Carole Keeton Strayhorn, Texas Comptroller, chastised the Texas Health and Human Services Commission for its $800 million contract with Accenture, a group that administers Medicaid enrollment and other social services. Citing mismanagement, Stayhorn says the contract “must be ended.”

According to the Houston Chronicle, Accenture’s call centers experience computer glitches and lost and backlogged applications. Strayhorn, who is running for governor, asked lawmakers to transfer project management to a “special master reporting directly to the governor and legislative leaders.”

More links at the Kaiser Network.

The Texas Health and Human Services Commission (HHSC) announced in the October 20 Texas Register that there will be a public hearing for comments on proposed interim Medicaid reimbursement rates that will apply to large, state-operated Intermediate Care Facilities for Persons with Mental Retardation. Included are state schools operated by the Texas Department of Aging and Disability Services.

The hearing will be held on Monday, November 6, 2006, at 2:00 p.m. in the Lone Star Conference Room at HHSC’s Braker Center office located in Austin, Texas, at 11209 Metric Boulevard, Building H. For more information, see the relevant section in the Texas Register.

For an example of how whistleblowers and the False Claims Act interact, read this article, Home Health Care Industry Reels from Medicare Scandal. Whistleblowers can bring qui tam lawsuits against providers and benefit hugely. In this particular case, the whistleblower benefits as follows:

The False Claims Act permits individuals to file qui tam lawsuits against companies that defraud the government. Liable companies pay as much as three times the government’s losses plus penalties for each false claim. When the government joins the case, whistleblowers are entitled to 15 percent to 25 percent of the government’s recovery.

The government, Diaz, and the defendants last year entered into a settlement agreement that led to $33,872,626.03 being repaid to the government. As a result of her whistleblower status, Diaz received 20.75 percent of that recovery. The case remained under seal during the ongoing investigation, and was unsealed last Oct. 10. (AJ)

What were the fraudulent activities that yielded such a repayment?

In her qui tam lawsuit, Diaz alleged that Perez employed “marketers” (also known as “cappers”) who recruited patients for home health services — whether the services were needed or not — and then billed Medicare for tens of millions of dollars’ worth of home health services that were never provided. Cappers were paid as much as $400 per enrolled patient, according to the lawsuit. Often patients were paid to enroll as well. Some of the patients also were cappers, getting paid to recruit other patients. The lawsuit said Perez paid kickbacks to doctors to get referrals.

Perez’s companies obtained the necessary physician certifications that home health services were required, even though the doctors generally didn’t see the patients they were certifying for the services, the lawsuit said. The doctors often made up diagnoses to qualify patients for Medicare and Medicaid, according to the lawsuit.

Patients received few, if any, visits, once they were enrolled. The companies billed Medicare and Medicaid for regular visits, falsifying documents to obtain payments. The companies also obtained many signatures from patients in advance, so they could use those signatures as needed for forms that Medicare and Medicaid periodically required.

Also, this week the defendent was sentenced to 46 months in prison and asked to pay Medicare an additional six million on top of the afore mentioned amount.

The fraud in this case appeared pretty evident, according to the prosecutor, given that the defendant’s home health business went from a start-up to one of the top agencies in California in only 18 months.

The Texas Department of Aging and Disability Services issued a provider letter that replaces PL #05-25, effective June 1, 2006.

The revised letter reflects changes in presurvey requirements, pursuant to 40 Texas Administrative Code Chapter 97 amendment. From the letter:

The administrator, alternate administrator, supervising nurse (if applicable), and alternate supervising nurse (if applicable) of a HCSSA applying for licensure must attend a presurvey conference per 40 TAC Section 97.13(a)…This training will cover the HCSSA licensing standards (40 TAC Chapter 97, Subchapters C, D, E, F, and G) as well as other general licensure information. Other interested persons may attend a HCSSA pre-survey conference for informational purposes but must also enroll online.

For more information, download the letter here.

