Chicago hospital defeats allegations of ‘ghost payroll’ scheme

https://www.beckershospitalreview.com/finance/chicago-hospital-defeats-allegations-of-ghost-payroll-scheme.html?utm_medium=email

False Claims Act & Physicians - Basic Primer

An Illinois federal court has dismissed a whistleblower lawsuit alleging University of Chicago Medical Center, Medical Business Office and Trustmark Recovery Services violated the False Claims Act, according to Bloomberg Law

MBO and Trustmark provided medical billing and debt collection services for UCMC. The whistleblowers, Kenya Sibley, Jasmeka Collins and Jessica Lopez, alleged MBO and Trustmark engaged in a “ghost payroll” scheme that involved regularly falsifying UCMC invoices, listing employes who didn’t work on the hospital’s collections and time charges from people who were not employees.

The whistleblowers, former employees of MBO and Trademark, alleged the companies and UCMC knew about the “ghost payroll” scheme, and that the allegedly falsified invoices caused the hospital to report overstated wages to the federal government, triggering a larger Medicare reimbursement than it was entitled to.

The complaint further alleged that MBO and Trustmark engaged in a “bad debt” scheme. “MBO would regularly write-off Medicare bad debts for amounts a Medicare beneficiary owed without conducting a reasonable collection effort, when Medicare beneficiaries were still paying on the debts, or when Medicare beneficiaries did not actually owe a debt,” the amended complaint states.

After writing off the bad debt, MBO would allegedly send the bad debt to Trustmark or another collection agency for further collection efforts.

On Sept. 14, Judge Harry Leinenweber of the U.S. District Court for the Northern District of Illinois dismissed the amended complaint, saying the whistleblowers failed to adequately allege the defendants engaged in a scheme to inflate bad debts and falsify invoices in University of Chicago’s cost reports. 

The allegations of a “ghost payroll” scheme fail because the whistleblowers failed to allege that defendants certified compliance with any regulation, which is required when filing a false claims case, the judge said in the decision. The amended complaint also fails to establish sufficiently UCMC’s knowledge of the alleged scheme.

The judge also ruled that the amended complaint failed to adequately allege a “bad debt” scheme. Allegations related to MBO’s and Trustmark’s bad debt reports to clients cannot satisfy the requirements to show that companies or their clients submitted improper claims for bad debt reimbursements to the government, reads the decision.

 

 

 

 

Urgent care network to pay $12.5M in billing fraud case

https://www.beckershospitalreview.com/legal-regulatory-issues/urgent-care-network-to-pay-12-5m-in-billing-fraud-case.html?utm_medium=email

Different Types of Fraud and Abuse found in Medical Billing - Leading Medical  Billing Services | medicalbillersandcoders

A company that owned and operated more than 30 urgent care centers has agreed to pay $12.5 million to resolve overbilling allegations, the Department of Justice announced Sept. 3. 

UCXtra Umbrella, which did business in Arizona as Urgent Care Extra, previously admitted to engaging in healthcare fraud and monetary transactions derived from unlawful activity. The company admitted that it had billing procedures in place that caused its providers to overstate the complexity of the medical services provided to patients. This resulted in falsely inflated reimbursement rates from health insurance companies, according to the Justice Department. 

The company also admitted that staff were encouraged to order tests and procedures that may not have been medically necessary to justify higher billing codes and reimbursement. 

Health insurance companies overpaid the company by an estimated $12.5 million due to the fraud scheme, according to the Justice Department.

 

 

An Unpleasant Surprise

An Unpleasant Surprise

An Unpleasant Surprise - Tradeoffs

Surprise medical bills have become a major issue for Americans, but federal legislation to protect consumers continues to stall. ICongress getting closer to halting this practice?

Listen to the full episode below, read the transcript or scroll down for more information.

https://podcasts.google.com/feed/aHR0cHM6Ly9yc3MuYWNhc3QuY29tL3RyYWRlb2Zmcw/episode/YTQzMDkzOGYtY2Q3MS00ZTU0LWI0ZTAtZGIyMGM3YWQ0ZTk4?sa=X&ved=2ahUKEwiRrfOb48zrAhXvmnIEHT-bBvgQkfYCegQIARAF&hl=en

The Basics: The Scope of the Problem

Surprise bills can occur when patients with insurance unknowingly receive care from an out-of-network provider while at an in-network facility (such as a bill from an anesthesiologist for a scheduled surgery).

That provider is not bound by a set rate negotiated with an insurer and may charge more for a service than the insurer is willing to pay, and patients can end up on the hook for the difference.

