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En SM & Associates, Inc queremos mantenerle informado sobre las últimos cambios y noticias revelantes para los profesionales del campo de la salud.

Former CEO at Ortho Hospital Charged with Fraud

publicado a la‎(s)‎ 4 oct. 2012 8:50 por Sally Montes   [ actualizado el 4 oct. 2012 8:50 por Carlos M Rivas ]

Written by Karen Long Created on Tuesday, 02 October 2012 06:38

A former hospital CEO allegedly extorted or solicited $1.4 million in a kickback scheme involving hospital vendors, a hospital employee and a healthcare organization in the United Kingdom.

John Reynolds also is charged with making false statements to law enforcement and was arrested Sept. 26, according to the U.S. Attorney’s Office in southern New York.

Reynolds was CEO of the Hospital for Special Surgery, the nation’s oldest orthopedic hospital, from 1997 until 2006. From 1996 to November 2002, he received about $420,000 in kickbacks from at least two hospital vendors in exchange for securing contracts for them, the U.S. Attorney’s Office states. From 2002 to 2005, he received $298,500 in kickbacks from a subordinate employee in exchange for the employee’s annual bonus. From 2005 to 2007, he received about $670,000 in kickbacks from the U.K. health care organization in exchange for facilitating a partnership with the hospital.

Reynolds allegedly withheld information from the hospital’s board of directors about the arrangements and conflicts of interest, the U.S. Attorney’s Office stated.

The racketeering charge Reynolds faces has a maximum sentences of 20 years in prison. The false statements charge has a maximum five-year prison sentence. For more on the case, visit http://www.justice.gov/usao/nys/pressreleases/September12/ReynoldsJohnArrestPR.html.

In other fraud news:

  • Nine people – including two home health agency owners and two doctors – allegedly paid and received kickbacks for Medicare home health referrals, according to the U.S. Attorney’s Office in northern Illinois. Between January 2008 and July 2012, the home health agency owners and an employee paid kickbacks generally ranging from $300 to $600 for patients who would receive at least five home health visits, which qualifies the agency for a full episode of payment. Other defendants received kickbacks that totaled as much as $24,000 just between March to July 2012. For more information on the case, visit http://www.justice.gov/usao/iln/pr/chicago/2012/pr0925_01.pdf.
  • A consultant and two directors of an ambulance company were charged in connection with a $2.5 million billing scheme that defrauded Medicare and Medicaid, according to the U.S. Attorney’s Office in western Texas. Andey Gray, owner of Crown Consulting and Billing, and Michael Farris and Sherry Trouten of Tejas Ambulance face 10 counts of healthcare fraud and two counts of theft or embezzlement in connection with health care fraud. Farris also is charged with one count of making a false statement. Tejas Ambulance was not authorized to bill Medicare or Medicaid but did so using numbers assigned to other entities. For more information on the case, visit http://www.justice.gov/usao/txw/press_releases/2012/Tejas%20Ambulance%20SA%20indictment.pdf.

Congelación parcial de códigos antes de la implementación del ICD-10

publicado a la‎(s)‎ 2 oct. 2012 7:19 por Sally Montes   [ actualizado el 2 oct. 2012 7:19 por Carlos M Rivas ]

Fecha efectiva: N/A

Fecha de implementación: N/A


El comité ICD-9-CM Coordination & Maintenance (C&M) committee implementó un congelamiento parcial de los códigos ICD-9-CM e ICD-10 (ICD-10-CM e ICD-10-PCS) antes de la implementación del ICD-10 que terminaría un año después de la implementación del ICD-10. La implementación de ICD-10 se retrasó desde el 1 de octubre de 2013, al 1 de octubre de 2014. El congelamiento parcial se llevará a cabo de la siguiente manera:
Las últimas actualizaciones regulares anuales para grupo de códigos ICD-9-CM y el ICD-10 se realizaron el 1 de octubre de 2012.
El 1 de octubre de 2012 y el 1 de octubre de 2013 sólo habrá actualizaciones limitadas de códigos tanto para el grupo de códigos ICD-9-CM, como para ICD-10 para capturar las nuevas tecnologías y enfermedades según lo requerido por la Sección 503(a) de Pub. L. 108-173.
El 1 de octubre de 2014 sólo habrá actualizaciones limitadas del grupo de códigos ICD-10 para capturar las nuevas tecnologías y enfermedades según lo requerido por la Sección 503(a) de Pub. L. 108-173. No habrá cambios al grupo de códigos ICD-9-CM, ya que no serán utilizados para reportes.
El 1 de octubre de 2015 se iniciarán actualizaciones regulares de ICD-10.
El enlace al artículo de la edición especial de MLN Matters® esSE1240. enlace externoa pdf

