As we are quickly approaching the end of the year and you are considering beginning or updating your office compliance manuals… These are some important items to be aware of, especially if you haven’t heard of them or were unsure what they really were. These three items desperately need to be included in your office practices, policies, and compliance plan, or they could be devastating to both you and your office: The Sunshine Act, The Medicare Enrollment Revalidation Initiative, and ACA Overpayments. Also be advised, as each of the legal pages I read stated: the following are guidelines and best understanding. For any actual legal advice particular to office and procedures, you should seek final guidance from your own legal guides.
Sunshine Act
The Sunshine Act is designed to give transparency of the money and dealings between physicians, pharmaceutical companies, medical device and other medical supply manufacturers. Physicians and manufacturers are to report (or disclose) any and all such incentives and payments they receive to CMS. Payments need to be reported by date and amount as well as list the nature of the payment or incentive (i.e. gifts, meals, speaking honoraria, etc).
The Sunshine Act was passed in 2011, but in May of this year (2012) CMS decided to delay data collection in connection with the act until January 2013.
For more information you can visit: Ober|Kaler Attorneys at Law http://www.ober.com/publications/1101-physician-payment-sunshine-act
Medicare Enrollment Revalidation Initiative
In 2011, Medicare announced that they would be revalidating Medicare physician enrollments for physicians who were enrolled prior to March 25, 2011. If you haven’t revalidated yet, there are only a few more months for them to complete this mass reenrollment, their original time-frame was to have the reenrollments completed by March of 2013 (*see below for possible date change via the American Bar Association). If you haven’t already received their reenrollment request, you will basically receive a letter/form from them to reenroll your physician(s) which must be completed and returned as soon as possible. Failure to respond within 60 days could result in a loss of Medicare billing privileges for a year effective within just 30 days of Medicare making their determination.
If you haven’t received the request for reenrollment from Medicare yet and you want to be pro-active and just do it… Well, you can’t. You have to wait for the request. When you get it, take care of it properly, thoroughly, and quickly. Otherwise you could find yourself on the outs with Medicare for a while, because even though an appeals process exists, there is no time frame for how long the process might take, and you are still out for the entire time of the process.
*The American Bar Association was holding a webinar regarding the revalidation/reenrollment of Medicare in March of 2012 and they had the following in their description:
“Due to changes in the Affordable Care Act (“ACA”), the Centers for Medicare and Medicaid Services has launched a major new Medicare enrollment revalidation effort, requiring that nearly all providers and suppliers authenticate and update the entire content of the Medicare enrollment records by 2015. Revalidation requests have already commenced. What’s more, the revalidations are subject to the new enrollment requirements of the ACA as well as updated enrollment forms. The means enrollment fees, contractor on- site reviews and new disclosure requirements regarding ownership thresholds.” (Bolding added.)
http://apps.americanbar.org/cle/programs/t12mrr1.html
For more information on Medicare enrollment and reenrollment process:
Gray, Plant, and Mooty Attorneys
http://www.gpmlaw.com/resources/newsletters/health-law-alert-medicare-enrollment-revalidation.aspx
AMA (American Medical Association)
http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/medicare-enrollment-process.page\
CMS http://www.cms.gov/Medicare/Medicare.html
ACA – Overpayments
A requirement became effective on March 23, 2010 because of the Affordable Care Act (ACA) that requires the reporting of Medicare and Medicaid "overpayments". Any overpayments are to be reported and returned within 60 days of the overpayment being "identified”.
In the simplest terms, if you’ve identified an overpayment or received a tip or suspect that an overpayment has possibly occurred and you have not investigated, reported, and returned the funds within the 60-day window, you’ve made a false claim. If you think that ignorance is bliss and by not knowing, being aware of, not investigating or checking lets you off the hook, you are sadly mistaken. If you fail to know, report, and repay, you will be seen as having acted in “reckless disregard and deliberate ignorance”. These are Federal funds, therefore being fined would be the least of your potential outcome worries. Federal prison for fraud and misuse of Federal funds would also be on the menu.
This naturally brings up the questions of: “What is an overpayment?” and “When is something identified?”
Well CMS generally gives the following as examples over overpayments:
- Payments for noncovered services.
- Duplicate claim payments.
- Payments above the allowed amount for a covered service.
- Payment from Medicare when Medicare is NOT the primary payor (i.e. another payor/insurance company has primary responsibility for payment for a service).
- Other “errors” and nonreimbursable expenses in cost reports.
In February of this year (2012) a proposed rule was issued to define “identified” (https://federalregister.gov/a/2012-3642). I couldn’t find any information saying that the proposed rule had been finalized. Included in this proposed rule is a requirement that providers report overpayments that have occurred not only going forward, but for up to 10 years prior (Medicare’s normal statute for which they can also audit you). However, not have a finalized definition of “identified” doesn’t absolve you of your ACA requirements for overpayments. Again, this has been in effect, as a law, since March 2010.
For a full legal description you can look here. It is a reference regarding overpayments from BrooksPierce Attorneys and Counsellors: http://www.brookspierce.com/assets/htmldocuments/FWC_Overpayments.pdf
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