Professionals — Health Hippo

Health Hippo: Professionals

US CODE ||CFR || CASES || REPORTS || CONGRESSIONAL RECORD || BILLS || FEDERAL REGISTER

Medicine is of all the Arts the most noble; but, not withstanding, owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgment of them, it is at present far behind all the other arts.

The Affordable Care Act includes federal investments in the health care
workforce designed to train new primary care providers –
including physicians, nurse practitioners and physician assistants – and
encourage primary care providers to practice in underserved areas. The
number of primary care providers in the National Health Service has more
than doubled, Community Health Centers have been funded nationwide,
primary care providers are being trained in community settings,
integrated care is being promoted for the chronically ill, and a new
“Innovation Center” is accepting, implementing and rewarding ideas that
deliver better care and lower costs to the Medicare and Medicaid
programs.

U.S. Code

Protecting Access to Medicare Act of 2014 The doc
fix law includes a short-term fix to the sustainable growth rate
(SGR).

Health Care and Education
Reconciliation Act: Professionals
- Sec. 1106. Physician
  ownership-referral.
- Sec. 1202.
  Payments to primary care physicians.
- Sec. 2303. Community health centers.

Affordable Care Act Quality and
Payments
- Sec. 3002. Improvements
  to the physician quality reporting system.
- Sec. 3003. Improvements to the physician
  feedback program.
- Sec. 3007.
  Value-based payment modifier under the physician fee schedule.
- Sec. 3011. National strategy.
- Sec. 3012. Interagency Working Group on Health
  Care Quality.
- Sec. 3013. Quality
  measure development.
- Sec. 3014. Quality
  measurement.
- Sec. 3015. Data
  collection; public reporting.
- Sec.
  3021. Establishment of Center for Medicare and Medicaid Innovation
  within CMS.
- Sec. 3022. Medicare shared
  savings program.
- Sec. 3023. National
  pilot program on payment bundling.
- Sec.
  3027. Extension of gainsharing demonstration.
- Sec. 3101. Increase in the physician payment
  update.
- Sec. 3102. Extension of the
  work geographic index floor and revisions to the practice expense
  geographic adjustment under the Medicare physician fee schedule.
- Sec. 3107. Extension of physician fee schedule
  mental health add-on.
- Sec. 3108.
  Permitting physician assistants to order post-Hospital extended care
  services.
- Sec. 3114. Improved access
  for certified nurse-midwife services.
- Sec.
  3501. Health care delivery system research; Quality improvement
  technical assistance.
- Sec. 3508.
  Demonstration program to integrate quality improvement and patient
  safety training into clinical education of health professionals.
- Sec. 3511. Authorization of appropriations.
- Sec. 6001. Limitation on Medicare
  exception to the prohibition on certain physician referrals for
  hospitals.
- Sec. 6002. Transparency
  reports and reporting of physician ownership or investment interests.
- Sec. 6003. Disclosure requirements for
  in-office ancillary services exception to the prohibition on physician
  self-referral for certain imaging services.
- Sec. 6801. Sense of the Senate regarding
  medical malpractice.
- Sec. 10310.
  Repeal of physician payment update.
- Sec.
  10321. Revision to community health teams.
- Sec. 10327. Improvements to the physician
  quality reporting system.
- Sec. 10330.
  Modernizing computer and data systems of the Centers for Medicare &
  Medicaid services to support improvements in care delivery.
- Sec. 10331. Public reporting of performance
  information.
- Sec. 10332. Availability
  of medicare data for performance measurement.
- Sec. 10333. Community-based collaborative
  care networks.
- Sec. 10908. Exclusion
  for assistance provided to participants in State student loan repayment
  programs for certain health professionals.

