EisnerAmper Blog

An EisnerAmper Health Care Services Blog

Fingerprint-Based Security Measures for Medicare Providers

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November 25, 2014

By Nancy Clark, CPC, CPC-H, CPB, CPMA, CPC-I 

Clark_NancyThe recently published 2015 Office of Inspector General (OIG) Work Plan indicates that enhanced provider security screening is now in place and will be reviewed by the OIG.

In August, the Centers for Medicare and Medicaid Services (CMS) began implementation of 42 CFR Part 1007, which was originally published in the Federal Register in 2011.   The new security provision was implemented on August 6, and includes fingerprinting-based background checks.  The contract for fingerprinting was awarded to Accurate Biometrics, in Chicago, Illinois

Medicare Administrative Contractors (MACs) have started sending letters to providers, listing all owners who require fingerprinting.  Providers must respond within 30 days from the date of the letter.  Failure to respond could result in either revocation of Medicare billing privileges or denial of Medicare enrollment applications.

These security background checks are now required for all individuals with a 5% or greater ownership interest in an organization and those that fall into the “high-risk” category.  High risk individuals include newly-enrolled Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) suppliers and home health care agencies (HHAs).

CMS is implementing other new measures in an effort to prevent fraud, waste and abuse resulting from weaknesses in the Medicare enrollment process.  These include background checks and an automated provider screening process for providers and home health agency workers.  For more information, see MLN Matters® Number SE1417.

Office of the Inspector General – 2015 Work Plan

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By Michael J. McLafferty, CPA, MBA, FACHE, FACMPE, FHFMA

 McLafferty_MikeOIG 2015 Work Plan

On October 31, 2014, the Office of the Inspector General (“OIG”) published in Work Plan for 2015. The annual plan suggests areas that the OIG intends to review and audit. The OIG typically focuses on activities it believes resulted from overutilization of services and potential fraud. Providers use the OIG Work Plan as a guide to prepare for potential audits and areas to review the effectiveness of their internal controls. The law firm of Hall Render has prepared a comprehensive summary of the OIG’s 2015 Work Plan. The 2015 OIG Work Plan is available here.


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November 12, 2014

By Steven Bisciello, MBA, CMPE

Bisciello_StevenLast week, $840 million dollars was earmarked by the Secretary of Health and Human Services (HHS), Sylvia M. Burwell, toward the Transforming Clinical Practice Initiative. The goal is to create and support networks developed to help physicians have timely access to health information and ultimately result in improved health outcomes. The investment is over the next four years and will support 150,000 clinicians.

Providers are being asked to redesign their practices, getting away from the patient volume model and moving towards a patient health outcome model.

These models will subsequently spawn coordinated health care networks which will include group practices, health care systems and others.

This model is being geared to help providers share patient health information safely within the network, to coordinate care and further improve the quality and delivery of care.  This strategy is also designed to reduce costs through this information sharing and coordination of care amongst the different providers and ultimately reduce hospital readmissions.

Some examples of this strategy include: Creation of shared patient portals where patients can communicate with their “team” of providers; allotting providers more access to pharmacies and patient medication information, to ensure and assist patients in medicating properly; and implementing and utilizing Electronic Medical Records (EMRs) to allow for safe, quicker sharing of patient health information amongst the provider team.

Participating provider practices and health care organizations will receive technical assistance and support from their peers to better provide synergetic patient care in a timely and efficient manner.

This will also prepare providers ahead of time to achieve success in a forthcoming health care arena, one that measure success and reimburse on value and outcomes.

Find out more about the Transforming Clinical Practice Initiative

CMS Introduces Modifiers to Combat Abuse

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October 22, 2014

By Nancy Clark, CPC, CPC-H, CPB, CPMA, CPC-I

Clark_NancyThe Office of Inspector General (OIG) has identified continued abuse of modifier 59, Distinct Procedural Service.  This modifier indicates when physicians’ services that are usually considered integral to each other may be reported separately for additional payment.  Frequently, this modifier is applied to services that should not be billed separately and the provider inappropriately receives reimbursement.  Transmittal 1422 states that the 2013 Comprehensive Error Rate Testing (CERT) data projected a $320 million error rate in physician claims and $450 million in facility claims appended with modifier 59. The Centers for Medicare and Medicaid Services (CMS) indicate that four new modifiers will be implemented in January 2015 in an attempt to better identify inappropriate claims. 

These new Healthcare Common Procedure Coding System (HCPCS) modifiers, referred to collectively as -X{EPSU} modifiers, are considered subsets of modifier 59:

  • XE indicates a Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter  
  • XP indicates a Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner    
  • XS indicates a Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure  
  • XU indicates an Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

CMS believes that by identifying specific reasons for utilizing modifier 59, it will be easier to filter claims that may be billed inappropriately.  Provider education is crucial for submitters to understand when a service can be appropriately “unbundled.”  Nonetheless, we can expect frequent audits of claims with both modifier 59 and the new subset modifiers.  Ensure that documentation substantiates distinct services whenever claims are submitted, or expect to forfeit payment and undergo potentially time-consuming audits.

Physician Open Payments Are Online at the CMS Website

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October 7, 2014


By Michael J. McLafferty, CPA, MBA, FACHE, FHFMA, FACMPE

McLafferty_MikeThe first batch of Open Payments data connecting your physicians to financial arrangements with certain businesses was published online September 30. Your physicians’ financial data may not be on the CMS website now even if it was collected, but that doesn’t mean it won’t be there eventually.

