CMS/Medicare

38 Lawmakers Push CMS on Hospice Integrity

mherndon — Thu, 09 May 2024 14:19:04 +0000

38 Lawmakers Push CMS on Hospice Integrity

WASHINGTON—On Wednesday, May 8, Congressman Earl Blumenauer (D-OR) and Congresswoman Beth Van Duyne (R-TX) led a bipartisan group of 38 lawmakers demanding answers from Centers for Medicare & Medicaid Services (CMS) on the implementation of recent reforms aimed at combatting hospice fraud and abuse.

“When electing to receive hospice care, individuals and their families must be confident the provider is committed to delivering individualized, compassionate care that optimizes quality of life; however, we continue to hear about instances of pervasive fraud and abuse,” the lawmakers wrote.

“CMS has taken positive steps to increase its oversight of hospice programs … However, we are deeply concerned by new reports indicating many potentially fraudulent hospices are continuing to bill Medicare and CMS is still enrolling suspicious new providers into the program,” they continued.

To better understand the steps CMS has taken to increase program integrity, the lawmakers continued the letter with detailed questions on the implementation of reforms. Read the full letter here.

“Thank you, Representatives Blumenauer and Van Duyne, for your leadership in holding CMS accountable and safeguarding hospice patients and families from fraudulent activities,” said Ben Marcantonio, interim CEO of the National Hospice and Palliative Care Organization. “Preserving the integrity of the Medicare Hospice Benefit is paramount to ensure high-quality care for Americans with serious illness and end-of-life care needs.”

The letter follows multiple congressional inquiries led by Blumenauer and Van Duyne in 2023 urging CMS to address program integrity within the hospice benefit.

mherndon Thu, 05/09/2024 - 09:19

The bipartisan group demanded answers from CMS on the implementation of recent reforms aimed at combatting hospice fraud & abuse

CMS/Medicare

CMS

House Ways and Means Committee

National Hospice and Palliative Care Organization (NHPCO)

Lexington Doctor Sentenced for Kickback Conspiracy

mherndon — Thu, 09 May 2024 14:13:51 +0000

Lexington Doctor Sentenced for Kickback Conspiracy

LEXINGTON, Kentucky—A Lexington doctor, Amr Mohamed, 55, was sentenced by U.S. District Judge Karen Caldwell to two years in prison for a kickback conspiracy.

Mohamed was a licensed physician with a specialty in nephrology practicing in Lexington and working for various telemedicine companies that arranged for physicians to prescribe a variety of medical equipment, topical creams and genetic testing for Medicare beneficiaries. According to his plea agreement, from March 2018 and April 2019, Mohamed entered into an agreement with RediDoc, to provide the telehealth services, and to order medically unnecessary medical equipment, topical creams and genetic testing, for which he received $20, on average, per beneficiary from RediDoc. The orders were unnecessary because Mohamed did not have a physician-patient relationship with the beneficiaries, did not use the results of the testing in his treatment, and because he was receiving a kickback for each beneficiary.

Between March 2018 and April 2019, Mohamed received $261,054 in kickbacks from RediDoc for ordering unnecessary medical equipment and services for more than seven thousand Medicare beneficiaries, and caused Medicare to pay $14,150,764.60 for medically unnecessary items. Mohamed was also ordered to pay $14,150,764.60 in restitution.

Under federal law, Mohamed must serve 85% of his prison sentence. Upon his release from prison, he will be under the supervision of the U.S. Probation Office for three years.

mherndon Thu, 05/09/2024 - 09:13

Mohamed was also ordered to pay $14,150,764.60 in restitution

CMS/Medicare

Anti-Kickback Statute

Medicare fraud

CMS Proposes New Intermittent Catheter HCPCS Codes

mherndon — Tue, 07 May 2024 14:56:52 +0000

CMS Proposes New Intermittent Catheter HCPCS Codes

WASHINGTON—Last week, the Centers for Medicare & Medicaid Services (CMS) released the 2024 Bi-Annual HCPCS Public Meeting Agenda for May 28-30. The first topic listed in the May 28 Agenda is CMS’s proposal to expand the HCPCS codes list for intermittent catheters (ICs). The request was submitted by the American Association for Homecare (AAHomecare) based on the analysis and review by the Intermittent Catheter Coding Reform Coalition (ICCRC), a coalition of IC manufacturers.

