4th Circuit Affirms Withholding of WV Medicaid Funds

Today the United States Court of Appeals for the 4th Circuit affirmed a ruling by the district court in West Virginia which sustained a disallowance of federal funding by the Centers for Medicare & Medicaid Services (CMS) against the West Virginia Medicaid Program.

The 4th Circuit Decision in West Virginia Department of Health and Human Resources, Bureau for Medical Services vs. Kathleen Sebelius, et al. ruled that CMS acted within its authority when it withheld from the West Virginia Department of Health and Human Resources, Bureau of Medical Services, West Virginia'a Medicaid Program (DHHR) approximately $634,000 (which was reduced to approximately $446,000)in Medicaid funding, which represented it share of overpayment made to providers as a result of Dey, Inc., a pharmaceutical company, alleged fraud. CMS notified DHHR of the disallowance after Dey entered into an $850,000 settlement of claims brought by the West Virginia Attorney General on behalf of West Virginia under West Virginia's Consumer Credit and Protection Act.

The disallowance by CMS was calculated by multiplying the state's estimated damages allocable to Medicaid, approximately 67% by the settlement amount adn then multiplied this figure by West Virginia's FMAP rate of 78.14% to arrive at the $446,000 amount. The HHS Department of Appeals Board concluded that this allocation methodology was reasonable.

I have only done an initial review of the decision and won't go into the merits of the arguments at this time. Read the full decision for a more complete understanding of the decision and check out today's article in the Charleston Daily Mail.

OIG HEAT Provider Compliance Training Webcast

The Office of Inspector General (OIG) has made available the Health Care Fraud Prevention and Enforcement Team (HEAT) Provider Compliance Training webcast. OIG is making the training information available to help highlight and educate providers on the the federal government's effort to fight health care fraud and abuse.

More information about  HEAT Task Force and its mission and efforts can be found on the StopMedicareFraud website. The training information includes 16 modules:

Welcome Remarks 4:37
Overview of OIG 9:56
Navigating the Fraud and Abuse Laws 26:26
Compliance Program Basics 17:01
Operating an Effective Compliance Program 15:59
Understanding Program Exclusions 10:26
Navigating the Government 5:10
Overview of Centers for Medicare and Medicaid Services 34:24
Importance of Documentation 17:06
OIG Subpoenas Audits Surveys and Self Disclosure Protocol 17:42
Health Care Fraud Enforcement Panel 6:08
Health Care Fraud Enforcement Panel with CMS Deputy Admin 13:43
Health Care Fraud Enforcement Panel with Special Agent 15:10
Health Care Fraud Enforcement Panel with Asst. US Attorney 17:08
Health Care Fraud Enforcement Panel - Fraud Control Unit 11:15
Adjournment 0:59

OIG Issues Roadmap on Avoiding Medicare and Medicaid Fraud and Abuse for New Physicians

The U.S. Department of Health and Human Services, Office of Inspector General (OIG) has issued a resource and educational guide for new physicians to help them better understand the key Federal fraud and abuse laws.

As a health care attorney who often deals with physicians on fraud and abuse related matters, I applaud the OIG's effort to provide educational information to help raise the level of understanding on these issues and increase the transparency of these federal laws. This guide won't just be useful for "new" physician but for all physicians to gain a better understanding of the very complex legal/regulatory structure of fraud and abuse laws in the United States.

The new OIG document is titled, "Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse." The physician education roadmap document summarized the five main Federal fraud and abuse laws, including the False Claims Act, the Anti-Kickback Statute, the Stark Law, the Exclusion Statute, and the Civil Monetary Penalties Law. The roadmap document provides tips to physicians on how they should comply with these laws in their relationships with payers (like the Medicare and Medicaid programs), relationships with vendors (like drug, biologic, and medical device companies), and relationships with fellow providers (like hospitals, nursing homes, and physician colleagues).

The roadmap guide was developed as a result of a survey conducted by OIG of medical school deans and designated institutional officials at institutions that sponsor residencies and fellowships to learn what types of instruction medical students, residents, and fellows receive on Medicare and Medicaid fraud, waste, and abuse. Nearly all respondents (92% of deans and 90% of designated institutional officials) reported they would like OIG to provide educational materials they can use. The complete survey, "Medicare and Medicaid Fraud and Abuse Training in Medical Education," was recently issued in October, 2010.

You can view online or download a PDF version of the roadmap guidance materials. I plan to include a copy of this as a part of my hand out materials when I talk to physicians and other health care providers on fraud and abuse issues.

WV Medicaid Offering Cash Incentive Program to New ePrescribers

The West Virginia Regional Health Information Technology Extension Center (WVRHITEC) announced this week that West Virginia's Medicaid Program is now offering cash incentives to health care providers who become a part of a new e-prescribing system.

