Kusserow on Compliance: Continued confusion regarding the CMS preclusion list

Those on list are prohibited from MA Plans or Part D Sponsors payment

Questions continue arise concerning the CMS Preclusion List final rule. The Preclusion List is a list generated by CMS that contains the names of prescribers, individuals, and entities that are unable to receive payment for Medicare Advantage (MA) items and service and or Part D drugs prescribed or provided to Medicare beneficiaries. The rule mandates Part D sponsors, or their pharmacy benefit managers, to screen against the Preclusion List and reject any pharmacy claim prescribed by an individual or entity on it. MA plans must deny payment for a health care item or service furnished by an individual or entity on the list. Plans and sponsors must also notify impacted beneficiaries who received care or a prescription from a provider on the Preclusion List in the last twelve months. The list includes those who are currently revoked from Medicare, are under an active reenrollment bar, and whose underlying conduct CMS has determined to be detrimental to the Medicare program; or have engaged in behavior for which CMS could have revoked the prescriber and determined the underlying conduct would have led to the revocation. Such conduct includes, but is not limited to: felony convictions and OIG exclusions. CMS indicated that individuals or entities appearing on the List of Excluded Individuals/Entities (LEIE) and/or the System for Award Management (SAM) list would also be placed on the Preclusion List.

MA plans and Part D sponsors are required to access the list through an Enterprise Identity Data Management (EIDM) account with CMS. The list is updated monthly.  The causes for most of the confusion is that only plans approved by CMS are granted access to the Preclusion List. As a result, many if not most, organizations use a vendor for sanction screening services. However, the vendors are not always given access to the List.  The way around this obstacle has been for Plans to give their vendor the list and have them include it in their screening services. Another point of confusion is that technically, it is not a sanction list. It includes many parties who have not been formally sanctioned to be included on the OIG LEIE, although many on the list are also on the LEIE.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

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Copyright © 2020 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG program exclusions reported for second half of 2019

Total of 2640 new exclusions added to the LEIE in 2019

Under the Social Security Act, the HHS Office of Inspector General (OIG) is able to exclude individuals and entities from participation in Medicare, Medicaid, and other Federal health care programs. Exclusions are required (mandatory exclusion) for individuals and entities convicted of the following types of criminal offenses: (1) Medicare or Medicaid fraud; (2) patient abuse or neglect; (3) felonies for other health care fraud; and (4) felonies for illegal manufacture, distribution, prescription, or dispensing of controlled substances. The OIG is also authorized (permissive exclusion) to exclude individuals and entities on several other grounds, including misdemeanors for other health care fraud (other than Medicare or Medicaid); suspension or revocation of a license to provide health care for reasons bearing on professional competence, professional performance or financial integrity; provision of unnecessary or substandard services; submission of false or fraudulent claims to a federal health care program; or engaging in unlawful kickback arrangements. The Patient Protection and Affordable Care Act (ACA) added another basis for imposing a permissive exclusion, that is, knowingly making, or causing to be made, any false statements or omissions in any application, bid, or contract to participate as a provider in a federal health care program, including managed care programs under Medicare and Medicaid, as well as Medicare’s prescription drug program.

During this semiannual reporting period, the OIG excluded 1,347 individuals and entities from Medicare, Medicaid, and other federal health care programs. Most of the exclusions resulted from convictions for crimes relating to Medicare or Medicaid, patient abuse or neglect, financial misconduct, controlled substances, or as a result of license revocation. The OIG completed the deployment of a new service for State Medicaid Fraud Control Units (MFCUs) to report convictions through a central web-based portal for exclusion. This improved reporting from those agencies. A list of excluded individuals and entities can be found at https://exclusions.oig.hhs.gov/.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2020 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: New CMS proposed outpatient rules

The 2020 annual rule cycle has been active for CMS with several proposed rules in the outpatient prospective payment system (OPPS) area. Hospitals and health system executives should monitor these annual rules carefully for provisions that will affect their organizations’ operations. Among the significant regulatory rule proposals for hospital and health system executives are the following:

