On January 1, 2022, a new federal law, “Requirements Related to Surprise Billing, Part I” (“The Rule”), goes into effect for health care providers and facilities and for providers of air ambulance services. The Rule will restrict excessive out-of-pocket costs to consumers which resulting from surprise billing and balance billing.
Group health plans and health insurers contract with a network of provider and health care facilities, these providers are considered as in-network providers. They agree to accept a specific payment for their services. Providers and facilities that are not contracted with a health plan or insurer are known as out-of-network providers (OON). They usually charge higher amounts than in-network providers. When OON providers do not receive full payment for their charge from the insurance payor, they charged the patient for the difference between the charge and the amount paid, a practice known as balance billing.Continue reading
Florida Department of Children and Families (DCF) is vested with authority over substance abuse services and is responsible to approve at least one credentialing entity to develop and administer a voluntary certification program for recovery residences also referred to as sober homes. DCF approved FARR (Florida Association of Recovery Residences) as the provider for the voluntary certification program, and it is the only certifying entity, it is the only game in town for sober homes. The issue at hand now is not whether certification is good or necessary for the sober living industry, rather, the issue is that sober homes have no due process giving them an entry point into the system to challenge DCF or FARR when their certification has been denied, revoked or suspended or some other sanction has been imposed!
While sober home certification is referred to as “voluntary” there is absolutely nothing voluntary about it. A sober home will not be able to keep its business running without FARR certification. This is because substance abuse providers cannot refer any of their clients to a sober home that is not FARR certified and cannot accept a referral from an uncertified sober home. This prohibition on referrals to and from non-FARR certified sober homes also makes it a first-degree misdemeanor for anyone who violates the prohibition. In addition, there is an administrative fine of $1000 per occurrence in the law should anyone violate the referral prohibition. Continue reading
When an overpayment is identified in Medicare Part A or B claims, providers can contest the overpayment amount by using the Medicare administrative appeals process. Because of the large difference between overpayment amount in a sample from an extrapolated amount, the OIG states that it is critical for the review process during an appeal to be fair and consistent. In the first and second levels of Medicare appeals (redetermination and reconsideration) extrapolated overpayments are reviewed by MAC (Medicare Administrative Contractors) and by QICs (Qualified Independent Contractors).
The OIG audit was to make sure that the MACs and the QICs reviewed the appealed extrapolated overpayments consistently and in compliance with CMS requirements.
What OIG found was that CMS did not always provide sufficient guidance and oversight to ensure that these reviews were performed in a consistent manner. The most significant inconsistency identified was the use of a type of simulation testing that was performed only by a subset of contractors. The test was associated with at least $42 million in extrapolated overpayments that were overturned in fiscal years 2017 and 2018.Continue reading
CMS has announced that it will resume Medicare Fee-For-Service (FFS) medical reviews August 3, 2020 regardless of the status of the COVID-19 public health emergency. These audits have been suspended since March 30 as a result of the crisis and applied to prepayment reviews and post-payment reviews conducted by Medicare Administrative Contractors (MAC).Continue reading
On November 15, 2019 Centers for Medicare and Medicaid Services (CMS) issued a final rule requiring hospitals to publicly disclose “standard charges, including payer-specific negotiated rates for items and services. Hospitals will be required to comply by January 1, 2021. The proposed rule is subject to 60 days of comment.
The final rule requires hospitals to make public in a machine-readable file online all standard charges (including gross charges, discounted cash prices, payer-specific negotiated charges) for all hospital items and services. It requires hospitals to de-identify minimum and maximum negotiated charges for at least 300 “shoppable” services.Continue reading
HHS found that a home health agency incorrectly billed Medicare and did not comply with Medicare Billing requirements for beneficiaries that were not homebound and for others that did not require skilled services at all.
In August and September 2018, physicians and the owner of a home health agency were each sentenced on multiple counts of conspiracy and healthcare fraud and ordered to pay $6.5 million in restitution. One physician was sentenced to 132 months in prison following trial. A physician who pled guilty was sentenced to 27 months in prison following a guilty plea. The home health agency owner was sentenced to 42 months in prison. The defendants paid and received kickbacks in exchange for patients and billed Medicare more than $8.9 million for services that were medically unnecessary, never provided, and/or not otherwise reimbursable. Additionally, certain defendants provided prescriptions for opioid medications to induce patient participation in the scheme.
