Kusserow on Compliance: CMS extends and expands enrollment moratoria in six states

CMS announced that it is extending for six months its temporary provider enrollment moratoria efforts in six states, as means to control fraud.  The agency is also expanding statewide the temporary provider enrollment moratoria on new Medicare Part B non‑emergency ground ambulance suppliers in New Jersey, Pennsylvania, and Texas and home health agencies (HHAs) in Florida, Texas, Illinois, and Michigan.  This statewide expansion also applies to Medicaid and Children’s Health Insurance Program (CHIP).  CMS also announced the Provider Enrollment Moratoria Access Waiver Demonstration (PEWD), which gives CMS the ability to allow for provider and supplier enrollment exceptions in the moratoria areas if accesses to care issues are identified and for the development and improvement of methods of investigating and prosecuting fraud in Medicare, Medicaid, and CHIP.  The agency will also immediately lift the current temporary moratoria on all Medicare Part B, Medicaid and CHIP emergency ground ambulance suppliers.  The purpose of these actions is to focus on identifying parties engaged in fraudulent practices and to find means to better control the programs against such actions.

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 Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2016 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Questionable billing for ambulance transportation

The rapidly growing ambulance service program now costs Medicare Part B $6 billion per year, however fraud and abuse has been growing right alongside the program. The Office of Inspector General (OIG) issued a report identifying both improper payments for ambulance transports and questionable billing by ambulance suppliers. The OIG’s findings restate previously identified problems with ambulance transportation, including that Medicare continues to pay for ambulance transports that did not meet program requirements to justify payment. There is hardly a day that goes by without a new reported enforcement action involving ambulance fraud. The problem was so severe that CMS imposed temporary moratoria in 2013 and 2014 on the enrollment of new ambulance suppliers in two major metropolitan areas.

History

The OIG analysis followed up on another report on the subject two years ago. In that report, the agency reviewed the program through the year 1996 and found that two-thirds of ambulance transports did not result in hospital or nursing home admissions or emergency room care. In 2002, 25 percent of the reviewed cases did not meet Medicare program requirements, resulting in hundreds of millions in overpayments. Additionally, 27 percent of total transports to independent dialysis facilities did not meet coverage requirements. The overall conclusion from the prior report reflects the same findings of the recent report, that is, that Medicare Part B payments for ambulance transports have grown at a much faster rate than all Medicare Part B payments with fraud and abuse growing rapidly as well.

Recent report

The OIG provided several examples of the identified problems and found that Medicare paid $17 million for transports that were to or from non-covered destinations, such as physicians’ offices, and another $30 million for transports when beneficiaries did not receive Medicare services at the pick-up or drop off locations, or anywhere else. Claims for services under these circumstances appear to have been inappropriate. Further, the OIG found that about one in five suppliers had questionable billing, which was identified when suppliers had an unusually high average mileage for the transports of beneficiaries residing in urban areas. There is also continuing evidence of questionable billing that is geographically concentrated, as more than half of all questionable transports were provided to beneficiaries that reside in four metropolitan areas.

In arriving at the findings, the OIG analyzed claims data for 7.3 million ambulance transports, including but not limited to, reviewing transport destinations, transport levels, distance of urban transports, other Medicare services that beneficiaries received, and the geographic locations where the beneficiary who received the transport resided. The findings indicate that inappropriate and questionable billing for ambulance transports pose vulnerabilities to Medicare program integrity and call for CMS to enhance existing fraud and abuse safeguards. Specifically, the OIG called for increased scrutiny of ambulance services due to the evidence of its vulnerability to fraud and abuse.

OIG recommendations

  • CMS should determine whether a temporary moratorium on ambulance supplier enrollment in additional geographic areas is warranted.
  • Ambulance suppliers should be required to include the National Provider Identifier (NPI) of the certifying physician on transport claims that require certification.
  • There should be an increased monitoring of ambulance billing.
  • CMS should determine appropriateness of claims billed by ambulance suppliers identified in the OIG report and take appropriate action.

