Susan St. John

Attorney

About me

“I love the law and assisting clients with their business needs: putting together “the deal” and preparing documents related to a client’s transactions necessary to achieve his or her vision

Want to know more?

Recent articles

View My Resume Read reviews Email me

So, you’ve received a letter from the Zone Program Integrity Contractor or “ZPIC” to review for the accuracy and justification of services reimbursed by the Medicare program. Now What?!

First, remain calm. Chances are an audit by ZPIC will go well if you have been diligent in completing patients’ medical records, justifying medical necessity, and your billing is accurate and well supported by the patients’ medical records. Even if errors are discovered, most errors do not represent fraud, that is, the errors were not committed knowingly, willfully and intentionally. Still, a ZPIC audit can be daunting and if Medicare has noticed a pattern of billing that it considers suspect, or there has been a complaint against you, the ZPIC audit will be rigorous, and often adversarial. The ZPIC’s job is to protect the program from potential fraud. It will conduct data analysis, including statistical outliers within a well-defined group, or other analysis to detect patterns within claims or groups of claims that might suggest improper billing. Data analysis can be undertaken as part of a general review of claims pre or post submission, or in response to information about specific problems arising from complaints, provider or beneficiary input, fraud alerts, CMS reports, Medicare Area Contractors, or independent governmental or nongovernmental agencies. Read on

DME Compliance Alert: Department of Health and Human Services, Office of Inspector General, updated its work plan in January 2018 to include heightened scrutiny of off-the-shelf orthotic devices, specifically back braces for HCPCS Cods L0648, L0650 and L1833 due to one MAC identifying improper payment rates as high as 79 to 91 percent. Of specific concern is the lack of documentation of medical necessity, including Medicare beneficiaries being prescribed back braceswithout an encounter with the referring physician within 12 months prior to an orthotic claim being filed. The OIG plans to analyze billing trends nationwide, and expects to issue a report sometime in 2019.

Read on

So you are considering starting a home medical equipment aka durable medical equipment (HME or DME) business to provide products and services to patients in Florida (and perhaps in other states, but that’s a topic for another day). In addition to deciding what products and/or services you are going to provide and your physical location, there a few things you need to know, steps to be taken, and information to be collected, to apply for an HME/DME license in Florida to get up and going.

THE BASICS

Florida defines an HME provider as “any person or entity that sells or rents or offers to sell or rent to or for consumers, any HME and service or HME that requires HME services.” Section 400.925(7), Florida Statutes. Further, HME “includes any product as defined by the Food and Drug Administration’s Federal Food, Drug, and Cosmetic Act, any products reimbursed under the Medicare Part B Durable Medical Equipment benefits, or any products reimbursed under the Florida Medicaid durable medical equipment program. HME includes oxygen and related respiratory equipment; manual, motorized, or customized wheelchairs and related seating and positioning, but does not include prosthetics or orthotics or any splints, braces, or aids custom fabricated by a licensed health care practitioner; motorized scooters; personal transfer systems; and specialty beds, for use by a person with a medical need.” Section 400.925(6), Florida Statutes.

Read on

Providing telehealth services can be a worthy compliment to your practice; however, caution should be exercised before entering into a contractual relationship with a telehealth company. Keep in mind, when a telehealth company touts itself as “HIPAA compliant,” this is only one area where it must maintain compliance. It, along with the telehealth contract, must also be complaint with federal and/or state laws for furnishing telehealth services.

Read on

adminSusan St. John