Affordable Care Act Health Care
Workforce
- Sec. 5001. Purpose.
- Sec. 5002. Definitions.
- Sec. 5101. National health care workforce
  commission.
- Sec. 5102. State health
  care workforce development grants.
- Sec.
  5103. Health care workforce assessment.
- Sec. 5201. Federally supported student loan
  funds.
- Sec. 5202. Nursing student loan
  program.
- Sec. 5203. Health care
  workforce loan repayment programs.
- Sec.
  5204. Public health workforce recruitment and retention programs.
- Sec. 5205. Allied health workforce
  recruitment and retention programs.
- Sec.
  5206. Grants for State and local programs.
- Sec. 5207. Funding for National Health Service
  Corps.
- Sec. 5208. Nurse-managed health
  clinics.
- Sec. 5209. Elimination of cap
  on commissioned corps.
- Sec. 5210.
  Establishing a Ready Reserve Corps.
- Sec.
  5301. Training in family medicine, general internal medicine,
  general pediatrics, and physician assistantship.
- Sec. 5302. Training opportunities for direct
  care workers.
- Sec. 5303. Training in
  general, pediatric, and public health dentistry.
- Sec. 5304. Alternative dental health care
  providers demonstration project.
- Sec.
  5305. Geriatric education and training; career awards; comprehensive
  geriatric education.
- Sec. 5306. Mental
  and behavioral health education and training grants.
- Sec. 5307. Cultural competency, prevention,
  and public health and individuals with disabilities training.
- Sec. 5308. Advanced nursing education grants.
- Sec. 5309. Nurse education, practice,
  and retention grants.
- Sec. 5310. Loan
  repayment and scholarship program.
- Sec.
  5311. Nurse faculty loan program.
- Sec.
  5312. Authorization of appropriations for parts B through D of title
  VIII.
- Sec. 5313. Grants to promote the
  community health workforce.
- Sec. 5314.
  Fellowship training in public health.
- Sec.
  5315. United States Public Health Sciences Track.
- Sec. 5401. Centers of excellence.
- Sec. 5402. Health care professionals training
  for diversity.
- Sec. 5403.
  Interdisciplinary, community-based linkages.
- Sec. 5404. Workforce diversity
- Sec. 5405. Primary care extension program.
- Sec. 5501. Expanding access to primary
  care services and general surgery services.
- Sec. 5502. Medicare Federally qualified health
  center improvements.
- Sec. 5503.
  Distribution of additional residency positions.
- Sec. 5504. Counting resident time in
  nonprovider settings.
- Sec. 5505. Rules
  for counting resident time for didactic and scholarly activities and
  other activities.
- Sec. 5506.
  Preservation of resident cap positions from closed hospitals.
- Sec. 5507. Demonstration projects To address
  health professions workforce needs; extension of family-to-family health
  information centers.
- Sec. 5508.
  Increasing teaching capacity.
- Sec.
  5509. Graduate nurse education demonstration.
- Sec. 5601. Spending for Federally Qualified
  Health Centers (FQHCs).
- Sec. 5602.
  Negotiated rulemaking for designating medically underserved populations
  and health professions shortage areas.
- Sec.
  5603. Reauthorization of the Wakefield Emergency Medical Services
  for Children Program.
- Sec. 5604.
  Co-locating primary and specialty care in community-based mental health
  settings.
- Sec. 5605. Key National
  indicators.
- Sec. 5701. Reports.
- Sec. 10501. Amendments to the Public Health
  Service Act, the Social Security Act, and title V of this Act.
  - Interagency Task Force To Assess And Improve Access To Health
    Care In The State Of Alaska
  - Demonstration Grants For Family Nurse
    Practitioner Training Programs
  - National Diabetes Prevention Program
  - Grants To Providers Of Medically Underserved Populations Or Other
    Special Populations
  - Rural Physician Training Grants
  - Preventive
    Medicine And Public Health Training Grant Program
- Sec. 10502. Infrastructure to Expand Access
  to Care.
- Sec. 10503. Community Health
  Centers and the National Health Service Corps Fund.
- Sec. 10504. Demonstration project to provide
  access to affordable care.
- Sec.
  10605. Certain other providers permitted to conduct face to face
  encounter for home health services.
- Sec.
  10908. Exclusion for assistance provided to participants in State
  student loan repayment programs for certain health professionals.

