Medicine & Health articles from July 2006

Medicine & Health archives from July 2006

P4P coming for home health providers--and MedPAC throws a curveball: HHAs are ready for P4P, report to Congress says.
July 3, 2006... Patient outcomes won't be the only thing setting home health agencies' pay level under pay-for-performance, if the Medicare Payment Advisory Commission gets its way. As far back as 2003, the influential advisory body to Congress...

Physicians can look forward to higher RVUs in 2007: everything changes starting next January. Will providers be ready?(Physicians)
July 3, 2006... Physicians' payments for evaluation & management services could rise dramatically next year. The Centers for Medicare & Medicaid Services published a proposed regulation in the June 29 Federal Register that would transform physician...

9 P4P measures rate HHAs' care quality: falling short on these consensus measures will hurt HHAs' bottom lines in a big way.(Brief article)
July 3, 2006... It's only a matter of time before Medicare implements a pay-for-performance system for home health agencies, experts agree. Here are nine measures that HHAs are likely to be judged--and paid--on in P4P's early days, since the Agency for...

Suppliers wait-and-see for nebulizer payment cuts: draft policy could reduce payment for one drug by 95 percent.
July 3, 2006... Whopping Medicare payment cuts may be looming for two top nebulizer-delivered drugs--a reality that has durable medical equipment suppliers calling on Congress for help. In March, the DME Program Safeguard Contractors--charged by the...

Report and request aren't enough for consults without medical necessity: use of modifier 25 exposes that doctor knew he flouted the rules, court says.
July 3, 2006... If providers are worried about running into trouble for their consult billing, then a recent case could be an important bellwether. A False Claims Act case against a Las Vegas critical care doctor can go to trial the U.S. District Court in...

CMS comes to providers' rescue on IVIG payments: one code will increase 12 percent next year.(Centers for Medicare & Medicaid Services )(Brief article)
July 3, 2006... Physicians' payments for Part B drugs won't change much in the third quarter of 2006--except for intravenous immune globulin. The Centers for Medicare & Medicaid Services says payment amounts for all drugs, including the drugs doctors...

Health plan can downcode physician's claims, court says.(Industry Notes)(Brief article)
July 3, 2006... A health plan had the right to withhold a physician's payments to recoup past overpayments, the U.S. Court of Appeals for the Second Circuit found in a recent case (05-6096-cv). An audit found New York internal medicine doctor Clinton...

MACs replace DMERCs next month.(Brief article)
July 3, 2006... In 18 states and the District of Columbia, "DMERC" will be an acronym of the past come July 1. On that date, two durable medical equipment Medicare administrative contractors--National Heritage Insurance Company Inc. and AdminaStar...

Providers prepare for imminent audits of ED visits.
July 3, 2006... Physicians' emergency department visits could be under more scrutiny soon. A recent survey by American Hospital Directory showed that evaluation & management levels in the ED increased in the past few years. For example, 24 percent of...

CMS backs down on transmission of OASIS for RAP billing.(Brief article)
July 3, 2006... Providers that don't want to transmit OASIS data daily will have to stick with locking OASIS data to achieve timely billing. That's the message of new CMS billing instructions on the new OASIS reporting regulation. In the May 24 Open Door...

It's not an urban legend: drug makers are succumbing to price pressure.(Industry Notes)(Brief article)
July 3, 2006... The Department of Veterans Affairs and several pharmacy benefits managers have proven once again that health plans can save tons of money when they buy drugs in bulk. The VA pitted one brand-name impotence medication maker against the other in...

Appeals court slaps down state's DME limits.(Brief article)
July 3, 2006... Missouri is wrong to deny coverage of medical equipment under Medicaid, a federal appeals court says in a June 22 ruling. The decision by the 8th U.S. Circuit Court of Appeals gives new life to a lawsuit over last year's Medicaid cuts in...

It may get harder for providers to figure out whether their contractor has received their appeal request, under newly manualized changes to the Medicare appeals process.(.)(Brief article)
July 3, 2006... It may get harder for providers to figure out whether their contractor has received their appeal request, under newly manualized changes to the Medicare appeals process. CMS no longer requires intermediaries and carriers to send acknowledgement...

Two Louisiana home care workers have been arrested on charges of Medicaid fraud.(Brief article)
July 3, 2006... Two Louisiana home care workers have been arrested on charges of Medicaid fraud. New Iberia residents Christina Mitchell and Mary A. Fuslier are charged with multiple fraud counts for submitting false claims to their employer, Unlimited Home...

