Free e-Newsletters

Compliance Monitor

This HTML e-mail newsletter delivers news on Medicare and Medicaid fraud and abuse, as well as recent documents and targets of the Office of Inspector General, CMS, and the Department of Justice each week. A second e-mail newsletter, Compliance Monitor Q&A, answers compliance questions from your peers.

2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 | 2005 | 2004 | 2003 | 2002 | 2001

Issue 99, December 16, 2005

• Billing issues related to teaching physicians

  Q: Residents at my facility trust that the registration insurance information recorded by the...

• Billing issues related to teaching physicians

  Q: Residents at my facility trust that the registration insurance information recorded by the...

• Evaluating business associate security

  Q: How should we evaluate business associate security?

Issue 98, December 14, 2005

• South Shore Hospital in Miami subject of OIG proposed exclusion

  The OIG has notified Miami's South Shore Hospitals and Medical Center that it is moving to exclude...

• Study: TAP, AZ settlement will cause oncologists to lose income

  A $1.1 billion Medicare fraud settlement with TAP and AstraZeneca will cause oncologists to earn...

• OIG delivers clean audit to California healthcare network

  Health Net of Woodland Hills, CA has received a clean audit from the OIG. The OIG's objective...

• Reporting compliance violations

  The following list of steps can be given to employees to help them report compliance problems.

Issue 97, December 9, 2005

• Be careful of compliance concerns related to group visits

  Q: Can you tell me how to bill for group medical visits? This issue has come up recently and any...

• Dealing with misuse of PHI

  Q: What should we do if one of our business associates or limited data set users misuses protected...

Issue 96, December 2, 2005

• Physician asks coder to change codes

  I am the ancillary coder for a small rural hospital. Several doctors have recently written orders...

• OIG saves, recovers $35.4 billion in 2005

  The OIG has nearly doubled its savings and recoveries in the past five years, according to its...

• AMA issues recommendation on foreign business associates

  Physicians must conduct due diligence with foreign vendors and include appropriate HIPAA items in...

• OIG: Colorado should repay $1.9 million

  The OIG has recommended that Colorado refund the federal government $1.9 million in light of an OIG...

• Government tipsters: They're who you least expect

  It's not easy to guess who is a potential government tipster. Disgruntled employees, competitors...

Issue 95, November 30, 2005

• Report: CMS should have better controls to account for technology spending

  CMS should have done a better job accounting for the $2.55 billion it received in technology...

• Payment council to look at inpatient costs, admissions

  There's a new proposal being considered by Medicare's payment advisory group MedPAC to measure...

• OIG: Nursing home did not follow state rules for employee background checks

  An OIG audit has determined that the Willow Ridge Center nursing home in Hatboro, PA complied with...

• Government tipsters: They're who you least expect

  It's not easy to guess who is a potential government tipster. Disgruntled employees, competitors...

Issue 94, December 2, 2005

• Physician asks coder to change codes

  Q: I am the ancillary coder for a small rural hospital. Several doctors have recently written...

Issue 93, November 23, 2005

• Home health agency agrees to repay Medicaid $7 million

  Americare Certified Special Services, Inc. (Americare), a home health agency based in Brooklyn, NY...

• Senate passes bill to establish use of information technology tools in healthcar

  Early Friday morning the Senate passed a bill to increase the use of health information technology...

• OIG completes the first in a series of FY 2003 cost report wage data

  The OIG has recommended that Day Kimball Hospital in Putnam, CT, revise its 2003 cost report to...

• Assess your facility’s risk controls

  Assessing existing risk controls is an important step in conducting a comprehensive risk...

Issue 92, November 18, 2005

• Protection offered by advisory opinions

  What legal protection is offered by a CMS advisory opinion?

• Information protection and disaster relief

  Are there limits on our ability to disclose information for disaster relief purposes?

Issue 91, November 16, 2005 - VIEW THE FULL ISSUE - VIEW THE FULL ISSUE

• Working with the media

  Facilities should have a plan in place for working with the media before a major event occurs. Have...

Issue 90, November 11, 2005

• CMS advisory opinion process

  Q: How does CMS process advisory opinion requests?

Issue 89, November 9, 2005

• Tip: Charitable donations and Stark

  The Stark regulations provide that "[b]ona fide charitable donations" made by a physician or...

• Cloning ban pending in Texas legislature

  A prohibition on human cloning is being considered in a proposed Texas state health and safety code...

• Michigan psychologist pleads guilty to healthcare fraud

  A Michigan psychologist pleaded guilty last week to filing false claims totaling $853,000...

• OIG: Home health agency must repay $63,425

  The OIG has recommended that Total Patient Care Home Health, LLC in Jacksonville, FL., repay...

Issue 88, November 4, 2005

• Order with no diagnosis code

  If an outpatient comes to the hospital for testing and the physician order does not contain a...

• Billing incident to cardiac cath supplies

  For diagnostic procedures in the cath lab, do I bundle the diagnostic supplies (e.g. diagnostic...

Issue 87, November 2, 2005

• Subpoenas issued to healthcare workers in the wake of Katrina

  Seventy-three employees of Memorial Medical Center in New Orleans have been subpoenaed in...

• Anthem Blue Cross and Blue Shield settles with doctors

  Anthem Blue Cross and Blue Shield in Kentucky and Ohio will increase reimbursements to local...

• OIG audit finds Indiana overstated available UPL payments

  The OIG has recommended that Indiana refund $3.2 million, after investigators determined that the...

