jurisdiction: US

text: b' Department of Health and Human Services\n OFFICE OF\n INSPECTOR GENERAL\n\n\n\n\n MEDICARE COMPLIANCE REVIEW OF\nDUKE UNIVERSITY HOSPITAL FOR THE\nPERIOD JANUARY 1, 2011, THROUGH\n SEPTEMBER 30, 2012\n\n\n Inquiries about this report may be addressed to the Office of Public Affairs at\n Public.Affairs@oig.hhs.gov.\n\n\n\n\n Lori S. Pilcher\n Regional Inspector General\n\n April 2014\n A-04-13-04012\n\x0c Office of Inspector General\n https://oig.hhs.gov\n\n\n\nThe mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is\nto protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the\nhealth and welfare of beneficiaries served by those programs. This statutory mission is carried out\nthrough a nationwide network of audits, investigations, and inspections conducted by the following\noperating components:\n\nOffice of Audit Services\n\nThe Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with\nits own audit resources or by overseeing audit work done by others. Audits examine the performance of\nHHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are\nintended to provide independent assessments of HHS programs and operations. These assessments help\nreduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS.\n\nOffice of Evaluation and Inspections\nThe Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress,\nand the public with timely, useful, and reliable information on significant issues. These evaluations focus\non preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of\ndepartmental programs. To promote impact, OEI reports also present practical recommendations for\nimproving program operations.\n\nOffice of Investigations\nThe Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and\nmisconduct related to HHS programs, operations, and beneficiaries. With investigators working in all 50\nStates and the District of Columbia, OI utilizes its resources by actively coordinating with the Department\nof Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI\noften lead to criminal convictions, administrative sanctions, and/or civil monetary penalties.\n\nOffice of Counsel to the Inspector General\nThe Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering\nadvice and opinions on HHS programs and operations and providing all legal support for OIG\xe2\x80\x99s internal\noperations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS\nprograms, including False Claims Act, program exclusion, and civil monetary penalty cases. In\nconnection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG\nrenders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides\nother guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement\nauthorities.\n\x0c Notices\n\n\n THIS REPORT IS AVAILABLE TO THE PUBLIC\n at https://oig.hhs.gov\n\n Section 8L of the Inspector General Act, 5 U.S.C. App., requires\n that OIG post its publicly available reports on the OIG Web site.\n\nOFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS\n\n The designation of financial or management practices as\n questionable, a recommendation for the disallowance of costs\n incurred or claimed, and any other conclusions and\n recommendations in this report represent the findings and\n opinions of OAS. Authorized officials of the HHS operating\n divisions will make final determination on these matters.\n\x0c EXECUTIVE SUMMARY\n\n Duke University Hospital did notfully comply with Medicare requirements for billing\n inpatient and outpatient services, resulting in estimated overpayments ofat least $626,133\n over nearly 2 years.\n\nWHY WE DID THIS REVIEW\n\nThis review is part of a series of hospital compliance reviews. Using computer matching, data\nmining, and other data analysis techniques, we identified hospital claims that were at risk for\nnoncompliance with Medicare billing requirements. For calendar year (CY) 2012, Medicare\npaid hospitals $148 billion, which represents 43 percent of all fee-for-service payments;\ntherefore, the Office of Inspector General must provide continual and adequate oversight of\nMedicare payments to hospitals.\n\nThe objective of this review was to determine whether Duke University Hospital (the Hospital)\ncomplied with Medicare requirements for billing inpatient and outpatient services on selected\ntypes of claims.\n\nBACKGROUND\n\nThe Centers for Medicare & Medicaid Services (CMS) pays inpatient hospital costs at\npredetermined rates for patient discharges. The rates vary according to the diagnosis-related\ngroup (DRG) to which a beneficiary\'s stay is assigned and the severity level of the patient\'s\ndiagnosis. The DRG payment is, with certain exceptions, intended to be payment in full to the\nhospital for all inpatient costs associated with the beneficiary\'s stay. CMS pays for hospital\noutpatient services on a rate-per-service basis that varies according to the assigned ambulatory\npayment classification.\n\nThe Hospital is a 924-bed acute care facility located in Durham, North Carolina. According to\nCMS\'s National Claims History data, Medicare paid the Hospital approximately $584 million for\n22,101 inpatient and 492,063 outpatient claims for services provided to beneficiaries during\nJanuary 1, 2011, through September 30, 2012 (audit period).\n\nOur audit covered $26,303,124 in Medicare payments to the Hospital for 2,905 claims that were\npotentially at risk for billing errors. We selected for review a stratified random sample of 251\nclaims with payments totaling $3,296,435. These 251 claims had dates of service in our audit\nperiod and consisted of 119 inpatient and 132 outpatient claims.\n\nWHAT WE FOUND\n\nThe Hospital complied with Medicare billing requirements for 179 of the 251 inpatient and\noutpatient claims we reviewed. However, the Hospital did not fully comply with Medicare\nbilling requirements for the remaining 72 claims, resulting in net overpayments of $262,884 for\nthe audit period. Specifically, 26 inpatient claims had billing errors resulting in net\noverpayments of $218,294, and 46 outpatient claims had billing errors resulting in overpayments\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012)\n\x0cof $44,590. These errors occurred primarily because the Hospital did not have adequate controls\nto prevent the incorrect billing of Medicare claims within the selected risk areas that contained\nerrors.\n\nOn the basis of our sample results, we estimated that the Hospital received overpayments of at\nleast $626,133 for the audit period.\n\nWHAT WE RECOMMEND\n\nWe recommend that the Hospital:\n\n \xe2\x80\xa2 \t refund to the Medicare contractor $626,13 3 in estimated overpayments for the audit\n period for claims that it incorrectly billed and\n\n \xe2\x80\xa2 \t strengthen controls to ensure full compliance with Medicare requirements.\n\nDUKE UNIVERSITY HOSPITAL COMMENTS AND OUR RESPONSE\n\nIn written comments on our draft report, the Hospital concurred with our findings and\nrecommendations with one exception. For one claim, the Hospital disagreed with our finding\nthat it submitted the claim to Medicare with an incorrect DRG code.\n\nIn addition, the Hospital described the actions it had taken to strengthen its controls to ensure full\ncompliance with Medicare requirements.\n\nAfter reviewing the Hospital\'s comments, we maintain that the Hospital billed the disputed claim\nincorrectly. We acknowledge the Hospital\'s efforts to strengthen its compliance with Medicare\nrequirements.\n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13 -04012) ii\n\x0c TABLE OF CONTENTS \n\n\n\nINTRODUCTION ........................................................................................................................... 1 \n\n\n Why We Did This Review ................................................................................................... 1 \n\n\n Objective .............................................................................................................................. ! \n\n\n Background ....................................................................................................................... ... 1 \n\n The Medicare Program ............................................................................................ 1 \n\n Hospital Inpatient Prospective Payment System ..................................................... 1 \n\n Hospital Outpatient Prospective Payment System .................................................. 1 \n\n Hospital Claims at Risk for Incorrect Billing ..........................................................2 \n\n Medicare Requirements for Hospital Claims and Payments ...................................2 \n\n Duke University Hospital ........................................................................................ 2 \n\n\n How We Conducted This Review ....................................................................................... 3 \n\n\nFINDINGS ....................................................................................................................................... 3 \n\n\n Billing Errors Associated With Inpatient Claims ............................................................... .4 \n\n Incorrectly Billed as Inpatient ................................................................................. 4 \n\n Incorrectly Billed Diagnosis-Related-Group Codes ................................................ 4 \n\n Incorrect Discharge Status ....................................................................................... 5 \n\n Manufacturer Credits for Replaced Medical Devices Not Reported ....................... 5 \n\n\n Billing Errors Associated With Outpatient Claims ............................................................. 6 \n\n Manufacturer Credits for Replaced Medical Devices Not Reported or Obtained ... 6 \n\n Incorrectly Billed Evaluation and Management Services ....................................... 7 \n\n Incorrect Healthcare Common Procedure Coding System Codes ........................... 8 \n\n\nOVERALL ESTIMATE OF OVERPAYMENTS .......................................................................... 8 \n\n\nRECOMMENDATIONS ................................................................................................................. 8 \n\n\nDUKE UNIVERSITY HOSPITAL COMMENTS AND \n\n OFFICE OF INSPECTOR GENERAL RESPONSE .................................................................. 8 \n\n\nAPPENDIXES\n\n A: Audit Scope and Methodology .................................................................................... 10 \n\n\n B: Sample Design and Methodology ................................................................................ 12 \n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13 -04012) iii\n\x0c C: Sample Results and Estimates ............. ........................................................................ 15 \n\n\n D: Results of Review by Risk Area .................................................................................. 16 \n\n\n E: Duke University Hospital Comments .......................................................................... 17 \n\n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) iv\n\x0c INTRODUCTION \n\n\nWHY WE DID THIS REVIEW \n\n\nThis review is part of a series of hospital compliance reviews. Using computer matching, data\nmining, and other data analysis techniques, we identified hospital claims that were at risk for\nnoncompliance with Medicare billing requirements. For calendar year (CY) 2012, Medicare\npaid hospitals $148 billion, which represents 43 percent of all fee-for-service payments;\ntherefore, the Office of Inspector General must provide continual and adequate oversight of\nMedicare payments to hospitals.\n\nOBJECTIVE\n\nOur objective was to determine whether Duke University Hospital (the Hospital) complied with\nMedicare requirements for billing inpatient and outpatient services on selected types of claims.\n\nBACKGROUND\n\nThe Medicare Program\n\nMedicare Part A provides inpatient hospital insurance benefits and coverage of extended care\nservices for patients after hospital discharge, and Medicare Part B provides supplementary\nmedical insurance for medical and other health services, including coverage of hospital\noutpatient services. The Centers for Medicare & Medicaid Services (CMS) administers the\nMedicare program. CMS contracts with Medicare contractors to, among other things, process\nand pay claims submitted by hospitals.\n\nHospital Inpatient Prospective Payment System\n\nUnder the inpatient prospective payment system (IPPS), CMS pays hospital costs at\npredetermined rates for patient discharges. The rates vary according to the diagnosis-related\ngroup (DRG) to which a beneficiary\'s stay is assigned and the severity level of the patient\'s\ndiagnosis. The DRG payment is, with certain exceptions, intended to be payment in full to the\nhospital for all inpatient costs associated with the beneficiary\'s stay.\n\nHospital Outpatient Prospective Payment System\n\nCMS implemented an outpatient prospective payment system (OPPS), which is effective for\nservices furnished on or after August 1, 2000, for hospital outpatient services. Under the OPPS,\nMedicare pays for hospital outpatient services on a rate-per-service basis that varies according to\nthe assigned ambulatory payment classification (APC). CMS uses Healthcare Common\nProcedure Coding System (HCPCS) codes and descriptors to identify and group the services\nwithin each APC group. 1 All services and items within an APC group are comparable clinically\nand require comparable resources.\n\n1\n HCPCS codes are used throughout the health care industry to standardize coding for medical procedures, services,\nproducts, and supplies.