by Jerri Lynn Ward, Garlo Ward, P.C.
Posted December 28, 2000
As many of you know, a common adverse action recommended by the Texas Department of Human Services is the Denial of Payment for New Admissions or DOPNA. Generally, this recommendation is accepted and imposed by the Health Care Financing Administration. In the past it was understood a facility would receive a refund for any payments denied for new admissions should the facility clear before the DOPNA went into effect. (Often surveyors will not resurvey before the DOPNA goes into effect so that a reimbursement is needed if the plan of correction date falls before the date of the DOPNA.)
HOWEVER, we have discovered HCFA has taken a peculiar position on this issue. If a facility files a claim for payment on a new admit during the period the DOPNA was in effect, even if they are not paid for the claim by the third party, the filing of the claim may be considered fraud. Even if the facility clears before the DOPNA date, the facility may be considered by HCFA as attempting fraud until they send an official notice rescinding the DOPNA action.
If the third party does not pay the claim on the new admit, it may still be considered attempting fraud.
If the plan of correction date falls before the DOPNA date and the facility clears but DOPNA goes into effect because the follow up survey was done after the DOPNA date, it may still be considered attempting fraud.
We hope you find this information helpful. We were alarmed to discover this position existed at HCFA and alert you in order to prevent unnecessary fraud investigations of your facility(s). Please feel free to contact our office should you have any questions or concerns regarding this HCFA position. The direct line to reach Jerri Lynn Ward is (512) 302-1103, ext. 115 or JWard@GarloWard.com.
All information in this article is informational only and is not legal advice. Should you have any questions or a situation requiring advice, please contact an attorney.
Copyright 2004 by Garlo Ward, P.C., all rights reserved
Austin, Texas 78752-3714 USA