Monthly Newsletter

October 2021 Monthly Newsletter

Hospital Former Compliance Director is Whistleblower in $3 Million Qui Tam Billing Modifier Case

The hospital’s former Director of Compliance, Erma Lee, filed complaint regarding how Tarrant County’s John Peter Smith Hospital (JPS) improperly appended billing modifiers -25, -29, and -XU on hundreds of claims. These modifiers unbundle services and should only be applied when documentation supports separately identifiable services.


Ms. Lee alleged that she alerted hospital leadership that JPS had been improperly adding these modifiers to claims between 70 and 95 percent of the time, in essence routinely double billing for certain aspects of patients’ care.  The allegations resolved by this settlement were originally filed under the qui tam provisions of the False Claims Act, which permits private persons with evidence of fraud to sue on behalf of the government and to share in any proceeds.


Ms. Lee will receive $912,635 as her statutory share of the settlement proceeds.  Read more about this case.  Learn more about Compliance Officer Training online (on-demand.


Cybersecurity and Infrastructure Security Agency (CISA) Update

Eradicate Cybersecurity Bad Practices

CISA announced the creation of a catalog to document bad cybersecurity practices that are exceptionally risky for any organization and especially dangerous for those supporting designated Critical Infrastructure or National Critical Functions.


The Bad Practices Catalog was created in July 2021 to raise awareness of some of the most egregious errors made in cybersecurity which can leave the door wide open to hackers.  Making efforts to tighten security and remove bad practices will improve your organization’s compliance to the HIPAA Security Rules.  While extensive guidance on cybersecurity “best practices” exists, additional perspective is needed. Ending the most egregious risks requires organizations to make a concerted effort to stop bad practices.


CISA encourages cybersecurity leaders and professionals to review Executive Assistant Director Eric Goldstein’s blog post and the new Bad Practices webpage and to monitor the webpage for updates. CISA also encourages all organizations to engage in the necessary actions and critical conversations to address bad practices.  Network and bring your questions for J. David Sims, CHITSP, CHMSP Security Expert & Managing Partner at Security First IT and co-host of the popular weekly podcast Help Me With HIPAA to the HIPAA Compliance Camp Oct 26-27, 2021 in Las Vegas.


Telehealth Updates

Telehealth policy has always varied by state, we have now entered into a new and confusing gray area as we phase out of pandemic-era policies, leaving many unsure what is still currently allowed and what will continue to be allowed via telehealth moving forward. Federally, not much has changed and since it has been indicated that the US public health emergency (PHE) will last through the end of the year most federal emergency flexibilities will remain in place through 2021.


Many states attached emergency telehealth expansions to state emergency orders, others gave discretion to administrative authorities to pick and choose what to continue, and some have moved to attach flexibilities to the federal PHE.  According to the National Academy on State Health Policy (NASHP) about half of the states have let their emergency orders expire.


Need to research State Policy?  Get to know how the laws, regulations, and Medicaid programs work in your state - The Center for Connected Health Policy (CCHP) is the federally designated National Telehealth Policy Resource Center.  Check out their look up policy page by jurisdiction – Click Here.


OIG, Behavioral Health and Telehealth Compliance Reports

During the COVID-19 pandemic, States expanded their use of telehealth to help meet the needs of enrollees while also reducing the risks from community spread of the virus. As the Nation confronts the psychological and emotional impact of COVID-19, the use of telehealth will be important in addressing behavioral health needs for Medicaid enrollees.  The Office of Inspector General (OIG) has published two reports related to oversight of telehealth and Behavioral Health services. 

CMS and State efforts to evaluate and oversee telehealth are critical to meeting Medicaid enrollees' behavioral health needs and to safeguarding the Medicaid program from potential fraud, waste, and abuse. These efforts are particularly important as the telehealth landscape continues to evolve and will continue to be monitored by the OIG.

FTC Warns Health Apps and Connected Device Companies

On September 15, 2021 the Federal Trade Commission (FTC) issued a policy statement which requires health apps and connected wearable devices that collect health information from a consumer to comply with the Health Breach Notification Rule.  The Rule ensures that entities not covered by the Health Insurance Portability and Accountability Act (HIPAA) face accountability when consumers’ sensitive health information is breached.


