For the second time in a month, the Manhattan-based urgent care chain will pay a fine to settle false claims allegations related to government-sponsored health insurance plans.
CityMD will pay New York State $883,000 to settle false claims allegations involving inappropriate facilities fees charged to the state's Empire Plan health insurance program for government workers and their families.
It's the second false claims payout in a month for the Manhattan-based urgent care franchise, which last month agreed to pay the federal government $6.6 million to settle allegations brought forward in a whistleblower lawsuit.
"My office will not tolerate healthcare providers who overbill government healthcare plans," New York Attorney General Barbara D. Underwood said of the latest settlement, in a media release issued Tuesday.
"Today's settlement makes clear that we will hold accountable any entity responsible for false payment claims to the Empire Plan or other government health plans," she said.
In a statement released Tuesday, CityMD said it was "pleased to have reached a satisfactory resolution to this matter, which involved past insurance billing and coding. This matter was unrelated to CityMD's patient care, which has consistently been of the highest quality."
New York State prosecutors found that:
From December 2010 to September 2013, CityMD knowingly overbilled the Empire Plan for facility fees to which they were not entitled.
Because CityMD had entered into Empire Plan contracts with United HealthCare, the urgent care chain's affiliates were prohibited from billing for facility fees – a detail that was explicitly made clear in the contracts.
CityMD ignored United HealthCare repeated warnings that facility fees were not permitted under the Empire Plan. Instead, CityMD claimed that facility fees that were separate from, and in addition to, the fees claimed for professional services.
CityMD admitted that despite the explicit prohibition written into the contract and UnitedHealthCare's warnings, it continued to bill for facility fees.
CityMD also admitted that it violated the New York False Claims Act and paid $706,400 to the state—including the $37,300 that was overbilled and not yet repaid, and over $669,000 in additional damages, fees, and costs.
The settlements come amid CityMD's aggressive expansion in the New York City area. Earlier this year, CityMD acquired STAT Health, an urgent care provider with 12 clinics on Long Island, and FirstMed Immediate Medical Care, an urgent care center in Queens.
CityMD Responds
CityMD issued the following statement: "CityMD is pleased to have reached a satisfactory resolution to this matter, which involved past insurance billing and coding. This matter was unrelated to CityMD's patient care, which has consistently been of the highest quality."
"Throughout CityMD's history, and especially over the past year, we have made substantial investments in strengthening our compliance program, which has included the enhancement and implementation of detailed compliance policies and procedures and the appointment of a new, full-time chief compliance officer."
"We earn the trust of the communities we serve by providing an exceptional experience through high-quality medical care and convenient access, and that includes ensuring everyone at CityMD understands that they are an integral part of our business and adheres to best-in-class compliance practices."
Using the old axiom, 'If you've seen one Medicaid program, you've seen one Medicaid program,' stakeholders say Scorecard data does not account for state-by-state program variations.
A key Medicaid stakeholder has raised concerns about what it calls the "beta version" of a new Scorecard for the program that was released this week by the Centers for Medicare & Medicaid Services.
The National Association of Medicaid Directors is questioning the comparability, accuracy and timeliness of the data that is reported on the scorecard, and the conclusions that may be drawn when comparing states with different structures and care delivery approaches.
While the Scorecard has been annotated to reflect some constraints, the measures remain problematic, NAMD said, adding that meaningful context for using the data is needed.
Problems include:
Most of the data are sourced to 2015;
In some cases, data reflect a state's beneficiaries in fee-for-service or managed care, but not necessarily beneficiaries in both delivery models. This can result in relatively healthy populations being compared to those with disabilities or complex conditions;
Some states reported using a claims-based only methodology while others used a hybrid methodology of claims and medical record review;
Variability in completeness of reporting as Medicaid Adult and Child Core set measures have been voluntary to date.
"Until these fundamental variances are addressed in the Scorecard, it will not be possible to make apples-to-apples comparisons between states," NAMD said.
Federal policymakers say the scorecard will usher in a new era of accountability by publishing state and federal Medicaid and CHIP outcomes.
The Centers for Medicare & Medicaid Services on Monday released its first ever Medicaid and Children's Health Insurance Program Scorecard.
CMS Administrator Seema Verma, in a media release, called the scorecarda central component in the modernization of Medicaid and CHIP through greater transparency and accountability for program outcomes.
"Despite providing health coverage to more than 75 million Americans at a taxpayer cost of more than $558 billion a year, we have lacked transparency in the performance and outcomes of this critical program," Verma said.
"The scorecard will be used to track and display progress being made throughout and across the Medicaid and CHIP programs, so others can learn from the successes of high performing states. By using meaningful data and fostering transparency, we will see the development of best practices that lead to positive health outcomes for our most vulnerable populations," Verma said.
