SDNY COURTHOUSE, March 26 -- The US has sued Anthem, Inc. for fraud, in a filing found by Inner City Press past 8 pm on March 26 on the docket of the U.S. District Court for the Southern District of New York. From the complaint, not yet assigned to any SDNY judge: "This is a civil fraud action brought by the Government against defendant Anthem, Inc. (“Anthem”) to recover treble damages sustained by, and civil penalties and restitution owed  to, the Government as result of Anthem’s violations of the False Claims Act (“FCA”), 31 U.S.C.  § 3729 et seq.  As set forth below, Anthem knowingly disregarded its duty to ensure the accuracy  of the risk adjustment diagnosis data that it submitted to the Centers for Medicare and Medicaid  Services (“CMS”) for hundreds of thousands of Medicare beneficiaries covered by the Medicare  Part C plans operated by Anthem.  By ignoring its duty to delete thousands of inaccurate  diagnoses, Anthem unlawfully obtained and retained from CMS millions of dollars in payments  under the risk adjustment payment system for Medicare Part C.  Case As a Medicare Advantage Organization (“MAO”), Anthem was responsible for covering the cost of services rendered by healthcare providers like hospitals and doctors’ offices  for the Medicare beneficiaries enrolled in Anthem’s Part C plans.  Anthem, in turn, received  monthly capitated payments from CMS for providing such coverage.  See infra ¶¶ 21-39. Anthem understood that CMS calculated the payments to Anthem pursuant to a risk adjustment system, under which the amounts of those payments were based directly on the  number and the severity of the diagnosis data — in the form of ICD diagnosis codes — that  Anthem submitted to CMS.  See infra ¶¶ 27-44. In most cases, Anthem submitted the diagnosis  codes reported by providers in the claims and data that the providers submitted to Anthem to  seek payments for treating Medicare beneficiaries enrolled in Anthem’s Part C plans. 4. Anthem knew that, because the diagnosis codes it submitted to CMS affected payment directly, it had an obligation to ensure that its data submissions were accurate and  truthful, including by complying with the ICD coding guidelines adopted by CMS regulations.   See infra ¶¶ 45-50.  Indeed, Anthem expressly promised CMS that it would “research and  correct” any “discrepancies” in its “risk adjustment data” submissions and that it would comply  with CMS’s regulatory and contractual requirement that diagnosis codes for risk adjustment  purposes must be substantiated by beneficiaries’ medical records.  See infra ¶¶ 79-82.  In  addition, Anthem repeatedly attested to CMS that its risk adjustment diagnosis data submissions  were “accurate, complete, and truthful” according to its “best knowledge, information and  belief.”  See infra ¶¶ 83-90.  As Anthem knew, the promises and attestations it made to CMS  placed on Anthem an obligation to make good faith efforts to delete inaccurate diagnosis codes." We'll have more on this. The case is US v Anthem, 20-cv-2593 (UA). http://www.innercitypress.com/sdny1anthemicp032620.html

Medicare coverage and payment of virtual services Summary of Medicare Telemedicine Services INTRODUCTION: Under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. These policy changes build on the regulatory flexibilities granted under the President’s emergency declaration. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19  – are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus.    Telehealth, telemedicine, and related terms generally refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health. Innovative uses of this kind of technology in the provision of healthcare is increasing.  And with the emergence of the virus causing the disease COVID-19, there is an urgency to expand the use of technology to help people who need routine care, and keep vulnerable beneficiaries and beneficiaries with mild symptoms in their homes while maintaining access to the care they need. Limiting community spread of the virus, as well as limiting the exposure to other patients and staff members will slow viral spread. EXPANSION OF TELEHEALTH WITH 1135 WAIVER:  Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020.  A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients.  Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs. Prior to this waiver Medicare could only pay for telehealth on a limited basis:  when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service.  Even before the availability of this waiver authority, CMS made several related changes to improve access to virtual care.  In 2019, Medicare started making payment for brief communications or Virtual Check-Ins, which are short patient-initiated communications with a healthcare practitioner. Medicare Part B separately pays clinicians for E-visits, which are non-face-to-face patient-initiated communications through an online patient portal. Medicare beneficiaries will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to a doctor’s office or hospital which puts themselves and others at risk. TYPES OF VIRTUAL SERVICES: There are three main types of virtual services physicians and other professionals can provide to Medicare beneficiaries summarized in this fact sheet:  Medicare telehealth visits, virtual check-ins and e-visits. MEDICARE TELEHEALTH VISITS:  Currently, Medicare patients may use telecommunication technology for office, hospital visits and other services that generally occur in-person.  The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.  