The Texas Department of Aging and Disability Services (DADS) issued an information letter to nursing facilities to clarify Medicaid-certified nursing facility emergency dental services. According to DADS, the current rule applies when an emergency dental procedure, which does not require prior authorization, is required. For more information, download the letter here.
DADS issued a provider letter to Intermediate Care Facilities for Persons with Mental Retardation or a Related Condition and Provider Associations about the 2007 Provider and Surveyor Conference: “Working Hand In Hand to Ensure Quality Services.”
The conference will be held from November 6-8 at The Commons Center, J.J. Pickle Research Campus, 10100 Burnet Road, Bldg 137, Austin, TX 78758. Download the letter for more information.
The Texas Department of Aging and Disability Services (DADS) informed Medically Dependent Children Program Camp Providers that the Texas Health and Human Services Commission (HHSC) has developed a camp provider rate change. The new payment ceiling rate, effective June 1, 2007, is $9.68/hour. Contact Lori Roberts at (512) 438-5391 or lori.roberts@dads.state.tx.us if you have questions. You may download the letter here.
HHSC has adopted new rates for Home and Community-Based Services Program and Texas Home Living Program Providers, effective September 1, 2007. The new cost ceilings can be found on the DADS communications page. From the letter:
DADS has also calculated new cost ceilings for the HCS and TxHmL Programs based on new rates adopted for the Intermediate Care Facilities for Persons with Mental Retardation (ICF/MR), effective September 1, 2007.
Download the entire letter here.
In what’s sure to be a hotly debated decision, the Centers for Medicare and Medicaid Services (CMS) informed the New York Medicaid Program last month that it can’t cover chemotherapy treatment for illegal aliens. (Kaiser Network)
CMS allows Medicaid coverage for illegal aliens for emergency services, but chemotherapy is not considered an emergency procedure.
Richard Daines, New York Health Commissioner, told the New York Times, “There are clearly situations that we consider emergencies where we need to give people chemotherapy. To say they don’t qualify is self-defeating in that those situations will eventually become emergencies.”
The national debate about illegal immigration will heat up this election cycle. Look for certain candidates to cite CMS’s decision as an urgent reason to support amnesty for millions of illegal aliens.
Proposed Rule
The Texas Health and Human Services Commission (HHSC) has proposed an amendment that will clarify that HHSC is responsible for setting the personal needs allowance for Medicaid recipients who live in long-term care facilities. For more information, see the relevant section of the September 14 Texas Register.
Correction, Open Meeting, and Pre-Application Orientation
Correction from HHSC: “Due to a Texas Register mistake, a typographical error appears in the first line of the notice on page 5212, second column. The number “07-0066″ should be “07-066″. The first line of the notice should read as follows:
‘The Texas Health and Human Services Commission announces its intent to submit Amendment 765, Transmittal Number TX 07-066…’”
HHSC will hold a public meeting on proposed Medicaid payment rates for procedure codes relating to physician-administered drugs and contraceptives. The meeting will be held on October 1, 2007, at 1:00 p.m., in the Lone Star Conference Room of the Texas Health and Human Services Commission, Braker Center, Building H, located at 11209 Metric Boulevard, Austin, Texas.
For more information about the correction and the hearing, see the relevant section of the September 14 Texas Register.
The Texas Department of Aging and Disability Services (DADS) will hold a Pre-Application Orientation for people who want to participate as a program contractor in the Home and Community-Based Services and/or the Texas Home Living Medicaid Waiver Programs. The processing fee for each registering legal entity is $25.00. For more information, see the relevant section of the September 14 Texas Register.
The Texas Department of Aging and Disability Services (DADS) issued a letter to Community Based Alternatives and Assisted Living/Residential Care Providers to inform them about Personal Care 3 Reimbursement Rates. These rates became effective on September 1, 2007. For more details, download the letter here.
DADS informed the Medically Dependent Children Program and Home and Community Support Service Agencies about increases in provider rates. New rates and billing codes can be accessed here and here. Download the information letter here.
In a provider letter to all Medicare- and/or Medicaid-Participating Nursing Facilities, DADS clarified Life Safety Code Enforcement Guidelines. Specifically, federal nursing home regulations at 42 Code of Federal Regulations Part 488, Subpart F, are applicable to Life Safety Code surveys as well as health surveys. For information on the process to be used in applying the enforcement regulations, download the letter here.