CMS proposes to modify the current three IC HCPCS codes to six HCPCS codes—establishing five new IC codes to distinguish the coating types and discontinuing existing codes that do not distinguish coating types, A4351 and A4352. CMS will maintain A4353 as is. CMS also plans to maintain pricing continuity as per regulatory requirements when implementing the new codes. This would entail mapping previous fee schedule amounts for discontinued codes to the new ones to ensure consistent pricing.

Pending further feedback and final determination, CMS anticipates the proposed changes to take effect on Jan. 1, 2026. The ICCRC said it is pleased that CMS has established new HCPCS codes for intermittent catheters, recognizing hydrophilic features separately from other catchers. AAHomecare, in collaboration with ICCRC, will be commenting on the proposed changes.

You can find the proposal on pages 3-8 of the May 28th HCPCS Public Meeting Agenda.

mherndon Tue, 05/07/2024 - 09:56

CMS proposes to modify the current three IC HCPCS codes to six HCPCS codes—establishing five new IC codes

CMS/Medicare

intermittent cathertization

AAHomecare

ICCRC

HCPCS Code

Leader Of $50 Million Health Care Fraud Pleads Guilty

mherndon — Fri, 03 May 2024 13:28:06 +0000

Leader Of $50 Million Health Care Fraud Pleads Guilty

NEW YORK—Damian Williams, the United States Attorney for the Southern District of New York, announced that Manishkumar Patel pled guilty in connection with a $50 million health care fraud and kickback scheme involving the sale of fraudulent prescriptions for durable medical equipment (DME), among other medical supplies, to suppliers, pharmacies and laboratories who obtained payment for those fraudulent prescriptions from Medicare. Patel pled guilty before U.S. Magistrate Judge Ona T. Wang and is scheduled to be sentenced on July 26, 2024, at 10 a.m. before U.S. District Judge Lorna Schofield.

“Behind every dollar siphoned through fraud lies a patient denied rightful care. Manishkumar Patel cost Medicare nearly $50 million in resources that could have been used to provide genuine care to those in need," said U.S. Attorney Damian Williams. "His guilty plea today is a step toward restoring integrity and trust in our health care system.”

Patel, 44, of Pelham Manor, New York, pled guilty to one count of conspiracy to commit health care fraud, one count of wire fraud, and one count of violating the Anti-Kickback Statute, each of which carries a maximum sentence of five years in prison. In addition, Patel was ordered to pay $48,150,692.49 in restitution to the U.S. Centers for Medicare and Medicaid Services and forfeit $6,839,900.

Between 2019 and 2022, Patel and a co-conspirator (CC-1) fraudulently sold prescriptions and doctors’ orders for DME, pharmaceuticals and laboratory tests (collectively, “scripts”) to DME suppliers, pharmacies and laboratories (collectively, the “Medicare providers”).

Patel obtained the scripts from call centers that called Medicare beneficiaries and asked them perfunctory questions designed to justify a script that would be reimbursed by Medicare. Patel turned the information from those calls into scripts by arranging cursory telemedicine appointments with the beneficiaries—a practice called “doctor chasing,” in which the information was sent to a doctor who signed the script without seeing the patient and who was frequently unaware of what they were signing—and obtaining forged scripts. Patel then sold the scripts to Medicare providers, which filled the orders and billed Medicare.

Because the scripts were fraudulently obtained, many beneficiaries rejected the items they were sent by the Medicare Providers, many doctors threatened to report Patel for fraud, and Medicare frequently refused to pay for the scripts.