Medicare To Penalize 2,211 Hospitals For Excess Readmissions

publicado a la‎(s)‎ 30 sept. 2012 6:04 por Sally Montes   [ actualizado el 30 sept. 2012 6:04 por Carlos M Rivas ]

By Jordan Rau

KHN Staff Writer

Aug 13, 2012

More than 2,000 hospitals — including some nationally recognized ones — will be penalized by the government starting in October because many of their patients are readmitted soon after discharge, new records show.

Together, these hospitals will forfeit about $280 million in Medicare funds over the next year as the government begins a wide-ranging push to start paying health care providers based on the quality of care they provide.

With nearly one in five Medicare patients returning to the hospital within a month of discharge, the government considers readmissions a prime symptom of an overly expensive and uncoordinated health system. Hospitals have had little financial incentive to ensure patients get the care they need once they leave, and in fact they benefit financially when patients don’t recover and return for more treatment.

Nearly 2 million Medicare beneficiaries are readmitted within 30 days of release each year, costing Medicare $17.5 billion in additional hospital bills. The national average readmission rate has remained steady at slightly above 19 percent for several years, even as many hospitals have worked harder to lower theirs.

The penalties, authorized by the 2010 health care law, are part of a multipronged effort by Medicare to use its financial muscle to force improvements in hospital quality. In a few months, hospitals also will be penalized or rewarded based on how well they adhere to basic standards of care and how patients rated their experiences. Overall, Medicare has decided to penalize around two-thirds of the hospitals whose readmission rates it evaluated, the records show.

The penalties will fall heaviest on hospitals in New Jersey, New York, the District of Columbia, Arkansas, Kentucky, Mississippi, Illinois and Massachusetts, a Kaiser Health News analysis of the records shows. Hospitals that treat the most low-income patients will be hit particularly hard.

A total of 278 hospitals nationally will lose the maximum amount allowed under the health care law: 1 percent of their base Medicare reimbursements. Several of those are top-ranked institutions, including Hackensack University Medical Center in New Jersey, North Shore University Hospital in Manhasset, N.Y. and Beth Israel Deaconess Medical Center in Boston, a teaching hospital of Harvard Medical School.

"A lot of places have put in a lot of work and not seen improvement," said Dr. Kenneth Sands, senior vice president for quality at Beth Israel. "It is not completely understood what goes into an institution having a high readmission rate and what goes into improving" it.

Sands noted that Beth Israel, like several other hospitals with high readmission rates, also has unusually low mortality rates for its patients, which he says may reflect that the hospital does a good job at swiftly getting ailing patients back and preventing deaths.

Penalties Will Increase Next Year

The maximum penalty will increase after this year, to 2 percent of regular payments starting in October 2013 and then to 3 percent the following year. This year, the $280 million in penalties comprise about 0.3 percent of the total amount hospitals are paid by Medicare.

According to Medicare records, 1,933 hospitals will receive penalties less than 1 percent; the total number of hospitals receiving penalties is 2,211. Massachusetts General Hospital in Boston, which U.S. News last month ranked as the best hospital in the country, will lose 0.5 percent of its Medicare payments because of its readmission rates, the records show. The smallest penalties are one hundredth of a percent, which 50 hospitals will receive.

Dr. Eric Coleman, a national expert on readmissions at the University of Colorado School of Medicine, said the looming penalties have captured the attention of many hospital executives. "I’m not sure penalties alone are going to move the needle, but they have raised awareness and moved many hospitals to action," Coleman said.

The penalties have been intensely debated. Studies have found that African-Americans are more likely to be readmitted than other patients, leading some experts to be concerned that hospitals that treat many blacks will end up being unfairly punished.

Hospitals have been complaining that Medicare is applying the rule more stringently than Congress intended by holding them accountable for returning patients no matter the reason they come back.

