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Posts tagged "Medicare"

Home Health Conditions of Participation

The Centers for Medicare & Medicaid Services (CMS) have finalized new Conditions of Participation ("CoPs") for home health agencies ("HHAs") that will become effective on January 13, 2018. These CoPs represent the first major update to the rules governing HHAs in roughly 20 years.

Government Continues To Focus On Therapy Issues In Nursing Homes

The provision of therapy services continues to be a focal point of government regulators. In its 2016 Work Plan, the OIG states that it will continue to review the provision of therapy in nursing homes, citing past findings of overutilization and fraudulent billing of such services. The OIG, in conjunction with the U.S. Department of Justice, has been active in prosecuting alleged therapy billing compliance issues, resulting in multi-million dollar settlements with nursing home providers, with several high-profile investigations still pending. RAC and ZPIC audits focusing on therapy services continue throughout the country. In September 2015, the OIG issued a report entitled "The Medicare Payment System For Skilled Nursing Facilities Needs To Be Reevaluated" which concluded that Medicare payments for therapy services greatly exceeded nursing facility costs, and that the current system encourages nursing homes to bill therapy services at the highest levels possible, in order to maximize reimbursement, without a corresponding demonstration of beneficiary need.

Court Holds Responsible Party Provisions are Consistent with Nursing Home Reform Act

In the recent case of Eades v. Kennedy, PC Law Offices, the United States Court of Appeals for the Second Circuit found that provisions of an admission agreement that imposed certain financial obligations on the husband of a nursing home resident did not violate the Nursing Home Reform Act (NHRA), and that the NHRA does not preempt Pennsylvania's indigent support statute. In that case, the daughter and husband of a deceased nursing home resident filed suit against the law firm hired by the nursing home to collect resident's unpaid bill. As part of their claim, the plaintiffs claimed that the responsible party provisions of the admission agreement were unlawful under the NHRA. They further argued that the NHRA preempted Pennsylvania's indigent support statute.

OIG Releases 2015 Work Plan

The OIG's 2015 Work Plan has been posted to its website and is available for review by providers. The Work Plan describes the activities and investigations planned by the OIG for 2015 and breaks down those plans by provider type. For long-term and post-acute providers, pertinent highlights include:

CMS Presses Pause on RAC Reviews

On February 18, 2014, the Centers for Medicare and Medicaid Services (CMS) announced that it had suspended the ability of Recovery Audit Contractors (RAC) to request documents for claims reviews until CMS has had an opportunity to finish the procurement process for new RAC contracts. Under the Recovery Audit Program, RACs are charged with identifying improper Medicare payments. The Program has long been a source of controversy, in part because RACs are paid a contingent fee based on a percentage of claims they deny. Currently, this fee ranges from 9% to 12.5%.

OIG Clarification on Medicare Exclusion Process

On May 8, 2013, the Office of Inspector General ("OIG") issued an Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs. Previously, the only official guidance from OIG on the scope and effect of its exclusion from participation was published in its 1999 Special Advisory Bulletin, which the Updated Bulletin replaces and supersedes. An OIG exclusion is a legal prohibition on payment by Federal health care programs, such as Medicare and Medicaid, for items or services furnished by (1) an excluded person or (2) at the medical direction or on the prescription of an excluded person. This prohibition extends beyond direct patient care and reaches administrative and management services payable by Federal health care programs.

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