CPI Spotlight Archive
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Open Payments released a short video to show how Open Payments works, what’s in the data, and how to use the search tool.
Open Payments is a national disclosure program that promotes a transparent and accountable health care system by making the financial relationships between the health care industry and health care providers available to the public. As of March 2021, the Open Payments data site houses more than 76 million records accounting for $53.01 billion of payments or transfers of value.
Check out the video to learn more!
On October 14, 2021, Acting United States Attorney Jennifer Arbittier Williams of the Eastern District of Pennsylvania announced three settlements and the filing of a complaint under the False Claims Act. These are the latest law enforcement actions in the national investigation into the scheme of improper billing involving P-Stim electro-acupuncture devices. Federal healthcare programs do not reimburse for P-Stim devices, whether they are characterized as an electro-acupuncture device or as an implantable neuro-stimulator.
The four enforcement actions announced by U.S. Attorney Williams allege that certain parties sold P-Stim devices and/or promoted them as billable to Medicare and other federal healthcare programs, which then caused providers to submit fraudulent claims. The United States alleges that these promoters profited by conspiring together to make false representations to providers that P-Stim was reimbursable under billing codes that paid thousands of dollars per procedure. Those codes were meant for legitimate, surgically implanted neuro-stimulators to manage chronic pain. However, P-Stim devices can be applied in a few minutes in an office setting without anesthesia by someone with minimal training. The promoters allegedly had knowledge that the P-Stim devices were not reimbursable by federal healthcare programs but pushed the non-surgical devices anyway.
“CMS is dedicated to removing fraudulent actors and protecting the people who rely on our programs,” said CMS Administrator Chiquita Brooks-LaSure. “We thank our partners at the Department of Justice and Department of Health and Human Services Office of Inspector General for collaborating with us to identify, investigate, and eliminate waste, fraud, and abuse in our federal health care programs.”
CMS aggressively investigates providers and suppliers to ensure appropriate payments are billed to federal healthcare programs, including through the use of data-analytic investigative tools. The U.S. Attorney’s Office for the Eastern District of Pennsylvania and other law enforcement partners have pursued and settled various False Claims Act cases against P-Stim providers and suppliers, recovering millions. Including the three settlements, the national P-Stim initiative has so far produced over 15 False Claims Act settlements across the country worth approximately $15 million. Additionally, outside of DOJ litigation, there are administrative enforcement actions by other federal agencies as well. In particular, CMS, through its Program Integrity Contractors, is auditing and recovering improperly paid P-Stim claims. HHS-OIG is also pursuing civil money penalties and exclusion remedies.
On Sept. 17, 2021, the Department of Justice announced criminal charges against 138 defendants in 31 federal districts across the U.S. The defendants were doctors, nurses, and other licensed medical professionals who allegedly participated in health care fraud schemes resulting in more than $1.4 billion in losses.
The charges include approximately $1.1 billion in telemedicine fraud, $29 million in COVID-19 health care fraud, $133 million in fraud arising from substance abuse treatment facilities (“sober homes”), and $160 million from illegal opioid distribution and other health care fraud schemes across the nation.
“Every dollar saved is critical to the sustainability of our Medicare programs and meeting the needs of seniors and people with disabilities,” said Chiquita Brooks-LaSure, Centers for Medicare & Medicaid Services (CMS) administrator. “CMS has taken actions against 28 providers on behalf of people with Medicare coverage and to protect the Medicare Trust Fund. Actions like this to combat fraud, waste, and abuse in our federal programs would not be possible without the successful partnership of the Centers for Medicare & Medicaid Services, the Department of Justice, and the U.S. Department of Health and Human Services Office of Inspector General.”
This video was created to emphasize the differences between an Initial Preventive Physical Examination (IPPE), Routine Physical Exam (RPE), and Annual Wellness Visit (AWV). The video provides health care professionals with guidance to understand expectations and requirements when submitting documentation for Annual Wellness Visits (AWV) for Medicare beneficiaries.
For more information about health risk assessments, coding, diagnosis, billing, and initial and subsequent components of an Annual Wellness Visit, visit the MLN Matters booklet Annual Wellness Visit, on the CMS website. This article can be found at MLN Matters® booklet (PDF).
Open Payments is a national disclosure program that promotes transparency in the health care industry by making information about the financial relationships between pharmaceutical companies and medical device manufacturers (reporting entities) and physicians and teaching hospitals (covered recipients) available to the public.
Starting in 2021, the type of data collected for Open Payments will expand to include:
- Five new provider types (in addition to physicians and teaching hospitals): physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and anesthesiologist assistants, and certified nurse midwives.
- Three new categories for describing the nature of payments: debt forgiveness, long-term medical supply or device loan, and acquisitions.
- Reporting requirements for the ‘device identifier’ component of the unique device identifier for medical supplies and devices.
The key dates to be aware of for these changes are:
- January 2021: Reporting entities begin collecting data that reflects these changes, including information on certain transactions between reporting entities and the newly-added covered recipient groups. Data collection continues for the duration of the year.
- February and March 2022: Reporting entities submit data from calendar year 2021 to Open Payments.
- April to mid-May 2022: Covered recipients, including the newly-added covered recipients, have the opportunity to review data reported about them before it is published and dispute it if necessary.
To prepare, learn more details about these changes for reporting entities and covered recipients and sign up for updates on the Contact Us page.
The Center for Program Integrity, Centers of Medicare & Medicaid Services (CMS) is proud of the Department of Justice’s announcement of one of the largest coordinate law enforcement actions to combat health care fraud related to COVID-19. On May 26, 2021, the Department of Justice announced criminal charges against 14 defendants. Additionally, CMS separately took adverse administrative actions against over 50 providers for their involvement in health care fraud schemes relating to COVID-19 or their abuse of CMS programs that were designed to encourage access to medical care during the pandemic.
Every dollar saved is critical to the sustainability of our Medicare program and meeting the needs of our beneficiaries. Actions like this to combat fraud, waste and abuse in our federal programs would not be possible without the successful partnership of CMS, the Department of Justice and Department of Health and Human Services Office of Inspector General.
Find more information please see the following links:
- Read the DOJ press release.
- Read - OIG Media Materials webpage.
- Visit the OIG COVID-19 Portal.
If you believe you have been the victim of COVID-19 fraud, immediately report it to:
- CMS/Medicare Hotline 1-800-Medicare
- HHS-OIG Hotline 1-800 HHS-TIPs
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