Balanced Budget Act Health
Professionals.
- Sec. 4501
  Establishment of single conversion factor for 1998.
- Sec. 4502 Establishing update to
  conversion factor to match spending under sustainable growth rate.
- Sec. 4503 Replacement of volume
  performance standard with sustainable growth rate.
- Sec. 4504 Payment rules for anesthesia
  services.
- Sec. 4505
  Implementation of resource-based methodologies.
- Sec. 4506 Dissemination of information
  on high per discharge relative values for in-hospital physicians’
  services.
- Sec. 4507 Use of
  private contracts by medicare beneficiaries.
- Sec. 4511 Increased medicare
  reimbursement for nurse practitioners and clinical nurse specialists.
- Sec. 4512 Increased medicare
  reimbursement for physician assistants.
- Sec. 4513 No x-ray required for
  chiropractic services.
- Sec.
  4621 Indirect graduate medical education payments.
- Sec. 4622 Payment to hospitals of
  indirect medical education costs for Medicare+Choice enrollees.
- Sec. 4623 Limitation on number of
  residents and rolling average FTE count.
- Sec. 4624 Payments to hospitals for
  direct costs of graduate medical education of Medicare+Choice enrollees.
- Sec. 4625 Permitting payment
  to nonhospital providers.
- Sec.
  4626 Incentive payments under plans for voluntary reduction in
  number of residents.
- Sec. 4627
  Medicare special reimbursement rule for primary care combined residency
  programs.
- Sec. 4628
  Demonstration project on use of consortia.
- Sec. 4629 Recommendations on
  long-term policies regarding teaching hospitals and graduate medical
  education.
- Sec. 4630 Study of
  hospital overhead and supervisory physician components of direct medical
  education costs.

42 U.S. Code Part B Peer Review of Utilization and Quality
of Health Care Services
- 42 USC Sec.
  1320c Purpose: Utilization Review
- 42 USC Sec.
  1320c-1 Utilization and quality control peer review organization
  defined
- 42 USC Sec.
  1320c-2 Contracts with utilization and quality control peer review
  organizations
- 42 USC Sec.
  1320c-3 Functions of peer review organizations
- 42 USC Sec.
  1320c-4 Right to hearing and judicial review
- 42 USC Sec.
  1320c-5 Obligations of health care practitioners and providers of
  health careservices
- 42 USC Sec.
  1320c-6 Limitation on liability
- 42 USC Sec.
  1320c-7 Application of this part to certain State programs
- 42 USC Sec.
  1320c-8 Authorization for use of certain funds to administer
  provisions of this part
- 42 USC Sec.
  1320c-9 Prohibition against disclosure of information
- 42 USC Sec.
  1320c-10 Annual reports
- 42 USC Sec.
  1320c-11 Exemptions of Christian Science sanatoriums
- 42 USC Sec.
  1320c-12 American Samoa, Northern Mariana Islands, andPacific
  Islands
- 42 USC Sec.
  1320c-13 100 percent peer review for certain surgical
  procedures
42 USC Sec.
1395hh Authority to prescribe regulations
42 U.S. Code Chapter 117, Subchapter I PROMOTION OF PROFESSIONAL
REVIEW ACTIVITIES
- 42 USC Sec.
  11111. Professional review
- 42 USC Sec.
  11112. Standards for professional review actions
- 42 USC Sec.
  11113. Payment of reasonable attorneys’ fees and costs
- 42 USC Sec.
  11114. Guidelines of Secretary
- 42 USC Sec.
  11115. Construction
42 U.S. Code Chapter 117, Subchapter II REPORTING OF INFORMATION
- 42 USC
  Sec. 11131. Requiring reports on medical malpractice payments
- 42 USC Sec.
  11132. Reporting of sanctions taken by Boards
- 42 USC Sec.
  11133. Reporting of certain professional review actions
- 42 USC Sec.
  11134. Form of reporting
- 42 USC Sec.
  11135. Duty of hospitals to obtain information
- 42 USC Sec.
  11136. Disclosure and correction of information
- 42 USC Sec.
  11137. Miscellaneous provisions
- 42 USC Sec.
  11151. Definitions
- 42 USC Sec.
  11152. Reports and memoranda of understanding
42 USC Sec.
13031. Child abuse reporting

