Providers Should Be Careful to Not Overbill for Multi-Dose Vials of Herceptin. Hospitals

August 2012

News

Make sure to tell all current customers as well as prospects to bookmark the Wolters Kluwer Law & Business Health Law web site and blog: Here are examples of some of the stories that first appeared on the blogin August.

Providers Should Be Careful to Not Overbill for Multi-Dose Vials of Herceptin. Hospitals and other provider should take care to properly bill for Herceptin, a medication that treats breast cancer once it has spread to other parts of the body. The Office of the Inspector General (OIG) found that during a two-year period nearly 14 percent of claims paid by one Medicare contractor were for full vials of Herceptin resulting in overpayments of nearly $2.4 million dollars.

Appeals Court Vacates Injunction Barring Texas Refusal to Fund Planned Parenthood. The Fifth Circuit Court of Appeals has vacated the injunction that protected Planned Parenthood’s participation in Texas Women’s Health Program (WHP). In a unanimous ruling, the three-member panel held that Planned Parenthood should not have been granted a preliminary injunction because it was not likely to succeed on the merits of the case. The district court erred because it struck down the Texas regulations as a whole rather than considering whether any of the provisions might be constitutionally permissible.

Readmission Reductions to Hit 2,200 Hospitals. As CMS begins implementation of the hospital readmission reduction program (RRP) on October 1, 2012, the first day of federal fiscal year (FFY) 2013, 2,211 hospitals face reductions to their reimbursement because of “excess readmissions,” an inordinate number of patients who return to an acute care hospital within 30 days of discharge. The percentage of Medicare patients who return to the hospital within 30 days of discharge has consistently hovered around 20 percent. CMS believes that these readmissions increase Medicare costs unnecessarily and could be avoided with better post-discharge planning, communication among patients’ treating providers and patient education. Therefore, Congress required the agency to institute the penalty for readmissions in sections 3025 and 10309 of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148), which added subsection (q) to Soc. Sec. Act sec. 1886. The statute applies to most acute care inpatient hospitals paid under the inpatient prospective payment system (IPPS). Cancer centers, long-term care, and psychiatric hospitals are excluded, as are hospitals in Puerto Rico and Maryland.

Obama Administration Unites Public and Private Sectors in Fight Against Healthcare Fraud. Several prominent health insurance organizations, fraud groups and other private health care organizations have joined forces with the Obama administration to create one of the largest fraud fighting networks to date, HHS announced, and they are set to get started as early as September. The program is a voluntary, collaborative arrangement designed to share information and best practices in order to improve detection and prevent payment of fraudulent health care billings. The first meetings of the Executive Board, the Data Analysis and Review Committee and also the Information Sharing Committee are scheduled for next month, however, there are many groups that are currently meeting, working to finalize a basic structure for the partnership and developing a work plan.

Eligible Providers Have Until October 3 to Start EHR Incentive Reporting Period. Eligible professionals (EPs) have until October 3, 2012 to commence their consecutive 90-day reporting period for the Medicare Electronic Health Records (EHR) Incentive Program for the 2012 calendar year. In order to receive an incentive payment for meeting meaningful use standards, EPs must participate in the reporting period. By participating in the Medicare EHR Incentive Program, EPs, eligible hospitals, and critical access hospitals may receive up to $44,000 over five years if they can demonstrate meaningful use of certified EHR technology. Providers in Health Professional Shortage Areas are eligible for additional incentive payments as well. EPs must begin participation in 2012 in order to receive the maximum incentive amount.

Chiropractors and doctors practicing medicine, osteopathy, dentistry, podiatry, and optometry qualify as EPs under the program. In order to receive an incentive payment, an EP must not be considered hospital-based; in other words, the EP must not perform 90 percent or more of his or services in an inpatient hospital or emergency room. Regardless of how many locations at which an EP practices, each EP is only eligible for one incentive payment annually.

Hospice PEPPER Adds New Flavor to Agency Data Analysis. Hospices now have the opportunity to take a first hand look at what its peers are doing and see how each hospice ranks with payment patterns and quality analysis using CMS’ new release of “PEPPER,” or the hospice “Program for Evaluating Payment Patterns Electronic Report.” Later this month, CMS and its partner TMF Health Quality Institute (TMF), will begin posting free hospice-specific comparative data reports for hospices nationwide, comparing a single hospice’s Medicare billing practices with other hospices in the state, Medicare Administrative Contractor (MAC) jurisdiction and nation. While PEPPER does not identify the presence of improper payments, hospices will want to use the PEPPER to help guide its auditing and monitoring activities.