Kusserow on Compliance: Technical Difficulties & What You Missed

The editorial team at Wolters Kluwer would like to apologize for a recent technical glitch that prevented the Kusserow on Compliance Newsletter from being sent out to its subscribers. The popularity of the content proved too much for our system, and after some adjustments and additions, we’d like to let you know we are back up and running. We’ve also listed all the posts written by Richard Kusserow during the newletter’s hiatus:

Kusserow’s Corner is Now Kusserow on Compliance

Everything you have come to rely on under “Kusserow’s Corner” has now been moved to Kusserow on Compliance. Please visit us on Tuesdays and Thursdays for insight from industry leader and former HHS OIG Inspector General, Richard Kusserow. You can sign up for the Kusserow on Compliance Newsletter here.


Father Daughter Duo to Pay $1.65M for Kickback Scheme Involving Sham Employees

Tracy Nemerofsky and her father, Stephen Nemerofsky, will pay $1.65 million to settle allegations of illegal patient referrals, according to the Department of Justice (DOJ). The two were accused of paying spouses of physicians for fake marketing jobs in order to induce patient referrals to the Nemerofskys’ home health business, A Plus. The scheme allegedly began in 2006, with its success resulting in Tracy’s salary of $685,000 in 2010 due to the increased revenue.

The DOJ noted that the home health market is heavily saturated in southern Florida, so the duo hired at least seven physicians’ spouses and one physician’s boyfriend to perform “marketing duties” for A Plus. In reality, the DOJ alleged that there were few, if any, duties and the jobs were a reward for Medicare patient referrals by the physicians. Low numbers of referrals by two physicians led to their spouses’ termination from A Plus by Tracy Nemerofsky.

“Kickback schemes undermine the integrity of our public health care programs,” said U.S. Attorney Wilfredo A. Ferrer for the Southern District of Florida. “The settlement announced today holds A Plus accountable for its submission of false claims, including restoring funds paid as a result of the false claims to Medicare.” The case began after William Guthrie, the former director of development at A Plus, brought a qui tam case against the business. The United States intervened in the case. Guthrie’s share of the settlement has not been calculated.


How Do You Expand Birth Control Access? Illinois Medicaid Program Would Pay Doctors More

Adding another layer of complexity to the current battle over birth control coverage in the United States, Illinois Governor Pat Quinn is seeking to improve access to birth control, particularly long-term birth control, for the state’s Medicaid beneficiaries. Currently the state’s Medicaid plan pays for 94 percent of the state’s births to teenage mothers and 54 percent of all deliveries. In 2012, average Medicaid costs per birth and the child’s first year of life was $18,500; those with low birth weights cost $302,000.

The Illinois Department of Healthcare and Family Services (HFS) has published its “Illinois Family Planning Action Plan” with a stated goal of “increasing access to family planning services for women and men in the Medicaid Program by providing comprehensive and continuous coverage to ensure that every pregnancy is a planned pregnancy”. HFS is accepting comments through September 15, 2014. The action plan provides for the following:


Action #1: Payments and operational policies reflect the value HFS places on providing the most effective form of contraception and will:

  • Double the provider reimbursement rate for intrauterine device insertion from $44 to $88;
  • Double the provider reimbursement rate for vasectomy service from $204 to $408;
  • Increase 340B medical providers’ dispensing fee for all long acting reversible contraceptives (LARC) from $20 to $35. Increase 340B medical providers’ dispensing fee for all hormonal contraceptives from $20 to $35 (three-month month supply required, except in extenuating circumstances);
  • Allow medical provider reimbursement (with modifier 25) for two services on the same day when one is a LARC procedure AND includes an initial or established annual exam or problem visit. Continue current practice allowing FQHCs to bill for one encounter rate;
  • Allow FQHCs to bill fee-for-service for permanent, non-surgical sterilization kits (Essure), consistent with LARC policy;
  • Investigate allowing hospitals to bill for LARC device insertion immediately postpartum.

Action #2: Health plans and providers in the Medicaid Program make all forms of family planning available to Medicaid clients in a convenient and seamless manner and will:

  • Communicate to all health plans and providers HFS’ commitment that clients receive evidence-based counseling and education on all FDA-approved contraceptives, from most-effective method to least-effective method [Informational Notice was sent to all Medical Assistance Providers on 6/26/14];
  • Communicate to all health plans and providers that cost sharing (co-pays/deductibles/co-insurance), step therapy failure requirements and prior authorization are not acceptable in the provision of family planning services [This was reflected in new and updated health plan contracts with most managed care entities];
  • Require annual submission of all health plans’ family planning policies to HFS, including referral policies by those plans with Right of Conscience objections to providing contraception;
  • Continue working with the LARC pharmaceutical industry to help ensure Medicaid providers have LARC inventory on the shelf for same day-insertion, with ongoing training, quality assurance and notice of any policy improvements;
  • Institute more effective communication regarding timely physician and FQHC reimbursements for current fee-for-service payments as well as contractual requirements for health plan payments.

The proposal has already drawn criticism from the Catholic church, who would be required under the plan to inform the state how they refer women elsewhere for services they do not provide. The Illinois Catholic Health Association, which represents 18 percent of hospitals in Illinois is worried that the plan will force Catholic hospitals from participating in the Medicaid program. The state of Illinois has previously ended contracts with Catholic groups for foster care when they referred gay couples to other agencies.