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Volume XV Number 6 S June 16, 2006

MEDICAL BOARD PROPOSES BRAIN DEATH RULE CHANGES

The NJ State Board of Medical Examiners (Board) is proposing to completely repeal its existing rule for the declaration of brain death and replace it with a new rule that reflects the changes in clinical practice standards for the declaration of brain death. The new rule would eliminate the need for a corroborating physician's assessment, because of the scope of the clinical examination, confirmatory tests and/or re-examination outlined in the new rule. The new rule would expand the list of physician specialists who can determine brain death to include a neurologist, neurosurgeon, critical care specialist and/or trauma surgeon, or any physician who has been granted hospital privileges to declare brain death (different specialists are required for patients under 12 months of age). Comments on the proposal must be submitted to the Board by July 14th.

OIG REPORTS MORE THAN $1 BILLION IN FRAUD, WASTE AND ABUSE AUDITS AND INVESTIGATIONS RECOVERIES IN FIRST HALF OF FY2006 -ST. BARNABAS HEALTH SYSTEMS PAYS $265 MILLION

The U.S. Department of Health & Human Services' Office of Inspector General (OIG) reports that it expects recoveries for the first half of fiscal year 2006 to encompass $288 million in audit-related recoveries and $732.4 million in investigative-related recoveries. In addition, OIG reported exclusions of 1,540 individuals and organizations for fraud or abuse, 226 criminal actions against persons or organizations engaged in crimes against HHS programs, and 119 civil actions, including False Claims Act, Civil Monetary Penalties Law settlements, and administrative recoveries related to provider selfdisclosure matters. In the second half of the fiscal year, the OIG already has reached a settlement with St. Barnabas Health Systems in a whistleblower case, requiring that it pay back $265 million to the Federal Government, based upon an alleged $500 million in overpayments related to fraudulent billing of outlier patients.

NJ ADOPTS RULE REQUIRING ACCREDITED CLEARINGHOUSES Both state and federal law provide for the electronic transmission and receipt of health care claim information. Most electronic claims pass through clearinghouses as they go back and forth between providers and payors. The NJ Department of Banking & Insurance, noting the compromises of consumer privacy in the banking and credit card industries, has adopted a rule requiring that payors who chose to use a clearinghouse for handling electronic claims only use clearinghouses accredited by a national standard setting organization. Although payors, providers and clearinghouses are already required by law to protect the security and privacy of patient information, the rule is to provide an added layer of assurance that these clearinghouses are adhering to required standards. Payors must comply by December 2006.

CMS REMINDS PHYSICIANS AND OTHER PROVIDERS OF REIMBURSEMENT FOR SERVICES TO UNDOCUMENTED ALIENS The Centers for Medicare & Medicaid Services (CMS) is concerned that physicians and other providers may not be receiving their share of the $250 million in federal funds allocated for reimbursement of certain costs of services provided to undocumented aliens. TrailBlazer Health Enterprises, LLC, is the national contractor for this program and processes all requests for payment. TrailBlazer enrolls eligible providers, assists providers with questions, and calculates provider payment amounts. Interested physicians should visit the TrailBlazer website at http://www.trailblazerhealth.com/section1011/ for information about the program.

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