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Headline News
NPI Registry Is Up and Running
WASHINGTON--After months of preparation, the eagerly awaited Internet registry of National Provider Identification numbers and other health care provider data is operational.

The system allows health care providers to locate their referral sources' NPI numbers and other critical data in order to submit compliant claims to Medicare. It was established by CMS as a means of complying with provisions in the Health Insurance Portability and Accountability Act.

The registry should be a help to both providers and HHS, CMS said in a notice published in the May 30 Federal Register. "Internet availability eliminates the need for entities to submit initial and ongoing requests for data to HHS and for HHS to process and respond to each of those requests," the notice said.

The data, which discloses only information obtainable through the Freedom of Information Act, is available in downloadable files and in a query-only database. Users can query by NPI or provider name to access the information, and data will be updated monthly. There is no charge to access the registry, and no user IDs or passwords are required.

"It is still good for providers to try and obtain the information from the physicians at the time of referral, but if that is not a possibility or the intake person has forgotten, the registry is a great tool," said Sarah Hanna, vice president of ECS Billing & Consulting in Tiffin, Ohio. "Our medical documentation department is using it and finding it to be helpful."

With the registry operational, it is critical that providers include NPI numbers on their claims, officials said. "Between the period of Sept. 3, 2007, and Oct. 29, 2007... Part B carriers and DME MACS will begin to turn on edits to validate the NPI/[legacy number] pairs submitted on claims. If the pair is not found on the Medicare NPI crosswalk, the claim will reject," CMS said in a communication to providers.

The agency also stressed the importance of validating that the National Plan and Provider Enumeration System has all NPI and legacy numbers a provider intends to use on claims. "If the information is different in the two systems, there is a very good chance your claim will reject," CMS said.

CMS said Medicare contractors might contact providers that have not been submitting their NPIs or those with a high volume of rejections in order to validate NPPES information.

To access the registry, click here.

For a Medlearn Matters article on using the NPI correctly on Part A and Part B claims, click here.

For information on using the NPI on the new CMS 1500 and UB-04 forms, click here.

Gallahue joined ResMed in January 2003 as president and COO of the Americas, and in September 2004 was named president and COO-ResMed Global. Before joining the company, Gallahue was president of Nanogen, a San Diego-based DNA research and medical diagnostics company. Earlier in his career, he worked for Instrumentation Laboratory, Procter & Gamble and General Electric.

Provider's Complaint Prompts Call for Audit of Medi-Cal
SACRAMENTO, Calif.--A Joint Legislative Audit Committee has agreed to an audit of Medi-Cal after a home medical equipment provider challenged the California Medicaid program over fee schedules that pit providers against a little-known law.

The committee of state Assembly and Senate members convened on Aug. 29 to consider the issue, which was brought before the panel by state Assemblyman Rick Keene of Chico.

"They agreed unanimously that they needed to make a determination on which law prevailed," said Tom Lambert, president of Maximum Comfort in Redding. Lambert enlisted Keene's help in taking the case to the JLAC after Medi-Cal auditors told him and other California HME providers that they were violating state law by submitting power wheelchair claims above state law limits--even though the claims adhered to Medi-Cal fee schedules and were pre-approved.

The claims, according to the auditors, exceeded the limits established under Title 22. Passed in 2003 with the intent of fighting HME fraud, the law essentially places a ceiling on what providers can bill Medi-Cal. However, Medi-Cal fee schedules generally exceed that ceiling, which tops off at 100 percent above invoice. (See HomeCare Monday, Aug. 27.)

"We're following the rules given to us by the Department of Health Services but we're made out to be the bad guys," Lambert said.

Lambert said he was heartened by the committee's call for an audit by the Bureau of State Audits. The audit should begin in October, he was told, and take about 60 days.

Bob Achermann, director of the California Association of Medical Equipment Product Suppliers, also applauded the committee's ruling but is cautious about its impact.

"It remains to be seen as to how all this comes out," he said, noting that the Bureau of State Audits can only make recommendations and observations; it cannot change laws. "They are going to look at [the issue]. What we don't know is what they are going to find or what they are going to conclude."

