Reimbursement Roundup

OIG expands fraud/abuse penalties

The Office of Inspector General (OIG) has released its final rule revising the exclusionary plus civil money penalties (CMP) for providers who commit fraud and abuse. The new rule:

— expands the OIG’s power to exclude provi ders beyond Medicare and state health care programs, to include all public health care programs;

— establishes permanent exclusions for individuals convicted of three or more health care-related crimes and 10-year exclusions for individuals convicted of two health care-related crimes;

— assesses CMPs of up to $10,000 against institutional providers that knowingly employ or enter into contracts for medical services with excluded individuals;

— establishes a new CMP of up to $25,000 for health plans that fail to report information to the Healthcare Integrity and Protection Data Bank;

— creates CMPs for providers who violate the anti-kickback statute of up to a maximum of $50,000 per violation, including a maximum penalty of not more than three times the amount of remuneration offered, paid, solicited, or received in the kickback scheme.


HCFA wants self-policing reports

If you’ve been overpaid by Medicare, the government wants to hear about it. The Health Care Financing Administration wants to extend a proposal that providers submit a quarterly credit balance report identifying any improper payments they received from Medicare. These reports will then go to Medicare intermediaries, who will collect the overpayments.

While logical on the surface, many health care groups worry about such things as self-incrimination and what happens when there is an honest difference of opinion about a payment.


Specialties back Stark changes

Many different medical specialties are backing legislation to revamp Stark physician referral rules introduced by House Ways and Means Health Subcommittee Chairman Bill Thomas (R-CA). H.R. 2651, the "Physician Self-Referral Amendments of 1999," is a "critical first step to remove barriers to medical group practice integration and evolution," says a joint statement by the Medical Group Man agement Association and the American Medical Group Association.

While you can expect a lot of activity surrounding the issue, most insiders feel it will be at least two to three years before any substantive changes in physician referral rules make their way into law.


Double-check your modifiers

HCFA has directed Medicare carriers to pay special attention to possible improper use of modifiers by providers when reviewing claims. This extra oversight may result in delays in or denials of payment. You should check with your intermediary to ensure the two of you are on the same page when it comes to use of the most common modifiers in your practice.