Volume 17, Number 12 • April 7, 2008
Weekly News and Analysis on New Enforcement Initiatives and Billing/Documentation Strategies
Contents
3
Charges Are Filed in
Connection With 2006
HIPAA Violation Case
4
Deciding When Modifier
-25 Is Appropriate
5
Records Headed for RAC
Audit Take Detour, Are Sold
As Scrap
6
8
Compliance Chronicle
News Briefs
DOJ Alleges Hospital Gave Better Panel
Access for Referrals in False Claims Suit
In a novel False Claims Act lawsuit, the Department of Justice (DOJ) is accusing a
major Cincinnati hospital of rewarding cardiologists for patient referrals by giving them
preferential assignments to a hospital-based unit that performs non-invasive cardiology
diagnostic tests. According to the complaint, originally filed by a whistle-blower and
unsealed April 1, cardiologists who referred the most patients to The Christ Hospital
(TCH) were allowed to dominate panel time at the hospital’s “Heart Station.” Because
panel time, which is billable to Medicare, is a gateway to other tests and procedures and
perhaps a lifelong relationship with patients, it has goldmine potential for cardiologists,
DOJ alleges.
Not so, says Washington, D.C., attorney Paul Danello, who represents TCH. “No
payment or other transfer of remuneration was involved in Heart Station panel assignments,” says Danello, who is with the law firm Squire Sanders & Dempsey L.L.P. An
exclusive arrangement with a large cardiology practice would have closed out other
practitioners from participation, and no solo practitioner or small cardiology practice
could provide the comprehensive, five-day-a-week coverage necessary to staff the
Heart Station, he maintains. “There is no evidence that TCH had any motivation to assign panel time to physicians with the intention of inducing referrals from them, a clear
requirement for finding a violation under the intent-based anti-kickback statute,” he
contends. TCH’s goal was to provide high-quality care, he says.
continued on p. 5
Disruptive MDs Heighten Risk at a Time
When Collaboration Is Key to Compliance
Managing Editor
Nina Youngstrom
Associate Editor
Eve Collins
Editor
Angela Maas
Executive Editor
James Gutman
Disruptive physicians — the kind who insult nurses, throw tantrums and toss scalpels around — have always been a problem for hospitals and their employees. But the
threat is looming larger given new developments, such as mandates that call for greater
physician-coder/nurse interaction on issues that aren’t purely clinical (e.g., present on
admission (POA) reporting, hospital-acquired conditions payment restrictions, Medicare-Severity DRGs) and the government’s push to link quality and payment. It’s hard
for a coder to team with a physician to make decisions about POA indicators if that
particular physician tells the coder she’s incompetent. And the hospital may struggle to
thrive under value-based purchasing if a physician’s contemptuousness leads to high
nurse turnover.
As hospitals grapple with disruptive physicians, a new trend has emerged, making a stubborn problem even more resistant to improvement, says Pittsburgh attorney
Henry Casale. Some disruptive physicians are trying to evade consequences for their
behavior by claiming that they are not disruptive at all. Rather, they are whistle-blowers
exposing hospital noncompliance and poor quality, but the hospital is trying to retaliate
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2 Report on Medicare Compliance
against their complaints by branding them troublemakers, he says.
“We are seeing this more and more,” says Casale,
who is with the law firm of Horty, Springer & Mattern.
“Disruptive physicians raise specious claims that have no
validity in an attempt to justify their disruptive behavior.
Hospitals want to know legitimate compliance concerns,
but if there were never any underlying compliance concerns, then lodging fictitious complaints is just another
act of disruptive behavior. It’s a very difficult issue, being
made more complex and being obfuscated by claims that
the disruptive behavior is part of some whistle-blowing
activity.”
Notwithstanding the distraction, the urgency for
a solution remains. The Joint Commission requires
hospitals to manage disruptive physicians. The code of
conduct that hospitals must adopt for Joint Commission
accreditation includes a standard for providing a “culture
Report on Medicare Compliance (ISSN: 1089-6872) is
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April 7, 2008
of safety and quality.” That means “leaders set expectations for behavior” in the workplace, according to its
Web site.
