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VGM Update - July 1st |
Jul 1 2005 10:10AM |
CONGRESS HEADS HOME FOR JULY 4th HOLIDAY
Members of both the House and Senate head back home for the July Fourth Recess. For the most
part members of Congress will be home for the entire week (July 1st through the 11th). This weekend
members of Congress will be in as many 4th of July parade and County Fairs that they can squeeze
into. When you see your member of Congress, ensure you introduce yourself and ask that they
support the “Small Business Provider” in the HME industry. If you have more than a few seconds
with your Congressman or Senator, ask if they will support the language in a letter that VGM sent to
Senator Charles Grassley (R-IA) on behalf of Small Business providers (see
http://www.vgm.com/files/manual/LettertoGrassleyJune05.pdf). If you are able to have dialog with
your elected official offer to host a “meet and greet” in August (see below).
THIS NEXT WEEK - CONTACT YOUR SENATOR AND CONGRESSMAN AND SET UP
A MEETING DURING THE AUGUST RECESS
Over this July 4th weekend go to www.vgm.com and click on D.C. Link. On the front page of D.C.
Link, click on the red box in the upper right hand corner marked “Contact Your Elected Officials”.
Plug in your Zip Code and determine who your elected officials are. From this location at D.C.
Link, obtain the telephone number or address to your nearest district office. Next week call or visit
the nearest district office and offer to host a “meet and greet” with you and your employees at your
location during the August Recess. Give dates that you think will work best (give several). Ask if
you can follow up with this individual in the next 7 – 10 days for confirmation. Within the next
couple of weeks the Industry (AAH, VGM and others) will provide detailed talking points to utilize
during the August Recess. The focus will be on the protection of small business, and the delay,
impediment or elimination of NCB. For now, simply state that you would like to host the “meet and
greet” and to discuss Medicare / Medicaid issues. If you have any questions or concerns, please to
not hesitate to give me a call at 800.642.6065 or email at john.gallagher@vgm.com.
ASCA Enforcement of Mandatory Electronic Medicare Claims Effective July 1, 2005
CMS is reminding all providers to make sure their billing staff submits all Medicare claims
electronically. However, if you believe that your facility meets one of the exception criteria, you
may need to complete a "Request for Documentation" letter from your DMERC to process your
claims. The process for electronic submittal enforcement is via post-payment review:
* The DMERC will analyze reports displaying the number of paper claims that all providers
submitted each quarter.
* By the end of the month following the quarter, selected providers who have submitted the highest
numbers of paper claims will be reviewed.
* The DMERC will ask these providers to provide information that establishes the exception criteria
(listed below).
If you, as one such provider, do not respond to an initial "Request for Documentation" letter within
45 days of receipt, your DMERC will notify you by mail that Medicare will deny and not pay any
paper claims that you submit beginning ninety days after the date of the initial request letter. If you
June 30, 2005
do respond to this initial letter, and your response does not establish eligibility to submit paper
claims, the DMERC will notify you by mail of your ineligibility to submit paper claims. This
Medicare decision is not subject to appeal.
For more information go to http://www.vgm.com/headlines/article.asp?ID=680
MEDICAID: GRASSLEY SAYS PHARMACEUTICAL FRAUD 'MUST BE ADDRESSED’
Senate Finance Committee Chair Chuck Grassley (R-Iowa) on Wednesday, the second day of the
committee's two-day hearing on Medicaid, said there is "evidence of systemic, industry wide
problems" regarding the drug industry's price manipulation for Medicaid and Medicare, Reuters
reports (Rovner, Reuters, 6/29).
Grassley said that Department of Justice and state attorneys general recovered nearly $2.5 billion
from pharmaceutical companies related to Medicaid and Medicare fraud (CQ HealthBeat, 6/29).
Patrick O'Connell, head of the Medicaid Fraud Section of the Texas attorney general's office, said
his office focused on fraud committed by drug companies because "whistleblowers brought us cases
which showed significant fraud in amounts which dwarfed the cases against other providers."
Beatrice Manning, who brought a federal whistleblower case against Schering-Plough for price
manipulation of the allergy drug Claritin, said the company had devised "an intricate scheme to
cheat Medicaid out of hundreds of millions, if not billions of dollars" (Rovner, CongressDaily, 6/30).
DOJ attorney Timothy Coleman said, "pharmaceutical pricing schemes perpetrated against state
Medicaid programs" in terms of dollar amount are the most significant kind of Medicaid fraud.
Coleman added that the current practice of basing Medicaid payments on average wholesale price is
"problematic and subject to manipulation." Grassley "sought assurances" from Marjorie Powell of
the Pharmaceutical Research and Manufacturers of America that the lobby was not funding a
campaign to change the False Claims Act, which is used by federal officials to recover money in
fraud cases from various industries. Powell said she was unaware of such an effort, but she added
that penalty provisions included in the act that exclude a drug company from participating in
Medicaid might be inappropriate because they could interfere with beneficiaries' treatment. Grassley
said to Powell that the hospital industry had attempted to weaken the False Claims Act, and he
"advised PhRMA to make sure it doesn't follow a similar course," CQ HealthBeat reports. Grassley
said pharmaceutical companies should educate employees about whistleblower-protection provisions
in the act (CQ HealthBeat, 6/29).
Testimony at the hearing also focused on tightening restrictions for elderly patients who shift assets
to family members in order to gain eligibility for Medicaid-funded nursing home care. Grassley
called such practices "legal shenanigans," and he estimated that tightening rules could save between
$1 billion and $2 billion over five years. A 1% reduction in Medicaid spending for long-term care
would save $2.9 billion over five years, the Los Angeles Times reports. Julie Stone-Axelrad, a social
policy analyst for the Congressional Research Service, identified more than half a dozen methods
that could be used to protect a family's wealth, despite current laws that attempt to penalize families
who shift assets to qualify for Medicaid. Stone-Axelrad said, "An industry of elder lawyers
specializing in Medicaid has sprung up across the nation." The Bush administration has proposed
making the transfers more difficult to carry out. The National Governors Association has endorsed
President Bush's proposal, though the "governors favor a carrot-and-stick approach that would not
solely rely on increased penalties," according to the Times. The governors would use untapped home
equity, currently excluded from Medicaid calculations, to help pay for nursing home care. The
governors also favor more widespread use of long-term care insurance. Ruth Pundt, a 71-year-old
nursing home resident, in testimony said, "As a taxpayer, I believe people with assets should not be
able to use loopholes to preserve their assets and shift the burden of paying for their care to others."
Judith Feder, dean of the Georgetown Public Policy Institute, said, "Solutions that focus only on
making Medicaid 'meaner' ... do our nation a disservice," adding, "The nation lacks a policy that
assures people access to quality long-term care, when they need it, without risk of impoverishment"
(Alonso-Zaldivar, Los Angeles Times, 6/30).
John E. Gallagher, Vice President of Government Relations 800.642.6065 ext. 6503
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