Tuesday, July 30, 2013

Proposed Payment Changes for
Medicare Home Health Agencies

The Centers for Medicare and Medicaid recently released a proposed rule involving 2014 payment changes for the Home Health Prospective Payment System. The rule projects that the changes could reduce Medicare payments to home health agencies by 1.5 percent. CMS estimates that 3.5 million beneficiaries currently receive home health services, costing Medicare approximately $18.2 billion in 2012, so a 1.5 percent reduction would be significant ($290 million, to be exact).

The proposed rule reduces reimbursement rates and proposes a number of other changes that will be discussed herein. Home health providers should become familiar with the rule and voice comments or concerns about it to CMS. Comments are due by August 26, 2013.

Friday, July 26, 2013

Sound Inpatient’s Unsound Practices
Lead to $14.5 Million Settlement

On July 3, 2013, the United States Department of Justice announced Sound Inpatient Physicians, Inc. will pay $14.5 million dollars to settle allegations that it over-billed Medicare and other federal health care programs. The Washington-based company employs more than 700 hospitalists and post-acute physicians in facilities in twenty-two states.

Under the whistleblower provisions of the False Claims Act, a former Sound Inpatient regional manager alleged the company was submitting evaluation and management (“E/M”) claims for reimbursement that were unsupported by medical documentation. The government then intervened; no surprise, considering that since January 2009, the Justice Department has recovered a total of more than $14.7 billion through False Claims Act cases.

Wednesday, July 17, 2013

Oxford Health Plans, LLC v. Sutter:
Don’t Forget to Read the Arbitration Provision

On June 10, 2013, the U.S. Supreme Court issued a decision confirming that payment disputes between a payor and its network providers may be resolved through group arbitration if allowed by the arbitrator, even if the use of class procedures is not expressly provided for in the agreement.

In Oxford Health Plans, LLC v. Sutter, John Sutter, a physician who provided medical services under a contract with Oxford Health Plans, sued Oxford on behalf of himself and a proposed class of other doctors alleging violation of the Oxford provider agreement and New Jersey state laws.  The Oxford provider agreement contained a binding arbitration provision so Oxford moved to compel arbitration of Sutter’s claims and the District Court agreed.

Monday, July 15, 2013

Hospitalist Billing Practices Under Scrutiny in
$14.5 Million False Claims Act Settlement

The United States Department of Justice recently announced a $14.5 million settlement with Sound Inpatient Physicians, Inc., ("Sound Inpatient"), a Tacoma, Washington-based hospitalist company. The settlement resulted from the government’s intervention in a qui tam lawsuit filed by a former Sound Inpatient regional manager, which alleged that Sound Inpatient violated the False Claims Act by submitting evaluation and management ("EM") claims for reimbursement that were not supported by adequate medical documentation.

Wednesday, July 10, 2013

The Preventing and Reducing Improper Medicare
and Medicaid Expenditures Act: Will Healthcare
Fraud Prevention Move to PRIME Time?

Members of the U.S. Senate and House of Representatives have introduced new legislation intended to further strengthen the effort to combat waste, fraud, and abuse in the government healthcare programs. The Preventing and Reducing Improper Medicare and Medicaid Expenditures Act ("PRIME") contains a number of provisions that would increase rewards and incentives for those who uncover healthcare fraud, as well as heighten penalties for those who commit it. PRIME would establish stronger fraud and waste prevention strategies within Medicare and Medicaid to help phase out the practice of "pay and chase," i.e., recouping monies already erroneously paid to providers instead of detecting problems on the front end. PRIME also would expand the fraud identification and reporting work of the Senior Medicare Patrol, and would take steps to help states identify and prevent Medicaid overpayments.

Squeezing Blood from a Turnip: Health Care
Reform & Kentucky’s Physician Shortage

Deloitte Consulting, a technology firm helping to establish the new Kentucky Health Benefit Exchange mandated by the Affordable Care Act, recently completed a review that paints quite a grim outlook for the future of healthcare in the Commonwealth. According to the review, Kentucky needs 3,790 additional physicians (including primary care doctors and specialists), 612 more dentists, 5,635 more registered nurses, 296 more physician assistants, and 269 more optometrists to meet current demand. The numbers are stunning on their own, but in light of healthcare reform and Medicaid expansion, they are downright staggering.

Friday, July 5, 2013

Employer Mandate Enforcement Delayed Until 2015

On July 2, 2013, the Obama Administration announced that enforcement of the employer mandate provision of the Affordable Care Act would be delayed until 2015, a year from its projected January 2014 start.

The mandate requires that businesses with 50 or more full-time equivalent employees provide affordable health insurance for those employees or pay penalties. The administration has been under substantial pressure to delay the mandate, in large part because employers are still struggling with understanding and implementing the provisions. Some small businesses had even considered reducing their workforces below the 50-employee threshold or cutting employee hours to escape penalties for not providing coverage.

Wednesday, July 3, 2013

Two Peas in a Pod: Licensing
Healthcare Facilities & Daycare Centers

Healthcare businesses are subject to complex rules and regulations, most of which are constantly changing. Providers of all types and sizes are constantly faced with licensure issues and compliance requirements. There are few industries as regulated as healthcare, but that is not to say that providers stand alone in the issues they face. In fact, one type of industry has a markedly similar oversight process: daycare centers.

In Kentucky, healthcare centers are inspected, monitored, licensed and certified by the Division of Health Care (“DHC”) within the Cabinet for Health and Family Services. DHC is responsible for investigating complaints against healthcare facilities, facility plans review and developing regulations. Also in the Cabinet for Health and Family Services is the Division of Regulated Child Care (“DRCC”). This division is responsible for licensing and investigating complaints against child daycare programs, residential child caring facilities and child-placing agencies.