It is difficult to capture the full extent of the problem, but research shows that surprise bills, also called balance bills, occur often, and have only been increasing in frequency and size over the past few years. 

42% of hospital and ER visits may come with an unexpected charge
$2,000 average size of a surprise bill for a hospital visit
66% of Americans fear surprise bills
80% of Americans support surprise bill protections

The Source: Who’s To Blame?

Physicians

Hospitals employ some physicians directly, but many also contract with speciality physician groups of surgical assistants, anesthesiologists, radiologists, emergency medicine doctors and pathologists who may not be in the same insurance networks as the hospital. This is why most surprise bills occur. Research shows that private equity firms also play an important role, buying up speciality physician groups and using surprise billing as a core part of their business model.

Insurers

Insurers often take a lot of heat for the price of health care, but they play a more limited role in surprise billing. They can create narrow networks that leave hospitals or doctors out and open the door to balance billing. Insurers also do a poor job of maintaining accurate in-network provider directories, which means patients may think they’re choosing an in-network doctor when they are not.

Hospitals

While surprise bills from hospitals are less common than from physicians, they do occur when, for instance, a hospital is not in a patient’s network, but the patient is rushed there because of an emergency.

Ambulances

Air and ground ambulances rides are another source of surprise bills. One analysis showed that air ambulances resulted in median potential surprise bills of almost $21,700.

The Fixes: The Legislation Landscape

Federal Proposals

Over the past two years, Congress has considered at least four bipartisan bills to protect patients from surprise charges, but all four have stalled. The proposals offer different approaches to determine how much insurers will pay out-of-network providers. These bills typically address the problem by adopting a payment standard, arbitration process or a hybrid of the two.

Payment Standard

Insurers reimburse providers for out-of-network bills based on a set amount. Most bills propose using established in-network rates.

Arbitration

This process requires an insurer and provider to submit payment offers to a neutral party who makes the final call.

Hybrid

This approach combines the payment standard with arbitration to resolve disputes. An insurer pays a set amount, and if the provider disagrees, it can initiate arbitration.

State Laws

With federal solutions at a standstill, 30 states have passed varying levels of protections from surprise billing. As of July, 2020, 16 states have more comprehensive protections, which ensure that insured patients are only responsible for paying in-network costs, even when receiving care from out-of-network providers or emergency services at an out-of-network facility. Georgia was the latest state to pass such a law in July 2020. The other 14 states offer far more limited protections.

But even states with comprehensive protections cannot protect all patients from surprise medical bills. States are not able to regulate job-based coverage that falls under a federal law known as the Employee Retirement Income Security Act, which applies to most employer sponsored insurance. These patients remain vulnerable to surprise medical bills until Congress takes action to ban the practice.

Click on the map below for an interactive map from the Commonwealth Fund that details each state’s protections.

State Balance-Billing Protections | Commonwealth Fund

The Sticking Point: Will Congress Pass Protections?

Despite strong bipartisan support for protecting patients from surprise bills, disagreement comes over how much physician groups should charge and how much insurers should pay. Essentially, resolving this issue may mean Congress has to pick sides.

As a result, stakeholders such as hospitals and private equity-backed physician groups, in particular, have pushed back on federal legislation, arguing that banning surprise billing will cripple their bottom line. These equity-backed physician groups have powerful lobbying groups, and in 2019, spent at least $5 million to persuade lawmakers to halt the legislation.

The pandemic has increased the risk that patients will unknowingly receive care from an out-of-network provider or at an out-of-network facility. The Trump administration tried to limit surprise bills for those in need of COVID-19 treatment by banning hospitals and providers that receive money from its Provider Relief Fund from sending balance bills to patients. But this approach leaves significant gaps and has had mixed success.

 

 

Hospital revenue at risk in CMS’ proposal to move joint replacement to outpatient care

https://www.healthcarefinancenews.com/news/hospital-revenue-risk-cmss-proposal-move-joint-replacement-outpatient-care

Hospital revenue at risk in CMS' proposal to move joint replacement to outpatient  care | Healthcare Finance News

The Centers for Medicare and Medicaid Services’ push to move procedures from inpatient to less expensive outpatient care continues, with revenue at risk for lucrative joint replacement starting in 2021.

CMS’s continued push to the outpatient setting has been going on for some time, but the agency has found its sea legs in the recent hospital outpatient prospective payment system proposed rule, according to Stuart Clark, a managing director for The Advisory Board Company, in an August 27 presentation on payment updates.

CMS is slowly phasing out the inpatient only list over the next three years and is adding more services to the ambulatory surgical center list. There’s around 1,400 total codes on the list right now which are expected to be phased out by 2024.

