Admissibility of statistical sampling to prove liability in FCA suit is fact dependent. In a February 14, 2017 decision, the Fourth Circuit declined to rule on the question of whether statistical sampling can be used to prove liability and damages in False Claims Act (FCA) lawsuits, concluding that it should not have agreed to [...]
Don’t shoot the messenger but compliance with Medicare and Medicaid rules just got tougher for hospice organizations. In the first judicial opinion on when a Medicare or Medicaid “Overpayment” is “identified” for purposes of the Affordable Care Act’s (ACA) 60-Day Repayment Law, a New York federal court’s interpretation complicates the already difficult task providers face in having sufficient time to assess and quantify potential overpayments.
I had not been paying much attention to NHPCO's flurry of activity during March regarding prognosis vs. diagnosis until I received an email from a well-respected hospice CEO that said, in part:
"Our Medical Director is livid and is adamant that what 'influences' the prognosis is very different from what is "related to" the prognosis. This seems like a fundamental shift from what we have been doing for thirty years - is it possible that everyone (including NHPCO) has been so wrong about this? We think we have financial challenges now - just wait!"
Every hospice physician has experienced difficulties in assessing “gray” patients. These are the ones who, at admission, do not have a principal diagnosis or terminal story that leaps out from the record, although for many of these patients, the physician is able to answer “no” to the “would you be surprised if your patient dies within the next six months” question.
- Are these patients truly terminally ill?
- Is a period of seeming stabilization sustainable?
- Should these patients be evaluated for discharge due to extended prognosis?
Since our last Part D blog, CMS issued the Revised Guidance for Part D, on July 18th, 2014, effective as of that date. There are some detailed, comprehensive resources (listed below) that address this complex issue. The purpose of this blog is to synthesize and recap “what’s new” in the Revised Guidance for Part D and highlight tools for navigating these changes.
I love that expression: "in the weeds." It has entered into the realm of jargon but, nevertheless, it so clearly describes how I have been feeling with the HIS implementation guide I have been writing with Melanie Merriman. Thoroughly in the weeds with the HIS -trying not to get choked, trying to sort through the gazillion details, trying to pull out the non-essential and get to the heart of the matter.
With a heavy heart I read the latest Washington Post article lambasting the hospice industry for not providing the higher levels of care: continuous care and general inpatient (GIP) when patients need it. Citing numerous examples, and naming specific hospices at fault, this latest investigative reporting by the Washington Post continues its general thesis from a previous article last December: the hospice industry, dominated by for profit providers, is doing a lousy job.
As of March 1, 2014, Medicare Part D providers will no longer pay for medications that are (or may be reasonably assumed to be) related to a patient’s primary hospice diagnosis and the comorbid conditions that are contributing to his or her terminal status. Rather, hospice providers will be responsible for covering all of the medications that are needed to manage and/or palliate end-of-life symptoms appropriately and effectively.
It is that time of year again... If you have not already notified the government of breaches of unsecured protected health information that affected less than 500 individuals that were discovered in 2013, you must do so by March 1, 2014.
Developing a consistent program for auditing your clinical records is critical in ensuring you are mitigating your risk of non-compliance and ultimately non-payment.