The Medicare providers made payments to Patel for the scripts in violation of the Anti-Kickback Statue. Patel and the Medicare providers entered into sham contracts for generic marketing services at flat rates in an attempt to conceal their illegal kickback scheme.

Patel was a leader of the scheme, which resulted in losses to Medicare of nearly $50 million.

mherndon Fri, 05/03/2024 - 08:28

Patel was a leader of a scheme which resulted in losses to Medicare of nearly $50 million.

CMS/Medicare

anti-fraud

Anti-Kickback Statute

Medicare fraud

HHS Surveys CGM Suppliers on Acquisition Costs & Prices

mherndon — Tue, 30 Apr 2024 13:51:41 +0000

HHS Surveys CGM Suppliers on Acquisition Costs & Prices

The American Association for Homecare (AAHomecare) reported that last week, the HHS Office of Inspector General (OIG) began sending emails and letters to a select group of continuous glucose monitor (CGM) suppliers as part of an evaluation for its study "Medicare Payments Compared to the Prices Available to Consumers and Suppliers for Continuous Glucose Monitors and Sensors." This study aims to determine the cost-effectiveness of Medicare payments in comparison to the supplier’s acquisition costs and other prices available to consumers.

The OIG's request for information on acquisition costs by suppliers will identify potential areas where Medicare can optimize savings. In the announcement of the report originally posted in the OIG’s Work Plan in November 2023, the OIG noted CMS allowed more than $1.1 billion in Medicare Part B payments for CGMs and sensors in 2022. If the OIG identifies opportunities for Medicare to realize cost savings, CMS has the authority to either introduce CGMs into the competitive bidding program or exercise their authority of inherent reasonableness to adjust Medicare payments accordingly, AAHomecare said.

CGM suppliers who are recipients of the OIG requests have likely been notified via email. AAHomecare recommended suppliers diligently monitor their email and mail correspondence for any communication from the OIG.

"It is imperative for suppliers who have received such requests to promptly respond within the specified timeframe to facilitate the OIG's analysis," AAHomecare said in a released statement.

AAHomecare is actively monitoring the development of the study. To ensure comprehensive coverage and timely updates, it encourages CGM suppliers who have received communication from the OIG to connect with Mina Uehara, senior director of regulatory affairs with AAHomecare at minau@aahomecare.org.

mherndon Tue, 04/30/2024 - 08:51

CGM suppliers who are recipients of the OIG requests have likely been notified via email

CMS/Medicare

OIG

CGM

AAHomecare

CMS

More on the Hill & Industry Insiders Voice Disappointment in Medicaid Access Rule

mherndon — Fri, 26 Apr 2024 13:32:16 +0000

More on the Hill & Industry Insiders Voice Disappointment in Medicaid Access Rule

Since the Centers for Medicare & Medicaid Services (CMS) released its Final Rule on "Ensuring Access to Medicaid Services" on Monday, April 22, many in the industry have voiced their disappointment in the rule, including the National Association for Home Care & Hospice (NAHC), who called it a "misguided policy" that will add more pressure to already stressed staffing in home- and community-based care.

The new rule institutes minimum staffing requirements at skilled nursing facilities (SNFs), and a new requirement for home- and community-based service (HCBS) providers that directs 80% of Medicaid payments to be spent on wages for aides and nurses

Recently, Lutheran Services in America, a nonprofit provider network of services for older adults in the United States, joined those expressing their concern regarding the rule.

“We strongly urge the administration to reconsider implementing these rules without further changes to address workforce shortages and adequate reimbursement rates," said Lutheran Services in America President and CEO Alesia Frerichs. "We share the administration’s goals of quality skilled nursing homecare along with greater access to home- and community-based services (HCBS)...These rules simply do not reflect or address realities in communities across the country—especially in rural and underserved areas. With Medicaid reimbursement unable to keep up with current costs and challenges with workforce recruitment, these rules will only force high quality nonprofit providers to close their doors—further constraining access to care.