The long term care insurance industry is not the only one that will feel the aging baby boomer surge. Geriatric physicians are in short supply, an imbalance that will become more obvious as baby boomers retire and require specialized treatment. (New York Times - free registration required)

Geriatrics is not a popular specialty in medical schools, and the fact that geriatric medicine doesn’t pay as well as other specialties means there’s no economic incentive to choose to focus on geriatrics.

Dr. Marie A. Bernard, head of the geriatrics department at the University of Oklahoma College of Medicine, told the New York Times that medical students “want to do laser-guided this and endoscopic that.” High-tech specialties are the most popular.

Experts say solutions to the shortage include limiting geriatric practice to patients over 85 and teaching “core principles” of the specialty to all medical students.

Physicians who provide care to Medicare patients with chronic conditions will have an incentive to do more paperwork. The Kaiser Network reports that the Centers for Medicare and Medicaid Services will begin a three-year pilot program that will pay physicians to report quality of care data. An excerpt:

The three-year program will begin next year in 800 small- or medium-sized practices in Arkansas, California, Massachusetts and Utah. During the first year, physicians will be paid for reporting data on quality measures. In subsequent years, doctors will be eligible for annual performance-based bonuses of $10,000 per physician and up to $50,000 per medical practice.

Medicare Part D beneficiaries with questions about the prescription drug program can now access more information online.

At the Centers for Medicare and Medicaid Services (CMS) web site, a tool called the “Drug Plan Finder” should contain information about all available drug plans, according to the Kaiser Network. Users can compare plans across states and learn how to lower costs during gaps in coverage.

Kaiser also reports that CMS released an analysis of prescription drug plan savings:

In related news, CMS on Friday released an analysis finding that beneficiaries enrolled in Medicare stand-along prescription drug plans will save an average of 53% compared with individuals who do not have prescription drug coverage. The analysis examines prices for the most common treatments taken by beneficiaries for conditions such as high blood pressure, high cholesterol and heart failure. According to CMS, beneficiaries enrolled in the lowest-priced plans will save up to 68%. Beneficiaries enrolled in the lowest-priced plans who use generic drugs could save up to 87% off brand-name drug prices…

According to a new Government Accountability Office (GAO) report, the computer system at the Centers for Medicare and Medicaid Services (CMS)has weaknesses that could result in unauthorized disclosures of medical records. (Source)

Former CMS administrator Mark McClellan, who left his position last weekend, told the Associated Press that the GAO didn’t find evidence of compromised records, and that “we appreciate GAO’s assistance in identifying important opportunities for the contractor to strengthen network security.”

Here are some vulnerabilities the GAO found:

• Inadequate ability to identify and authenticate users who manage the network;
• Inadequate control of network access and privileges;
• Inadequate ability to protect the network from external attacks; and
• Inadequate audit trails to determine the source of transactions within the network.

In a letter to Home and Community Support Services Agencies, the Texas Department of Aging and Disability Services (DADS) reminds these providers of the requirement to report allegations of abuse, neglect, or exploitation of clients to DADS and the Department of Family and Protective Services (DFPS).

These incidents previously were investigated by on-site visits. In September 2004, the process was changed to allow desk reviews instead of on-site visits. The provider letter answers frequently asked questions about the desk review process. You may download the letter here.

In other provider news, DADS issued a letter to Nursing Facilities, Community Services Providers, ICF/MR Providers, and Therapy Providers about the National Provider Identifier (NPI) Collection Process.

The agency will begin collecting NPI from all heath care entities contracting with it. For information on how NPI notifications will be accepted and where to send them, download the letter here.

Nursing schools had to turn away over 41,000 qualified applicants in 2005 because there weren’t enough faculty to teach. This is an unfortunate trend because of the overall nursing shortage nationwide.

According to USA Today, 7.9 percent of faculty positions at nursing schools remain unfilled, and the Department of Health and Human Service reports that the 10 percent RN vacancy rate will increase to 36 percent by 2020.

In July, I blogged about the high turnover rate in health care jobs and cited the National Sample Survey of Registered Nurses. As more baby boom generation nurses retire in a few years, the nursing shortage will get worse. For more information about the nursing shortage and possible solutions, see Nursing World’s fact sheet.