OIG audits and evaluations found that Medicare inappropriately paid for hospice services that did not meet certain Medicare requirements.
Our objective was to determine whether hospice services provided by Franciscan Hospice (Franciscan) complied with Medicare requirements.
How OIG Did This Audit
Our audit covered 21,537 claims for which Franciscan (located in University Place, Washington) received Medicare reimbursement of $101.5 million for hospice services provided from January 1, 2016, through December 31, 2017. We reviewed a random sample of 100 claims. We evaluated compliance with selected Medicare billing requirements and submitted these sampled claims and the associated medical records to an independent medical review contractor to determine whether the services met coverage, medical necessity, and coding requirements.
What OIG Found
Franciscan received Medicare reimbursement for hospice services that did not comply with Medicare requirements. Of the 100 hospice claims in our sample, 79 claims complied with Medicare requirements. However, the remaining 21 claims did not comply with the requirements. Specifically, for 19 claims, the clinical record did not support the beneficiary's terminal prognosis, and for the remaining 2 claims, there was no documentation to support the hospice services that Franciscan billed to Medicare.
Improper payment of these claims occurred because Franciscan's policies and procedures were not effective in ensuring that the clinical documentation it maintained supported the terminal illness prognosis and the hospice services billed to Medicare. On the basis of our sample results, we estimated that Franciscan received at least $13 million in unallowable Medicare reimbursement for hospice services.
What OIG Recommends and Franciscan Comments
We recommend that Franciscan: (1) refund to the Federal Government the portion of the estimated $13 million for hospice services that did not comply with Medicare requirements and that are within the 4-year reopening period; (2) based upon the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation; and
(3) strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.
In written comments on our draft report, Franciscan disagreed with our findings for 12 of the 19 sampled claims for which the clinical record did not support the beneficiary's terminal prognosis and said that
a physician's clinical judgment is fundamental in determining that prognosis.
Franciscan also disagreed with our use of extrapolation across the audit period.
Franciscan agreed with our second recommendation and disagreed with our first and third recommendations.
After reviewing Franciscan's comments, we maintain that our findings and recommendations are valid.
Federal regulations require that clinical information and other documentation support the beneficiary's terminal prognosis and be filed in the medical records.
The report contains the details of our response.
In perpetuity.
Le chanson morte a tue, fatalite noir de 1ere degree x 3 comorbidity.
Franciscan Missionaries of Our Lady Health System, covered entity affiliates, Our Lady of the Lake, Franciscan Missionaries of Our Lady University (FranU) and their subsidiaries comply with Federal civil rights laws discriminate ... FMOL and covered entity affiliates exclude
Coletta Barrett olol RMC civilrights@ololrmc.com 765-3295 Leslie Yander FMOLHS Health Plan Essen Lane Leslie.Yander@FMOLHS.org (225) 765-6827 St. Dom Jackson Hospital K. Jerry Farr, Chair, Grievance icare@stdom.com 601-200-5123 phone
Southern Society for Clinical Investigation
www.ssciweb.org
Office for Civil Rights
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
hhs
1-800-368-1019
https://oig.hhs.gov/documents/false-claims-act/254/Louisiana.pdf
Section 1909(b)(2) of the Act requires State law to contain provisions effective in rewarding qui tam actions for false and fraudulent claims as sections 3730 through 3732 Federal False Claims Act. FFC Act, Patient Protection Affordable Care Act, in action or claim were publicly disclosed (i) in a Federal criminal, civil, or administrative hearing, Government or its agent is a party; (ii) congressional, Gov Accountability, Federal report, hearing, audit, investigation; (iii) news media, unless brought by Attorney General See 31 U.S.C. § 3730(e)(4)(A).
