The Edge

The Edge_November 2010 -

Medicare Quarterly Provider Compliance

Newsletter - Guidance to Address Billing


Mori Moriuchi

Regional Director


The first issue has been published of a new Medicare Learning

Network (MLN) educational product entitled the “Medicare Quarterly

Provider Compliance Newsletter,” which is intended to help

physicians, providers, suppliers, and their billing staff understand

how to avoid certain billing errors and other improper activities

(such as failure to submit timely medical record documentation)

when dealing with the Medicare Fee-For-Service (FFS) program.

The newsletter highlights, where appropriate, the consequences

related to these billing errors or noncompliance with Medicare regulations

and policies. It also provides summary information about

claims processing, medical review, program integrity, and other

compliance-related issues discovered as the Centers for Medicare &

Medicaid Services (CMS) reviews activity and expenditures under

the Medicare program, especially as those activities relate to FFS

providers. The newsletter describes the issue, the problems that may

occur as a result of the issue, the steps CMS has taken to make providers

aware of the issue, and the recommendations on what providers

need to do to avoid the problem. In addition, the newsletter

refers providers to other documents for more detailed information

where such documents exist.

In this first edition, CMS presents a number of issues that impact

a variety of provider types as a way to introduce the product to

a wide audience of providers. Future issues will focus on the “top”

issues of that particular quarter; therefore, it may focus on a single

provider type or a particular set of items or services. Many of the

issues presented are uncovered as a result of reviews by the General

Accountability Office and/or the Office of the Inspector General

(OIG) in the U.S. Department of Health and Human Services. The

issues are also identified by CMS activities and those of its contractors,

such as the Recovery Audit Contractors (RACs), Program Safeguard

Contractors, Zone Program Integrity Contractors, and Medicare

Administrative Contractors (MACs).

The issues addressed in this newsletter are listed below. All issues

of the newsletter will be available at the CMS website.

• Inpatient Hospitals and SNFs failure to submit requested

documentation within 45 days of the ADR Letter.

• Other Services with Excessive Units - Units billed exceeded

the number approved per CPT/HCPCS Code descriptions.

RACs determined that IP claims totaling almost $10 million

dollars were made for services exceeding the approved


• Inpatient Hospital Services - Respiratory System Diagnosis

with Ventilator Support: Principal diagnosis on the claims

did not match the principal diagnosis in the medical record.

Hospitals should ensure that the principal and secondary

diagnosis codes on the claim for DRG 475, MS-DRG 207

(formerly DRG 565), and MS-DRG 208 (formerly DRG 566)

match the information in a patient’s medical record.

• Other Cardiac Pacemaker Implantation (DRG 116) - Not

medically necessary to receive care in inpatient setting.

RACs identified improper payments totaling more than $21



Continued on page 4

Fraud and Abuse Training in Medical


Timothy S. Brady, Ph.D., FHFMA, FACHE

Regional Inspector General

U.S. Department of Health and Human Services

The Affordable Care Act creates a requirement for Medicare

and Medicaid providers to establish a compliance program. While

education programs are only part of a comprehensive compliance

program, they are an essential part of helping providers understand

their obligations to avoid being caught in unintended violations of

regulations that could affect their ability to work in and bill in the

Federal healthcare programs.

A recent Office of Inspector General (OIG) inspection of medical

schools and medical centers offering physician residency and fellowship

programs assessed the extent to which such programs provided

instruction on compliance with Medicare and Medicaid fraud and

abuse laws, the False Claims Act, and anti-kick back statutes. The

inspection identified what type of instruction medical students, residents,

and fellows received and what type of educational resources

the OIG could provide that may be of assistance in conducting training.

Although there are no Federal requirements to conduct this type

of training for students, 44 percent of the medical school respondents

said they conducted some type of training. Most indicated that they

used classroom instruction, typically less than two hours. Other

methods included providing reading materials for the students and

lectures in clinical settings. The majority provided instruction specifically

about the false Claims Act, self-referral, and anti-kickback.

Interestingly, 68 percent of the institutions that provide residency

and fellowship programs conduct some degree of training

regarding compliance with Medicare and Medicaid fraud, and abuse

laws. Approximately half reported providing four hours or less of

instructional training per year. Only 22 percent offered training in

the first year of residency while an additional 38 percent provided

annual training.

The programs use a variety of methods for training residents

and fellows. The most common are on-line training and offering

participants reading materials for self-study. More than threequarters

of the hospitals reported that they cover the False Claims

Act, the anti-kick back statute, and the physician self-referral law.

More than 90 percent of the medical school deans and the directors

of the residency and fellowship programs indicated an interest

in having a standardized set of educational materials highlighting

the general principles related to the Medicare and Medicaid fraud

and abuse laws. As a result of these findings the OIG is planning to

develop a comprehensive package of educational materials related to

compliance to be used in medical schools and residency and fellowship

programs. The next step is to develop a similar package for

administrators, executives and other practitioners. !

The Edge - Northern California Chapter’s Newsletter! 3

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