December 19, 2011

Hospitals Settle False Claims Allegations

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Two hospitals have settled allegations of overcharging the government for infusion therapy and lithotripsy services, the U.S. Attorney for eastern California announced Dec. 7.

Sutter Health Association paid more than $1.4 million for the 25 northern California affiliate hospitals that were involved in the case, the U.S. Attorney stated.

Catholic Healthcare West paid more than $875,000 for the 36 affiliate hospitals in California, Nevada and Arizona that were involved in the case, the U.S. Attorney stated.

The Department of Health and Human Services' Office of Audit Services discovered the two health systems had duplicated charging for the administration of infusion therapy, unbundled infusion therapy services that should have been billed together and duplicated billing of lithotripsy services under separate revenue codes, the U.S. Attorney stated.

Another hospital, New Milford (Conn.) Hospital, had to pay almost $472,000 to resolve False Claims Act allegations involving improper billing for injections of leuprolide acetate, as previously reported in RAC Alert.

Region A RAC Posts 29 Issues

DCS, the Region A RAC, posted 29 inpatient issues Dec. 9 through Dec. 15. For more detail on the issues, see the list below.

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 216, cardiac valve and other major cardiothoracic procedures with cardiac catheterization with MCC

12/15/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 709, penis procedures with CC-MCC

12/15/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 834, acute leukemia without major O.R. procedure with MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 825, lymphoma and nonacute leukemia with other O.R. procedure without CC-MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 433, cirrhosis and alcoholic hepatitis with CC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 455, combined anterior/posterior spinal fusion without CC-MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 025, craniotomy and endovascular intracranial procedures with MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 585, breast biopsy, local excision and other breast procedures without CC-MCC

12/13/11

 

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 822, lymphoma and leukemia with major O.R. procedure without CC-MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 219, cardiac valve and other major cardiothoracic procedures without cardiac catheterization with MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 822, lymphoma and leukemia with major O.R. procedure without CC-MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 219, cardiac valve and other major cardiothoracic procedures without cardiac catheterization with MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 781, other antepartum diagnoses with medical complications

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 284, acute myocardial infarction, expired with CC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 444, disorders of the biliary tract with MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 199, pneumothorax with MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 024, craniotomy with major device implant/acute complex central nervous system principal diagnosis without MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 407, pancreas, liver and shunt procedures without CC-MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 037, extracranial procedures with MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 462, bilateral or multiple major joint procedures of lower extremity without MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 462, bilateral or multiple major joint procedures of lower extremity without MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 032 ventricular shunt procedures with CC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 945, rehabilitation with CC-MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 023, craniotomy with major device implant/acute complex central nervous system principal diagnosis with MCC or chemo implant

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 923, other injury poisoning toxic effect diagnosis without MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 327, stomach, esophageal and duodenal procedures with CC

12/9/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 506, major thumb or joint procedures

12/9/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 442, disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC

12/9/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

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