“Safety and quality thrive in an environment that
supports working in teams and respecting other people,
regardless of their position in the organization. Undesirable behaviors that intimidate staff, decrease morale, or
increase staff turnover can threaten the safety and quality
of care,” the Joint Commission says.
Given the stakes, hospitals should consider ways to
help disruptive physicians change their behavior, experts
say. One approach is to do what hospitals do for any
other outlier: confront physicians with data. Physicians
respond to concrete information, even if it is about their
own behavior, says Miami psychologist Larry Harmon,
Ph.D. He runs a teamwork improvement program for
disruptive physicians around the country.
Disruptive physicians are the kind who make life
miserable for the people with whom they work — their
health care team — with belittling remarks (e.g., “Are
you a moron?”), sarcasm (e.g., “It’s hard to believe you
even have a nursing degree!”), yelling and screaming
when things don’t go their way and throwing things
around the room.
Some physicians behave this way partly because of
the milieu in which physicians are trained and practice,
Harmon says. “Learning medicine is not a team activity,”
he says. “They spend much of their time learning technical skills, not teamwork skills.” Also, physicians are what
Harmon calls “feedback starved.” The more prestigious
the specialty (e.g., surgeons), the less likely someone will
call the physicians on their behavior, he says. As a result,
disruptive physicians may be highly skilled and passionate advocates for their patients, but nightmares as
colleagues.
Physicians Respond to Feedback
So Harmon developed an educational program designed to get disruptive physicians to stop mistreating
the health care team by giving them feedback they lack
and helping them see themselves through other peoples’
eyes.
There are three phases. First, there is assessment.
Harmon sends personal e-mail surveys to the people
who work with the disruptive physician. They are asked
to answer, anonymously, a series of motivating (positive)
questions and discouraging questions.
Examples of positive questions: To what extent does
the physician treat team members with respect? To what
extent does the physician adapt to changing policies? To
what extent does the physician respond to conflict by trying to work out solutions? To what extent does the physician handle difficult team members effectively? To what
EDITORIAL ADVISORY BOARD: TONY CAPULLO, Professional Provider Services, PAUL R. DeMURO, Esq., CPA, MBA, Latham & Watkins, EDWARD GAINES, Esq., Healthcare
Business Resources, DEBI HINSON, Compliance Consultant, WALTER METZ, CPA, MS, JD, Brookhaven Memorial Hospital Medical Center, DAVID B. ORBUCH, Allina Hospitals & Clinics, Minneapolis, MARK PASTIN, PhD, Council of Ethical Organizations, ANDREW RUSKIN, Esq., Morgan, Lewis & Bockius LLP, DAVID SCHIMEL, National Health
Resources, L. STEPHAN VINCZE, TAP Pharmaceutical Products Inc., BOB WADE, Esq., Baker & Daniels, D. McCARTY THORNTON, Esq., Sonnenschein Nath & Rosenthal,
JULIE E. CHICOINE, JD, RN, CPC, compliance director, Ohio State University Medical Center
April 7, 2008
Report on Medicare Compliance
3
extent does the physician point out mistakes in a helpful
way? To what extent does the physician communicate
clear expectations?
Examples of discouraging questions: To what extent
does the physician talk down to team members? Overreact when little things go wrong? Yell and swear? To what
extent does the physician get sarcastic or angry when
asked important questions?
feedback to doctors-in-training. Harmon provides his
program to all the medical students at the University of
Miami Miller School of Medicine. “Periodically giving
and receiving feedback” is essential, he says. “You can’t
change what you don’t know.”
Contact Harmon at [email protected] and Casale at [email protected]. ✧
Avoidance, Favorable Comments Most Effective
Charges Are Filed in Connection
With 2006 HIPAA Violation Case
Harmon summarizes the responses from the physician’s team members and prepares a summary report
and recommendations for the physicians. “Most [physicians] are surprised how negative the feedback is,” he
says. However, hearing the truth about how they are
perceived “is necessary to break through the denial and
defensiveness and to help the physician understand that
his or her behavior is having a negative impact on
others.”