MORE ON REIMBURSEMENT

Hospital revenue at risk in CMS’ proposal to move joint replacement to outpatient care

At stake is $3.2 billion in revenue for a one-day length of stay as 80% of revenue for all services is in joint replacement.

Susan Morse, Managing Editor

 

The Centers for Medicare and Medicaid Services’ push to move procedures from inpatient to less expensive outpatient care continues, with revenue at risk for lucrative joint replacement starting in 2021.

CMS’s continued push to the outpatient setting has been going on for some time, but the agency has found its sea legs in the recent hospital outpatient prospective payment system proposed rule, according to Stuart Clark, a managing director for The Advisory Board Company, in an August 27 presentation on payment updates.

CMS is slowly phasing out the inpatient only list over the next three years and is adding more services to the ambulatory surgical center list.

There’s around 1,400 total codes on the list right now which are expected to be phased out by 2024.

For 2021, CMS has added 11 new procedures to the ASC list, including musculoskeletal services and total hip replacement.

WHY THIS MATTERS 

Eighty percent of hospital revenue for all services is in joint replacement. At stake is $3.2 billion in revenue for a one-day length of stay.

Per hospital, 12-15 procedures may shift from a one-day stay to outpatient, according to Clark and Shay Pratt, vice president of Strategy and Service Line Research for the Advisory Board.

Hospitals may not see a huge amount of revenue at risk if they can continue to keep the services in-house, but in an outpatient setting.

However, there is less revenue to be made from the move to a lower cost care setting. And an estimated 83% of ambulatory surgical centers are physician-owned.

There is still debate on the efficacy of total hip replacement done as an outpatient service. Commercial payers say ASCs can provide total hip replacement, while opponents say they are not equipped for the service, according to the Advisory Board.

The comment period for the proposed rule is set to close on October 5.

Next year, CMS is expected to add cardiovascular services to the outpatient list, but the volume and revenue is not on as large a scale as joint replacement.

THE LARGER TREND IN TELEHEALTH

In telehealth, CMS is implementing incremental change as its use has increased dramatically during the coronavirus pandemic.

For Medicare reimbursement, 22 services have been added to the telehealth list. Of these, nine codes have been added permanently and 13 are approved through the end of the year in which the public health emergency ends.

Audio-only services are eligible under the public health emergency, but CMS is inviting input on how long they should remain eligible. The agency has said it’s uncertain about the value of an audio-only visit.

 

 

 

 

CMS to require positive COVID-19 test results for Medicare pay boost

https://www.beckershospitalreview.com/finance/cms-to-require-positive-covid-19-test-results-for-medicare-pay-boost.html?utm_medium=email

CMS to Pay For Hospital COVID-19 Care Furnished in Other Settings

CMS recently released guidance that includes a new requirement for hospitals to get a Medicare payment boost for caring for patients diagnosed with COVID-19. 

The Coronavirus Aid, Relief and Economic Security Act provided a 20 percent add-on payment to the inpatient prospective payment system diagnosis-related group rate for treating patients diagnosed with COVID-19. Until now, a physician’s documentation that a patient has COVID-19 was sufficient to receive the add-on payment. However, recent guidance from CMS adds the requirement to have a positive COVID-19 laboratory test documented in the patient’s medical record for the claim to be eligible for the add-on payment. The new requirement applies to admissions occurring on or after Sept. 1.

To receive the payment boost under the new guidance, the COVID-19 test must be taken within 14 days of the hospital admission. Only the results of viral testing that are consistent with CDC guidelines can be used. Tests performed by an entity other than the hospital, such as a local government-run testing center, can be manually entered into the patient’s medical record, CMS said.

Meeting the new requirement for the add-on payment could be difficult for hospitals, Ronald Hirsch, MD, vice president of the regulations and education group at R1 Physician Advisory Services, told Becker’s Hospital Review

“There is no way to indicate on a claim for a hospital patient that a test was positive or negative,” he said. “First, the hospital will manually need to go into every record for a patient with U07.1 as a diagnosis and look for a positive test in their own lab system. If one is not found, they will need to search the notes to see if the patient had a test in the 14 days prior to admission and if that test was positive. If there is a note the patient self-reported that they had a positive test, the hospital must decide if they must go through due diligence and attempt to get that actual test result for their records.”

In cases where there isn’t a positive test noted in the medical record, hospitals would need to notify the Medicare audit contractor that they are submitting a claim for a COVID-19 diagnosis that was made clinically, Dr. Hirsch said. The MAC would need to make the appropriate adjustment to ensure the 20 percent add-on payment is not made.

