As Noted at the Los Angeles DOJ / HHS Health Care Fraud Summit — Data Mining is Being Used by DOJ to Target Health Care Providers
(August 31, 2010): Introduction: Last week, department heads of the U.S. Department of Justice (DOJ) and the Department of Health and Human Services (HHS), met in Los Angeles, CA and conducted the second of a planned series of “Regional Health Care Fraud Prevention Summits.” Following-up on a similar conference held in Miami, DOJ Attorney General Eric Holder HHS Secretary Kathleen Sebelius discussed a number of ongoing concerns and remedial steps that are being taken to identify, investigate and prosecute instances of Medicare fraud. In addition to these agency heads, participants learned of current and additional planned fraud enforcement initiatives from Federal ...
With ZPICs, PSCs, and RACs Fighting Most, If Not All, Extrapolation Challenges, Experienced Counsel Is Imperative if You Hope to Have the Extrapolation Invalidated
(July 20, 2010): In recent years, we have seen agents for the Centers for Medicare & Medicaid Services (CMS) increasingly rely on statistical extrapolation estimates when assessing claims overpayments. In early cases, we successfully invalidated countless extrapolations by identifying relatively basic reasons for why the calculations were inconsistent with accepted statistical principles and practices. Now, however, providers should expect for ZPICs and PSCs (and soon, RACs) to send a team of statisticians and attorneys to vigorously oppose most (if not all) hearings challenging the validity of the extrapolation calculation. Regardless of whether you are providing Partial Hospitalization, Evaluation and Management (E/M), ...
South Texas Medicare Providers. . . Watch Out! ZPICs Are In Town and They Are NOT Happy
(July 16, 2010): If there were ever any doubts that ZPICs are going to make their presence known in South Texas now that they have replaced PSCs, those doubts can be put to rest. Health Integrity LLC, the Zone 4 contractor, is proving to be an active and aggressive auditor of physician practices, physical therapy services, home health care, and other types of Medicare covered treatment in the region. Even in a nationwide environment of intensifying oversight, Medicare providers in South Texas are under particularly close scrutiny. According to a study by the Dartmouth Institute for Health Policy & Clinical Practice, ...
“Finders Keepers” May Apply in the Schoolyard But It Doesn’t Apply to Medicare Overpayments
(July 15, 2010): Since the May 2009 passage of the Fraud Enforcement and Recovery Act (FERA) and subsequent enactment of the PPACA, we’ve heard a lot about how the government looks at Medicare overpayments and how providers should handle them. Two major misconceptions seem to underlie the public response to provisions clarifying that failure to timely refund Medicare overpayments can result in False Claims Act (FCA) liability. I. Historical Overview of the “Overpayment” Issue Prior to the clarification and statutory reinforcement of the “overpayment” issue provided by PPACA, a number of providers have mistakenly believed that in the absence of ...
Don’t Take ZPICs’ or RACs’ Extrapolation Calculations at Face Value — Can Their Results Be Readily Reproduced? Don’t Fail to Address These and Other Deficiencies in the Contractor’s Actions
(July 14, 2010): Imagine a ZPIC, PSC, or RAC hands you a claims analysis rife with alleged errors, an indecipherable list of statistical formulas, and an extrapolated recovery demand that will cripple your practice or clinic. What steps should you take to analyze their work? Based on our experience, providers can and should carefully assess the contractor’s actions, use of formulas and application of the RAT-STAT program when selecting a statistical sample and extrapolating the alleged damages based on the sample pulled. Over the years, we have challenged the extrapolation of damages conducted by Medicare contractors around the country, covering ...
Are ZPICs Using “Sampling” to Maximize Medicare Overpayment Recoupments? Unfortunately, Yes. . . Here’s How We Fight Back. . .
(July 12, 2010): A ZPIC’s use of extrapolation can be a surefire way of destroying a provider’s practice. We’ve known it for years and yet the government’s passion for statistical sampling only seems to be growing. This makes it essential for providers to involve experienced counsel as soon as possible after the audit has been conducted. “Extrapolation” is the process of using statistical sampling in a review to calculate and project (extrapolate) alleged overpayments made in connection with Medicare claims. Basically, ZPICs seek out errors in an alleged “statistically relevant sample” of the provider’s Medicare claims and then calculate and apply ...
HHS-OIG Issues Its Semi-Annual Report for the First Half of Fiscal Year 2010
(July 11, 2010): As set out in HHS-OIG’s Semi-Annual Report covering the first half of Fiscal Year (FY) 2010, the agency reported that “expected recoveries” for the period would be approximately $3.1 billion (which included $667.3 million in audit receivables and $2.5 billion in investigative receivables). During this period, HHS-OIG reported exclusions of 1,935 individuals and entities from participation in Federal health care programs. The agency was also involved in 293 criminal actions against individuals and / or entities in connection with program-related criminal allegations. HHS-OIG was also involved in 164 civil actions during the period. Should you have any questions regarding ...