Disruptive physicians are particularly responsive to
two kinds of feedback: (1) avoidance comments, such as
when nurses state on the surveys that “I call in sick to
work when I know you are scheduled [to perform] surgery” and “I am trying to get a job in another part of the
hospital so I don’t have to work with you”; and (2) favorable comments, such as “You’re a great surgeon (even
though I can’t stand working with you)” and “I would
take my mother to you for surgery.” In other words,
they are deprived of the compliments because of their
demeanor.
Once all the feedback is in, Harmon analyzes it to
home in more specifically on the disruptive physician’s
problem behaviors. That way, education can be tailored
to the physician. There are education modules on frustration management, conflict management, people management and time management. For example, a physician
who yells and screams a lot probably has an anger management problem.
Physicians then watch a video tailored to the triggers
of their disruptive behaviors. It’s designed to help the
physicians change their behavior and work better as part
of the health care team. They have to take an online test
afterward to ensure they understood and absorbed the
content, Harmon says.
Finally, Harmon monitors physicians for a year or so
after the training to ensure the changes are sticking and
bad behavior doesn’t re-emerge. “We do periodic surveys [of the health care team] until the physician had had
a sustained period of improvement,” he says.
Harmon says that over the next five to 10 years,
hospitals will emphasize “getting professionalism back.
It will become routine.” In fact, medical schools are already are addressing the importance of giving behavioral
On April 1, eight separate indictments were unsealed
against six individuals charged with using stolen patient
information to submit fraudulent claims to Medicare,
says the U.S. Attorney’s Office for the Southern District
of Florida. Although the indictments stem from a 2006
HIPAA violation case — the first-ever HIPAA trial and
conviction — the defendants are not charged with violating that statute.
The six people charged are all owners of durable
medical equipment companies or clinics and allegedly
billed Medicare for services that were not rendered or
equipment that was not supplied, the feds say. One of the
people billed for as much as $1.8 million between May
and October 2006. The defendants allegedly used patient
information that was stolen from the Cleveland Clinic in
2006 in these billings, according to the feds.
Each is charged with 10 counts of health care fraud,
and all face 10 years in prison on each count if convicted.
Attorneys for the defendants could not be reached for
comment.
In September 2006, the U.S. attorney’s office
charged Isis Machado, a former scheduler at the Cleveland Clinic’s Weston, Fla., office with violating HIPAA,
aggravated identity theft, computer fraud and conspiracy, including Medicare fraud allegations (RMC 9/18/06,
p. 5). The feds said she allegedly stole 1,500 patients’
protected health information and sold it to her cousin,
Fernando Ferrer, who owned his own clinic and also
was indicted in 2006.
According to these most recent indictments, Machado received $5 to $10 for each patient’s information.
Federal officials said the theft resulted in the submission of more than $7 million in fraudulent Medicare
claims, with approximately $2.5 million paid to providers
and suppliers.
Machado pleaded guilty in January 2007 and received three years probation. She testified at Ferrer’s trial.
He was convicted and received 87 months in prison in
April 2007. Each of them also was ordered to pay $2.5
million in restitution.
Visit www.usdoj.gov.usao/fls. ✧
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4 Report on Medicare Compliance
April 7, 2008
Deciding When Modifier -25 Is Appropriate
With some U.S. attorneys’ offices investigating hospital billing for modifier -25 (RMC 3/10/08, p. 1), hospitals may want to ramp
up monitoring of this tricky modifier. Modifier -25 allows hospitals to override a National Correct Coding Initiative (NCCI) edit
that prevents Medicare reimbursement for two claims for two evaluation and management (E/M) services provided to the same
patient on the same day by the same physician. Medicare will pay for the second E/M service as well as the original procedure
when it is “significant and separately identifiable.” But hospitals must use modifier -25 to convey that both procedures deserve
payment, says Nickie Braxton, compliance officer for Hartford Hospital and Hartford Health Care Corp. in Connecticut and
creator of the decision tree. This tool reflects the impact on the modifier of Medicare’s fairly new benefit, the Initial Preventive
Physical Examination (IPPE) “Welcome to Medicare Examination,” which is provided once to new beneficiaries during the
first six months of Medicare enrollment (CMS HCPCS code G0344). It also offers recent clarification regarding new patient
visits. The Modifier -25 Decision Tree reflects the current guidance provided by NHIC, Corp., the Medicare Part B contractor
for California, Maine, Massachusetts, New Hampshire and Vermont, that is available at www.medicarenhic.com/cal_prov/
articles/modifier25_1006.htm. Braxton says the guidance at that Web site is very informative and sheds a lot of compliance
light on modifier -25. (RMC published a similar decision tree on modifier -25, with a story and a modifier -59 decision tree, in
the Jan. 16, 2006, issue. But new information is provided in this decision tree. Both decision trees were drafted by Braxton).