\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13 -04012) I\n\x0cHospital Claims at Risk for Incorrect Billing\n\nOur previous work at other hospitals identified these types of claims at risk for noncompliance:\n\n \xe2\x80\xa2 inpatient short stays,\n\n \xe2\x80\xa2 inpatient claims paid in excess of charges,\n\n \xe2\x80\xa2 inpatient and outpatient manufacturer credits for replaced medical devices,\n\n \xe2\x80\xa2 inpatient claims billed with high-severity-level DRG codes, \n\n\n \xe2\x80\xa2 outpatient claims with payments greater than $25,000, \n\n\n \xe2\x80\xa2 outpatient claims billed with evaluation and management (E&M) services, \n\n\n \xe2\x80\xa2 outpatient claims billed for Doxorubicin Hydrochloride, and \n\n\n \xe2\x80\xa2 outpatient claims billed for Lupron injections. \n\n\nFor the purposes of this report, we refer to these areas at risk for incorrect billing as "risk areas."\nWe reviewed these risk areas as part of this review.\n\nMedicare Requirements for Hospital Claims and Payments\n\nMedicare payments may not be made for items or services that "are not reasonable and necessary\nfor the diagnosis or treatment of illness or injury or to improve the functioning of a malformed\nbody member" (the Social Security Act (the Act),\xc2\xa7 1862(a)(l)(A)). In addition, the Act\nprecludes payment to any provider of services or other person without information necessary to\ndetermine the amount due the provider(\xc2\xa7 1833(e)).\n\nFederal regulations state that the provider must furnish to the Medicare contractor sufficient\ninformation to determine whether payment is due and the amount of the payment (42 CFR\n\xc2\xa7 424.5(a)(6)).\n\nThe Medicare Claims Processing Manual (the Manual), Pub. No. 100-04, chapter 1, section\n80.3.2.2, requires providers to complete claims accurately so that Medicare contractors may\nprocess them correctly and promptly. Chapter 23, section 20.3, of the Manual states that\nproviders must use HCPCS codes for most outpatient services.\n\nDuke University Hospital\n\nThe Hospital is a 924-bed acute care facility located in Durham, North Carolina. According to\nCMS\'s National Claims History (NCH) data, Medicare paid the Hospital approximately\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) 2\n\x0c$584 million for 22,101 inpatient and 492,063 outpatient claims for services provided to\nbeneficiaries during January 1, 2011, through September 30, 2012 (audit period).\n\nHOW WE CONDUCTED THIS REVIEW\n\nOur audit covered $26,303,124 in Medicare payments to the Hospital for 2,905 claims that were\npotentially at risk for billing errors. We selected for review a stratified random sample of 251\nclaims with payments totaling $3,296,435. These 251 claims had dates of service in our audit\nperiod and consisted of 119 inpatient and 132 outpatient claims.\n\nWe focused our review on the risk areas identified as a result of prior OIG reviews at other\nhospitals. We evaluated compliance with selected billing requirements and subjected 65 claims\nto medical review and coding review to determine whether the services were medically\nnecessary and properly coded. This report focuses on selected risk areas and does not represent\nan overall assessment of all claims submitted by the Hospital for Medicare reimbursement.\n\nWe conducted this performance audit in accordance with generally accepted government\nauditing standards. Those standards require that we plan and perform the audit to obtain\nsufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions\nbased on our audit objectives. We believe that the evidence obtained provides a reasonable basis\nfor our findings and conclusions based on our audit objectives.\n\nSee Appendix A for the details of our scope and methodology.\n\n FINDINGS\n\nThe Hospital complied with Medicare billing requirements for 179 of the 251 inpatient and\noutpatient claims we reviewed. However, the Hospital did not fully comply with Medicare\nbilling requirements for the remaining 72 claims, resulting in net overpayments of $262,884 for\nthe audit period. Specifically, 26 inpatient claims had billing errors resulting in net\noverpayments of $218,294, and 46 outpatient claims had billing errors resulting in overpayments\nof $44,590. These errors occurred primarily because the Hospital did not have adequate controls\nto prevent the incorrect billing of Medicare claims within the selected risk areas that contained\nerrors.\n\nOn the basis of our sample results, we estimated that the Hospital received overpayments of at\nleast $626,133 for the audit period. See Appendix B for sample design and methodology,\nAppendix C for sample results and estimates, and Appendix D for the results of review by risk\narea.\n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13 -04012) 3\n\x0cBILLING ERRORS ASSOCIATED WITH INPATIENT CLAIMS\n\nThe Hospital incorrectly billed Medicare for 26 of the 119 inpatient claims that we reviewed.\nThese errors resulted in net overpayments of$218,294. One claim contained more than one type\nof error. 2\n\nIncorrectly Billed as Inpatient\n\nMedicare payments may not be made for items or services that "are not reasonable and necessary\nfor the diagnosis or treatment of illness or injury or to improve the functioning of a malfotmed\nbody member" (the Act,\xc2\xa7 1862(a)(1)(A)).\n\nFor 8 of the 119 inpatient claims, the Hospital incorrectly billed Medicare Part A for beneficiary\nstays that should have been billed as outpatient or outpatient with observation services. The\nHospital said that one of these errors occurred because of miscommunication between the case\xc2\xad\nmanagement staff and the billing department. The case-management staffhad identified the\nclaim as not being medically necessary for inpatient but the billing staff did not bill the claim\ncorrectly. The Hospital said that it has begun using electronic communication between the case\xc2\xad\nmanagement and billing departments, which should help prevent such errors. The Hospital said\nthat the other errors occurred because of the interpretations of medical data by the physicians\nadmitting the patients.\n\nAs a result of these errors, the Hospital received overpayments of$109,736. 3\n\nIncorrectly Billed Diagnosis-Related-Group Codes\n\nMedicare payments may not be made for items or services that "are not reasonable and necessary\nfor the diagnosis or treatment of illness or injury or to improve the functioning of a malformed\nbody member" (the Act, \xc2\xa7 1862(a)(l)(A)). In addition, the Manual states: "In order to be\nprocessed correctly and promptly, a bill must be completed accurately" (chapter 1, \xc2\xa7 80.3.2.2).\n\nFor 15 ofthe 119 inpatient claims, the Hospital submitted claims to Medicare with incorrect\nDRG codes. For example, the Hospital submitted a claim with a secondary diagnosis of\nuniversal ulcerative colitis. However, the medical records did not support the coding of this\ndiagnosis. By including this secondary diagnosis, the Hospital increased the weight of the DRG,\nwhich resulted in an overpayment. In another example, the Hospital submitted a claim with a\nprincipal diagnosis code of hypertensive chronic kidney disease for a beneficiary admitted to the\n\n\n2\n For randomly sampled claims that contained more than one type of error, the total claim overpayment was used for\nerror estimation. We did not estimate errors on the same claim twice.\n3\n The Hospital may be able to bill Medicare Part B for all services (except for services that specifically require an\noutpatient status) that would have been reasonable and necessary had the beneficiary been treated as a hospital\noutpatient rather than admitted as an inpatient. We were unable to determine the effect that billing Medicare Part B\nwould have on the overpayment amount because these services had not been billed and adjudicated by the Medicare\ncontractor prior to the issuance of this report.\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) 4\n\x0cHospital with a diagnosis ofhyperkalemia,4 which resulted from the patient\'s not properly\ngetting necessary dialysis treatments. The Hospital treated the patient with dialysis. Coding\nguidance directs using hyperkalemia as the principal diagnosis in this circumstance. By\nincluding hypertensive chronic kidney disease as the principal diagnosis, the Hospital increased\nthe weight of the DRG, which resulted in another overpayment.\n\nThese errors occurred because of the Hospital coders\' interpretation ofthe medical records or\ntheir application of coding rules.\n\nAs a result of these errors, the Hospital received net overpayments of $94,454.\n\nIncorrect Discharge Status\n\nFederal regulations state that a discharge of a hospital inpatient is considered to be a transfer\nwhen the patient\'s discharge is assigned to one of the qualifying DRGs and the discharge is to\nhome under a home health agency\'s written plan of care for home health services that begin\nwithin 3 days after the date of discharge (42 CFR \xc2\xa7 412.4( c)). A hospital that transfers an\ninpatient under the above circumstance is paid a graduated per diem rate for each day of the\npatient\'s stay in that hospital, not to exceed the full DRG payment that would have been paid if\nthe patient had been discharged to another setting (42 CFR \xc2\xa7 412.4(f)).\n\nFor 2 of the 119 inpatient claims, the Hospital incorrectly billed Medicare for patient discharges\nthat should have been billed as transfers. Specifically, the Hospital coded the discharge status as\nto home instead of to home health. Thus, the Hospital received the full DRG payment instead of\nthe graduated per diem payment it would have received if it had correctly coded the patient\'s\ndischarge status. The Hospital stated that these errors occurred because of individual coders\'\nmistakes.\n\nAs a result of these errors, the Hospital received overpayments of $9,1 04.\n\nManufacturer Credits for Replaced Medical Devices Not Reported\n\nFederal regulations require reductions in the IPPS payments for the replacement of an implanted\ndevice if (1) the device is replaced without cost to the provider, (2) the provider receives full\ncredit for the cost of a device, or (3) the provider receives a credit equal to 50 percent or more of\nthe cost ofthe device (42 CFR \xc2\xa7 412.89). The Manual states that, to bill correctly for a\nreplacement device that was provided with a credit, a hospital must code its Medicare claims\nwith a combination of condition code 49 or 50, along with value code "FD" (chapter 3, \xc2\xa7 100.8).\n\nFor 2 of the 119 inpatient claims, the Hospital received reportable medical device credits from a\nmanufacturer for replaced devices but did not adjust its inpatient claims with the proper\ncondition and value codes to reduce payment as required.\n\n\n\n4\n Hyperkalemia is an abnormally elevated level of potassium in the blood. It is usually caused by kidney\ndysfunction.\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13 -040 12) 5\n\x0cFor one of the claims, the Hospital did not report the credit due to a misinterpretation of CMS\nguidelines. Hospital staff calculated the percentage of the credit to the cost of the device\nincorrectly by including the cost of all devices replaced during a procedure instead of including\nonly the cost of the individual device associated with the credit received. As a result, the staff\nincorrectly calculated a percentage less than 50 percent, and, therefore, the Hospital did not\nreport the credit. The Hospital said it had subsequently taken steps to educate staff on the correct\ninterpretation of CMS \'s guidelines.\n\nFor the other claim, the Hospital did not report the credit because of a step in the billing process\nin which a staff member removed the proper condition and value codes that would have reduced\nthe payment. The Hospital stated that the removal was inadvertent and blamed inconsistent\nmonitoring of the claims-submission process.\n\nAs a result of these errors, the Hospital received overpayments of$5,000.\n\nBILLING ERRORS ASSOCIATED WITH OUTPATIENT CLAIMS\n\nThe Hospital incorrectly billed Medicare for 46 of the 132 outpatient claims that we reviewed.\nThese errors resulted in overpayments of $44,590. Three claims contained more than one type of\nerror. (See footnote 2.)\n\nManufacturer Credits for Replaced Medical Devices Not Reported or Obtained\n\nFederal regulations require a reduction in the OPPS payment for the replacement of an implanted\ndevice if (1) the device is replaced without cost to the provider or the beneficiary, (2) the\nprovider receives full credit for the cost of the replaced device, or (3) the provider receives\npartial credit equal to or greater than 50 percent of the cost of the replacement device (42 CFR\n\xc2\xa7 419 .45). The CMS Provider Reimbursement Manual (PRM) reinforces these requirements in\nadditional detail (Pub. No. 15-1). 5\n\nCMS guidance in Transmittal1103, dated November 3, 2006, and the Manual, chapter 4, section\n61.3, explain how a provider should report no-cost and reduced-cost devices under the OPPS.\nFor services furnished on or after January 1, 2007, CMS requires the provider to report the\nmodifier "FB" and reduced charges on a claim that includes a procedure code for the insertion of\na replacement device if the provider incurs no cost or receives full credit for the replaced device.\nlfthe provider receives a replacement device without cost from the manufacturer, the provider\nmust report a charge of no more than $1 for the device.