JUNE 2017 COMPLIANCE UPDATES

by Becky Amann, Compliance Manager

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

PROVIDER COMPLIANCE

CMS’s website contains a Provider Compliance section that provides Compliance-related and Fraud and Abuse-related resources. This section includes a link to their “Fast Facts” that is updated regularly. Some of the topics include Preventive Services, Evaluation and Management Services, Hospital Discharge Day, Medical Necessity Documentation…. just to name a few.

These resources are located at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html

MEDICAID – REQUEST FOR PROVIDER DOCUMENTATION – PAYMENT ERROR RATE MEASUREMENT (PERM)

CMS in conjunction with the NYS Office of the Medicaid Inspector General (OMIG) will be measuring improper payments for Medicaid and Child Health Plus programs, under the Payment Error Rate Measurement (PERM) program.

Documentation for medical review of randomly selected claims will be requested by Chickasaw Nation Industries Advantage, LLC, who is the new CMS review contractor. Requests for documentation began in May and could be requested for claims paid during the timeframe of October 1, 2016 through September 30, 2017.

Failure to provide the requested documentation will result in a determination of erroneous payment and OMIG will pursue recovery.

Please ensure your staff is aware of these documentation requests.

OFFICE OF THE INSPECTOR GENERAL (OIG)

PROVIDER COMPLIANCE – REPORTING CHANGES IN OWNERSHIP

A recent report issued by the Office of the Inspector General (OIG) has indicated that providers may not be informing CMS of ownership changes. Providers must update their enrollment information within 30 days of any changes in ownership.

Owners are individuals or corporations with a 5 percent or more ownership or controlling interest. Failure to comply could result in revocation of your Medicare billing privileges. Please refer to the following MLN Matters Article for further information:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1617.pdf

For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.com

JULY 2017 COMPLIANCE UPDATES

by Becky Amann, Director of Compliance

OFFICE OF THE INSPECTOR GENERAL (OIG)

In June, the OIG reported that Medicare has paid millions of dollars in Electronic Health Record (EHR) Incentive Payments that did not comply with Federal Requirements.

As an incentive for using certified EHR technology, the Federal Government makes payments to Eligible Professionals (EP’s) that attest to “meaningful use” of EHR’s, by self-reporting data to the Centers for Medicare and Medicaid Services (CMS).

The OIG reviewed EHR incentive payments that Medicare issued to EP’s from May 2011 to June 2014 and selected a random sample of EP’s who received payment. Based on the sample reports, the OIG has estimated that CMS inappropriately paid $729.4 million to EP’s who did not meet the meaningful use requirements.

The OIG has recommended that CMS recover $291,000 in payments made to the sampled EP’s who did not meet meaningful use requirements. In addition, the OIG recommends that CMS review EP incentive payments to determine which EP’s did not meet meaningful use for each program year to attempt to recover the $729.4 million in estimated inappropriate incentive payments.

For OIG’s full report, please access their website at: https://oig.hhs.gov/oas/reports/region5/51400047.asp

For Compliance questions, please contact Becky Amann at 716-389-3202 or beckya@pracfirst.com

WHAT YOU NEED TO KNOW/DO ABOUT RANSOMWARE

By Emilie DiChristina MBA, for PracticeFirst

In the NEWS…RANSOMWARE

Last week, approximately June 28, 2017, major organizations in Europe and the US were attacked by the “Petya” RANSOMWARE. In Pittsburg, Pennsylvania, Heritage Valley Health System were hot by this malware, impacting the safety and treatment of patients across their hospitals and health centers.

About 6 weeks ago everyone heard of the RANSOMWARE attack on the Erie County Medical Center Corporation, and of course on companies across the world.

Possibly the first RANSOMWARE attack in our immediate area, occurred in May 2016 impacting the public, mental and health departments of the Niagara County Health Departments?

SCARY STUFF

Whether you are a provider or a patient, having your records held hostage is scary. The risk of incorrect prescribing, delayed surgeries, unknown allergies and delayed test results and possibly completely lost records cannot be oversold.

Having your records possibly viewed by a hacker is scary. Although the medical information loss is worrisome, the loss of vital identifiers can also be frightening. Your DOB, SS, address, bank account information…shall we go on?

Even scarier, the inability to get the information back, explaining to the government why you were unable to secure your data, and possible law suits, penalties and the loss of trust.

GOVERNMENT?

