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Compliance
Program for Medicare Fraud and Abuse
 In
the January, NACMED NEWS, I discussed the recently enacted Compliance
Guidance Regulations for Medicare fraud and abuse. In this issue, I will
discuss the minimum requirements for a compliance plan as laid out by
HCFA.
I have been unable to find, and there may not yet
be available, a template that will serve all practices in creating their
compliance program. I suspect an entrepreneurial physician will soon
write such a program. The MSSNY has a committee considering this as
well. Until then, the compliance manual must have the following key
areas covered.
- Outline who is involved in the billing
operations of your practice. You are ultimately responsible for all the
billing which occurs so your program of meeting with your billing staff
and for periodic review of claims should be stated in your plan.
- Audit your own practice for conflict of
interest contracts with vendors, labs, rental partners, physician
referrers, etc. Have any signed vendor agreements reviewed by legal
council.
- Review carefully everything you receive from
Medicare such as newsletters, audit notices and rejected claims. Have a
process for outlining a response to these inquires.
- Monitor actions of disgruntled employees. Have
a system in place for employees to air their grievances.
- Limit access of your billing information to
only those individuals that must know. Have a written and easily
understandable policy for waiving co-payments and deductibles. Ensure
that it is fair and based on financial hardship.
- Train your staff to bill and code correctly.
Have an outline of how your coding practices are discussed with new
trainees. Consider sending staff to Medicare coding courses. Have a plan
for reviewing uncommon and new procedure codes.
- Aggressively resolve patient billing
complaints. Have a written plan for tracking these complaints. The next
disgruntled patient may be your whistleblower. Remember the government
is offering a $1,000 bounty for information leading to your arrest!
- Finally, don't ignore any requests for
documentation from Medicare/HCFA. However, do not respond until you have
consulted with legal council. The Nassau County Medical Society can
direct you to attorneys who are familiar with compliance regulations and
also know your rights and obligations when responding to HCFA inquires.
GOOD LUCK!
David
Eskreis, MD
| Radio
HealthLine is Back on the Air |
After a hiatus of several years,
Nassau County Medical Society's Radio "Healthline" is back on
the air thanks to the tireless efforts of Felix A. Monaco, MD,
Chairman of the Communications and Media Committee, and Burton Glass,
MD, committee member and Second Vice President of NCMS.
Radio
"Healthline" will be broadcast once a week on WGBB Radio 1240
AM beginning
Saturday, March 15 at 8:30 AM.
Each week, the show will feature
expert members of the Society who will present information to the public
on a wide variety of medical topics. The show is currently slated to run
for 13 weeks.
Members are urged to encourage
their patients to tune in to this program for the latest updates in
medicine.
|
Collective
Bargaining Bill Reintroduced |
Legislation has been reintroduced this session
which enacts provisions relating to collective negotiations by health
care providers with health care plans (A.5466).
The bill would allow collective negotiations by
health care providers and is designed to restore fairness in the
contracting process between physicians and large managed care plans by
allowing doctors to join together to negotiate contract provisions.
This legislation would not authorize strikes or
boycotts of health benefit plans by physicians. But, by allowing
physicians to negotiate some patient-care provisions of their contracts
with HMOs, while being closely monitored by the state, this legislation
would give physicians greater ability to advocate for their patients.
Any negotiations involving fee-related matters would only be permitted
when an individual managed care plan controls a substantial share of the
managed care market.
Fifty-six Assemblymembers decided to co-sponsor
the measure, including DiNapoli, Hooper, Sidikman and Weisenberg from
Nassau County.
| Physician
Due Process Bill Introduced |
Assemblyman Thomas DiNapoli from Nassau County has
introduced legislation on behalf of the Medical Society which would
protect physicians from retribution by the insurance industry.
Currently, physicians are afforded a due process
hearing to ensure that they are not being punished for advocating for
their patients, only when a plan decides to dismiss the physician during
the term of his or her contract with the plan. Unfortunately, many
insurers are skirting the law by simply not renewing the contracts of
physicians.
