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CCH® Health Care Compliance Integrated Library
The Health Care Compliance Integrated Library delivers the latest information on health law. The Library includes seven invaluable titles:

• Civil False Claims and Qui Tam Actions - An essential tool for bringing or defending Qui Tam action.
• Clinical Research Compliance Manual: An Administrative Guide - Essential guidance on the laws and regulations affecting clinical research and trials.
• Defending and Preventing Health Care Fraud and Abuse Cases: An Attorney's Guide - Clear, expert guidance on protecting against charges of health care fraud and abuse.
• Health Care Fraud and Abuse Compliance Manual - Giving health care providers a clear perspective on fraud and abuse laws, written in plain-language.
• Health Law and Compliance Update - Find the latest information on emerging issues. Each section is authored by an expert in the area and includes in-depth analysis of the latest health law and compliance issues.
• Hospital Contracts Manual - Expert, current know-how in dealing with numerous hospital contract scenarios.
• Hospital Law Manual - Health Law expertise covering treatment and payment issues in the delivery of health care services.

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One of the key aspects of CMS' strategy to combat Medicare Part D fraud and abuse is the use of innovative techniques for data analysis by Medicare Drug Integrity Contractors (MEDICs). Beginning in 2007, CMS awarded contracts to three regional MEDICs to address potential Part D fraud and abuse. For this report, the Office of Inspector General (OIG) reviewed MEDIC data covering FY 2008, to determine: (1) the extent to which MEDIC identified and investigated potential Part D fraud and abuse incidents, (2) whether these incidents were identified through external sources or proactive methods, and (3) any issues or barriers MEDICs encountered. The OIG made the following findings: Incidents and investigation. MEDICs identified 4,194 incidents of potential fraud and abuse with eighty-seven percent (3,641) identified through external sources, primarily complaints and 13 percent (553) identified through proactive methods, such as data analysis. MEDICs conducted 1,320 fraud and abuse investigations with ninety-six percent of the incidents identified through external sources. Data access and use problems. MEDICs did not receive access to prescription drug event (PDE) data until August 2007, nearly a year after their contracts began. After receiving access to PDE data, MEDICs reported that important variables were not part of the data. Lack of authority. MEDICs did not have the authority to obtain prescriptions and medical records directly from pharmacies, pharmacy benefit managers, and physicians, only plan sponsors. In addition, while MEDICs are responsible for conducting audits of plan sponsors’ compliance plans, none of these audits were conducted in FY 2008 because CMS did not give its approval. Non-referral by plan sponsors. MEDICs may not have been aware of some potential incidents of fraud and abuse because plan sponsors are encouraged to refer incidents, but not required to do so. OIG recommendations. The OIG recommends that CMS: (1) ensure MEDICs have access to accurate and comprehensive data; (2) authorize MEDICs to directly obtain information from pharmacies, pharmacy benefit managers, and physicians; (3) require plan sponsors to report all potential fraud and abuse incidents that are referred to law enforcement agencies to MEDICs as well; and (4) ensure MEDICs have approval to conduct compliance plan audits. OIG Report, OEI-03-08-00420, Oct. 2009, Health Care Compliance Reporter.

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The 2010 Medicare physician fee schedule (PFS) implements a number of provisions in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (PubLNo 110-275), including provisions related to the Physician Quality Reporting Initiative (PQRI) and the E-Prescribing Incentive Program. PQRI. The PQRI is a voluntary reporting program that provides an incentive payment to eligible professionals who satisfactorily report data on quality measures for covered professional services during a specified reporting period. The term “eligible professional” means any of the following: (1) physician, (2) practitioner, (3) physical or occupational therapist or a qualified speech-language pathologist, or (4) qualified audiologist. Beginning in 2010, participants may earn an incentive payment of two percent of the eligible professionals' estimated total allowed charges for professional services covered under Part B. The PFS moreover adds 30 individual PQRI measures and six measures groups, and an electronic health record-based reporting mechanism to promote the use of electronic health records. CMS will post on its website the names of eligible professionals and group practices that satisfactorily report quality measures following the distribution of the 2010 incentive payments. E-Prescribing Incentive Program. The E-Prescribing Incentive Program provides for incentive payments to eligible professionals who are successful electronic prescribers (e-prescribers). Beginning in 2010, the program will impose penalties on eligible professionals who are not successful e-prescribers. CMS will broaden eligibility for the e-prescribing incentive by including professional services furnished in skilled nursing facilities, domiciliary care, or the home care setting as part of the list of services for which the electronic prescribing measure is reportable, and enable group practices to qualify for a 2010 e-prescribing incentive payment based on a determination at the group practice level, rather than at the individual level. CMS will post on its website the names of individual eligible professionals and group practices that are successful e-prescribers for the 2010 E-Prescribing Incentive Program following the distribution of the 2010 incentive payments. CCH Chicago Bureau, Oct. 30, 2009.

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Almost all grantees of the Ryan White program complied with the core medical services pursuant to the Ryan White CARE Act, according to the Office of Inspector General (OIG). The core medical services requirement applies to funds provided under Parts A, B and C of the Ryan White CARE Act. Part A grants are awarded to metropolitan areas for HIV-related services. Part B base grants, along with supplemental funds, are awarded to states and territories to improve the quality, availability, and organization of health care and support services. Part C Early Intervention Services grants are made to public and private nonprofit organizations to fund comprehensive primary health care in an outpatient setting for people living with HIV. Core medical services requirement. The core medical services requirement established in 2006 states that Parts A, B and C grantees must spend at least 75 percent of their funds on core medical services. The core medical services include: outpatient and ambulatory health services; pharmaceutical assistance, including medications provided through the AIDS Drug Assistance Program; and oral health care, among others. Compliance with core medical services requirement. The majority of grantees complied with the core medical services requirement in 2007 and 2008. Parts A, B and C grantees collectively spent an average of 93 percent of their grant funds on core medical services in 2007. The average spending of Part A grantees on core medical services in 2007 and their allocated expenditures in 2008 were 82 percent. Part B and Part C grantees' average spending on core medical services in 2007 were 94 and 95 percent, respectively; in 2008, their allocated expenditures for core medical services were both 94 percent. OIG Report, No. OEI-07-08-00240, Oct. 2009.

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