Hospitals That Serve Poor Are Hit Harder Than Others

Some safety-net hospitals that treat large numbers of low-income patients tend to have higher readmission rates, which the hospitals attribute to the lack of access to doctors and medication these patients often experience after discharge. The analysis of the penalties shows that 76 percent of the hospitals that have a lot of low-income patients will lose Medicare funds in the fiscal year starting in October. Only 55 percent of the hospitals treating few poor patients are going to be penalized, the analysis shows.

"It’s our mission, it’s good, it’s what we want to do, but to be penalized because we care for those folks doesn’t seem right," said Dr. John Lynch, chief medical officer at Barnes-Jewish Hospital in St. Louis, which is receiving the maximum penalty.

"We have worked on this for over four years," Lynch said, but those efforts have not substantially reduced the hospital’s readmissions. He said Barnes-Jewish has tried sending nurses to patients’ homes within a week of discharge to check up on them, and also scheduled appointments with a doctor at a clinic, but half the patients never showed. This spring, the hospital established a team of nurses, social workers and a pharmacist to monitor patients for 60 days after discharge.

"Some of the hospitals that are going to pay penalties are not going to be able to afford these types of interventions," said Lynch, who estimated the penalty would cost Barnes-Jewish $1 million.

Atul Grover, chief public policy officer for the Association of American Medical Colleges, called Medicare’s new penalties "a total disregard for underserved patients and the hospitals that care for them." Blair Childs, an executive at the Premier healthcare alliance of hospitals, said: "It’s really ironic that you penalize the hospitals that need the funds to manage a particularly difficult population."

Medicare disagreed, writing that "many safety-net providers and teaching hospitals do as well or better on the measures than hospitals without substantial numbers of patients of low socioeconomic status." Safety-net hospitals that are not being penalized include the University of Mississippi Medical Center in Jackson and Denver Health Medical Center in Colorado, the records show.

Bill Kramer, an executive with the Pacific Business Group on Health, a California-based coalition of employers, said the penalties provide "an appropriate financial incentive for hospitals to do the right thing in terms of preventing avoidable readmissions."

The government’s penalties are based on the frequency that Medicare heart failure, heart attack and pneumonia patients were readmitted within 30 days between July 2008 and June 2011. Medicare took into account the sickness of the patients when calculating whether the rates were higher than those of the average hospital, but not their racial or socio-economic background.

The penalty will be deducted from reimbursements each time a hospital submits a claim starting Oct. 1. As an example, if a hospital received the maximum penalty of 1 percent and it submitted a claim for $20,000 for a stay, Medicare would reimburse it $19,800.

The Centers for Medicare & Medicaid Services has been trying to help hospitals and community organizations by giving grants to help them coordinate patients’ care after they’re discharged. Leaders at many hospitals say they are devoting increased attention to readmissions in concert with other changes created by the health law.

Sally Boemer, senior vice president of finance at Mass General, said she expected readmissions will drop as the hospital develops new methods of arranging and paying for care that emphasize prevention. Readmissions "is a big focus of ours right now," she said.

Gundersen Lutheran Health System in La Crosse, Wis., and Intermountain Medical Center in Murray, Utah, were among 1,156 hospitals where Medicare determined the readmission rates were acceptable. Those hospitals will not lose any money. On average, the readmissions penalties were lightest on hospitals in Utah, South Dakota, Vermont, Wyoming and New Mexico, the analysis shows. Idaho was the only state where Medicare did not penalize any hospital.

Even some hospitals that won’t be penalized are struggling to get a handle on readmissions. Michael Baumann, chief quality officer at the University of Mississippi Medical Center, said in-house doctors had made headway against heart failure readmissions by calling patients at home shortly after discharge. "It’s a fairly simple approach, but it’s very labor intensive," he said.

The problems afflicting many of the center’s patients—including obesity and poverty that makes it hard to afford medications—make it more challenging. "It’s a tough group to prevent readmissions with," he said.

Data for individual hospitals are available as a PDF file and as a CSV spreadsheet.

