Archive for the ‘Medicare and Medicaid Reimbursement’ Category
Wednesday, January 24th, 2018
By Fisher, JD, CHC, CCEP
Authentication of Verbal Orders
In a past blog article, I discussed the need for physicians to promptly authenticate verbal orders. The failure of a physician to timely sign a verbal order can have reimbursement implications. In some cases, in some states, another responsible provider can sign a verbal order that is originally given by another practitioner. This option is not always available and depends a lot on whether state law permits the practice. Some states require the practitioner who gave the verbal order to authenticate the order. With the use of electronic medical records, practitioners cannot expect leniency on these types of requirements.
In states that permit one practitioner to authenticate for another, the authenticating proxy practitioner should understand that he or she is accepting responsibility for the authenticated verbal order. State scope of practice rules apply to cross authentication of orders. In otherwords, the practitioner authenticating the order must have practice authority to have provided the original verbal order. Facilities can develop policies that a more restrictive then what the law permits. Policy can eliminate or restrict cross authentication practices. There is inherent risk in permitting cross authentication because the authenticating provider did not give the original verbal order. Additionally, as
Read more here: Health Law Blog
Tags: Authentication, Physician Orders, Verbal Orders
Posted in Health Law Practice, Medicare and Medicaid Reimbursement, Physician Issues, Reimbursement Issues, Uncategorized, Wisconsin Health Laws, Wisconsin Physician Issues | Comments Off on Authentication of Verbal Orders by Other Responsible Practitioner
Wednesday, May 21st, 2014
By John Fisher, JD, CHC, CCEP
Private Reimbursement for Telemedicine – State Private Payment Mandates
Failure of private reimbursement sources is one significant factor that impedes the development of telemedicine. Some states have enacted laws that mandate some level of reimbursement for services provided by telemedicine. The American Telemedicine Association has reported that 8 additional states have introduced telemedicine reimbursement laws already in 2013. Those states include Florida, District of Columbia, Connecticut, Mississippi, Nebraska, Indiana, South Carolina, and New Mexico. Some of the listed states have introduced general requirements that telehealth be reimbursed without discrimination. Others have addressed more limited coverage . Read more on this topic in the blog article that I posted on the Health Law Blog.
Read more here: Telemdicine Private Reimbursement
Tags: Telemedicine Reimbursement
Posted in Medicare and Medicaid Reimbursement, Telemedicine, Uncategorized | Comments Off on Some States Mandate Telemedicine Private Reimbursement
Tuesday, May 20th, 2014
By John Fisher, JD, CHC, CCEP
How Broad is the Employee Exception
Parameters of the Stark Law and Anti-kickback Statute Exception
Both the Anti-Kickback Statute and the Stark Law contain exceptions that apply to employer/employee relationships. Recent developments in the health law area indicate that there may be limits on the employment exception that were not previously contemplated. I posted an article on the Health Law Blog that discussed possible limited to compensation structures for employed physicians.
Read more here: Health Law Blog
Tags: Employee Compensation, Employment Exception, Stark Law Exceptions, Wisconsin Health Law
Posted in Fraud and Abuse, Health Law Practice, Medicare and Medicaid Reimbursement, Stark Law and Anti-Kickback Issues, Uncategorized | Comments Off on Employment Exceptions From Anti-kickback Statute
Tuesday, April 8th, 2014
By John Fisher, JD, CHC, CCEP
Provider Self Disclosure Decisions – Voluntary Disclosure Process
The decision whether or not to voluntarily disclose to the government can be very difficult. Not every case is clear.
Clearly not every situation where there has been a billing error amounts to fraud or wrongdoing requiring use of the self-disclosure protocol. Many over-payments that are identified through audit can be dealt with at the intermediary level. Where investigation raises questions about whether incorrect bills are “knowingly” submitted, the self disclosure process may provide some mitigation of potential loss. Situations where the provider perhaps “should have known” raise more difficult issues of analysis.
The situation is also complicated because a potential whistle-blower may view a situation much differently than a provider who finds what it believes to be an innocent mistake through the audit process. A provider may sincerely believe that there was no “wrongdoing” and that a simple mistake has been identified. Finding such a mistake may actually be evidence that the provider’s compliance efforts are working. On the other hand, there is a whole legal profession out there now that is advertising for people to come forward with these types of mistakes. With potential recover under the False Claims Act of 3 times
Read more here: Health Law Blog
Tags: Medicare Overpayments, Overpayment, Self Disclosure
Posted in Compliance Issues, Fraud and Abuse, Medicare and Medicaid, Medicare and Medicaid Reimbursement | Comments Off on Voluntary Self Disclosure Decisions Can Be Complicated
Friday, February 14th, 2014
By John Fisher, JD, CHC, CCEP
Personal Care Service Providers – Wisconsin Medical Assistance
Wisconsin Statute § 49.45(42)(d)3 describes the types of organizations that qualify to receive Medicaid reimbursement for “personal care services.” Qualified entities include licensed home health agencies and other entities that are certified under section (2)(a)(11) to provide personal care services under section 49.46(2)(b)6j. The DHS does not appear to have implemented regulations that specifically describe the criteria that “other entities” must meet in order to become qualified to receive reimbursement from Medicaid for the provision of personal care services.
