January 1, 2013 Departments

News in Brief: January 2013

Federal Case Alleges Company Committed Medicare Fraud

Life Care Centers of America systematically defrauded Medicare of millions of dollars by pressuring therapists to perform expensive, unnecessary treatments, alleges a recently unsealed federal complaint [PDF].

The 2008 complaint, filed by the Justice Department in district court in Chattanooga, alleges a company-wide effort to pressure its therapists in skilled nursing facilities to document high levels of therapy to boost reimbursement from Medicare and TRICARE, the military health care program.

The Justice Department claims that Tennessee-based Life Care, which operates 200 skilled nursing facilities, assisted living, retirement, home care and Alzheimer's centers in 28 states, set aggressive targets for "ultra high" therapy levels "that were completely unrelated to its beneficiaries' actual conditions, diagnoses or needs." The company allegedly pressured therapists to reach the targets through corporate presentations, visits from top company officials and action plans for underperforming facilities.

Life Care succeeded in billing almost 68 percent of its Medicare rehabilitation days at that level by 2008, compared with the 35 percent average of all skilled nursing facilities, the government said.

Two former Life Care employees, a nurse in Tennessee and an occupational therapist in Florida, brought separate "whistleblower" cases against Life Care, according to the complaint. The Justice Department joined their lawsuits.

The complaint mentions several patients who allegedly didn't need therapy or could be harmed by it, but got it anyway: Therapists recorded 48 minutes of physical therapy, 47 minutes of occupational therapy and 30 minutes of speech therapy for a 92-year-old medically fragile cancer patient in Orlando two days before his death. The day he died, the patient allegedly received 35 minutes of physical therapy and was scheduled for more.

Life Care Centers, in a statement on its website, says it "strongly disagrees with the allegations" and that intensive and relatively expensive therapy actually reduces Medicare spending by allowing patients to improve and be discharged more quickly. 

Cochlear Implant Alliance Hires Executive Director 

The newly established American Cochlear Implant Alliance has hired its first staff, appointing Donna L. Sorkin as executive director. The nonprofit organization focuses on eliminating barriers to cochlear implantation through research, advocacy and awareness for people of all ages.

Sorkin previously served as executive director of the Alexander Graham Bell Association for the Deaf and Hard of Hearing and the Hearing Loss Association of America, working with patients, families, health professionals, educators, government officials, researchers and others to increase understanding of key hearing loss issues that affect children and adults. As a cochlear implant recipient, she has often spoken of her own experiences.

Most recently, Sorkin was vice president for consumer affairs at Cochlear Americas, where she developed legislative and advocacy programs to expand private and government health plan reimbursement of cochlear implantation. 

The ACI Alliance plans to conduct awareness campaigns, develop and sponsor clinical trials and research documenting the benefits of CIs, educate health care and government officials about the value of CI coverage, and foster new research and encourage best clinical practices for standardized outcomes. Its governing board includes audiologists, speech-language pathologists, physicians and educators.

American Psychiatric Association Approves DSM-5 Revisions  

The American Psychiatric Association Board of Trustees has approved the final diagnostic criteria for the fifth edition of the "Diagnostic and Statistical Manual of Mental Disorders." 

A summary of the changes is available at the American Psychiatric Association website, and ASHA's recommendations throughout the revision process are archived at our DSM-5 page. After the APA publishes the DSM-5 in May, a larger article comparing ASHA's comments to the final criteria will appear in the Leader.

Proposed Federal Rules Mandate Habilitation Services, Equal Access to Care

"Rehabilitative and habilitative services and devices" must be included as essential health benefits under the Affordable Care Act, according to a proposed rule issued by the Department of Health and Human Services. The rule does not, however, define the terms, nor does it provide a list of devices, leaving significant flexibility to states to shape how these benefits are defined.

A second proposed HHS rule prohibits health insurance companies from denying coverage because of a pre-existing or chronic condition. 

The provisions apply to health plans participating in health care exchanges (organized marketplaces that will make health insurance available to previously uninsured or underinsured people, also called health care markets).

Essential health benefits must include, according to the proposal, items and services in at least 10 specific categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

The proposed rule defines essential health benefits based on a state-specific benchmark plan, chosen from among several options identified in the proposed rule, and specifies that all plans offer benefits substantially equal to those of the benchmark plan. According to a statement released by the Centers for Medicare and Medicaid Services, "this approach balances consumers' desires for an affordable and comprehensive benefit package, our legal requirement to reflect the current marketplace, and issuer flexibility to offer innovative benefit designs and a choice of health plans."

ASHA submitted comments on the essential benefits rule, continuing advocacy to ensure that "rehabilitation" and "habilitation" are clearly defined, and that augmentative and alternative communication systems, hearing aids and assistive listening devices are included.

The rule on pre-existing conditions would allow insurance companies to vary premiums based only on age, tobacco use, family size and geography. The companies may not vary premiums based on current or past health problems, gender, occupation, employer size or industry size. 

New Directory for Pediatric Audiologists

A new online directory available to users in the spring is soliciting information about pediatric audiology services.

The Early Hearing Detection and Intervention-Pediatric Audiology Links to Services, a Web-based directory and search engine, is designed to help parents, hospital personnel and physicians identify pediatric audiology facilities that will meet the needs of children and their families. Facilities listed in EHDI-PALS must have the appropriate equipment and personnel to provide audiology evaluation and treatment services to children younger than 5. These services must be provided by licensed audiologists.

To ensure that your facility's information is included in the initial launch, complete the 10- to 20-minute online survey at www.ehdi-pals.org as soon as possible. Your facility's online profile will be developed from information you provide. No quality ratings are assigned.

Only practices responding to the survey will be included in the directory. You will be able to update your information as needed and you will receive annual reminders to keep your information current.


  

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