Contact Braxton at [email protected].
Modifier -25 Decision Tree
Was the E/M service SIGNIFICANT, SEPARATELY IDENTIFIABLE, performed by the
SAME PHYSICIAN on the SAME DAY? (can be utilized at any site, i.e., hospital, outpatient or office)
YES
NO
Is this the ‘Welcome to Medicare
Examination’ (IPPE)?
NO
Is this a new
patient E/M
explicitly bundled
to procedure by
NCCI edit?
NO
Is this a new patient
E/M service with minor
procedure/surgery (global
period: 000 or 010?)
YES
YES
Do not bill using modifier -25
Do these E/M services involve any of the
following: separate and unique diagnosis,
services, procedures, incisions, excisions,
lesions or anatomical sites?
NO
YES
Does the E/M visit for established patients include
the required evaluation AND decision-making
components documented in the medical record?
Can problem-oriented E/M stand alone as billable?
NO
YES
BILL SERVICES APPENDING MODIFIER -25 TO E/M
ENSURE PROPER SUPPORTING DOCUMENTATION
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April 7, 2008
Records Headed for RAC Audit
Take Detour, Are Sold as Scrap
Medical records for 28 patients of Central Florida
Regional Hospital that were meant for a CMS recovery
audit contractor (RAC) were lost in transit and ended up
in the hands of a Utah teacher who was looking for scrap
paper, the facility’s spokesman tells RMC.
The records were in one of several boxes that were
being shipped to a firm in Nevada. The box was diverted
to a UPS disposal warehouse where the shipping company scraps unclaimed shipments, says Craig Bair, the
hospital spokesman.
“It was properly labeled, but nobody bothered to
open it or check it,” he says.
A teacher who was shopping for scrap paper for
her students bought the box and discovered the medical
records, Bair explains. She gave them to a reporter acquaintance of hers who wrote an article about the events
for a local newspaper. The patients’ medical information,
however, was not included in the story.
“UPS did pretty well with the recovery,” Bair says.
“They got the records back and got everything under
control.” The hospital contacted all the patients involved
and has provided them with credit monitoring, but Bair
says there was “minimal disclosure” except for the teacher, the reporter and his editor.
So what does this event do for the debate about paper records versus electronic records? “There is still a lot
of debate as to how safe electronic records are as well,”
Bair says. “We are definitely re-evaluating all of our options. Shipping them…is still the safest thing out there”
because you can track packages, he says. “Is there a better way to do it? At this point, there is nothing that I have
been informed about.”
Visit www.centralfloridaregional.com. ✧
DOJ: Panel Access Was Reward
continued from p. 1
At the moment, the hospital, which denies the allegations, has no intentions of settling the lawsuit, says
Danello.
“The government is stretching the anti-kickback and
Stark laws out of shape by claiming the mere opportunity for physicians to earn a fee for legitimate services
somehow in and of itself represents a payment for referrals,” Danello contends. “Utterly novel theories are being
applied.”
The case has some unusual twists. There are two
other defendants. One is the Health Alliance of Greater
Cincinnati, which TCH joined in 1995. Two years ago,
Report on Medicare Compliance
5
TCH sought to extricate itself from the Health Alliance,
which was a joint operating agreement among six Cincinnati-area hospitals to consolidate management and
operations. TCH successfully maintained its right to
withdraw in the courts over the opposition of the Health
Alliance, Danello says, although the two parties are still
in litigation over the amount of money the Health Alliance must give TCH before the divorce is final.