Boletín Informativo de SM & Assoc., Inc. Ed 2 4/2012

publicado a la‎(s)‎ 5 may. 2012 10:22 por Carlos M Rivas   [ actualizado el 5 may. 2012 10:27 ]

Ya salió el Boletín Informativo Ed. núm 2 de SM & Associates, Inc. Les invitamos a leerlo para que se oriente y evalue si su facilidad está en el camino correcto en el proceso de transición al nuevo conjunto de códigos de ICD-10. 
Tambien verás los cursos pautados para los meses de Mayo y Junio, 2012 en ICD-10 CM y de Cumplimiento (Prevención de Fraude y Abuso) 

Boletín Informativo de SM & Assoc., Inc. Ed 1 3/2012

publicado a la‎(s)‎ 23 feb. 2012 12:26 por Carlos M Rivas   [ actualizado el 23 feb. 2012 12:28 ]

Ya salió el Boletín Informativo Ed. núm 1 de SM & Associates, Inc. Les invitamos a leerlo para que se oriente y evalue si su facilidad está en el camino correcto en el proceso de transición al nuevo conjunto de códigos de ICD-10. 
Tambien verás los cursos pautados para el mes de marzo, 2012 en ICD-10 CM y de Cumplimiento (Prevención de Fraude y Abuso y Actualización Ley HIPAA) 
Y por úlitmo podrás ver lo importante y convenienete que es tener un sistema de digitalización de documentos en su facilidad 

DOJ joins lawsuit against national for-profit hospice

publicado a la‎(s)‎ 5 ene. 2012 5:30 por Carlos M Rivas   [ actualizado el 5 ene. 2012 5:30 ]

By Stephanie Bouchard, Associate Editor
Created 01/04/2012

WASHINGTON – The United States Justice Department has joined a whistleblower case alleging that a national chain of for-profit hospices violated the False Claims Act by spending millions of taxpayer dollars to care for Medicare recipients in hospice who were not terminally ill.

For-profit hospice companies may receive Medicare dollars for Medicare patients who have a medical prognosis of six months or less to live. The suit against AseraCare Hospice, a chain of about 65 providers in 19 states, “knowingly submitted false claims” to Medicare, misspending millions of Medicare dollars for patients who didn’t meet the medical prognosis.

“Congress intended that the hospice care benefit be used during the last several months of an individual’s life,” said Daniel R. Levinson, inspector general of the Department of Health and Human Services in a statement released by the Justice Department on Tuesday. “We will continue to recover misspent Medicare funds from companies that abuse the hospice benefit."

AseraCare’s owner, Golden Living, refutes the charges.

“We are disappointed by the Department of Justice’s decision to intervene in the qui tam litigation,” said AseraCare’s General Counsel David Beck in a statement released by the company yesterday. “This action is especially troubling because we believe it could constrain certain patients – most notably those who suffer from unpredictable disease – from utilizing the hospice benefit. The allegations contained in the complaint are without merit, and AseraCare operates in full compliance with the law.”

“Consistent with hospice providers nationwide, AseraCare Hospice has evolved in recent years to treat more terminally ill patients with unpredictable disease progressions,” said AseraCare Hospice President and Chief Medical Officer David Friend, MD, in the statement. “It is simply not possible to precisely predict how patients will respond to challenging illnesses such as end-stage heart, lung and kidney disease, AIDS and Alzheimer’s.”

For-profit hospice companies have come under increased scrutiny in recent months, with some in the hospice industry and government claiming that the rapid growth of for-profits may be due to these companies “cherry picking” patients, such as those with dementia, that end up staying longer in hospice care.

[See also: Concerns raised about increase in for-profit hospice care.]

Last summer, the Office of Inspector General released a report that examined the use of hospice for nursing facility residents. The report concluded that there was enough evidence to suggest concern about how the Medicare hospice benefit is being used. The OIG recommended that hospices should be more carefully scrutinized going forward and that the Medicare payment for hospice may need to be reduced to eliminate any improper incentives.

[See also: Hospices should be scrutinized, says OIG.]

AseraCare hasn’t ruled out that the DOJ’s interest may stem from the call for more scrutiny of hospices. “There does appear to have been an increase in government review of the hospice benefit, as that benefit is being more frequently utilized,” said Blair Jackson, Golden Living’s vice president of corporate communications in an email toHealthcare Finance News. “It may be that this action is connected with that increased scrutiny.”

If the federal government succeeds in proving that AseraCare knowingly submitted false claims, it can claim three times the damages and a penalty of $5,500 to $11,000 per claim. The whistleblowers would be entitled to a portion of the money recovered by the government.

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