AAPA Provides Clarification on the Medicare Enrollment of PAs

The American Academy of Physician Assistants (AAPA) recently contacted NAMSS, providing the information below, which may be helpful to MSPs who are responsible for the credentialing and Medicare enrollment of Physician Assistants (PAs):

With the new PECOS requirement, hospitals have been scurrying to get employed PAs enrolled to meet the “ordering/referring” rule.

Some MSPs who are responsible for physician credentialing and enrollment in Medicare have been asked to present Medicare contractors with current certification information. In some states, maintenance of certification is not a requirement for licensure; nor is it a requirement for Medicare enrollment. The PA must have passed the certifying exam. There is no mention of maintenance of certification. Transcripts from the PA program are not required if proof can be presented that the PA is NCCPA certified. In this case, certification and license are all that is required.

The relevant Medicare regulations are below:

Medicare Benefit Policy Manual
Chapter 15 – Covered Medical and Other Health Services
Table of Contents
(Rev. 117, 12-18-09) http://www.cms.gov/manuals/Downloads/bp102c15.pdf

190 - Physician Assistant (PA) Services
(Rev. 1, 10-01-03)
B3-2156

Effective for services rendered on or after January 1, 1998, any individual who is participating under the Medicare program as a physician assistant for the first time may have his or her professional services covered if he or she meets the qualifications listed below and he or she is legally authorized to furnish PA services in the State where the services are performed. PAs who were issued billing provider numbers prior to January 1, 1998 may continue to furnish services under the PA benefit.

See the Medicare Claims Processing Manual, Chapter 12, “Physician and Nonphysician Practitioners,” §110, for payment methodology for PA services. Payment is made under assignment only.

A. Qualifications for PAs

To furnish covered PA services, the PA must meet the conditions as follows:

1. Have graduated from a physician assistant educational program that is accredited by the Accreditation Review Commission on Education for the Physician Assistant (its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or
2. Have passed the national certification examination that is administered by the National Commission on Certification of Physician Assistants (NCCPA); and
3. Be licensed by the State to practice as a physician assistant

The AAPA contacted CMS to seek clarification on this issue. The following response was received on January 19, 2011:

“The regulations at 42 CFR 410.74 that contain the PA qualifications should be
interpreted as follows:

1. Have graduated from a PA educational program that is accredited by the Commission on Accreditation of Allied Health Education Programs and be licensed by the State to practice as a PA; or

2. Have passed the national certification examination that is administered by the National Commission on Certification of PAs and, be licensed by the State to practice as a PA.”

For more information, or questions regarding the credentialing and enrollment of PAs, please contact:

Tricia Marriott, PA-C, MPAS
Director, Reimbursement Policy
American Academy of Physician Assistants
tmarriott@aapa.org

Government Cracks Down on $225 Million in False Claims

Last week, the Medicare Fraud Task Force brought criminal charges against 111 people including doctors, nurses, and healthcare executives nationwide have been linked to $225 million in false Medicare claims.

The Medicare Task Force is a joint effort between the Department of Health and Human Services, the Department of Justice, and FBI to crack down on Medicare fraud and false claims in an effort to avoid wrongful and wasteful spending.

Actions of the charged individuals include the submission of claims for services and equipment never rendered and the recruitment of patients in order to receive financial kickbacks.

It is reported that since the Task Force started in 2007, it has recovered more than $4 billion. The average prison sentence for those convicted has been 43 months.

To read the full article, click here:
http://articles.latimes.com/2011/feb/17/nation/la-na-medicare-fraud-20110218


Source: Los Angeles Times

NAMSS Member Seeks Input on Medicare/Medicaid Sanctions

A NAMSS member has been asked to conduct a survey asking the following question:

“What provisions are listed in your bylaws regarding possible actions that may be taken when a medical staff member has been sanctioned by Medicare/Medicaid?”

Feel free to post your examples in the comment field on the blog or send them to news@namss.org by Thursday, January 20.

CMS Will Postpone Denying Claims from Doctors Not in PECOS

The Centers for Medicare and Medicaid Services (CMS) announced that it will no longer enforce the January 3, 2011 deadline for denying claims for services performed by providers not listed in the Provider Enrollment, Chain and Ownership System (PECOS). PECOS was developed to move the Medicare enrollment process to an electronic format.

