Department of Health and Human Services (HHS)

CMS: RAC program has recovered more than $1B

Anne Zieger — Mon, 14 Jul 2008 10:42:13 -0400

CMS has released a new report stating that Medicare has recovered more than $1 billion through the Recovery Audit Contractor program since 2005, with 85 percent of the money having been taken back from hospitals. When the costs of collecting the money were taken into account--along with the small number of refunds made to providers--CMS was able to return $693.6 million to the Medicare trust fund.

In its analysis, CMS said that most of the improper payments made to providers occurred due to billing and coding errors, frequently when one procedure was billed repeatedly. Other problems discovered by RACs included incorrect procedure codes and submission of duplicate claims that both got paid. When the RACs challenged Medicare payments, 14 percent of providers appealed. Of those decision that were appealed, 33.3 percent were eventually overturned. (Bear in mind that this means that almost 70 percent of providers lost their appeal--and those were the ones who felt they had a strong enough case to go through the appeals process!) Not surprisingly, CMS acting administrator Kerry Weems called the results a success.

That being said, the report also notes that CMS has made some significant changes to the program over time. For example, the agency changed the amount of time a RAC could look back into old provider records from a four-year window to three years. Still, providers and Congressional legislators continue to criticize the RAC program, which HHS is required to make a permanent, national effort by Jan. 1, 2010.

To learn more about the report:
- read this Modern Healthcare article (reg. req.)

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CMS says new system will avoid payments using dead doctors' names

Anne Zieger — Fri, 11 Jul 2008 09:39:26 -0400

While probably embarrassed by the revelation that crooks have been profiting handsomely by billing Medicare for equipment prescribed by dead doctors, CMS has a system in place to end the practice. That, at least, is what CMS Deputy Administrator Herb Kuhn told Congress at a Senate Homeland Security and Government Affairs Investigations Subcommittee hearing. Kuhn said that since May, the agency has had a system in place that cross-checks the names of doctors that appear on Medicare claims with the Social Security Administration's database of death reports. Under the new system, all doctors are being assigned a National Provider Identifier, rather than the existing Unique Physician Identifier, and they're making sure that no dead physicians get NPI, Kuhn said.

In defending the agency, Kuhn noted that it didn't consider this type of fraud to be its biggest vulnerability when it made an assessment in 2004. He also noted that the budget for the Medicare Integrity Program, which fights abuse and fraud, hasn't grown from $720 million since 2003. Medicare officials would like to see another $300 million added to fight fraud.

To learn more about this issue:
- read this Kaiser Daily Health Policy Report piece

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Did Glaxo conceal Paxil users' risk of suicide?

Fri, 13 Jun 2008 06:59:55 -0400

Did drugmaker GlaxoSmithKline conceal suicide risks for users of its antidepressant Paxil within the mountains of data it submitted to the FDA? That's a question Sen. Chuck Grassley (R-Iowa) would like to see answered, and in some detail. Grassley would like to find out who within Glaxo knew what, and when, about the medicine's possible link to increased suicidal behavior. In his correspondence with the FDA and HHS Secretary Michael Leavitt, Grassley notes that the U.K. recently concluded that the firm withheld safety information when submitting data for approval in Europe. Now, he wants to know whether Glaxo did the same in the U.S. In testimony on the Senate floor, Grassley noted that a report by one Harvard researcher contends that Glaxo probably knew about Paxil safety concerns all the way back in 1989, when it first asked the FDA for approval--and that it probably manipulated studies to diminish the perceived risk.

To learn more about Grassley's concerns:
- read this Wall Street Journal blog entry

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Walgreens agrees to $35M drug-switching settlement

Thu, 05 Jun 2008 06:59:58 -0400

Walgreen Co. has agreed to pay $35 million to the U.S. Department of Justice to resolve allegations that it had switched patients to more expensive drugs to boost its Medicaid reimbursement. In the settlement, Walgreen Co. denies any wrongdoing. The case arose from a whistle-blower suit filed in 2003; the whistleblower asserted that between 2001 and 2005, Walgreens dispensed capsules rather than tablets of generic Zantac and Prozac, and brand-name and generic Eldepryl to Medicaid patients when doctors hadn't specified. Forty-six states and Puerto Rico will share the $16.4 million, and the federal portion of the settlement is $18.6 million. Whistleblower Bernard Listiza should receive a total of $5 million, which will be drawn from those moneys.

To learn more about the case:
- read this Modern Healthcare article (reg. req.)