• Tip: Using modifier -78 and modifier -79

  This week's tip is a clarification on modifiers -78 and -79.

Issue 86, October 28, 2005

• Billing inpatient-only procedures for an outpatient

  Our utilization management staff is being asked to change patient types based on the CMS...

• Physician must be present when monitoring HBO therapy

  Can you please clarify if there are any explicit guidelines as to who can monitor patients...

Issue 85, October 26, 2005

• Tennessee hospital agrees to $40 million settlement

  Erlanger Medical Center in Chattanooga, TN, agreed Monday to pay a $40 million settlement to end...

• Implantable microchips arouse FDA suspicions of potential privacy threats

  The Food and Drug Administration (FDA) is currently pondering the privacy implications of new...

• OIG: Reimbursements for cancer drugs exceed cost

  The OIG has concluded that physician practices specializing in hematology, hematology/oncology, and...

• Tip: Using modifier -79

  Use modifier -79 to indicate that the performance of a procedure or service by the same physician...

Issue 84, October 21, 2005

• Are we liable for an errant coding manual?

  Q. An employee at my facility has taken it upon herself to put together a coding training manual...

• What if a sanctioned doc sees only non-Medicare patients?

  Q. I heard an attorney say, "I don’t see a problem having a sanctioned physician on staff as...

Issue 83, October 19, 2005

• Settlement: Drug company to pay $704 million

  A Swiss corporation has agreed to pay $704 million to settle charges that it illegally marketed an...

• Former health center executive indicted on fraud charges

  A federal grand jury has returned an 11-count indictment against the former executive director of a...

Issue 82, October 14, 2005

• Observation status in a critical access hospital setting

  Q: We are a critical access hospital. If we have a patient in observation that is not discharged...

• OIG to North Carolina: Refund $8.2 million

  The OIG has determined that North Carolina should refund $8.2 million in federal money that was...

• Tip: Using modifier -78

  Use modifier -78 to indicate that another procedure was performed during the postoperative period...

Issue 81, October 12, 2005

• Patient advocacy organizations: Gainsharing may diminish quality of care

  Thirteen patient advocacy organizations have released a statement opposing gainsharing on grounds...

• Bill single unit of 90788 for split dose

  If a physician orders an intramuscular injection of Gentamycin (160 mg), and one of our nurses...

• Groups gather Katrina evacuees’ medical information

  A group of pharmacies and providers have compiled medical information on Hurricane Katrina evacuees...

• OIG: New York schools owe repayment of $96 million in transportation claims

  The OIG has determined that the New York City Department of Education (NYCDE) claimed $96 million...

• Tip: Using modifier -77

  Use modifier -77 to indicate that a basic procedure performed by another physician had to be...

Issue 80, October 7, 2005

• How should my facility respond to an FDA Form 483?

  Q: If FDA inspectors file a Form 483 outlining compliance observations and list problems for a...

• Should we pay thousands of dollars to ensure that our computer system records th

  Q. My facility's computer system records which administrative person scans images-such as driver's...

Issue 79, October 5, 2005

• Medicare competition begins

  Earlier this week, insurers got the government go-ahead to start pitching their new Medicare drug...

• Doc arrested in connection with power wheelchair scheme

  A Houston doctor has been arrested in connection with an alleged $10 million power wheelchair...

• The OIG will audit for fraud and abuse in the wake of Hurricane Katrina

  It's no surprise to those involved in the compliance field: The wake of Hurricane Katrina has...

• Tip: Using modifier -76

  Use modifier -76 to indicate that a procedure or service was repeated in a separate operative...

Issue 78, September 30, 2005

• What are EMTALA's follow-up care requirements?

  Under EMTALA, what are the requirements for on-call physicians to provide follow-up care?

• Can we bill for triage and admit for a patient who left before being seen?

  Q: If a nurse triages a patient in the ER setting and then takes the patient to a waiting room, but...

Issue 77, September 28, 2005 - VIEW THE FULL ISSUE

• CMS announces new demonstration project

  CMS announced that it is soliciting proposals for a demonstration project to improve quality while...

• OIG: State agency may be responsible for duplicate payments

  The Connecticut Department of Social Services may have overpaid as much as $1.8 million for home...

• Tip: Using modifier -74

  Use modifier -74 when, due to extenuating circumstances, the physician cancels a surgical or...

Issue 76, September 23, 2005

• Directory "opt-out" rules

  What should we do if we are unable to properly inform the patient of the "opt-out" of the facility...

Issue 75, September 23, 2005

• Inpatient-only procedure list

  Q: How can we better comply with the inpatient-only procedure list? I understand changes were made...

Issue 74, September 16, 2005

• Are we liable for an errant coding manual?

  Q: An employee at my facility has taken it upon herself to put together a coding training manual...

• Judge rules that those who can’t pay are still entitled to healthcare

  A Minnesota judge has ruled that patients who cannot afford to pay a Medicare copay are still...

• Chargemaster maintenance

  How often should the chargemaster (CDM) be maintained?

• Medical assistant pleads guilty to Medicaid fraud

  A former medical assistant in New Hampshire faces three months in jail after using patients&rsquo...

• OIG: Hospital failed to follow year-end claims billing rules

  The OIG found that a Maine hospital did not bill fiscal year-end claims for its inpatient...

• Tip: Using modifier -73

  Use this modifier for discontinued outpatient hospital/ambulatory surgery center (ASC) procedures...