The other defendant in the lawsuit is Ohio Heart &
Vascular Center, Inc., which is the group of cardiologists
who allegedly benefited from their patient referrals with
access to panel time at the Heart Station, according to the
complaint.
Case Began With MD Whistle-blower
The lawsuit was launched by a whistle-blower.
Cardiologist Harry Fry, M.D., who was then employed
at TCH as assistant director of cardiology, filed the suit
in U.S. District Court for the Southern District of Ohio.
According to the complaint, only a certain number of
cardiologists can work at the Heart Station at any one
time. The hospital provides all the equipment and technical support for the tests, which are then interpreted by
the cardiologists.
Ohio Heart accounted for 70% to 80% of all TCH’s
cardiology billings. The Heart Station was a prize in the
eyes of Ohio Heart — it was seen as a source of new
patients, the complaint alleges.
So in 1999, DOJ alleges, TCH implemented a system of panel-time allocation based on the “volume of
referrals from the physician to TCH for lucrative cardiac
procedures such as cardiac catheterization and angioplasties,” according to the complaint. “The more patients
a physician referred to TCH for procedures, the more he
was rewarded with additional panel time at the Heart
Station.” The scheme continued until 2004, DOJ claims.
“This system of panel time allocation was designed
to favor Ohio Heart. Ohio Heart was aware that its panel
time was based upon the volume of its referrals to TCH,”
the complaint alleges.
The government’s argument is that because the services performed and billed to Medicare stemmed from illegal financial services, the claims submitted to Medicare
for them are false claims.
But Danello says the picture painted in the complaint doesn’t comport with the reality of operations at
TCH and the Heart Station. “While many hospitals are
required by market forces to pay physicians to interpret
cardiology tests, TCH was fortunate that it had sufficient
medical staff cardiologists committed to staff the Heart
Station without being forced to pay,” he says. Most physicians viewed the assignments as an obligation rather
than a reward, says Danello, because interpreting EKGs,
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6 Report on Medicare Compliance
graded exercise stress tests, echocardiograms and other
non-invasive tests doesn’t generate much Medicare
reimbursement.
And despite DOJ’s allegations, cardiologists rarely
got new, long-term patients as a result of supervising
or interpreting Heart Station tests, he says, because all
results were sent back to the patient’s treating physician,
who often had ordered the tests in the first place.
Lawyer: Routine Staffing, Not Kickbacks
Danello says other hospitals should be alarmed by
the road DOJ is traveling with this lawsuit.
“The assignment of medical staff physicians to hospital-based diagnostic reading panels and the characterization of that panel time are issues that apply to every
physician group practicing in a hospital that staffs reading panels,” he said. “Whether medical staff and clinical
privileges granted by a hospital constitute remuneration
within the meaning of the anti-kickback statute has been
a highly contentious policy question for years,” accord-
April 7, 2008
ing to Danello. But the government has never before
asserted that the opportunity to earn a fee paid by the
federal Medicare or Medicaid program can be illegal
remuneration under these laws, he said.
Ohio Heart’s attorney, Ken Seibel, says DOJ’s allegations are “patently false.” It’s obvious partly because, he
says, TCH has an open system for panel time, and “two
other large [cardiology] groups refuse to do it.” He adds
that Ohio Heart’s percentage of panel time has risen.
Contact Danello at [email protected]. ✧
Medicaid Fraud Crackdowns and Compliance is
packed with case studies that illustrate what new compliance initiatives health care entities should expect under the
federal Deficit Reduction Act (DRA).This report explains
what sparked the Medicaid enforcement push, how it affects
providers and what actions your organization should take
now. For more information, go to the MarketPlace at www.
AISHealth.com and click on “Books and Directories,” or call
AIS at 800-521-4323.
COMPLIANCE CHRONICLE
Following is a list of proposed rules, notices, transmittals, audit reports, advisory opinions and Office of Evaluation and
Inspections reports released by CMS between Feb. 18 and March 28. For more information on these, visit AIS’s Government
Resources at the Compliance Channel at www.AISHealth.com.