This is the second time PECOS enforcement has been postponed. CMS has not announced a new enforcement date; however, they encourage providers who have not enrolled in PECOS to do so sooner rather than later.


Source: BNA

OIG Study Examines Medical School Education on Fraud and Abuse

There is and will continue to be more and more investigation into Medicare and Medicaid fraud and abuse which is costing the US taxpayers billions of dollars each year.

One question being discussed is where and when should medical students be provided with instruction on compliance with Medicare and Medicaid laws to prevent fraud and abuse, or is this better left to residency and fellowship training programs?

In the report from the Office of Inspector General (OIG), Department of Health and Human Services, it is reported that Medicare and Medicaid compliance is being provided in medical schools and graduate medical education programs:

44% of medical schools are providing instruction to students

66+% of graduate medical education programs and fellowship programs

The OIG realized that it is difficult for medical schools to incorporate comprehensive education on Medicare and Medicaid fraud and abuse into the medical curriculum. Therefore, it plans to develop educational materials that can be distributed to medical school programs and to engage in conversations with program directors regarding the usefulness of these materials.


To read the full report, click here:
http://oig.hhs.gov/oei/reports/OEI-01-10-00140.pdf

Watch out for H.E.A.T.

The Obama Administration will be increasing the HEAT to help combat healthcare fraud. The US Attorney General and Secretary of Health of Human Services created the Healthcare Enforcement Action Team (HEAT) in 2009 to investigate cases of fraud. HEAT strike teams are currently present in seven cities. The increase will expand HEAT presence to twenty metropolitan areas.

The HEAT strike teams are responsible for targeting and investigating healthcare fraud cases, something that the FBI and Department of Justice have not been able to handle on their own. Billions of dollars are currently being wasted due to fraudulent claims. The Obama Administration hopes that the success of HEAT will help to prevent and recover these claims, so that money can be better spent on improving quality and controlling costs for Medicare beneficiaries.


Source: Lexology (log-in required)
http://www.lexology.com/library/detail.aspx?g=d1c31f72-1a22-41dd-a1b6-84a7f2c46d61&utm_source=Lexology%20Daily%20Newsfeed&utm_medium=Email&utm_campaign=Lexology%20subscriber%20daily%20feed&utm_content=Lexology%20Daily%20Newsfeed%202010-09-03&utm_term

Former CEO of LA Hospital Sentenced for Role in Billing Scheme

On August 31, Rudra Sabaratnam, former CEO of the now-defunct City of Angels Medical Center in Los Angeles, CA was sentenced to two years in prison and ordered to pay $4.1 million in restitution for his role in a Medicare and Medi-Cal billing scheme (US v. Sabaratnam).

Sabaratnam, along with former board chairman Robert Bourseau, paid an employee of a homeless recruitment center in the "Skid Row" district of Los Angeles to refer homeless patients to the City of Angels Medical Center for unnecessary inpatient treatment so that the facility could bill Medicare and Medi-Cal. Bourseau was sentenced earlier this year for his role.

Often reports of fraudulent Medicare billing involve physicians and other providers. This case serves as a reminder that corruption and abuse of power can occur at all levels of healthcare delivery -- from the provider to the administrator.


Source: BNA

AHA Responds to Recent CMS Telemedicine Expansion: "We Believe the Proposed Changes Do Not Go Far Enough"

In response to CMS' proposed changes regarding credentialing and privileging requirements for telemedicine, the American Hospital Association (AHA) submitted a letter to the new CMS Administrator, Donald Berwick, stating that it is in support of the rule but that the changes do not apply to physician groups or other entities that provide telemedicine service.

Click here to read the letter in it's entirety.

AARP Pledges Support for Two House, One Senate Medicare Fraud-Fighting Bills

AARP endorsed three bills July 27, two in the House and one in the Senate, that focus on fighting Medicare fraud. The bills in question are the Medicare Fraud Enforcement and Prevention Act (H.R. 5044), a companion bill in the Senate (S. 3632), and the Fighting Fraud with Innovative Technology Act (H.R. 5546) (114 HCDR, 6/16/10).

H.R. 5044, sponsored by Reps. Ron Klein (D-Fla.) and Ileana Ros-Lehtinen (R-Fla.), would increase penalties for Medicare fraud, such as doubling monetary fines and doubling jail time.