Issue 73, September 14, 2005

• Implantable microchips arouse FDA suspicions of potential privacy threats

  The Food and Drug Administration (FDA) is currently pondering the privacy implications of new...

• CA grand jury points out hospital's security issues

  Officials from Arrowhead Regional Medical Center in Victorville, CA, are working hard to fix...

• Tip: Using modifier -52

  This modifier identifies that a service or procedure was partially reduced or eliminated at the...

Issue 72, September 9, 2005

• When is a privacy acknowledgement valid?

  Q: How long is a privacy acknowledgement valid? If the patient is admitted into a facility within...

• Prohibitions on physician ownership in a medical device company

  Q: Is there any prohibition on physician ownership in a medical device company (not a durable...

Issue 71, September 7, 2005

• Regulations relaxed in wake of hurricane

  CMS and state governments are relaxing many normal operating procedures to speed the provision of...

• Healthcare professionals and other volunteers needed

  Healthcare professionals do not need to be concerned about offering help across state lines. Normal...

• OIG recommends that CMS clarify cardiac rehab rules

  The OIG has recommended that CMS clarify national Medicare cardiac rehabilitation coverage...

• Tip: Using modifier -50

  Use modifier -50 to report bilateral procedures performed during the same session. The following...

Issue 70, September 2, 2005

• Who can bill for an x-ray when a patient requires surgery?

  Q. A patient has an x-ray done and the radiologist reads the x-ray. It is determined the patient...

• Caring for patients with acute renal failure

  How should we handle Medicare patients diagnosed with acute renal failure who no longer require...

Issue 69, August 31, 2005

• Kentucky black lung advocate convicted on fraud charges

  Ten years in prison and up to $250,000 in fines. That's the maximum punishment faced by the...

• CMS issues Stark advisory opinion

  CMS has issued an advisory opinion allowing a group of physicians to hold stock in their nonprofit...

• OIG approves the donation of a hospital office building to a medical school

  The OIG has posted an advisory opinion allowing a hospital to donate a medical office building to a...

Issue 68, August 26, 2005 - VIEW THE FULL ISSUE

• Staffing guidelines to set OR facility fees

  Q: We have encountered a couple of hospitals that bill operating room (OR) rates based on the...

Issue 67, August 24, 2005

• Jury awards widow $253M in Vioxx verdict

  A Texas jury found Friday that the painkiller Vioxx contributed to the death of Robert Ernst, and...

• Whistleblower surgeon receives $2.5 million in settlement

  The University of Illinois agreed Wednesday to pay a $2.5 million settlement to a surgeon who...

• OIG: Stent placement services received overpayments

  Medicare overpaid 15 providers a total of $35,291 for claims that did not meet requirements for...

• Tip: Using modifier -25

  Use modifier -25 for a significant, separately identifiable evaluation and management (E/M) service...

Issue 66, August 19, 2005

• Instant messaging and HIPAA

  Is instant messaging (IM) to communicate at work an acceptable practice under HIPAA?

Issue 64, August 12, 2005

• Inpatient-only procedure list

  Q: How can we better comply with the inpatient-only procedure list? I understand changes were made...

• Advice for billing inpatient admission in error

  Are any services billable when they're rendered during an admission deemed by hospital utilization...

• Cardiologist: Vioxx not responsible for man's death

  A cardiologist who testified for Vioxx Manufacturer Merck & Co. last week said that the painkiller...

• Tip: Review controls for drug storage, counting, and safekeeping

  Follow these five steps to review controls for drug storage, counting, and safekeeping.

• The OIG posts new enforcement actions

  Fraud, kickbacks and theft. Those were crimes at the center of three enforcement actions handed...

Issue 63, August 10, 2005

• SEC questions judge in Scrushy's criminal trial

  The Securities and Exchange Commission [SEC] is questioning key rulings by the judge in the...

• CMS: Electronic claims must meet HIPAA standards

  Healthcare providers must meet yet another aspect of the Health Insurance Portability and...

• Report: How to reopen former hospitals to treat Hurricane Katrina survivors

  The U.S. Department of Health and Human Services has released information on how public health...

• OIG: CMS must strengthen citizenship verification controls

  States should do more to verify Medicaid recipients are actually United States citizens, according...

• Tip: Tackle your facility's security risk

  Protect patients and staff by assessing your organization's security risks and determining the...

Issue 62, August 5, 2005

• Paying plastic surgeons $900 to be on call

  Q: Our four plastic surgeons are in one group and have said that they will resign from staff if we...

• Defining economic credentialing

  How would you define economic credentialing?

Issue 61, August 3, 2005

• President Bush approves medical errors database

  President George W. Bush signed a bill Friday that will create a database for healthcare providers...

• Arizona nursing board: Check for impostor nurses

  The Arizona State Board of Nursing is urging providers to be vigilant when screening job candidates...

• Proposed changes would reduce Medicare physician fee schedule

  A proposed change to the payment rate for the Medicare physician fee schedule would reduce payment...

• Tip: Limit bad press: Prepare for unanticipated events

  The compliance risks your facility faces don't just come from government actions. Should an...

• Tip: Using modifier -27

  Use modifier -27 for multiple outpatient hospital evaluation and management (E/M) encounters on the...

Issue 59, July 27, 2005 - VIEW THE FULL ISSUE

• Hospital pays $3.6 million to settle upcoding allegations

  A California healthcare provider has paid $3.6 million to settle allegations that it routinely...