Let’s review what you, as a covered entity are required to do regarding electronic data…

CMS requirements for Electronic Security for any “covered entity” which means anyone:

  • Any provider of medical or other health care services or supplies who transmits any health information in electronic form in connection with a transaction for which HHS has adopted a standard
  • Any individual or group plan that provides or pays the cost of health care (e.g., a health insurance issuer and the Medicare and Medicaid programs).
  • Health Care Clearinghouses – A public or private entity that processes another entity’s health care transactions from a standard format to a non-standard format, or vice-versa.

Why then, if healthcare providers are following the CMS Electronic Security Rules, are they falling victim to RANSOMWARE attacks, or in fact, any virus?

CMS/HIPAA General Rules of meeting the Security Standard includes the following safeguards:

ADMINISTRATIVE – Security Management Process – Assigned Security Responsibility – Workforce Security – Information Access Management – Security Awareness and Training – Security Incident Procedures – Contingency Plan – Evaluation – Business Associate Contracts and Other Arrangements

PHYSICAL – Facility Access Controls – Workstation Use – Workstation Security – Device and Media Controls

TECHNICAL SAFEGUARDS – Access Control – Audit Controls – Integrity – Person or Entity Authentication – Transmission Security

So therefore, if an organization has policies, procedures, and documentation requirements in place to meet the CMS requirements for electronic device and information security, viruses and RANSOMWARE should not be a problem…Right?

Unfortunately, there are 2 major issues (and a host of minor ones) that may put your organization at risk from either a violations of the EPHI security requirements of CMS, or of suffering a virus or RANSOMWARE attack.

THE THINGS THAT PUT YOUR ORGANIZATION AT RISK

The first MAJOR RISK is that we all use, or are, PEOPLE.

The 2017 Level 3 Healthcare Security Study conducted by HIMSS Analytics and sponsored by Level 3 Communications found that approximately 80% of surveyed health IT executives and professional report that employee security awareness is their greatest concern regarding healthcare data security.

In large organizations there are large numbers of people, from the big guns of the Administrators and Providers, extending to housekeeping, students, security and Business Associates.

These big entities have people writing HIPAA and E-Security policies, giving inservices, even auditing HiPAA and e-Security. The job of these “people” are specifically to insure that the rules of CMS are followed up to and including those regarding E-Security.

So, why have these big entities been hit by viruses and RANSOMWARE?

Unfortunately, the sheer volume of people in these organizations make security a real issue both in physical plant (how to prevent someone claiming slip and fall injury), ID theft (people stealing a patient’s demographic information), HIPAA violations (both inadvertent such as the lobby conversation and deliberate as in reviewing the info of a VIP patient), and of course in E-Security.

E-Security can also be the defining factor in the theft of patient information or HIPAA data breaches as well as malware and viruses entering your IT system. Just think how many people have personal phones or other devices such as IPADs, as well as institution provided electronic devices. How many Medical and Dental residents are coming into these places in July, each getting their own usernames, passwords, VPN access to all kinds of IT systems and programs?

People are the issue in small and medium sized healthcare businesses as well. In these situations, the problem may be too little people, with not enough expertise to handle IT concerns, or a feeling that as a small business neither CMS nor RANSOMWARE attackers will come after you.

Personnel working in smaller practices may use their personal electronic devices for work, or may, as with any business plug them into the workstation by USB. Further, people in smaller organizations often travel between offices, take home HIPAA material or electronic devices. Also, more often than not, you begin to think of staff as family members or you have family members working there so you cannot conceive of them doing something that could harm your practice.

When you see this screen in smaller organizations, it is likely that data from your PC can be migrated to the personal device, or from the personal device. This is a common sources of virus and malware transmission as well as HIPAA breaches and data theft!

 

Bottom line? Unless every person you hire, use as a Business Associate, allow to intern, shadow, contract, clean, etc. for you is completely honest, follows all the rules, never opens personal email or uses personal devices on your system, never uses open Wi-Fi, and always turns off their computer at least once per week (not logging off, turning off) to allow for patches, people put you at risk.

The Identity Theft Resource Center and CyberScout released a survey in 2017 that showed the leading causes of healthcare data breaches was employee error or negligence.

The second MAJOR RISK(s) would be a combo of time, money and fatigue.

The HIMSS Analytics survey listed competing priorities and budget concerns as the top barriers in adopting a comprehensive security program.

While budget concerns may limit the number of people we have monitoring employee behavior, the ability to afford full time IT support, or even whether or not you have purchased licenses for the newest operating systems, the competing priority and fatigue issues may be worse.