\n\n\n5\n The PRM states: "Implicit in the intention that actual costs be paid to the extent they are reasonable is the\nexpectation that the provider seeks to minimize its costs and that its actual costs do not exceed what a prudent and\ncost conscious buyer pays for a given item or service" (part I, \xc2\xa7 2102.1). Section 2103 further defines prudent buyer\nprinciples and states that Medicare providers are expected to pursue free replacements or reduced charges under\nwarranties. Section 2103(C)(4) provides the following example: "Provider B purchases cardiac pacemakers or their\ncomponents for use in replacing malfunctioning or obsolete equipment, without asking the supplier/manufacturer for\nfull or partial credits available under the terms ofthe warranty covering the replaced equipment. The credits or\npayments that could have been obtained must be reflected as a reduction of the cost of the equipment."\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) 6\n\x0cFor 2 of the 132 outpatient claims, the Hospital incorrectly billed Medicare for medical devices\nthat were under warranty.\n\nFor one claim, the Hospital did not obtain a credit for a replaced medical device for which a\ncredit was available under the terms of the manufacturer\'s warranty. The Hospital stated that the\nerror occurred because of misinformation from the manufacturer and that accurate information\nfrom the manufacturer was crucial to the credit process. The Hospital said it had subsequently\ntaken steps to improve communication with the manufacturer by establishing communications\nwith its warranty office rather than by relying on its sales representatives.\n\nFor the other claim, the Hospital received a reportable credit from a manufacturer for a replaced\ndevice, but did not report the credit. The Hospital said that it did not report the credit because it\nmisinterpreted CMS guidelines. Hospital staff incorrectly calculated the percentage of the credit\nto the cost of the device by including the cost of all devices replaced during a procedure instead\nof including only the cost of the individual device associated with the credit received. As a\nresult, the staff incorrectly calculated a percentage less than 50 percent, and, therefore, the\nHospital did not report the credit. The Hospital said it had subsequently taken steps to educate\nstaff on the correct interpretation of CMS \'s guidelines.\n\nAs a result of these errors, the Hospital received overpayments of $42,470.\n\nIncorrectly Billed Evaluation and Management Services\n\nThe Act precludes payment to any provider of services or other person without information\nnecessary to determine the amount due the provider(\xc2\xa7 1833 (e)). The Manual states that a\nMedicare contractor pays for an E&M service that is significant, separately identifiable, and\nabove and beyond the usual preoperative and postoperative work of a procedure (chapter 12,\n\xc2\xa7 30.6.6(B)). In addition, the Manual specifically states that E&M HCPCS code 99211 should\nnot be paid with a nonchemotherapy drug infusion HCPCS code or a chemotherapy\nadministration HCPCS code (chapter 12, \xc2\xa7 30.5(F)).\n\nFor 36 of the 132 outpatient claims, the Hospital incorrectly billed Medicare for E&M services.\nFor these claims, the E&M services were not significant, separately identifiable, and above and\nbeyond the usual preoperative and postoperative work of the procedure. For example, for 25 of\nthe 36 claims, the Hospital staff incorrectly billed the E&M services with HCPCS code 99211\nfor encounters that involved a nonchemotherapy drug infusion (HCPCS code 96365) or a\nchemotherapy administration (HCPCS code 96413).\n\nThe Hospital said the errors occurred because staff members did not always identify encounters\nas "procedure only" (i.e., the E&M service is not a significant, separately identifiable service).\n\nAs a result of these errors, the Hospital received overpayments of$1,620.\n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) 7\n\x0cIncorrect Healthcare Common Procedure Coding System Codes\n\nThe Act precludes payment to any provider of services or other person without infonnation\nnecessary to determine the amount due the provider(\xc2\xa7 1833(e)). In addition, the Manual states:\n"In order to be processed correctly and promptly, a bill must be completed accurately" (chapter\n1, \xc2\xa7 80.3.2.2).\n\nFor 11 of 132 outpatient claims, the Hospital submitted claims to Medicare with incorrect\nHCPCS codes. These incorrect codes occurred because, in some cases, Hospital staff did not\nfollow its Medicare contractor\'s guidance or, in other cases, human error caused claims to be\ncoded incorrect}y.\n\nFor 8 of the 11 errors, the Hospital billed a chemotherapy administration HCPCS code for\nadministration of a certain drug, but, according to billing guidance issued by the Hospital\'s\nMedicare contractor, it should have billed a nonchemotherapy drug infusion HCPCS code. Even\nthough the Medicare contractor issued the billing guidance after the effective date and after the\ndates of service for the claims in question, the Hospital should have filed corrected claims for all\nclaims that were subject to the guidance.\n\nFor 3 of the 11 errors, the Hospital billed a higher-level E&M HCPCS code than was supported\nby the medical records. The Hospital billed these higher-level codes because of human error\nwhen coding the claims for billing purposes.\n\nAs a result of these errors, the Hospital received overpayments of $500.\n\n OVERALL ESTIMATE OF OVERPAYMENTS\n\nBased on our sample results, we estimated that the Hospital received overpayments of at least\n$626,133 for the audit period.\n\n RECOMMENDATIONS\n\nWe recommend that the Hospital:\n\n \xe2\x80\xa2 \t refund to the Medicare contractor $626,133 in estimated overpayments for the audit\n period for claims that it incorrectly billed and\n\n \xe2\x80\xa2 \t strengthen controls to ensure full compliance with Medicare requirements.\n\n DUKE UNIVERSITY HOSPITAL COMMENTS AND OFFICE OF INSPECTOR\n GENERAL RESPONSE\n\nIn written comments on our draft report, the Hospital concurred with our findings and\nrecommendations with one exception. For one claim, the Hospital disagreed with our finding\nthat it submitted the claim to Medicare with an incorrect DRG code.\n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) 8\n\x0cIn Addition, the Hospital described the actions it had taken to strengthen its controls to ensure\nfull compliance with Medicare requirements.\n\nAs we indicated in Appendix A, during our audit, we used a CMS Medicare contractor\'s medical\nreview staff and coders to determine whether certain claims in our sample, including the claim in\nquestion, were properly coded. The contractor examined all of the medical records and\ndocumentation submitted for this claim and determined that it was not submitted with the correct\nDRG code. On the basis of the contractor\'s conclusion, we maintain that the Hospital billed the\ndisputed claim incorrectly.\n\nWe acknowledge the Hospital\'s efforts to strengthen its compliance with Medicare requirements.\n\nThe Hospital\'s comments are included in their entirety as Appendix E.\n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) 9\n\x0c APPENDIX A: AUDIT SCOPE AND METHODOLOGY \n\n\nSCOPE \n\n\nOur audit covered $26,303,124 in Medicare payments to the Hospital for 2,905 claims that were\npotentially at risk for billing errors. We selected for review a stratified random sample of 251\nclaims with payments totaling $3,296,435. These 251 claims consisted of 119 inpatient and 132\noutpatient claims and had dates of service from January 1, 2011, through September 30,2012\n(audit period).\n\nWe focused our review on the risk areas identified as a result of prior OIG reviews at other\nhospitals. We evaluated compliance with selected billing requirements and subjected 65 claims\nto medical review and coding review to determine whether the services were medically\nnecessary and properly coded.\n\nWe limited our review of the Hospital\'s internal controls to those applicable to the inpatient and\noutpatient areas of review because our objective did not require an understanding of all internal\ncontrols over the submission and processing of claims. We established reasonable assurance of\nthe authenticity and accuracy of the data obtained from the NCH file, but we did not assess the\ncompleteness of the file.\n\nThis report focuses on selected risk areas and does not represent an overall assessment of all\nclaims submitted by the Hospital for Medicare reimbursement.\n\nWe conducted our fieldwork at the Hospital from April 2013 through September 2013.\n\nMETHODOLOGY\n\nTo accomplish our objective, we:\n\n \xe2\x80\xa2 \t reviewed applicable Federal laws, regulations, and guidance;\n\n \xe2\x80\xa2 \t extracted the Hospital\'s inpatient and outpatient paid claims data from CMS\'s NCH file\n for the audit period;\n\n \xe2\x80\xa2 \t obtained information on known credits for replaced cardiac medical devices from the\n device manufacturers for the audit period;\n\n \xe2\x80\xa2 \t used computer matching, data mining, and analysis techniques to identify claims\n potentially at risk for noncompliance with selected Medicare billing requirements;\n\n \xe2\x80\xa2 \t selected a stratified random sample of251 claims (119 inpatient and 132 outpatient)\n totaling $3,296,435 for detailed review (Appendix B);\n\n \xe2\x80\xa2 \t reviewed available data from CMS\' s Common Working File for the sampled claims to\n determine whether the claims had been cancelled or adjusted;\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) 10\n\x0c \xe2\x80\xa2 \t reviewed the itemized bills and medical record documentation provided by the Hospital\n to support the sampled claims;\n\n \xe2\x80\xa2 \t requested that the Hospital conduct its own review of the sampled claims to determine\n whether the services were billed correctly;\n\n \xe2\x80\xa2 \t reviewed the Hospital\'s procedures for assigning DRG, HCPCS and admission status\n codes for Medicare claims;\n\n \xe2\x80\xa2 \t discussed the incorrectly billed claims with Hospital personnel to determine the \n\n underlying causes of noncompliance with Medicare requirements; \n\n\n \xe2\x80\xa2 \t used a CMS Medicare contractor\'s medical review staff and coders to determine whether\n 65 claims met medical necessity requirements and were properly coded;\n\n \xe2\x80\xa2 \t calculated the correct payments for those claims requiring adjustments;\n\n \xe2\x80\xa2 \t used the results of the sample review to calculate the estimated Medicare overpayment to\n the Hospital (Appendix C); and\n\n \xe2\x80\xa2 \t discussed the results of our review with Hospital officials.\n\nWe conducted this performance audit in accordance with generally accepted government\nauditing standards. Those standards require that we plan and perform the audit to obtain\nsufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions\nbased on our audit objectives. We believe that the evidence obtained provides a reasonable basis\nfor our findings and conclusions based on our audit objectives.\n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) 11\n\x0c APPENDIX B: SAMPLE DESIGN AND METHODOLOGY \n\n\nPOPULATION \n\n\nThe population contained inpatient and outpatient claims paid to the Hospital for services\nprovided to Medicare beneficiaries during the audit period.\n\nSAMPLING FRAME\n\nAccording to CMS\'s NCH data, Medicare paid the Hospital $583,605,859 for 22,101 inpatient\nand 492,063 outpatient claims for services provided to beneficiaries during the audit period.\n\nWe obtained a database of claims from the NCH data totaling $417,766,466 for 11,565 inpatient\nand 163,608 outpatient claims in 27 risk areas. From these 27 areas, we selected 9 consisting of\n98,535 claims totaling $254,900,928, for further review.\n\nWe then removed the following:\n\n \xe2\x80\xa2 \t $0 paid claims,\n \xe2\x80\xa2 \t claims under review by the Recovery Audit Contractor, and\n \xe2\x80\xa2 \t claims duplicated within individual risk areas.\n\nFor inpatient claims, we assigned each claim that appeared in multiple risk areas to just one area\nbased on the following hierarchy: Manufacturer Credits for Replaced Medical Devices, Claims\nBilled With High-Severity-Level DRG Codes, Claims Paid in Excess of Charges, and Short\nStays. For outpatient claims, we used the following hierarchy: Manufacturer Credits for\nReplaced Medical Devices, Claims With Payments Greater Than $25,000, Claims Billed for\nLupron Injections, Claims Billed With Evaluation and Management (E&M) Services, and\nClaims Billed for Doxorubicin Hydrochloride. This resulted in a sampling frame of 2,905\nunique Medicare claims in 9 risk areas totaling $26,303,124.\n\n Number Amount of\n Risk Area of Claims Payments\n 1. \t Inpatient Manufacturer Credits for Replaced Medical\n Devices 9 $221,671\n 2. \t Inpatient Claims Billed With High-Severity-Level DRG 1,244 15,909,155\n Codes\n 3. \t Inpatient Claims Paid in Excess of Charges 79 2,135,778\n 4. \t Inpatient Short Stays 152 1,677,894\n 5. \t Outpatient Manufacturer Credits for Replaced Medical\n Devices 7 112,817\n 6. \t Outpatient Claims With Payments Greater Than $25,000 155 5,191,611\n 7. \t Outpatient Claims Billed for Lupron Inj ections 90 364,840\n 8. \t Outpatient Claims Billed With E&M Services 1,034 218,332\n 9. \t Outpatient Claims Billed for Doxorubicin Hydrochloride 135 471,026\n Total \t 2,905 $26,303,124\n\n\nMedicare Compliance Review ofDuke University Hospital (A -04-13-040 12) 12\n\x0cSAMPLE UNIT\n\nThe sample unit was a Medicare paid claim.\n\nSAMPLE DESIGN\n\nWe used a stratified sample. We stratified the sampling frame into nine strata based on the risk\narea. All claims were unduplicated, appearing in only one area and only once in the entire\nsampling frame.