The owner of 1st Choice Medical Supplies and Equipment pleaded guilty May 30 to multiple charges of Medicare fraud.(.)
July 3, 2006... The owner of 1st Choice Medical Supplies and Equipment pleaded guilty May 30 to multiple charges of Medicare fraud, according to the U.S. Department of Justice. During his plea, Harold Iyalla admitted that as president of the Houston,...

CMS feels the heat as consumers fume about Part D benefit services; industry leaders want state regulators to protect consumers.(Part D)
July 10, 2006... In response to steady criticism about vendor accountability and their ineffectiveness at fielding Medicare Part D beneficiary complaints, the Centers for Medicare & Medicaid Services issued a statement outlining their procedures for getting...

New report may be the ticket to staving off Medicare cuts for home O2 therapy; cost data could drive change.(Oxygen)
July 10, 2006... A new report on home oxygen therapy costs could help oxygen suppliers breathe easier. "There is more to providing oxygen therapy than delivering a piece of equipment, and this report provides hard evidence of that," says Joseph Lewarski,...

HHAs have new doc orders option under revised ABN; providers will use new option the most, CMS says.
July 10, 2006... The new home health advance beneficiary notice may cut down on confusion in one vital area, but there's still plenty to go around. After postponing the new ABN's June 1 deadline, the Centers for Medicare & Medicaid Services now has issued...

Physicians need to brace themselves for these work RVU hits; skin debridement, hip arthroplasty may be money losers next year.(Reimbursement)(Brief article)
July 10, 2006... Work relative value units could drop more than l0 percent for some codes. Of the 709 codes which the Centers for Medicare & Medicaid Services referred to the Relative Value Update Committee for review, most either increased or stayed the...

Not all good news for RVU-E/M changes; higher-level E/M codes are biggest winners.
July 10, 2006... Not all evaluation & management codes will see a significant change in their work relative value units next year, if a new proposal goes through. The Centers for Medicare & Medicaid Services proposed to increase work RVUs for E/M codes and...

Doctors look to prevent steep cuts to oncology drugs; oncology drugs overpriced by as much as 185 percent.(Brief article)
July 10, 2006... Five commonly billed oncology drugs are at least 5 percent cheaper than the prices Medicare pays physicians for them, the HHS Office of Inspector General claims in a new survey. The OIG claims that carboplatin (J9045) is overpriced by a...

Cardiologists may have to close their in-office cath labs or scanning centers; RVU changes could mean $200,000 pay cut per cardiologist.
July 10, 2006... Cardiologists face just a 4-percent decrease in their reimbursement by 2010 due to changes to work and practice expense relative value units, the Centers for Medicare & Medicaid Services claims. But some cardiology practices could be much...

Providers ready themselves for more drastic Medicare cuts; plus: more hope for reimbursement of cancer drugs' off-label uses.
July 10, 2006... New legislation approved by the Senate Budget Committee could lead to home care cuts. The Stop Overspending Act of 2006 (S. 3521) calls for across-the-board spending cuts in Medicare if certain spending levels are reached and other mechanisms...

8th U.S. Circuit Court of Appeals.(Brief article)
July 10, 2006... Missouri is wrong to deny coverage of medical equipment under Medicaid, a federal appeals court says in a June 22 ruling. The decision by the 8th U.S. Circuit Court of Appeals gives new life to a lawsuit over last year's Medicaid cuts in...

Leonza Health Management Group Clinic.(In Other News ...)
July 10, 2006... Prosecutors accused the owners of Leonza Health Management Group Clinic of billing Medicare for injected drugs that they didn't administer, administered in smaller quantities than billed, or administered in return for kickbacks. They billed...

Ali Makki.(In Other News ...)
July 10, 2006... Dearborn, MI physician Ali Makki allegedly overbilled $500,000 for unnecessary medical tests, faked medical records in response to a Medicare audit, and provided false medical records for more than 500 green-card applicants. He allegedly gave...

Palmetto GBA.(.)(Brief article)
July 10, 2006... Providers completing an electronic National Provider Identifier application should be able to obtain their new NPI number within 10 days, expects RHHI Palmetto GBA. But "we cannot predict the amount of time it will take to obtain [an NPI]...

A federal judge dismissed doctors' class action suit against a variety of managed care insurers.(In Other News ...)
July 10, 2006... A federal judge dismissed doctors' class action suit against a variety of managed care insurers. All of the defendants except Coventry Healthcare and United HealthCare had already paid large amounts to settle the suit, which accused the...