The first version of the Scorecard includes measures voluntarily reported by states, and federally reported measures in three areas: state health system performance; state administrative accountability; and federal administrative accountability.
The metrics in the first Scorecard include well child visits, mental health conditions, children's preventive dental services, and other chronic health conditions.
The Scorecard is the first time that CMS is publishing state and federal administrative performance metrics, such as state/federal timeliness of managed care capitation rate reviews, time from submission to approval for Section 1115 demonstrations, and state/federal state plan amendment processing times.
At hospitals seeing fewer than 225 immunosuppressed patients with sepsis each year, these patients were 38% more likely to die while hospitalized, compared to 21% more likely to die at hospitals that saw 225 or more of these patients yearly.
Mortality rates for immunosuppressed patients with sepsis are higher when they're treated in hospitals with small numbers of these patients, a new study shows.
"While there is a lot of focus on improving sepsis outcomes through early interventions, some patients have poor outcomes from sepsis because their chronic medical conditions may worsen after the initial infectious insult," said study author Jared A. Greenberg, MD an assistant professor and critical care physician at Rush University Medical Center in Chicago.
"We hypothesized that septic patients who are immunocompromised may have improved outcomes if they are managed at hospitals that have the most experience managing immunocompromising conditions," Greenberg said in comments accompanying the study.
The researchers analyzed medical records of 350,183 patients with sepsis at 60 hospitals. One of five of those patients was classified as being immunocompromised based on being HIV-positive or having an intrinsic immune disorder, having a blood cancer or being prescribed an immunosuppressive drug for certain medical conditions while hospitalized.
The study found:
15% of immunosuppressed patients with sepsis died during hospitalization compared to 12% of non-immunosuppressed patients with sepsis at all hospitals.
At hospitals seeing fewer than 225 immunosuppressed patients with sepsiseach year, these patients were 38% more likely to die while hospitalized, compared to 21% more likely to die at hospitals that saw 225 or more of these patients yearly.
Above 225, caring for greater numbers of immunosuppressed patients with sepsis(one hospital treated 1,056 such patients) did not appear to reduce mortality.
Immunosuppressed patients withsepsis were more likely than non- immunosuppressed patients to return to their homes after discharge, rather than another health facility, 60% vs. 50%, respectively.
Greenberg said the last finding was a surprise. He said non-immunosuppressed patients may have been in declining health before sepsis than immunosuppressed patients, as they were more likely to be older and to be admitted directly from other healthcare facilities.
The study does not explain why survival rates are higher in hospitals that treat more immunosuppressed sepsis patients, but the authors speculate that "immunosuppressed patients with sepsis had improved survival at hospitals where clinicians had greater familiarity caring for immunosuppressed patients."
Sepsis kills 258,000 people each year in the United States and costs more than $24 billion. It represents 6.2% of all hospital costs across the nation, which makes it the most expensive condition in the nation's healthcare system, according to the federal government's Healthcare Cost and Utilization Project.
The Franklin, TN-based for-profit hospital chain continues to unload hospitals in its ongoing effort to reduce debt.
Community Health Systems, Inc. this week finalized the previously announced sale of three hospitals in its Tennova Healthcare subsidiary to West Tennessee Healthcare, a Jackson-based public, not-for-profit health system.
The three hospitals are: 225-bed Tennova Healthcare Dyersburg Regional; 150-bed Tennova Healthcare Regional Jackson; and 100-bed Tennova Healthcare Volunteer Martin.
Financial terms were not disclosed, but local media estimated the value of the deal at $67 million.
The three hospitals are among the planned divestitures discussed on the company's fourth quarter 2017 earnings call. CHS has been working to reduce the debt burden it accrued with the 2014 acquisition of Naples, FL-based Health Management Associates.
The WTH deal includes all physician clinics and outpatient services associated with the three hospitals, which will also become part of WTH’s 18-county network of medical centers and outpatient services.
When the deal was announced in March, WTH CEO James E. Ross called the acquisition "consistent with our stated mission to improve the health and well-being of the communities we serve while providing exceptional and compassionate care."
The Tennova hospitals were acquired and rebranded by CHS in 2014 when it bought out HMA. With the WTH sell-off, Tennova will operate 12 hospitals across Tennessee.
Infection rates were thought to be in the neighborhood of one in a million, but new research shows the rate of infection is more than 1 in 1,000 for screening colonoscopies and 1.6 per 1,000 for non-screening colonoscopies.
The rates of infection following colonoscopies and upper-GI endoscopies at some outpatient specialty centers is more than 100 times higher than previously believed, Johns Hopkins researchers say.
Using an all-payer claims database, the researchers examined 2014 data from six states — California, Florida, Georgia, Nebraska, New York and Vermont — to track infection-related emergency room visits and unplanned inpatient admissions within seven and 30 days after a colonoscopy or EGD.
