CNN reported an astounding number of individuals charged with false billing. There was about $900 million in false billing that involved Medicare and Medicaid fraud. Along with the $900 in false billing, $36 million in Detroit involved a front for a narcotics diversion scheme. There were 301 defendants charged in the United States involving 61 medical professionals’ 36 Federal Judicial districts and 28 doctors were charged.

Electronic submission of staffing data through the Payroll-Based Journal (PBJ) is required of all long-term care facilities starting July 1. The last day to submit data for fiscal quarter four (July 1 through September 30) is November 14, 2016. Nursing homes can register now in the PBJ system to prepare:

Medicare is implementing a three year Pre-Claim Review Demonstration of Home Health Services in the states of Illinois, Florida, and Texas beginning in 2016, and in the states of Michigan and Massachusetts beginning in 2017.  CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits.

On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals and 150 organizations.

Medicare plans to start a Skilled Nursing Facility Value-Based Purchasing Program (SNFVBP), beginning fiscal year 2019. This program will be used to promote better clinical outcomes for skilled nursing facility patients and improve care during their stay at a skilled nursing facility.   Skilled nursing facilities will be paid for participating. Starting the summer of 2016 then quarterly Medicare will send confidential quality feedback reports on measurement performance; the results will be posted on Nursing Home Compare.

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In 2010, Medicare's policy for payment of outpatient services provided on either the date of a beneficiary's admission or during the three calendar days immediately preceding the date of a beneficiary's inpatient admission to a “subsection (d) hospital” subject to the inpatient prospective payment system, “IPPS” (or during the one calendar day immediately preceding the date of a beneficiary's inpatient admission to a non-subsection (d) hospital) became effective.   A Medicare Subsection D (d) hospital is an acute care, short-term hospital.

There are numerous Medicare & Medicaid review programs which have been created to stop the problems of improper payments, fraud and abuse within these federal programs. CMS is currently working with Integrity Management Services to consolidate and simplify. The resulting Unified Program Integrity Contractors (UPIC) aims to coordinate audits, investigations, and data analyses. Additionally, the official stated intent is to also lower the burden on providers who are trying to meet all the requests of different auditing agencies.

The Affordable Care Act of 2010 established the Hospital VBP Program, which

applies to payments beginning in FY 2013 (discharges on or after October 1, 2012)

and affects payment for inpatient stays in hospitals across the country.  Under the

Hospital VBP Program, Medicare makes incentive payments to hospitals based on


     How well they perform on each measure, or

     How much they improve their performance on each measure compared to their

                performance during a baseline period

As you know, the PQRS (Physician Quality Reporting System) includes the reporting of particular G codes to communicate with Medicare, details of the Functional Outcome Assessment and Pain Assessment and Follow-Up measures. These measures must be completed on at least 50% of an eligible professional's active patients to avoid penalty.

Recently, letters have been sent out to practices informing practices that they have not satisfactorily reported those PQRS measures and therefore, a negative payment adjustment (penalty) will be assessed from 2016 Medicare reimbursements.


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