Another unknown is how Medi-Cal will respond to the bureau's findings, he said.

Achermann also warned that the Medi-Cal audit wouldn't necessarily end the audits of California HME providers that are already under way or on the audit dockets. Through those audits, at least a dozen HME providers, including Lambert, have been hit with sizeable repayment notices ranging from $50,000 to $500,000.

The Medi-Cal audit, Achermann said, simply "lays the groundwork for legislation."

Keene's press secretary, Evan Oneto, said the next step hinges on the audit results. "Their findings will have a great bearing on what we decide to do with it," he said. "If they find that these two standards are different, then we need to fix that."

That was encouraging to Lambert. He said he expected that Medi-Cal would eventually release the $165,000 it has offset from him as part of the $469,000 it demanded in repayment, and he anticipates the same for other providers in similar situations.

Lambert credited Keene with the JLAC victory. "He didn't just save me, he saved all the dealers in California who do Medi-Cal," he said.

Three S. Fla. Fraud Schemes Derailed by Strike Force
MIAMI--The operators of several HME companies that defrauded Medicare of more than $22 million are set for sentencing in three separate cases announced last week by the U.S. Attorney for the Southern District of Florida and the Miami Field Office of the FBI.

The cases are part of a massive crackdown on health care fraud in South Florida that was announced earlier in the year by U.S. Attorney R. Alexander Acosta of the Southern District of Florida and the Department of Justice. (See HomeCare Monday, May 14.) Since March, the Medicare Fraud Strike Force has brought over 70 cases of health care fraud involving 85 defendants, authorities said.

In the largest of the three cases, the owner of two Miami-based HMEs pleaded guilty Aug. 31 to defrauding Medicare in a $6.4 million scheme. Raul Rodriguez, 34, of Miramar, owner of R & J Medical Services and N.R. Medical Services, pleaded guilty to four separate counts of health care fraud, money laundering and conspiracy to obstruct an FBI investigation, prosecutors said.

Rodriguez, who also owned Coral Way Professional Health Services, an HIV medical clinic, agreed to a $5.7 million judgment and forfeiture of a bank account, cash and a $100,000 Land Rover. He faces a maximum sentence of 20 years in prison and potential fines of $12.8 million. He will be sentenced Nov. 30.

Rodriguez became the eighth defendant to plead guilty in the case. Armando Arias, Carlos Enrique Monteagudo, Alain Rhaf Vega, Marisol Gonzalez-Torres, Edith Balog, Yulen Arderi and Jannette Morales entered guilty pleas in August. Two others, Lazaro Jorge Ocejo and Ramon De Los Santos, were sentenced earlier this year on fraud conspiracy and money laundering charges in related cases. De Los Santos was sentenced to a prison term of 21 months, while Ocejo was sentenced to 37 months.

According to the authorities, from 2004 through 2005, Rodriguez and the co-defendants submitted more than $12.5 million in false and fraudulent claims for medical equipment, HIV treatments and medications. The scheme involved recruiting and paying patients to be treated at the Coral Way clinic. The patients were injected with saline instead of prescribed drugs, Rodriguez, Arias and Gonzalez-Torres admitted.

Rodriguez and Arias laundered much of the fraud proceeds through shell corporations set up for the sole purpose of concealing the illicit monies, authorities said. Beginning in September 2005, Rodriguez and Arias, who also pled guilty to a conspiracy charge, met with potential government witnesses and encouraged them to lie to FBI agents and/or a federal grand jury. That continued through March of this year, authorities said.

Two other cases involving HME providers also were announced last week.

Gianni Suarez Vazquez pleaded guilty to a multi-million-dollar money laundering and mail fraud scheme. According to court records, Suarez Vazquez set up two medical equipment companies, GK Medical and Suplident International Corp., in Palm Beach County between November 2003 and August 2004. He concealed his ownership of the companies and instead used nominee owners, including his mother, to obtain Medicare provider numbers for both companies.