The “undue burden” that the new requirement will place on hospitals was one of the concerns the American Hospital Association highlighted in an Aug. 26 letter to CMS Administrator Seema Verma. The group is also concerned that requiring a positive COVID-19 test will lead to unnecessary additional testing.

“Basing the COVID-19 diagnosis code on clinical judgment alone — in line with coding rules — continues to be an important approach given that test accuracy may not be reliable, re-testing is unnecessarily onerous, and some communities face persistent testing shortages.” 

The AHA is urging CMS to drop the new requirement and allow provider documentation of a COVID-19 diagnosis to be sufficient for the add-on payment if the test result is unavailable. 

 

 

 

 

Geisinger chooses VisitPay as its new digital financial platform

https://www.healthcarefinancenews.com/news/geisinger-chooses-visitpay-its-new-digital-financial-platform

Geisinger chooses VisitPay as its new digital financial platform ...

The partnership will give Geisinger’s 1.5 million customers and 13 hospitals a consolidated and personalized healthcare billing experience.

Geisinger, a health system serving Pennsylvania and New Jersey, announced this week a new partnership with the digital financial service platform VisitPay.

The partnership will give Geisinger’s 1.5 million customers and 13 hospitals a consolidated and personalized healthcare billing experience through VisitPay.

Its financial services integrate within existing electronic medical record systems and can equip internal revenue cycle teams with a customer service portal for employees to manage patient obligations, customer requests and internal workflow.

Additionally, VisitPay’s system uses artificial intelligence and machine learning to give patient payment recommendations. It also offers point-of-service devices to collect payments and co-pays up front.

For patients who are offline, the platform provides the option to choose between electronic or paper billing statements.

WHY THIS MATTERS

The COVID-19 pandemic has created “historic financial pressures for America’s hospitals and health systems,” according to the American Hospital Association.

The AHA estimated a financial impact of $202.6 billion in losses for hospitals and health systems between March and June as a result of COVID-19.

As a result, many hospitals and health systems are looking for ways to turn around their finances.

VisitPay has found that using greater price transparency and more personalized and convenient payment options may be the way to do so. The company conducted research showing that while healthcare providers experienced a 47% decline and daily total patient payments between March and May, those who used VisitPay’s platform saw a 10% increase in patient payments.

The platform uses a five-point plan designed to give patients the flexibility they need while keeping them engaged in the financial cycle, ensuring providers sustain revenue.

The plan’s points are to maximize self-service, communicate purposefully, make precise offers, target relief appropriately, and balance patient satisfaction and payment rate.

THE LARGER TREND

To help health systems recover financially from the pandemic, Congress allocated $175 million in the Provider Relief Fund of the Coronavirus Aid, Relief, and Economic Security Act and in the Paycheck Protection Program and Healthcare Enhancement Act.

However, many hospitals are still feeling financial burdens and have asked for more assistance.

As they wait for aid, many hospitals have needed to reduce expenses through layoffs and furloughs. Others have created new strategies to recoup lost revenue, some of which include relying on telehealth to continue seeing patients, creating flexible workflows and ensuring positive patient engagements.

ON THE RECORD

“At Geisinger our sole focus is to make health easier for the communities we serve — it is our North Star and guides all of our strategic decisions,” said Kevin Roberts, the executive vice president and CFO at Geisinger. “Partnering with VisitPay is the latest step in that direction and highlights our mission to make healthcare more accessible for our patients, especially given the financial challenges caused by COVID-19. We are thrilled to roll out VisitPay’s solutions as we feel they will be extremely beneficial to our communities.”

 

 

 

 

Fewer than 10% of primary care practices have stabilized operations amid COVID-19 pandemic

https://www.fiercehealthcare.com/practices/fewer-than-10-primary-care-practices-have-stabilized-operations-amid-covid-19-pandemic?mkt_tok=eyJpIjoiWTJGaE1qTTRaalpsT1dGayIsInQiOiJTNWFxb3VcL3J3ZmE4ZWV0bFwvOGJCYUc0Ukd3TWp4WlM1SzBzT01aeVJIUGlsSWkwNTlVajJxekJqUUsrcWoxZ0IwTUNqVlhTWVJLQmZkSk1XNGtKVEdCOWg3NmRWeFdldFpsSmlONnFvTTFGQ2l1bzQ4S3ZqNWpoaUx2d1pHaSs1In0%3D

Fewer than 10% of primary care practices have stabilized ...

Four months into the COVID-19 pandemic, fewer than 10% of U.S. primary care practices have been able to stabilize operations.

Nearly 9 in 10 primary care practices continue to face significant difficulties with COVID-19, including obtaining medical supplies, meeting the increasing health needs of their patients, and finding sufficient resources to remain operational, according to a recent survey of close to 600 primary care clinicians in 46 states.