A home health agency is heading to federal court to fight CMS for its rightful therapy reimbursement.(.)(Brief article)
July 10, 2006... A home health agency is heading to federal court to fight CMS for its rightful therapy reimbursement. As expected, the CMS Administrator overturned the Provider Reimbursement Review Board's (PRRB) favorable ruling for The Medical Team in...

Non-physician practitioners can't sign a home health plan of care.(In Other News ...)
July 10, 2006... Non-physician practitioners can't sign a home health plan of care, but they can bill for home health care plan oversight services, CMS says in Transmittal 993, dated June 23.

Lumbar artificial disk replacement with the Charite lumbar artificial disk is non-covered for Medicare patients over 60.(In Other News ...)
July 10, 2006... Lumbar artificial disk replacement with the Charite lumbar artificial disk is non-covered for Medicare patients over 60, CMS said in Transmittal 60, dated June 23.

Insurers use their clout to get providers on the EHR train: the faster providers are onboard, the faster plans will recoup their HIT investment.
July 17, 2006... Since President Bush put forth the ambitious goal of bringing health care into the computer age through universal adoption of electronic health records, the EHR and health information technology train has been gathering steam. The Department of...

Poor access to cancer care puts CMS in a tough spot: CMS called on the carpet for IVIG, oncology access problems.(Disease/Disorder overview)
July 17, 2006... The House Ways & Means Health Subcommittee tried to make the Centers for Medicare & Medicaid Services feel oncologists' pain in a July 13 hearing. In the hearing, members of Congress tore into CMS Director Herb Kuhn and other officials...

NHIN is cooking, and 600 healthcare leaders start to stir the broth: IT leaders make requirements the first stop on the long road to an NHIN.(Nationwide Health Information Network)
July 17, 2006... Ask an engineer about the challenges of building a requirements document for a company's computer network, and he or she might say it involves a lot of soul searching, research, interviews, arguments, politicking, and hashing and rehashing to...

Resident-on-resident abuse yields 3rd largest nursing home verdict in U.S. history: the facility knew of the perpetrator's past violence, plaintiff proves.(Brief article)
July 17, 2006... Corporate greed came back to haunt Summit Care Corp. on Feb. 22, 2006. On that day, a Bexar County, TX jury awarded Rosamarie Paradez $160 million for injuries her father, Tranquilino Mendoza, suffered while a resident at Comanche Trail Nursing...

Gap in the enrollees who have reduced cost-sharing with HSA/HDHPs: health plans may need to increase cost sharing for the most expensive enrollees.(HSAs)
July 17, 2006... Those out-of-pocket caps in health plans HSA/HDHPs are the main reason why beneficiary cost sharing decreased rather than increased, a new study shows. But for enrollees who are the biggest spenders, this may not be good news for the health...

Medicare opens its arms to CDHPs--how this will change the marketplace: in addition to the new MSAs, Medicare benes can now access other HSA-like plans.
July 17, 2006... Medicare is trying to keep up with the increasing consumer demand for alternative health insurance products. And the Centers for Medicare & Medicaid Services is using Medicare Advantage programs to take more flexible coverage options a step...

CMS wants more evidence to fast-track coverage determinations: plus: nursing homes need to get their NPIs early.
July 17, 2006... After the Centers for Medicare & Medicaid Services' recent announcement that it is re-thinking its national coverage determination on clinical research coverage, the agency is now revising its guidance for NCDs that demand extra patient data....

LTC facilities may need NPIs for recertification soon.(Long-term care )(Brief article)
July 17, 2006... Long-term care providers' claims won't require a National Provider Identifier until May 2007, but they may need one sooner. That was the preliminary word from federal officials speaking at the SNF/Long-Term Care Open Door Forum held June 6....

Download new OASIS manuals, CMS instructs.(Brief article)
July 17, 2006... CMS has revised its OASIS manuals in light of the new reporting regulation that took effect last month. Among other things, the new reporting regulation eliminated the seven-day lock date, although agencies still must lock or transmit their...

New guidance instructs surveyors doing annual surveys to "verify correction of current noncompliance" as they would on a revisit.(In Other News ...)
July 17, 2006... New guidance instructs surveyors doing annual surveys to "verify correction of current noncompliance" as they would on a revisit. The surveyors will use a variety of methods to determine whether a nursing facility corrected the past problem and...