The data collection mandated by the federal Sunshine Act and performed from Aug. 1 to Dec. 31, 2013, is broken into three categories:

  • General payment details including all payments or other transfers of value from applicable group purchasing organizations (GPOs) or manufacturers to physicians and teaching hospitals that have nothing to do with research agreements or protocols;
  • Research payment details for those payments or transfers of value that do involve research agreements or protocols; and
  • Physician ownership information about physicians who have an ownership or investment interest in a manufacturer or GPO.

Your data could be there but ‘de-identified’

The data your doctors’ financial partners submitted may not be identifiable, or tied to your providers, in this edition of Open Payments.

About 4.4 million records have been collected, but CMS estimates that 40% of them — which would come to 1.76 million records — have been stripped of identifying details, or “de-identified,” while 199,000 other records are not published at all.

All the records were checked against the National Plan & Provider Enumeration System (NPPES); the Medicare Provider Enrollment, Chain and Ownership System (PECOS); and a private database to confirm the connection between the physicians and teaching hospitals and the payment information, CMS explained on a press call September 30. Records that were fully confirmed against physician names, national provider identifiers (NPIs) and licenses are published and the physicians are identified; those that were not confirmed have been published without identifying the physician.

Also de-identified are records for which providers entered a dispute in the review period but did not have 45 days to pursue it as the law allows

Of the unpublished records, 190,000 are not available because the GPOs or manufacturers requested that the information be held for reasons relating to ongoing research, as the law allows, while 9,000 are unpublished because a dispute lodged by a provider is ongoing.

CMS says the agency expects the de-identified 2013 data will be updated during the next reporting cycle in 2015 so that the physicians are identified.

Beware of Big Files

The Open Payments website has a download library and a “data visualization” tool to help you navigate the data — including a search feature for looking for individual doctors or teaching hospitals.

The online files are big. The largest identified data for general payments is 1.4 gigabytes, and CMS warns that you may have trouble importing these large files into regular spreadsheet programs such as Excel.

If you have an IT team, you can use a database server such as MySQL to put the big file into a database and then develop a simple user interface for you to view and work with the files, suggests Sean Vogt, director of operations at Greenview Data in Ann Arbor, Mich. Alternately, you can use a commercial file editor such as Vedit which Greenview developed, to split the files into parts that can fit into Excel, he says.


Meaningful Use Deadline

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By Steven Bisciello, MBA, CMPE

Bisciello_StevenWith the October 1, 2014 deadline for eligible professionals to attest to the meaningful use EHR Incentive Program rapidly approaching, attention has been turned to the CMS attestation website. 

Recently, the reporting options were expanded by CMS, allowing eligible professionals to utilize either the 2011 or 2014 Certified EHR Technology (CEHRT), or a combination of the two, to be able to secure the 2014 payment and avoid the Medicare payment adjustment which will go into effect in 2015.

However, there is an issue with the current website used to report. It does not allow new eligible professionals to attest using these new options until after the October 1 date has passed (the site actually won’t allow reporting until mid-October).  Reporting in mid-October results in the eligible providers being unfairly subjected to the 2015 payment adjustment.  Eligible Providers have begun to lobby CMS to oppose the utilization of this website. 

Professional organizations such as the Medical Group Management Association have joined the protest, and recently sent a letter to CMS on behalf of the eligible providers and its members.  The letter requested that CMS Immediately modify their attestation website, extend the attestation deadline for new eligible providers and communicate these changes to the provider community immediately.

We will pay close attention to CMS’s response and any changes to the reporting period and its subsequent website.

As a reminder, if you are a Medicare provider in your second year of Stage 1 Meaningful Use in 2014, you must select a three-month reporting period in a respective quarter.  The only start date left would be October 1.
If you are starting Stage 2 in 2014, again the only start date left is October1 and there are additional core measures that were not required in Stage 1. For more information on the Stage 2 requirements, check out the CMS guide to Stage 2 criteria changes .

For more specifics overall on Meaningful Use and the quality measure, please click here

Auditors to Review Physician Fees ‘Related’ to Denied Hospital Claims

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September 16, 2014

By Michael McLafferty, CPA, MBA, FACHE, FHFMA, FACMPE

McLafferty_MikeAccording to AIS’s Medicare Compliance newsletter, if hospitals suddenly find that more physicians embrace compliance and documentation improvement, it’s probably because Medicare auditors are now authorized to rebuff professional fees “related” to hospital payment denials, according to the Center for Medicare and Medicaid Services (CMS). As of Sept. 8, auditors may deny physicians’ claims based on hospital records, upping the ante for the quality of documentation outside their offices.

Medicare Transmittal 534 issued by CMS on Aug. 8, gives Medicare administrative contractors (MACs), recovery audit contractors (RACs) and zone program integrity contractors (ZPICs) the authority to review physician payments “related” to hospital and other claims that are rejected because they are not considered medically necessary for various reasons.

Transmittal 534 says MACs and ZPICs will soon have the discretion to deny physician claims before or after related hospital versions are submitted. “If documentation associated with one claim can be used to validate another claim, those claims may be considered related,” according to the transmittal, which provides two examples of claims that can be denied as related:

  • Inpatient vs. outpatient: The MAC reviews Part B payments from admitting physicians and/or surgeons if the inpatient admission is denied as not reasonable and appropriate for Part A payment because the services could have been provided in an outpatient or observation bed. If the MAC decides the physician service was “reasonable and necessary,” it will be recoded “to the appropriate outpatient evaluation and management service.”
  • Medical necessity of the procedure: The MAC recoups Part B payments from admitting physicians and/or surgeons post-payment when the patient’s history and physical, physician progress notes or other hospital documentation doesn’t back up the medical necessity of the procedure.

CMS has recently replaced Medicare Transmittal 534 with Transmittal 540 to adhere to CMS’s inpatient recording policy standards.

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