The action has the same practical effect, from the
patients' perspective, of denying access to a trusted health care
practitioner. In order to assure that plans have legitimate reasons for
not renewing contracts, and not simply to punish physicians, Assemblyman
diNapoli has introduced Assembly Bill 5569.
| Parity
Bill Introduced by Mental Health Committee |
Assemblyman Martin Luster, Chairman of the
Assembly Mental Health Committee, recently introduced the Fair Insurance
Treatment Act of 2001. Under the proposal, which has nearly 40 Assembly
co-sponsors, all health insurance plans not exempted by federal law will
be required to provide equal coverage for physical health, mental health
and chemical dependency treatment.
Insurance companies would be prohibited from
having higher co-payments, deductibles or co-insurance for mental health
and chemical dependency visits, which is a common practice today. The
bill would also prohibit limiting visits for mental health and chemical
dependency to less than those covering physical health.
| Family
Health Care Decision Act Introduced |
Assemblyman Richard Gottfried recently introduced
legislation (A.5523) to establish procedures for making health care
decisions on behalf of patients unable to decide about treatment for
themselves.
The Family Health Care Decision Act authorizes
family members and other persons close to patients who lack
decision-making capacity to decide about treatment in consultation with
physicians and other health care professionals.
| Malpractice
Awards Rocket Upwards |
The national median jury award in a
medical malpractice action rose 7%, $750,000 to $800,000 from 1998 to
1999, according to a recent survey announced by Jury Verdict Research.
This continues the alarming trend of increased malpractice verdicts
nationally which, according to the survey have gone up 76% since 1996.
Other surveys have shown that New York State physicians are being
particularly hard hit by this upswing in awards. With the average New
York State malpractice verdict having increased from $1.7 million in
1994 to $5.5 million in 1999, according to the 2000 New York Verdict
Survey.
The Jury Verdict Research study also
indicated an increased frequency of malpractice awards of $1 million or
more, with 45% of jury awards being $1 million or more in 1998-99, as
compared to 39% in 1997-98.
Settlement medians were also on the rise,
with the median settlement in 1999 being $650,000, 30% higher than in
1998. These alarming statistics indicate
that an Excess Medical Liability Insurance Program is needed in New York
State as much now as ever before, unless and until the State Legislature
takes action to establish a cap on the amounts that can be awarded in a
malpractice action.
| Bill
Would Require Speedier Payments from Insurers |
Legislation has recently been introduced
in both houses, which would require an insurer to pay a submitted claim
within thirty days instead of forty-five days. This bill amends section
3224-A of the insurance law to require an insurer to pay a claim to a
policy holder or a health care provider within 30 days unless it is not
reasonably clear that the person is covered under the policy or there is
specific information that the claim was submitted fraudulently.
Current law states that an insurer has 45 days to
pay a claim to a policy holder or a health care provider unless it is
not reasonably clear that the person is covered under the policy or
there is specific information that the claim was submitted fraudulently.
The Insurance Department has repeatedly
recognized, however, the failure of insurers to comply with the
provision of the law. Policyholders or health care providers are
entitled to expediently receive payment for claims covered under their
respective policies. By mandating that claims are processed within 30
days, it is our hope that insurers will finally be forced to change
their procedures and start to efficiently process and pay claims.
| Society
Opposes New Fees for Radiologists |
Opposition was voiced to a proposed rule by the
NYS Dept. of Health to impose an increase in the annual registration and
inspection fees for private radiology offices. The purpose of the
increase is to generate $1.8 million to fund the current cost of
operating the radiation protection program. Funding had previously come
from the general fund. With its current surplus, the Society believes
that funding should continue to come from the general fund.
| HCFA
Concerns Re: Reimbursement Unwarranted |
The Health and Human Services Office of Inspector
General (OIG) reports that the HCFA concerns about provider exploitation
of critical care codes are not warranted. To be considered critical, an
illness or injury must acutely impair one or more vital organ systems
such that the patient's survival is jeopardized. Critical care is
usually but not always, given in a critical care area, such as a
coronary, intensive, respiratory or emergency care unit. HCFA outlays
for critical care amounted to $353 million in FY 1999, principal audit
year.
HCFA, local carriers, and practitioners has all
voiced concern for Medicare's reimbursement of critical care (a) by
provider specialties not usually associated with critical care, (b) for
unbundled services (those which should not be separately billed), and
(c) which were excessive amounts of services billed. The OIG audit
determined that (1) internal medicine and pulmonary disease account for
nearly 50% of critical care claims submitted, while eight other
specialties account for approximately 40%; (2) contractors are not
paying for services that should have been bundled into critical care
codes "based on our analysis of 1999 data, [OIG] estimates that
carriers allowed only 2,900 services for a total of $51,800 that should
have been bundled into critical care payments;" and (3)
questionable payments for services, based on an absence of "first
hour" claims, have dropped by three quarters since 1998. The OIG
report emphasized that its focus was on contractor outlays as a function
of provider claims.