Using bogus prescriptions and CMNs with forged physicians' signatures, Suarez Vazquez and his unnamed partners, through Miami billing companies, submitted a total of $9.8 million in fraudulent claims that Medicare reimbursed.

Suarez Vazquez will be sentenced on Nov. 15.

And in a case involving aerosol medications, Marianela Smith, owner of Smith Medical Equipment and M.P. Residence, an assisted living facility in Miami, was found guilty by a federal grand jury of conspiracy to defraud the U.S. government, submitting false claims to Medicare, conspiracy to commit health care fraud and three counts of receiving kickbacks in exchange for referring patients to a co-conspirator pharmacy.

According to a statement from the U.S. Attorney's office, Smith conspired with the owners of Lily's Pharmacy to refer paid patients to the pharmacy in exchange for half of what Medicare paid for compounded aerosols. Smith referred at least 48 patients and their Medicare billing information to Lily's. Along with those patients, Smith provided phony prescriptions for compounded aerosol meds purchased from local physicians.

One of the patients testified during the seven-day trial that Smith paid him $150 per month to use his Medicare card and to obtain phony prescriptions in his name that were ultimately provided to the pharmacy, the statement said. Lily's billed Medicare more than $271,000 using the phony prescriptions provided by Smith. In exchange, Smith received more than $81,000 in kickbacks.

"Trial testimony established that compounding was done for the sole purpose of defrauding Medicare, and the prescriptions were predetermined before any of the over 1,000 beneficiaries at Lily's saw a physician or received a prescription," the statement said.

Smith faces a maximum sentence of 30 years imprisonment. She will be sentenced Nov. 9.

In 2006, Medicare paid for more than $155 million in aerosol medications in Miami-Dade County alone, according to the statement. These drugs were the single most common item billed to Medicare Part B and accounted for more than 32 percent of all claims filed in the county.

Miami-Dade County alone accounted for more paid DME claims than every state in the country except California, Texas, New York, Michigan and Ohio, the statement said.

Weems Designated Acting Administrator of CMS, Kuhn Appointed Deputy
WASHINGTON--On Tuesday, President Bush designated Kerry N. Weems as acting CMS administrator.

Bush nominated Weems, a longtime federal official, for the top CMS post in May, and the Senate held a confirmation hearing on the nomination July 25.

But according to news reports, no vote on the nomination has been scheduled, and Senate Finance Committee Chairman Max Baucus, D-Mont., has said there won't be one until committee members get all of their questions answered.

During the nomination hearing, committee members made several requests for an extension to CMS' July 27 competitive bidding deadline for DMEPOS. Citing providers' difficulties in bidding, Sen. Pat Roberts, R-Kan., wrapped up the hearing by reading a list of providers' specific bidding problems--including technical difficulties with the bidding system and lack of details about the program--into the hearing record. Two days later, just hours before the 9 p.m. deadline, CMS extended the bid window until Sept. 25.

A 24-year government veteran, Weems served most recently as deputy chief of staff to HHS Secretary Mike Leavitt, advising on budget issues as the Bush administration tries to restrain the pace of federal health spending. While the administration said it will continue to work to have Weems confirmed, Leavitt said on Wednesday that while the CMS nomination is pending, "it is important that we have solid leadership in place now with the authority to head this critical agency."

If confirmed, Weems would succeed Mark McClellan, who resigned in October.

Leavitt also announced the appointment of Herb Kuhn as deputy CMS administrator. Kuhn has served for nearly a year as acting deputy administrator.

Speaking at the American Association for Homecare's Legislative Conference in June, Kuhn told the group that CMS is moving toward full implementation of competitive bidding and intends to enforce its final rule on the program--mandated by the Medicare Modernization Act of 2003--as it stands. (See HomeCare Monday, June 11.)

CMS Confirms Home Infusion Providers Not Target of Fraud Demo
WASHINGTON--After asking CMS for a clarification of the "infusion providers" targeted under a recently announced fraud demonstration program, the National Home Infusion Association got the answer it wanted: Home infusion therapy providers are not included.