\n\nSAMPLE SIZE\n\nWe randomly selected 251 claims for review as follows:\n\n Claims in\n Sampling Claims in\n Stratum Risk Area Frame Sample\n 1 Inpatient Manufacturer Credits for Replaced\n Medical Devices 9 9\n 2 Inpatient Claims Billed With High-Severity-\n Level DRG Codes 1,244 50\n 3 Inpatient Claims Paid in Excess of Charges 79 30\n 4 Inpatient Short Stays 152 30\n 5 Outpatient Manufacturer Credits for Replaced\n Medical Devices 7 7\n 6 Outpatient Claims With Payments Greater\n Than $25,000 155 35\n 7 Outpatient Claims Billed for Lupron Injections 90 30\n 8 Outpatient Claims Billed With E&M Services 1,034 30\n 9 Outpatient Claims Billed for Doxorubicin\n Hydrochloride 135 30\n Total 2,905 251\n\nSOURCE OF RANDOM NUMBERS\n\nWe generated the random numbers using the Office of Inspector General, Office of Audit\nServices (OTG/OAS) statistical software Random Number Generator.\n\nMETHOD FOR SELECTING SAMPLE UNITS\n\nWe consecutively numbered the claims within strata 2, 3, 4, 6, 7, 8, and 9. After generating the\nrandom numbers for strata 2, 3, 4, 6, 7, 8, and 9, we selected the corresponding claims in each\nstratum. We selected all claims in strata 1 and 5.\n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) 13\n\x0cESTIMATION METHODOLOGY\n\nWe used the OIG/OAS statistical software to estimate the total amount of Medicare\noverpayments in our sampling frame for the Hospital during the audit period.\n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13 -04012) 14\n\x0c APPENDIX C: SAMPLE RESULTS AND ESTIMATES \n\n\nSAMPLE RESULTS \n\n\n Number of\n Incorrectly\n Frame Total Billed Value of\n Size Value of Sample Value of Claims in Overpayments\n Stratum \n (Claims) Frame Size Sample Sample in Sample\n 1\n 9 $221,671 9 $221,671 4 $45,313\n 2\n 1,244 15,909,155 50 524,374 6 18,619\n 3\n 79 2,135,778 30 775,228 6 69,800\n 4\n 152 1,677,894 30 291,815 10 84,562\n 5\n 7 112,817 7 112,817 2 42,470\n 6\n 155 5,191,611 35 1,138,458 24 1,179\n 7\n 90 364,840 30 124,245 0 0\n 8\n 1,034 218,332 30 4,699 11 623\n 9\n 135 471,026 30 103,128 9 318\n Total \n 2,905 $26,303,124 251 $3,296,435 72 $262,884\n\nESTIMATES\n\n Estimates of Overpayments for the Audit Period\n Limits Calculated for a 90-Percent Confidence Interval\n\n Point Estimate $1,191,431\n Lower limit $626,133\n Upper limit $1,756,729\n\n\n\n\nMedicare Compliance Review ofDuke University Hospital (A -04-13-04012) 15\n\x0c APPENDIX D: RESULTS OF REVIEW BY RISK AREA \n\n\n\n Value of Claims With\n Selected Selected Underpayments/ Value of Net\n Risk Area Claims Claims Overpayments Overpay ments\nInpatient\n\nShort Stays 30 $291,815 10 $84,562\n\nClaims Paid in Excess of Charges 30 775,228 6 69,800\nManufacturer Credits for Replaced Medical\n 9 221,671 4 45,313\nDevices\nClaims Billed With High-Severity-Level\n 50 524,374 6 18,619\nDRG Codes\n Inpatient Totals 119 $1,813,088 26 $218,294\n\n\n\nOutpatient\nManufacturer Credits for Replaced Medical\n 7 $112,817 2 $42,470\nDevices\nClaims With Payments Greater Than\n 35 1,138,458 24 1,179\n$25,000\nClaims Billed With E&M Services 30 4,699 11 623\nClaims Billed for Doxorubicin\n 30 103,128 9 318\nHydrochloride\nClaims Billed for Lupron Injections 30 124,245 0 0\n\n Outpatient Totals 132 $1,483,347 46 $44,590\n\n\n\n Inpatient and Outpatient Totals 251 $3,296,435 72 $262,884\n\n\n Notice: The table above illustrates the results of our review by risk area. In it, we have organized inpatient and\n outpatient claims by the risk areas we reviewed. However, we have organized this report\'s findings by the types of\n billing errors we found at the Hospital. Because we have organized the information differently, the information in\n the individual risk areas in this table does not match precisely with this report\'s findings.\n\n\n\n\n Medicare Compliance Review ofDuke University Hospital (A-04-13 -04012) 16\n\x0c APPENDIX E: DUKE UNIVERSITY HOSPITAL COMMENTS \n\n\n\nU\n ~ DUKE UNIVERSITY HEALTH SYSTEM\n Compliance Office\n\n\n\nMarch 31, 2014\n\n\nMs. Lori S. Pilcher\nRegional Inspector General for Audit Services\nDepartment of Health and Human Services\nOffice of Inspector General\nOffice of Audit Services, Region IV\n61 Forsyth Street, SW. Suite 3T41\nAtlanta, GA 30303\n\nRE: \t Draft Report entitled Medicare Compliance Review of Duke University Hospital for the\n Period January 1, 2011 through September 30, 2012\n Report Number: A-04-13-04012\n\nDear Ms. Pilcher:\n\nDuke University Hospital (DUH) appreciates the opportunity to review and comment on the\nOIG\'s Draft Report entitled Medicare Compliance Review of Duke University Hospital for the\nPeriod January 1, 2011 through September 30, 2012, Report Number: A-04-13-04012 (Report).\nDUH is highly committed to ensuring that it complies with all federal healthcare program rules\nand directives. As part of that commitment, DUH has implemented and operates a\nsophisticated compliance program covering DUH\'s clinical and billing activities. DUH continues\nto improve its internal controls and to perform proactive reviews to prevent billing errors.\n\nDUH\'s responses to the OIG\'s findings and recommendations detailed in the Report are\nprovided in this letter. Except as stated in responses to the finding of Incorrectly Billed\nDiagnosis-Related Group Codes under Inpatient Claims section, DUH concurs with the findings\nof the Report and the recommendation to refund Palmetto GBA the estimated overpayments\ndescribed in the Report.\n\nDUH Responses:\n\nBILLING ERRORS AsSOCIATED WITH INPATIENT CLAIMS\n\n\nIncorrectly Billed as Inpatient\nThe Report found that DUH incorrectly billed 8 of the 119 inpatient claims to Medicare Part A\nthat should have been billed as outpatient or outpatient with observation services.\n\nWith respect to this finding, DUH has taken the following actions:\n1. \t DUH has established a utilization management {UM) review process to facilitate the\n determination of the appropriate patient status based upon the patient\'s severity of illness\n\n\n\n Box 3162- Durham, NC 27710- tel (919) 668-2573- fax (919) 668-2575\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13 -04012) 17\n\x0c and needed intensity of services. UM staff use electronic lnterQual to review and assess\n appropriate patient status. In addition, DUH increased UM staff to permit Emergency\n Department and Saturday coverage.\n2. \t DUH has established a bill hold to permit pre-bill submission review by a nurse medical chart\n auditor, which will include a screening review of 0-2 day Medicare inpatient admissions to\n determine appropriate patient status and claim type prior to submission of the claim.\n3. \t DUH has engaged Executive Health Resources to perform secondary reviews of admissions\n and provide peer to peer documentation education to providers.\n4. \t DUH UM staff are to perform ongoing training in collaboration with physician advisors to\n accurately document patient status at admission.\n5. \t DUH initiated an electronic workflow process between UM and revenue management staff\n to improve tracking of change requests to reduce errors.\n6. \t DUH has implemented the FY 2014 IPPS Rule "2 Midnight Presumption" as an Inpatient\n Admission criterion with documentation supporting medical necessity.\n\nIncorrectly Billed Diagnosis-Related Group Codes\nThe Report found that DUH submitted 15 of the 119 inpatient claims to Medicare with incorrect\nDRG codes. We disagree with the OIG finding that sample 83 was incorrectly coded. DUH\ncorrectly identified ICD-9 Code 996.84 (complications of transplanted organ, lung) as the\nprincipal diagnosis. See MPIM, Chapter 6, Section 6.5.3 and the AHA Coding Clinic. Pre-existing\nconditions and medical conditions that develop after the transplant are coded as complications\nof the transplanted organ, when they affect the function of that organ.\n\nWith respect to this finding, DUH has taken the following actions:\n1. \t Health Information Management {HIM} Coding Department is structured to include\n compliance specialists to provide guidance, training and oversight to the inpatient coders.\n The compliance specialists focus on quality and accuracy of coding, response to coders\'\n questions and review of physician queries.\n2. \t The compliance specialists are supported by HIM clinical documentation analysts who are\n registered nurses to assist in the interpretation of clinical documentation, assist with\n physician queries, and provide education to coders, compliance specialists and physicians.\n3. \t HIM Coding Department performs monthly quality reviews of coders\' accuracy and training,\n and ongoing coding education.\n4. \t DUH is making improvements to its Clinical Documentation Improvement {COl} Program,\n which is designed to improve clinical documentation education for providers. DUHS has\n hired a new CD/ Director and Physician Advisor and is hiring additional CD/ nurses. These\n nurses concurrently review clinical documentation and address physician queries to clarify\n documentation with the providers.\n\nIncorrect Discharge Status\nThe Report found that DUH incorrectly billed 2 of 119 inpatient claims to Medicare for patient\ndischarges that should have been billed as transfers.\n\n\n\n\nReport Number: A-04-13-04012 \t Page 2 of 4\nMedicare Compliance Review ofDuke University Hospital (A -04-13-040 12) 18\n\x0cWith respect to this finding, DUH has taken the following actions:\n1. \t HIM Coding Management will continue to provide training to coders.\n2. \t Case Management will provide discharge disposition notes to permit accurate discharge\n status coding.\n3. \t HIM Coding Management will provide monthly quality reviews of coders\' assignment of\n codes.\n\nManufacturer Credits for Replaced Medical Devices Not Reported\nThe Report found that DUH received reportable medical device credits from a manufacturer for\nreplaced devices for 2 of the 119 inpatient claims, but did not adjust its inpatient claims with\nthe proper condition and value codes to reduce payment as required.\n\nWith respect to this finding, DUH has taken the following actions:\n1. \t DUH has updated policies and procedures for clinical department staff and materials staff\n associated with devices and revenue management staff assigned to device billing.\n Additional training has been provided regarding verification of receipt of manufacturer\'s\n warranty information for devices and coding and claims processing of credit device\n adjustments.\n2. \t The revenue management staff assigned to device billing will be responsible for notifying the\n appropriate staff of any changes to the current year DRGs and APCs to which the No\n Cost/Full Credit and Partial Credit Device Adjustment Policy will apply.\n3. \t Instruction has been provided to clinical department staff regarding completion of the\n internal standardized form that identifies costs and applied credits, and forwarding of the\n form to the revenue management staff to complete the appropriate claims processing and\n charge corrections.\n4. \t Instruction has been provided to clinical staff regarding coordination with the relevant\n manufacturer to obtain current manufacturer warranty information to ensure compliance\n with each manufacturer\'s credit policies.\n5. \t Revenue management staff will perform quality review of paid claims to verify accuracy of\n codes and submitted claim.\n\nBILLING ERRORS AsSOCIATED WITH OUTPATIENT CLAIMS\n\n\nManufacturer Credits for Replaced Medical Devices Not Reported or Obtained\nThe Report found that DUH incorrectly billed Medicare for 2 of the 132 outpatient claims for\nmedical devices that were under warranty.\n\nWith respect to this finding, please see the above response regarding Inpatient Claims for\nManufacturer Credits for Replaced Medical Devices Not Reported\n\nIncorrectly Billed Evaluation and Management Services\nThe Report found that DUH incorrectly billed Medicare for 36 of the 132 outpatient claims for\nEvaluation and Management Services in which the services were not separately identifiable,\n\n\n\nReport Number: A-04-13-04012 \t Page 3 of4\n\nMedicare Compliance Review ofDuke University Hospital (A-04-13-04012) 19\n\x0cand above and beyond the usual preoperative and postoperative work associated with the\nprocedure.\n\nWith respect to this finding, DUH has taken the following actions:\n1. \t A billing edit has been implemented to prevent submission of a claim with HCPCS code level\n ofservice with nonchemotherapy or chemotherapy administration HCPCS code.\n2. \t Ancillary staff will receive continued training related to circumstances in which it is\n appropriate to bill procedure and Evaluation and Management code during the same\n encounter, as well as when to bill a procedure code only.\n\nIncorrect Healthcare Common Procedure Coding System Codes\nThe Report found that DUH submitted 11 of 132 outpatient claims to Medicare with incorrect\nHCPCS codes.\n\nWith respect to this finding, DUH has taken the following actions:\n1. \t Based on timing of contractor\'s guidance, revenue management staff will review paid claims\n and file corrected claims as appropriate.\n2. \t Coding staff will receive continued coding training.\n3. \t Comprehensive Charge Description Master {COM} review was performed in 2012 to review\n accuracy of procedural codes. Review and updating of the COM occurs annually.\n\nWe would like to thank the OIG audit staff who conducted the compliance review of DUH for\ntheir openness, collegiality and willingness to work with the DUH Compliance staff. If you have\nany additional questions or need additional information regarding DUH\'s responses, please\ncontact Colleen Shannon at (919) 668-2573 or colleen.shannon @duke.edu .\n\nSincerely,\n\n/Colleen M. Shannon/\n\nColleen M. Shannon\nChief Compliance & Privacy Officer\nDuke University Health System\n\ncc: \t Victor J. Dzau, M.D., President and Chief Executive Officer\n Mark D. Gustafson, Deputy General Counsel for Health Affairs\n\n\n\n\nReport Number: A-04-13-04012 \t Page 4 of4\n\nMedicare Compliance Review ofDuke University Hospital (A-04-1 3-04012) 20\n\x0c'


type: contracts

jurisdiction: EU

text:
 8.5.2008
 PL
 Dziennik Urzędowy Unii Europejskiej
 L 124/33
 DECYZJA WSPÓLNEGO KOMITETU EOG
 nr 166/2007
 z dnia 7 grudnia 2007 r.
 zmieniająca załącznik XIII (Transport) do Porozumienia EOG
 WSPÓLNY KOMITET EOG,
 uwzględniając Porozumienie o Europejskim Obszarze Gospodarczym, zmienione Protokołem dostosowującym Porozumienie o Europejskim Obszarze Gospodarczym, zwane dalej „Porozumieniem”, w szczególności jego art. 98,
 a także mając na uwadze, co następuje:
 (1)
 Załącznik XIII do Porozumienia został zmieniony decyzją Wspólnego Komitetu EOG nr 145/2007 z dnia 26 października 2007 r. (1).
 (2)
 W Porozumieniu należy uwzględnić rozporządzenie Komisji (WE) nr 593/2007 z dnia 31 maja 2007 r. w sprawie opłat i honorariów pobieranych przez Europejską Agencję Bezpieczeństwa Lotniczego (2).
 (3)
 Rozporządzenie (WE) nr 593/2007 uchyla uwzględnione w Porozumieniu rozporządzenie Komisji (WE) nr 488/2005 (3), które w związku z powyższym należy uchylić w ramach Porozumienia,
 STANOWI, CO NASTĘPUJE:
 Artykuł 1
 W załączniku XIII do Porozumienia pkt 66s (rozporządzenie Komisji (WE) nr 488/2005) otrzymuje brzmienie:
 „32007 R 0593: rozporządzenie Komisji (WE) nr 593/2007 z dnia 31 maja 2007 r. w sprawie opłat i honorariów pobieranych przez Europejską Agencję Bezpieczeństwa Lotniczego (Dz.U. L 140 z 1.6.2007, s. 3).”.
 Artykuł 2
 Teksty rozporządzenia (WE) nr 593/2007 w językach islandzkim i norweskim, które zostaną opublikowane w Suplemencie EOG do Dziennika Urzędowego Unii Europejskiej, są autentyczne.
 Artykuł 3
 Niniejsza decyzja wchodzi w życie z dniem 8 grudnia 2007 r., pod warunkiem że Wspólny Komitet EOG otrzyma wszystkie notyfikacje przewidziane w art. 103 ust. 1 Porozumienia (4).
 Artykuł 4
 Niniejsza decyzja zostaje opublikowana w sekcji EOG i w Suplemencie EOG do Dziennika Urzędowego Unii Europejskiej.
 Sporządzono w Brukseli dnia 7 grudnia 2007 r.
 W imieniu Wspólnego Komitetu EOG
 Stefán Haukur JÓHANNESSON
 Przewodniczący
 (1) Dz.U. L 100 z 10.4.2008, s. 89.
 (2) Dz.U. L 140 z 1.6.2007, s. 3.
 (3) Dz.U. L 81 z 30.3.2005, s. 7. Rozporządzenie ostatnio zmienione rozporządzeniem (WE) nr 779/2006 (Dz.U. L 137 z 25.5.2006, s. 3).
 (4) Nie wskazano wymogów konstytucyjnych.


type: wikipedia

text:
O AGO C.IV foi um avião de reconhecimento biplano, monomotor alemão de dois lugares em configuração de tração, utilizado a partir de 1916.
 Projeto
 Esse modelo representou uma mudança significativa nos projetos da AGO até então, abandonando a configuração de impulsão e passando a adotar uma configuração de tração convencional, com o motor e a hélice à frente "puxando" o avião. O layout, era o de um biplano convencional com as asas afilando gradualmente no comprimento.
 Grandes encomendas foram feitas para a AGO e outros fabricantes construindo sob licença, mas menos que cem foram realmente entregues. Apesar de rápido e bem armado, o C.IV demonstrou ser instável em voo e era em geral reprovado por suas tripulações. As primeiras versões de produção tinham um leme em forma de vírgula com ailerons descasados, enquanto as versões finais do avião, tinham um leme curvo com ailerons duplos na mesma estrutura reforçada.
 Usuários
 Estônia
 Império Alemão
 Especificação
 Estas são as características do AGO C.IV
 Características gerais:
 Tripulação: dois
 Comprimento: 8,25 m
 Envergadura: 11,9 m
 Altura: 3,5 m
 Área da asa: 37,5 m2
 Peso vazio: 900 kg
 Peso máximo na decolagem: 1.350 kg
 Motor: 1 x Benz Bz.IV, um 6 cilindros em linha, refrigerado à água, de 220 hp.
 Performance:
 Velocidade máxima: 190 km/h
 Autonomia: 4 horas
 Teto de Serviço: 5.500 m
 Tempo de subida: 3.000 m em 22 minutos
 Armamento:
 Armas:
 1 x metralhadora LMG 08/15 "Spandau" voltada para a frente acionada pelo piloto de 7,92 mm
 1 x metralhadora Parabellum MG 14 montada em suporte circular para o observador de 7,92 mm
 Ver também
 LVG C.IV
 Bibliografia
 Gerdessen, F. "Estonian Air Power 1918 - 1945". Air Enthusiast No 18, April - July 1982. Pages 61–76. ISSN 0143-5450.
 Airwar.ru
 Ligações externas
 AGO C.IV (a)
 AGO C.IV (b)
 Ago C.IV 1917
 Aviões produzidos na Alemanha
 C.IV
 Aviões da Primeira Guerra Mundial (Alemanha)
 Aviões militares de reconhecimento


type: caselaw

text:
 6.12.2008
 RO
 Jurnalul Oficial al Uniunii Europene
 C 313/23
 Hotărârea Tribunalului de Primă Instanță din 15 octombrie 2008 — Gogos/Comisia Comunităților Europene
 (Cauza T-66/04) (1)
 („Funcție publică - Funcționari - Concurs intern de trecere într-o altă categorie - Numire - Încadrare în grad - Articolul 31 alineatul (2) din Statutul funcționarilor’)
 (2008/C 313/40)
 Limba de procedură: greaca
 Părțile
 Reclamant: Christos Gogos (Waterloo, Belgia) (reprezentanți: inițial C. Tagaras, ulterior N. Korogiannakis, avocați)
 Pârâtă: Comisia Comunităților Europene (reprezentanți: J. Currall, agent, asistat de P. Anestis, avocat)
 Obiectul
 Cerere de anularea a deciziei Comisiei privind încadrarea reclamantului în gradul A7, treapta 3, și a deciziei din 24 noiembrie 2003 privind respingerea reclamației administrative.
 Dispozitivul
 1)
 Respinge acțiunea.
 2)
 Comisia Comunităților Europene suportă în întregime cheltuielile de judecată.
 (1) JO C 94, 17.4.2004.


type: legislation

text:
 29.7.2017
 DE
 Amtsblatt der Europäischen Union
 L 199/13
 BESCHLUSS (GASP) 2017/1401 DES POLITISCHEN UND SICHERHEITSPOLITISCHEN KOMITEES
 vom 18. Juli 2017
 zur Verlängerung des Mandats des Leiters der Mission der Europäischen Union zur Unterstützung des integrierten Grenzmanagements in Libyen (EUBAM Libya) (EUBAM Libya/1/2017)
 DAS POLITISCHE UND SICHERHEITSPOLITISCHE KOMITEE —
 gestützt auf den Vertrag über die Europäische Union, insbesondere auf Artikel 38 Absatz 3,
 gestützt auf den Beschluss 2013/233/GASP des Rates vom 22. Mai 2013 über die Mission der Europäischen Union zur Unterstützung des integrierten Grenzmanagements in Libyen (EUBAM Libya) (1), insbesondere auf Artikel 9 Absatz 1,
 in Erwägung nachstehender Gründe:
 (1)
 Nach Artikel 9 Absatz 1 des Beschlusses 2013/233/GASP ist das Politische und Sicherheitspolitische Komitee (PSK) im Einklang mit Artikel 38 des Vertrags ermächtigt, geeignete Beschlüsse zur Wahrnehmung der politischen Kontrolle und strategischen Leitung der Mission der Europäischen Union zur Unterstützung des integrierten Grenzmanagements in Libyen (EUBAM Libya) zu fassen, einschließlich des Beschlusses zur Ernennung eines Missionsleiters.
 (2)
 Das PSK hat am 30. August 2016 den Beschluss (GASP) 2016/1634 (2) angenommen, mit dem Herr Vincenzo TAGLIAFERRI vom 1. September 2016 bis zum 21. August 2017 zum Leiter der Mission EUBAM Libya ernannt wird.
 (3)
 Der Rat hat am 4. August 2016 den Beschluss (GASP) 2016/1339 (3) angenommen, mit dem der Beschluss 2013/233/GASP geändert und bis zum 21. August 2017 verlängert wurde.
 (4)
 Der Rat hat am 17. Juli 2017 den Beschluss (GASP) 2017/1342 (4) angenommen, mit dem das Mandat der EUBAM Libya vom 22. August 2017 bis zum 31. Dezember 2018 verlängert wurde.
 (5)
 Die Hohe Vertreterin der Union für Außen- und Sicherheitspolitik hat am 12. Juli 2017 vorgeschlagen, das Mandat von Herrn Vincenzo TAGLIAFERRI als Leiter der Mission EUBAM Libya vom 22. August 2017 bis zum 21. August 2018 zu verlängern —
 HAT FOLGENDEN BESCHLUSS ERLASSEN:
 Artikel 1
 Das Mandat von Herrn Vincenzo TAGLIAFERRI als Leiter der Mission EUBAM Libya wird vom 22. August 2017 bis zum 21. August 2018 verlängert.
 Artikel 2
 Dieser Beschluss tritt am 21. August 2017 in Kraft.
 Geschehen zu Brüssel am 18. Juli 2017.
 Im Namen des Politischen und Sicherheitspolitischen Komitees
 Der Vorsitzende
 W. STEVENS
 (1) ABl. L 138 vom 24.5.2013, S. 15.
 (2) Beschluss (GASP) 2016/1634 des Politischen und Sicherheitspolitischen Komitees vom 30. August 2016 über die Ernennung des Leiters der Mission der Europäischen Union zur Unterstützung des integrierten Grenzmanagements in Libyen (EUBAM Libya) (EUBAM Libya/1/2016) (ABl. L 243 vom 10.9.2016, S. 10).
 (3) Beschluss (GASP) 2016/1339 des Rates vom 4. August 2016 zur Änderung und Verlängerung des Beschlusses 2013/233/GASP über die Mission der Europäischen Union zur Unterstützung des integrierten Grenzmanagements in Libyen (EUBAM Libyen) (ABl. L 212 vom 5.8.2016, S. 111).
 (4) Beschluss (GASP) 2017/1342 des Rates vom 17. Juli 2017 zur Änderung und Verlängerung des Beschlusses 2013/233/GASP über die Mission der Europäischen Union zur Unterstützung des integrierten Grenzmanagements in Libyen (EUBAM Libya) (ABl. L 185 vom 18.7.2017, S. 60).


text:
Ralph Bathurst (* 1620 in Hothorpe, Northamptonshire; † 14. Juni 1704 in Oxford) war ein englischer Chemiker, Arzt und Geistlicher.
 Leben
 Bathurst studierte Theologie am Trinity College der Universität Oxford mit dem Bachelor-Abschluss 1638 und wurde 1644 als Priester der Anglikanischen Kirche ordiniert. Aufgrund des Englischen Bürgerkriegs wurden seine Karriereaussichten in der Kirche schlecht und er wandte sich der Medizin zu und gehörte zu einem Kreis von experimentellen Wissenschaftlern in Oxford (unter anderem John Wilkins, Thomas Willis, Christopher Wren, Robert Boyle), die später vielfach zu den Gründern der Royal Society gehörten. Außerdem war er einem Medizinerkreis, der der Tradition William Harveys folgte, aber den Royalisten nahestanden. In den 1650er Jahren praktizierte er als Arzt in Abingdon (Oxfordshire) und unter Daniel Whistler (1619–1684), bei der Behandlung verwundeter Seeleute der Royal Navy aus dem Ersten Englisch-Niederländischen Krieg. Nach der Restauration wandte er sich wieder einer kirchlichen Karriere zu. 1664 wurde er Präsident des Trinity College in Oxford und initiierte von seinem Freund Christopher Wren entworfene Neubauten. 1670 wurde er zusätzlich Dekan der Kathedrale von Wells und war 1673 bis 1676 Vizekanzler der Universität Oxford.
 In seiner medizinischen Dissertation Praelectiones tres de respiratone in Oxford 1654 (veröffentlicht 1761) entwarf er Theorien der Atmung, die von John Mayow (1669) und Robert Boyle aufgegriffen wurden. Die Luft enthielt nach ihm einen salpeterartigen Nährstoff (Pabulum nitrosum), der über die Lunge und das Blut zu den Organen gelangte. In Experimenten in geschlossenen Gefäßen fand er, dass Atmung wie die Verbrennung ohne Luft nicht möglich ist. Das von ihm als Salpeter-artig bezeichnete Element der Luft wurde im 18. Jahrhundert als Sauerstoff identifiziert (Joseph Priestley u. a.).
 Er war einer der Ärzte bei der Obduktion von Anne Greene, die gehängt worden war aber bei Beginn der Obduktion wiederbelebt werden konnte.
 1663 wurde er Fellow der Royal Society.
 Er fand lobende Erwähnung als Gelehrter in einem Gedicht von John Dryden. Auch von Bathurst stammen englische und lateinische Gedichte.
 Literatur
 Winfried R. Pötsch (Federführung), Annelore Fischer, Wolfgang Müller: Lexikon bedeutender Chemiker, Harri Deutsch 1989, S. 30
 J. M. Guy: Leading a double life in 17th-century Oxford: Ralph Bathurst (1620–1704), physician-physiologist and cleric. J. Med. Biogr., 2006, S. 17–22, PMID 16435028
 Matthew Steggle: Ralph Bathurst, Dictionary of National Biography, 2004
 Weblinks
 Gemälde von Godfrey Kneller (englisch)
 Einzelnachweise
 Chemiker (17. Jahrhundert)
 Mediziner (17. Jahrhundert)
 Anglikanischer Geistlicher (17. Jahrhundert)
 Hochschullehrer (University of Oxford)
 Mitglied der Royal Society
 Brite
 Geboren 1620
 Gestorben 1704
 Mann


text:
 7.4.2014
 BG
 Официален вестник на Европейския съюз
 C 102/36
 Жалба, подадена на 3 януари 2014 г. — Banco de Santander и др./Комисия
 (Дело T-6/14)
 2014/C 102/57
 Език на производството: испански
 Страни
 Жалбоподатели: Banco de Santander, SA (Сантандер, Испания); Santander Investment, SA (Сантандер, Испания) и Naviera Séneca, AIE (Las Palmas de Gran Canaria, Испания) (представители: J. Buendía Sierra, E. Abad Valdenebro, R. Calvo Salinero, A. Lamadrid de Pablo и A. Biondi, abogados)
 Ответник: Европейска комисия
 Искания на жалбоподателите
 Жалбоподателите искат от Общия съд:
 —
 да отмени обжалваното решение, доколкото то квалифицира съвкупността от мерки, които според посоченото в него съставляват т. нар. испанска система за финансов лизинг, като нова и несъвместима с вътрешния пазар държавна помощ,
 —
 при условията на субсидиарност, да отмени членове 1 и 4 от обжалваното решение, които определят инвеститорите от обединенията по икономически интереси като бенефициери на предполагаемите помощи и като единствени адресати на разпореждането за възстановяване,
 —
 при условията на субсидиарност, да отмени член 4 от обжалваното решение, доколкото с него се разпорежда възстановяването на предполагаемите помощи,
 —
 да отмени член 4 от обжалваното решение, доколкото той се произнася относно законосъобразността на частноправните договори между инвеститорите и други организации, и
 —
 да осъди Комисията да заплати съдебните разноски по това производство.
 Правни основания и основни доводи
 Правните основания и основните доводи са същите като вече посочените по дело T-700/13, Bankia/Комисия.