In every organization, your specific priority depends on your role in the organization. A CEO or CIO will have different priorities that a clinical provider who just wants to log on, complete a task and get the job done.

The smaller practice gets impact by monetary priority fairly significantly as they cannot always afford IT personnel or regular updates to computer programs, they are often the entities using older Operating Systems, and many do not even have a written compliance and E-Security plan, let alone constantly reminding staff about it. If you are working in a small practice, go to your Administrator or Principle MD and say, “Does our practice have E-security threat intelligence, sandboxing or DDoS mitigation in place?” and watch their eyes glaze over.

And fatigue – One major reality of health care is overall fatigue, mental and physical. It is as real as what we call ICU alarm fatigue – too many things beeping and we tune everything out and miss something important.

We have been bombarded with HIPAA training for about 2 decades. When E-Security was added, we were already so exhausted by HIPAA, we barely listened to the new training.

We have passwords and usernames for so many programs we do the unthinkable, that is to use the same passwords where allowed or to write everything down and stick it near our work station or on our phones, etc.

We also, although trying to remember to log out of programs, or even the PC we are using, often do not turn the actual PC off (the necessary patches and updates to prevent malware can take place when the PC is turned back on0. The reason most of us conveniently forget to turn off the PC is the delay we experience when turning the PC back on, the patches and updates can take quite a bit of time if the machine hadn’t been turned off recently.

We are also so focused on getting our jobs done that we forget the exact policy or process related to IT security, for example clicking on an attachment in an email you think is from a colleague, or accessing streaming sites for radio, music, YouTube, or worse, accessing your Facebook from your work computer.

And we allow people to plug their personal USB or USB driven devices into their work stations!! Making it easy for malware to get into our system and for ePHI or Demographic data to be transferred to the personal device!!!

The HIMSS Analytics study also listed clinical workflows, employee awareness and in-house expertise as top security program barriers.

As they say – brown stuff happens, and sometimes it hits the fan!

So, if you have limited time, limited money, conflicting priorities, your best bet to protect your organization against malware, viruses or RANSOMWARE, even in the smallest organization, is to have a thorough and effective E-Security program as required by CMS.

Sounds too simple? Think about this…

RANSOMWARE attacks, virus intrusions, malware all violate the major 3 tenets of HIPAA Security:

Confidentiality – EPHI is accessible only by authorized people and processes (obviously if your system is hacked… someone unauthorized may be looking

Integrity – EPHI is not altered or destroyed in an unauthorized manner (RANSOMWARE threatens to destroy your data, which would include patient records if you don’t pay up, and even if you don’t pay, some data may still be lost depending on how long ago you backed up data.

Availability – EPHI can be accessed as needed by an authorized person (When a virus or RANSOMWARE locks up your system, and no one can access patient records… well you get the drift).

SUMMARY

  1. Make sure you are following the regulations put forth by CMS, no matter how small your organization may be, and that you have the required policies, enforce those policies and audit staff performance under those policies. This may not stop RANSOMWARE or other malware but it can indeed mitigate some of the financial, penalty and risk fallout after the event.
  1. Updated the policies and procedures and have your people sign off on each of them or the entire manual, minimally yearly, when hired and if found to be doing something incorrect.
  2. Have a plan to work without your electronic medical records. How will you cancel patients, move patients, schedule patients? How will you treat those needing immediate care? How will you record your treatment, and then insure if gets updated into the full EMR later?
  3. Strictly enforce, and punish, use of personal devices, use of personal email, opening of streaming radio, YouTube, Facebook, and any email download without first putting through a virus check.
  1. Require all staff in small offices, offices where workstations are not shared, etc. to not only log off, but also shut down their PCs and workstations at the end of their work week so IT updates (if you have an active IT provider), operating system patches, and Anti-Virus and Malware program updates can be installed when the computer is turned on again at the beginning of the week.
  1. Make sure that all of your systems, EMR, medical equipment related, billing related, even things like Quickbooks, etc. are updated regularly.

 

 

 

 

MAY 2017 COMPLIANCE UPDATES

PROVIDER COMPLIANCE

The Centers for Medicare and Medicaid Services (CMS) has implemented a series of videos for the Medicare Learning Network (MLN) to help providers of all types improve in areas identified with a high degree of noncompliance.

These videos are referred to as Provider Minute Videos as the recordings last anywhere from one to three minutes and are an educational resource to the provider community.