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 Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2015 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG reports investigative results for first half of 2015

The Office of Inspector General (OIG) mission is to provide independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of HHS. It investigates allegations of fraud, waste, and abuse in all of the Department’s programs and is mandated to report to Congress semi-annually on the progress of meeting these mission goals. On June 1, 2015, the OIG released its first half of fiscal year (FY) 2015’s report, which included the following statistical results from investigations:

• Expected recoveries of over $1.8 billion ($544.7 million in audit receivables and $1.26 billion in investigative receivables that includes $142 million in areas such as the states’ shares of Medicaid restitution);
• 486 criminal actions against individuals/entities engaged in crimes against HHS programs;
• 326 civil actions, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters;
• 1,735 individuals and entities excluded from participation in federal health care programs.

The largest body of work in the report involved the investigation of matters related to the Medicare and Medicaid programs, such as: (1) patient harm; (2) billing for services not rendered, medically unnecessary services, or services more extensive than those actually provided; (3) illegal billing, sale, diversion, and off-label marketing of prescription drugs; and (4) solicitation and receipt of kickbacks, including illegal payments to patients for involvement in fraud schemes and illegal referral arrangements between physicians and medical companies. The OIG also investigated cases involving organized criminal activity, medical identity theft, and fraudulent medical schemes that are established for the sole purpose of stealing Medicare dollars. Those who participate in these schemes may face heavy fines, jail time, and exclusion from participating in federal health care programs. The OIG took special note to highlight common criminal fraud scheme case types that occurred in the following areas:

• controlled and non-controlled prescription drugs;
• home health agencies and personal care services;
• ambulance transportation;
• durable medical equipment (DME); and
• diagnostic radiology and laboratory testing.

It also cited the results from the Health Care Fraud Prevention and Enforcement Action Team (HEAT) started in 2009 by HHS and the Department of Justice (DOJ) to strengthen programs and invest in new resources and technologies to prevent and combat health care fraud, waste, and abuse. HEAT continued to identify those who seek to defraud Medicare and Medicaid. The Medicare Fraud Strike Force, which operates in nine major cities and is a key component of HEAT, coordinates law enforcement operations conducted jointly by federal, state, and local law enforcement entities that prosecute health care fraud. During the first half of FY 2015, the efforts of this team resulted in the filing of charges against 69 individuals or entities, 124 criminal actions, and $163 million in investigative receivables. As part of the endeavors, the team refers credible allegations of fraud to CMS so that it can suspend payments to the suspected perpetrators, thereby immediately preventing losses from claims by Strike Force targets.

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 Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2015 Strategic Management Services, LLC. Published with permission.

 

Kusserow on Compliance: Enrollment moratoria for new ambulance suppliers and home health agencies in several states

Over the last two years, I have been reporting on a large number of enforcement actions by the Department of Justice (DOJ) led Medicare Strike Force in eight target cities relating to cases involved home health agencies and ambulance services that many consider to be among the most vulnerable to fraud in health care. The OIG has issued a number of reports related to this problem. Going back to July 2013, CMS made their initial use of authority under the Patient Protection and Affordable Care Act (P.L. 111-148) to use temporary enrollment moratoria to prevent fraud where they have found that certain trends warranted such a moratorium on home health providers and ambulance suppliers in these geographic areas. Once again, they have issued a notice extending the temporary moratoria on the enrollment of new ambulance suppliers and home health agencies (HHAs) in specific locations within metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey. CMS also placed temporary moratoria on the enrollment of ground ambulance suppliers in Harris County, Texas and other surrounding counties and in Philadelphia, Pennsylvania and surrounding counties. CMS had previously extended all of the above-mentioned moratoria through February 2, 2015. The programs affected by the CMS decision is especially vulnerable to fraud are those that allow the Medicaid recipient to control the selection and payment of personal care attendants.

In determining to extend the moratoria again, CMS considered factors suggesting a high risk of fraud, waste, or abuse by relying on law enforcement’s experience with fraud trends and activities through investigations and prosecutions. CMS then confirmed a high risk of fraud, waste, or abuse in these provider and supplier types through data analysis. The resulting extended moratoria lasts for a period of six months.