The audit did not take into account whether the
billing for critical care was medically necessary or, indeed, whether
any fraud could be attributed to any claim. As for such performance
shortfalls as were detected, OIG concluded that HCFA's internal
regulatory mechanisms could correct these.
| Dept.
of Labor Issues Rules Re: Processing ERISA Claims |
The US Department of Labor has issued regulations
to expedite the review and appeal process for health insurance claims
that are submitted to ERISA-covered health plans. The rules will govern
all claims that are submitted to ERISA plans on or after January 1,
2002. ERISA plans are generally exempt from the various state rules that
govern the filing of health care claims, including New York State's 1996
Managed Care Bill of Rights Law, 1997 Prompt Payment Law and 1998
External Appeals Law.
Among the various provisions of this regulation
are that any ERISA plan must make a determination on a request for
urgent care within 72 hours after receiving the claim, within 15 days
for reviewing pre-certification requests that are not "urgent"
and within 30 days for reviewing claims for services that have been
rendered.
With regard to appeals of denied claims, the
determination must be rendered within 72 hours if the claim is urgent,
within 30 days for reviewing pre-certification requests that are not
urgent, and within 60 days for reviewing claims for care that has been
rendered.
If a plan fails to make a timely decision or
otherwise fails to comply with the regulation, claimants may go to court
to enforce their rights. The regulations also permit a patient up to 180
days to appeal following the receipt of notice of an adverse benefit
determination, and require the plan to consult with appropriate health
care professionals in deciding appealed claims involving medical
judgment.
However, it is important to note that these new
rules, while they should be helpful to physicians and patients, only
apply to the internal coverage decisions of ERISA plans and do not
create a meaningful external appeals mechanism for reviewing denied
claims. They also do not set forth the required time frame within which
a physician must be paid for rendering the service that is the subject
of the claim determination.
Because of the limited application of these new
regulations, the Medical Society along with the AMA, will continue to
work with the Bush Administration and the US Congress towards the
enactment of a true, meaningful Patients' Bill of Rights law.
| SUNY
Seeks Medical Officer For Training Ship |
SUNY Maritime College at Fort Schuyler is seeking
a MD to serve as Medical Officer on board the Training Ship Empire State
for its Summer 2001 Sea Term. On board there will be approximately 400
Cadets and staff.
The Summer Sea Term begins on May 07, 2001 and
ends July 18, 2001. Ports-of-call include Philadelphia; Los Palmas,
Canary Islands; Copenhagen; and Edinburgh. The nature of work performed
by the cadets is quite physical, as they stand watches, perform
maintenance repair on equipment and also attend classroom instruction.
The on-board clinic consists of a treatment room
capable of supporting minor surgery and examination. It also included 2
wards. The staff includes one physician, one nurse and a cadet corpsman.
The MD will receive qualification by the college as a Coast Guard
registered Medical Officer. For particulars, call Captain Robert Weaver
at 718-409-7352.
Jose B. Banzon, MD,
has been appointed to the Board of Trustees of Franklin Hospital Medical
Center. Dr. Banzon has been a member of its medical staff since 1973. He
operates a private practice in Franklin Square.
Seymour Katz, MD, was the recipient
of the 2000 Samuel S. Weiss Award, presented to a Fellow of the American
College of Gastroenterology (ACG) in recognition of his/her outstanding
career service to the College.
As President of the Association, Dr.
Katz was primarily responsible for shaping and implementing the
college's strategies for securing enactment of the Medicare colorectal
cancer screening benefit.
The award represents a 5-1/2 year battle to gain coverage for cancer
screening using colonoscopy.
Eugene Thompson, MD,
has been named to the Board of Directors of South Nassau Communities
Hospital. Dr. Thompson had served as Medical Director of the Methadone
Clinic for Nassau County and as Medical Officer of the New York City
Fire Department.
Holds
National Databank Hearing
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March
2001
In
the News This Month...
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