To locate the videos, please access the Provider Compliance section of CMS’s website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html

and click on: CMS Provider Minute YouTube playlist

OFFICE OF THE MEDICAID INSPECTOR GENERAL 2017-2018 WORK PLAN

In mid-April, the NYS Office of the Medicaid Inspector General (OMIG) announced the release of its 2017-2018 Work Plan. The Plan details OMIG’s program integrity focus areas in the Medicaid Program for the State Fiscal year 4/1/17 through 3/31/18.

This Work Plan is focusing on the following to help fight Fraud, Waste and Abuse in the Medicaid Program.

  • Physician Excessive Ordering – OMIG’s Recipient Investigation Unit (RIU) will review recipient data to identify physicians prescribing excessive amounts of controlled substances or providing unnecessary services. Identified providers are then referred for investigation to the Provider Investigations Unit (PIU).
  • Network Provider Review of Managed Care Organizations (MCO) – The Network Provider Review Project Team continues to conduct audits of network providers in MCO’s. The audits will ensure accuracy of claim submissions and confirm that provider records are in regulatory and contractual compliance. OMIG will identify improper claims that contribute to inflate capitation payments. OMIG will coordinate with the MCO’s and their Special Investigation Units in its audit efforts.
  • Provider Investigations – OMIG’s undercover investigators receive services from Medicaid providers and record the provider’s conduct during the undercover operation. The provider’s subsequent claims are reconciled with the investigator’s written report and evidence obtained by the investigator. These undercover operations are conducted t o identify quality-of-care issues and billing problems. They can also identify systemic fraud, such as paying recipients to undergo unnecessary medical tests. These investigations gather important intelligence on how providers/organizations operate and the types of drugs/services being abused. These investigations will continue in the course of OMIG’s program integrity efforts.
  • Recovery Audit Contractor (RAC) – The Medicaid RAC contractor in NYS is Health Management Systems Inc. (HMS). HMS reviews provider’s claims for services rendered to Medicaid recipients through fee-for-service or Medicaid Managed Care. HMS is responsible to identify both overpayments and underpayments. OMIG and HHS collaborate and coordinate their recovery initiatives with several other state agencies and CMS contractors. Audits include review of claims submitted for recipients that are dually eligible for Medicaid and Medicare, retroactive member disenrollment and recovery of capitation payments for beneficiaries who are no longer enrolled or eligible for Medicaid Managed Care coverage.

OMIG’s 2017-2018 Work Plan can be reviewed at:

https://omig.ny.gov/images/stories/work_plan/SFY_2018_OMIG_Work_Plan_FINAL.pdf

For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.com

 

COMPLIANCE UPDATES APRIL 2017

By Becky Amann, Compliance Manager

MEDICARE LEARNING NETWORK (MLN)

The Centers for Medicare and Medicaid Services (CMS) has recently reminded providers regarding their MLN publication pertaining to HIPAA Basics for Providers: Privacy, Security and Breach Notification Rules.

PF will be utilizing this document as part of our ongoing employee training regarding HIPAA.

This publication is located: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf

For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.com

 

THE SMARTPHONE – POSSIBLE RISK TO YOUR PRACTICE?

By Emilie DiChristina for PracticeFirst

Almost everyone has a smartphone now, but even the old style flip phone can be a risk to your practice.

Patient phones can present a HIPAA problem, a customer service nightmare and a medico-legal/malpractice issue. This shouldn’t be a surprise to you, but may be overlooked due to the ubiquitous nature of the technology. We are used to seeing a cell phone in everyone’s hand, no big deal right?

It can be a big deal from a medico-legal standpoint as the presence of a cell phone in the examination room can mean:

  • Your interaction, or your staff member’s interaction is being recorded – even if the phone is not out in the open, it may be recording the conversation. This could be a positive in that the patient is hoping to not miss any vital instruction. It could also be a negative in that any interaction the patient is unhappy with can wind up on social media, or in the hands of a lawyer.
  • When a second person is in the exam room with the patient, they may appear to be playing a game on this phone but may instead by video- taping the interaction. Now you have the same issues of the interaction ending up on social media, or in the hands of a lawyer, or being a civil rights/HIPAA violation.
  • Also, whether it is an old style flip phone or smart phone, pictures can be taken of charts, records, dirt in the corner of an exam room, over-flowing sharps containers…you get where this is going.

Staff and provider phones can also present HIPAA, customer service and medico-legal/malpractice issues as well as Human Resource issues.

