Monthly Newsletter

Lack of Obtaining Authorization Results in HIPAA Violation

HIPAA Violation Results in $80,000 Settlement a Corrective Action Plan

The Office for Civil Rights (OCR) investigated Saint Joseph’s Medical Center after the Associated Press published an article about the medical center’s response to the COVID-19 public health emergency, which included photographs and information about the facility’s patients. These images were distributed nationally, exposing protected health information including patients’ COVID-19 diagnoses, current medical statuses and medical prognoses, vital signs, and treatment plans.  To review St. Joseph’s Medical Center resolution agreement, click here.

Holiday Workforce Stress – Make Work Better

Recognize Holiday Workplace Stress

With the holiday season here, it is important for leadership to recognize additional stresses on our workforce.  The World Health Organization estimate that for every dollar U.S. employers spend treating common mental health issues, they receive a return of $4 in improved health and productivity. Employers can make a difference when it comes to helping their staff manage stress.

According to the National Institute of Mental Health, it is estimated that more than one in five U.S. adults live with a mental illness. Mental illnesses include many different conditions that vary in degree of severity, ranging from mild to moderate to severe.

The Occupational Safety and Health Administration (OSHA) states workplace stress has been reported to cause 120,000 deaths in the U.S. each year!  OSHA also states that workplace stress and poor mental health can negatively affect workers through:

• Job performance
• Productivity
• Work engagement and communication
• Physical capability and daily functioning

Read through helpful information about SAD (Seasonal Affective Disorder) and download the PDF from the National Institute of Mental Health.  Access resources on OSHA’s website “Workplace Stress  Make Work Better – Mental Health Matters.”

SAMHSA Releases National Survey on Drug Use and Health Data

On November 13, 2023, the U.S. Department of Health and Human Services (HHS), through the Substance Abuse and Mental Health Services Administration (SAMHSA), released the results of the 2022 National Survey on Drug Use and Health (NSDUH).

The report shows how people living in United States reported about their experience with mental health, substance use, and treatment related behaviors in 2022.  Click Here for more information, highlights and FAQ and click here for the annual national report.

2024 Physician Fee Schedule (PFS)

In November, the Centers for Medicare and Medicaid Services (CMS) published the Calendar Year 2024 PFS which outlines policy changes for Medicare payments.  There are various revisions effective January 1, 2024.  A few more notable items are:

Overall payment rates reduced by 1.25%

Payments are based on the relative resources typically used to furnish the service. Relative value units (RVUs) are applied to each service for work, practice expense, and malpractice expense.  Even with massive inflation for health care providers, a reduction of 1.25% goes into effect January 1^st.

• By factors specified in law, overall payment rates under the PFS will be reduced by 1.25% in CY 2024 compared to CY 2023.
• CMS is also finalizing significant increases in payment for primary care and other kinds of direct patient care. 
• The final CY 2024 PFS conversion factor is $32.74, a decrease of $1.15 (or 3.4%) from the current CY 2023 conversion factor of $33.89.

Services Related to SDOH

Coding and payment changes to better account for resources involved in furnishing patient-centered care is finalized for 2024 by CMS. 

• Specifically, CMS is finalizing to pay separately for Community Health Integration, Social Determinants of Health (SDOH) Risk Assessment, and Principal Illness Navigation services to account for resources when clinicians involve certain types of health care support staff such as community health workers, care navigators, and peer support specialists in furnishing medically necessary care.

Consider learning more by registering for AIHC’s short course Capturing and Coding Social Determinants of Health (SDoH) for Physicians and Hospitals.

Evaluation and Management (E/M) Visits

Beginning January 1, 2024, CMS is finalizing implementation of a separate add-on payment for healthcare common procedure coding system (HCPCS) code G2211.

• This add-on code will better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care.
• Generally, it will be applicable for outpatient and office visits as an additional payment, recognizing the inherent costs involved when clinicians are the continuing focal point for all needed services, or are part of ongoing care related to a patient’s single, serious condition or a complex condition.

Split (or Shared) Evaluation and Management (E/M) visits

Split (or shared) E/M visits refer to visits provided in part by physicians and in part by other nonphysician practitioners in hospitals and other institutional settings.

• For CY 2024, CMS is finalizing a revision to the definition of “substantive portion” of a split (or shared) visit to include the revisions to the Current Procedural Terminology (CPT) guidelines, such that for Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making.
• This responds to public comments asking that we allow either time or medical decision making to serve as the substantive portion of a split (or shared) visit.

Click Here for more PFS information from CMS.  Click Here for the November press release which provides a summary of changes.

OIG Issues Remote Patient Monitoring (RPM) Alert

The Office of Inspector General (OIG) is alerting the public about a fraud scheme involving monthly billing for remote patient monitoring.  Please educate your staff and pass on this important information to your patients.

Legitimate RPM involves using medical devices such as scales, glucose monitors, blood pressure cuffs, cardiac rhythm devices, and other equipment to remotely monitor for anomalies in patients with chronic medical conditions. This new treatment is beneficial for those whose condition might deteriorate quickly, where monitoring can reduce complications, hospitalizations, or death.

However, the OIG has found un scrupulous companies are signing up Medicare enrollees for this service, regardless of medical necessity. Most often, the monthly monitoring never happens, but the enrollee is billed monthly anyway.

Scammers have several ways to make contact. It may involve phone solicitations (“cold calling”), internet ads (“click bait”), or television advertising. These contacts may originate from a Durable Medical Equipment Company (DME) or pharmacy. Equipment may or may not be sent or is equipment that is not FDA approved. Billing then occurs for set-up, patient teaching, and monthly monitoring of data. Learn more from the OIG website.

Physician Guilty of Subjecting Patients to Unnecessary and Invasive Tests

Felony Charges Levied After MFCU Investigation

According to the New York Attorney General, Payam Toobian, M.D. and his company, America’s Imaging Center, Inc., were found guilty on charges related to running a kickback scheme that defrauded Medicaid and subjected patients to invasive procedures they did not need. The investigation was led by the Medicaid Fraud Control Unit (MFCU).

Charges involve Toobian defrauding Medicaid and subjecting patients to medically unnecessary and often invasive radiological testing without the direction, consent, or approval of the referring physicians responsible for the underlying care of those patients. The additional tests included MRIs of the brain, cervical spine, and lumbar spine, all “with contrast,” which required subjecting patients to unnecessary and invasive injections. Toobian then directed his staff to submit claims for payment to Medicaid for those medically unnecessary tests.  Learn more about this case.

LPN Guilty of Sex Crime Charges Against Nursing Home Resident

Licensed Practice Nurse Towodi T. Shequoyah was recently found guilty and sentenced to 8 years in prison for attempt to commit criminal sexual conduct, 5 years in prison for attempted abuse of a vulnerable adult and 3 years in prison for indecent exposure.

Shequoyah willfully, maliciously, and indecently exposed his genitals while in the bedroom of a resident at the facility in an attempt to sexually assault the resident. The victim was classified as a vulnerable adult under South Carolina law. The conduct was reported to law enforcement after another employee entered the room to check on the resident and witnessed the incident.  Read more about this case. 

Access the free Human Resources video playlist on Workplace Violence and Addressing Harassment.