• Handling acute renal failure

  How should we handle Medicare patients diagnosed with acute renal failure who no longer require...

• CPT coding for urgent care clinics

  Q: I'm hearing several different responses to the issue about urgent care "visits" and what current...

• Discounted sports physicals for local athletes

  In our area, medical clinics that are associated with hospitals-and hospitals themselves-are giving...

• Scrushy asks court to drop civil charges

  Former HealthSouth Chief Executive Officer Richard Scrushy has asked a judge to throw out...

• Tip: Auditing the registration process

  It's helpful to conduct an audit to ensure that the registration staff in your organization...

Issue 58, July 22, 2005

• Recovering from a system breach

  What should we do if someone outside our organization hacked into our computer system?

Issue 57, July 20, 2005

• Lester Crawford approved to head FDA

  The U.S. Senate has confirmed Lester Crawford to oversee the Food and Drug Administration.

• Court: Hospitals must provide EMTALA screenings to newborns

  Newborns born in a hospital birthing center with an emergent condition are entitled to a medical...

• Medicare to up payments for outpatient services

  The Centers for Medicare & Medicaid Services (CMS) plans to provide acute care hospitals a 3.2...

• Tip: Five steps for setting up an EHR system

  When designing and implementing your electronic health records (EHR) system, follow these five...

Issue 56, July 15, 2005

• Charge diagnostic mammogram for patient with history of cancer

  When a non-symptomatic mammography patient has a previous history of breast cancer, do you charge...

Issue 55, July 13, 2005

• Scrushy memo gave prosecutors a heads up

  More than a year before former HealthSouth Chief Executive Officer Richard Scrushy's trial began, a...

• Ortquist to head Tenet corporate compliance

  Tenet Healthcare, Corp. has named Steven W. Ortquist as the company's new senior vice president...

• New database for tracking HIPAA complaints underway

  The Centers for Medicare & Medicaid Services (CMS) has announced the formation of a new system to...

• Ensure that your staff knows how to verify immigrant status

  Although CMS specifically states that a provider should not ask a patient whether he or she is an...

Issue 54, July 8, 2005

• Medical director service compensation

  Are dialysis facilities required to limit compensation for medical director services to the amount...

Issue 53, July 6, 2005

• Judge won't delay Vioxx wrongful death trial

  A judge has declined Merck & Co.'s request for a two-month delay for jury selection in the wrongful...

• HHS releases report on health information exchange

  The Department of Health and Human Services has released a report summarizing more than 500...

• Lab agrees to refund improperly billed patients

  MDS Inc, a Canadian-based company that performs medical laboratory services, has agreed to pay...

• Tip: What to do when patients won't sign an ABN

  Under Medicare's Limitations on Liability provision, providers can bill beneficiaries who refuse to...

Issue 52, July 1, 2005

• ESRD exception rates

  Q: Would you please clarify ESRD exception rates?

Issue 51, June 29, 2005

• Scrushy acquitted on all charges

  Since 2003, 15 former HealthSouth executives have pleaded guilty in a $2.7 billion healthcare fraud...

• HealthSouth devalues 2000-2001 profit statements by $1B

  As jurors deliberated for a 20th day in the $2.7 billion healthcare fraud trial of HealthSouth CEO...

• NC fraud enforcement efforts lead to substantial payback

  Stricter attention to healthcare fraud and abuse is netting record recoveries in North Carolina...

• Tip: Conduct a Stark compliance audit

  To ensure compliance with Stark (the physician self-referral law), you must be sure that your...

Issue 50, June 24, 2005

• Three-day window rule

  Q: We have an outpatient visit that starts at about 8 p.m. on the 7th and the patient does not go...

• HIPAA and FDA compliance

  Q. What activities are considered to be related to the quality, safety, or effectiveness of an...

Issue 49, June 22, 2005

• Class action suit may change view of corporate integrity agreements

  A New York-based attorney has filed a class action lawsuit against medical device maker Guidant...

• Mattress supplier targeted in $10 million fraud scheme

  The federal government on June 16 filed an information against a medical supply company accused of...

• Grand jury indicts man for allegedly posing as physician

  A federal grand jury on June 17 indicted a 51-year-old Hamden, CT, man who allegedly has been...

• Grand jury indicts man for allegedly posing as physician

  A federal grand jury on June 17 indicted a 51-year-old Hamden, CT, man who allegedly has been...

• Tip: How to apply charity-care criteria

  Because a number of factors are involved in making an appropriate charity determination, staff...

Issue 48, June 17, 2005

• Assessing physician competence

  Q: Do you have any suggestions to help medical staff evaluate physician competence?

• Discount policies for noncharity patients

  Q: I’m looking for some creative ways to administer a discount policy for patients who do not...

Issue 47, June 15, 2005

• OIG semiannual report shows savings in billions

  The OIG on June 13 announced the publication of its semiannual report, claiming savings and...

• HealthSouth settles SEC fraud charges for $100 million

  HealthSouth Corp. put an end to its latest dealings with the Securities and Exchange Commission...

• Report: Ohio Medicaid overpaid pharmacies by $69 million

  An independent study of the Ohio Medicaid program revealed that pharmacies were overpaid by $69...

• Tip: Create a strong infection control program

  An effective infection control program is a critical component of patient safety and quality care...

Issue 46, June 10, 2005

• Access to facility directories

  Q: Who is entitled to access the information in the facility directory?