  • Customer service can be impacted when employees or providers are perceived as being too involved with their phones. You may be looking up a PDR notation, but to the patient, you are not looking at them. When phones are seen on the desks of staff, patients will assume the worst as well.
  • Of course, recording or video-taping can also be an issue with employees. There are many stories of HIPAA violations when employees have taken pics of a special tattoo, or piercing and posted them on social media for example. Staff can also take a pic of a patient demographic sheet or computer screen as well, allowing PHI or ID information to leave the practice quit easily.
  • Other examples of HIPAA risk include providers and staff texting any information about a patient without using proper encryption software, losing a phone that has any PHI on it, and…
  • An often forgotten risk – the employee plugging their phone into a computer via USB to recharge. Unless your computers are hardened against intrusion, when the phone is plugged in, it becomes a storage device potentially allowing the download of PHI or ID information such as Social Security #’s, DOB, addresses, etc. directly on to the phone. One requirement of HIPAA/OCR is that you have a plan in place to prevent this because the risk is so significant.
  • For people with access to the financial records of the practice or providers, downloading this data to the phone can be a nice safeguard for potential termination.
  • When phones (and other devices) are plugged into computers used for patient care or practice issues there is also the risk of a virus or malware transferring into the computer and/or network. If insurers and governments can get hacked or be held hostage to data breach, your practice is at risk as well.

And there are HR risks as well. Allowing your staff to have a cell phone readily available to them during hours of operation reduces productivity. Practice costs are high enough, but hearing there is not enough time for your staff to get their work done, when you have seen them with their phone in hand should trigger an alert.

Human resources professionals often recommend that employee phones not be allowed in personnel meetings whether it is a positive or negative meeting. You may be aware of the trend for employees to post reviews of former employers, but if they have audio or video to go with their claims, the problems rises to a recruitment nightmare and possible Labor Board investigation should the recorded meeting be juicy enough.

So what do you do?

  • All phones that are used for texting/emailing PHI need to be owned by the practice, be password protected, be able to be wiped immediately if lost or stolen, and should use proper encryption software. These phones should also not be used for personal purposes by staff.
  • Non-provider staff members should not be allowed to use their personal phones at that work station, nor should they be carrying them on their person (e.g. keep them in locker or purse), and use should; be restricted to break time only, and only in a non-patient care area like a break room. Staff members should also be prohibited from charging their personal devices on a practice computer.
  • Providers using their phones in front of patients should explain why/what they are doing so the patient understands that they are not being ignored.
  • Practices should consider requesting that no cell phones be used in examination rooms, even by an accompanying visitor. To make this more palatable, it should be explained that the medical experience is improved when all parties are paying attention to the patient.<

COMPLIANCE UPDATES – APRIL 2016

OCR LAUNCHES PHASE 2 OF HIPAA AUDIT PROGRAM

As part of its continued efforts to assess compliance with the HIPAA Privacy, Security and Breach Notification Rules, the HHS Office for Civil Rights (OCR) has begun its next phase of audits of covered entities and their business associates.

The audit process begins with verification of an entity’s address and contact information. This is handled through an e-mail sent to covered entities (CE) and business associates (BA) requesting that their contact information be provided to OCR in a timely manner. Once verification has been received, a pre-audit questionnaire will be transmitted to gather data from the CE. OCR will ask that the covered entity identify their business associates. They are encouraging covered entities to prepare a list of each business associate with their contact information, so they are able to respond to this request. The data that is gathered will be used along with other information to create a potential audit subject pool.

If a CE or BA does not respond to OCR’s request for verification or their pre-audit questionnaire, OCR will use publically available information about the entity to create its audit subject pool. Therefore, if no response is received, the entity may still be selected for an audit or be subjected to a compliance review.

Please check your junk or spam e-mail for any e-mails from OCR. As your business associate, please notify Becky Amann at Practicefirst, should you receive any e-mails from the OCR regarding a Phase 2 audit. This will allow us to watch for any e-mails from OCR as well.

Additional information regarding Phase 2 of the HIPAA Audit Program is available at: http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/audit/index.html

For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.com

COMPLIANCE UPDATES FEBRUARY 2016

by Becky Amann, Director of Compliance

OIG 2016 WORK PLAN

The Office of Inspector General (OIG) has issued their Work Plan for 2016 which summarizes new and ongoing reviews and activities that they will pursue.