Texas Psychiatrist Indicted and Arrested
(July 9, 2010): On June 14, 2010 the U.S. Attorney’s Office for the Western District of Texas announced that a Federal Grand Jury had returned a 99-count indictment against a pain management physician who operated clinics in San Antonio and El Paso. The physician was charged with 21 counts of health care fraud, 20 counts of false statements relating to health care fraud matters, 21 counts of mail fraud, 16 counts of wire fraud, 4 counts of unlawful distribution of a controlled substances and 16 counts of money laundering. The indictment alleges that the physician “caused to be submitted claims ...
President Obama Appoints New Head of CMS
(July 9, 2010): On Wednesday, President Obama announced the recess appointment of Dr. Donald Berwick to be the Administrator of the Centers for Medicare and Medicaid Services (CMS). He was nominated on April 19, 2010. According to the White House’s press release, Dr. Berwick is a pediatrician, Harvard University professor, and President and Chief Executive Officer of the Institute for Healthcare Improvement. Some consider him a controversial candidate. According to Senator Pat Roberts, Dr. Berwick “plans to use rationing as a cost cutting tool to achieve the billions of dollars in cuts to Medicare called for in the health care reform ...
Look at RACs — Part III: What Should Physicians and other Medicare Providers Know about Appeals and Recoupment?
(July 2, 2010): CMS’ Recovery Audit Contractor (RAC) program is now permanent and nationwide. As we discussed in Part I of this series, while small providers were largely ignored during the demonstration program, physicians, home health, hospice, and durable medical equipment (DME) suppliers should be on the lookout for increased attention. In Part II, we discussed some ways providers can prepare for and respond to an audit request. In this Part III, we will discuss a provider’s appeal options in the event that a RAC identifies an alleged overpayment as a result of its audit. It is important to remember that ...
Medicare Audit Guidance
With ZPICs, PSCs, and RACs Fighting Most, If Not All, Extrapolation Challenges, Experienced Counsel Is Imperative if You Hope to Have the Extrapolation Invalidated(July 20, 2010): In recent years, we have seen agents for the Centers for Medicare...
South Texas Medicare Providers. . . Watch Out! ZPICs Are In Town and They Are NOT Happy(July 16, 2010): If there were ever any doubts that ZPICs are going to make their...
“Finders Keepers” May Apply in the Schoolyard But It Doesn’t Apply to Medicare Overpayments(July 15, 2010): Since the May 2009 passage of the Fraud Enforcement and Recovery...
HHS-OIG Issues Its Semi-Annual Report for the First Half of Fiscal Year 2010(July 11, 2010): As set out in HHS-OIG’s Semi-Annual Report covering the first...
President Obama Appoints New Head of CMS(July 9, 2010): On Wednesday, President Obama announced the recess appointment of...
What is Causing the Spike in Partial Hospitalization Overpayment Actions?(June 29, 2010): Are Partial Hospitalization Programs (PHPs) and Community Mental...
Read More Posts From This CategoryZPIC / PSC / RAC Audit Issues
As Noted at the Los Angeles DOJ / HHS Health Care Fraud Summit — Data Mining is Being Used by DOJ to Target Health Care Providers(August 31, 2010): Introduction: Last week, department heads of the U.S. Department...
Don’t Take ZPICs’ or RACs’ Extrapolation Calculations at Face Value — Can Their Results Be Readily Reproduced? Don’t Fail to Address These and Other Deficiencies in the Contractor’s Actions(July 14, 2010): Imagine a ZPIC, PSC, or RAC hands you a claims analysis rife with...
Are ZPICs Using “Sampling” to Maximize Medicare Overpayment Recoupments? Unfortunately, Yes. . . Here’s How We Fight Back. . .(July 12, 2010): A ZPIC’s use of extrapolation can be a surefire way of destroying...
Look at RACs — Part III: What Should Physicians and other Medicare Providers Know about Appeals and Recoupment?(July 2, 2010): CMS’ Recovery Audit Contractor (RAC) program is now permanent...
A Look at RACs — Part II: How Should Physicians and Other Providers Respond to a RAC Audit?(June 28, 2010): In Part I of this series, we reacquainted you with the design and...
Read More Posts From This CategoryHEAT
Texas Psychiatrist Indicted and Arrested(July 9, 2010): On June 14, 2010 the U.S. Attorney’s Office for the Western District of Texas announced that a Federal Grand Jury had returned a 99-count indictment against a pain management physician who operated clinics in San Antonio and El Paso. The physician was charged with 21 counts of health care fraud, 20 counts of false statements relating... [Read more of this review]
Read More Posts From This CategoryThis site sponsored by
4400 MacArthur Blvd. NW
Suite 203
Washington, DC 20007
(202) 298-8750
525 N. Sam Houston Parkway E.
Suite 415
Houston, TX 77060
(713) 432-4747
101 Stumberg St.
San Antonio, TX 78204
(210) 225-0900
www.lilesparker.com