Vitamin D may reduce the risk of falls and fractures in older adults, according to a study reported by researchers at the University of California at San Diego School of Medicine at the American Geriatrics Society annual meeting.(In Other News ...)
July 17, 2006... Vitamin D may reduce the risk of falls and fractures in older adults, according to a study reported by researchers at the University of California at San Diego School of Medicine at the American Geriatrics Society annual meeting. The...

Unnecessary surgery harms patients because it subjects them to needless pain and suffering, according to the Court of Appeal of California.(medical malpractice case)(Brief article)
July 17, 2006... Unnecessary surgery harms patients because it subjects them to needless pain and suffering, according to the Court of Appeal of California. In a recent medical malpractice case, Marian Tortorella sued Dr. Dan Castro, contending, among...

Lawsuit follows new Medicaid citizenship documentation rule: law could leave millions of otherwise eligible benes without health care, consumer groups charge.(Medicaid)
July 24, 2006... A federal district court judge has expedited a class-action lawsuit against the new Medicaid citizenship documentation rule, which became effective on July 1. And despite the Centers for Medicare & Medicaid Services' recent revisions to the new...

Senators, representatives fight to protect hospitals' IPPS payments: lawmakers try to stall Medicare payment changes to avoid a hasty implementation.
July 24, 2006... If hospitals are worried about how much the Centers for Medicare & Medicaid Services' proposed changes to their Medicare payment system will rock their boats, now they have a reason to breathe a (small) sigh of relief. Influential...

CMS reveals the bright side of a revamped IPPS: agency tries to set the record straight regarding its proposed rule.(Centers for Medicare & Medicaid Services' )
July 24, 2006... Hospital payments could actually increase under the Centers for Medicare & Medicaid Services' new proposed rule, despite lawmakers' anxiety about the rule's ground-shaking changes and rushed implementation dates. CMS didn't officially...

Surprising findings: uninsured don't visit EDs more often than others: immigration is not a major contributing factor to ED crowding, study reveals.(Uninsured)
July 24, 2006... Researchers have blown away one widely accepted belief about the uninsured and emergency departments. Communities with larger uninsured or immigrant populations generally have much lower rates of hospital ED use per person compared to...

Providers brace themselves for more payment system shake-ups, P4P adoption: new expenditure data could spark further payment reforms.
July 24, 2006... Although revised Part D spending projections are surprisingly $34 billion lower than the projections in President Bush's budget, estimates for Part A and Part B expenditures are considerably higher. Providers need to prepare themselves now for...

IRS scrutinizing tax-exempt hospitals, and finance committee wants real reforms: questionnaire should not be just a 'fact-gathering exercise,' Grassley warns.(Internal Revenue Service)
July 24, 2006... In May, the Internal Revenue Service began investigating tax-exempt hospitals' compliance with the community benefit standard and compensation practices. But what may be--as the IRS calls them--simple "inquiries" and not "examinations" might...

Feds will use Medicare fraud-fighting tactics for Medicaid: contractor audits, payment scrutiny ensues for providers.
July 24, 2006... At least 100 full-time Centers for Medicare & Medicaid Services staff will be collaborating with state officials to scrutinize providers' Medicaid billing practices. In an "unprecedented" effort to fight Medicaid fraud, CMS announced on...

It's official--Part D desperately needs changes: industry leaders want benefit-structure adjustments to Medicare drug benefit.
July 24, 2006... Despite recent statistics showing that many health care industry leaders believe that Part D is good for beneficiaries, even more industry leaders want to see fundamental changes in the system. Two thirds of respondents to a recent...

Hospital stays for injuries more likely among uninsured: plus: whistleblower gets more than $2.3 million in fraud settlement.(Brief article)
July 24, 2006... Despite the new statistics showing that the uninsured don't use emergency departments as much as experts previously assumed (see article on page 2), those who do visit hospitals are doing so often for injuries. Injuries accounted for 11.3...

National hospice Provider Pays Out $12.9 Million For Medicare Fraud.(Brief article)
July 24, 2006... One major hospice provider allegedly tried to pull the proverbial wool over Medicare's eyes--and now it's paying a hefty price. Dallas-based national hospice provider, Odyssey HealthCare, has paid the federal government $12.9 million to...

Organization puts up $3.5 million for new PHR program.(Brief article)
July 24, 2006... A new program is brewing to spark innovations in health information technology. The Robert Wood Johnson Foundation is kick-starting a national initiative, called Project HealthDesign, to design the "next generation" of personal health...

