1. Beneficiary Bulletin Issued
In August, the Medicare/Medicaid Office of Inspector General published an Advisory Opinion entitled “Offering Gifts and Other Inducements to Beneficiaries.” This provision, enacted under HIPAA, establishes a $10,000 fine for those who offer or transfer to a Medicare or Medicaid beneficiary any remuneration that is likely to influence the beneficiary’s selection of a particular provider. The statute defines “remuneration” to include waivers of copayments and deductible amounts (or any part thereof) as well as the offering of free or discounted services. The statute contains five exceptions including non-routine, unadvertised waivers of copayments or deductible amounts based on individualized determinations of financial need or exhaustion of reasonable collection efforts.
The Hospital through its Emergency, Admitting, Access Services, Ambulatory Registration, Ambulatory Practices, Community Health Centers and Patient Accounts Departments obtains, records and verifies demographic and financial information including sources of payment from patients. Patients who do not have health insurance or whose insurance provides less than adequate coverage will be requested by the hospital to provide additional financial information and counseled regarding eligibility for public assistance funding or free care.
2. Medicare Office of Inspector General (OIG) Issues Workplan
The OIG issued their 2003 workplan in September. The workplan is an outline of various projects to be addressed by the agency during the fiscal year and once again includes several projects related to “Medicare Physicians and
Other Health Professionals” as follows:
1 Consultations: OIG will look to determine the appropriateness of billings for physician consultation services ($2 billion in 2000) and the financial impact of inaccurate billings on the Medicare program (e.g. billing consultation codes when documentation does not include evidence of a request for advice or opinion; need for review of the identified problem and report back to the requestor).
2 Coding of Evaluation and Management Services:
OIG will examine whether physicians accurately coded evaluation and management services, for which Medicare paid over $17 billion in 2001 (e.g. coding Evaluation and Management visits at higher levels than the documentation supports based on 1995 or 1997 guidelines).
3 Medicare Payments to Nonphysician Practitioners:
OIG will analyze trends in non-physician practitioners’ (including nurse practitioners, clinical nurse specialists, and physician assistants) billings, proportion of complex procedures that they perform, and assess whether they have billed for procedures not covered by their scopes of practice. OIG noted a fourfold increase in nonphysician practitioner services.
If you have questions relative to these or other compliance concerns, please contact Neil Walsh at 617-732-9377.