• Access to facility directories

  Q: Who is entitled to access the information in the facility directory?

• ABNs and EMTALA

  Q: My question and concern is that EMTALA strictly prohibits emergency departments (ED) from...

Issue 45, June 8, 2005

• Judge orders Planned Parenthood to turn over youths’ records

  An Indiana judge ruled May 31 that the state’s Planned Parenthood program must turn over...

• Feds investigate drug company pricing fraud allegations

  In advance of a January law that will increase government spending on prescriptions under the...

• Quest Diagnostics risk-sharing contract provisions under scrutiny

  The nation’s largest supplier of medical lab tests is under investigation by the U.S. Justice...

• Tip: Color-code observation patients

  Because observation is a status, not a location, hospitals don’t need an area dedicated...

Issue 44, June 3, 2005

• Crime and disclosure

  Q: What is involved in disclosing information to report a crime in an emergency?

• Dealing with acute renal failure

  Q: How should we handle Medicare patients diagnosed with acute renal failure who no longer require...

Issue 43, June 1, 2005

• HIPAA: Good for privacy, bad for business?

  Although HIPAA is achieving its desired effect of protecting patient privacy and the security of...

• U.S. government joins suit against Caremark Rx

  The federal government has joined a lawsuit against Caremark Rx in an effort to recoup funds it...

• Louisiana man sentenced for $2 million Medicare fraud

  A Baton Rouge, LA, businessman who ran home health companies employing more than 100 people was...

• Tip: Auditing the registration process

  It’s helpful to conduct an audit to ensure that the registration staff in your organization...

Issue 42, May 27, 2005

• Waiving deductibles, copays

  Q: I have a question regarding the waiver of copays and deductibles. What is the ruling if a...

• Changes to patient status

  Q: Could you please answer a question for our facility regarding change of status of Medicare...

Issue 41, May 25, 2005

• Staten Island hospital forced to repay $76.5 million to Medicaid

  For the second time in seven years, Staten Island (NY) University Hospital has agreed to a...

• IN chiropractor named in $3 million fraud indictment

  A South Bend, IN, chiropractor was charged May 19 in a 34-count indictment that alleges healthcare...

• U.S. Justice Department helps FL suits against Tenet

  The U.S. Justice Department in a friend-of-the-court brief last week disputed Tenet Healthcare...

• Tip: How to handle donor-restricted gifts

  Sometimes donors restrict the way their grants, gifts, and endowments can be used. If your facility...

Issue 40, May 20, 2005

• OR facility fees and staffing guidelines

  Q: We have encountered a couple of hospitals that bill operating room (OR) rates based on the...

• Billing for observation

  Q. A consulting company instructed our facility that we cannot bill observation charges to Medicare...

Issue 39, May 18, 2005

• GAO report: FBI can't account for designated fraud-fighting funds

  Despite FBI statements that the agency has put an allotted $114 million into fighting healthcare...

• Brand name v. generic medications

  Q: How do I bill for a brand-name drug v. a generic drug? Do you have any suggestions for how I can...

• Bush administration earmarks $1 billion for care for illegal immigrants

  The Bush administration announced May 9 that it has approved $1 billion to pay for emergency care...

• Former NFL player pleads guilty in $1.3 million Medicaid fraud

  A former professional football player admitted last week to defrauding Medicaid of $1.3 million...

• Tip: Improving the revenue cycle starts with the front end

  Assessing your front end to identify target areas for improvement means paying close attention to...

Issue 38, May 13, 2005

• Dialysis for transient patient

  Q: We have a dialysis and acute-care Medicare provider number. Some of the charges on the...

• Accreditation and disclosure

  Q. Are the JCAHO and other accrediting agencies considered health oversight agencies such that we...

Issue 37, May 11, 2005

• Economic panel recommends tackling fraud to curb Medicaid costs

  Rather than simply slashing billions of dollars from Medicaid, a group of health policy analysts...

• Mississippi rehab providers charged with Medicare fraud

  The federal government this week charged two unaffiliated rehab clinics in Mississippi with...

• Power wheelchair supplier fires back at federal government

  Power wheelchair seller Scooter Store, Inc., has enlisted a former President Bush aide to fight...

• Tip: How to detect and prevent financial fraud

  It’s critical to stay on top of your organization’s financial statements to detect and...

Issue 36, May 6, 2005

• ED collections management

  Q: I'm looking for some examples of how hospitals manage collections in the emergency department...

• ESRD Conditions of Coverage

  Q: What were the fundamental principles that guided the development of the new ESRD Conditions of...

Issue 35, May 4, 2005

• SEC may file civil charges against Tenet

  The Securities and Exchange Commission (SEC) told Tenet Healthcare Corp. and some of its former...

• CMS proposes 2006 rate increases for inpatient stays in acute-care hospitals

  CMS announced April 25 that acute-care hospitals that submit data on 10 quality measures will...

• Carle Foundation's tax-exempt status called into question

  Most of the lawsuits filed in federal court by Richard Scruggs and other attorneys alleging...

• Tip: Review controls for drug storage, counting, and safekeeping

  Last week we discussed the steps auditors should take to ensure the effectiveness of their...

Issue 34, April 29, 2005

• Fall risk assessments

  Q: How can we get our nurses to do a risk assessment, or even to do a medication evaluation as part...

