Archive for May, 2013

Leader of Hospital Identity Theft Ring Sentenced

The ringleader of an identity theft/tax fraud ring that involved Troy Regional Medical Center in Alabama has received a 10-year prison sentence, the Troy Messenger newspaper reports.

Rhashema Deramus pleaded guilty for operating a ring that stole patient information from the hospital, used the identities to file fraudulent tax returns, and placed the refunds on at least 520 pre-paid debit cards, which ring members then cashed out at ATMs, collecting nearly $1.2 million. In her plea bargain, she agreed to testify against other defendants.

A contract employee at the hospital who recently was sentenced to 65 months in prison provided Deramus the information on 881 patients. The information included names, dates of birth and Social Security numbers, among other data.

A Secret Service agent told the newspaper that about 7,000 individuals were affected by the identity theft.

No Testing For ICD10 with Providers Directly

Jurisdiction 11 Part B

  Will providers be able to test ICD-10 claims with their contractor in advance of the October 1, 2014, implementation date?

A   Medicare does not plan to pursue testing of Medicare fee-for- service (FFS) claims directly with providers for ICD-10 at this time. The Centers for Medicare & Medicaid Services (CMS) feels confident that the current level of testing that is done each quarter for any changes to the Medicare claims processing systems is effective to ensure that claims will be processed properly and that ICD-10 diagnosis codes will be accepted and claims will be processed correctly.

CMS follows a very rigorous system development life cycle in which the changes to the Medicare FFS systems are tested. When changes are developed, the following protocol is used:

  • The maintainers conduct alpha testing for one month
  • The single testing contractor conducts beta testing for two months
  • Part A and Part B Medicare Administrative Contractors (A/B MACs) conduct user acceptance testing for one month

In addition, because most ICD-10 system changes are expected to be completed by October 1, 2013, a full year ahead of schedule, CMS plans to conduct additional testing prior to the October 1, 2014, implementation date.

Special Advisory Bulletin From OIG

 The Office of the Inspector General (OIG) has posted a Special Advisory Bulletin describing the scope and effect of the legal prohibition on payment by Federal health care programs for items or services furnished:

  • by an excluded person or
  • at the medical direction or on the prescription of an excluded person. 

OIG Updates Self-Disclosure Protocol

The Department of Health and Human Services Office of Inspector General (OIG) has revised its Provider Self-Disclosure Protocol (SDP), which allows healthcare providers to voluntarily identify, disclose and resolve potential healthcare fraud involving federal healthcare programs. Under the limited conditions set forth in the SDP, providers that self-disclose may pay reduced damages for violations and may be able to mitigate potential exposure for returning overpayments within 60 days of it being identified.

United Healthcare Changes Protocols – Effective July 1, 2013

Important Changes to and Expansion of Radiology and Cardiology Notification and Prior Authorization Protocols — Effective July 1, 2013

United Healthcare Commercial Plan – Beginning July 1, 2013:

United Healthcare’s existing Outpatient Radiology Notification Protocol and Cardiology Notification Protocol will include a prior authorization requirement when a United Healthcare Commercial member’s benefit document requires health services to be medically necessary in order to be covered. For those members, after you notify United Healthcare of a planned service subject to the protocols, we will conduct a clinical coverage review to determine whether the service is medically necessary. You will be informed of the decision. You do not need to determine whether a clinical coverage review is required in a given case or for a given member because once you notify us of a planned service we will let you know whether a clinical coverage review is required.

Radiology prior authorization – Beginning July 1, 2013:

Ordering providers that are subject to United Healthcare’s Physician, Health Care Professional, Facility and Ancillary Provider 2013 Administrative Guide for Commercial and Medicare Advantage Products (Administrative Guide) must notify United Healthcare prior to scheduling certain CT, MRI/MRA, PET scan, nuclear medicine and nuclear cardiology procedures for United Healthcare Commercial members. The advanced imaging procedures requiring advance notification are referred to as Advanced Outpatient Imaging Procedures. For a complete list of CPT codes requiring notification, please refer to  2013 Radiology Prior Notification/Authorization CPT Code List by clicking here.

Once advance notification of a planned Advanced Outpatient Imaging Procedure is received, United Healthcare will conduct a clinical coverage review to determine whether the service is medically necessary if the member’s benefit document requires health services to be medically necessary in order to be covered. If the member’s benefit document does not require clinical coverage review to determine medical necessity, and if the service does not meet evidence-based clinical guidelines, or if additional information is needed, we will let you know whether you must engage in a physician-to-physician discussion.

Rendering providers that are subject to the Administrative Guide must confirm that the prior authorization process has been completed and a coverage decision has been issued before rendering any Advanced Outpatient Imaging Procedure. If the ordering provider does not participate in United Healthcare’s network and is unwilling to complete the prior authorization process, the rendering provider must complete the prior authorization process and verify that a coverage decision has been issued prior to rendering the Advanced Outpatient Imaging Procedure.

Providers are not required to notify United Healthcare of any advanced imaging procedures rendered in an emergency room, urgent care center, observation unit or during an inpatient stay.

United Healthcare Reimbursement Policy Changes Delayed for Radiology

Commercial Reimbursement Policy Changes Delayed to Second Quarter 2013

Unless otherwise noted, these reimbursement policies apply to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent or its successor form. UnitedHealthcare reimbursement policies do not address all factors that affect reimbursement for services rendered to UnitedHealthcare members, including member benefit plan documents, UnitedHealthcare medical policies and the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Once implemented the policies may be viewed in their entirety here.  In the event of an inconsistency or conflict between the information provided in the Network Bulletin and the posted policy, the provisions of the posted policy prevail.

The implementation of the following reimbursement policy enhancements announced in the November 2012 Network Bulletin as effective first quarter 2013 , is being delayed and the policies will instead be effective in the second quarter 2013.

Reimbursement Policy Enhancements November Network Bulletin
Contrast and Radiopharmaceutical Materials Policy – Revision for POS 24  Page 10 
Durable Medical Equipment Policy – Revision to Require Modifiers when an item can be rented versus purchased  Page 10 
Obstetrical Policy: Duplicate Services Revision  Page 11 
Professional/Technical Component Policy: Duplicate Services for PC/TC Indicator 2 (professional component only) Codes – Revision  Page 12 
Professional/Technical Component Policy – Revision for Selected Radiology Services Reported in a POS 24  Page 12