Compliance will be enforced by the FTC, which has the authority to impose financial penalties.  Companies that fail to comply with the rule could be subject to monetary penalties of up to $43,792 per violation per day. Click Here for the September 15, 2021 press release.  Read the article written by Susan Walberg, JD, MPA, CHC posted to the AIHC blog page.


CMS Launches COVID-19 Nursing Home Vaccination Data Site

New Nursing Home Comparative Site to Check COVID-19 Staff and Resident Vaccination Rates


As of September 21, 2021 the Centers for Medicare & Medicaid Services (CMS) is making it easier to check COVID-19 vaccination rates for nursing home staff and residents with a new feature on Medicare.gov. The announcement makes vaccination data available in a user-friendly format to help people make informed decisions when choosing a nursing home for themselves or a loved one, applying pressure to nursing home facilities to improve staff and resident vaccination rates.  Search for a Nursing Home colored coded map (click on “Visualize Data”) demonstrating which homes have less than 75% staff vaccinated (in red) and green where the home has 75% or more vaccinated.

Increasing Diversity and Addressing Social Determinants of Health (SDoH)

A recently introduced bill in Congress seeks to address SDoH in HR 5030 Diversifying Investigations Via Equitable Research Studies for Everyone Trials Act (DIVERSE Trials Act).  The bill attempts to encourage drug and device manufacturers to provide participants with digital health technologies for free, specifically when used in any phase of clinical development to facilitate inclusion of diverse patient populations that would otherwise not be able to participate. Additional provisions allow the Secretary to contract with groups that can help promote outreach to and participation by underrepresented communities, including working with community health centers and other health care providers. HR 5030 includes the requirement of COVID-19 data collection to further address demographic data gaps and SDoH in addition to research around a national interoperable data platform that can provide better access to health data during future public health emergencies. 


Read the full text on HR 5030.  Take the Capturing and Coding Social Determinants of Health (SDoH) short course to learn more about documentation and coding for SDoH.

Joint Commission Quick Safety Issue 61: NVHAP

According to Joint Commission, there is an estimated 1 out of every 100 hospitalized patients are affected by non-ventilator hospital-acquired pneumonia or NVHAP and that there is no national tracking or accountability mechanism in place.  This means that it is likely an issue unaddressed by many health care organizations.  On September 16, 2021, Joint Commission published a New Quick Safety Advisory entitled “Preventing non-ventilator hospital-acquired pneumonia.”  The Quick Safety provides recommended safety actions for hospitals to prevent NVHAP while improving patient safety and quality of care, lowering the risk of sepsis, reducing health care costs, and ultimately saving lives. Some of the actions include:

  • Obtain buy-in from leadership about NVHAP prevention.
  • Overcoming beliefs such as oral hygiene and mobility are optional tasks rather than standard-of-care interventions.
  • Educating staff about the risks of NVHAP and prevention methods such as aspiration precautions.
  • Evaluating workflows from a systems perspective and establishing processes that facilitate the prevention of NVHAP.
  • Evaluating patients for swallowing issues and adjusting nutrition and feeding assistance based on this evaluation.
  • Perform outcome and/or process surveillance to determine rates of infection and compliance with processes to prevent NVHAP.
  • Develop operational NVHAP tracking systems to assess the impact of prevention initiatives.

Download Quick Safety Issue 61.

Michigan Doctor Convicted for $100 Million Fraud Scheme

On September 22, 2021, doctor Francisco Patino has been convicted for his role in masterminding and executing a complex scheme to defraud Medicare and other health insurance programs by administering medically unnecessary spinal injections in exchange for prescriptions of high doses of opioids to patients in Livonia, Michigan.


Patino also developed illegal kickback relationships with at least one diagnostic laboratory, under which he was paid in exchange for referring his patients’ samples to that lab. The evidence showed that the labs funneled money into bank accounts held by others, who then distributed the money to Patino or spent it on his behalf. Patino also spent funds he derived from these various schemes on jewelry, cars, and vacations. Read more about this case. Want to learn more about compliance and obtain certification (online)?  Click Here for more information.

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Capturing and Coding Social Determinants of Health (SDoH) 

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