Issue 33, April 27, 2005

• Government unseals whistleblower fraud suits against Louisville firm

  The federal government unsealed three whistleblower suits against Louisville, KY-based...

• Child abuse and disclosure

  Q. Is an authorization required by anyone before we make a disclosure about child abuse?

• Battle over minors’ privacy waged in Indiana

  A fight over patient privacy and government access to medical records is playing out in an Indiana...

• Tip: Steps for a drug-purchasing audit

  An audit of the internal workings of your organization’s pharmacy will ensure that effective...

Issue 32, April 22, 2005

• White boards in the ED

  Q: Our ER manager wants to list the name and location of emergency department (ED) patients. Does a...

• Nebulizer treatment billing

  Q: If our ED nursing staff performs nebulizer treatments, may they be billed separately, or do the...

Issue 31, April 20, 2005

• FL physician faces charges linked to unnecessary cancer surgery

  A Sarasota, FL, physician was charged with $3.2 million in healthcare fraud after turning himself...

• Kaiser ordered to pay $1.9 million to settle fraud allegations

  U.S. and state attorneys general ordered three divisions of Kaiser Permanente to pay $1.9 million...

• Minnesota nurse charged in unauthorized flu shot clinic fraud

  Federal authorities have charged a Minnesota nurse with conducting illegal flu shot clinics...

• Tip: Managing uncompensated care

  Healthcare financial managers face the increasing challenge of managing not only revenue and...

Issue 30, April 15, 2005

• Dialysis and discharge

  Q: In a recent audit of our hemodialysis procedures, I discovered that almost 14% of our...

• Casting and strapping

  Q: Coders at our facility continue to struggle with the definitions of strapping and casting. Could...

Issue 29, April 13, 2005

• Nevada hospital faces suit over alleged denial of treatment

  A Las Vegas hospital is on trial this week, accused of denying medical care to an indigent man who...

• Gambro whistleblower awarded $56 million share of fraud settlement

  Steven Bander, MD, a former chief medical officer for Gambro Healthcare U.S.A., was awarded $56...

• FL doctor sentenced to four months in prison for role in fraud

  A Stuart, FL, physician was sentenced April 8 to four months in prison for his conviction on 22...

• Tip: Steps for conducting an IRB audit

  It's a good idea to conduct an audit of your organization's institutional review board (IRB) to...

Issue 28, April 8, 2005

• Deductibles and financial assistance

  Q: As chargemaster coordinator for my hospital, I calculate cash prices for patients without...

• Organized healthcare arrangements

  Q. What is an organized healthcare arrangement (OHCA)?

Issue 27, April 6, 2005

• CMS announces launch of Hospital Compare Web site

  CMS and the Hospital Quality Alliance on April 1 announced the launch of their joint Hospital...

• Federal authorities indict 10 in alleged $24 million fraud ring

  Ten people in Southern California have been indicted in a $24 million Medicare fraud case that...

• Judge declares mistrial in $4 million wheelchair fraud case

  Prosecutors are planning to retry a Houston-area physician after a judge declared a mistrial in a...

• Tip: How to use condition code 44 to change patient status

  Facilities can change a patient's status through the use of condition code 44 (inpatient admission...

Issue 26, April 1, 2005

• Guardianship of minors

  Q: We received a phone call from a five-month-old patient’s aunt. The patient’s mother...

• ESRD conditions of coverage

  Q: What sanctions might a provider face if it is not in compliance with the new Medicare end stage...

Issue 25, March 30, 2005

• PharMerica settles OIG claim for record $5.975 million

  The OIG on March 29 announced that it reached a $5.975 million settlement--its largest ever in a...

• Testimony in Scrushy trial leads auditor to sue HealthSouth

  Ernst & Young, LLP, filed suit against HealthSouth on March 18, alleging that the Birmingham...

• CMS proposes changes to take pressure off hospitals, practitioners

  CMS last week announced a proposed rule designed to alleviate hospitals of some burdensome...

• Tip: Ensure correct handling of petty cash

  An audit of a physician practice should include a review of the organization’s cash and cash...

Issue 24, March 25, 2005

• Disclosure and authorization

  Q: Do we need authorization prior to disclosing information regarding the location of a patient?

• ABNs and status indicator E

  Q: If a service is known to be noncovered because of the status indicator E-for instance CPT codes...

Issue 23, March 23, 2005

• MA physician charged in $5.4 million fraud scheme

  A Brookline, MA, physician was charged last week with mail fraud, healthcare fraud, obstruction of...

• Tennessee man sentenced to federal prison for Medicaid fraud

  A Tennessee man was sentenced on March 17 to 18 months in federal prison after pleading guilty to...

• Tip: Simple, affordable efforts make small providers HIPAA-ready

  With the HIPAA security rule deadline only a month away, you need to pick up your compliance...

Issue 22, March 18, 2005

• Document retention

  Can you help me? I’m saving all my old EOB’S, but I’m not sure how long I have to...

• Clearinghouses

  Q: What is a healthcare clearinghouse?

Issue 21, March 16, 2005

• BCBS, FBI team up to bring down alleged $1 billion fraud ring

  A collaboration involving 12 Blue Cross and Blue Shield (BCBS) plans and the Federal Bureau of...

• Dialysis chain, prospective buyer face increased federal scrutiny

  Three months after settling Medicare fraud charges with the government for $350 million, Gambro...

• Removal of CMS’s Medically Unbelievable Edits only temporary

  More than a few astute Compliance Monitor readers alerted us to the fact that the links provided in...

