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MEDCAC Meeting 7/22/2015 - Lower Extremity Peripheral Artery Disease Print E-mail
Written by CMS.gov   
Tuesday, 05 May 2015 10:18

On July 22, 2015, the Centers for Medicare & Medicaid Services (CMS) will convene a panel of the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC). The MEDCAC panel will examine the scientific evidence of existing interventions that aim to improve health outcomes in the Medicare population, and address areas where evidence gaps exist, related to lower extremity peripheral artery disease (PAD). For purposes of this MEDCAC, we will focus on three categories along the disease progression continuum (asymptomatic, intermittent claudication, and critical limb ischemia).

Clinical outcomes of interest to the Medicare program include reduction in pain; avoidance of amputation; improvement in quality of life and/or functional capacity including walking distance; wound healing; avoidance of cardiovascular events, including myocardial infarction, stroke, cardiovascular death, and all-cause mortality; and avoidance of harms from the interventions. By voting on specific questions, and by their discussions, MEDCAC panel members will advise CMS about the extent to which it may wish to use existing evidence as the basis for any future determinations about Medicare coverage for interventions related to lower extremity peripheral artery disease. MEDCAC panels do not make coverage determinations, but CMS often benefits from their advice.

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2015 Office of Inspector General (OIG) Work Plan Physicians and other Part B Providers Print E-mail
Written by Benjamin Frosch   
Tuesday, 16 December 2014 08:47
 
With the passage the Affordable Health Care Act (Health Care Reform) and the Medicare program in financial jeopardy, the OIG 2015 Work Plan is possibly more important than any of their previous work plans.  With a few thousand staff members throughout the United States, the Office of Inspector General (OIG) plans and performs audits, investigations, evaluations, and legal activities pertaining to the Department of Health and Human Services (HHS). With the Issuance of the 2015 OIG Work Plan there are a variety of important Medicare issues that they will evaluate pertaining to Medicare physicians and other health care providers.
 
With more federal agencies taking a closer look at Medicare fraud and abuse than ever before, it is very clear that there is a zero tolerance for Medicare fraud and abuse. The OIG for 2014 expects recoveries of over $4.9 billion and exclusions of 4,017 individuals and entities from participation in Federal healthcare plans, 971 criminal actions, and 533 civil actions. Therefore, this may be a good opportunity to evaluate compliance in your practice or entity with respect to these specific 2015 OIG issues listed below and to review the entire 2015 work plan. The following is a list of what I think are some of the hottest physician and other provider subjects targeted in the 2015 OIG Work Plan:
 
Home Health Services               
The OIG will evaluate compliance with various aspects of the home health PPS, including the documentation required in support of the claims paid by Medicare. They will review whether home health claims were paid in accordance with Federal laws and regulations. Past OIG reports found that one in four home health agencies had questionable billing. Since 2010, nearly $1 billion in improper payments and fraud has been identified relating to the home health benefit. 

Place of Service Errors
The OIG has and will continue to review physician coding on Medicare Part B claims for services performed in Ambulatory Surgical Centers (ASC) and hospital out-patient departments to determine whether they are coded properly with the correct place of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed.  Medicare pays a physician a higher amount when a service is performed in a non-facility setting, such as a physician office, than it does when a service is performed in hospital outpatient department or, with certain exceptions, in an Ambulatory Surgical Centers.  

PART B Imaging Services
The OIG will continue to evaluate Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices.  Physicians are paid for services pursuant to the Medicare Fee Schedule, which covers the major categories of cost, including the physician professional cost component, malpractice cost, and practice expenses. Practice expenses are those such as office rent, wages of personnel, and equipment. For selected imaging services, the OIG will focus on the practice expense components, including the equipment utilization rate. 
 
Diagnostic Radiology-Medical Necessity of High Cost tests
The OIG will also review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and to determine the extent to which use has increased for these tests. Medicare will not pay for items that are not medically reasonable and necessary.

Chiropractic Services
The OIG will be taking a hard look at Part B payments for non-covered services and questionable billing practices. Previous OIG reviews have demonstrated a history of vulnerabilities relative to inappropriate payments for chiropractic services, including a recent audit that identified a chiropractor with a 93 percent claim error rate and inappropriate payments of about $700,000. Part B only reimburses for chiropractic manual manipulation of the spine to correct a subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment. Chiropractic maintenance therapy is not considered to be medically reasonable and necessary and is therefore not payable. 