There has been a rate increase for providers of Home and Community-based Services and Texas Home Living Waiver Services, effective September 1, 2007. See the new rates here and here. You may download the letter for more information.
In a letter to Nursing Facilities, the Texas Department of Aging and Disability Services (DADS) alerted these providers to changes in the code required by Senate Bill 344, passed by the 80th Legislature, Regular Session, 2007. Changes to Section 242.0336, Temporary Change of Ownership (CHOW) License, include:
- The Department of Aging and Disability Services (DADS) may not issue a temporary NF CHOW license prior to the 31st day after receiving (1) the application from the CHOW license applicant and (2) written notification from the current license holder of the license holder’s intent to transfer operation of the facility to the license applicant.
- If DADS does not receive the CHOW application and the written notification from the current license holder at least 30 days prior to the CHOW effective date requested in the application, the effective date of the temporary NF CHOW license is the 31st day after the date DADS receives both the application and the written notification from the current license holder.
- DADS is required to issue or deny a temporary NF CHOW license no later than the 31st day after receipt of the completed application.
Download the letter to read about other changes.
DADS informed Home and Community-Based Services Providers, Texas Home Living Program Providers, Community Living Assistance and Support Services Providers, Case Management Agencies, Direct Services Agencies, and Deaf Blind Multiple Disabilities Providers that new convictions barring employment were added to the Health and Safety Code Chapter 250.
For more information about these additions, download the letter here.
The Texas Department of Aging and Disability Services (DADS) notified Community Based Alternatives (CBA), Home and Community Support Services Agencies, CBA Assisted Living/Residential Care Providers, Consolidated Waiver Program Providers, Deaf-Blind with Multiple Disabilities Waiver Providers, Medically Dependent Children’s Program Providers, Primary Home Care Providers, and Day Activity and Health Services Providers that the Texas Health and Human Services Commission has raised the minimum wage for attendant care services, recognizing the impact of the federal minimum wage increase on certain provider types, effective August 1, 2007.
A second rate increase was effective on September 1, 2007. For more information, download the letter here.
DADS notified Non-state Operated Intermediate Care Facilities for Persons with Mental Retardation (ICF/MR) about Medicaid reimbursement rates for the ICF/MR Program, effective September 1, 2007 through August 31, 2009. Download the letter for more information.
The Texas Department of Health and Human Services (HHSC) has notified providers about new per diem payment rates for the nursing facilities program operated by the Texas Department of Aging and Disability Services. The new payment rates were effective on September 1, 2007. For more information, see the relevant section of the August 31 Texas Register.
HHSC issued several public notices of its intent to submit amendments to the Texas State Plan for Medical Assistance, under Title XIX of the Social Security Act. Beginning with this link, scroll down to read all notices.
In the September 7 edition of the Texas Register, HHSC announced that it will hold a public hearing on September 24, 2007, at 10:00 a.m., to receive public comment on the proposed Medicaid payment rates for procedure codes relating to physician-administered drugs and biologicals and Durable Medical Equipment, Prosthetics, Orthotics and Supplies.
The hearing will take place in the Lone Star Conference Room of the Health and Human Services Commission, Braker Center, Building H, located at 11209 Metric Blvd, Austin, Texas. For more information, see the relevant section.
I wrote here about a decision by the Texas Medical Board to reject an ALJ’s proposal-for-decision.The case involves the Board’s rejection of the ALJ’s Proposal that the case against the physician be dismissed. The physician had committed a one time error by responding to a patient’s request for medical records with a bill based on the amount that hospitals are allowed to charge, rather than in accordance with the Board rule laying out what physicians are allowed to charge. All of the parties acknowledged that there was no intent or pattern of this exhibited by the physician.
In response to my post, I received a gracious e-mail from the General Counsel for the Texas Medical Board taking issue with some of my comments and explaining the Board’s reasoning. A copy of the Order was also sent and it is here
First, I raised a question about why the Board attorneys would assist in forwarding the case if, the ALJ was correct that it was disallowed by law, and the General Counsel took issue with my comment in his e-mail:
I want to assure you that I do not lightly consider legal issues that come before the Board and neither I nor others who provide legal counsel to the Board would ever participate in changing Findings of Fact and Conclusions of Law proposed by an ALJ without serious consideration.
