Medicare Compliance & Reimbursement

Auditors Accuse CIGNA of Overbilling Medicare by $28 Million

If you think medical practices are the only entities under the microscope for improper billing practices, think again. On May 1, the OIG recommended that CIGNA Healthcare of Arizona repay at least $151,000 in improper charges due to a “significant error rate,” and suggested that CIGNA may have overbilled the Medicare program by $28 million in 2007, the Arizona Republic reported.

The disparity comes from an audit of $328 million that the government paid CIGNA for administering its Medicare Advantage program in 2007, the article states, although CIGNA is appealing the government’s recommendation.

Medicare Ramps Up Readmission Penalties

In its latest proposed payment rule for hospitals, the Centers for Medicare & Medicaid Services bumps up the maximum payment penalty for overly high admissions from 1 to 2 percent in 2014, CMS notes in a release.

“CMS also proposes to add two new readmission measures which could be used to calculate readmission penalties for FY 2015,” the agency adds. In addition to heart attack, heart failure, and pneumonia, CMS proposes to add hip/knee arthroplasty and chronic obstructive pulmonary disease to the readmission penalty list.

Also: For FY 2014, CMS proposes a revised methodology to take into account planned readmissions for the three existing readmissions measures, the agency says in a fact sheet.

Texas Doctor Faces Up to 10 Years in Jail for Changing Dx Codes

Fraudulent medical coding doesn’t always involve CPT or supply codes. You can face hard time for changing diagnoses as well.

That’s the lesson that a Texas physician learned this week after being charged with seven counts of health care fraud. Between 2010 and 2013, the general practitioner is alleged to have added, changed, deleted, and incorrectly sequenced diagnosis codes “in a way that did not reflect the actual diagnoses and conditions of the patients,” an April 23 Department of Justice news release said. These ICD-9 code changes resulted in the doctor submitting false claims of over $1.1 million to Medicare and Medicaid, the DOJ reports.

The physician faces up to ten years in prison if he is found guilty of the accusations. To read more about the case, visit www.justice.gov/usao.

Self-Disclosure Heads Off CIA Under New Policy

If you discover improprieties that you must self-disclose to the HHS Office of Inspector General, you have a newly updated set of guidelines to follow. After publishing its initial self-disclosure protocol in 1998 and issuing three Open Letters to Health Care Providers on the topic in 2006, 2008, and 2009, the OIG has revised the SDP “in its entirety at this time,” the watchdog agency says.

Take note: One of the most important changes is that the OIG “has implemented a ‘presumption’ against imposing corporate integrity agreement obligations on disclosing parties in exchange for a ‘release of OIG’s permissive exclusion authority,’” reports law firm Sidley Austin in an analysis of the new protocol. “According to the SDP, corporate integrity agreements are not needed in such circumstances because ‘good faith disclosure’ and ‘cooperation’ are ‘typical indications of a robust and effective compliance program,’” the firm notes.

The SDP also sets out specific requirements related to disclosures involving excluded individuals, Sidley Austin notes. “If a disclosing party has employed an excluded individual, it must disclose facts about the excluded individual and describe the existing screening process in place to identify excluded individuals, any flaws in that process that led to the employment of the excluded individual, and a description of how the conduct was discovered,” the firm details. “In addition, before the disclosure, the provider must screen all current employees against the List of Excluded Individuals and Entities.”

The new SDP is at http://go.usa.gov/TDZG. and a training video is at http://go.usa.gov/TDBd.

Monitor Your Home Health RAPs

With Home Health & Hospice Medicare Administrative Contractor Palmetto GBA setting RAPs to pay nothing if you have too many auto-cancels, smart agencies will take preventive action. The National Association for Home Care & Hospice (NAHC) “recommends that home health agencies monitor their outstanding [Request for Anticipated Payment],” the trade group says in its member newsletter. “If they believe they will be unable to submit the final claim before the 120 days, they should cancel those RAPs before they are auto-cancelled.”

Palmetto won’t pay RAPs for agencies that had 100 or more auto-cancels in the first quarter. The MAC is considering adjustments — including for agency size — to its threshold for suppressing RAP payments based on auto-cancels, NAHC reports.