Medicare administrative contractors (MACs) will recoup money for annual wellness visits erroneously paid to both facilities and physicians for the same visit.

CMS paid duplicate visits on the same patient on the same day because instructions to carriers wrongly permitted it. The erroneous claims date back to April 4, 2011, and could continue through March 31 because the fix won’t be implemented until April 1 of this year, according to transmittal 1190 published Feb. 15.

CMS confirmed to DecisionHealth that it would recoup the payment from whoever billed the claim second.

For more information, see transmittal 1190 at

Fraud News

Off-label Marketing Allegations Cost Pharmaceutical $45 million

With the settlement, Par Pharmaceutical Companies, based in New Jersey, resolves its criminal and civil liability for allegedly marketing Megace ES as Food and Drug Administration approved, according to the Justice Department. The company had pleaded guilty to charges of criminal misdemeanor for misbranding the drug in violation of the federal Food, Drug and Cosmetic Act. Megace ES is FDA-approved to treat anorexia, cachexia and other significant weight loss in AIDS patients. The FDA had not approved the drug’s use for non-AIDS-related geriatric wasting.

New York U.S. Attorney Sues Alleging Medicare Billing Fraud

Park Avenue Medical Associates and Park Avenue Medical Associates PC allegedly billed Medicare for services provided to elderly, mentally ill patients that did not comply with Medicare regulations, according to the U.S. Attorney in southern New York. The company’s employees provided psychotherapy to patients with severe dementia who “lacked the capacity to benefit from it” – a violation of Medicare and the company’s policies. The company billed Medicare “for a far larger number of services per psychiatrist and psychologist during the period 2001 through 2012 than any other provider with similar patient population …,” the U.S. Attorney stated.

RAC News

Recovery auditors in Regions A, B and D posted issues this week for durable medical equipment suppliers, inpatient hospitals and outpatient hospitals. See the chart below for more detail.


About the Author

Karen Long is the editor of Physician Solutions for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation’s leading independent authority on home healthcare business, regulation and reimbursement.

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