Medicare 30 Compliance Report No. 8 (March 1, 2021)

According to a CMS spokespersonCMS has not yet determined when the Targeted Probe and Educate reviews will resume. “ “CMS continues to temporarily suspend retroactive reviews of short stays to ease the burden on providers for compliance with COVID-19 waivers,” the spokesman told RMC. Livanta, a beneficiary and family-oriented organization dedicated to improving the quality of care, “conducts retrospective reviews of Medicare Part A entitlements to ensure that the care provided under the Medicare program is medically necessary, appropriate, and meets professionally recognized standards appropriate environment. ”It is unclear when they will be back. Livanta is also reviewing higher weighted DRGs, the spokesman said.

Grant Memorial Hospital in Petersburg, West Virginia agreed to pay $ 320,175 to resolve allegations it filed against Medicare, Medicaid, TRICARE, and Railroad Retirement programs from September 2014 to March 2016said the US Attorney’s Office for the northern district of West Virginia on Feb. 24.[1] The hospital billed outpatient and inpatient services and items with the National Provider Identifier and a recognized physician’s name when the services and items were actually provided by an unauthorized physician, the U.S. law firm said. The comparison resulted from a self-disclosure to the HHS General Inspectorate.

In the first article by MLN Matters (SE21001)[2]Issued under the Biden administration, CMS addresses Hospital compliance with Medicare Transfer Policy “with resumption of home health services and other information on patient discharge codes.” The MLN affairs came in the wake of OIG reports finding non-compliance with the Medicare Post-Acute Care Transfer (PACT) payment policy, which requires hospitals to charge daily rates instead of MS-DRGs when patients qualify Home Health will be referred to nursing homes and other facilities. Hospitals are allowed to bypass the PACT policy in certain circumstances using condition code 42 or 43. “Medicare’s IPPS [inpatient prospective payment system] Post-acute care transfer guidelines require hospitals to apply the correct discharge status code to claims where patients are receiving HH [home health] Services within 3 days of discharge. This includes the resumption of household services before the inpatient stay, ”says CMS.

CareOne Management LLC, now known as ABC1857 LLC (CareOne), a senior care company in New Jersey, is paying $ 714,996 to settle false claims related to Medicare bad debts, the New Jersey District Attorney’s Office said on February 18th with.[3] Medicare reimburses providers for deductibles and co-insurance amounts that they cannot collect from Medicare beneficiaries. This is known as bad debt. The US law firm announced that CareOne had filed claims with Medicare to reimburse Medicare bad debts, based on allegations in the January 1, 2012 to July 2, 2018 settlement. The company misrepresented its compliance with applicable legal and regulatory criteria, including “Eligible Bad Debt Criteria,” which requires a vendor to demonstrate that reasonable collection efforts have been made to pay the amounts owed by the beneficiaries before a vendor makes the Filing a claim as a bad debt with Medicare. “The case was originally brought by a whistleblower. CareOne has not admitted any liability in billing.

1 Department of Justice, US District Attorney for Northern District of West Virginia, “West Virginia Hospital Pays More Than $ 300,000 for Medicare Fraud,” News Release, Feb. 24, 2021
2 CMS, “Review of Hospital Compliance with Medicare Transfer Policies for Home Health Services Resumption and Other Information Regarding Patient Discharge Codes,” MLN Matters, SE21001, February 22, 2021,
3 Department of Justice, New Jersey District Law Firm, “Senior Care Company Agrees to Pay $ 714,996 to Resolve False Claims Act Allegations,” press release dated February 18, 2021,

[View source.]