  1. Mandated disclosure of negotiated charges between health plans and hospitals for all items and services for about 300 “shoppable” services
  2. Proposed penalties which would be over $100,000 a year for noncompliant hospitals
  3. The addition of several ASC procedures
  4. The removal of total hip arthroplasty from the inpatient-only list for 2020, allowing the procedure to be performed on an outpatient basis
  5. Reduction of supervision level for hospital outpatient department from direct to general for hospital outpatient departments
  6. A requirement for prior authorization of certain outpatient department services.
  7. Continued payment reduction for 340B purchased drugs
  8. Increased per-day cost threshold for separate payment for certain outpatient drugs
  9. The establishment a prior authorization process for five categories of services that often may be cosmetic: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation
  10. Various updates to Hospital Outpatient Quality Reporting Program requirements

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

CMS final rule reduces hospital administrative burdens

 

CMS issued a final rule to reduce unnecessary burden for health care providers, allowing them to focus on their priority—patients. Included in the rule is the removal of Medicare regulations identified as unnecessary, obsolete, or excessively burdensome. The rule removes the requirements for a facility to:

 

  • Request or allow swing-bed patients to perform services for the facility.
  • Provide an ongoing activities program that is directed by a qualified professional because the patient’s activity needs are addressed in the nursing care plan.
  • Employ a qualified social worker on a full-time basis because of the hospital swing-bed and Critical Access Hospital (CAH) bed limit requirements for those with more than 120 beds.
  • Assist residents in obtaining routine and 24-hour emergency dental care because of the existing requirement for hospitals and CAHs to provide care in accordance with the needs of the patient.
  • For CAHs, to perform a review of all their policies and procedures.
  • To disclose the names of people with a financial interest in the CAH.
  • For Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), to review the patient care policies and facility evaluation annually, changing the frequency to every two years.
  • For a hospital’s medical staff, to attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest.

 

Hospitals, CAHs, and Home Health Agencies (HHAs) under the rule will be required to:

 

  • Have new discharge planning requirements—as mandated by the IMPACT act for hospitals, HHAs, and CAHs—which require facilities to assist patients, their families, or the patient’s representative in selecting a post-acute care (PAC) services provider or supplier by using and sharing PAC data on quality measures and resource use measures.
  • Have revised language that now requires a hospital (or CAH) to discharge the patient, and also transfer or refer the patient where applicable, along with his or her necessary medical information (current course of illness and treatment, post-discharge goals of care, and treatment preferences), at the time of discharge, to not only the appropriate post-acute care service providers and suppliers, facilities, agencies, but also to other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care.
  • Have revised compliance language for HHAs that now requires these facilities to send all necessary medical information (current course of illness and treatment, post-discharge goals of care, and treatment preferences), to the receiving facility or health care practitioner to ensure the safe and effective transition of care, and that the HHA must comply with requests made by the receiving facility or health care practitioner for additional clinical information necessary for treatment of the patient.
  • Send necessary medical information to the receiving facility or appropriate PAC provider (including the practitioner responsible for the patient’s follow-up care) after a patient is discharged from the hospital or transferred to another PAC provider or, for HHAs, another HHA.
  • In the case of hospitals, ensure and support patients’ rights to access their medical records in the form and format requested by the patient, if it is readily producible in such form and format.
  • Allow multi-hospital systems to have unified and integrated Quality Assessment and Performance Improvement (QAPI) programs and unified and integrated infection control and antibiotic stewardship programs for all their member hospitals.
  • Allow hospitals the flexibility to establish a medical staff policy describing the circumstances under which a pre-surgery/pre-procedure assessment for an outpatient could be utilized, instead of a comprehensive medical history and physical examination.
  • Additionally, CMS is moving to clarify the requirement to allow the use of non-physician practitioners and doctors of medicine/doctors of osteopathy (MD/DOs) to document progress notes of patients receiving services in psychiatric hospitals.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.