Additionally, those on Capitol Hill have also said the rule will only put further stress on those seeking to provider care to the senior population.

House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-WA) released the following statement after the Biden administration announced its final Minimum Staffing Rule and Medicaid Access Rule:

“The President’s one-size-fits-all, Washington-knows-best approach to long-term care is an unfunded mandate that will drive up costs and threaten access for patients," Rodgers said. "The minimum staff-to-patient ratio is unworkable for nearly 80% of nursing homes, requiring facilities to increase costs for patients or close their doors to new patients. The so-called ‘access rule’ creates untenable standards for home health agencies to meet. Both rules in practice will result in reduced access to care for those that need it most and their families."

Another Chairman, House Ways and Means Committee Chairman Jason Smith (MO-08), called the mandate a "disaster".

“Seniors could lose access to 280,000 nursing home beds, forcing older Americans to pick up and move to nursing homes far from friends and family, if they are lucky enough to find an open spot," Smith said. "Nursing homes are not suffering from a lack of mandates. They’re facing a lack of nurses. This rule would only make things worse for our seniors and the health care providers who support them.

“Over 1,000 nursing home groups have spoken out against this overreaching regulation, yet the Biden Administration is again choosing to ignore the American people in favor of bigger and more intrusive government. The Ways and Means Committee has passed bipartisan legislation to block the implementation and enforcement of this staffing mandate. We will continue to fight for quality care for American seniors in every single community.”

mherndon Fri, 04/26/2024 - 08:32

More have spoken on the rule which many believe will only add more pressure to already stressed staffing in home- and community-based care.

CMS/Medicare

Legislation & Regulation

Ensuring Access to Medicaid Services

CMS

CMS final rule

CMS-2442-F

A Dual Dilemma

mherndon — Fri, 26 Apr 2024 13:07:37 +0000

A Dual Dilemma mherndon Fri, 04/26/2024 - 08:07

CMS Releases The 'Ensuring Access to Medicaid Services Final Rule' (CMS-2442-F)

mherndon — Tue, 23 Apr 2024 13:30:28 +0000

CMS Releases The 'Ensuring Access to Medicaid Services Final Rule' (CMS-2442-F)

WASHINGTON—The Centers for Medicare & Medicaid Services released its Final Rule on "Ensuring Access to Medicaid Services" on Monday, April 22. Executive Order 14009 in 2021 established the policy objective to protect and strengthen Medicaid and the Affordable Care Act (ACA), and to make high-quality health care accessible and affordable for every American.^[1] In 2022, Executive Order 14070 directed agencies to identify ways to continue to expand the availability of affordable health coverage, to improve the quality of coverage, to strengthen benefits and to help more Americans enroll in quality health coverage.^[2]

The Access rule addresses critical dimensions of access across both Medicaid FFS and managed care delivery systems, including for HCBS. These improvements seek to increase transparency and accountability, standardize data and monitoring, and create opportunities for states to promote active beneficiary engagement in their Medicaid programs with the goal of improving holistic access to care.

The table below provides highlights of the provisions included in the final rule:

Topic:	Final Rule:
(A) Medicaid Advisory Committee and Beneficiary Advisory Council	Renames and expands the scope of states’ Medical Care Advisory Committees. The renamed Medicaid Advisory Committees (MAC) will advise states on an expanded range of issues. Requires states to establish a Beneficiary Advisory Council (BAC) comprised of Medicaid beneficiaries, their families, and/or caregivers. Establishes minimum requirements for MAC membership, including a requirement that 25% of the MAC members will be drawn from the BAC. Requires states to make information about the MAC and BAC activities publicly available including bylaws, meeting schedules, agendas, minutes, and membership lists. Requires states to make at least two MAC meetings per year open to the public. These meetings must include a public comment period. Requires states to provide staff to support the planning and execution of the MAC and BAC activities. Requires states to create and publicly post an annual report summarizing MAC and BAC activities.
(B) Home- and Community-Based Services	Strengthens oversight of person‑centered service planning in HCBS. Requires that states meet nationwide incident management system standards for monitoring HCBS programs. Requires that states establish a grievance system for HCBS delivered through FFS. Requires that in three years, states report on their readiness to collect data regarding the percentage of Medicaid payments for homemaker, home health aide, personal care, and habilitation services spent on compensation to the direct care workers furnishing these services; and in four years, states report on the percentage of Medicaid payments for homemaker, home health aide, personal care, and habilitation services spent on compensation to the direct care workers furnishing these services, subject to certain exceptions. Requires that, in six years, states generally ensure a minimum of 80% of Medicaid payments for homemaker, home health aide, and personal care services be spent on compensation for direct care workers furnishing these services, as opposed to administrative overhead or profit, subject to certain flexibilities and exceptions (referred to as the HCBS payment adequacy provision). The HCBS payment adequacy provision provides states the option to establish: (1) a hardship exemption based on a transparent state process and objective criteria for providers facing extraordinary circumstances and (2) a separate performance level for small providers meeting state-defined criteria based on a transparent state process and objective criteria. The HCBS payment adequacy provision also exempts the Indian Health Service and Tribal health programs subject to 25 U.S.C. 1641 from complying with its requirements. Requires states to report on waiting lists in section 1915(c) waiver programs; service delivery timeliness for personal care, homemaker, home health aide, and habilitation services; and a standardized set of HCBS quality measures. Promotes public transparency related to the administration of Medicaid‑covered HCBS through public reporting of quality, performance, and compliance measures.
(C) Fee-for-Service (FFS)	Requires states to publish all FFS Medicaid fee schedule payment rates on a publicly available and accessible website.Requires states to compare their FFS payment rates for primary care, obstetrical and gynecological care, and outpatient mental health and substance use disorder services to Medicare rates, and publish the analysis every two years. Requires states to publish the average hourly rate paid for personal care, home health aide, homemaker, and habilitation services, and publish the disclosure every two years. Requires states to establish an advisory group for direct care workers, beneficiaries, beneficiaries’ authorized representatives, and other interested parties to meet at least every two years, and advise and consult on payment rates paid to direct care workers for personal care, home health aide, homemaker, and habilitation services. Requires states to demonstrate access sufficiency through an initial analysis when submitting a state plan amendment with a rate reduction, or restructuring in circumstances that could result in diminished access, for all services. If the state does not meet the requirements of the initial analysis, they must perform an additional, more extensive analysis.

For more information, please see the final rule and a chart outlining the applicability dates for all regulatory changes.

Additional information and resources on the final rule are available at: medicaid.gov/medicaid/access-care/index.html

For questions about the HCBS provisions, contact: HCBSAAccessRule@cms.hhs.gov.

mherndon Tue, 04/23/2024 - 08:30

Actions are the latest in a series of steps the Biden-Harris Administration has taken intending to improve safety, provide support for care workers and family caregivers & to expand access to affordable, high-quality care

CMS/Medicare

Biden Administration

Kamala Harris

White House

NAHC Expresses Disappointment Regarding Medicaid Access Final Rule

mherndon — Tue, 23 Apr 2024 13:22:06 +0000

NAHC Expresses Disappointment Regarding Medicaid Access Final Rule

WASHINGTON—The National Association for Home Care & Hospice (NAHC) released a statement noting that it was, 'extremely disappointed that the Centers for Medicare and Medicaid Services (CMS) elected to finalize the “payment adequacy” provision in the Medicaid Access Final Rule (CMS 2442-F).'

