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  Expansion of the Fraud and Abuse Laws Under PPACA Expansion of the Fraud and Abuse Laws Under PPACA
August 2010
The Patient Protection and Affordable Care Act (referred to as "PPACA") was signed into law on March 23, 2010, followed a week later by The Health Care and Education Reconciliation Act of 2010 which amended PPACA. PPACA made several significant changes to the health care fraud and abuse laws, and also greatly increased the government's funding (to the tune of an additional $350 million) for fraud and abuse enforcement, approximately one-third of which is allocated to the 2011 budget year. PPACA provides the federal government with new fraud and abuse enforcement tools and enhances both civil and criminal penalties for noncompliance with the fraud and abuse laws.
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  It's FINAL! Reviewing the Current Medicare Appeals Process It's FINAL! Reviewing the Current Medicare Appeals Process
March 2010
During the last decade, the Centers for Medicare and Medicaid Services (CMS) underwent significant changes in an attempt to improve output, reduce waste, and streamline processes. As part of this overhaul, the Medicare Appeals Process was revised.
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  The Medicare Opt-out: Navigating the Process The Medicare Opt-out: Navigating the Process
November 2009
Everywhere you turn the topic of health care costs arises. Currently, the most well-known and used government payor plan is Medicare. However, the cost of the Medicare program is crippling the country. While lawmakers try to develop a new health care system that will address skyrocketing health care costs, the more immediate question remains how to control Medicare costs and spending. The easiest answer to that question is to cut reimbursement rates for providers, which has been consistently done over the years. As additional cuts in Medicare reimbursement rates are expected, the new questions that arise for practitioners are, "Do I want to continue participating in the Medicare program?" and "Can I afford to continue participating in the Medicare program?".
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  PECOS: What Practitioners Need to Know About Medicare's New On-line PECOS: What Practitioners Need to Know About Medicare's New On-line
September 2009
The Centers for Medicare and Medicaid Services (CMS) began using a new national provider enrollment system, the Provider Enrollment Chain and Ownership System (PECOS), in 2002. Over the last few months CMS has expanded the use of the PECOS system to physician and non-physician practitioners in the District of Columbia and the 50 states. The goal of CMS in developing this program is to standardize the Medicare enrollment process using an electronically maintained national system. Once provider information is entered into and maintained in the PECOS system, that information will be available to all Medicare Administrative Contractors (MAC) across all jurisdictions.
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  KOSENSKE: PHYSICIAN-HOSPITAL ARRANGEMENT QUESTIONED UNDER STARK KOSENSKE: PHYSICIAN-HOSPITAL ARRANGEMENT QUESTIONED UNDER STARK
July 2009
On January 21, 2009, a three-judge panel of the Third Circuit Court of Appeals reversed a summary judgment granted in favor of defendants Carlisle HMA, Inc. and Health Management Associates finding that the defendants failed to establish that a relationship between a hospital and its exclusive anesthesiology providers satisfied the requirements of the personal service exception to the federal Stark Law and the safe harbor to the federal Anti-Kickback Statute applicable to personal services and management contracts.
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  Update on Medicare Administrative Contractors (MAC) Awards from CMS Update on Medicare Administrative Contractors (MAC) Awards from CMS
May 2009
In accordance with the timeline originally set forth by the Centers for Medicare and Medicaid Services (CMS), all of the jurisdictional awards for the Part A/Part B Medicare Administrative Contractors (MAC) have been made. Furthermore, many of these new MACs have already begun processing the claims within their jurisdictions.
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  CMS Further Revises the Medicare Anti-Markup Rule Effective January 1, 2009 CMS Further Revises the Medicare Anti-Markup Rule Effective January 1, 2009
March 2009
The Centers for Medicare and Medicaid Services ("CMS") made additional changes to the Medicare anti-markup rule in the 2009 final Medicare Physician Fee Schedule, which was published in the Federal Register on November 19, 2008.
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  Hospital Acquired Conditions and Never Events: How They May Affect the Payment of Claims Hospital Acquired Conditions and Never Events: How They May Affect the Payment of Claims
January 2009
Medicare is the largest purchaser of health care and managed care in the United States. Approximately fourteen percent (14%) of the Federal Budget is allocated towards the Medicare program. With the rising cost of health care, the Centers for Medicare & Medicaid Services (CMS) has begun to focus on patient safety policies to promote higher quality, more efficient health care through the development of value-based purchasing plans (VBP).
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  CMS Makes Further Tweaks to the Medicare Anti-Markup Rule in the 2009 Proposed Medicare Physician Fee Schedule CMS Makes Further Tweaks to the Medicare Anti-Markup Rule in the 2009 Proposed Medicare Physician Fee Schedule
November 2008
In the final 2008 Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services ("CMS") made dramatic changes to the Medicare anti-markup rule (contained at 42 C.F.R. - 414.50).
