Additional Cities will have HEAT Teams in 2011

August 27, 2010 by  
Filed under Featured, HEAT Enforcement

(August 27, 2010): Yesterday, Attorney General Eric Holder and U. S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius conducted the second of a planned series of “Regional Health Care Fraud Prevention Summits.”  The first summit was recently conducted in Miami, Florida.  This summit was held in Los Angeles, California. 

In addition to these agency heads, summit participants learned of current and additional planned initiatives from a number of Federal and State law enforcement officials. 

Describing the progress made in the last fiscal year, Attorney General Holder noted that:

“In just the last fiscal year, we’ve won or negotiated more than $1.6 billion in judgments and settlements, returned more than $2.5 billion to the Medicare Trust Fund, opened thousands of new criminal and civil health care fraud investigations, reached an all-time high in the number of health care fraud defendants charged, and stopped numerous large-scale fraud schemes in their tracks.”

Notably, Attorney General Holder also made it clear that the government’s joint Health Care Fraud Prevention and Enforcement Action Team (HEAT) program is slated for further expansion over the next year.  As he noted:

HEAT’s impact has been recognized by President Obama, whose FY 2011 budget request includes an additional $60 million to expand our network of Strike Forces to additional cities.   With these new resources, and our continued commitment to collaboration, I have no doubt we’ll be able to extend HEAT’s record of achievement.   And this record is extraordinary.” (emphasis added).

These additional funds will be to supplement, not supplant, existing health care fraud enforcement efforts currently underway around the country.  While the additional cities slated fro HEAT expansion were not announced at this event, all CMHC providers, regardless of location, should be especially vigilant in their efforts to ensure that Medicare coding and billing practices regulating partial hospitalization services must comply with applicable statutory and agency requirements.  We strongly recommend that all CMHC providers examine both basic issues such as the “core elements” required of CMHCs, as well as their operational approach, documentation, coding and billing practices.

 Should you have questions regarding a health care fraud issue, you may call Robert W. Liles or another of our attorneys.  Call 1 (800) 475-1906 for a free consultation.

“Medical Records Retention” Issues Continue to be Important for CMHCs

August 17, 2010 by  
Filed under Compliance, Featured, Medicare Audits

(August 17, 2010): The Centers for Medicare and Medicaid Services (CMS) recently issued MLM Matters SE1022, titled Medical Record Retention and Media Formats for Medical Records” which serves as a helpful reminder regarding a number of medical records retention issues faced by Community Mental Health Centers (CMHCs) around the country.  As reflected in the guidance, MLM Matters SE1022 directly applies to health care providers (such as CMHCs) submitting claims to Medicare contractors for services provided to Medicare beneficiaries.

 While medical record retention requirements are generally governed by State law and can vary from State to State, it is important to remember that under HIPAA’s administrative simplification rules,  “covered entities” such as CMHCs,  must retain required medical records for a period of “six years from the date of its creation or the date when it last was in effect, whichever is later.”  As CMHC providers can readily attest, this requirement can be quite difficult to apply when the care as issue involve partial hospitalization program services.  For example, the supporting documentation covering partial hospitalization services provided during a specific period may relate back, and be supported by, a Psychiatric Evaluation, Physician Orders, Hospital Discharge Orders and other documents that were have been created many months prior to the specific dates at issue.  As a result, strict adherance to the six year requirement (assuming that the State retention requirements are six years are less since  HIPAA requirements preempt State laws if the State laws require a shorter medical records retention period) could make it difficult to fully support partial hospitalization claims if an audit is conducted.    Having said that, there are opposing compliance reasons to properly cull outdated medical records when possible.  Finding an acceptable balance between these goals is often difficult and should involve the advise of your legal counsel.

As MLM Matters SE1022 further notes:

 The Centers for Medicare & Medicaid Services (CMS) requires records of providers submitting cost reports to be retained in their original or legally reproduced form for a period of at least 5 years after the closure of the cost report. This requirement is available at 42 CFR 482.24[b][1].