I acknowledge that my comment was unwarranted and unfair. Upon reviewing the Board Order, it does appear that there is a justifiable legal argument against the ALJ’s Proposal for Decision which underlies the prosecution of this action by the Board.
Therefore, I apologize the Board attorneys and the Board itself and to my readers for my comment (which I have removed).
According to the General Counsel:
The Final Order clearly sets out the basis for the disagreement with Judge Harvel. Her PFD was based on her conclusion that, as you state, “the law clearly states that physicians cannot be disciplined for ‘unknown and isolated billing errors.’” Board staff attorneys and the Board disagreed with that conclusion, because Section 311.025, Health and Safety Code, has no application to this case. It clearly applies only to “a bill for a treatment.” It does not apply to charges for copies of medical records.
The statute to which he refers reads as follows:
§ 311.0025. AUDITS OF BILLING. (a) A hospital, treatment
facility, mental health facility, or health care professional may
not submit to a patient or a third party payor a bill for a treatment
that the hospital, facility, or professional knows was not provided
or knows was improper, unreasonable, or medically or clinically
unnecessary.
(b) If the appropriate licensing agency receives a
complaint alleging a violation of Subsection (a), the agency may
audit the billings and patient records of the hospital, treatment
facility, mental health facility, or health care professional.
(c) A hospital, treatment facility, mental health facility,
or health care professional that violates Subsection (a) is subject
to disciplinary action, including denial, revocation, suspension,
or nonrenewal of the license of the hospital, facility, or
professional. Disciplinary action taken under this section is in
addition to any other civil, administrative, or criminal penalty
provided by law.
(d) In this section:
(1) “Health care professional” means an individual
licensed, certified, or regulated by a health care regulatory
agency who is eligible for reimbursement for treatment ordered or
rendered by that professional.
(2) “Hospital” means a hospital licensed under Chapter
241.
(3) “Mental health facility” means a mental health
facility licensed under Chapter 577.
(4) “Treatment facility” means a treatment facility
licensed under Chapter 464.
(e) A licensing agency may not take disciplinary action
against a hospital, treatment facility, mental health facility, or
health care professional for unknowing and isolated billing errors.
The General Counsel explained the reasoning of the Board for pursuing this case:
As the Final Order makes clear, this was a case akin to running a stop sign. It is not a priority issue with the Board, but the Board cannot accept Judge Harvel’s conclusion of law. To do so would obliterate the Board’s authority to protect the public’s right to obtain a copy of their medical record in a timely fashion and for a reasonable cost.
The Board respects Judge Harvel and all of the ALJs at SOAH. In this case, however, we had a basic and genuine disagreement with her conclusion of law.
Of course, I disagree with the Board’s enforcement action against a physician for something as minimal as this. I think the mistake is more comparable to driving with one brake light that one doesn’t realize is broken than running a stop light. It is the kind of mistake that any doctor could make given the breadth of regulations he or she must follow–and in this case it was rectified even before the Board took action. It seems that it would have been more appropriate for the Board to use the same kind of discretion that police officers sometimes when they don’t issue a ticket, but just give a verbal warning for a minor traffic violation. The fact that the legislature does preclude disciplinary action for “unknowing and isolated billing errors” regardless of whether or not this was meant to apply to billing for medical records or only treatment, seems to convey the intent that this is not the kind of case that it intended for the Board to pursue.
However, my opinion about the Board’s use of discretion in prosecuting this does not justify my unwarranted comment and my apology stands.
According to a new Government Accountability Office (GAO) report, the Centers for Medicare and Medicaid Services (CMS) failed to properly audit private insurance companies for overpayments or to recover the excess payments. (Kaiser Network)
Medicare-participating private insurers kept “tens of millions of dollars” that could have been passed on to beneficiaries or returned to the government. Federal law requires CMS to audit financial records of at least one-third of such companies every year.
CMS contends that it has no legal authority to require private insurers to return overpayments. GAO claims otherwise; however, despite CMS’s failure to follow the law, the GAO said that “there is a low probability of the audits identifying intentional misrepresentations.”