Code of Federal Regulations

32 CFR Sec. 199.15 Peer Review
Organization Program.
42 CFR
PART 456 UTILIZATION CONTROL
- SUBPART
  A General Provisions (456.1 – 456.6)
- SUBPART
  B Utilization Control: All Medicaid Services (456.21 – 456.23)
- SUBPART
  C Utilization Control: Hospitals (456.50 – 456.145)
- SUBPART
  D Utilization Control: Mental Hospitals (456.150 – 456.245)
- SUBPART E [Reserved]
- SUBPART
  F Utilization Control: Intermediate Care Facilities (456.350 –
  456.438)
- SUBPART
  G Inpatient Psychiatric Services for Individuals Under Age 21:
  Admission and Plan of Care Requirements (456.480 – 456.482)
- SUBPART
  H Utilization Review Plans: FFP, Waivers, and Variances for
  Hospitals and Mental Hospitals (456.500 – 456.525)
- SUBPART
  I Inspections of Care in Intermediate Care Facilities and
  Institutions for Mental Diseases (456.600 – 456.614)
- SUBPART
  J Penalty for Failure To Make a Satisfactory Showing of an Effective
  Institutional Utilization Control Program (456.650 – 456.657)
- SUBPART
  K Drug Use Review (DUR) Program and Electronic Claims Management
  System for Outpatient Drug Claims (456.700 – 456.725)
45 CFR PART
60 NATIONAL PRACTITIONER DATA BANK
- Sec.
  60.1 The National Practitioner Data Bank.
- Sec. 60.2
  Applicability of these regulations.
- Sec. 60.3
  Definitions.
- Sec. 60.4
  How information must be reported.
- Sec. 60.5
  When information must be reported.
- Sec. 60.6
  Reporting errors, omissions, and revisions.
- Sec. 60.7
  Reporting medical malpractice payments.
- Sec. 60.8
  Reporting licensure actions taken by Boards of Medical Examiners.
- Sec. 60.9
  Reporting adverse actions on clinical privileges.
- Sec.
  60.10 Information which hospitals must request
- Sec.
  60.11 Requesting information from the National Practitioner Data
  Bank .
- Sec.
  60.12 Information which hospitals must request from the National
  Practitioner Data Bank.
- Sec.
  60.13 Requesting information from the National Practitioner Data
  Bank.
- Sec.
  60.14 Fees applicable to requests for information.
- Sec.
  60.15 Confidentiality of National Practitioner Data Bank
  information.
- Sec.
  60.16 How to dispute the accuracy of National Practitioner Data Bank
  information.

Case Law

NLRB v.
Health Care & Retirement Corp. (U.S., May 23, 1994) (NLRB test
for determining whether nurses are supervisors was inconsistent with the
NLRB statute)
Sammon v. New Jersey Board of Medical Examiners (3d Cir.,
September 15, 1995) (New Jersey licensing statute regulating the
practice of midwifery passes constitutional muster)