Anesthesia Services
The OIG will review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. They will also determine whether Medicare payments for anesthesia services reported on claims with the “AA” modifier were appropriate. Physicians report the appropriate anesthesia modifier to denote whether the service was personally performed or medically directed. Reporting an incorrect modifier on the claim as if services were personally performed by an anesthesiologist when they were not will result in Medicare’s paying a higher amount.  

Sleep Disorder Clinics- High use of sleep-testing procedures
The OIG will examine Medicare payments to physicians, hospital outpatient departments, and independent diagnostic testing facilities for sleep–testing procedures to determine the appropriateness of Medicare payments for high-use sleep-testing procedures to determine if they meet Medicare rules, regulations, and guidelines. A past analysis of 2010 Medicare payments for certain sleep disorder CPT codes totaling $415 million, showed high utilization associated with these procedures.
 
Outpatient Physical Therapy Services
The OIG will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. In the past, the OIG has identified claims for therapy services provided by independent physical therapists that were not, medically reasonable and necessary, or properly documented. The OIG will focus on independent therapists who have a high utilization rate for outpatient physical therapy services because of their concern that they may not be medically reasonable and necessary.
 
Clinical Laboratories Services
The OIG will take a look at Medicare payments to independent clinical laboratories to determine their compliance with certain billing requirements. The OIG will use the results of these reviews to identify clinical laboratories that routinely submit improper claims. In the past these reviews and investigations have identified independent clinical laboratory areas at risk for non-compliance with Medicare billing requirements.  

Ophthalmologists-Inappropriate and questionable billing
The OIG will examine Medicare claims data to identify potentially inappropriate and questionable billing services provided in 2012.They will use this data to determine the locations and specialties of providers with questionable billing. In 2010, Medicare allowed more than $6.8 billion for services provided by ophthalmologists.

End-stage renal disease facilities-Payment system for renal dialysis and drugs
The OIG will review Medicare payments for and utilization of renal dialysis services and related drugs pursuant to the new bundled end-stage renal disease prospective payment system. The OIG will compare facilities acquisition costs for certain drugs to inflation –adjusted cost estimates and determine how costs for the drugs have changed. Past OIG reviews found that data did not accurately measure changes in facilities acquisition costs for high dollar drugs.  

Ambulatory Surgical Centers
The OIG will review the appropriateness of Medicare’s methodology for setting ambulatory surgical center payment rates under the revised payment system. The OIG  will determine whether a payment disparity exists between ASC and hospital outpatient department payment rates for similar surgical procedures provided in both settings.

Mr. Frosch is the President of Frosch Medical Consultants in Plantation, FL.  Got a Question for Ben?  Click Ask Ben.

Last Updated on Tuesday, 16 December 2014 09:23
 
Medicare Provider Enrollment - part 2 Print E-mail
Written by Benjamin L. Frosch   
Friday, 16 May 2014 16:07

                            Medicare Q & A

Q:  For new physicians, are there certain attachments that should be submitted with their CMS 855I?

-Administrator
Specialty Group Administrator
 
A:  In addition to submitting the CMS 855I, you should include copies of their medical school diploma, medical license, and board certification if applicable. It is also a good idea to submit a copy of a passport or driver's license to confirm their signature. Also include the CMS 855R reassigning their benefits to your group.
 
Q:  During the revalidation process, if an error or information is missing on the physician's CMS 855I application, will their billing privileges be de-activated?
 
-Office Manager
Internal Medicine
Miami FL

A:  They would not be deactivated. They would receive a letter from Medicare Provider Enrollment requesting that additional information should be sent or that the application requires a correction. They are usually very specific in their correspondence and they will give you thirty days to submit the requested information. If you fail to respond, you will be deactivated.

Q:
  We are a busy practice in Miami and are adding 2 new physicians in July. A colleague shared with me that he is waiting months for approval because he is waiting to be "interviewed" by Medicare prior to being issued billing privileges. Is this something new and how do we expedite the process?

-Managing Partner
Cardiology Group
Miami, FL

A:  I would not call it an "interview". It is part of the enrollment process in most of Florida to stop fraud. It should only take a few minutes for Medicare to speak to the physician and confirm his/her identity and his/her reassignment to your group. This is done by Medicare in person, where they go to the practice location to see the physician, or by phone. 

