Lawsuit Accuses Company Of Fraudulently Cycling Patients Through Nursing Homes, Hospice Care

By Jordan Rau

Kaiser Health News Staff Writer

Originally published January 4, 2012

A national hospice company improperly cycled patients through nursing homes and hospice with a goal of making as much profit as possible from Medicare, according to a whistleblower lawsuit announced this week.

Federal attorneys also sued the hospice company, AseraCare, alleging it milked Medicare’s hospice benefit by pressuring its employees to enroll people into hospice who weren’t dying and resisted discharging them despite evidence they weren’t deteriorating. One hospice patient who should have been immobile from end-stage heart disease was healthy enough to go to his granddaughter’s graduation and a berry-picking excursion with a friend, the government charges.

For years, some critics of Medicare’s hospice benefit have said that the way the government pays providers gives them financial incentives to abuse the system. The suits against AseraCare, a Fort Smith, Ark.-based hospice company operating in 19 states, follow several other suits against big hospice companies but go further in their allegations that the company coordinated its use of nursing care and hospice care to maximize Medicare reimbursements.

The entire story is here.

Three Weeks to Stop Medicare Cuts

Ethics is more than a code.  Ethical behavior extends beyond treating our patients to advocating on behalf of our patients.

Even if you do not work with Medicare patients, many insurance companies base reimbursement schedules on Medicare rates.

TO:   All Psychologists 

RE:    Three Weeks to Stop Medicare Cuts

Legislative leaders have begun to discuss options to address critical, time-sensitive issues by the end of the year, including the expiration of unemployment benefits, the Alternative Minimum Tax patch, tax extenders and Medicare extenders.

Now is the time for psychologists to make their voices heard and remind Congress that their patients and practices will soon face a 5% cut to psychotherapy payments in addition to a 27.4% Sustainable Growth Rate (SGR) cut to all services scheduled for 2012 if they fail to act. 

Congress has blocked the SGR cut 12 times since 2001 and the APA Practice Organization has successfully secured the psychotherapy restoration 3 times since 2008, but practitioners face a tougher climate this time around in light of the unprecedented focus on deficit reduction and the broadening divide between legislative leaders.

Your profession needs you to take action NOW to ensure legislators are attentive to these critical priorities.

Take Action Now!

Click here to urge your Senators and your US Representative to halt Medicare cuts to psychological services.

Please TAKE ACTION by Tuesday December 6.

Feel free to leave a comment on this blog so that other psychologists know how easy and simple the process really is......as well as the importance of this advocacy effort!

Message:

 My patients and practice are only a few weeks away from major reimbursement cuts that will impact patient access and put my small business at risk.  As a psychologist and constituent, I urge you to extend the Medicare mental health add-on through 2012.

 Congress has repeatedly found extension of the 5% psychotherapy payment restoration necessary to address the unintended impact of CMS's last Five-Year Review on access to Medicare mental health services.  An extension is necessary until completion of the current Five-Year Review of psychotherapy codes, which has been delayed into 2012.

 As Congress works toward end-of-year action on several pressing priorities, please make my patients and the mental health extender a priority, as well as halting the 27.4% Sustainable Growth Rate (SGR) cut.  Thank you for your time and consideration.

 Additional Background:

CONGRESS SHOULD PROTECT MEDICARE MENTAL HEALTH PAYMENT

To ensure the viability of the Medicare outpatient mental health benefit, Congress should extend through 2012 the restoration of cuts to Part B mental health services made in 2007.

Mental Health Extender.  Congress restored payments temporarily but they now need to be extended.  Through the Medicare Improvements for Patients and Providers Act of 2008, Congress partially restored the cuts made by the Centers for Medicare & Medicaid Services (CMS) "Five-Year Review" through 2009. Subsequent laws then extended the restoration through December 2011. The valuation of psychotherapy codes in the 2011 Five-Year Review has been delayed into 2012.  Congress should pass new legislation to extend payments through 2012, until the Five-Year Review is completed.

Effect on Beneficiaries. Extending psychologist payments cut by the Five-Year Review is crucial to protecting access to Medicare mental health services.  Psychologists and social workers provide almost all of the Medicare psychotherapy and testing services, but many have indicated that they may have to reduce their caseloads or leave Medicare if they are faced with these reimbursement cuts. The cost of protecting mental health services is very low, increasing costs by only $30 million per year.