In September 2018, the co-owner and administrator of a home health agency was sentenced to 24 months in prison, ordered to pay over $2.2 million in restitution, and ordered to forfeit over $1.1 million. The co-owners participated in a home healthcare fraud conspiracy that resulted in Medicare paying at least $2.2 million on false and fraudulent claims. The owners and their co-conspirators paid kickbacks to doctors and patient recruiters in exchange for patient referrals, billed Medicare for services that were medically unnecessary, and caused patient files to be falsified to justify the fraudulent billing.
Back in February 2018, the owner of more than twenty home health agencies was sentenced to 240 months in prison and ordered to pay $66.4 million in restitution, jointly and severally with his co-defendants, after pleading guilty to one count of conspiracy to commit health care fraud and wire fraud. A patient recruiter for the home health agencies, who also owned a medical clinic and two home health agencies of her own, was sentenced to 180 months in prison. Another patient recruiter, who also was the owner of two home health agencies, was sentenced to 115 months in prison. These conspirators paid illegal bribes and kickbacks to patient recruiters in return for the referral of Medicare beneficiaries many of whom did not need or qualify for home health services. Medicare paid approximately $66 million on those claims.
Illegal kickbacks in exchange for referrals of Medicare beneficiaries, lack of medical necessity for home health services, failing to meet the guidelines, fraudulent billing, billing for services beneficiaries did not receive and fraudulent documentation continues to plague the home healthcare industry.
In a fraudulent operation that the Department of Justice calls, “unprecedented”, elderly or disabled patients nationwide were lured into providing their DNA for testing in a widespread genetic testing fraud scheme powered by a large telemarketing network. The doctors involved were paid to write orders prescribing the testing without any patient interaction or with only a brief telephone conversation.Continue reading
A Final Rule recently issued by CMS will require Medicare, Medicaid, and CHIP (Children’s Health Insurance Program) providers and suppliers to disclose current and previous affiliations (direct or indirect) with a provider or supplier that: (1) has uncollected debt; (2) has been or is excluded by the OIG (Office of Inspector General) from Medicare, Medicaid or CHIP, or (3) has had its billing privileges with either of these three programs denied or revoked. Such provider affiliations may lead to enrollment being denied if it poses a risk to fraud, waste or abuse.Continue reading
When providers or suppliers self-report overpayments to Medicare Part C Managed Care organization, there is some uncertainty on what lookback period applies and whether there actually is an overpayment obligation. Is it Medicare’s 60-day overpayment rule that applies or do the Managed Care Part C organizations impose a different lookback period for overpayments?
CMS (The Centers for Medicare & Medicaid Services) published its Final Rule clarifying the procedures applicable to the statutory requirement under the Affordable Care Act (“ACA”) for providers and suppliers to self-report and return overpayments. (The Final Rule was published on February 12, 2016). The Final Rule applies to Medicare Parts A and B and addresses the procedures that a provider or supplier need to follow to investigate, identify, quantify to self-report and return an overpayment. The Final Rule clarifies the obligations of Medicare providers and suppliers to report and return overpayments for claims originating only under Medicare Parts A and B. The final rule does not address, or reference, the obligations of providers to return overpayments to Medicare Advantage organizations for Part C claims.Continue reading
State licensed addiction treatment facilities with licenses that include community housing are confused about whether they have to also be certified by the Florida Association of Recovery Residences (FARR) by July 1, 2018. Attorney Karina Gonzalez has filed a petition with the Department of Children and Families (DCF) to clarify the issue. A fairly recent state law (397.4873, Fla. Stat.) requires addiction treatment service providers in Florida to refer clients only to recovery residences certified by FARR.
FARR is a private, non-governmental entity approved by DCF to develop and administer a voluntary certification program for recovery residences. FARR has taken the position that it has also been approved to develop and administer a voluntary certification program for DCF-licensed community housing providers. “We think,” attorney Gonzalez said, “they’ve got it wrong. It makes no sense to stack the FARR certification requirement on top of existing state licensure.”