Rules:
◆ FR 15937–15939 [E8–6164], posted March. 26, “Medicare and State Health Care Programs; Fraud and Abuse;
Issuance of Advisory Opinions by OIG.” (See brief, p. 8)
◆ FR 11043 [E8–3861], posted Feb. 29, “Changes to the
Medicare Claims Appeal Procedures; Continuation of Effectiveness and Extension of Timeline for Publication of Final
Rule.”
◆ Trans. 1483 (CR 5969), posted March 25, “April 2008
Integrated Outpatient Code Editor (I/OCE) Specifications
Version 9.1.”
◆ Trans. 1480 (CR 5970), posted March 21, “Website for
Additions and Deletions of ZIP Codes Requiring a Plus Four
ZIP Code Extension.”
◆ Trans. 1482 (CR 5980), posted March 21, “April Update
to the 2008 Medicare Physician Fee Schedule Database.”
◆ FR 9679–9685 [E8–2938], posted Feb. 22, “Medicare
Secondary Payer (MSP) Amendments.”
◆ Trans. 33 (CR N/A), posted March 21, “Update to Chapter
2, ‘The Certification Process,’ Sections 2021 and 2022.”
◆ FR 9672–9679 [E8–2811], posted Feb. 22, “Prior Determination for Certain Items and Services.”
◆ Trans. 247 (CR 5832), posted March 21, “Model Letters
for Provider Enrollment.”
Notice:
◆ Trans. 1481 (CR 5977), posted March 21, “Type of Service (TOS) Corrections.”
◆ FR 9807–9810 [E8–2798], posted Feb. 22, “Extension of
Certain Hospital Wage Index Reclassifications.”
Transmittals:
◆ Trans. 249 (CR 5995), posted March 28, “Carrier Assignment of Provider Identification Numbers (PINs).”
◆ Trans. 1485 (CR 5899), posted March 28, “Chapter 29
Clean-Up.”
◆ Trans. 438 (CR 5971), posted March 28, “Signature
Requirements Clarification.”
◆ Trans. 1479 (CR 5965), posted March 14, “April 2008
Inpatient Rehabilitation Facility (IRF) Prospective Payment
System (PPS) Pricer Changes.”
◆ Trans. 1478 (CR 5923), posted March 14, “Additional
Clarification to Chapter 17, Section 40, Regarding Processing
of Drug Claims with the JW Modifier.”
◆ Trans. 1477 (CR 5913), posted March 14, “New Waived
Tests.”
Subscribers to RMC are eligible to receive up to 12 Continuing Education Credits per year, which count toward
certification by the Compliance Certification Board. For more information, contact CCB at 888-580-8373.
April 7, 2008
Report on Medicare Compliance
7
COMPLIANCE CHRONICLE (continued)
◆ Trans. 435 (CR N/A), posted March 7, “Updates Chapter
3, Bad Debts, Charity, and Courtesy Allowances and the
Table of Contents reflects deleted page numbers.”
◆ Trans. 1475 (CR 5942), posted March 7, “Remittance
Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Update.”
◆ Trans. 326 (CR 5725), posted March 7, “Medicare Fraud
Edit Module.”
◆ Trans. 1473 (CR 5792), posted March 7, “Payment for
Inpatient Hospital Visits — General (Codes 99221-99239).”
◆ Trans. 1472 (CR 5893), posted March 6, “Update of
Institutional Claims References.”
◆ Trans. 322 (CR 5873), posted March 5, “Limitation of
Recoupment — FISS Recoupment and Claims Adjustment
Process.”
◆ Trans. 1468 (CR 5947), posted Feb. 29, “Claim Status
Category Code and Claim Status Code Update.”
◆ Trans. 244 (CR 5906), posted Feb. 29, “Collapsing
Medicare Provider Transaction Access Numbers (PTANs)
to Ensure a One-to-One National Provider Identifier (NPI)
Match.”
◆ Trans. 85 (CR 5204), posted Feb. 29, “Psychological and
Neuropsychological Tests.”