 CMS requires Medicare managed care program providers to retain records for 10 years. This requirement is available at 42 CFR 422.504 [d][2][iii].

 Finally, the guidance points out that the Medicare program:

“. . . does not have requirements for the media formats for medical records. However, the medical record needs to be in its original form or in a legally reproduced form, which may be electronic, so that medical records may be reviewed and audited by authorized entities. Providers must have a medical record system that ensures that the record may be accessed and retrieved promptly.”

 The issue of “records retention” can be quite complex, especially when dealing with partial hospitalization claims.  This issue is further complicated if the CMHC is being audited or under investigation by the government or a Medicare contractor.  In such a situation, we typically advise clients to curtail all document (paper and electronic) destruction activities are until the external review is resolved.  In light of these considerations, it is strongly recommended that you work with your legal counsel to better ensure that your CMHC is meeting its document retention obligations. 

 Should you have questions regarding these issues, you may call your current counsel or you may call Liles Parker for a complimentary consultation at 1 (800) 475-1906.

CMS is Requiring that ZPICs and PSCs Strictly Adhere to “Signature Requirements” When the Contractors are Conducting Medical Reviews

August 5, 2010 by  
Filed under Featured, Medicare Audits

  • (August 4, 2010): The Centers for Medicare and Medicaid Services (CMS) has recently updated its “signature requirement” instructions to Medicare contractors, Change Request (CR) 6698, (including affiliated contractors such as CERT reviewers, ZPICs and PSCs) to be applied as they conduct Medicare claims audits and reviews.  

 As the guidance reflects, this issuance is intended to “clarify and update” Medicare’s Program Integrity Manual.  Importantly, this guidance is not intended to replace any existing specific requirements that may be contained in LCDs or other CMS manuals which may set out specific signature requirements (such as signature and timeliness requirements which must be made in connection with Treatment Plans or Plans of Care prepared by CMHCs when providing partial hospitalization program care).

 Several examples of the strict approach that CR 6698 requires include:

  • For medical review purposes, Medicare requires that services provided / ordered be authenticated by the author.  The method used shall be a hand written or an electronic signature.  Stamp signatures are not acceptable.

Our comments:  Despite the fact that “stamp signatures” have been problematic for years, we are still seeing cases where a provider has continued to use a stamp of his signature on orders and at the end of record entries. Get rid of signature stamps in your office or clinic!  Contractors that may be looking for an excuse to deny your claims will readily do so if your have used a stamp instead of documenting your signature by hand. 

  • If there are other reasons for denial, unrelated to signature requirements, the reviewer shall not proceed to signature authorization.  If the criteria in the relevant Medicare policy cannot be met but for a key piece of medical documentation which contains a missing or illegible assessment, the reviewer shall proceed to the signature assessment.   

 Our comments:  This requirement reinforces the fact that Medicare reviewers are required to assess the adequacy of medical documentation (and presumably of medical necessity), separate and apart from their review of the signature itself.  Once they determine that the medical documentation is otherwise acceptable for coverage purposes, then they will assess whether the signature meets applicable requirement

  • If the signature is missing from an order, ACs, MACs, PSCs, ZPICs and CERT shall disregard the order during the review of the claim.

Our comments:  This requirement can be extremely harsh, especially when considering the fact that many claims depend on an initial order by a referring or ordering physician.  If in the absence of such an order, the claim will be denied, it becomes readily apparent that providers must be especially diligent in their review of orders to ensure that each one is properly signed.

 These examples represent only a few of the many examples and changes highlighted in CR 6698.  We strongly recommend that you review these changes with each of the providers in your practice or clinic to ensure that everyone is aware of how CMS expects its contractors to proceed when conducting medical reviews. 

Should you have any questions regarding these changes, don’t hesitate to contact us.  For a complementary consultation, you may call Robert W. Liles or one of our other attorneys at 1 (800) 475-1906.