Criminal and Civil Enforcement

December 2011

December 14, 2011; U.S. Department of Justice

Three Patient Recruiters for Miami Home Health Companies Sentenced to Prison in $25 Million Health Care Fraud Scheme WASHINGTON - Two patient recruiters for a Miami health care agency were sentenced today to 18 and 12 months in prison, respectively, for their participation in a $25 million home health Medicare fraud scheme, announced the Department of Justice, the FBI and the Department of Health and Human Services.

December 14, 2011; U.S. Department of Justice

Owners of Houston Mental Health Company and Assisted Living Facility Indicted for Alleged Roles in $90 Million Medicare Fraud Scheme WASHINGTON - Two owners of a Houston mental health care company, Spectrum Care P.A., and the owner of a Houston assisted living facility were arrested today on charges related to their alleged participation in a $90 million Medicare fraud scheme, announced the Department of Justice, the Department of Health and Human Services and the FBI.

December 14, 2011; U.S. Attorney; Eastern District of Pennsylvania

Philadelphia Doctor Charged With Running Pill Mill
PHILADELPHIA - A 23-count Indictment was returned and four Informations were unsealed today charging a total of eight defendants, including Philadelphia physician Dr. Kermit B. Gosnell and members of his former staff, in a drug conspiracy case. Gosnell is charged with illegally prescribing highly-addictive painkillers and sedatives outside the usual course of professional practice and not for a legitimate medical purpose, along with related charges.

December 14, 2011; U.S. Attorney; District of Arizona News Release

Pain Management Doctor and Clinic Administrator Indicted On 130 Counts
PHOENIX- A federal grand jury in Phoenix returned a 130 count indictment against Angelo Chirban, 62, and Marilyn Chirban, 60, of Queen Creek, Arizona, for Conspiracy to Illegally Distribute Controlled Substances, Illegal Distribution of Controlled Substances, Health Care Fraud Conspiracy, Health Care Fraud, and Transactional Money Laundering.

December 12, 2011

Co-owners of Pocatello Physical Therapy, P.A. Sentenced in Federal Court
POCATELLO - The co-owners of Pocatello Physical Therapy, P.A., were sentenced in U.S. District Court today for altering records in a federal health care audit, U.S. Attorney Wendy J. Olson announced. Dan DesFosses, 65, and Colin "Ric" Benedetti, 58, both of Pocatello, appeared before U.S. District Judge Edward J. Lodge at the federal courthouse. DesFosses and Benedetti were each sentenced to three years of probation. DesFosses was fined $1,000 and ordered to pay $9,757.66 in restitution. Benedetti was ordered to pay $2,442 in restitution. Both will be required to do 300 hours of community service.

December 13, 2011; U.S. Attorney; District of New Jersey

Fourteen New Jersey Health Care Providers Arrested, Charged With Taking Cash Payments for Patient Referrals
NEWARK, N.J. - Thirteen New Jersey doctors and a nurse practitioner are charged in a cash-for tests referral scheme for allegedly taking illegal kickback payments to refer patients to an Orange, N.J., medical testing facility, New Jersey U.S. Attorney Paul J. Fishman and U.S. Department of Health and Human Services, Office of Inspector General Special Agent in Charge Tom O'Donnell announced.

Local Coverage Determinations [LCD]

Local Coverage Determination (LCD) formerly known as Local Medical Review Policies (LMRP) is defined as a decision by a fiscal intermediary (FI) or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (e.g., a determination as to whether the service or item is reasonable and necessary) - Section 522 of the Benefits Improvement and Protection Act (BIPA). Refer: http://www.cms.hhs.gov/mcd/overview.asp for more information.

CMS Local Coverage Determination for all States
http://www.cms.hhs.gov/mcd/search.asp

Similarly Commercial insurances has developed Local Coverage Determinations based on the Medical necessity and are generally known as Medical Coverage Guidelines.