I suggest that the new physician's best contact phone number be put in Section 2 of their CMS 855I. Insert the office number or the physician's cell number. You should alert the front desk staff and your new physician to expect to be contacted by Medicare Provider Enrollment. If the physician is not available by phone, please have him return the contact call from Medicare as soon as possible or the application will be delayed.
 
Mr. Frosch is the President of Frosch Medical Consultants in Plantation, FL.  Got a Question for Ben?  Click Ask Ben

Last Updated on Wednesday, 02 July 2014 09:17
 
Medicare Provider Enrollment Print E-mail
Written by Benjamin L. Frosch   
Wednesday, 14 May 2014 11:58

Medicare Q & A

Q:  I understand that we can now apply online for Medicare enrollment. If we decide to apply using the electronic enrollment option, will we be able to bill retroactive beyond the thirty days?

-Administrator

Specialty Group Practice

Naples, FL

A:  The same 30-day rule would apply. The date of filing for internet-based Provider Enrollment, Chain and Ownership System (PECOS) applications for physicians, non-physicians, and organizations is the date the contractor received an electronic version of the enrollment application, a signed certification statement and all the required attachments that were all processed to completion.

Q:  Are there any other "time limit" changes pertaining to Medicare provider Enrollment for other providers?

-Administrator

Specialty Group Practice

Miami, FL

A:  There are "time limits" that address other Medicare provider issues. Physicians, Physician-Assistants, Nurse-Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, Certified Nurse Midwives, Clinical Social Workers, Clinical Psychologist, Registered Dietitians, or Nutrition Professionals, and organizations (groups practices) consisting of any of the categories of individuals identified above, must notify Medicare provider enrollment of certain changes within thirty days.

Other changes that must be reported in 30 days are a change in practice location, change of ownership, or a final adverse action. In the event that Medicare providers do not comply with these reporting requirements relating to change of ownership, practice location, or a final adverse action, the provider may be accessed an overpayment back to the date of the final adverse action, change of practice location, or change of ownership.

Mr. Frosch is the President of Frosch Medical Consultants in Plantation, FL.  Got a Question for Ben?  Click Ask Ben  
 
2014 Office of Inspector General (OIG) Work Plan Physicians and other Part B Providers Print E-mail
Written by Benjamin L. Frosch   
Friday, 07 February 2014 10:53

MEDICARE QUESTIONS AND ANSWERS

With the passage the Affordable Health Care Act (Health Care Reform) and the Medicare program in financial jeopardy, the OIG 2014 Work Plan is possibly more important than any of their previous work plans. I would say it is one of the most detailed OIG work plans, which explains the 3 month delay of the OIG issuing the 2014 work plan.  With a few thousand staff members throughout the United States, the Office of Inspector General (OIG) plans and performs audits, investigations, evaluations, and legal activities pertaining to the Department of Health and Human Services (HHS).   With the Issuance of the 2014 OIG Work Plan there are a variety of important Medicare issues that they will evaluate pertaining to Medicare physicians and other health care providers.  This may be a good opportunity to evaluate compliance in your practice with respect to the following Part B subjects that are in the OIG Work Plan.  With more federal agencies taking a closer look at Medicare fraud and abuse than ever before, it is very clear that there is a zero tolerance for Medicare fraud and abuse.  

The following is a list of what I think are some of the hottest physician subjects targeted in the 2014 OIG Work Plan:
 
EVLAUATION AND MANAGEMENT SERVICES- Inappropriate payments             

This is going to be a subject under the microscope in 2014 and beyond. The OIG will be identifying providers that exhibit questionable billing for E/M services in 2010.  Medicare payments for E&M services in 2010 represented 19% of all Medicare Part B payments. The OIG will review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare has noted an increased frequency of medical records with identical documentation across services. Providers are responsible for ensuring that the E/M codes that they submit accurately reflect the services actually provided and were medically necessary.  E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established.  

PLACE OF SERVICE ERRORS

The OIG has and will continue to review physician coding on Medicare Part B claims for services performed in Ambulatory Surgical Centers (ASC) and hospital out-patient departments to determine whether they are coded properly with the correct place of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed. Prior OIG reviews determined that physicians did not always correctly code non-facility places of service submitted to and paid by Medicare. Medicare pays a physician a higher amount when a service is performed in a non-facility setting, such as a physician office, than it does when a service is performed in hospital outpatient department or, with certain exceptions, in Ambulatory Surgical Centers.  
 
