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In a past week’s issue of Smart Brief for Health Care Leaders, there are several issues of interest to both health care providers and patients.
1) Medicare for all has gained traction amongst patients due to the continued rise in health care costs and debt frustration for all patient demographics; and
2) Implementation of such a plan has many significant challenges. These include but are not limited to funding, claims processing, types of coverage offered etc. Will this plan be modeled after current private plans or closer to NHS plans in Europe.
As was noted in a previous column, CMS will now be annually auditing every Part C Medicare plan. A report from the Duke Margolis institute outlines a new plan to modernize the current Medicare Advantage risk adjustment calculations using EHR and patient-reported outcomes.
The third story involves CMS introducing yet another fraud investigation model. This would have CMS taking on a more active role in investigations with the contractors. CMS would assign various contractors and have more oversight in investigations.
Another interesting story appeared in Lexology in the continuing sage of skin substitute investigations. In what has been a very busy week in health care news, comes from the DOJ. In their story, “More skin in the game”, the DOJ has made no secret that they are going to pull out all the stops involving Cellular Tissue Product (CTP) fraud and abuse.
The DOJ, HHS-OIG, and CMS all independently have made announcements that they will be enforcing the LCD and/or medical necessity matters regarding the use of CTP. The unified message heard from these entities has suggested that one can mitigate their risks by adhering to the need to:
1) document more than the basics of medical necessity (read the upcoming October and November/December issues of Podiatry Management);
2) fully understand and document debridement coding;
3) have support for your skin substitute billing and acquisition cost;
4) have supportive documentation, which should accurately reflect the patient’s condition and the care provided;
5) document EHR default settings and billing controls, which are tailored to the regulations, and
6) if there are any financial incentives, your vendor and distributor relationships must be vetted by a health care attorney.
CTP have the potential to save limbs, but due to their abuse by a small segment of health care providers, they have come under intense scrutiny.
The last story comes from Becker’s ASC Review, about prison sentences resulting from fraud amounting to $1.5B in DME claims. Most of these have to do with telemarketers targeting Medicare patients, and practitioners signing orders for braces without examining the patients. Both the telemarketer and the practitioner are paid a percentage of the fraudulent paid claims.
As is often the case, the offshore companies have long left the DME market or simply resurface with a new name. As a result of these and other investigations, it has become extremely difficult to revalidate your PTAN or enroll as a new supplier. It’s the old tale of the fraudulent few making it difficult for the honest masses. Cherish your PTAN and enlist the help of a seasoned professional to re-enroll or initially enroll you as a DME provider. Be sure you educate your patients to check their EOMB as you do your monthly credit card statements for fraud.
—Paul Kesselman, DPM