Reports

Improper
Payments for Evaluation and Management Services Cost Medicare Billions
in 2010 (OIG 2014) In total, Medicare inappropriately paid $6.7
billion for claims for E/M services in 2010 that were incorrectly coded
and/or lacking documentation, representing 21 percent of Medicare
payments for E/M services that year. We found that 42 percent of claims
for E/M services in 2010 were incorrectly coded, which included both
upcoding and downcoding.
Uniformed Services University of the Health Sciences
Recent Federal Register notices.
Medicare: Nurse
Anesthetists Billed for Few Chronic Pain Procedures (GAO 2014) Of
all CRNA claims for selected procedures, the share billed by CRNAs in
rural areas fell from 66 percent in 2009 to 39 percent in 2012. Chronic
pain costs the nation about $600 billion each year, a quarter of which
is borne by Medicare. One MAC, Noridian Healthcare Solutions (Noridian),
began denying CRNA claims for certain chronic pain services in 2011,
citing patient safety concerns. CMS issued a rule, effective January
2013, clarifying that CRNAs can bill Medicare for “any services that a
[CRNA] is legally authorized to perform in the state in which the
services are furnished,” including chronic pain management services.
Public Comment on the Release of Medicare Physician Data (CMS 2013)
CMS sought input regarding: (1) whether physicians have a privacy
interest in information concerning payments they receive from Medicare,
and if so, how to properly weigh the balance between that privacy
interest and public interest in disclosure of Medicare payment
information; (2) what specific policies CMS should consider with respect
to disclosure of individual physician payment data; and (3) the form
that should be taken for any data release.
Medicare Provider Utilization and Payment Data: Physician
and Other Supplier (CMS 2013) The Physician and Other Supplier PUF
contains information on utilization, payment (allowed amount and
Medicare payment), and submitted charges organized by National Provider
Identifier (NPI), Healthcare Common Procedure Coding System (HCPCS)
code, and place of service.
MedPac: Physician and Other
Health Professionals Payment System (2014) Physician services
include office visits, surgical procedures, and a broad range of other
diagnostic and therapeutic services. These services are furnished in all
settings, including physicians’ offices, hospitals, ambulatory surgical
centers, skilled nursing facilities and other post-acute care settings,
hospices, outpatient dialysis facilities, clinical laboratories, and
beneficiaries’ homes. Among the 1 million clinicians in Medicare’s
registry, approximately half are physicians who actively bill Medicare.
The remainder includes health professionals such as nurse practitioners,
physician assistants, and physical therapists.
MedPac: Site Visits to Selected
Institutions With Innovations In Residency Training (2010) Although
approaches differed, several innovation foci emerged from our site
visits, including: transforming practices into Patient-Centered Medical
Homes (PCMHs); developing IT resources; working in multidisciplinary
teams; improving patient-provider continuity; separating inpatient and
outpatient clinical activities; working in community-based settings;
implementing curricula for teaching quality improvement methods and
delivering high-quality chronic disease care; exposing residents to
community issues and community-based resources; working in systems
encouraging high- performance and efficiency; and redesigning inpatient
teaching units.
Improvements
Are Needed To Ensure Provider Enumeration and Medicare Enrollment Data
Are Accurate, Complete, and Consistent (OIG 2013) Inaccurate,
incomplete, and inconsistent provider data coupled with insufficient
oversight place the integrity of the Medicare program at risk and
present vulnerabilities in all health care programs. CMS should require
Medicare Administrative Contractors to implement program integrity
safeguards for Medicare provider enrollment as established in the
Program Integrity Manual.
Lack
of Data Regarding Physicians Opting Out of Medicare (OIG 2012)
Although the percentage of physicians who choose to opt out may be small
(perhaps less than 1 percent1), monitoring the number of opted-out
physicians and their specialties is important to ensure that Medicare
beneficiaries have sufficient access to providers, including specialized
providers.
CMS
Reporting to the Healthcare Integrity and Protection Data Bank (OIG
2012) The Healthcare Integrity and Protection Data Bank (HIPDB) is a
national data bank containing reports of adverse actions against health
care practitioners, providers, and suppliers (collectively referred to
as providers). Complete and accurate HIPDB information helps prevent the
employment of potentially fraudulent or abusive providers.
Health
Education Assistance Loan Defaulters With Income in Fiscal Year 2008
(OIG 2010) Based on wages identified through SIDI, 486 of the 1,065 HEAL
defaulters earned income in FY 2008. The remaining 579 defaulters did
not have income information identified in SIDI. Of the 486 defaulters,
312 made no loan payments during that time. These 312 HEAL defaulters
owed $47.5 million on their loans and earned $13.4 million in FY 2008.
Foreign
Physicians: Data on Use of J-1 Visa Waivers Needed to Better Address
Physician Shortages (GAO 2006) More than 1,000 waivers were