• Stay aware of what's next on the horizon: APC groups

  Achieving a significant reduction in clinical denials is no small feat. But Mary Johnson, RN, BS...

Issue 20, March 11, 2005

• Modifiers and medical necessity

  Q: My facility has been struggling to confirm whether -GA, -GY, and -GZ modifiers can be used on a...

• ABNs

  Are facilities required to provide ABN’s? If so, please cite the regulation.

Issue 19, March 9, 2005

• FL suit alleges Tenet took $1 billion in improper reimbursement

  The state of Florida on March 2 filed a lawsuit against Tenet Healthcare Corp. charging the...

• CMS’s Medically Unbelievable Edits lead to instant denial

  CMS announced March 1 in Medlearn Matters number 2987 that effective July 5, all Medicare...

• CMS’s Medically Unbelievable Edits lead to instant denial

  CMS announced March 1 in Medlearn Matters number 2987 that effective July 5, all Medicare...

• Cross examination takes former HealthSouth CFO to task over light sentencing

  After four days on the witness stand detailing former CEO Richard Scrushy’s alleged...

• Tip: Preparing for credentialing and privileging audits

  Conducting an audit of the medical staff office’s (MSO) credentialing and privileging...

Issue 18, March 4, 2005

• Minors requesting privacy restrictions

  Q: If a 15-year-old (or any minor) had a family planning issue that she wanted kept private from...

• Ongoing therapy

  Q: CMS regulations require patients who are receiving physical therapy to be seen by their...

Issue 17, March 2, 2005

• Power wheelchair advocates call for changes to CMS coverage proposal

  Medical equipment suppliers, Medicare beneficiaries, and clinicians on February 25 urged CMS to...

• Former HealthSouth CFO says Scrushy was aware of finances

  The prosecution in the fraud trial of former HealthSouth chief executive Richard Scrushy solidified...

• Fired whistleblower’s suit seeks millions from HP

  Robert Hindin, a former Hewlett-Packard Co. (HP) production manager and manufacturing engineer who...

• Tip: Help physicians learn to perform a medical necessity check

  Before performing a medical-necessity check, be sure physicians review test orders for all required...

Issue 16, February 25, 2005

• Modifier -52, part two

  Q: Should a -52 modifier ever be appended to G0101? Is there a source that answers this question on...

• Reporting bundled services under OPPS, part two

  Q: If a drug has a HCPCS code and it’s a bundled service, does CMS expect or require us to...

Issue 15, February 23, 2005

• DOJ: $1.8 billion negotiated in settlements in 2003

  The federal government won or negotiated more than $1.8 billion in judgments and settlements in...

• Agreement keeps Medicaid agency from having to repay $1 billion

  The Alabama Medicaid Agency settled a 15-year feud with the federal government last week and...

• Judge declares mistrial in Tenet kickback case

  A federal court judge declared a mistrial in a criminal case against Tenet Healthcare’s...

• Tip: Why are claims denied?

  An audit of your organization’s billing system will help to recoup lost dollars from claims...

Issue 14, February 18, 2005

• HIPAA and minors

  Q: What does HIPAA say about allowing parents the right to see the medical records of their minor...

• Duplicate gross charges

  Q: I represent a physician pathology group. Sometimes we bill more than one gross charge on a case...

Issue 13, February 9, 2005

• Report: HealthSouth billed Medicare for A-list entertainers

  With former chief executive officer Richard Scrushy’s trial already under way, the going got...

• CT hospital to pay more than $300,000 to settle False Claims allegations

  The United States Attorney for the District of Connecticut announced on February 14 that...

• HCCA: 91% of compliance officers don’t report to audit department

  The Health Care Compliance Association (HCCA) last week conducted a survey that asked members...

• Tip: Keep PHI safe when your employees work from home

  An employee working at home leaves her computer for a quick bathroom break. While she’s away...

Issue 12, February 9, 2005

• Modifier -52

  Q: Should a -52 modifier ever be appended to G0101? Is there a source that answers this question on...

• Reporting bundled services under OPPS

  Q: If a drug has a HCPCS code and it's a bundled service, does CMS expect or require us to report...

Issue 11, February 9, 2005

• CMS proposes new coverage criteria for wheelchairs, scooters

  The Centers for Medicare & Medicaid Services (CMS) on February 3 released draft coverage criteria...

• NIH imposes restrictions on scientists to avoid conflicts of interest

  The National Institutes of Health (NIH) on February 1 announced a plan aimed at eliminating...

• Whistleblower awarded $8.1 million from HealthSouth settlement

  An 83-year-old Reading, PA, man was awarded $8.1 million of a $325 million settlement from...

• Tip: Determining the appropriateness of admissions

  When a patient is admitted to your facility, it is important to be sure that the admission and...

Issue 10, December 21, 2005

• Mental health counselor sentenced in Medicare fraud case

  A mental health counselor was ordered to pay $52,622 in restitution and sentenced to three years of...

• Primary Exception rules

  Q: How do you handle a situation when a teaching physician does not see the patient but the...

• OIG: Connecticut hospital correctly accounted for dental residents

  John Dempsey Hospital of Farmington, CT correctly accounted for dental residents in full-time...

• Cardiac rehabilitation and stent placement

  Q: If a patient had an initial diagnosis of unstable angina before stent placement, will the...

• Peer review using a retired physicain without liability insurance

  Q: We want to use a retired physician who is on our emeritus staff for outside peer review. He does...

