Archive for the ‘Medicare and Medicaid Reimbursement’ Category

Some States Mandate Telemedicine Private Reimbursement

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

  

Employment Exceptions From Anti-kickback Statute

Tuesday, May 20th, 2014

By John Fisher, JD, CHC, CCEP

employment exception safe harbor regulations

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

  

Voluntary Self Disclosure Decisions Can Be Complicated

Tuesday, April 8th, 2014

By John Fisher, JD, CHC, CCEP

OIG Self Disclosure Decisions

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

  

Personal Care Service Providers and Wisconsin Medicaid

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

  

Payment Suspension Fraud and Abuse – End To Pay and Chase

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.

Physician Pay Cut Averted By Doc Fix in the Fiscal Cliff Legislation

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

Op. 7, No. 2 – The Rooms in Cerro Concepción (Tom Fahy) / CC BY-SA 3.0
 
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

2013 Skilled Nursing Facility PPS Rates Announced By CMS

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.