requested in each of fiscal years 2003 through 2005 by states and three
federal agencies–the Appalachian Regional Commission, the Delta
Regional Authority, and HHS. At the end of fiscal year 2005, the
estimated number of physicians practicing in underserved areas through
J-1 visa waivers exceeded the number practicing there through the
National Health Service Corps (NHSC)–HHS’s primary mechanism for
addressing physician shortages.
HHS
Agencies ComplianceWith the National Practitioner Data Bank Malpractice
Reporting Policy (OIG 2005) We found that, as of October 2004, HHS
agencies failed to report as many as 474 medical malpractice cases to
the NPDB that should have been reported.
Managed Care
Organization Nonreporting to the National Practitioner Data Bank: A
Signal for Broader Concern (OIG 2001) With close to 100 million
individuals enrolled in these organizations and hundreds of thousands of
physicians and dentists associated with them, fewer than 1,000 adverse
action reports over nearly a decade serves for all practical purposes as
“nonreporting.”
Foreign
Physicians: Exchange Visitor Program Becoming Major Route to Practicing
in U.S. Underserved Areas (GAO 1996) GAO reviewed the extent to
which state and federal agencies used waivers to meet physician
shortages in medically underserved areas, focusing on: (1) how many
foreign physicians with J-1 visas receive waivers, where they practice,
and their medical specialties; (2) whether federal agencies and states
effectively coordinate policies and procedures for granting these
waivers; and (3) the extent to which foreign physicians who receive
waivers comply with waiver requirements to practice in underserved
areas.
Insurance:
Profitability of the Medical Malpractice and General Liability Lines
(GAO 1997) Medical malpractice line incurred losses when the reserves
were valued at their full estimated payout, but was profitable when the
reserves were discounted to present values.
Medical Malpractice: Federal Tort Claims Act
Coverage Could Reduce Health Centers’ Costs (GAO 1997) Pursuant to a
legislative requirement, GAO reviewed the implementation of Federal Tort
Claims Act (FTCA) coverage for community health centers.
Medicare: Private-Sector and Federal Efforts to
Assess Health Care Quality (GAO 1996) GAO discussed the Health Care
Financing Administration’s (HCFA) efforts to provide health care quality
information to Medicare beneficiaries joining health maintenance
organizations.
Practice
Guidelines: Managed Care Plans Customize Guidelines to Meet Local
Interests (GAO 1996) Pursuant to a congressional request, GAO
reviewed how managed health plans make use of existing clinical practice
guidelines.
Medicare: Federal Efforts to Enhance Patient
Quality of Care (GAO 1996) Pursuant to a congressional request, GAO
reviewed the Health Care Financing Administration’s (HCFA) efforts to
enhance the quality of care for Medicare beneficiaries.
Medicare:
Millions Can Be Saved by Screening Claims for Overused Services (GAO
1996) GAO provided information on Medicare payments for unnecessary
medical services.
Medical
Liability: Impact on Hospital and Physician Costs Extends Beyond
Insurance (GAO 1995) GAO reviewed the types of medical liability
costs that affect hospitals and physicians, and whether existing studies
include these costs in their estimates of hospital and physician
liability expenses.
Practice
Guidelines: Overview of Agency for Health Care Policy and Research
Efforts (GAO 1995) In 1989, Congress created the Agency for Health
Care Policy and Research–part of the Public Health Service–to serve as
the federal government’s focal point for effectiveness and outcomes
research.
Medicare: Graduate Medical Education Payment Policy
Needs to Be Reexamined (GAO 1994) It is widely held that the United
States is not training enough primary care physicians relative to other
types of physicians.
Medical
Education: Curriculum and Financing Strategies Need to Encourage Primary
Care Training (GAO 1994) The proportion of active doctors who are
primary care physicians–family and general practice physicians, general
internists, and pediatricians–has dropped from 53 to 35 since 1960.
Primary Care Physicians: Managing Supply in
Canada, Germany, Sweden, and the United Kingdom (GAO 1994) GAO
examined the methods used by four nations–Canada, Germany, Sweden, and
the United Kingdom–to manage their physician supply and specialty
distribution.
Medical
Malpractice: Maine’s Use of Practice Guidelines to Reduce Costs (GAO
1993) As part of a larger goal of reducing health care costs and
improving medical care, Maine is testing an innovative medical
malpractice reform initiative.
Practice
Guidelines: The Experience of Medical Specialty Societies (GAO 1991)
GAO also found that it was unable to make any recommendations on
guideline development because of the: (1) variability in guideline
development in the past and in the opinions about how it should proceed
in the future; and (2) absence of evaluative studies on guideline
development and guideline impacts.
Use of
Medicare Offset Agreements and Exclusions for National Health Service
Corps and Health Education Assistance Loan Defaulters (OIG 1991)
Medicare offset and exclusion procedures are not being employed against
defaulters in the Deparment of Health and Human Services’ scholarship
and loan programs for students in the heathprofessions. To date, the