On Aug. 20, the Department of Health and Human Services, CMS and the Department of Justice announced a two-year demonstration program designed to remove criminal and fraudulent "infusion providers" from the Medicare program.

However, the NHIA said, "the infusion providers in question were not clearly described in the written materials released to the public, and numerous observers assumed that CMS was referring to home infusion therapy providers." The association asked CMS for "an immediate and public clarification" of whether home infusion therapy providers were implicated in the planned demonstration program. (See HomeCare Monday, Aug. 27.)

In response, CMS amended a fact sheet making it clear that the demonstration program does not involve providers who offer infusion in the home setting. Rather, it will be limited to clinics and solo practitioners in South Florida providing intravenous infusion therapy and/or intramuscular and subcutaneous injections in the office setting only.

"We commend CMS for responding quickly to clarify that home infusion therapy providers are not involved in this demonstration program," said Russell Bodoff, NHIA executive director, in a press release about the clarification. The release also said NHIA "strongly supports the passage of H.R. 2567, the Medicare Home Infusion Therapy Coverage Act of 2007, which would provide for meaningful coverage of home infusion therapy, as well as the development of essential quality standards."

To view the revised fact sheet on the infusion therapy fraud demonstration, click here.

'F as in Fat:' Report Says Obesity Rates Continue to Grow
WASHINGTON--Adult obesity rates increased in 31 states last year--and no states saw a decrease.

According to "F as in Fat: How Obesity Policies are Failing in America, 2007," the fourth annual report from health advocacy group Trust for America's Health says 22 states saw increased obesity for the second year in a row. And for the third year in a row, Mississippi weighed in at number one. Of the 15 states with the highest rates of obesity, 10 are in the South.

Among the report's other findings:

--Mississippi, with a 30.6 percent adult obesity rate, is the first state to top 30 percent.
--Colorado is the leanest state, though its obesity rate increased from 16.9 to 17.6 percent over the past year.
--Adult obesity rates are now greater than 25 percent in 19 states, up from 14 states last year and nine states in 2005; no state had a rate greater than 20 percent in 1991.
--Rates of overweight children age 10 to 17 were highest in Washington, D.C. (22.8 percent), and lowest in Utah (8.5 percent).
--Of the 10 states with the highest rate of overweight children, eight are in the South.
--22 percent of adults in the country say they do not engage in any physical activity.

TFAH advocates the implementation of a national strategy to combat obesity by the federal government and says the plan "should involve every federal government agency, define clear roles and responsibilities for states and localities, and engage private industry and community groups."

The report can be downloaded at the Trust for America's Health Web site, www.healthyamericans.org.

In Brief
Reps. John Tanner, D-Tenn., and David Hobson, R-Ohio, will kick off Medtrade 2007, which will be held Oct. 2-4 at the Orange County Convention Center in Orlando, Fla. The two congressmen are lead sponsors of H.R. 1845--known as the Tanner-Hobson bill--which would amend the competitive bidding program to allow all qualified providers to participate in Medicare at the bid rate. The video keynote address will be presented Tuesday, Oct. 2, at 7:30 a.m. in Room W110A/B. For more information about the trade show, visit www.medtrade.com.

AAHomecare reported last week that it had sent a letter to Cigna outlining concerns about the DME MAC Jurisdiction C transition from Palmetto to Cigna. On Wednesday, several members of the association staff and its Regulatory Committee held a conference call with Cigna to discuss redeterminations that were sent to Palmetto in April and May and transferred to Cigna that have not be processed. Providers are getting close to the 120-day timely filing deadline for those claims. As well, providers are having trouble getting through to the Cigna call center. According to AAHomecare, Cigna said it is aware of the backlog and is working to address it by hiring additional staff for the call center and recommended that providers call during off-peak hours or use the IVR system when possible. Given the backlog and other transition issues, Cigna said that in instances where providers could show they had taken the proper steps to file determinations within the 120-day window, "they would be a bit flexible" with the timely filing deadline.

Tomorrow marks the sixth anniversary of the 9/11 terrorist attacks. This issue is dedicated to those who lost their lives on that day in 2001.

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