H.R. 5044, would amend section 1128B of the Social Security Act, which governs criminal penalties for false statements involving federal health programs, removing the existing fine of $25,000 per claim and replacing it with a $50,000 fine per claim, and doubling jail sentences from five years to 10 years. Additionally, the bill would create new penalties for illegally purchasing, selling, or distributing Medicare or Medicaid beneficiary information, as well as billing information. Penalties for this violation would include up to three years in prison as well as monetary fines under Title 18 of the U.S. Code.

The bill would also establish a five-year pilot biometric program, designed to verify the identity of all Medicare beneficiaries. Upon receiving certain services or supplies, a beneficiary would have to undergo a biometric scan. The bill would allow the HHS secretary to create the list of services requiring a biometric test, and the secretary would be allowed to provide financial incentives to providers to take part in the pilot program.

Kevin G. McAnaney, an attorney with the Law Offices of Kevin G. McAnaney, Washington told BNA July 28 that the bill was a mixed bag, with some positive provisions, such as the penalties for selling Medicare beneficiary numbers, but several questionable sections.

“The bill would substantially expand the definition of ‘items and services' for purposes of civil monetary penalties from ‘medical care or services and items' to include ‘without limitation, any medical, social, management, administrative, or other item or service used in connection with or directly or indirectly related to a federal program',” McAnaney said.

H.R. 5546 would create a pre-payment review prevention system that would review Medicare claims, identifying high-risk claims using predictive modeling technology. All flagged claims would be fully reviewed by the HHS secretary, who would have the final say as to whether the claim was paid or denied. The system would work by assessing the risk level of all Medicare transactions on a near real-time basis and would identify suspicious patterns that increased the likelihood of fraud.

“I think this bill simply provides for a robust pre-payment review of claims akin to what the credit card companies do. I don't know if it will work, but it is certainly something they should be trying,” McAnaney said.

It should be made aware that these pieces of legislation highlight the fact that the House and Senate are continuously watching the Medicare program and taking measures to prevent fraud and abuse.

Swann, James. "AARP Pledges Support for Two House, One Senate Medicare Fraud-Fighting Bills." BNA Health Care Daily Report. 29 July 2010. Web. 29 July 2010. http://news.bna.com/hdln/HDLNWB/split_display.adp?fedfid=17565311&vname=hcenotallissues&fn=17565311&jd=a0c3w0p2a1&split=0

New Physician Survey Finds Medicare Payment Change Hurts Care Coordination Efforts - AMA

The elimination of Medicare’s consultation codes has had a negative impact on physician efforts to improve care coordination and reduced the treatment options available to Medicare patients, according to a new survey released today by medical specialty societies and the American Medical Association (AMA). Consultation codes are used most frequently by specialists after a patient referral from a primary care physician.

The survey indicates that the approximately 5,500 physicians who completed the survey have been forced to take a number of cost-cutting steps to offset revenue losses associated with the elimination of these codes.

After analyzing survey data, representatives of these specialties and the AMA identified several technical improvements that would make the policy more equitable. They joined with 16 other organizations in a letter outlining their concerns and asking the Centers for Medicare and Medicaid Services (CMS) to review and modify its current policy to prevent further deterioration of care coordination between physicians.

For more information on the survey results, the organization letter, and survey participants, please visit the American Medical Association website.

American Medical Association. "New Physician Survey Find Medicare Payment Change Hurts Care Coordination Efforts: Medical OrganizationsCall on CMS to Review Consultation Code Policy."
AMA. July 16, 2010. Web. July 201, 2010.
http://www.ama-assn.org/ama/pub/news/news/medicare-consultation-codes.shtml

California Doctor Pleads Guilty to Fraudulent Medicare Billing

On April 14, Dr. Glen R. Justice pleaded guilty to five counts of healthcare fraud. In addition to upcoding insurance claims, Justice submitted fraudulent claims to Medicare and other insurers for cancer medications that were never given to patients. (United States v. Justice)

Justice admitted that his scheme took place between 2004 and 2009 and that he had collected payments totalling up to $1 million.

The number of reports of practitioners bilking Medicare and Medicaid continues to grow. This is especially disconcerting in the midst of health reform, since these fraudulent payments are taking up funds that can be used to provide real coverage and care to patients. These fraud cases only highlight the need for better regulation of these programs and safeguards for catching practitioners in the act of fraudulent billing.


Source: BNA