A new committee has been formed by the HHS and US Attorney General that will also stand to strengthen the provisions that allow for whistle blowers to share in the recovered funds.  With the new laws going into effect, we could stand to see a higher level of lawsuits filed.

Durable medical equipment in the home has been the targeted area for fraud for many years.  If a hospital was overpaid by Medicare a few years back and did not repay the money, the could be liable, and this stands to go back a few years, so when analyzing any payments made, it may not be a bad idea to double check the number if in doubt.

Also as part of the package, the attorney general can delegate the authority to make civil investigative demands to lower level government lawyers, so less legal cost for government attorneys if it can be held at a local level in civil courts.  

In addition, there are some additional pending amendments that could or could not be added.

With scant money in the federal budget available to overhaul the way healthcare is provided and paid for in the U.S., the Obama administration and Democratic leaders in Congress would like their hands on tens of billions of Medicare and Medicaid dollars lost each year to fraud and abuse.
The government often relies on whistle-blowers and the False Claims Act to get at more complicated and subtle forms of fraud and abuse, and in healthcare allegations are often based on violations of the anti-kickback statute and the restrictions on physician self-referral known as the Stark Law. The Justice Department credits the False Claims Act with returning $14.3 billion to HHS since 1986, when Congress reinvigorated the Civil War-era statute.

Re-Enrollment has changed quite drastically from 27 months to 30 days, so something to be aware of.  Also, if a change of address or location is not made within 30 days, there’s the risk of being expelled for 2 years.  This comes at a time when many physicians are actually dropping many Medicare and Medicaid patients.  The changes must be registered with the Medicare contractor.

One large concern is the paper flow as a physician could go to work before the initial process is completed for enrollment.  The AMA is pushing to get the deadline extended for such changes to 90 days.  Practices are not holding off on purpose, it’s just that there’s some real big mountains of administrative work that pile up today.

If the contractor denies enrollment instead of rejecting there’s a 30 day window for the physician and contractor to rectify the initial errors, so this could also offer some relief.  Guidelines state that internet enrollments should be within 45 days, while 60 days is the expected time frame for those enrolling with paper.
Washington — Physician practices are anticipating major difficulties with Medicare enrollment rules that went into effect amid protests from doctors and practice managers. A wrong step by a practice could mean that it loses Medicare revenue or even gets kicked out of the program altogether.

http://www.ama-assn.org/amednews/2009/04/20/gvl10420.htm

  DME suppliers have until September 31, 2009 to complete the accreditation process to meet Medicare’s supplier and quality standards.  On average this process can take 6-7 months to complete but can take as long as 9 months.  Suppliers that have not obtained accreditation by September 30, 2009 risk having their Medicare Part B billing privileges revoked on October 1, 2009.

  Please visit the CMS website for more information or contact your DMERC Region.

http://www.cms.hhs.gov/MedicareProviderSupEnroll/

The New York Times reports the Senate has decided to investigate and has requested hearings this week to find out how a subsidiary of United Health Care is functioning.

The purpose of the investigation is to find out if consumers have been short changed with payment compensation.   In January, Andrew Cuomo, Attorney General for the state of New York,  reached a settlement with Ingenix, related to the same issues.  Out of network compensation does not cover 70 or 80% of the charges, it is 70 to 80% of the usual and customary fees.

Under the settlement, United Health Care (Ingenix)  is required to create a new data base to calculate such compensation items in the future.   Recently the American Medical Association and the California Medical Association have joined in the ranks as well to determine if the practice is widespread, as balance billing is a very large issue in California as well.

Senator Rockefeller wants a full explantion as to how the process works and is determined to see if in fact consumers have been paying more than what should have been paid, when patients have consulted with physicians or hospitals out of network.

The full story can be read at the New York Times:

http://www.nytimes.com/2009/03/31/business/31insure.html?ref=business