March 02, 2023
As mentioned in a previous article, an individual or entity can be excluded from participating in Federal health care programs for a variety of reasons. The individual/entity will receive notification from the OIG indicating the period of time for which they are going to be excluded.
In January 2023, the Office of the Inspector General (OIG) collected over half-a-million dollars in Civil Monetary Penalties (CMP) from three health care organizations that employed individuals who were excluded from participating in any Federal health care program.
On January 24, 2023, CMS conducted its quarterly stakeholder call and reviewed 2022 successes and provided a high-level overview of their 2023 plans and initiatives. CMS Strategic Pillars (see infographic) were highlighted by each CMS leader who discussed their area of responsibility.
On February 9, 2023, the Department of Health and Human Services (HHS) released a Fact Sheet providing a Public Health Emergency (PHE) Transition Roadmap. DHHS Secretary Xavier Becerra confirmed that the PHE would end on May 11, 2023. Below are a few items from the Fact Sheet. Access this link to view the Fact Sheet in entirety: https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html
On Monday, January 30, 2023, President Joe Biden announced that the public health emergency (PHE) will end on May 11, 2023. There will be many changes as a result of the PHE ending. One in particular will be the delivery, coding and billing of telehealth services. CMS had expanded telehealth benefits temporarily during the PHE through the Corona Virus Waiver 1135. There is a 151-day transition period, after the end of the PHE, for the required changes to take place.
The need for access to additional behavioral health services is a known issue. Tele-behavioral health has become one of the go-to solutions in responding to the access issue. Recently, the parent company of Harvard Pilgrim Health Care and Tufts Health Plan, Point32Health, announced a partnership with Valera Health to provide increased access to their patients. “Valera Health provides adult and pediatric behavioral health patients access to therapists and psychiatrists through telehealth. The organization covers 37 million Americans through partnerships with more than 20 health plans, including Medicaid, Medicare, and commercial plans across several states.”
The government continues to actively enforce the False Claims Act [31 U.S.C. §§ 3729-3733] (FCA) which states that “it is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.” Examples of this include filing claims that are not medically necessary, billing for services not rendered, billing for a service at a higher level than actually performed (upcoding), etc.
St. Luke’s Health reported a data breach involving almost 17,000 patients, as a result of a hack into a third-party vendor’s email system. Two employees of the vendor had their email accounts hacked which lead to the breach of personally identifiable information, diagnoses, and other elements of PHI.
It is vital to ensure that third-party vendors who have access to your PHI/PII are fully vetted from a HIPAA Security & Privacy perspective.
It is critical for providers to keep strict control of their prescription pads and access into e-prescribing.
An office manager in Chicago, IL has been sentenced to federal prison for writing over 3,000 fraudulent opioid prescriptions for individuals who were not patients of the provider. She and her co-conspirator used family and friends, who were not patients nor in need of opioid medications, to take the fraudulent prescriptions to the pharmacy to get filled and then return the drugs to them. Some of these drugs were later sold throughout Chicago, for profit.
ONC Health IT Certification Program Updates *Important Deadline Coming Up: December 31, 2022 The Promoting Interoperability Program started in 2011 with requiring certain clinical data be captured electronically, which including providing functionality so that patients could receive electronic copies of their health records (Stage 1). In Stage 2, there was a requirement to provide Meaningful…
- CMS Responding to Data Breach at Contractor
- Martin’s Point Health Care Inc. to Pay $22,485,000 to Resolve False Claims Act Allegations
- Lansing-Area Health System Agrees To Pay $671,300 To Settle False Claims Act Allegations Relating To Improper Billing
- Primary Care Physicians settle false claims allegations for unsupported diagnoses to Medicare Advantage Program
- Senate Subcommittee Hearing – Medicare Advantage Denials and Delays of Care