down the 3000 plus pages of legislation into easy to understand topics related to the hospital, pharmaceutical, and legal industries.

Learn More »


Medicare and Medicaid Guide

Your exclusive source for all Medicare and Medicaid information, with emphasis on the critical issue of payment. Offers comprehensive, full-text reporting of federal Medicare and Medicaid law and regulation provisions and summary reporting of state.

Learn More »

About this Newsletter

To access IntelliConnect full text documents you must be a subscriber to the Medicare and Medicaid GuideIntelliConnect products.*

Links within news stories display full text documents including legislation, regulations, court decisions, rulings and government reports.

The first time you click on a link you will be taken to the standard IntelliConnect login page, where you will need to enter your ID and password. Subsequent links will take you directly to the desired document.

Sign up for NetNews

Receive the NetNews newsletters via e-mail and to stay up-to-date on all the latest developments.

Subscribe Now

Privacy Policy