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  OIG Self-Disclosure Protocol: What the 2008 Open Letter Means for You OIG Self-Disclosure Protocol: What the 2008 Open Letter Means for You
September 2008
In 1998 the Office of Inspector General ("OIG") developed a Provider Self-Disclosure Protocol ("SDP") to enable the health care community to ensure the integrity of the federal health programs by voluntarily disclosing evidence of potential fraud discovered by the health care provider. This program replaced the voluntary disclosure pilot program previously put in place by the OIG. While the SDP did not protect the disclosing health care providers from civil or criminal action, the OIG indicated that this self-reporting could be a mitigating factor.
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  The New Medicare ABN CMS-R-131: What the Notifier Needs to Know The New Medicare ABN CMS-R-131: What the Notifier Needs to Know
July 2008
For the protection of Medicare beneficiaries and notifiers, Medicare has set forth certain rights and protections related to financial liability for Fee-for-Service Medicare programs. Part of this protection includes the requirement that the notifier, which includes physicians, providers (including institutional providers like outpatient hospitals), practitioners and suppliers paid under Part B, as well as hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Part A, give beneficiaries certain notices. One of those notices is the Advanced Beneficiary Notice (ABN). Medicare published a new ABN form, the CMS-R-131, on March 3, 2008. This new form is available for use by notifiers now and will be required for all providers effective September 1, 2008.
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  Recent Developments with Respect to the Medicare Anti-Markup Rule - Who will be Affected and When? Recent Developments with Respect to the Medicare Anti-Markup Rule - Who will be Affected and When?
May 2008
In the 2008 Medicare Physician Fee Schedule released on November 1, 2007, and published in the Federal Register on November 27, 2007, the Centers for Medicare and Medicaid Services ("CMS") recently revised the longstanding Medicare anti-markup rule, which previously applied only to billing for the technical component of diagnostic tests. The newly revised rule will have a potentially dramatic effect on the ways that physicians and other suppliers provide and bill for diagnostic tests.
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  Making The Adjustment To Medicare Administrative Contractors (MAC) Making The Adjustment To Medicare Administrative Contractors (MAC)
March 2008
After years without change, the Medicare billing contractor system is getting a facelift. For the first time, Medicare Part A and Medicare Part B will be administered by one entity rather than the traditional fiscal intermediaries and carriers that have administered the programs to both beneficiaries and providers.
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  Making the Most of the Medicare: Incident-to billing rules Making the Most of the Medicare: Incident-to billing rules
May 2007
The Medicare "incident-to" billing rules, which allow physicians and certain mid-level practitioners, including physician assistants and nurse practitioners, to bill Medicare for services of non-professional "auxiliary personnel" as if the physician or practitioner performed the service himself, can greatly enhance office productivity. However, the rules can be tricky and failure to follow each of them can result in overpayment and even false claims liability.
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  Cleaning Up the Mess: Refunding Money to the Medicare Program Cleaning Up the Mess: Refunding Money to the Medicare Program
November 2006
Dealing with Medicare is a serious business and potentially a mine-field for many billers and coders. Todd Rodriguez explains the obligations in regards to refunding overpayments to Medicare.
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  Minding Your E's and M's: The OIG Takes Aim at Physician Consults Minding Your E's and M's: The OIG Takes Aim at Physician Consults
July 2006
When it comes to Medicare billing, few services cause more compliance headaches for physicians than Evaluation and Management ("E/M") services. The E/M documentation and coding rules are extremely complex and, as one of the most commonly billed types of service, one mistake can be perpetuated many times over, resulting in the need to make enormous repayments to the Medicare program and other payors. Moreover, while "gaming the system" by upcoding here and there might seem fairly simple and innocuous, abuses of E/M billing can land a provider in hot water.
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  TIPS AND TOOLS FOR PAYOR CONTRACTING TIPS AND TOOLS FOR PAYOR CONTRACTING
May 2006
Todd A. Rodriguez gives BC Advantage some tips and tools for insurance company contracts
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  MEDICARE INQUIRIES: PROCEED WITH CAUTION MEDICARE INQUIRIES: PROCEED WITH CAUTION
March 2006
With Medicare fraud a top priority for many Government agencies, Todd A. Rodriguez writes how to be prepared if you are the target of an audit or investigation
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Contributor: Todd A. Rodriguez, Attorney, Health Care
 

Todd is a regulatory and transactional health care attorney with a primary focus on fraud and abuse counseling, Medicare Part B reimbursement, physician representation, managed care and corporate and contracting issues. He has extensive experience in physician legal representation in all aspects of medical practice including medical practice mergers and acquisitions, contract negotiation and drafting, and consulting on operational and business planning issues affecting physician medical practices and other providers.

Click here to read full bio
 

 
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First Incident-To Handbook for Medicare’s Incident-To Billing