OFFICE OF THE LOUISIANA ATTORNEY GENERAL
Baton Rouge, LA 70802 (225) 326-6705
http://www.ag.state.la.us/
Louisiana Department of Justice Medicaid Fraud Unit Louisiana MFCU combat incorrect reporting of diagnoses or procedures to maximize payments; billing for services, medical supplies or equipment not furnished; misrepresentation of the dates and descriptions of services furnished, the identity of the recipient or the individual furnishing services; and billing for noncovered or nonchargeable services as covered items. discriminate against a beneficiary (e.g., prevent them from signing up for a plan based on their age, health status, race or income), entice beneficiaries to enroll in a more costly plan than they require, or erroneously - and vigorously prosecute criminals who prey
(225) 326-6210
www.ag.state.la.us
Karen Glassman
202-708-9777
Susan Gillin
202-205-9426
Justice Department Reaches Settlement Agreement with Physicians Group in El Paso Over Allegations of Violating the False Claims Act
EL PASO –El Paso Ear, Nose & Throat Associates (EPENT) has agreed to pay $750,000 to settle allegations that they violated the False Claims Act by billing Medicaid, Medicare and other federal healthcare programs by upcoding evaluation and management codes.
Action Details
- Date:June 23, 2021
- Agency:U.S. Attorney’s Office, Western District of Texas
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Enforcement Types:
- Criminal and Civil Actions
State False Claims Act Reviews
The Office of Inspector General (OIG), in consultation with the Attorney General, determines whether States have false claims acts that qualify for an incentive under section 1909 of the Social Security Act. Those States deemed to have qualifying laws receive a 10-percentage-point increase in their share of any amounts recovered under such laws.
To qualify for the financial incentive, a State's false claims act must:
- establish liability to the State for false or fraudulent claims, as described in the Federal False Claims Act (FCA), with respect to Medicaid spending;
- contain provisions that are at least as effective in rewarding and facilitating qui tam actions for false or fraudulent claims as those described in the FCA;
- contain a requirement for filing an action under seal for 60 days with review by the State Attorney General; and
- contain a civil penalty that is not less than the amount of the civil penalty authorized under the FCA.
Since the effective date of section 1909 of the Social Security Act, the FCA has been amended by the Fraud Enforcement and Recovery Act of 2009 (FERA), the Patient Protection and Affordable Care Act (ACA), and the Dodd-Frank Wall Street Reform and Consumer Protection Act (the Dodd-Frank Act). These three acts, among other things, amended bases for liability in the FCA and expanded certain rights of qui tam relators. In addition, effective August 1, 2016, the civil penalties authorized under the FCA increased pursuant to the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015. Going forward, the civil penalties authorized under the FCA will incrementally increase on an annual basis. As such, the civil penalties authorized under a State's false claims act must also increase at the same rate and time as those authorized under the FCA in order for the State to continue to receive the financial incentive.
To request a review of a false claims act, States should submit a complete copy of the law and any other relevant information to: officeofcounsel@oig.hhs.gov
OIG also strongly encourages States with draft legislation to submit their drafts for informal review and discussion before the draft legislation is passed.
Mr. Nicholas J. Diez Assistant Attorney General State of Louisiana Department of Justice P.O. Box 94005 Baton Rouge, LA 70804-9005 Dear Mr. Diez: The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) has received your office’s request to review Louisiana’s amended Medical Assistance Programs Integrity Law, La. Rev. Stat. Ann. §§ 46:437 through 46:440, under the requirements of section 1909 of the Social Security Act (the Act). Section 1909 of the Act provides a financial incentive for a State to enact a law that establishes liability to the State for individuals and entities that submit false or fraudulent claims to the State Medicaid program. For a State to qualify for this incentive, the State law must meet certain requirements enumerated under section 1909(b) of the Act, as determined by the Inspector General of HHS in consultation with the U.S. Department of Justice (DOJ). We have determined, after consulting with DOJ, that the amended Louisiana Medical Assistance Programs Integrity Law does not meet the requirements of section 1909(b) of the Act. Section 1909(b)(1) of the Act requires the State law to establish liability for false or fraudulent claims described in the Federal False Claims Act with respect to any expenditure described in section 1903(a) of the Act. The Federal False Claims Act, as amended by the Fraud Enforcement and Recovery Act of 2009, establishes liability for, among other things, conspiring to commit a violation of another subsection of section (a)(1) of the Federal False Claims Act. See 31 U.S.C. § 3729(a). In contrast, the amended Louisiana Medical Assistance Programs Integrity Law does not establish liability for the same breadth of conduct as the Federal False Claims Act, as amended. Section 1909(b)(2) of the Act requires the State law to contain provisions that are at least as effective in rewarding and facilitating qui tam actions for false and fraudulent claims as those described in sections 3730 through 3732 of the Federal False Claims Act. The Federal False Claims Act, as amended by the Patient Protection and Affordable Care Act, provides that the court shall dismiss an action or claim under the Federal False Claims Act, unless opposed by the Government, if substantially the same allegations or transactions as alleged in the action or claim were publicly disclosed (i) in a Federal criminal, civil, or administrative hearing in which the Government or its agent is a party; (ii) in a congressional, Government Accountability Office, or other Federal report, hearing, audit, or investigation; or (iii) by the news media, unless the action is brought by the Attorney General or the person bringing the action is an original source of the information. See 31 U.S.C. § 3730(e)(4)(A). In contrast, the amended Louisiana Medical.
