Physicians who refer or order services for Medicare patients must be enrolled in PECOS, the Medicare Provider Enrollment, Chain, and Ownership System database, and physicians who bill Medicare are required to list the name and National Provider Identifier (NPI) of the ordering/referring physician on their claims in order to be paid.  The source of these requirements is Section 6405 of the Affordable Care Act. CMS is about to implement an automatic edit so that claims submitted on or after May 1st for certain services ordered by a physician or healthcare provider who is not enrolled in PECOS, even if his or her name and National Provider Identifier (NPI) are on the claim, will be denied.  This change may affect a relatively small but important set of anesthesiologists, who have raised questions about the issue.  As part of the pre-operative evaluation of surgical patients, anesthesiologists may order clinical laboratory or even imaging...

Benjamin Franklin said, “An ounce of prevention is worth a pound of cure.” It is certain that Mr. Franklin was not speaking about the value of preemptive compliance work, yet the old adage aptly applies to the work done by physician groups to prevent allegations of fraud or abuse. The Office of Inspector General for the Department of Health and Human Services (“OIG”) recently reported that the government expected to set a record of $6.9 billion in recoveries from its investigations and enforcement actions for its fiscal year 2012.1 As the chart in Figure 1 shows2, this $6.9 billion is part of a trend of continuously increasing recoveries. For this reason, many physician groups have implemented compliance programs designed to minimize the chances that the group will commit what the government perceives to be fraud or abuse. One key to effective compliance is an understanding of those issues of particular importance...

ABC is receiving some very good questions from anesthesia and pain practices regarding more details on how the sequestration 2% Medicare payment cut will impact their reimbursement.  We are continuing to monitor various Medicare carriers’ websites, including Palmetto, CGS, Novitas, First Coast Service Options and NHIC. These Q&As can help you track and ensure proper payments.Question:Does the 2% payment reduction under sequestration apply to the payment rates reflected in Medicare fee-for-service fee schedules or does it only apply to the final payment amounts?Answer:Payment adjustments required under sequestration are applied to all claims after determining the Medicare payment including application of the current fee schedule, coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments. All fee schedules, Pricers, etc., are unchanged by sequestration; it’s only the final payment amount that is reduced. Question:How is the 2% payment reduction under sequestration identified on the electronic remittance advice (ERA) and the standard paper...

All of you are familiar with some of the regulatory requirements that affect your practice, as identified by their acronyms and initials: HIPAA, CMS, CoPs,PQRS, SCIP, ACO, HCAHPS. For hospital-based practices, there are now two additional “ingredients” in our regulatory alphabet soup that will require your attention: OPPE and FPPE. Historically, hospital medical staff appointments and reappointments have been primarily a subjective process, where the clinical chief signed off on credential/privilege requests, perceived competencies and specific skills. The Joint Commission and other accrediting bodies and payers have established more stringent guidelines for the ongoing evaluation of medical staff members. The Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) are now becoming part of every hospitalbased anesthesia practice’s routine. These evaluations are expected to occur on a regular basis and serve as the key component to the hospital reappointment process. Key Components   In adopting the Accreditation Council for...

The Centers for Medicare and Medicaid Services (CMS) has been encouraging the growth of accountable care organizations (ACOs) and other integrated models under the impetus of the Affordable Care Act (ACA).  The Federal Trade Commission (FTC), on the other hand, remains fiercely protective of competition.  If competitors coalesce into a single large organization, there will be fewer competitors. The ACA provides that “nothing [in the legislation] shall be construed to modify, impair or supersede the operation of the antitrust laws.”  In October 2011 the FTC jointly with the Department of Justice issued its Final Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations—following, but not allaying, much criticism of the corresponding proposed rule. The tension between the two drives, integration versus competition, has increased steadily since the passage of the ACA.  A recent and unusual FTC decision to go to court to block the acquisition of a medical group by a hospital...