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Your words will carry more weight when you approach doctors in a thoughtful, respectful way. In the coding and auditing world, the provider is in the driver’s seat. Generally, the provider documents the services rendered and is ultimately responsible for the accuracy of claims submitted under their name. Most providers recognize, however, that coding and […]
The post 10 Tips to Improve Provider Trust appeared first on AAPC Knowledge Center.
Tallahassee Health Care Provider Arrested for Medicaid Fraud
A Tallahassee health care provider has been arrested for billing the Florida Medicaid Program around $ 50,000 for fraudulent medical services, according to Florida Attorney General Ashley Moody.
Rodney Burt, 57, was arrested Friday on Medicaid fraud charges after he billed the state’s Medicaid program for phony services from May 2016 to November 2019, the press release said.
“That is why my Medicaid Fraud Control Unit attorneys and investigators aggressively chase down leads and uncover abuses in this taxpayer funded health care program to ensure those who would aim to rip off taxpayers are stopped and brought to justice.”
The investigation revealed he was assigning inaccurate billing codes to claims he submitted to the Florida Medicaid Program to increase reimbursements, which fraud investigators call “upcoding.” Burt’s charge of Medicaid provider fraud of $ 50,000 or more is a first-degree felony.
The post Tallahassee Health Care Provider Arrested for Medicaid Fraud appeared first on The Coding Network.
Does new ‘lost revenues’ clarification help or hurt agencies? On Dec. 16, 2020, the Department of Health and Human Services (HHS) announced that it added $ 4.5 billion to the Provider Relief Fund’s (PRF) phase 3 distribution to mitigate the impact of COVID-19 on healthcare providers. “HHS is providing more than $ 24 billion in new relief […]
The post More Provider Relief Fund Money for Home Health appeared first on AAPC Knowledge Center.
When to report a provider to the OIG.
The post When Do I Report a Provider to the OIG? appeared first on AAPC Knowledge Center.
Billions more available to beleaguered providers. Add-on payments are available for healthcare providers “on the frontlines” of the coronavirus (COVID-19) pandemic. The Department of Health and Human Services (HHS) announced Oct. 1 an additional $ 20 billion under a Phase 3 General Distribution allocation of the Provider Relief Fund (PRF). Who Qualifies for Add-On Payments? The […]
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There’s no excuse for not keeping careful records of your healthcare-related expenses attributable to the novel coronavirus (COVID-19) now. The U.S. Department of Health and Human Services (HHS) has clarified what those are. Hazy Requirements Leave Providers Wanting In accepting CARES Act Provider Relief Fund money, HHS initially said that providers must agree to terms […]
The post Provider Relief Fund Facts Clarified appeared first on AAPC Knowledge Center.
The Centers for Medicare & Medicaid Services (CMS) has announced that its scaling back on some restrictions surrounding provider enrollment in the wake of the COVID-19 outbreak. Under Section 1135 of the Social Security Act, CMS is exercising its waiver authority for physicians and non-physician practitioners (NPPs) to help expedite the enrollment process. Call for […]
The post CMS Loosens Provider Enrollment Restrictions appeared first on AAPC Knowledge Center.
While there has been more than a $ 5.3 billion decrease in estimated improper payments for home health services over the past three years, the projected improper payment amount for home health services during the 2018 report period was $ 3.2 billion. This translates to a Medicare Fee-For-Service (FFS) improper payment rate of 17.6 percent, accounting for […]
The post Provider Compliance Tips for Home Health Services appeared first on AAPC Knowledge Center.
On November 19, 2018, Southern Connecticut Vascular Center, LLC (SCVC), Stratford, Connecticut, entered into a $ 792,076.76 settlement agreement with OIG. The settlement agreement resolves allegations that SCVC submitted claims for Healthcare Common Procedure Coding System (HCPCS) code 96965 when those claims were for a procedure that was already included as a component of the duplex ultrasound procedures for which SCVS submitted claims using HCPCS codes 93970 or 93971 for the same beneficiary on the same dates of service. The OIG further contends that the submission of claims for HCPCS code 93965 were for a procedure that should not have been separately billed and was not medically necessary. Senior Counsels Geoffrey Hymans and Joan Matlack, with the assistance of Program Analyst Mariel Filtz, represented OIG.
The post Connecticut Diagnostic Services Provider Settles Case Involving False Claims appeared first on The Coding Network.
Sutter Health LLC, a California-based healthcare services provider, and several affiliated entities, Sutter East Bay Medical Foundation, Sutter Pacific Medical Foundation, Sutter Gould Medical Foundation, and Sutter Medical Foundation, have agreed to pay $ 30 million to resolve allegations that the affiliated entities submitted inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans, which resulted in the plans and providers being overpaid, the Justice Department announced today. Sutter Health is headquartered in Sacramento, California.
“The Medicare Advantage Program provides benefits to a significant portion of federal health care beneficiaries,” said Assistant Attorney General Jody Hunt of the Department of Justice’s Civil Division. “The Department of Justice will help ensure that accurate information is supplied to the Medicare Advantage Program by plans and providers, and to pursue appropriate remedies when it is not.”
Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed healthcare insurance plans called Medicare Advantage Plans (“MA Plans”) that are owned and operated by private Medicare Advantage Organizations (“MAOs”). MA Plans are paid a capitated, or per-person, amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans. The Centers for Medicare and Medicaid Services (“CMS”), which oversees the Medicare program, adjusts the payments to MA Plans based on demographic information and the health status of each plan beneficiary. The adjustments are commonly referred to as “risk scores.” In general, a beneficiary with more severe diagnoses will have a higher risk score, and CMS will make a larger risk-adjusted payment to the MA Plan for that beneficiary.
Sutter Health, a non-profit public benefit corporation that provides healthcare services through its affiliates, including hospitals and medical foundations, contracted with certain MAOs to provide healthcare services to California beneficiaries enrolled in the MAOs’ MA Plans. In exchange, Sutter received a share of the payments that the MAOs received from CMS for the beneficiaries under Sutter’s care.
Sutter submitted diagnoses to the MAOs for the MA Plan enrollees that they treated. The MAOs, in turn, submitted the diagnosis codes to CMS from the beneficiaries’ medical encounters, such as office visits and hospital stays. The diagnosis codes were used in CMS’ calculation of a risk score for each beneficiary.
The settlement announced today resolves allegations that Sutter and its affiliates submitted unsupported diagnosis codes for certain patient encounters of beneficiaries under their care. These unsupported diagnosis scores inflated the risk scores of these beneficiaries, resulting in the MAO plans being overpaid.
Earlier this month, the government filed a complaint against Sutter and a separate affiliated entity, Palo Alto Medical Foundation, alleging that they violated the False Claims Act by knowingly submitting unsupported diagnosis scores. That case is captioned United States ex rel. Ormsby v. Sutter Health, et al., Case No. 15-CV-01062-JD (N.D. Cal.), and is still ongoing.
“Misrepresenting patients’ risk results in higher payments and wasted Medicare funds,” said Steven J. Ryan, Special Agent in Charge with the Office of Inspector General for the U.S. Department of Health and Human Services. “With some one-third of people in Medicare now enrolled in managed care Advantage plans, large health systems such as Sutter can expect a thorough investigation of claimed enrollees’ health status.”
The settlement was the result of a coordinated effort by the Civil Division’s Commercial Litigation Branch, the United States Attorney’s Office for the Northern District of California, and HHS-OIG.
The claims resolved by the settlement are allegations only, and there has been no determination of liability.
Topic(s):
False Claims Act
Component(s):
Press Release Number:
19-379
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