The applicable provisions of section 49.45(2)(a)(11) do not contain specific criteria that “other entities” must meet but simply refers to the requirement that DHS promulgate rules establishing qualifications of providers. The referenced statutory provision does not refer specifically to the requirements that “other entities” must meet in order to qualify to receive reimbursement for personal care services.
The requirements that must be met in order to become a licensed home health are more extensive than the personal care services entity. However, becoming licensed as a home health agency will qualify you to provide and bill for personal care services directly. It would also permit you to bill private pay patients for skilled nursing and other
Read more here: Health Law Blog
Tags: Home Health Agency, Personal care Agency, Wisconsin Long Term Care
Posted in Health Law Practice, Home Health, Long Term Care, Medicare and Medicaid, Medicare and Medicaid Reimbursement, Wisconsin Health Laws, Wisconsin Long Term Care | Comments Off on Personal Care Service Providers and Wisconsin Medicaid
Monday, May 27th, 2013
Payment Suspension – Moving Away from Pay and Chase
CMS now has the authority to suspend further payments to a provider following receipt of any “credible allegation of fraud.” Allegations are deemed to be credible when they have an “indication of reliability.” The allegation can come from a number of possible sources such as employee complaints, whistleblower claims, provider audits, false claims allegations, or virtually any other source as long as CMS deems the allegation to be credible. The suspension of payment may last up to eighteen (18) months or longer if a referral is made for further administrative action.
Suspension of payment is an extremely draconic remedy which can threaten the financial existence of some providers. The remedy is available even before there is solid proof that fraud has been committed. The possibility of having payment suspended is yet another reason for providers of all types to adopt sensible, scaled compliance programs. An effective compliance program is the provider’s best proactive defense to the potentially devastating impact of having payment suspended.
Tags: Fraud Remedies, Pay and Chase, Suspension of Payment
Posted in Compliance Issues, Health Care Legislation, Medicare and Medicaid, Medicare and Medicaid Reimbursement, Reimbursement Issues | Comments Off on Payment Suspension Fraud and Abuse – End To Pay and Chase
Monday, January 7th, 2013
Physicians can breathe a sigh of relief that their Medicare reimbursement will not be decreased for at least another year. The “fiscal cliff” legislation that was passed by Congress on New Year’s Day and signed by President Obama Wednesday night (January 2, 2013) averted the planned cut in Medicare payments for physicians that were scheduled to take place on January 1, 2013. The press has primarily focused on the income tax aspects of the American Taxpayer Relief Act of 2012. However, the legislation included several provisions relating to health care and the Medicare program, not the least of which was the “doc fix” provision that averted the “physician pay cut.”
Doc Fix – V-Blog Presentation
You can view our v-blog presentation in the Fiscal Cliff and the Doc Fix by clicking on the following link:
Fiscal_Cliff_Doc_Fix.
Note: Music provided under Creative Commons License: Op. 7, No. 2 – The Rooms in Cerro Concepción by Tom Fahy
For coverage of additional health care provisions that were contained in the Fiscal Cliff Legislation, view our more recent blog post.
Health Care – Fiscal Cliff
Tags: Doc Fix, Fiscal Cliff, Medicare Reimbursement, Physician Fee Schedule, Physician Pay Cut
Posted in Medicare and Medicaid Reimbursement, Wisconsin Health Laws, Wisconsin Physician Issues | Comments Off on Physician Pay Cut Averted By Doc Fix in the Fiscal Cliff Legislation
Wednesday, August 1st, 2012
CMS Announces Skilled Nursing Facility PPS Rates for 2013
On July 27, 2012, the Centers for Medicare & Medicaid Services announced PPS increases for skilled nursing facilities for fiscal year 2013. Skilled nursing facilities will receive a 2.5% market basket update which will be reduced by a 0.7% productivity adjustment.
The rate incorporates adjustments for facility case mix. The RUG-IV case-mix classification system provides urban facilities with a 1.9% update and rural facilities with a 1.5% update.
A net Medicare prospective payment system increase of 1.8% ($670 million) will be provided to skilled nursing facilities in fiscal year 2013.
Access the announcement from CMS.
Tags: Medicare Reimbursement, Prospective Payment System, Skilled Nursing Facilities
Posted in Medicare and Medicaid Reimbursement, Wisconsin Long Term Care | Comments Off on 2013 Skilled Nursing Facility PPS Rates Announced By CMS