◆ Trans. 245 (CR 5945), posted Feb. 29, “Processing Part B
Therapy Claims While the Therapy Cap Exceptions Process
is in Effect.”
◆ Trans. 137 (CR 5789), posted Feb. 29, “Reporting Costs
Directly Associated with the RAC Program.”
◆ Trans. 321 (CR 5928), posted Feb. 29, “Refinements in
Cost Reporting Due to CMS’s Revised Procedures for Recalibrating DRG Relative Weights Under the Inpatient Prospective Payment System.”
◆ Trans. 1464 (CR 5936), posted Feb. 22, “Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 14.1,
Effective April 1, 2008.”
◆ Trans. 1466 (CR 5791), posted Feb. 22, “Payment for
Hospital Observation Services (Codes 99217 - 99220) and
Observation or Inpatient Care Services (Including Admission and Discharge Services — Codes 99234 - 99236).”
◆ Trans. 1460 (CR 5794), posted Feb. 22, “Subsequent
Hospital Visits and Hospital Discharge Day Management
Services Codes (99231-99239).”
◆ Trans. 1461 (CR 5910), posted Feb. 22, “Clarification to
CR 5744 — Payment Allowance Update for the Influenza
Virus Vaccine CPT 90660 and Further Instruction Regarding
the Pneumococcal Vaccine CPT 90669.”
◆ Trans. 1465 (CR 5793), posted Feb. 22, “Payment for
Initial Hospital Care Services (Codes 99221 - 99233) and Observation or Inpatient Care Services (Including Admission
and Discharge Services) (Codes 99234 - 99236).”
◆ Trans. 243 (CR 5908), posted Feb. 22, “Implementation
of A PIMR Edit Effectiveness Report For Program Safeguard
Contractors (PSCs).”
◆ Trans. 1462 (CR 5951), posted Feb. 22, “Healthcare Provider Taxonomy Codes (HPTC) Update April 2008.”
◆ Trans. 1457 (CR 5859), posted Feb. 22, “Redeterminations of Overpayments.”
OIG Audit Reports:
◆ A-05-07-00066, posted March 27, “Review of Excessive
Payments for Outpatient Services Processed by National
Government Services in Michigan and Wisconsin for Calendar Years 2004 and 2005.”
◆ A-02-07-01047, posted March 12, “Review of St. Peter’s
University Hospital’s Reported Fiscal Year 2005 Wage Data.”
(See brief, p. 8.)
◆ A-02-07-01041, posted March 7, “Review of High-Dollar
Payments for Medicare Part B Claims Processed by Triple-S,
Inc., for the Period January 1, 2003, Through December 31,
2005.”
◆ A-09-07-00059, posted March 7, “Review of Excessive
Payments for Outpatient Claims Processed by National
Government Services for Calendar Years 2003 Through
2005: California Providers.”
◆ A-09-07-00072, posted Feb. 28, “Audit of Medicare
Administrative Costs Claimed by Blue Cross Blue Shield of
Arizona for the Period October 1, 2004, Through September
30, 2006.”
◆ A-02-07-01042, posted Feb. 20, “Review of High-Dollar
Payments for Medicare Part B Claims Processed by HealthNow New York, Inc., for the Period Jan. 1, 2003, Through
Dec. 31, 2005.”
OIG Office of Evaluations and Inspections Report:
◆ OEI-09-07-00550, posted March 3, “Los Angeles County
Suppliers’ Compliance With Medicare Standards: Results
From Unannounced Visits.”
OIG Advisory Opinion:
◆ 08-05, posted Feb. 22, “concerning a pharmaceutical
company’s proposal to place in certain physicians’ offices
electronic kiosks that offer patients free disease state screening questionnaires.”
Call 800-521-4323 or visit the MarketPlace at www. AISHealth.com for more information on AIS’s comprehensive looseleaf services, A Guide to
Auditing Health Care Billing Practices and A Guide to Complying With Stark Physician Self-Referral Rules (with quarterly updates and e-Alerts).