They found that:
Patients who underwent one of the common procedures at ambulatory surgery centers were at greater-than-expected risk of bacterial infections, including E. coli and Klebsiella.
The rate of infection seven or fewer days after the procedure was slightly higher than 1 in 1,000 for screening colonoscopies and about 1.6 per 1,000 for non-screening colonoscopies. Rates for EGDs within that time were more than 3 per 1,000.
Almost 45 in 1,000 patients who'd been hospitalized within 30 days prior to a screening colonoscopy visited a hospital with an infection within a month.
Within those parameters, the rate of infection-related hospitalization for EGDs was more than 59 patients per 1,000.
Among the ASC post-procedure infections, the rates were slightly higher for diagnostic procedures, as opposed to screening procedures.
ASCs with the highest volume of procedures had the lowest rates of post-endoscopic infections.
The Ambulatory Surgery Center Association reports that 64% of ASCs were owned by physicians, while 28% were affiliated with hospitals or health systems.
Study lead author Susan Hutfless, an assistant professor of medicine at the Johns Hopkins University School of Medicine, said that many ASCs lack electronic medical records connected to hospital emergency departments, so they're unlikely to learn about patients' infections.
"If they don't know their patients are developing these serious infections, they're not motivated to improve their infection control," Hutfless said in remarks accompanying the study.
Hutfless said patients should be aware of infection risk associated with all endoscopic procedures.
The investigation of now-defunct Biodiagnostic Laboratory Services has resulted in convictions for 38 physicians, in what is believed to be the largest number of medical professionals prosecuted in a bribery case.
Another New York area physician was sent to prison this week for his role in a sweeping bribery scheme that paid kickbacks for test referrals with the now-defunct by Biodiagnostic Laboratory Services LLC.
Thomas V. Savino, 59, of Staten Island, is the53rd person – and 38th physician – to be sentenced in the scheme when he was handed four years in prison by a federal judge in Newark, New Jersey this week.
Savino was convicted in October of 10 criminal counts related to the Anti-Kickback Statute.
Federal prosecutors showed that Savino received cash bribes totaling at least $25,000 in 2012 and 2013 from BLS in return for referring his patients' blood specimens to BLS. Savino's referrals generated approximately $375,000 in lab business for BLS.
In addition to the prison time, Savino was handed three years of supervised release, fined $100,000 and ordered to forfeit $27,500.
The BLS scheme's organizers have admitted that their scheme involved millions of dollars in bribes and resulted in more than $100 million in payments to BLS from Medicare and private payers.
The scheme has resulted in what is believed to be the largest number of medical professionals ever prosecuted in a bribery case. The investigation has recovered more than $15 million through forfeiture.
Officials at the now-shuttered BLS in Parsippany, New Jersey, pleaded guilty in June 2016 and forfeited all assets.
Feds say 91% of eligible clinicians participated in the first year of the initiative, and that submission rates for rural ACOs and clinicians were at 98% and 94%, respectively.
More than 90% of clinicians eligible for the Merit-based Incentive Payment System participated in the first year of the Quality Payment Program, Centers for Medicare & Medicaid Services Administrator Seema Verma said Thursday in a blog post.
"Remarkably, the submission rates for Accountable Care Organizations and clinicians in rural practices were at 98% and 94%, respectively," Verma said. "What makes these numbers most exciting is the concerted efforts by clinicians, professional associations, and many others to ensure high quality care and improved outcomes for patients."
Verma said the high participation rates come as CMS reduces regulatory burdens for clinicians and through its Patients over Paperwork initiative.
In particular, she said CMS:
Reduced the number of clinicians who are required to participate giving them more time with their patients, not computers.
Added bonus points for small practice clinicians who treat complex patients, or use 2015 Edition Certified Electronic Health Record Technology to promote interoperability.
Increased the opportunities for clinicians to earn a positive payment adjustment.
Continued offering free technical assistance to clinicians in the program.
Verma said CMS will use statutory authority provided under the Bipartisan Budget Act of 2018 to continue a gradual implementation of requirements for three more years to further reduce burden in areas of MIPS.
When the rising numbers of non-admitted patients held for observation is factored in, declines in readmissions disappear. Are hospitals trying to skirt readmissions penalties, or are there valid reasons for the increase in observational status?
A study out today in the New England Journal of Medicine suggests that the much-ballyhooed reduction in hospital readmissions in recent years all but disappears when researchers factor in the increase in non-admitted patients being kept for observational stays.
Study co-author Brad Wright, an associate professor of Health Management and Policy at University of Iowa in Iowa City, spoke with HealthLeaders Media on the subject.
The following is an edited transcript.
HLM: Does your study mean we've made no progress in lowering readmissions?
