Health law is the federal, state, and local law, rules, regulations and other jurisprudence among providers, payers and vendors to the healthcare industry and its patient and delivery of health care services; all with an emphasis on operations, regulatory and transactional legal issues.
Due to the increasing number of forms being required these days it is all too common for practices to get lost in the vast terminology, rules, and coding requirements that have to be followed as well. An area that practices have one of the most difficult times with is operationalizing the issuance of an ABN properly. I am frequently asked to consult for practices that ask who does which part, when, and with whom in regards to ABNs? In other instances, many practices I have worked with simply make the mistake that they can solve the complexities of trying to understand the nuances of how to properly utilize ABNs by deciding to issue ABNs to every Medicare patient for every service which is not a viable option either. The solution that many offices try that I just described is called issuing blanket ABNs, which in turn may cause Medicare to invalidate all issued ABNs from the practice, including those that may been appropriate which is why it is very important that blanket ABNs are never issued.
One thing in common with practices that issue ABNs in a proper manner is that they all have a process in place for identifying potential denied services prior to delivering them. To many practices this may sound easy, but to ensure that your practice is as effective as possible it will take some claims data analysis to ensure that your practice is capturing all potential opportunities for ABN issuance. The aim of this article will be to provide practices with 5 steps that will make ABN issuance easier. read more
The Office of Inspector General (OIG) and other Federal agencies charged with responsibility for enforcement of Federal law have emphasized the importance of voluntarily developed and implemented compliance plans. The government, especially the OIG, has a zero- tolerance policy towards fraud and abuse and uses its extensive statutory authority to reduce fraud in Medicare and other federally funded health care programs. The OIG believes that through a partnership with the private sector, significant reductions in fraud and abuse can be accomplished. Compliance plans offer a vehicle to achieve that goal. The OIG has provided a model compliance plan for clinical laboratories to assist laboratory providers in crafting and refining their own compliance plans.
The OIG suggests that the comprehensive compliance program should include the following elements:
Almost two years after “Operation Brace Yourself” regarding purported telemedicine and orthotic bracing fraud made national headlines, on February 4, 2021 the Department of Justice Announced that a major player in that fraud – Florida businesswoman Kelly Wolfe – recently pled guilty to criminal health care and tax fraud charges.
Operation Brace Yourself was a 2019 crackdown on the illegal use of telemarketing and telemedicine to generate fraudulent claims for DME orders, whose reach spanned continents and ultimate implications defrauded taxpayers out of billions of dollars.
According to the Department of Justice Press Release and Settlement Agreement, Mr. Wolfe was seemingly a significant mastermind in establishing hundreds of DME companies that went on to defraud US taxpayers and Medicare beneficiaries.
Here are some highlights of the recently signed Settlement Agreement between the United States DOJ, Kelly Wolfe and her company Regency, Inc. read more
On November 13, 2020 Centers for Medicare and Medicaid Services (CMS) announced that all Americans will have access to the COVID-19 vaccine at no cost. CMS has clearly communicated to private insurers, Medicaid programs and Medicare that it is their responsibility to cover the vaccine at no charge to beneficiaries. CMS states that Operation Warp Speed ensures that States, provider’s and health plans have the information and direction they need to ensure broad vaccine access and coverages for all. As a condition of receiving free COVID-19 vaccines from the federal government, providers will be prohibited from charging consumers for administration of the vaccine.
Beneficiaries with Medicare will not pay anything for the COVID-19 vaccine and their coinsurance/copayment and deductible amounts will be waived. In 2021, for Medicare Advantage beneficiaries, Medicare will pay directly for the vaccine and its administration for those enrolled in MA plans. MA plans are not responsible for reimbursing providers to administer the vaccine. MA beneficiaries do not pay for the vaccine and copayment/coinsurance and deductibles are waived. read more
Medicare’s DMEPOS Competitive Bidding Round 2021 is now in full effect as of January 1, 2021. (See previous articles about what CBID Round 2021 is all about).
DME providers either participated in the process with hopes of being awarded a bid, or they abstained from doing so. Of those who participated, with Medicare’s recent bid winner announcements, bid winners were happy and bid losers, well not so much – as only those providers awarded a contract could service a Medicare Part B beneficiary for competitively bid product(s) for patients residing in competitive bid areas (“CBA”).
Now what? What are the options for the relationships between ‘winners’ and ‘losers’ in moving forward, if any? Let’s briefly discuss subcontracting. read more
On January 1, 2021, every hospital in the United States (with very few exceptions) will be required to post clear, accessible pricing information online about the items and services they provide. These “standard charges” must be provided in two ways: first, as a comprehensive list of all items and services offered by the hospital in a machine readable format; and second, as a display of “shoppable services” in a consumer friendly format. According to CMS, the stated goal of the new rule is to empower patients “with the necessary information to make informed health care decisions.”
With the first requirement, the list must include gross charges, discounted cash prices, payor-specific negotiated charges, and de-identified minimum and maximum negotiated charges. The items and services covered are basically anything for which the hospital has established a standard charge, regardless of location or whether the item or service is provided on an inpatient or outpatient basis. These include, but are not limited to, supplies, surgical implants, procedures, room and board, and professional charges.
COVID-19 has affected all aspects of everyday life and healthcare rules and regulations are no exception. All areas of healthcare have been impacted, including the patient’s financial responsibility for healthcare services in the form of co-insurance, copays and deductibles. The waiver of a patient’s financial responsibility for healthcare services is regulated by federal and state law. The waiver of co-pays, co-insurance and deductibles has been deemed a violation of the federal Anti-Kickback statue. A provider who routinely waives the patient’s financial obligation may be violating the participating provider agreement with commercial carriers, state law and federal law with respect to Medicare beneficiaries. Waiving patient fees is seen as an inducement to the patient to prefer one provider over another for financial reasons. However, The Centers for Medicare and Medicaid Services (CMS) and commercial carriers have been authorized by the federal government to waive patient financial responsibility during the pandemic in order to encourage the public to get treated for COVID-19 and non-COVID medical conditions without fear of a hefty bill.
CMS has announced that it will resume Medicare Fee-For-Service (FFS) medical reviews August 3, 2020 regardless of the status of the COVID-19 public health emergency. These audits have been suspended since March 30 as a result of the crisis and applied to prepayment reviews and post-payment reviews conducted by Medicare Administrative Contractors (MAC). read more
On January 31, 2020 the US Department of Health and Human Services (“HHS”) declared a public health emergency surrounding the COVID-19 coronavirus pandemic, which was renewed again for a period of 90 days effective July 25, 2020.
In an attempt to focus on patients over paperwork and to remove obstacles from access to patient care, HHS relaxed or suspended certain healthcare provider requirements. Several such changes directly impact current or prospective providers of durable medical equipment (“DME”) to Medicare Part B beneficiaries.
Here’s a high-level breakdown of some of those changes: read more
On March 4, 2020, the Centers for Medicare & Medicaid Services (CMS) issued three Quality, Safety & Oversight Memoranda, all concerning the Coronavirus. According to these documents, effective immediately, the government will begin to focus its inspections exclusively on issues related to infection control and other serious health and safety threats. According to CMS Administrator Seema Verma, the memoranda should be seen as a “call to action across the healthcare system.” The goal of the guidance given in the memoranda is to continue to keep Americans safe and prevent the spread of the Coronavirus.
The first memorandum resets the focus of governmental surveys. The order of priority for government surveys will now be: