Payer Reimbursement

Concierge Medicine Practices: Medicare Compliance Risks

May 23, 2022 | Little Health Law

iStock_000033418316_Medium-e1626470315777 Increasingly, our healthcare and business law firm’s clients are interested in opening concierge medicine practices. Little Health Law’s last blog post provided an overview of what concierge medicine is with references to compliance risks. This post outlines those very serious compliance risks for practices that treat Medicare patients and are not opted out of Medicare. If you have questions regarding this blog post or starting a concierge practice, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@littlehealthlaw.com. You may also learn more about our law firm by visiting www.littlehealthlaw.com.

Understanding the compliance risks associated with concierge medicine practices requires understanding a fairly easy and, perhaps, obvious concept: Providers cannot bill patients for services paid for by their insurance; a practice referred to as “double billing.” Applying that concept is easier said than done. Consider the complexity in this: a concierge medicine practice requires a $200/month fee that includes “longer appointments,” which is a clear benefit to patients. Assuming the appointment itself is covered by insurance, is the fact that it’s longer something that insurance does not cover? Maybe, but maybe not. There are ample examples of how complex this question is and, as it relates to Medicare, CMS and the Office of Inspector General (“OIG”) offer minimal guidance.

What to do if Your Medicare Privileges are “Deactivated”

May 4, 2022 | Little Health Law

Medicare-Money-square_7_0-300x300 There are numerous adverse actions that can be taken against a provider’s Medicare ordering and referring or billing privileges. In general, however, deactivation is not considered such an “adverse action” that will reflect on the providers PECOS; however, it does “stop” your ability to use your Medicare privileges. If you have experienced an adverse action on your privileges, such as your privileges being revoked or excluded, please investigate yourself or call counsel to understand the rules and strict deadlines around what to do to preserve your right to appeal the decision. This blog post covers “deactivation” only. If you have questions regarding this blog post or wish to discuss your Medicare privileges, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@littlehealthlaw.com. You may also learn more about our law firm by visiting www.littlehealthlaw.com.

What is a Deactivation of Medicare Privileges?

The Medicare code defines “Deactivate” as “the provider or supplier’s billing privileges were stopped but can be restored upon the submission of updated information.” 42 C.F.R. § 424.502. Importantly, “[t]he deactivation of Medicare billing privileges does not have any effect on a provider’s or supplier’s participation agreement or any conditions of participation,” but “[a] provider or supplier may not receive payment for services or items furnished while deactivated.” 42 C.F.R. §§ 424.540(c), (e). Generally, on PECOS, the deactivation will not appear as an adverse action, but may appear in the history tab.

AseraCare Settlement with DOJ A Win for Hospice Providers Under Federal False Claims Act

March 4, 2020 | Little Health Law

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In a landmark federal False Claims Act case closely watched for many years by hospice administrators, other healthcare providers and legal experts, last week the Department of Justice (DOJ) entered a joint dismissal in settlement of the case against AseraCare Inc., a national hospice provider company. The settlement marks an effective win for the defendants, in that the government agreed to accept repayment of $1 million, reduced from its initial demand of more than $200 million. https://www.businesswire.com/news/home/20200227005767/en/

Georgia-based Healthcare Reimbursement and Compliance Attorneys

Allegations in the case were brought initially between 2008 – 2010 by several former employees of AseraCare and the Department of Justice, alleging that AseraCare had submitted false claims to Medicare for patients who were arguably not terminally ill, and thus ineligible for hospice benefits, placing pressure on employees to enroll more patients using questionable recruitment practices – including targeting near-death patients so that length of stay numbers were kept low.

Fraud and Abuse Update: Billing Schemes and Medicare Fraud and the OIG’s National Health Care Fraud Takedown

November 9, 2018 | Little Health Law

1066058_patrol_hat_too1 In our Georgia business and healthcare law firm, we have noticed that cases involving Medicare fraud and billing compliance issues are published on virtually a daily basis, underscoring the critical need that physicians, nurses and other care providers and billing professionals exercise caution and vigilance in billing Medicare or other third party payers. For example, last week in Dallas, Texas, two physicians and three nurses were sentenced to prison for submitting fraudulent claims to Medicare through a home healthcare agency. The financial harm and potential billing fraud and serious “zero tolerance policy” of the Office of the Inspector and Federal Government for Medicare fraud has enhanced the financial and legal risks to healthcare providers and billing companies for all billing discrepancies. The OIG published its 2018 National Health Care Fraud Takedown providing the following statistics, which reflect law enforcement efforts to combat healthcare fraud and abuse:

CMS Announces Numerous Rule Changes

August 28, 2018 | Little Health Law

law-education-series-3-68918-m In early August, the Centers for Medicare & Medicaid Services (CMS) published an updated set of guidelines stating that hospitals will now be required to annually publish a list of charges online. CMS announced that the change in guidelines will “help improve access to hospital price information” and “give patients greater access to their health information.” However, hospitals are contending that the new guidelines may be problematic as they do not show prices after negotiating with insurance companies. Jeffrey Bomme, the chief legal officer at Adventist Health System, commented on the new guidelines stating the charges will not be relevant to patients because the bill may be reduced or some services may have no charge due to a hospital’s charity policy. These reported prices may also mean that patients neglect needed care because of the listed price and not the price that they may have to pay out of pocket, says Tom Nickels, executive vice president for government affairs and public policy at the American Hospital Association. Yet, the CMS feels as though the new rule will “incentivize value-based, quality care at these facilities.”

DOXIMITY STUDY SHOWS UPTICK IN PHYSICIAN DEMAND AND COMP IN 2017

December 29, 2017 | Little Health Law

medical-doctor-1314903-m1 Earlier this month, Doximity released a new study that provides a national review of physician compensation information and job trends, as the strong trend of physician employment by hospital systems continues. Doximity, formed in 2011, is “the largest community of healthcare professionals in the country,” according to its website. More than 70% of physicians in the United States are verified Doximity members. Doximity is a network of physicians and other healthcare practitioners. Doximity’s membership also includes many nurse practitioners, physician assistants and pharmacists. More about Doximity can be learned from its website, www.doximity.com.

The study analyzes thousands of job advertisements posted in 20 of the nation’s largest cities and involving 15 common medical specialties. Compensation growth was calculated using self-reporting from compensation surveys of tens of thousands of full time U.S. physicians. Physician compensation grew 5.1 percent in 2017, according to the study.

Fraud and Abuse Update: HHS Issues Health Care Fraud and Abuse 2016 Report

January 23, 2017 | Little Health Law

US-SUP-CT The United States Department of Health and Human Resources (HHS) and the United States Department of Justice (DOJ) recently issued a joint annual report for 2016 (the Report) providing details about the federal fraud and abuse program and, in particular, annual financial recoveries. Fraud and abuse law enforcement efforts continued to be a top priority for the Federal Government and an important means of defraying the rising costs of our nation’s healthcare delivery system. According to the Report, the Federal Government obtained over $2.5 billion in additional revenue in 2016 by way of health care fraud judgments and settlements.

HHS Complains of Court Order to Fix Medicare Appeals Backlog

December 30, 2016 | Little Health Law

1330873_courthouse The US Department of Health & Human Services (HHS) says that it cannot meet the requirements of a federal court order to reduce the horrible backlog of Medicare appeals cases that for many years has plagued the United States and adversely impacted the ability of health care providers to be paid. The problem has been under scrutiny for some time, and the US General Accountability Office (GAO) has outlined in a report various inefficiencies to which the GAO attributes the problem. Health care providers in many instances are completely unable to, in a timely manner, vindicate their claims in Medicare appeals. Nevertheless, HHS contends that it needs more money from Congress to fix the problem.

In a case styled Am. Hosp.Assn v. Burwell, D.D.C., No. 14-cv-851, the United States District Court for the District of Columbia entered a recent Order wherein the Federal Court set annual backlog reduction targets of 30, 60, 90 and 100 percent over the next four years. In the case, the American Hospital Association and affiliated entities requested that the United States District Court compel HHS to adjudicate pending Medicare-reimbursement appeals in compliance with statutory deadlines. As explained in the Order, hundreds of thousands of appeals have languished in a terrible backlog. In the case, HHS contended that mandamus (i.e., a Court-ordered solution) was not necessary and that HHS would, eventually, resolve the issue. The Plaintiff, however, contended that a Court-ordered (and enforceable) time table for a solution was required in light of HHS’ failure thus far to fix the problem. The Plaintiff proposed the following timetable for reduction of the backlog:

Physician Credentialing

October 21, 2016 | Little Health Law

Overview

Credentialing is used to evaluate physicians for different purposes and is required of almost all physicians. It is utilized by hospitals when evaluating physicians for medical staff positions and hospital privileges and when enrolling in health insurance plans as a participating provider. Unfortunately, this process has not been streamlined and can be very time consuming and complex.

Provider credentialing is meant to verify experience, expertise, and willingness to provide medical care. It is often a complex, ongoing process that can take several months to be completed and approved and is an administrative hassle for employers, insurance companies, and physicians. While credentialing was historically just proof of licensure, modern credentialing goes far beyond proof of diploma and license.

General Accounting Office Issues Findings Regarding Medicare Appeals Backlog

July 1, 2016 | Little Health Law

files Earlier this month, the United States General Accounting Office (GAO) issued its monthly anticipated report (the Report) to Congress about the status of the Medicare Appeals backlog. The Report states on the first page, “Opportunities Remain to Improve Appeals Process,” which is a gross understatement and will likely be received with frustration by unpaid providers. At least it appears the backlog is on Congress’ radar and someone is trying to do something to improve this very difficult problem that adversely impacts so many providers.