8 Report on Medicare Compliance
April 7, 2008
NEWS BRIEFS
◆ The mail-fraud trial of former compliance officer
Patricia Syling has been postponed until spring
2009 because she is seven months pregnant as
of this month and has fired her lawyer, the federal
prosecutor on the case tells RMC. Syling is now out
on bail and living in Florida, pending the trial. Syling
was compliance officer and revenue cycle manager
for The Queen’s Medical Center, the largest private
hospital in Hawaii. The U.S. Attorney’s Office for the
District of Hawaii indicted Syling for allegedly causing hospital compliance, HIPAA and collection contracts to be awarded to consulting firms she secretly
owned (RMC 10/29/07, p. 1). Meanwhile, the 600-bed
nonprofit Honolulu hospital is suing Syling to recover the money she allegedly stole, but Syling is
countersuing for money she says is still owed to her
under contracts she signed with the hospital. Visit
www.usdoj.gov/usao/hi.
◆ Psychiatrist Gulshan Sultan, M.D., will pay $1.1
million to settle federal and state officials’ allegations that she submitted false claims to Medicare
and Medicaid, the U.S. Attorney’s Office for the
Eastern District of Tennessee said March 20. The civil
complaint alleged that she submitted false claims
under two separate codes in her name when the services were not provided by her, but by a nurse who
did not have the training or a license for psychiatry,
the feds say. She also submitted bills for 200 separate
days for face-to-face, time-based services she allegedly did not perform. According to the agreement,
Sultan admitted to some of the violations alleged in
the complaint, but not all of them. The parties settled
to avoid further litigation, it says. Sultan also was
charged in a criminal case for submitting false claims,
pleaded guilty and was sentenced in July 2006 to
two years of probation. And she was excluded from
participating in Medicare and TennCare, Tennessee’s
Medicaid program. For more information, visit
www.usdoj.gov/usao/tne.
◆ Rita Campos Ramirez was sentenced to 10
years in prison for her role in a scheme to defraud
Medicare of $170 million, the U.S. Attorney’s Office
for the Southern District of Florida said April 2. She
was also ordered to forfeit $207,000, her three homes
and an automobile and to pay $105 million in restitution. She pleaded guilty in August 2007 to one count
of conspiracy to commit health care fraud and one
count of submitting false Medicare claims, the feds
say. She admitted to submitting about $170 million in
fraudulent Medicare claims on behalf of 75 HIV infusion clinics as part of her medical billing business.
Visit www.usdoj.gov/usao/fls.
◆ The HHS Office of Inspector General (OIG) has
revised its procedure for the payments it requires
for the costs incurred while doing an advisory opinion, according to an interim final rule released March
26. The changes take effect April 25. Read more about
the advisory-opinion process at www.oig.hhs.gov/
fraud/advisoryopinions.html.
◆ Leslie Howell, a former employee of a health
care provider in Oklahoma City, was charged in a
February indictment with violating HIPAA. According to the indictment filed in the U.S. District Court
for the Western District of Oklahoma, Howell allegedly knowingly disclosed individually identifiable
health information for a purpose not permitted by
HIPAA with the intent to use the information for
personal gain. She allegedly provided more than
100 patient files to two people “knowing the two
individuals would use the information contained
within the patient files to commit access device fraud
and identity theft,” the indictment says. An attorney
representing Howell said she could not comment on
the case. The case is U.S. v. Howell. Visit www.okwd.
uscourts.gov.
◆ In February, a California physician was sentenced to 30 months in prison and was ordered
to pay $558,000 in restitution for his part in a
conspiracy that defrauded Medicare, OIG says in
updated enforcement actions on its Web site. The
physician allegedly wrote prescriptions for enteral
nutrition products and signed certificates of medical
necessity for motorized wheelchairs and hospital beds
that were not medically necessary. In many cases, OIG
says, the items were not provided to beneficiaries. A
durable medical equipment company allegedly paid
the physician kickbacks for the prescriptions, it says.
The physician allegedly also billed Medicare for treating patients who were recruited to come to his clinic
with the promise of receiving free products. He then
allegedly referred them to companies for ancillary
services and received kickbacks from those firms,
OIG claims. Visit AIS’s Government Resources at the
Compliance Channel at www.AISHealth.com; click on
“OIG Enforcement Actions.”
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