• Connecticut HMOs forced to release information

  Health maintenance organizations (HMOs) that oversee state-funded Medicaid plans must allow the...

• Web site gets new look; navigation improved

  As of December 15, the Hospital Quality Alliance has updated its consumer-oriented Web site for...

• OIG: Ohio must pay back $142,964

  The OIG has recommended that the Ohio Department of Job and Family Services refund Medicaid...

• AHA says government proposed rule related to electronic health records should be

  The government should expand its proposed changes to anti-kickback and physician self-referral...

• E-mail retention issues

  A lot of organizations are addressing e-mail retention now because of the documentation that HIPAA...

• Understand when an appeal is appropriate

  Knowing when and when not to appeal is the first step in the denials-management process. Following...

Issue 9, February 2, 2005

• OIG issues supplemental compliance program guidance for hospitals

  The Office of Inspector General (OIG) on January 27 announced an update to its voluntary compliance...

• MA men indicted on fraud, money laundering charges

  Four Massachusetts men were arrested and charged in federal court January 20 with fraud and money...

• Accountant testifies HealthSouth’s false data came from top level

  An accountant on January 27 testified that officials at HealthSouth’s Birmingham, AL...

• Tip: Three steps to satisfy HIPAA security

  If you neglected to consider the looming security deadline when you made your New Year’s...

Issue 8, January 27, 2005

• Cardiovascular disease screening coverage

  I have heard CMS is planning to cover cardiovascular disease screening beginning in 2005. Is that...

Issue 7, January 26, 2005

• Patients file suit over IL hospital’s billing practices

  Two former patients at Champaign, IL-based Carle Foundation Hospital filed a lawsuit against the...

• 400 cases to be reconsidered after change in sentencing guidelines

  The U.S. Supreme Court on January 24 ordered federal appeals courts to reconsider more than 400...

• HealthSouth founder’s trial begins in Birmingham

  The trial of Richard Scrushy, founder and former chief executive officer of Birmingham, AL-based...

• Tip: Hardline tactics for reducing denied claims

  The number of denied claims from Elkhart (IN) General Hospital decreased significantly in 2004 from...

Issue 6, January 20, 2005

• G codes and IV infusions and injections

  Q: There seems to be a lot of confusion regarding the new G-codes for intravenous (IV) infusions...

• HIPAA and home care

  Q: Do the HIPAA regulations apply to private duty nurses hired privately by the patient to care for...

Issue 5, January 19, 2005

• Pharmacy benefits manager claims system is compliant

  Caremark Rx, Inc., was forced to defend its product sales this week after the Chicago Tribune...

• Drug wholesaler agrees to $960 million fraud settlement

  McKesson Corp. agreed to pay $960 million to settle a class-action lawsuit filed by its...

• Johnson & Johnson recalls potentially defective stents

  Admitting it is taking a "conservative" approach, Johnson & Johnson last week voluntarily recalled...

• Tip: Auditing observation services

  Conduct an audit to ensure that your organization is properly billing and coding observation...

Issue 4, January 13, 2005

• Debarment lists, employees, and contractors

  Q: We are a continuing care-community. We check the Office of Inspector General (OIG) and General...

• Self auditing and conflict of interest

  Q: Our auditors must code charts due to a coding staff shortage. One of our auditors has the...

Issue 3, January 11, 2005

• Seattle doctor sent to prison for false claims

  A Seattle physician was sentenced January 7 to one year in prison and ordered to pay $1 million for...

• Pharmaceutical manufacturer adds $1.275 billion to settlement fund

  Wyeth Pharmaceuticals lent its support this week to an additional settlement fund designed to...

• Settlement stirs up financial trouble for Tenet Healthcare

  A $395 million lawsuit settlement entered by Tenet Healthcare Corp. has created further financial...

• Tip: Joint effort by HIM and the business office helps manage the revenue cycle

  Teaming with health information management (HIM) can help you measure and track your revenue cycle...

Issue 1, January 5, 2005

• U.S. Attorney indicts five in pharmaceutical sample misuse

  Three pharmacists and two physicians in Pennsylvania were charged December 27 with illegally...

• HealthSouth settles government fraud charges for $325 million

  Embroiled in controversy, Birmingham, AL-based HealthSouth agreed on December 30 to pay the U.S...

• Pay-per-view article: Q&A: Tips for security rule readiness

  With the HIPAA security rule deadline drawing near, it's time to make sure everything is working as...

• Massachusetts physician to pay $100,000 Medicare fraud settlement

  A Braintree, MA, physician agreed to pay $100,000 to the United States government last week to...

• Tip: Take these 10 steps to check outpatient cardiac rehab billing compliance

  Make sure that all outpatient cardiac rehabilitation (OCR) services that your hospital provides...

Issue 40, October 4, 2005

• Auditing graduate medical education

  This week, we'll wrap up our discussion of steps for auditing graduate medical education (GME...

Issue 2, January 7, 2005

• HIPAA security response procedures

  Q: How do I know whether my security incident-response procedures will work?

• Pay-per-view article: Coding audits: Review priorities, validate findings

  The government wants you to do more than go through the motions of a compliance program. Your goal...

• Three-day stay

  Q: If a patient goes to the emergency room at 22:00 hours and is admitted at 23:50 hours, does the...

• Quick survey: When did you last update your compliance training program?

  When did you last update your compliance training program?