Affordable Care Act: Fraud Prevention

Feb22
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The Affordable Care Act became law by President Obama’s signature in March 2010. This act in part sets to prevent fraudulent healthcare billing practices. Those most noteworthy include:
• Medicare and Medicaid fraud are under increased scrutiny. Fines for such offenses increased 20-50% for fraud of more than $1 million.
• The Office of the Inspector General (OIG) now has the ability to impose larger civil fines against those who are fraudulent. Also, providers who show repeated violations may be banned receiving future reimbursements from Medicare, Medicaid or other federal health insurance programs.
• The bill brings the big government health players together. Officials from CMS, OIG, and the Departments of Health and Human Services and Justice are expected and encouraged to coordinate efforts to prevent and determine federal healthcare fraud. The bill also funds sharing data between government entities to improve communication and efficiency of law enforcement working on systemic fraud.
For more information about the bill, visit: www.healthcare.gov/law/index.html

Medicare Prepayment Target of CMS Auditors

Feb17
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CMS is set to launch a prepayment review of claims initiative in June. These claims are set to increase from 1.2 million to 2.7 million annually. The motivation is an estimated $28.8 billion in estimated erroneous Medicare fee-for-service claim payments in 2011.
Funded by the Affordable Care Act – passed to improve such anti-fraud measures — CMS officials anticipate sweeping success. Government auditors reported a 167% increase since 2008 of recovered fraudulent payments – adding up to a whopping $5.6 billion in 2011. CMS is now using a predictive model to spot fraudulent claims from providers.
First Coast Services Options, a Medicare Administrative Contractor in Florida, recently went after cardiology and orthopedic procedures with the predictive modeling system. Using data showing a high rate of errors on such claims, officials are now reviewing those procedures that do not meet Medicare national coverage decision criteria – such as cardiac pacemaker implantation. Florida hospitals and physicians are trying to fight the new audit, which has First Cost withholding payment until physician documentation is reviewed. The system is expected to target 30-50% of all claims for the aforementioned procedures.
Additionally, CMS has added three demonstration projects, including recovery audit contractors who will review incorrect payments utilizing new analysis software. Previously, such auditors were limited to postpayment review. Now they are also charged with prepayment. Eleven states in particular will be the focus of the RAC prepayment review – Florida, California, Michigan, Texas, New York, Louisiana, Pennsylvania, Ohio, North Carolina, Missouri and Illinois. The initial focus of the review will be inpatient hospital claims.

Medical Coding: 10 Most Expensive Prescription Drugs

Feb15
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Did you know there are several prescriptions in the US that cost more than $100,000 per year? The ten most expensive prescription drugs currently approved by the FDA are:

1. Solaris: $409,500 annually. The drug, created by Alexion Pharmaceuticals, treats hemoglobinuria – a rare blood disease. Some 8,000 Americans are treated for this, resulting in more than $500 million in sales annually.

2. Elaprase: $375,000 annually. Prescribed to treat an enzyme deficiency (iduronate sulfatase) costs $4,215 per vial. Some 500 Americans are treated annually for Hunter syndrome, resulting ing more than $350 million in annual sales.

3. Naglazyme: $365,000 annually. This human enzyme medication is used to treat a rare genetic metabolic condition: Maroteaux-Lamy syndrome. Untreated, the illness causes mental retardation in children. The drug is also given for increased range of motion and pain management.

4. Cinryze: $350,000 annually. Prescribed to treat a C1 inhibiotr protein found in hereditary angioedema. The synthetic protein is a CI esterase inhibitor, manufactured by Viropharma. The disease is rare, yet the company reports $350 million in annual sales.

5. Folotyn: $320,000 annually. The cancer drug helps those with T-cell lymphoma. The short-course treatment is typically not given annually, but in $30,000 per month increments.

6. ACTH: $161,000 per average treatment. Prescribed to aid seizures in infants, the drug costs $23,000 per vial, with a typical treatment being 6-7 vials. The drug is not currently approved to treat infantile spasms, although it is also often prescribed off label – thereby not covered by insurance.

7. Myozyme: $100,000 (children), $300,000 (adults) annually. The treatment for Pompe disease allows suffers to typically stay off of respirators and continue to speak and walk. The disease and drug were featured in the movie Extraordinary Measures. Pompe disease disables the heart and skeletal muscles, leaving those without access to the drug immobile.

8. Arcalyst: $250,000 annually. Given to those who suffer from genetic immune system diseases, including Familiar Cold Auto-inflammatory Sndrome and Muckle-Wells Syndrome. The drug has also shown to help reduce incidence of gout.

9: Ceredase/Cerezyme: $150,000 annually. The expense of this drug to treat Gaucher disease – where the body pools fat in muscles and other areas due to an enzyme deficiency – is expensive due to supplies required. The drug is made in part from human placentas, which replace the missing enzyme. The drug results in more than $1 billion in annual sales.

10. Fabrazyme: $200,000 annually. Created to treat Fabry disease, an enzyme deficiency-related illness, Fabrazyme provides the ability for patients to metabolize lipids.

Source: www.medicalbillingandcoding.org/blog/the-11-most-expensive-medicines-in-america/

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