Distant site practitioners who can furnish and get payment for covered telehealth services (subject to state law) can include physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals.  It is imperative during this public health emergency that patients avoid travel, when possible, to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness.  Accordingly, the Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act.  To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency. KEY TAKEAWAYS: Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances. These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits. Starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings. While they must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility or hospital for the visit, effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home. The Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs. To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency. VIRTUAL CHECK-INS: In all areas (not just rural), established Medicare patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. We expect that these virtual services will be initiated by the patient; however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation.  Medicare pays for these “virtual check-ins” (or Brief communication technology-based service) for patients to communicate with their doctors and avoid unnecessary trips to the doctor’s office. These virtual check-ins are for patients with an established (or existing) relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would generally apply to these services. Doctors and certain practitioners may bill for these virtual check in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012). The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.  Standard Part B cost sharing applies to both. In addition, separate from these virtual check-in services, captured video or images can be sent to a physician (HCPCS code G2010). KEY TAKEAWAYS: Virtual check-in services can only be reported when the billing practice has an established relationship with the patient.  This is not limited to only rural settings or certain locations. Individual services need to be agreed to by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient agreement.  HCPCS code G2012: Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. HCPCS code G2010: Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment. Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare telehealth visits, which require audio and visual capabilities for real-time communication. E-VISITS:  In all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient. For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services. Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal. Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes: 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes 99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes. Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes: G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes  G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes. KEY TAKEAWAYS: These services can only be reported when the billing practice has an established relationship with the patient.  This is not limited to only rural settings. There are no geographic or location restrictions for these visits. Patients communicate with their doctors without going to the doctor’s office by using online patient portals. Individual services need to be initiated by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient initiation.  The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable. The Medicare coinsurance and deductible would generally apply to these services. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA):  Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.   For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet COVID-19 Telehealth Coding and Billing Practice Management Tips This toolkit is intended to help practices make adjustments now, and in the coming weeks, due to COVID-19.  This CMS FAQ provides information about cost-sharing requirements for COVID-19 testing and treatment. Any new guidance for physicians will be posted on ACP’s COVID-19 resource page.  https://www.acponline.org/practice-resources/business-resources/covid-19-telehealth-coding-and-billing-practice-management-tips

Here is a collection of resources from the #MedTwitter community! Proposed Clinical-Therapeutic Classification Download the paper here: https://els-jbs-prod-cdn.literatumonline.com/pb/assets/raw/Health%20Advance/journals/healun/Article_2-1584647583070.pdf Click here for a full size image A Seattle Intensivist’s One-Pager on COVID-19 #criticalCare #ID #ARDS #COVID-19 A one page summary of what I have read and seen caring for people with COVID-19. This is a distillation of data and guidelines available elsewhere complete with references (see PDF version). Available for download as a PDF, PNG, or PPT. Freely available for reuse under a CC BY-SA 3.0 license Current version: 2.6.0 (2020-03-22 14:30PST) now with updated information about treatment, prognosis to reflect the emerging US data. Original handwritten version available here. Harvard Medical School COVID-19 Curriculum I am excited to announce a COVID-19 curriculum put together by Harvard Medical School students, ft basic science, epidemiology, clinical management, testing, vaccines, and more! https://tinyurl.com/MedStudentCOVID19Curriculum "In conclusion, we found that lopinavir–ritonavir treatment did not significantly accelerate clinical improvement, reduce mortality, or diminish throat viral RNA detectability in patients with serious Covid-19" https://nejm.org/doi/full/10.1056/NEJMoa2001282