Franciscan Missionaries of Our Lady Health System Earns 2020 CHIME Digital Health Most Wired Recognition
10/22/2020
The College of Healthcare Information Management Executives (CHIME) is pleased to announce that Franciscan Missionaries of Our Lady Health System has earned 2020 CHIME Digital Health Most Wired recognition as a certified Level 8 in acute care. The CHIME Digital Health Most Wired program conducts an annual survey to assess how effectively healthcare organizations apply core and advanced technologies into their clinical and business programs to improve health and care in their communities.
“Digital technology has been a driver of innovation in healthcare for many years now, but never to the degree that we saw in 2020 with the pandemic,” said CHIME President and CEO Russell P. Branzell. “The Digital Health Most Wired program underscores why healthcare organizations keep pushing themselves to be digital leaders and shows what amazing feats they can achieve. This certification recognizes their exemplary performance in 2020.”
“Our mission and our teams are committed to serving our communities both in-person and digitally. Technology is the cornerstone to our strategic priorities, and we are constantly adapting to meet the needs of consumers in a way that benefits them,” said Will Landry, FMOLHS vice president of Technology Innovation. “We are honored to be recognized with this award for our Louisiana and Mississippi markets as it shows that we are among the top health systems in the nation to provide digitally integrated healthcare services.”
A total of 30,091 organizations were represented in the 2020 Digital Health Most Wired program, which this year included four separate surveys: domestic, ambulatory, long-term care and international. The surveys assessed the adoption, integration and impact of technologies in healthcare organizations at all stages of development, from early development to industry leading.
This is the third year that CHIME has conducted the survey and overseen the program. In each successive year, CHIME has expanded the survey to capture more types of organizations that serve patients across the continuum of care. CHIME also continues to promote the program internationally to provide a global overview of digital health advancements.
As in past years, CHIME will publish an industry trends report based on Digital Health Most Wired responses from U.S. participants. The 2020 National Trends Report is scheduled to be released in November during CHIME20 Digital. For more information about the CHIME Digital Health Most Wired program, please go here.
About the Franciscan Missionaries of Our Lady Health System
The Franciscan Missionaries of Our Lady Health System is one of the largest healthcare systems based in Louisiana and is the leading healthcare provider for more than half the state’s population. The health system is a non-profit, Catholic organization sponsored by the Franciscan Missionaries of Our Lady. Headquartered in Baton Rouge, Louisiana, the ministry serves patients in Louisiana and Mississippi through a network of hospitals, clinics, physicians, elderly housing and integrated systems. The health system’s unified physician organization is comprised of 900 adult and pediatric primary care physicians and specialists. The system’s nine hospitals include St. Francis Medical Center in Monroe, Our Lady of the Lake Regional Medical Center in Baton Rouge and Gonzales, Our Lady of the Lake Children’s Hospital in Baton Rouge, Our Lady of Lourdes Regional Medical Center, Heart Hospital, and Women's & Children's in Lafayette, Our Lady of the Angels in Bogalusa, and St. Dominic Hospital in Jackson, Mississippi. For more information, visit www.fmolhs.org.