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Take note of compliance changes for 2011 –
important for Medicare and Medicaid physicians
e-Reports, December 27, 2010
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Part I (See the next ISMA Reports for Part II on pay and bonuses) Untitled document

Krieg DeVault, LLP attorneys presented a compliance update for medical groups at the ISMA last month, detailing key policy and enforcement changes arising from the Patient Protection and Affordable Care Act (PPACA). In an overview, the presenters discussed audit and enforcement trends, claims issues, fraud and anti-kickback statute changes, payment and other topics of significance for medical practices.

Highlights from the session are included here.

Increased enforcement – The federal government has more power to fight fraud, and recouped billions of dollars in 2010, increasing Washington interest in discovering fraud. Be aware that the U.S. Department of Health and Human Services (HHS) is doubling the size of its Senior Medicare Patrol, comprised of Medicare beneficiaries nationwide trained to detect fraud.

“This is significant,” said attorney Leeanne Coons. “More Medicare beneficiaries will be trained and will ask you more questions about their bills.”

Recovery Audit Contractor (RAC) expansions – The PPACA extended the RAC program to Medicaid. States must contract with an auditing firm by January, for program implementation in April 2011.

“Prepare by doing routine auditing and training your staff,” Coons suggested. Medicaid RACs will have a state-specific appeal process, not a national process like Medicare. “For example, if you see patients from Kentucky or Illinois, you will need to use that state’s appeal process,” explained Coons.

Claims filing – Effective Jan. 1,

Medicare has reduced claims submission timeframes, which in the past stretched up to three years. Generally speaking, for services delivered before Jan. 1, 2010, a bill must be filed no later than Dec. 31,

2010. For services delivered on or after Jan. 1, 2010, the allowable period is one year after date of service. The Centers for Medicare & Medicaid Services (CMS) also has established certain limited exceptions to the new claims submission time requirements.

Suspension of payment – HHS and the state can suspend your Medicare and Medicaid payments pending an investigation of a “credible allegation” of fraud – upon consultation with the Office of the Inspector General.

Be sure to read the next ISMA Reports for part II discussing payment and bonuses.

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