Archive for June, 2011

Compliance Oversight for Healthcare Leaders and Compliance Plans

June 29, 2011 Leave a comment

In a new seven minute video presentation, OIG Inspector General Daniel Levinson and Chief Counsel Lewis Morris discuss the role of compliance and its importance to the health care industry.

By now, I think we all know that compliance with healthcare laws and regulations is good, and that noncompliance can be very bad.  There is nothing much to learn in seven minutes.  However, there is an important reminder in the video that the OIG wants providers to have effective compliance plans in place. 

Nursing homes are required by the healthcare reform law to have such plans, and  the law gives the OIG the power to require other healthcare industry groups to have compliance plans.  

It is only a matter of time before this requirement is imposed on physicians.     The OIG published guidance for physician compliance plans over 10 years ago.  That guidance is worth reading again.  Similar compliance guidance can be found at the OIG website for other kinds of healthcare providers. 

This is something that healthcare providers should not put off any longer.

CMS Issues Stark Advisory Opinion 2011-01

June 28, 2011 Leave a comment

In CMS Advisory Opinion AO-2011-01, the Centers for Medicare & Medicaid Services issued an advisory opinion permitting a group to include a covenant not to compete in its employment agreement with a physician whose recruitment to the group was funded by a local hospital. 

In its advisory opinion, CMS stated that the the physician recruitment exception to the Stark law “requires that the physician practice not impose additional practice restrictions on the recruited physician other than the conditions related to quality of care.”  However, CMS acknowledged that, in its commentary to the Phase III Stark rulemaking, it had concluded “that non-competition provisions should not be categorically prohibited from recruitment arrangements.”

In determining that this particular noncompetition covenant did not impose practice restrictions that “unreasonably restrict the [p]hysician’s ability to practice medicine in the geographic area served by the [h]ospital,” CMS looked at the following factors:

  • The time period restriction of one year was reasonable.
  • The distance requirement of 25 miles was reasonable based on the geographic area served by the hospital.
  • Even with the time period and distance restrictions, the physician would still be permitted to practice at certain hospitals both within and outside of the recruiting hospital’s geographic service area within the one year time period.
  • The hospital had certified that the noncompetition covenat complied with applicable state and local laws. 

As with all such advisory opinions, it is issued only to the requesting party and cannot be relied upon by any other individual or entity.

Nevertheless, this advisory opinion provides guidance for the first time on how CMS will analyze the language of the statute, the regualtions, and its own commentary in specific physician recruitment fact situations.

Medicare Fraud — Physical Therapy Clinic Employees

June 24, 2011 Leave a comment

The Department of Justice announced yesterday another Medicare fraud scheme.  This announcement dealt with employees of the Solstice Wellness Center in the Brooklyn-area.  

The employees pleaded guilty to paying kickbacks to Medicare beneficiaries to induce them to visit Solstice where they were to receive physicians’ services, physical therapy, and diagnostic tests that were neither actually performed nor medically necessary.   Solstice billed Medicare over $3.4 million.

Categories: Fraud and Abuse

CMS Podcasts for 2011 ICD-10 Implementation

June 22, 2011 Leave a comment

On January 12, 2011, CMS held a national provider call on “Preparing for ICD-10 Implementation in 2011.” From the audio of that event, CMS has created the following four podcasts:  

  • Welcome and ICD-10 Overview – Pat Brooks, CMS 
  • Implementation Strategies for 2011 – Sue Bowman, AHIMA 
  • Question and Answer Session, part 1 
  • Question and Answer Session, part 2 

These podcasts are now available here in the downloads section.


Categories: CMS Updates


June 21, 2011 Leave a comment

Predictive modeling once was used to help pick stocks on the rise and now is going to be used to identify Medicare cheats. 

CMS announced in a press release on June 17, 2011 that it will be using new technology to track down healthcare fraud.  CMS states in its press release that this technology is similar to tools used by credit card companies.  This is part of the White House’s continuing campaign to cut waste in the Medicare program.

You can learn more about this technology at this CMS Factsheet.

Better Care and the Bottom Line

June 20, 2011 Leave a comment

According to a survey of health leaders published in a HealthLeaders Media Intelligence Report, “Better Care and the Bottom Line” (June 2011), best practices for chronic care and evidence-based medicine are needed to overcome drivers of waste such as overutilized services and a lack of integration.

  • 52% of the survey respondents put overutilization of services in their top 3 drivers of waste in the healthcare system
  • 67% say a realistic goal for readmission rates is 1% to 3%, but only 40% have achieved that goal
  • The top three tools cited to address medical cost escalation are chronic care management, evidence-based medicine, and medical liability reform.

Healthcare providers are being presented with numerous avenues for achieving better quality and more cost effective medical care — ACOs, consolidation of practices, and affiliation with hospitals, to name just a few.  

If you would like to get a copy of the Report, click here.

Whistleblowers Have Rights, Too

June 15, 2011 Leave a comment

I just picked up this story from Outpatient Surgery

Apparently, a sheriff in Winkler County, Texas decided to punish two nurses who complained about his physician friend. The nurses had filed an anonymous complaint about a variety of questionable practices by the physician.   When the shreiff discovered who had filed the complaint, he charged the nurses with “misuse of medical information.”

The sheriff now faces jail time and a $6,000 fine.

Tampa Area Sleep Doctors Come under Federal Scrutiny

June 15, 2011 Leave a comment

In a press release yesterday, the Department of Justice announced that a complaint has been filed under the False Claims Act (“FCA”) against Bay Area Sleep Associates LLC, d/b/a SomnoMedics LLC, and its owner, Edward Kilmer, Jr. 

The complaint alleges that the defendants hired unlicensed sleep technicians to perform sleep tests at one or more of their facilities beginning in 2004 or earlier. 

The lawsuit stems from a qui tam or “whistleblower” suit filed by William Revels, a former sleep study technician employee.  The government has intervened in that suit.  If the suit is successful, Revels will receive a percentage of the government’s recovery.

One take away from all this is that health care providers cannot think that no one will find out when they do bad things.   Their employees know, and those employees, especially former ones, can be the eyes and the ears of the government.  So, people do find out, and fraudulent providers need to beware.

Categories: Fraud and Abuse
%d bloggers like this: