Colorado Chosen by CMS to Develop Dual Eligible Integrated Care Model

Posted on May 2, 2011 by Lisa Rothrock

The new CMS Innovation Center, in cooperation with the Federal Coordinated Health Care Office, announced recently that it is partnering with fifteen states across the U.S. in an effort to design new approaches to better coordinate care for dual eligibile patients (i.e., those patients eligible for both Medicare and Medicaid). 

Colorado and fourteen other states were each awarded up to $1 million to develop a model describing how the state would structure a patient-centered approach to coordinate care across primary, acute, behavioral health, and long-term supports and services for dual eligible individuals.  This initiative is funded by the Affordable Care Act.

CMS has explained that the goal of this demonstration program is to identify delivery system and payment coordination models that eliminate duplication of services, expand access to care, and lower costs for dual eligibles.   After federal review of the proposals, CMS will work with states to implement the plans that hold the most promise, eventually testing them and replicating them in other states.

For more information on this new initiative, see the CMS Innovation Center's announcement or CMS's website and press release.

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OIG Collects $26 Billion in Health Care Fraud Recoveries and Savings

Posted on December 21, 2010 by Lisa Rothrock

The Department of Health & Human Services ("HHS") Office of Inspector General ("OIG") recently reported in its Semiannual Report that for fiscal year ("FY") 2010 it expected recoveries and savings of approximately $25.9 billion, which includes $3.8 billion in investigative receivables and $1.1 billion in audit receivables.  The other $21 billion included in the total amount includes various cost-saving actions supported by OIG's recommendations in audits and evaluations.  The FY 2010 expected recoveries and savings were more than FY 2009, when OIG reported savings and expected recoveries of $21 billion.

In addition, OIG reported exclusions of 3,340 individuals and entities from participation in Medicare or other federal health care programs in the 2010 fiscal year.  OIG initiated 647 criminal lawsuits and 378 civil lawsuits against individuals and entities for violations of health care laws and regulations.

OIG focused particularly in the Semiannual Report on the successes of its Medicare Fraud Strike Force teams, which coordinate with federal, state, and local law enforcement to investigate health care fraud.  The Strike Force participated in an unprecedented takedown in seven cities that resulted in charges against 94 doctors, health care company owners, executives, and others for more than $251 million in alleged false billing.

Another highlight of fraud enforcement in FY 2010 was the $520 million that AstraZeneca agreed to pay the government to settle alleged false claims violations for kickbacks it allegedly offered to doctors in connection with unapproved uses of AstraZeneca's drug Seroquel.

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OIG Finds That Unqualified Nonphysicians Are Performing "Incident To" Services and Calls on CMS to Revise its Rule

Posted on August 11, 2009 by Heather L. Kenney

Medicare Part B permits physicians to bill for services that were provided by nonphysicians “incident to” the physicians’ services.  However, in a report issued by the OIG on August 6th, the Office of Inspector General (OIG) concluded that 21% of the time these “incident to” services were being performed by unqualified nonphysicians.

Nonphysicians were deemed to be unqualified when either (1) they were not properly licensed or certified under State laws, regulations, or Medicare rules, or (2) they provided rehabilitation therapy even though they had not been trained accordingly.

In conducting its research, the OIG analyzed Medicare Part B claims made during the first quarter of 2007.  By randomly selecting 250 days in which physicians billed for more than 24 hours of services during a single day, it was able to identify services not provided by the physicians themselves.

When physicians’ billed hours exceeded 24 hours/day, the OIG found that half of the services were performed by nonphysicians, and that 21% of these “incident to” services were performed by nonphysicians who were not qualified to do so.  During that three-month period in 2007, Medicare paid out $12.6 million for services provided by unqualified nonphysicians.

Based on these findings, the OIG recommend that the Centers for Medicare and Medicaid Services (CMS) revise its “incident to” rule in the following ways:

 

1.      CMS should require physicians who bill for services they did not personally perform to ensure that the nonphysicians performing these services possess the appropriate training, certification and/or licensure pursuant to Medicare regulations and State law.

2.      CMS should require physicians who bill Medicare for services not personally performed by them to use a service code modifier in order to identify those services on their Medicare claims.

3.      CMS should address and take appropriate action in regard to those service claims that were identified as having been billed by physicians and performed by nonphysicians that were not, by definition, “incident to” services (e.g., initial patient visits).  In addition, CMS should address those claims for rehabilitation services where it was found that the nonphysician did not have adequate training as a therapist.

 

In its response, CMS agreed with #1 and #3 of the OIG recommendations, but stated that it needed to further examine the feasibility of creating a service code modifier, as recommended in #2.

Read the full OIG report as well as CMS' response--Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services.

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