Public Heath Service (PHS), which is responsible for debt management
activities, has not yet implemented the offset procedure, and has
initiated the exclusion option against only one National Heath Service
Corps (NHSC) scholarship defaulter.
Health
Education Assistance Loan (HEAL) (OIG 1991) This study was initiated
because of high-level concerns about financial problems the HEAL program
has been experiencing due to an increasing default rate. The Public
Health Service (PHS) projects the Student Loan Insurance Fund (SLIP) wil
not have suffcient funds to pay the increasing number of claims.
Health
Education Assistance Loan Program (OIG 1985) In case of default ,
death, disability or bankruptcy, the holder of the loan is reimbursed
the full amount of principal and accrued interest from the Student Loan
Insurance Fund (SLIF). Deposits to the fund are derived from insurance
premiums (currently 2 percent) deducted from the loan principal at the
time of award.
Coding
Trends of Medicare Evaluation and Management Services (OIG 2012)
Medicare payments for evaluation and management (E/M) services increased
by 48 percent, from $22.7 billion to $33.5 billion. E/M services have
been vulnerable to fraud and abuse. In 2009, two health care entities
paid over $10 million to settle allegations that they fraudulently
billed Medicare for E/M services. The Centers for Medicare & Medicaid
Services (CMS) also found that certain types of E/M services had the
most improper payments of all Medicare Part B service types in 2008.
South
Florida Medicare Comprehensive Outpatient Rehabilitation Facilities
(OIG 2011) CORFs provide multidisciplinary outpatient rehabilitation
services at a single location. Medicare allowed approximately $70
million for almost 40,000 beneficiaries nationwide who received CORF
services in 2010. Of this amount, more than $22 million was for claims
by South Florida CORFs. In 2010, more than 25 percent of all CORFs were
in South Florida.
Medicaid
Services Provided in an Adult Day Health Setting (OIG 2011) On many
service days, beneficiaries’ only documented services were meals and/or
snacks. Many also received therapy services from staff who were not
supervised in accordance with State requirements. Our findings indicate
the need for (1) explicit requirements regarding the provision of health
services in Medicaid adult day health centers and (2) enforcement of
current therapy supervision requirements.
Inappropriate
Claims for Medicaid Personal Care Services (OIG 2010) PCS attendants
provide the elderly and people with disabilities with the assistance
they need to remain in their homes and communities. Combined State and
Federal Medicaid expenditures for PCS totaled $9.9 billion in 2006, an
increase of 20 percent since 2004.
Prevalence
and Qualifications of Nonphysicians Who Performed Medicare Physician
Services (OIG 2009) Medicare Part B pays for services that are
billed by physicians but are performed by nonphysicians. These services
often are called “incident to” services, or services provided under the
“incident to” rule. “Incident to” services may be vulnerable to
overutilization and may put beneficiaries at risk of receiving services
that do not meet professionally recognized standards of care.
Medicare
Payment for Nonphysician Clinical Staff in Cardiothoracic Surgery
(OIG 2002) This inspection assesses the frequency, payment, and reasons
cardiothoracic surgeons use their own nonphysician clinical staff to
perform surgery-related hospital duties and the manner and extent to
which Medicare pays for these services.
Medicare
Coverage of Non-Physician Practitioner Services (OIG 2001) To
describe the scope of services nurse practitioners, clinical nurse
specialists, and physician assistants provide to Medicare beneficiaries,
and to identify any potential vulnerabilities that may have emerged
since the Balanced Budget Act of 1997.
Nonprofessional Services in Skilled Nursing Facilities (OIG 1995)
This report examines the extent of Part B billings for nonprofessional
institutional services such as enteral nutrition services, incontinence
care services, and surgical dressings provided to beneficiaries during
Medicare covered SNF stays. We did not review situations where an
individual in a SNF was not covered by Part A but receiving a SNF level
of care.
Carriers
Still Need to Purge Unused Provider Numbers (OIG 1995) In a May 1991
report the Office of Inspector General (OIG) found that most carriers
did not systematically update provider files. The OIG found that
carriers could reduce Medicare’s vulnerability to abuse and save
administrative costs by periodically deactivating provider numbers with
no billing history.
National
Practitioner Data Bank Reports to Hospitals: Their Usefulness and
Impact (OIG 1995) Hospital officials are receiving reports in a much
more timely fashion and they are now much more likely to characterize
Data Bank information as useful. At the same time, our data reveal that
Data Bank reports seldom affect privileging decisions of hospitals.
National
Practitioner Data Bank Reports to Managed Care Organizations: Their
Usefulness and Impact (OIG 1995) Almost all–96 percent–managed
care organizations receiving information from the Data Bank find it
usefid. In fact, this percent is considerably higher than the percent of
hospitals finding the information useful (83 percent). At the same time,