text:
 8.12.2011
 NL
 Publicatieblad van de Europese Unie
 L 325/44
 UITVOERINGSVERORDENING (EU) Nr. 1275/2011 VAN DE COMMISSIE
 van 7 december 2011
 tot vaststelling van de forfaitaire invoerwaarden voor de bepaling van de invoerprijs van bepaalde groenten en fruit
 DE EUROPESE COMMISSIE,
 Gezien het Verdrag betreffende de werking van de Europese Unie,
 Gezien Verordening (EG) nr. 1234/2007 van de Raad van 22 oktober 2007 houdende een gemeenschappelijke ordening van de landbouwmarkten en specifieke bepalingen voor een aantal landbouwproducten („integrale-GMO-verordening”) (1),
 Gezien Uitvoeringsverordening (EU) nr. 543/2011 van de Commissie van 7 juni 2011 tot vaststelling van nadere bepalingen voor de toepassing van Verordening (EG) nr. 1234/2007 van de Raad, wat de sectoren groenten en fruit en verwerkte groenten en fruit betreft (2), en met name artikel 136, lid 1,
 Overwegende hetgeen volgt:
 Bij Uitvoeringsverordening (EU) nr. 543/2011 zijn, op grond van de resultaten van de multilaterale handelsbesprekingen van de Uruguayronde, de criteria vastgesteld aan de hand waarvan de Commissie voor de producten en de perioden die in bijlage XVI, deel A, bij die verordening zijn vermeld, de forfaitaire waarden bij invoer uit derde landen vaststelt,
 HEEFT DE VOLGENDE VERORDENING VASTGESTELD:
 Artikel 1
 De in artikel 136 van Uitvoeringsverordening (EU) nr. 543/2011 bedoelde forfaitaire invoerwaarden worden vastgesteld in de bijlage bij de onderhavige verordening.
 Artikel 2
 Deze verordening treedt in werking op 8 december 2011.
 Deze verordening is verbindend in al haar onderdelen en is rechtstreeks toepasselijk in elke lidstaat.
 Gedaan te Brussel, 7 december 2011.
 Voor de Commissie, namens de voorzitter,
 José Manuel SILVA RODRÍGUEZ
 Directeur-generaal Landbouw en plattelandsontwikkeling
 (1) PB L 299 van 16.11.2007, blz. 1.
 (2) PB L 157 van 15.6.2011, blz. 1.
 BIJLAGE
 Forfaitaire invoerwaarden voor de bepaling van de invoerprijs van bepaalde groenten en fruit
 (EUR/100 kg)
 GN-code
 Code derde landen (1)
 Forfaitaire invoerwaarde
 0702 00 00
 AL
 58,7
 MA
 51,1
 MK
 68,6
 TN
 95,6
 TR
 87,5
 ZZ
 72,3
 0707 00 05
 TR
 159,0
 ZZ
 159,0
 0709 90 70
 MA
 41,1
 TR
 152,1
 ZZ
 96,6
 0805 10 20
 AR
 29,4
 BR
 41,5
 MA
 56,6
 TR
 48,7
 UY
 42,5
 ZA
 55,6
 ZZ
 45,7
 0805 20 10
 MA
 81,2
 ZZ
 81,2
 0805 20 30, 0805 20 50, 0805 20 70, 0805 20 90
 HR
 32,0
 IL
 76,9
 JM
 129,1
 TR
 78,6
 ZZ
 79,2
 0805 50 10
 TR
 54,3
 ZZ
 54,3
 0808 10 80
 CA
 120,5
 CL
 90,0
 CN
 71,1
 US
 137,2
 ZA
 180,1
 ZZ
 119,8
 0808 20 50
 CN
 56,5
 TR
 133,1
 ZZ
 94,8
 (1) Landennomenclatuur vastgesteld bij Verordening (EG) nr. 1833/2006 van de Commissie (PB L 354 van 14.12.2006, blz. 19). De code „ZZ” staat voor „overige oorsprong”.


type: other

text:
Hallituksen kokous 1/2004 | Suomen Tolkien-seura Kontu ry
 Puheenjohtaja Karoliina Leikomaa avasi kokouksen kello 12.21.
 Kokouksen puheenjohtajaksi valittiin Karoliina Leikomaa. Sihteeriksi valittiin Jukka Galkin.
 Kokous todettiin lailliseksi ja päätösvaltaiseksi. Läsnä olivat Karoliina Leikomaa, Jukka Galkin, Benjamin Bainton, Juho Gröndahl, A n t o n H i r o p o u l o s ja Inkeri Kontro.
 §4 Kokouksen esityslistan hyväksyminen
 §5 Suomen Tolkien-seura ry:n vuoden 2004 hallituksen järjestäytyminen
 Sihteeri Maria Maja
 Rahastonhoitaja, jäsenrekisterivastaava Jukka Galkin
 Smialvastaava Inkeri Kontro
 Paino- ja postitusvastaava Benjamin Bainton
 Julkisuusvastaava Juho Gröndahl
 Varajäsenet A n t o n H i r o p o u l o s, Erkki Leitsaro
 §6 Ilmoitusasiat
 Inkeri Kontro ilmoitti etsivänsä Hobittilan Sanomien avulla ruotsinkielisiä aktiiveja. Hän ilmoitti myös kartoittavansa tarvetta nuorten smialille pääkaupunkiseudulla.
 §7 Hobittilan Sanomat 1/04
 HobSanin deadline on 13.2.2004. Lehteen kerätään hallituksen jäseniltä lyhyet esittelyt. Ne tulisi lähettää Karoliina Leikomaalle sähköpostiosoitteeseen karoliina.leikomaa@env.tpu.fi mahdollisimman pian. Benjamin Bainton lupasi laatia jutun vuosijuhlasta. Hobittilan Sanomat kaipaa juttuja ja kuvia.
 §8 Legolas 1/04
 Legolaksen deadline on 12.1.2004. Legolas kaipaa artikkeleita ja kuvia.
 Postissa ei toistaiseksi ole ollut mitään erityistä.
 §10 Vuosi 2004
 Vuosikokous järjestetään lauantaina 6.3.2004 kello 13.00 Benjamin Bainton lupautui varaamaan tilan. Maria Maja laatii ilmoituksen Hobittilan Sanomiin.
 Vuosikokouksen käsiteltäväksi on ehdotettu muutoksia yhdistyksen sääntöihin. Muutettavaksi on ehdotettu seuraavia kohtia:
 – Suomen Tolkien-seura ry:n kuvauksen päivitys vastaamaan nykytilaa
 – Vuosi- ja vaalikokouksessa käsiteltävien asioiden päivitys
 – Jäsenen eronneeksi katsomisen aikarajan päivitys
 Markus Neuvonen ja Jukka Galkin valmistelevat vuosikokoukselle tarjottavan esityksen sääntömuutoksista. Sääntömuutosehdotuksia käsitellään seuraavassa hallituksen kokouksessa helmikuussa.
 Kevättapaaminen järjestetään lauantaina 22.5.2004. Se on tarkoitus järjestää hobittihenkisenä nyyttikestipiknikkinä Suomenlinnassa. Suomen Tolkien-seura hankkii kevyttä purtavaa tapahtumaan. A n t o n H i r o p o u l o s tarjoutui laatimaan mainoksen Hobittilan Sanomiin.
 Kesätapaaminen on tarkoitus järjestää Finnconin yhteydessä Jyväskylässä. Juho Gröndahl lupautui selvittämään asiaa.
 Mahdollisuutta syystapaamisen järjestämiseen tiedustellaan Kotkan paikallisseura Thorondorilta ja Tampereen Morelilta.
 Juho Gröndahl lupautui hankkimaan myyntipöydän Ropecon ry:ltä.
 Tiedustellaan Smial Gulhothilta ja Finnconin järjestäjiltä mahdollisuutta esittää tapahtumassa Gulhothin näytelmä ”Keskeneräisten tarujen kirja”. Juho Gröndahl ottaa selvää mahdollisuudesta saada myyntipöytä.
 Tiedustellaan Ilana Rimónilta mahdollisuutta toimia raadin puheenjohtajana. Myös Marianna Leikomaan ja Erkka Leppäsen halukkuutta toimia raadissa tiedustellaan.
 Benjamin Bainton tiedustelee, haluaisiko edellisen vuoden kalenterin koonnut Katri Niinikangas koota kalenterin myös tänä vuonna.
 §11 Tammikuu
 Jukka Galkin ja Markus Neuvonen huolehtivat nimenkirjoittajien päivityksestä yhdistysrekisteriin ja tilinkäyttöoikeuksien päivityksestä. [Henkilötietoja]
 §12 Hankinnat
 Pyydetään Markus Neuvosta ottamaan yhteyttä yritykseen, josta hän tiedusteli rintanappikonetta viime vuonna. Juho Gröndahl lupautui ottamaan yhteyttä Scansalesiin.
 Kännykkä ja prepaid-liittymä
 Päätettiin hankkia Seuralle oma käytetty kännykkä ja prepaid-liittymä. Rahastonhoitaja Jukka Galkin lupautui hankkimaan kännykän.
 Päätettiin hankkia lukollinen kaappi. Jukka Galkin ja Markus Neuvonen käyvät tiedustelemassa asiaa Kierrätyskeskuksesta.
 Päätettiin hankkia ruoan ja juoman tarjoilua varten seuraavat: – 2 pumpputermoskannua
 Nämä seuraavat kovaa muovia, jos mahdollista:
 – mehukannu
 – maitokannu, kermakko ja sokerikko
 – salaattikulho
 – salaattiottimet
 Marianna Leikomaa päivittää Suomen Tolkien-seura ry:n sivut, kunhan saa toimivan tietokoneen.
 Inkeri Kontro ja Juho Gröndahl huolehtivat addressista Kersti Juvalle.
 Sovittiin alustavasti sunnuntaille 8.2.2004 kello 14.00 kerhotilalle.
 Puheenjohtaja päätti kokouksen klo 13.44


text:
* it- testment awtentiku (jew « pubbliku »), imfassal min-nutar fil-presenza ta’ zewg xhieda u registrat fir-Registru Pubbliku.
 * it- testment issiġillat (jew “sigriet”), li jitqiegħed f’envelop issiġillat u ikkonsenjat lil Nutar fil-presenza ta’ zewg xhieda u depositat il-Qorti ta’ Gurisdizzjoni Volontarja. Dan jista’ jigi depositat ukoll mit-Testatur innifsu.
 Iva, jeżisti reġistru tat-testmenti awtentiċi, amministrat mnn Identity Malta, l-agenzija taht il-Ministeru tal-Ġustizzja, li hija responsabbli mir-Registru tal-Artijiet u r-RegistruPubbliku. Dan jikkonsisti f’reġistru li fih informazzjoni fuq l-atti kollha li jittrasferixxu drittijiet fuq proprjeta’, testmenti u kawzi ta’ preferenza bejn kredituri (djun registrati – ipoteki, privileggi).
 Fl-istessħin, it-testmenti ssiġillati jigu registrati fir-reġistri li jinżammu mill-qorti lokali.
 1. Ir-reġistrazzjoni tat-testment tiegħu/tagħha
 Huwa obbligatorju li t-testmenti awtentiċi jiġu rreġistrati fir-reġistru pubbliku.
 Testment sigriet ghandu jigi depositat fil-Qorti ta’ Gurisdizzjoni Volontarja, jew mit-testatur innifsu, jew inkella minn Nutar Pubbliku li lilu jigi ikkonsenjat it-testment sigriet.
 Testment li ma jinstabx huwa ekwivalenti għal testment li ma jeżistix.
 Minn min tista’ sseħħir-reġistrazzjoni ?
 In-nutar iwettaq ir-reġistrazzjoni tat-testmenti awtentiċi fir-reġistru pubbliku. It-testatur jieħu r-responsabbiltà li jirreġistra t-testment issiġillat tiegħu fil-qorti. It-testatur jista’wkoll jikkonsenja it-testment sigriet tieghu lil Nutar fil-presenza ta’ zewg xhieda biex jigi depositat fil-Qorti.
 Fir-reġistru pubbliku ma jkunx hemm miktub il-kontenut tat-testment iżda informazzjoni li tippermetti li dan jinstab. Fl-istess ħin, it-testment jitressaq il-qorti f’envelopp magħluq, biex id-dispożizzjonijiet li saru mit-testatur jinżammu sigrieti. Tista’ ssir ricerka fir-registru tat-testmenti sigrieti biss jekk it-testatur ikun mejjet.
 In-nutar huwa responsabbli miż-żamma tat-testmenti awtentiċi, imfassla minnu sakemm dawn jingabru fl-ahhar tas-sena biex issirilhom l-ispezzjoni mill-Ufficjali Revizuri tal-Qorti ghar-Revizjoni tal-Atti Nutarili. Wara l-ispezzjoni, it-testmenti originali jigu depositati l-Arkivju Nutarili.
 Il-Qorti ta’ Gurisdizzjoni Volontarja żżomm it-testmenti ssiġillati li t-testatur iressaq f’envelopp magħluq.
 Ir-reġistru pubbliku jista’ jiġi kkonsultat b’mod ħieles u huwa possibbli, li f’każ ta’ riċerka dwar kuntratti li saru minn persuna, tinkixef l-eżistenza tat-testment. Il-kontenut tat-testment qatt ma jinkixef sakemm it-testatur ikun ħaj.
 Ir-reġistrazzjoni ta’ testment fir-reġistru pubbliku tiswa €6.40.
 Ir-reġistrazzjoni ta’ testment fil-Qorti ta’ Gurisdizzjoni VOlontarja tiswa €20.
 Kull persuna tista’ taghmel ricerka ghal testmenti fuq persuna ohra fir-Registru Pubbliku. Madankollu, il-kontenut tat-testment jibqa’ sigriet sal-mewt tat-testatur.
 Wara l-mewt tat-testatur, il-qraba tal-mejjet jistgħu jikkonsultaw ir-reġistru huma stess jew permezz ta’ professjonist tal-liġi (nutar, imħallef, avukat) sabiex jinstab it-testment awtentiku. Din il-konsultazzjoni hija obbligatorjaminħabba li tagħti garanzija li jiġu rispettati l-aħħar xewqat tat-testatur. Ir-riċerka ma tistax issir qabel 21 jum wara l-mewt.
 Biex jinstab testment issiġillat, għandha ssir talba lir-registru tal-qorti fejn jigi presenta tic-certifikat tal-mewt tat-testatur.
 Il-ħruġ ta’ċertifikat tal-mewt huwa obbligatorju ?
 Iva, certifikat tal-mewt huwa obbilgatorju ghal ricerka ta’ testment sigriet u sabiex jinfetah testment pubbliku.
 Riċerka fir-reġistru pubbliku tiswa €5. Riċerka fir-reġistru tal-Qorti tiswa €15.