Cut By MEI Rebasing.  A CMS technical advisory panel will be asked to examine the effect of a 4% cut to Medicare part B reimbursement for psychologists in January 2011 due to "rebasing" of the Medicare Economic Index (MEI).  In the 2011 fee schedule, CMS used more recent survey data that showed practice expense and malpractice became a larger share of the payment formula while provider's time became smaller. This increased payments for some services, particularly of professionals who utilize expensive technology.  Due to budget neutrality requirements, CMS reduced other reimbursement work values, which hit services of psychologists and social workers the hardest because they are typically provided at lower cost and lower overhead.

These cuts are not related to the Sustainable Growth Rate.  Psychologists were saved from a second and even more devastating reduction when Congressional action halted the projected 25% SGR cut through December 31, 2011.  Ultimately Congress must replace the flawed SGR formula with one that responsibly and permanently addresses provider payments.

Psychologists will leave Medicare.  In a 2008 survey, 11% of psychologists reported that they have dropped out of Medicare participation and a primary reason cited was low reimbursement rates.

Stanford Hospital & Clinics vows to fight $20M class action

By Jason Green

MercuryNews.com

Stanford Hospital & Clinics vowed Monday to "vigorously defend" itself against a $20-million class-action complaint filed in the wake of a data breach that saw the medical records of 20,000 patients posted on a commercial website for nearly a year.

Shana Springer filed the complaint on Sept. 28 in Los Angeles County Superior Court, on behalf of fellow patients treated in Stanford's emergency room between March 1, 2009, and Aug. 31, 2009. She is seeking $1,000 per patient, as well as other penalties, damages and attorneys fees.

The nine-page complaint alleges the hospital violated the Confidentiality of Medical Information Act, a state law that requires medical providers to safeguard patient information and prohibits its disclosure without written consent.

"On its website, Stanford claims that its patients' 'health care experience is [its] highest priority.' Thus, it should be no surprise that when patients are treated at Stanford's facilities, they expect that their private medical information will be kept confidential and will not be disclosed to anyone without their authorization," the complaint states.

In a brief statement released Monday, Stanford placed the blame on complaint codefendant Multi-Specialty Collection Services LLC, saying it was the subcontractor that mishandled the data. The hospital has since cut ties with the Woodland Hills-based company, which provided collection and billing services.

The entire story can be read here.

Antipsychotics overprescribed in nursing homes

By M. Price

The Monitor on Psychology

September 2011, Volume 42, No. 8

Print Version: Page 11

Physicians are widely prescribing antipsychotics to people in nursing homes for off-label conditions such as dementia, and Medicare is largely picking up the bill, even though Medicare guidelines don't allow for off-label prescription reimbursements, according to an audit released in May by the U.S. Department of Health and Human Services Office of the Inspector General.

The findings underscore the fact that antipsychotics are often used when behavioral treatments would be more effective, psychologists say.

The office reviewed Medicare claims of people age 65 and older living in nursing homes in 2007—the most recent data at the time the study began—and found that 51 percent of all claims contained errors, resulting $116 million worth of antipsychotics such as Abilify, Risperdal and Zyprexa being charged to Medicare by people whose conditions didn't match the drugs' intended uses. Among the audit's findings are:

• 14 percent of the 2.1 million elderly people living in nursing homes use Medicare to pay for at least one antipsychotic prescription.
• 83 percent of all Medicare claims for antipsychotics are, based on medical reviews, prescribed for off-label conditions, specifically dementia.
• 22 percent of the claims for antipsychotics do not comply with the Centers for Medicare and Medicaid Services' guidelines outlining how drugs should be administered, including those guidelines stating that nursing home residents should not receive excessive doses and doses over excessive periods of time.

The report suggests that Medicare overseers reassess their nursing home certification processes and develop methods besides medical review to confirm that medications are prescribed for appropriate conditions.

Why such high rates of overprescription for antipsychotics? HHS Inspector General Daniel Levinson argued in the report that pharmaceutical companies' marketing tactics are often to blame for antipsychotics' overprescribing. Victor Molinari, PhD, a geropsychologist at the University of South Florida in Tampa, says that another important issue is the dearth of psychologists trained to provide behavioral interventions to people in nursing homes. While he agrees that people in nursing homes are taking too much antipsychotic medication, he believes nursing home physicians are often responding to a lack of options.

Many nursing home administrators are quite savvy in their mental health knowledge and would prefer to offer their residents the option of behavioral treatments, Molinari says, but when residents need immediate calming, physicians will turn to antipsychotic medication because it's quick and available. Additionally, he says, many nursing home staff aren't educated enough about nonmedical options, so they go straight for the antipsychotics.

"It follows the saying, 'If your only tool is a hammer, everything is a nail,'" he says. "Nursing homes are not just straitjacketing residents with medications as a matter of course, but because there are a host of barriers to giving them optimal care."