Florida BCBS Medical Coverage Guidelines http://mcgs.bcbsfl.com/

Humana Medical Coverage Guidelines http://apps.humana.com/tad/tad_new/Home.aspx

Wellcare Coverage Guidelines http://www.wellcare.com/Provider/CCGs

Anthem BCBS Medical Coverage Guidelines http://www.anthem.com/wps/portal/ca/popcontent?content_path=provider/f0/s0/t0/pw_a112249.htm&label=Medical%20Policies%20and%20Clinical%20UM%20Guidelines

Anthem BCBS Anesthesia Coding and Billing Guidelines http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a050123.htm

BCBS Illinosis Medical Coverage Guidelines http://medicalpolicy.hcsc.net/medicalpolicy/disclaimer.do?corpEntCd=IL1#hlink

Aetna Medical Coverage Guidelines https://xsearch.aetna.com/searchresults.aspx

UHC Medical Coverage Guidelines https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=cdc94e74bc62c010VgnVCM100000c520720a____

Cigna Medical Coverage Guidelines http://www.cignagovernmentservices.com

Physicians United Plan (PUP) Referral and Authorization Guide http://www.pupcorp.com/PDFDocuments/RAG.pdf

BCBS Texas Reimbursement for Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) and applicable Modifiers

CPT codes 99221-99233 vs 99241 - 99255

Can we bill CPT 99221 as a replacement code for Hospital Consultations that do not met "a detailed or comprehensive history” and “a detailed or comprehensive examination”?

No you cannot report CPT 99221 since physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.

In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.

Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.

Please note: Medicare contractors have been advised to expect changes to physician billing practices accordingly. Contractors will not find fault with providers who report subsequent hospital care codes (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected),even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.
Reference: Medicare Learning Network MM7405

Integumentary System 2012 CPT changes

Integumentary System
For CY 2012, the CPT Editorial Panel deleted 24 skin substitute codes and established a 2-tier structure with 8 new codes (CPT codes 15271 through 15278) to report the application of skin substitute grafts, which are distinguished according to the anatomic location and surface area rather than by product description. Additionally, the CPT Editorial Panel created a new add-on code (CPT code 15777) to report implantation of a biological implant for soft tissue reinforcement. The detail list and of added and deleted CPT codes are as follows.
New CPT codes

15271 Skin sub graft trnk/arm/leg (Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area)

15272 Skin sub graft t/a/l add-on (Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure))

15273 Skin sub grft t/arm/lg child

15274 Skn sub grft t/a/l child add

15275 Skin sub graft face/nk/hf/g

15276 Skin sub graft f/n/hf/g addl

15277 Skn sub grft f/n/hf/g child

15278 Skn sub grft f/n/hf/g ch add

15777 Acellular derm matrix implt

Deleted CPT codes

15170 Acell graft trunk/arms/legs

15171 Acell graft t/arm/leg add-on

15175 Acellular graft f/n/hf/g

15176 Acell graft f/n/hf/g add-on

15300 Apply skinallogrft t/arm/lg

15301 Apply sknallogrft t/a/l addl

15320 Apply skin allogrft f/n/hf/g

15321 Aply sknallogrft f/n/hfg add

15330 Aply acell alogrft t/arm/leg

15331 Aply acell grft t/a/l add-on

15335 Apply acell graft f/n/hf/g

15336 Aply acell grft f/n/hf/g add

15340 Apply cult skin substitute

15341 Apply cult skin sub add-on

15360 Apply cult derm sub t/a/l

15361 Aply cult derm sub t/a/l add

15365 Apply cult derm sub f/n/hf/g

15366 Apply cult derm f/hf/g add

15400 Apply skin xenograft t/a/l

15401 Apply skn xenogrft t/a/l add

15420 Apply skin xgraft f/n/hf/g

15421 Apply skn xgrft f/n/hf/g add

15430 Apply acellular xenograft
15431 Apply acellular xgraft add

2012 HCPCS code changes -J codes

New J codes effective for the year 2012

J0131 Acetaminophen injection

J0221 Lumizyme injection

J0257 Glassia injection

J0490 Belimumab injection

J0588 Incobotulinumtoxin

J0712 Ceftaroline fosamil inj

J0840 Crotalidae poly immune fab

J0897 Denosumab injection

J1557 Gammaplex injection

J1725 Hydroxyprogesterone caproate

J2265 Minocycline hydrochloride

J2507 Pegloticase injection

J7131 Hypertonic saline sol

J7180 Factor XIII anti-hem factor

J7183 Wilate injection

J7326 Gel-one

J7665 Mannitol for inhaler

J8561 Oral everolimus

J9043 Cabazitaxel injection

J9179 Eribulin mesylate injection

J9228 Ipilimumab injection

Deleted codes

J7130 Hypertonic saline solution

J7184 Wilate injection

Purse Optimal Efficiency Strategies 5-6

Use six workflow strategies to improve your bottom line.

Strategy No.5:
Track Denials

Don't underestimate the importance of following up on denials. They often can ve reversed on appeal; even if they cannot, they can help identify flaws in upfront processes that can be fixed to prevent further denials. Typically, there are filing deadlines associated with appeals, so you should run denial reports daily to support quick identifications and response.