Wright: Yes, more or less. There is still a very small reduction in readmissions but yeah, you're reading that correctly. But that is only when we include observation in both components of the calculation. That is not just looking at people who were hospitalized who bounced back and now we are putting them all on observation. That takes away some of the reduction in readmissions but not all of it. It's when you also include the observation stays as initial index events. That's where the wipe out happens.
HLM: Are hospitals gaming the system?
Wright: I hesitate to say that. It's difficult to say that from the claims data. It could happen, but more than likely what we are seeing is simply the result of two different things. One being the increase in the use of observations, which is happening for a host of reasons alongside the readmissions reduction program. The argument we are making is not that hospitals are somehow purposely and malevolently gaming the system. It's just a confluence of events and these are the implications.
HLM: If it's not gaming, how else could this be explained?
Wright: One piece, and this is gaming of another sort, is audits from Medicare contractors. If they are denying payments for shorter inpatient stays that they think are inappropriate and should have been handled as observations, hospitals obviously don’t want to forego payment. So, there is pressure to put more patients in observation.
From the clinical side, you've given physicians a space where, as technology has improved, patients who would have at one time been handled in the inpatient setting can now be handled appropriately in an outpatient observation setting.
The other piece is that you create a space for physicians to ensure patient safety. Patients in the past would have been discharged home. You now have created an avenue for them to be kept in the hospital to rule out potentially life-threatening causes for whatever is going out with them.
HLM: Given your findings, has this effort to reduce readmissions been a big waste of time?
Wright: I don’t think we would necessarily say that. If you look at just the inpatient events, you see a reduction in those readmissions. Something seems to be working on that side of things. But it's not being applied to patients in observation. So, perhaps hospitals are focusing resources on insuring good transitions of care for their admitted folks when they're discharged, but they're maybe not doing that for the observation patients because they're not on the hook for having their finances penalized by that group of patients.
We're not saying get rid of the hospital readmissions program. We're not arguing for keeping it either. We are saying that you're missing out here because this group of observation patients looks a whole lot like a hospital stay. If we are trying to incentivize quality the way we figured out to do it, we should include this group of patients as well.
HLM: Is Readmissions a valid quality metric?
Wright: We're not trying to wade into the fray about the validity of readmissions as a quality measure. We're saying that for better or worse this is a metric that is widely used. We stay clear of whether or not this works. In my own personal opinion, I do think that readmissions are an important thing to measure. We have created a policy of paying hospitals a capitated amount. That puts pressure on them to get patients out of the hospital more quickly. So it's important that the pendulum doesn’t swing too far in the other direction, and you end up playing policy whack-a-mole and push it back in the other direction.
HLM: Are there ramifications for patients?
Wright: I saw recently that 10% of observation stays end up costing the patient more than an inpatient stay would, out of pocket. That never should happen. It's fine for them to be classified as outpatient until that time that their costs would exceed an inpatient stay. That should be the basis upon which we categorize them. It doesn’t seem right that patients who are technically outpatients should have to pay more than if they were an inpatient in the hospital.
HLM: Does your study come with caveats?
Wright: You have to put the caveat in that this is a commercially insured population, but that does include Medicare Advantage, so it's not completely different from FFS Medicare. But we have to be careful and we can't generalize. At the same time, because some of the other work that has looked across these different populations has found pretty comparable findings. There is a good chance that this would hold in other contexts.
A review of emergency department claims for employer-sponsored plans from 2009 through 2016 found that the average prices for higher severity billing codes rose faster than lower severity codes.
Emergency department spending per employer-sponsored plan enrollee increased 99% from 2009 to 2016, even as overall ED use for that cohort flat-lined, the Health Care Cost Institute reports.
HCCI examined trends in spending, price and utilization for five Current Procedural Terminology codes used to record the complexity and severity of ED visits over the seven-year span.
The findings:
While average prices for all five ER CPT codes were higher in 2016 than in 2009, the average prices for higher severity codes rose at a faster rate than low severity codes.
Combined with more use of the high severity codes, these price increases contributed to large spending hikes – per person spending for the two most severe codes grew by more than 100% over seven years.
ED visit spending per person increased 99% while overall ED use remained the same.
Overall ED spending growth was largely driven by higher severity visits, on which spending more than doubled.
Per person spending on the highest severity ED visit rose 145%, with price increasing 77% and use increasing 38%.
The second-highest severity ED visit experienced the largest price increase of any severity level (94%) and an above average increase in utilization (16%), resulting in a 124% spending increase.
A state-by-state review of the data found that:
Mississippi had the highest overall ED spending increase, rising 153% from 2009 to 2016 – 21 states saw spending increases of over 100%.
Nevada had the highest overall ED price increase, rising 147% from 2009 to 2016 – 25 states saw price increases of 100% or more.
Between 2009 and 2016, ED use remained unchanged in 18 states, decreased in 22, and increased in 11.