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SPOTLIGHT: HHS, DoD send mental health workers for PTSD treatment

Thu, 05 Jun 2008 06:59:52 -0400

Admitting (critics say rather belatedly) to the reality that many soldiers are suffering from post-traumatic stress disorder, the Department of Defense and HHS have announced a program under which they'll send 200 psychiatrists, social workers and other mental healthcare pros to military facilities to treat such patients. HHS will coordinate scientific research on the mental health care needs of soldiers. Article

Federal spending bill could limit physician hospital ownership

Wed, 04 Jun 2008 06:59:57 -0400

A group of Republican Congress members are raising objections to language in a war supplemental spending bill that they say would harm physician-owned hospitals. Sens. Jon Kyl (R-AZ) and Tom Coburn (R-OK), along with Texas republican Reps. Sam Johnson and Joe Barton, object to an amendment that would prohibit new physician owned hospitals built after this coming September, while offering no protection for hospitals still under development as of that date. They're also unhappy about rules that would force hospitals to meet what they deem "extreme qualifications" to expand, rather than grow as they see fit. In a letter to the Senate Appropriations Committee, the legislators call these provisions "a national certificate-of-need program... access to [which] would likely be denied to almost every physician-owned hospital."

To learn more about the legislators' challenge to physician-owned hospital regs:
- read this Modern Healthcare piece

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Medtronic Spine settles false claims charges for $75M

Fri, 23 May 2008 06:59:56 -0400

A subsidiary of Medtronic Spine agreed this week to pay the federal government $75 million to settle allegations that it caused submission of false claims to Medicare by a subsidiary. The allegations concerned Kyphon Inc., bought by Medtronic Spine in November 2007 for $3.9 billion after whistleblower allegations had already been made. In addition to the settlement,
Kyphon has entered into a Corporate Integrity Agreement with HHS's Office of Inspector General.

Kyphon was accused of submitting fraudulent claims for kyphoplasty procedures, minimally invasive surgeries used to treat compression fractures of the spine caused by osteoporosis, cancer or benign lesions. According to the allegations made by whistleblowers, Kyphon engaged in a marketing scheme that caused some hospitals to bill Medicare for inpatient kyphoplasties when cheaper outpatient procedures would have been clinically appropriate. The allegations came from two former Kyphon employees, who under the False Claims Act will receive a total of $14.9 million for having reported the allegations.

To learn more about the settlement:
- read this article from Business First of Buffalo

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Feds to display hospital satisfaction ratings in newspaper ads

Wed, 21 May 2008 06:59:56 -0400

In an effort to put some money behind its philosophy, the federal government has budgeted about $1.9 million to put full-page ads in newspapers around the U.S. disclosing individual hospital satisfaction rates. The newspaper ads, which are running in 58 newspapers in 49 states, draw their data from CMS's Hospital Compare website (http://www.hospitalcompare.hhs.gov). The patient satisfaction data used in the campaign was released voluntarily by the hospitals in question.

The ads will show responses to two questions: the percentage of patients who always received help when they needed it, and the percentage who received antibiotics one hour before surgery. The second question relates to a measure commonly held to be important in fighting hospital-acquired infections. In addition to listing specific hospital numbers, the ads will list statewide averages for the given survey question.

To learn more about this campaign:
- read this Associated Press article

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Serious nursing home quality problems still exist

Fri, 16 May 2008 06:59:57 -0400

According to new Congressional testimony by officials from the HHS inspector general's office, care at many nursing homes is actually dangerous to patients, despite ongoing efforts by CMS to identify and expose such problems. Lewis Morris, chief counsel to HHS' inspector general, told the House Energy and Commerce oversight and investigations subcommittee that at least one in five nursing homes delivers care that is directly harmful to patients.

At the same hearing, the Government Accountability Office released a report suggesting that state nursing home inspectors routinely miss life-threatening problems such as whether homes ensure proper nutrition and hydration.

Meanwhile, at the same hearing, Connecticut Attorney General Richard Blumenthal described how difficult it was to force nursing home owners into compliance even when their quality problems were known. His particular battle with nursing home operator Haven Healthcare demonstrated to him that with the complex ownership structures employed by such homes' operating companies, it could be almost impossible to win this kind of battle, Blumenthal said.

Despite having failed to address nursing home issues for more than 20 years, Congress is expected to respond to these and other reports with new rules sometime this year.

To learn more about the nursing home investigation:
- read this Modern Healthcare article (reg. req.)

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Study: Gain-sharing with physicians controls hospital costs

Wed, 14 May 2008 06:59:57 -0400

A new study has concluded that paying physicians a cash reward to cut hospital spending cuts costs without harming care quality or access. Some policymakers have raised concerns that such programs would encourage physicians to avoid patients with health problems, but that didn't seem to be the case in this study, researchers said.

The study, which looked at 220,000 over five years, compared six cardiac cath labs that implemented gainsharing with 123 labs that didn't. Researchers found that gainsharing cut hospital costs by 7.4 percent, or $315 per patient, most of which came from lower prices for coronary stents. This suggests that nationwide use of gainsharing could cut hospital costs for coronary stent patients by roughly $195 million a year, researchers concluded.

To learn more about the study:
- read this HealthDay News item
- read this Modern Healthcare article (reg. req.)

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