New investigations in 2016:

  • Physicians – Referring/ordering Medicare services and supplies:

The OIG will review select Medicare services and supplies referred/ordered by physicians and non-      physician practitioners to identify whether the payments were made in accordance with Medicare       requirements. CMS requires that physicians and non-physician practitioners who order certain services       and supplies are required to be Medicare-enrolled physicians or non-physician practitioners and legally       eligible to refer/order services and supplies. If they are not eligible, Medicare should not make payment       on the claims.

  • Anesthesia non-covered services

The OIG will review Medicare Part B claims for anesthesia services to determine whether they were       supported in accordance with Medicare requirements. Specifically, they will review anesthesia       services to determine whether the beneficiary had a related Medicare service. Medicare will not pay for items or services that are not “reasonable and necessary.”

  • Prolonged services – reasonableness of services

            The OIG will determine whether Medicare payments to physicians for prolonged evaluation and  management (E&M) services were reasonable and made in accordance with Medicare requirements. Prolonged services are for additional care provided to a beneficiary after an E&M service has been performed. Physicians submit claims for prolonged services when they spend additional time beyond  the time spent with a beneficiary for a usual companion E&M service. The necessity of prolonged             services is considered to be rare and unusual.

Continuing investigations in 2016:

  • Imaging Services: The OIG will review Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, they will focus on the practice expense components, including the equipment utilization rate. The report on their findings is expected to be issued in 2016.
  • Anesthesia Services: The OIG will continue to review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. They will also determine whether Medicare payments for anesthesiologist services reported on a claim with the “AA” modifier met Medicare requirements. Reporting an incorrect modifier on the claim, as if services were personally performed, when they were not, will result in Medicare paying a higher amount. The report on their findings is expected to be issued in 2016.

All practices and facilities should read the OIG Work Plan in its entirety and take steps to identify and rectify any potential issues they may have, before the OIG does.

The full 2016 Work Plan can be accessed at:

http://oig.hhs.gov/reports-and-publications/workplan/index.asp

For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfir

COMPLIANCE UPDATES JULY 2015

By Becky Amann, Compliance Manager

Medicare – Exclusions From Coverage

National Government Services (NGS) recently published an article regarding: Charges Imposed by Immediate Relatives of the Patient or Members of Household. NGS has recently identified claims submitted by providers who furnished services to their immediate relatives or to members of their household. Medicare does not pay for these services, since they are ordinarily furnished gratuitously because of the relationship between the Medicare beneficiary and the provider. Immediate relatives are defined as:

  • Husband or wife
  • Natural or adoptive parent, child and sibling
  • Stepparent, stepchild, stepbrother or stepsister
  • Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law or sister-in-law
  • Grandparent or grandchild
  • Spouse

A step-relationship and an in-law relationship continue to exist even if the marriage upon which the relationship is based terminates through divorce or death of one of the parties.

Members of Household are defined as:

Persons sharing a common abode with the patient as part of a single family unit, including those related by blood, marriage or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.

This Medicare exclusion applies whether the provider is a sole proprietor who has a relationship (as identified above) to the patient, or a partnership in which one of the partners is related to the patient.

Please refer to the Medicare Benefit Policy Manual, Chapter 16, Section 130 for further information regarding these exclusions from coverage. The Medicare manuals are located on CMS’s website under their Guidance section at:

http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html

*** Please note: These exclusions also pertain to Medicare Advantage Plans ***

Univera – Risk Adjustment Review of Medical Records

Univera has contracted with Verisk Health to retrieve medical record documentation from providers. The record retrieval is a necessary part of their Risk Adjustment Program that is designed to capture the medical complexity of their Medicare Advantage members. CMS requires Medicare Advantage plans to confirm that the diagnosis codes submitted via claims are supported in the medical records. The record review also ensures the documentation properly reflects the clinical conditions of the patient.

Verisk Health will begin contacting selected providers in July to schedule the retrieval of medical records reflecting services rendered from January 1, 2014 to present.

For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.com<

COMPLIANCE UPDATES JUNE 2015

NEW MEDICARE CARDS ARE COMING 

To protect seniors from identity theft, President Obama recently signed a bill that requires the Dept. of Health and Human Services (HHS) to issue new Medicare cards that do not display beneficiaries Social Security Numbers.

The new bill gives HHS four years to issue new cards to new beneficiaries and four more years to issue new cards to existing beneficiaries. This will take time, planning and effort for HHS to develop an identifier to replace the SSN and then issue new Medicare cards.

The announcement can be viewed at the Office of Inspector General’s, Social Security Administration website at: http://oig.ssa.gov/newsroom/blog/apr29-medicare-card-SSN

For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.com