Medicare turns imaging services reimbursement upside-down.
July 24, 2006... A series of drastic reforms to payment for imaging services under the Medicare physician fee schedule are all underway. The changes have come about after lawmakers noticed that spending on imaging services had skyrocketed in recent years. ...

Multi-billion-dollar problem: medication errors come under the microscope; CMS thinks e-prescribing is the answer to this dangerous problem.
July 31, 2006... More than 1.5 million adverse drug events occur every year from preventable medication errors, making medication errors "surprisingly common," a new Institute of Medicine study reveals. Although the IOM discovered that data on costs...

Battle between hospitals and physicians for specialty services rages on; growing service-line competition raises self-referral concerns.
July 31, 2006... Hospitals' incomes are at stake as specialty-service lines become more and more competitive among hospitals and physicians, a new report says. As the traditional lines separating hospitals' and physicians' health care services blur and the...

Numbers of Part D complaints are 'relatively low,' CMS claims; more complaints about stand-alone PDPs than MA PDPs.
July 31, 2006... The bulk of Part D complaints are about enrollment and--surprisingly--not about customer service, new statistics from the Centers for Medicare & Medicaid Services reveal. In June, CMS received about 2.3 complaints per 1,000 Medicare benes...

Physicians urge 2007 pay hike; payments have been frozen since 2001, senators note.(Brief article)
July 31, 2006... If Congress doesn't get its act together, physicians could face another 5-percent cut to their overall Medicare reimbursement next year, warns a new letter from Senators Jon Kyl (R-AZ) and Deborah Stabenow (D-MI). And payments are set to...

Part D paying off for big pharma: drug companies are cashing in, especially on Medicaid benes who now have Medicare drug coverage.
July 31, 2006... In related Medicare Part D news, pharmaceutical companies are releasing their second quarter earnings, which show a drug-sales windfall thanks to the new drug benefit. Pfizer, Inc.'s anti-cholesterol drug Lipitor ranked as the top-selling...

Providers can fight billing revocations all the way to court: they can appeal enrollment denials to an ALJ.(Brief article)
July 31, 2006... Providers need to prepare for some changes to the appeals system soon. If a contractor revokes a provider's billing privileges or denies the provider's enrollment in Medicare, the provider can appeal that decision to an administrative law...

2-year delay possible for steep imaging cuts: new bill offers solid alternatives to payment cuts.(Brief article)
July 31, 2006... Imaging scans such as CT angiography to examine heart arteries or PET/CT exams to pinpoint a tumor location could face cuts of around 50 percent next year, the American College of Radiology warned in a July 18 hearing of the House Energy and...

Medicaid is getting an expensive makeover; two major initiatives give states a huge cash-injection from the federal government.(Medicaid)
July 31, 2006... Policymakers have a vision for the Medicaid of the future--and the money they spend on remodeling Medicaid now could pay off big down the road. Two separate initiatives from the Centers for Medicare & Medicaid Services are offering a total...

CMS experiments with transferring claims data to PHRs; My.Medicare.gov pages not 'true' PHRs, agency says.(Centers for Medicare & Medicaid Services )(Brief article)
July 31, 2006... The Centers for Medicare & Medicaid Services is spending $500,000 on testing new online consumer-oriented tools. The new project will test "the feasibility of integrating Medicare claims history information with other Internet-based...

Two major quality watchdog organizations are teaming up to make their quality information available.(Brief article)
July 31, 2006... Two major quality watchdog organizations are teaming up to make their quality information available to patients on the Internet. The Ambulatory Care Quality Alliance (AQA) and the Hospital Quality Alliance (HQA) have created a new national...

Naseem Chaudhry.(.)(Brief article)
July 31, 2006... Downers Grove, IL psychiatrist Naseem Chaudhry allegedly billed for more than 24 hours worth of services in one day, prosecutors allege. He also allegedly admitted patients to a facility where he worked as medical director to claim Medicare...

More and more physicians are going house-call only, which means they don't have to have an office, according to an article in the Naples, FL News.(.)(Brief article)
July 31, 2006... More and more physicians are going house-call only, which means they don't have to have an office, according to an article in the Naples, FL News. The May issue of the Journal of the American Medical Association said that house calls to...

Recent transmittals from CMS said that.(Centers for Medicare and Medicaid Services .)(Brief article)
July 31, 2006... * CMS has posted a list of new, revised and deleted ICD-9 diagnosis codes online on its Web site at www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp. CMS also includes a complete list of the code changes in Transmittal 990,...