In recent years, many Medicare providers who have received significant overpayment determinations from Medicare contractors have gone out of business while waiting to be heard before an Administrative Law Judge (ALJ) for a hearing. That is the result of 2 factors. The first is that there is currently a 3-5 year backlog of appeals waiting … Continue Reading
For years, CMS has had the authority to refuse to enroll new Medicare providers if they or their owners have an unpaid Medicare overpayment, but CMS was not exercising this authority. Now, it appears that CMS is going to start. In January, CMS published Transmittal 1998 announcing that it intends to begin denying provider enrollment … Continue Reading
Big news for home health agencies and others whose business comes from referral sources: the Florida Supreme Court just held that referral sources are the kind of protectable business interest that will support a non-compete agreement. Home health agencies, like other health care businesses, routinely use non-compete agreements to prevent marketing employees from leaving and … Continue Reading
MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) is bi-partisan legislation that was enacted to change Medicare reimbursement from being based on the current system of volume of services provided to reimbursement based on the quality of care, as well as value and participation in alternative payment and delivery models. MACRA replaces the … Continue Reading
Healthcare providers of all kinds, as well as medical equipment suppliers, have traditionally relied upon discounts as a legitimate means of attracting patients and commercial clients without running afoul of the federal anti-kickback statute (AKS). Congress specifically created the discount “safe harbor” to the AKS years ago based on its policy of encouraging discounts that … Continue Reading
Universal Health Services, Inc. v U.S. ex rel. Escobar On June 16, 2016, the U.S. Supreme Court in Universal Health Servs., Inc. v. United States ex rel Escobar, No. 13-317, — S. Ct. — (June 16, 2016), confirmed that the implied certification theory may serve as a basis for liability under the False Claims Act … Continue Reading
A win for efficiency: The AHA suit may force shorter adjudication times for Medicare administrative appeals. In 2014, the American Hospital Association (AHA), along with three hospital systems, filed suit against the U.S. Department of Health and Human services, alleging that the lengthy adjudication time for administrative appeals of Medicare claim denials caused severe economic … Continue Reading
Four years after publication of its proposed rule related to reporting and returning overpayments within 60 days, CMS has issued a final rule that responds to comments and provides greater clarity. The published rule is under the Affordable Care Act requirement that providers report Medicare and Medicaid overpayments and return the overpayment within 60 days … Continue Reading
Florida law makers have decided it is high time to stop allowing addiction recovery residences to operate without regulatory oversight. In its last session, the Florida Legislature passed a new law (CS/CS/HB 21) requiring that the Department of Children and Families (DCF) create a voluntary certification program for substance abuse recovery residences, as well as … Continue Reading
In a Fraud Alert issued on June 9, 2015, the U.S. Department of Health and Human Services Office of Inspector General (OIG) notified the healthcare community that physician compensation arrangements are on the OIG’s radar screen. While many physician compensation arrangements may be legitimate, the OIG has noted that “a compensation arrangement may violate the … Continue Reading
Members of healthcare governing boards now have direction from the OIG as to what is expected of them as they oversee the regulatory compliance of their organizations. And the good news is that the board members don’t have to leaf through 200 pages of regulations in the Federal Register to find the answer. The new … Continue Reading
A federal court in New Jersey has permitted a defendant in a False Claims case to defend itself on the grounds that the whistleblower/ex-employees breached their employment agreements by using and disclosing confidential company information. The Defendant, Boston Scientific Neuromodulation Corp. (“Boston Scientific”) is a medical device manufacturer. While in Boston Scientific’s employ, the whistleblowers … Continue Reading
On June 25, 2014, the U.S. Department of Health and Human Services Office of Inspector General (OIG) issued a Special Fraud Alert entitled “Laboratory Payments to Referring Physicians.” While the Alert breaks no new ground (see, e.g., its 1994 Special Fraud Alert), it demonstrates the OIG’s continuing concerns about clinical laboratories’ offering inducements to referring … Continue Reading
Providers on prepayment review could be facing exclusion from Federal healthcare programs if they don’t correct the problems which caused them to be subject to prepayment review. CMS has directed its contractors to consider excluding physicians and other providers who have been on prepayment review for extended periods of time without correcting their “inappropriate behavior” … Continue Reading
Late last week, the IRS issued proposed rules intended to ease the reporting requirements that employers will face once the “employer-mandate” portion of the Affordable Care Act (“ACA”) becomes effective in 2015. The employer-mandate requires that employers with 50 or more full-time employees offer health coverage to those employees or pay a fine. If employers … Continue Reading
Physicians and Durable Medical Equipment (DME) suppliers need to be aware that, effective July 1, 2013, and to be enforced as of October 1, 2013, Medicare requires a physician/patient face-to-face encounter within 6 months prior to the physicians order for an item on an extensive DME list. This type of face-to-face encounter has been required … Continue Reading
For years now, ancillary providers ranging from durable medical equipment providers (DMEs), independent diagnostic testing facilities (IDTFs), and home health agencies have been required under Medicare regulations to obtain copies of referring physicians’ medical records to prove medical necessity for the items and services the physician ordered. Providers are to utilize a template “Dear Physician” … Continue Reading
In January, a Federal District Court in Oklahoma issued a ruling in favor of a former marketing representative of a medical equipment distributor. The Court determined that Gary Weaver was, in fact, engaged on an independent contractor basis, not as an employee, and therefore his employment agreement with Joint Technology, Inc. was an unenforceable illegal … Continue Reading