text:
La Catedral de San José(en búlgaro: катедрала „Св. Йосиф“)
 es una catedral católica en Sofía, la capital de Bulgaria. Es la concatedral de la diócesis de Sofía y Plovdiv, junto a la catedral de San Luis en Plovdiv.
 La catedral, reconstruida en su ubicación anterior después de que fuese destruida por los bombardeos aliados durante la Segunda Guerra Mundial, fue inaugurada el 21 de mayo de 2006 en presencia del Secretario de Estado, cardenal Angelo Sodano, decano del Colegio de Cardenales de la Iglesia católica. La primera piedra de la nueva catedral fue colocada personalmente por el Papa Juan Pablo II durante su visita a Bulgaria en 2002 .
 "San José " es la mayor catedral católica en Bulgaria tiene 350 asientos y puede albergar hasta 1.000 fieles. La catedral tiene 23 metros de largo, 15 metros de ancho, y se encuentra a 19 metros de altura del cuerpo principal del edificio con una altura de techo de 23 metros y una torre que está equipada con cuatro campanas operadas electrónicamente, a 33 metros de altura.
 Véase también
 Iglesia católica
 Catedral de San José
 Referencias
 San Jose
 Iglesias de Sofía
 Arquitectura de Bulgaria del siglo XXI
 Sofia


text:
1.5.2010
 IT
 Gazzetta ufficiale dell'Unione europea
 C 113/44
 Sentenza del Tribunale 10 marzo 2010 — Baid/UAMI (LE GOMMAGE DES FACADES)
 (Causa T-31/09) (1)
 («Marchio comunitario - Domanda di marchio comunitario denominativo LE GOMMAGE DES FACADES - Impedimento assoluto alla registrazione - Carattere descrittivo - Art. 7, n. 1, lett. c), del regolamento (CE) n. 40/94 [divenuto art. 7, n. 1, lett. c), del regolamento (CE) n. 207/2009] - Obbligo di motivazione - Art. 73, prima frase, del regolamento n. 40/94 (divenuto art. 75, prima frase, del regolamento n. 207/2009)»)
 2010/C 113/70
 Lingua processuale: il francese
 Parti
 Ricorrente: Baid SARL (Parigi, Francia) (rappresentante: avv. M. Grasset)
 Convenuto: Ufficio per l'armonizzazione nel mercato interno (marchi, disegni e modelli) (UAMI) (rappresentante: A. Folliard-Monguiral, agente)
 Oggetto
 Ricorso proposto avverso la decisione della prima commissione di ricorso dell’UAMI 30 ottobre 2008 (procedimento R 963/2008-1) relativa a una domanda di registrazione, quale marchio comunitario, del segno denominativo LE GOMMAGE DES FACADES
 Dispositivo
 1)
 Il ricorso è respinto.
 2)
 La Baid SARL è condannata alle spese.
 (1) GU C 69 del 21.3.2009.


text:
tauragesvvg - Europe Direct
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text:
 28.4.2012
 NL
 Publicatieblad van de Europese Unie
 L 116/17
 UITVOERINGSVERORDENING (EU) Nr. 368/2012 VAN DE COMMISSIE
 van 27 april 2012
 tot wijziging van Verordening (EU) nr. 44/2012 van de Raad tot vaststelling, voor 2012, van de vangstmogelijkheden in de EU-wateren en, voor EU-vaartuigen, in bepaalde niet-EU-wateren, voor sommige visbestanden en groepen visbestanden waarvoor internationale onderhandelingen worden gevoerd of internationale overeenkomsten gelden
 DE EUROPESE COMMISSIE,
 Gezien het Verdrag betreffende de werking van de Europese Unie,
 Gezien Verordening (EU) nr. 44/2012 van de Raad van 17 januari 2012 tot vaststelling, voor 2012, van de vangstmogelijkheden in de EU-wateren en, voor EU-vaartuigen, in bepaalde niet-EU-wateren, voor sommige visbestanden en groepen visbestanden waarvoor internationale onderhandelingen worden gevoerd of internationale overeenkomsten gelden (1), en met name artikel 5, lid 4,
 Overwegende hetgeen volgt:
 (1)
 De vangstbeperkingen voor de visserij op zandspieringen in de EU-wateren van de ICES-gebieden IIa, IIIa en IV zijn vastgesteld in bijlage IA bij Verordening (EU) nr. 44/2012.
 (2)
 Krachtens punt 4 van bijlage IIB bij Verordening (EU) nr. 44/2012 moet de Commissie de voor 2012 geldende totaal toegestane vangsten (TAC’s) en quota voor zandspieringen in de daar bedoelde gebieden herzien op basis van wetenschappelijk advies voor elk van de zeven beheersgebied die in die bijlage zijn omschreven.
 (3)
 In zijn op 1 maart 2012 uitgebrachte advies over zandspieringen stelt de Internationale Raad voor het Onderzoek van de Zee (ICES) voor beheersgebied 1 een vangst van maximaal 23 000 t voor in plaats van het voorlopige cijfer van 200 000 t dat in Verordening (EU) nr. 44/2012 voor dat gebied is vastgesteld.
 (4)
 Voorts adviseert ICES dat in elk van de beheersgebieden 2, 3 en 4 vangsten van maximaal 5 000 t moeten worden toegestaan met het oog op de monitoring van het bestand in die gebieden, dat in beheersgebied 6 niet meer mag worden gevangen dan de voor 2011 vastgestelde hoeveelheid van 420 t en dat in de beheersgebieden 5 en 7 niets mag worden gevangen.
 (5)
 Bijlage IA bij Verordening (EU) nr. 44/2012 moet daarom dienovereenkomstig worden gewijzigd.
 (6)
 De in deze verordening vervatte maatregelen zijn in overeenstemming met het advies van het Comité voor de visserij en de aquacultuur,
 HEEFT DE VOLGENDE VERORDENING VASTGESTELD:
 Artikel 1
 Bijlage IA bij Verordening (EU) nr. 44/2012 wordt gewijzigd overeenkomstig de bijlage bij de onderhavige verordening.
 Artikel 2
 Deze verordening treedt in werking op de dag na die van de bekendmaking ervan in het Publicatieblad van de Europese Unie.
 Deze verordening is verbindend in al haar onderdelen en is rechtstreeks toepasselijk in elke lidstaat.
 Gedaan te Brussel, 27 april 2012.
 Voor de Commissie
 De voorzitter
 José Manuel BARROSO
 (1) PB L 25 van 27.1.2012, blz. 55.
 BIJLAGE
 In bijlage IA bij Verordening (EU) nr. 44/2012 wordt de tabel betreffende zandspiering in de EU-wateren van de ICES-zones IIa, IIIa en IV vervangen door:
 „Soort
 :
 Zandspieringen en bijvangsten
 Ammodytes spp.
 Gebied
 :
 EU-wateren van IIa, IIIa en IV (1)
 (SAN/2A3A4.)
 Denemarken
 17 376 (2)
 Analytische TAC
 Verenigd Koninkrijk
 380 (2)
 Duitsland
 26 (2)
 Zweden
 638 (2)
 EU
 18 420 (2)
 Noorwegen
 20 000
 TAC
 38 420
 Bijzondere voorwaarde:
 Binnen de limieten van de bovenstaande quota mag in de onderstaande beheersgebieden voor zandspieringen als bepaald in bijlage IIB, niet meer worden gevangen dan de hieronder opgegeven hoeveelheden:
 Gebied
 :
 EU-wateren van de beheersgebieden voor zandspieringen
 1
 2
 3
 4
 5
 6
 7
 (SAN/*234_1)
 (SAN/*234_2)
 (SAN/*234_3)
 (SAN/*234_4)
 (SAN/*234_5)
 (SAN/*234_6)
 (SAN/*234_7)
 Denemarken
 2 830
 4 717
 4 717
 4 717
 0
 395
 0
 Verenigd Koninkrijk
 62
 103
 103
 103
 0
 9
 0
 Duitsland
 4
 7
 7
 7
 0
 1
 0
 Zweden
 104
 173
 173
 173
 0
 15
 0
 EU
 3 000
 5 000
 5 000
 5 000
 0
 420
 0
 Noorwegen
 20 000
 0
 0
 0
 0
 0
 0
 Totaal
 23 000
 5 000
 5 000
 5 000
 0
 420
 0”
 (1) Exclusief wateren binnen zes mijl van de basislijnen van het Verenigd Koninkrijk bij Shetland, Fair Isle en Foula.
 (2) Ten minste 98 % van de TAC-aanlanding moet bestaan uit zandspieringen. Bijvangsten van schar, makreel en wijting worden in mindering gebracht op de resterende 2 % van de TAC.
 Bijzondere voorwaarde:
 Binnen de limieten van de bovenstaande quota mag in de onderstaande beheersgebieden voor zandspieringen als bepaald in bijlage IIB, niet meer worden gevangen dan de hieronder opgegeven hoeveelheden:
 Gebied
 :
 EU-wateren van de beheersgebieden voor zandspieringen
 1
 2
 3
 4
 5
 6
 7
 (SAN/*234_1)
 (SAN/*234_2)
 (SAN/*234_3)
 (SAN/*234_4)
 (SAN/*234_5)
 (SAN/*234_6)
 (SAN/*234_7)
 Denemarken
 2 830
 4 717
 4 717
 4 717
 0
 395
 0
 Verenigd Koninkrijk
 62
 103
 103
 103
 0
 9
 0
 Duitsland
 4
 7
 7
 7
 0
 1
 0
 Zweden
 104
 173
 173
 173
 0
 15
 0
 EU
 3 000
 5 000
 5 000
 5 000
 0
 420
 0
 Noorwegen
 20 000
 0
 0
 0
 0
 0
 0
 Totaal
 23 000
 5 000
 5 000
 5 000
 0
 420
 0”