PART B IMAGING SERVICES

The OIG will continue to evaluate Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices.  Physicians are paid for services pursuant to the Medicare Fee Schedule, which covers the major categories of cost, including the physician professional cost component, malpractice cost, and practice expenses.   Practice expenses are those such as office rent, wages of personnel, and equipment.   For selected imaging services, the OIG will focus on the practice expense components, including the equipment utilization rate. 

DIAGNOSTIC RADIOLOGY-Medical Necessity of High Cost tests

 The OIG will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which utilization has increased for theses diagnostic tests. They will also look again at imaging services ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.

ANESTHESIA SERVICES-Payments for personally performed services  

The OIG will review the appropriateness of Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. They will review whether Medicare payments for anesthesiologist services reported on a claim with the “AA” service code modifier met Medicare regulations. Physicians report the appropriate anesthesia modifier code to denote whether the service was personally performed or medically directed. Reporting an incorrect modifier on the claim as if services were personally performed when they were not will result in Medicare paying a higher amount.

OPHTHALMOLOGISTS – Questionable billing

Billing and payment issues -  The OIG plans on reviewing claims data to identify inappropriate payments and/or questionable billing for ophthalmological services during 2012. They will determine the geographic locations of providers exhibiting questionable billing for ophthalmological services in 2012. In 2010, Medicare allowed over $6.8 billion for services provided by ophthalmologists.
 
SLEEP DISORDER CLINICS – High utilization of sleep-testing procedures

The OIG will take a closer look at Medicare payments to physicians, hospital outpatient departments, and Independent diagnostic testing facilities (IDTF’s) for sleep–testing procedures to assess the appropriateness of Medicare payments for high utilization sleep-testing procedures and determine whether they were in accordance with Medicare requirements. An OIG analysis of CY 2010 payments for CPT codes 95810 and 95811, which totaled approximately $415 million, showed high utilization associated with these sleep-testing procedure. Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered because it is not medically reasonable and necessary under the Medicare program.

OUTPATIENT PHYSICAL THERAPY SERVICES

The OIG will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. In the past, the OIG has identified claims for therapy services provided by independent physical therapists that were not, medically reasonable and necessary, or properly documented. The OIG will focus on independent therapists who have a high utilization rate for outpatient physical therapy services because of their concern that they may not be medically reasonable and necessary. 

CLINICAL LABORATORY SERVICES

The OIG will take a look at and review trends in laboratory utilization under Medicare, such as in the types of laboratory tests and the number of tests ordered and identify questionable billing. Medicare is the largest payer of clinical lab tests in the nation. Medicare’s payments for lab tests in 2008 represented an increase of 92 percent over payments in 1998. In 2010, Medicare paid about $8.2 billion for lab tests, accounting for 3 percent of all Medicare Part B payments.

CHIROPRATIC SERVICES - Part B payments for non covered services
 
The OIG will be reviewing billing and payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements. Prior OIG reviews identified inappropriate payments for chiropractic services during calendar year 2006. In 2013, the OIG identified unallowable Medicare payments for chiropractic services. Medicare pays only for a chiropractor’s manual manipulation of the spine to correct a subluxation if there is no neuro - musculoskeletal condition for which such manipulation is appropriate treatment. Chiropractic maintenance therapy is not considered medically reasonable or necessary, and is therefore not payable under the Medicare program.

ELECTRO DIAGNOSTIC TESTING- Questionable Billing

The OIG will review Medicare claims data to identify questionable billing for electrodiagnostic testing. They will evaluate the extent to which Medicare utilization rates differ by provider specialty, diagnosis, and geographic area for these services. Electrodiagnostic testing, which assists in the diagnosis and treatment of nerve or muscle damage, includes the needle electromyogram and the nerve conduction test. The OIG is concerned about the use of electrodiagnostic testing for inappropriate financial gain poses a growing vulnerability to Medicare.

ASCs and HOSPITAL OUTPATIENT DEPARTMENTS-Safety and Quality of Surgery and Procedures

The OIG will review the safety and quality of care for Medicare beneficiaries having surgeries and procedures in ASCs and Hospital outpatient departments. They will assess care in preparation for and provided during surgeries and procedures in both settings. The OIG will identify adverse events in both settings.  

Mr. Frosch is the President of Frosch Medical Consultants in Plantation, FL.  Got a Question for Ben?  Click Ask Ben.

Last Updated on Saturday, 08 February 2014 08:20
 
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