"This is a misguided policy that will result in agency closures, force providers to exit the Medicaid program, and will ultimately make access issues worse around the country," a statement from the organization read. "As NAHC and our partners across the homecare industry have demonstrated, such a provision is not only unworkable due to the varied nature of Medicaid programs across the country, CMS also lacks statutory authority to impose this mandate."

“We know that CMS has good intentions and a desire to improve the lives of workers, but this policy is ill-advised and will have serious negative impacts on providers and their clients around the country," said Jennifer Sheets, co-chair of the NAHC Medicaid Advisory Council (MAC).

David Totaro, president and executive director of BAYADA Hearts for Home Care and NAHC MAC co-chair, said, “It is unfortunate that the final rule included a mandatory pass-through requirement. There are so many positive and necessary changes in the regulation, so it is disappointing that this one provision will undermine all the good things about the rule.”

NAHC President, William Dombi promised to continue advocacy against the pass-through requirements.

“We all agree that more needs to be done to support the direct care workforce; however, this policy will make things worse, not better," Dombi said. "NAHC remains committed to overturning this devastating policy and instead advocating for more feasible and rational policies that address the root causes of low worker compensation.”

NAHC said it strongly believes in the value of, and care provided by, the direct care workers, and it is committed to finding workable solutions that address the struggles of this valuable group of people. "Unfortunately, the realities of the various Medicaid programs around the country make any uniform requirement a nonstarter," NAHC said.

You can learn more about the Access final rule and receive updates on NAHC advocacy at the NAHC website.

Attend our webinar on Thursday, April 25, 2024 to learn more. Register here.

mherndon Tue, 04/23/2024 - 08:22

The organization said the Final Rule will result in agency closures, force providers to exit the Medicaid program and make access issues overall worse

CMS/Medicare

NAHC

CMS

Medicaid

CMS final rule

Owner of Telemedicine Companies Pleads Guilty to $110M Medicare Fraud Scheme

mherndon — Fri, 05 Apr 2024 15:57:33 +0000

Owner of Telemedicine Companies Pleads Guilty to $110M Medicare Fraud Scheme

BOSTON—The owner of Expansion Media (Expansion) and Hybrid Management Group (Hybrid) plead guilty on April 3 in connection with a $110 million telemedicine fraud scheme involving medically unnecessary durable medical equipment (DME), including orthotics such as back and knee braces.

Steven Richardson, 40, of Parkland, Florida, pleaded guilty to one count of conspiracy to commit health care fraud. U.S. District Court Judge Nathaniel M. Gorton scheduled sentencing for July 18, 2024. Richardson was charged by Information in February 2024.

Between March 2016 and January 2023, Richardson, through his companies Expansion and Hybrid, entered into business relationships with telemarketing companies that generated leads by targeting Medicare beneficiaries. The telemarketers then paid Expansion and Hybrid on a per-order basis to generate orders for DME for these beneficiaries. To arrange for these orders to be signed, Richardson worked with medical staffing companies—including one in Massachusetts—to find doctors and nurses who were willing to review and sign prepopulated orders, typically without any contact with the beneficiaries. The records falsely portrayed the medical providers as having performed a legitimate examination of the beneficiary. Richardson then provided the signed orders to the telemarketing companies, which sold the orders to DME suppliers. Richardson knew that these DME suppliers would use the signed orders to submit claims to Medicare for DME that was medically unnecessary, based on false documentation and tainted by kickbacks.

The charge of conspiracy to commit health care fraud provides for a sentence of up to 10 years in prison, supervised release for up to three years and a fine of up to $250,000 or twice the gross gain or loss, whichever is greater. Sentences are imposed by a federal district court judge based upon the U.S. Sentencing Guidelines and statutes that govern the determination of a sentence in a criminal case.

mherndon Fri, 04/05/2024 - 10:57

teven Richardson, 40, of Parkland, Florida, pleaded guilty to one count of conspiracy to commit health care fraud

CMS/Medicare

anti-fraud

Medicare fraud

DME fraud

Telemedicine