Part B Insider (Multispecialty) Coding Alert

Physician Notes:

New Medicaid Rule Rewards Providers for Quality Care

Published on Mon May 02, 2016

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Plus: Miami physician gets prison time in Medicare scam

In an effort to provide greater clarity and responsibility while offering superior managed care in Medicaid and the Children’s Health Insurance Program (CHIP), the Department of Health and Human Services (HHS) announced a Final Rule, which aims to revamp the programs and improve the health care system, according to an April 25 HHS news release.

In short, the new overhaul targets four objectives that would improve quality of care, increase the states’ involvement and delivery of the programs, reform past discrepancies in the areas of provider adequacy and fiscal responsibility, and provide a detailed rating system for engaging in this new managed care initiative.

An abbreviated version of the four goals are as follows:

Support states’ efforts to advance delivery system reform and improvements
Strengthen the consumer experience
Strengthen program integrity by improving accountability and transparency
Align rules across health insurance coverage programs

With a start date of July 1, 2017, the new rule will be executed over a span of three years and aims to aid both physicians and patients in navigating Medicaid and CHIP more efficiently.

“Today’s significant changes strengthen the program by improving the consumer’s care experience and supporting state efforts to deliver more coordinated, higher-quality care,” said HHS Secretary Sylvia M. Burwell in the statement.

Resource: To read more about the rule concerning Medicaid and CHIP, visit www.hhs.gov/about/news/2016/04/25/hhs-issues-major-rule-modernizing-medicaid-managed-care.html.

In other news…

The Medicare Fraud Strike Force sentenced a Miami physician to 108 days in prison and over $30 million in payback fines to the federal government.

The doctor was found guilty of massive fraudulent behavior that included taking kickbacks and bribes, falsifying patient records, writing unnecessary prescriptions and more, according to an April 18 Department of Justice news release.

The doctor “admitted that his and his co-conspirators’ actions caused multiple Miami-Dade home health care agencies and other providers to bill Medicare for services that were not medically necessary or not provided, and that Medicare made payments on these fraudulent claims,” the DOJ said.

The Medicare Fraud Strike Force has apprehended thousands of practitioners since 2007, recovering billions and making physicians everywhere accountable.

Resource: To read more about Medicare fraud and this case, visit www.justice.gov/opa/pr/miami-physician-sentenced-108-months-prison-his-role-30-million-health-care-fraud-scheme.