Strategy No.6:

Provide Effective Cross Training

Although it is a time-intensive endeavor, cross training can bring more to your practice that just staff coverage during illnesses or vacations. When done well, cross training promotes better patient service and improves financial performance by broadening the knowledges base of every employee.

Thoroughness is the key to good cross-training program. Offering front-desk staff only a high-level view of back office operations, for instance, is not enough. Instead, solid cross training should reveal in detail how front-desk tasks affect the back-end, and vice versa. An effective program will also:

    *  Engage the most experienced individuals in the "teaching" roles

    *  Map out specific learning objectives for each staff member

    *  Occur frequently (ideally, twice per year, or more frequently in instances of high staff turnover)

    *  Allow staff members to experience both morning and afternoon shifts during training, with no
        department having more than one person cross- training at a time.

These workflow strategies require commitment and buy-in from everyone in your practice - including providers, administrators, and staff. While not always easy to implement, these strategies can enhance evenue cycle management and improve efficiency, ultimately helping your practice realize measurable financial gains.

Pursue Optimal Efficiency Strategies 3-4

Use six key workflow strategies to improve your bottom line.

Strategy No. 3:
Seek Prior Authorization

This is critical because failure to obtain proper authorization can have a drastic affect on practice income. Insurers will not pay for procedures if they correct prior authorization is not received, and most contracts restrict practices from billing the patient in these situations.

Although neccessary, keeping track of prior authorization policies is challenging. Each health plan has its own set of requirements, which can change frequently. Some Medicaid payers, for instance, request one "blanket" referral authorization before patients see certain specialists; the specialist is not required to obtain prior authorization for every procedure. Other plans are much more restrictive, approving prior authorization for specified procedures only when certain criteria and diagnoses are met.

Here are three actions you can take to help navigate the prior authorization process:

    1.  Designate someone to oversee all authorizations.
         This allows a particular individual to become knowledgeable about each payer's unique
          requirements. This person should track the authorization allowed and used for procedure codes
         and visits, and be diligent about obtaining authorizations. By gaining a more thorough underst-
         anding of payer policies, this person can better fight inappropriate authorizations denials.

    2.  Open the line of communication. Two-way communication between physicians and
         authorization staff is essential. Providers should document completely and tell staff why a
         patient is being seen, so staff can inform providers about the treatment options the patient's
         payer will accept. Providers can them make treatment decisions based on all relevant knowledge.

    3.  Leverage technology. It can be helpful to develop a spreadsheet listing the guidelines for payer
         authorizations, including which specific codes require authorization. The spreadsheet should
         explain what justifies medical necessity for each procedure, according to each payer. Using
         this tool, you can quickly decide when to submit an authorization request. Note: Some payers
         publish their pre-authorization guidelines on their website, while others require you to call and
         request these.

Strategy No.4:
Ensure Timely Charge Entry

Lagging charge entry can delay payment and hinder accounts receivable (A/R) negatively affecting your practice's bottom line. An important way to improve the timeliness of charge entry is to ensure coding staff has a solid understanding of ICD-9, ICD-10 (prior to October 2013), CPT, and HCPCS Level II codes, and modifiers. Hold meetings once or twice a month for coding staff to discuss coding- related issues and new developments to make sure everyone is up to speed on current requirements.

Educate physicians on importance of timely charge entry as well. Such education may involve explaining the consequences of delayed charge entry, and how those consequences affect physicians directly.

Once coded, claims may be run through claim scrubbers, clearinghouses applications, or other tools that verify accuracy. By ensuring a clean claim upfront, your practice can avoid costly delays and reimbursement headaches from denials down the road.

Pursue Optimal Efficiency

Use six key workflow strategies to improve your bottom line.

Successful practices provide quality patient care while achieving good revenue cycle performance. They seek to be more efficent. From the front end of the office to the back, each employee finds ways to be more productive and ensure that the revenue stream is maintained.

In such practices, revenue cycle management is not haphazard, but involves specific workflow strategies that streamline processes, enhance productivity, and bolster patient satisfaction. Let's take a closer look at six specific workflow strategies to help your practice improve overall efficiency and, ultimately, strengthen your bottom line.

Strategy No 1:

Communicate Proactively with Patients

Share information proactively with patients about what they can expect from your practice - both clinically and financially - to help avoid misunderstandings, ehance patient satisfaction, and encourage repeat business. And, have an employee make courtesy calls prior to patients' visits to explain both payment policies and expectations and to help patients become aware of their out-of-pocket costs.

