Medicare & Medicaid Law and RAC Report Recap | Knicole Emanuel

Practus LLPLegal Insights

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An October Roundup of Monitor Mondays: Medicare & Medicaid Law Updates

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Healthcare industry expert and Practus Partner, Knicole Emanuel, is a weekly panelist to the healthcare podcast, Monitor Mondays by RACmonitor. This includes RAC Report podcast summaries in October pertaining to the Centers for Medicare & Medicaid Services (CMS), COVID-19, as well as additional improvements, warnings and recommendations to be aware of during the continued PHE.  

 October RAC Report Summaries

  • Medicare-Covered Telehealth Services Continue During COVID-19
  • The Medicaid Single-State Agency Requirement and Fraud Investigations
  • Health Providers Navigate CMS Revoking Previously-Covered Services
  • Warning: Opdivo is New RAC Target

Be sure to tune into the RACReport on Monitor Monday’s every week as well!

Medicare-Covered Telehealth Services Continue During COVID-19

Air Date: October 26, 2020

Some good news healthcare providers can count on during the pandemic is the approval to continue coverage of telehealth services via Medicare. It was also announced that this list of covered services would also be expanded. It’s important to note that many of these telehealth exceptions will most likely lose coverage once the government declares the Public Health Emergency is over. Knicole points out that President Trump is actually a proponent of continuing the telehealth service coverage even post-COVID-19. 

11 new services added to the covered list include neurostimulator analysis and programming services and cardio and pulmonary rehabilitation services. The full list of newly covered services may be found at the Centers for Medicare & Medicaid Services (CMS) website’s telehealth codes section of general medicare information.

CMS actually has expanded the list of approved services during PHE outside of the normal rule making.  Since the beginning of PHE, CMS added more than 135 approved services like ER visits, and discharge state management services to name a few. Between mid March and August 2020, more than 12.1 million people of Medicare beneficiaries have received telehealth medicine. 

Providers should note that with these new exceptions come new audits. Always check the CMS informational website to ensure billing and coding is being followed according to their rules and regulations for telehealth. 

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 40: Beware of Audit Hot Spots Highlighted by the CARES Act

The Medicaid Single-State Agency Requirement and Fraud Investigations

Air Date: October 19, 2020

The importance of “Single-state agency” is examined in this episode to highlight the necessity of replying to a request for records. Each state has its own CMS, Centers for Medicare & Medicaid Services, that dole set the state’s rules and regulations to be followed by providers. These state agencies then rely on contracted organizations to run the daily interactions with providers and ensure the rules are followed. Knicole touts the importance of the CMS and notes they are the end all be all. 

An example of this power includes an Illinois Medicare fraud case involving child care providers. Because their single-state agency is actually IDHS, which administers the Child Care Assistance Program, the defendants will be issued a summons to appear for arraignment in federal court in Springfield. The charges were investigated by the Illinois state government and federal government. No MCO, MAC, or other vendor was involved.

To hear more about the consequences of ignoring a request for records from a single-state agency listen to the full episode below.

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 39: Stopping the Bleeding: More Cuts Proposed for 340B

Health Providers Navigate CMS Revoking Previously-Covered Services

Air Date: October 12, 2020

In this episode Knicole Emanuel breaks down the concerning possibility of providers dealing with retroactive billings for services that were previously covered via Medicare. 

Knicole runs through a specific example, pertaining to using code L 86-79. Recently, the Practus Healthcare Law team has been approached by multiple chiropractors and medical holistic providers who are being told that they are being retroactively billed for using this code. In these instances, many who had been using the code did so under the direct guidance of CMS, MAC or another Medicare authority. With that being said, is this then a situation that becomes a question of fairness? Does the Centers for Medicare & Medicaid Services (CMS) have the right to request these funds, even if the provider used the code based on guidance provided directly from CMS?

Another example involves providers that became victim to using products and devices that were falsely claimed to become covered by Medicare. This is a complicated and concerning matter that unfortunately is quite common. 

Listen to the full breakdown and legal insight provided from Knicole by enjoying the full episode.

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 38: Has Focus on Length of Stay Run its Course?

Warning: Opdivo is New RAC Target

Air Date: October 5, 2020

A non-COVID related story we have this month revolves around a newer cancer treatment called Opdivo that is predicted to become the newest RAC target for audit. This drug is specifically geared towards advanced lung cancer and other certain resistant cancers as well. The drug is approved by the original Medicare program – Parts A, B & C depending on cancer phase and treatment location –  under 2020 valid code J9299. As it’s covered via an outpatient infusion, the consumer is expected to pay 20%. 

While covered by Medicare, Opdivo does come at a high cost, at $6,580 specifically per infusion. This higher cost has lead to the drug being flagged by RAC auditors, specifically Performant Recovery Inc. CMS has actually instructed PRI to be on the lookout for the Opdivo code due the cost remaining high whether in name brand or generic form.

Facilities prescribing the drug should ensure Opdivo is billed in multiples of the doses specified in the code long descriptor. Number of units billed should be assigned by the dosage units specified and based on actual units administered, including any appropriate discarded drug waste. Claims billed with excessive or insufficient units will be reviewed by a nurse or registered pharmacist or a Certified Pharmacy Technician or certified coder to determine the actual amount administered and the correct number of billable and payable units.

Following the appropriate billing format will ensure that any auditor doesn’t come knocking. To hear more details about the specific ways to avoid audits for the use of Opdivo check out the full episode. 

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 37: Telehealth Fraud Bust: Fed Takedown Nets $6 Billion, 345 Defendants

Healthcare Law Attorney Knicole EmanuelAbout Knicole C. Emanuel, Esq.

For more than 20 years, Knicole Emanuel has provided healthcare law services with specialties in Medicare & Medicaid litigation, healthcare regulatory compliance, administrative law and regulatory law. She has tried over 2,000 administrative cases in over 30 states and has appeared before multiple states’ medical boards. 

She has successfully obtained federal injunctions in 33 states, allowing healthcare providers to remain in business, address abhorrent billings, and streamline data mining. Knicole lectures across the country on healthcare law. This includes the impact of the Affordable Care Act & regulatory compliance for providers, home health &  hospice, dentists, chiropractors, hospitals and medical equipment providers.

Knicole is a member of the RACmonitor editorial board and a popular panelist on the healthcare industry-related podcast, Monitor Mondays.