Only 13% of primary care clinicians say they are adapting to a “new normal” in the protracted pandemic, the survey found.

More than four months into the pandemic and at a time when 39 states are experiencing an increase of COVID-19 cases, fewer than 4 in 10 clinicians feel confident and safe with their access to personal protective equipment, according to the survey from the Larry A. Green Center in partnership with the Primary Care Collaborative, which was conducted July 10 to July 13.

Among the primary care clinicians surveyed, 11% report that staff in their practice have quit in the last four weeks over safety concerns.

A primary care provider in Ohio said this: “The ‘I can do 4-6 weeks of this’ transition to ‘this feels like a new/permanent normal’ is crushing and demoralizing. Ways to build morale when everyone is at a computer workstation away from other staff (and patients) feels impossible.”

“In the first few months of the pandemic, the country pulled together to stop the spread of the virus, and it seemed like we were making progress. Primary care clinicians and practices were working hard, against tremendous challenges,” said Rebecca Etz, Ph.D., co-director of The Larry A. Green Center in a statement.

“But now the country is backsliding, and it’s clear that primary care doesn’t have enough strength to deal with the rising number of cases. If primary care were a COVID-19 patient, it would be flat on its back,” Etz said.

The survey conducted by the Larry A. Green Center is part of an ongoing series looking at the attitudes of primary care clinicians and patients during the COVID-19 pandemic and the abilities of practices to meet patients’ needs.

Close to 40% of primary care providers report they are maxed out with mental exhaustion and 18% say they spend each week wondering if their practice or job will still be there next week.

In addition to feeling stressed, clinicians and their practices are also experiencing upheaval. The survey found that 22% of clinicians report skipped or deferred salaries, and 78% report preventive and chronic care is being deferred or delayed by patients.

Primary care clinicians report that 42% of in-person volume is down but overall contact with patients is high, while 39% report not being able to bill for the majority of work delivered, the survey found.

“Given the rapidly rising infection rates and persistent lack of PPE, more than a third of primary care clinicians are reporting feeling unsafe at the office, and 20% are cutting back on face-to-face visits while doing more remote outreach,” said Ann Greiner, president and CEO of the Primary Care Collaborative in a statement.

Greiner said this is a clear signal that payers must advance or retain parity for telehealth and telephonic calls.

“It also is a clarion call to move to a new payment system that doesn’t rely on face-to-face visits and that is prospective so practices can better manage patient care,” she said.

Providers say they need more support from private insurers, particularly when it comes to reimbursing for telehealth and telephone visits. 

According to the survey, a primary care doctor in Illinois said, “Recently told we would not be able to conduct telephone visits due to lack of reimbursement. I work in a low-income Medicare population which has low health literacy and no technology literacy. We were 80% telephone and 20% Zoom and in-office. This further exemplifies the extreme health care disparities in the U.S.”

 

 

 

Increasing unemployment alters national payer mix

https://mailchi.mp/9075526b5806/the-weekly-gist-july-24-2020?e=d1e747d2d8

 

One in every five workers is now collecting unemployment benefits as the country struggles to get the COVID-19 outbreak under control. A recent Families USA study estimates a quarter of the 21.9M workers that were furloughed or laid off between February and May lost their health insurance. And the payer mix will continue to change as the pandemic wears on.

The graphic below highlights a study from consultancy Oliver Wyman, looking at the impact of rising unemployment (at 15, 20 and 30 percent) on insurance coverage. With each five to ten percent rise in unemployment, the commercially insured population decreases by three to five percentThose who lose employer-sponsored insurance either remain uninsured, buy coverage on the Obamacare marketplaces, or qualify for Medicaid.

Surprisingly, Washington State and California are reporting little to no enrollment growth in Medicaid programs thus far. Experts point to lack of outreach and consumer awareness as key contributors to the slow growth—but Medicaid enrollment will likely begin to rise quickly in coming months as temporary furloughs convert to more permanent layoffs.

The right side of the graphic spotlights the growing number of uninsured individuals in those states with the highest uninsured rates. The previous record for the largest increase in uninsured adults was between 2008 and 2009, when nearly 4M lost coverage. The current pandemic-driven increase has crushed that record by 39 percent.

On average, states are seeing uninsured populations increase by two percent, with some as high as five percent. And the two states with the highest uninsured rates, Florida and Texas, are also dealing with the largest surge in COVID-19 cases and deaths. The ranks of the uninsured will continue to climb as states reimpose shutdowns, government assistance ends, and layoffs grow.