our data reveal that Data Bank reports seldom affect privileging
decisions of managed care organizations.
Hospital
Reporting to the National Practitioner Data Bank (OIG 1995) Our
review suggests a sufficient basis for concern about the hospitals’
response to the Data Bank reporting requirements. The wide variation in
reporting rates from State to State is in itself troubling. It could
suggest differences in the quality of care rendered or perhaps in the
capacity or willingness of hospitals to submit reports to the Data Bank.
National
Practitioner Data Bank: Profile of Matches Update (OIG 1995) When a
request names a practitioner who has been reported to the Data Bank, the
request-report pair is referred to as a “match.” As a result of the
queries made by April 1994, 152,941 matches had occurred.
Enhancing the
Utilization of Nonphysician Health Care Providers (OIG 1993) This
report focuses on making the delivery of health care more productive by
using nonphysician providers differently. It is not a formal evaluation
of the success or failure of health care organizations in reaching this
goal. Rather, the report identifies and describes approaches that some
organizations are taking to make better use of such personnel. We also
describe fundamental barriers that inhibit the broader use of such
approaches.
Enhancing the
Utilization of Nonphysician Health Care Providers: Three Case
Studies (OIG 1993) Evercare, a managed care delivery system in
Minneapolis illustrates how nurse practitioners working in collaboration
with physicians can enhance the delivery of care to nursing home
residents. St. Joseph’s Hospital of Atlanta is using professional and
nonprofessional hospital staff on two units to dliver more patient care
services directly at the bedside. Chicago’s Mercy Hospital and Medical
Center is training nonprofessional workers to perform technical tasks
and to work in permanent teams with registered nurses in a hospital-wide
expansion of the hospital’s nursing service.
National
Practitioner Data Bank: Usefulness and Impact of Reports to State
Licensing Boards (OIG 1993) Most licensing boards have not queried
the Data Bank. Among their reasons for not querying is that they already
receive much of the information sent to the Data Bank. Our results
suggest, however, that boards may be underestimating the value of
querying the Data Bank.
National
Practitioner Data Bank: Usefulness and Impact of Reports to
Hospitals (OIG 1993) Our findings indicate that the usefulness and
impact of the information in the Data Bank are strongly affected by the
timeliness of the reports. Our recommendations identify steps that PHS
and hospitals need to take to improve the timeliness of Data Bank
reports, since PHS shares the responsibility for timeliness with the
hospitals that query the Data Bank.
State
Dental Boards and Dental Discipline (OIG 1993) The information
presented in this report reinforces the concerns of many State dental
board officials about the capacity of the boards to carry out their
disciplinary responsibilities. But the significance of the information
goes beyond whether or not out-of-State dentists should be licensed by
any given board. It suggests that many boards may not be providing
adequate protection to consumers.
Carrier
Assignment of Medicare Provider Numbers (OIG 1992) Medicare carriers
assign provider numbers to qualified providers of Part B services who
furnish services or supplies to Medicare beneficiaries. The numbers are
used in processing claims and establishing Medicare pricing and
utilization profiles. To obtain a provider number from a carrier,
providers typically complete the carrier’s provider number application
form and meet criteria specified by Medicare regulations.
National
Practitioner Data Bank–Unauthorized Access by Ineligible Health Care
Entities (OIG 1992) Representatives of the Data Bank Executive
Committee as well as the media have raised concerns about the Data Bank
information being provided to ineligible health care entities.
National
Practitioner Data Bank: Malpractice Reporting Requirements (OIG
1992) Because our inspection was limited in scope, we cannot offer a
definitive recommendation as to whether or not to change the Data Bank
reporting requirements. Additional information, such as the predictive
value of open claims and small payments and the overall distribution of
malpractice payment amounts, is needed to make such an assessment.
National
Practitioner Data Bank: Profile of Matches (OIG 1992) When a
hospital, licensing board, or other health care entity requests
information on a certain practitioner from the Data Bank, and that
practitioner has been reported to the Data Bank, the query-record pair
is referred to as a “match.”
Carrier
Maintenance of Medicare Provider Numbers (OIG 1991) If the provider
of services does not have a provider number, payment may not be made for
services. To obtain a provider number from a carrier, providers need to
complete the carrier’s application form and met criteria specified by
Medicare mgulations.
National
Practitioner Data Bank–Use of Authorized Agents (OIG 1990) We
recommended that PHS implement policies to assure that authorized agents
are reputable and that such agents utile appropriate security measures
to assure the confidentiality of Data Bank information. We also
recommended that Data Bank forms be modified to describe the
confidentiality requirement.