WVeScript, is a new web-based ePrescribing tool implemented by the West Virginia Bureau for Medical Services (BMS) and provided to all Medicaid program prescribers and pharmacies. It is located on the BMS MediWeb Clinical Web Portal. This tool can be used to ePrescribe for all patients, not just those with Medicaid insurance. FAQs with more information about the WVeScript and MediWeb Clinical Web Portal.

The announcement by WVRHITEC also indicates that as an added incentive, West Virginia Medicaid will provide cash assistance in the amount of $1,000.00 for the purchase of a computer or to pay toward web access when a provider enrolls in the ePrescribing program at www.WVeScript.com. At the end of March 31, 2011, if a provider has electronically prescribed at least 70% of his or her prescriptions for Medicaid members, she or he will receive an additional $1,000.00. In addition, training is available, and a provider can earn two CME credits for completing the on-line web-based training. The incentives are available to a limited number of providers, so please sign up today.

CMS Awards WV Medicaid $945K Federal Matching Funds for EHR Incentive Programs

iHealthBeat reports that West Virginia Medicaid along with five other states will receive federal matching funds from the Centers for Medicare and Medicaid (CMS)to help implement electronic health record (EHR) incentive programs.

West Virginia Medicaid will receive $945,000 in federal matching funds. The CMS press release indicates that West Virginia will use the funds for planning activities that include conducting a comprehensive analysis to determine the current status of HIT activities in the state. The funds will be used to gather information on issues such as existing barriers to its use of EHRs, provider eligibility for EHR incentive payments, and the creation of a State Medicaid HIT Plan.

The CMS press release states:

WEST VIRGINIA TO RECEIVE FEDERAL MATCHING FUNDS FOR ELECTRONIC HEALTH RECORD INCENTIVES PROGRAM

In another key step to further states’ role in developing a robust U.S. health information technology (HIT) infrastructure, the Centers for Medicare & Medicaid Services (CMS) announced today that West Virginia’s Medicaid program will receive federal matching funds for state planning activities necessary to implement the electronic health record (EHR) incentive program established by the American Recovery and Reinvestment Act of 2009 (Recovery Act). West Virginia will receive approximately $945,000 in federal matching funds.

EHRs will improve the quality of health care for the citizens of West Virginia and make their care more efficient. The records make it easier for the many providers who may be treating a Medicaid patient to coordinate care. Additionally, EHRs make it easier for patients to access the information they need to make decisions about their health care.

The Recovery Act provides a 90 percent federal match for state planning activities to administer the incentive payments to Medicaid providers, to ensure their proper payments through audits and to participate in statewide efforts to promote interoperability and meaningful use of EHR technology statewide and, eventually, across the nation.

“We congratulate West Virginia for qualifying for these federal matching funds to assist its plan for implementing the Recovery Act’s EHR incentive program,” said Cindy Mann, director of the Center for Medicaid and State Operations at CMS. “Meaningful and interoperable use of EHRs in Medicaid will increase health care efficiency, reduce medical errors and improve quality-outcomes and patient satisfaction within and across the states.”

West Virginia will use its federal matching funds for planning activities that include conducting a comprehensive analysis to determine the current status of HIT activities in the state. As part of that process, West Virginia will gather information on issues such as existing barriers to its use of EHRs, provider eligibility for EHR incentive payments, and the creation of a State Medicaid HIT Plan, which will define the state’s vision for its long-term HIT use.

State Medicaid Fraud Control Units Annual Report FY 2008

The DHHS Office of Inspector General has issued the Fiscal Year 2008 State Medicaid Fraud Control Units Annual Report. The report covers FY 2008 (October 1, 2007 - September 30, 2008.

The summary of the report provides background on the Medicaid Fraud Control Unit (MFCU) grant program, the number of states participating, the amounts recovered and number of convictions obtained in FY 2008:

During this reporting period, 49 States and the District of Columbia participated in the Medicaid fraud control grant program through their established MFCUs. The mission of the MFCUs is to investigate and prosecute Medicaid provider fraud and patient abuse and neglect. MFCUs’ authority to investigate and prosecute cases varies from State to State.

Forty-three of the MFCUs are located within Offices of State Attorneys General. The remaining seven MFCUs are located in various other State agencies.

In FY 2008, MFCUs recovered more than $1.3 billion in court-ordered restitution, fines, civil settlements, and penalties. They also obtained 1,314 convictions. MFCUs reported a total of 971 instances in which civil settlements and/or judgments were achieved. Of the 3,129 OIG exclusions from participation in the Medicare, Medicaid, and other Federal health care programs in FY 2008, 755 exclusions were based on referrals made to OIG by the MFCUs.

The report also contains examples of Medicaid fraud and patient abuse and neglect case investigations and prosecutions undertaken during FY 2008.

Read the full report for more information on the role that state MFCUs play in the oversight of the Medicaid program.