This call also provides the opportunity to address any potential payment problems early on, and avoid reimbursement issues on the back end. Informed patients improve morale because back-end staff spend less time chasing down payments and talking to patients who are dissatisfied because they did not fully understand their obligations to the practice.

Strategy No 2:
Verify Eligibility Upfront

To support proactive communication, revenue cycle staff must know a patient's insurance coverage, co-pay, and other financial details. Verifying this information prior to a patient's arrival at the practice allows staff to determine upfront whether a procedure is allowable through insurance; what the fee schedule is for the procedure; and the approxmate patient responsibility. This helps avoid unwelcome surprises, minimizing practice risk and preventing physicians from providing services for which they will not be paid.

Eligibility verification can be done manually or automatically. In a manual process, assigned staff members contact insurance providers via phone or website to verify patient benefits and eligibility. An automted process, which involves verification software, requires fewer staff resources and can lead to quicker eligibility verification. Either way, verification should be done prior to the patient visit.

Use Revised ABN by Jan.1 2012

Providers (including independent laboratories), physicians, practitioners, and suppliers now have until Jan. 1 2012 to begin using revised Advanced Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131.

The orginal implementation date was Sept 1 2011 but the Centers for Medicare & Medicaid Services (CMS) extended the manditory use date to Nov. 1 2011 and then Jan. 1 2012 to give providers and suppliers more time to transistion to using the new form, and to use up stockpiles of old forms.

The revised form replaces the ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB(Form CMS-20007). The latest version of the ABN has a release date of March 2011 printed in the lower- left corner. All ABNs with a release date of March 2008 that are used on or after Jan.1 2012 will be considered invalid.

The ABN should be used in situations where Medicare payments is expected to be denied. Skilled nursing facilities (SNFs) should use the revised ABN form when services are expected to be denied under Medicare Part B only.

Download the revised ABN at www.cms.gov/BNI/02_ABN.asp, available now for immediate use.

Why OutSource Medical Billing

Medical billing is one of the fastest-growing and most dynamic sectors of the health care industry. As a medical billing company, we serve as intermediaries between physicians or other health care providers and insurance companies, be they private or government-owned. Our process involves collecting fees from insurance companies in order to compensate doctors and healthcare providers for their services. We excel at providing one of the best services in the industry, helping our clients collect from the insurance companies faster than ever before.
As a medical billing company, our role is very significant in achieving efficiency for healthcare companies. Healthcare companies outsource their physician billing requirements for various reasons like reducing the facility costs and labour costs requeried. Outsourcing medical billing can increase the revenue of the healthcare facilities to a large extent. There is a high chance of encountering losses by managing the billing process on their own. For this main reason these companies go for outsourcing the physician billing services. As leaders in the industry we also strive to achieve maximum profits for our medical insurance billing clients.
Medical billing is a function that is crucial to any medical practice and hospital, big or small. More practices have run into trouble because they neglected financial part of their practice. It used to be normal for either the doctor to handle this himself or just hire someone to come into his office and take care of this either full time or part time. But things have changed drastically over the years and it is simply not practical for a doctor or any medical practitioner to take care of the medical billing and coding himself or hire someone who is not trained for this.
It also used to be very difficult and cumbersome in the days when the entire physician billing and claims filling and processing was done manually. It was slow and prone to a lot of errors. It was also very expensive. For a small practice or hospital with a few hundred or thousand patients, it became very difficult to maintain records. It was extremely difficult and slow to store, maintain and retrieve any information. There are many medical billing companies, but we are confident that we will remain as the industry leader, providing excellent services at a reasonable price. Here at T.E.A.M Medical Billing Services LLC we do just that.
We have a number of health care providers as our clients who rely on our medical billing service process rather than handling their billing on their own. We save physicians and their practices valuable time that they can instead devote to providing better care to their patients, and their expertise ensures that the procedure is carried out correctly. This makes the process easier on the insurance companies, and enables doctors to receive their payments in a more timely fashion. Additionally, our professional processes saves patients the trouble of dealing with doctors, insurance providers or even collections agencies. Often times a doctor will have to spend countless hours trying to make light of a rejected insurance claim, or trying to get ahead of aging account receivables. We provide an essencial solution to these doctors, allowing for increased ROI and better use of the physicians time.

Contact us today
T.E.A.M Medical Billing Services LLC
24 Blue Water Court
Wendell, NC 27591

1-800-881-0563
1-800-963-1686                        http://teammedicalbilling.com