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.
The U.S. Attorney arrested 13 people in a $100 Million healthcare fraud scheme in NY and NJ involving automobile insurance claims. Some of the facts alleged include—
Bribed 911 operators and hospital employees for confidential information of insured drivers
Unnecessary and painful medical procedures
A non-physician owning medical clinics
Paying hundreds of thousand of dollars to “runners” who used the money to bribe people
Healthcare businesses that largely serve people injured in motor vehicle accidents remain a top tier focus for law enforcement and special investigative units (SIUs) of insurers. But so do many other providers in the healthcare sector, such as pharmacies, durable medical equipment (DME) providers, addiction treatment providers and labs. Payer and governmental presumption is often that financial motives are driving clinical behavior, NOT documented medical necessity. Hence the need for active compliance plans and policies and procedures that don’t sit on a shelf, but rather are woven into daily business and clinical operations. Nothing less than the right contracts, the right compliance plan and the right business culture will establish and maintain a sustainable healthcare business!
On November 8, 2021, The Department of Health & Human Services (HHS), Office of Inspector General (OIG) released a revised and renamed Provider Self-Disclosure Protocol (SDP), now known as the “Health Care Fraud Self Disclosure “protocol. The SDP was created in 1998, and the protocol can be used to voluntarily identify, disclose and resolve instances of potential fraud involving federal healthcare programs. As described on the OIG website, “Self-disclosures give persons the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation.” read more
More and more seniors are finding safety and security in continuing care communities (CCCs) throughout the country. And, while they want the increased safety and security, they do not want to lose their independence. Aging in place and maintaining that independence often involves the use of various personal service providers (PSPs) who come onto the CCC campus and create new risks. PSPs go by many names and perform many functions, including housekeeping, meal preparation, assistance with activities of daily living (bathing, grooming, eating), grocery shopping, dog walking, and driving the resident to various offsite appointments. read more
It should come as no surprise that the federal government has decided to delay enforcement of the No Surprises Act. So although the Act will still take effect on January 1, 2022, the government will not enforce certain provisions of the law until applicable rules are in place. This will hopefully allow the providers, and the government, time to figure out the best way to comply with the law.
The most difficult provision of the No Surprises Act will likely be the “good faith estimate” requirement. Under the law, when an individual provider or facility schedules a patient for services, they will be required to gather information about the patient’s payor status. If the patient has insurance, the provider/facility must send a good faith estimate of the expected charges, billing and diagnostic codes to the insurer. If the patient is uninsured, that information must be given to the patient. read more
There are very strict rules and regulations in place for any business working in a lab, both to protect the healthcare professionals working in that lab and the clients and customers the lab serves.
To make sure that your company is in compliance with these laws, it is recommended to hire a laboratory compliance specialist to double check the details and make sure that all processes are up to code.
What Is Laboratory Compliance?
Laboratory compliance is an ongoing effort put forth by healthcare businesses to ensure that they are up-to-date on all licensing and regulatory requirements.
State, local, and federal agencies may require compliance with a long list of ever-changing rules and directives. It is the responsibility of the business to maintain awareness of those regulations and to ensure that they are operating according to standards and providing proof of that when necessary.
Laboratory Compliance Specialist Definition
When it comes to maintaining laboratory compliance, a laboratory compliance specialist is essential. Sometimes called compliance officers, these professionals are responsible for keeping up with the latest changes and requirements and making sure that the company is doing everything they need to do.
This doesn’t just mean coming in once a year to check that everything is in compliance or responding when there is a violation. It means creating a compliance program that includes policies, processes, and procedures that ensure continual compliance.
Additionally, if there is an audit, investigation, or suspicion of a violation, the laboratory compliance specialist will dive into the problem, handle whatever results from the audit, and adjust policies and procedures accordingly.
Does Your Healthcare Business Need a Laboratory Compliance Plan?
Learn more about how laboratory compliance can impact your healthcare business legally and create a laboratory compliance plan that will protect you in court when you call Florida Healthcare Law Firm now.
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:
Regulatory compliance audits can help you head off lawsuits before they get started. Learn how to set a schedule based on your organization’s unique risks and benefits, and let trained legal counsel help you.
As a healthcare executive, it’s your job to craft policies that protect your patients, your staff, and your community. Regulatory compliance audits help you do your work effectively. But if you dread them, you’re not alone.
It’s not uncommon for organizations to postpone and delay compliance work. No one likes the hassle. But a healthcare practice attorney could help you both set up an audit schedule and complete your tasks with ease.
When Is a Regulatory Compliance Audit Required?
Every healthcare organization faces a unique set of compliance risks. It’s critical for you to understand your environment intimately and design your audit schedule accordingly.
Typically, regulatory compliance audits are performed:
On a schedule. If your organization is large and includes plenty of service lines, you’ll need to assess risks more frequently than a smaller, targeted organization.
After an issue is detected. Some healthcare legislation requires proof that you’ve learned from your mistakes. If a compliance problem appears, an audit can help you determine how it happened and what you can do to prevent the next issue.
After hefty staff turnover. Everyone on your team must understand how the rules work and why they are important. That’s not always easy for health professionals. Attorney support can be critical.
Your schedule may change as your organization grows or shrinks. And you may need more audits one year than another. Flexibility is critical.
Why Do Healthcare Practice Attorneys Perform Audits?
If you’re a do-it-yourself executive, the thought of hiring someone to help you achieve compliance may seem unusual or strange. But the benefits are both real and plentiful.
Expertise. The rules and regulations you must follow can be hard to both read and understand. Healthcare practice attorneys specialize in these sorts of documents, and they can explain them to you quickly and carefully.
Impartiality. It’s easy to make excuses for your employees (and yourself). Professionals can look over your records dispassionately, so you can make smart decisions.
At Florida Healthcare Law Firm, we specialize in regulatory compliance audits. Our healthcare practice attorneys can walk you through the laws and help you stay on the right side of the law. Contact us to find out more about how these audits work and how you can get started.
Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988. CLIA established quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test was performed. In 2003, the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) published the CLIA Quality Systems laboratory regulations. The quality system approach includes a laboratory’s policies, processes, procedures, and resources needed to obtain consistent, high quality testing services.
The laboratory must be under the direction of a qualified person and that person must fulfill all responsibilities of the lab director as outlined by CLIA. CLIA prohibits a laboratory director from directing more than five non-waived laboratories. Some states may have additional restrictions regarding the number of labs the lab director can direct. The lab director must meet education and experience requirements to hold the position and meet all requirements of the position. The responsibilities include ensuring that there are sufficient personnel with adequate experience and training and make sure that every position in the lab is staffed by a person who is qualified to have the position and can perform all tasks required of the position. read more
You do everything right. You’re careful to dot your i’s and cross your t’s. Compliance is hard-wired because you’re in an industry that’s highly regulated and you’ve built into your operations a series of compliance checks and balances. However, even with strong controls in place, compliance efforts sometimes fall short– and whether you’re a physician group, a pharmacy, a durable medical equipment company, a home health agency, or any other health care provider, someday you might find yourself face-to-face with law enforcement officials or regulatory enforcement authorities. What do you do? How do you assure the most successful outcome with minimal business disruption?
Compliance is the foundation to mitigating the risks inherent in any health care operation. Compliance can reduce the likelihood that regulators or law enforcement suddenly appear on your doorstep. But preparation for emergencies and uncertainties is the key to reducing the risk that non-compliance leads to lengthy business interruption. Although you may be saying “if”, you really should be thinking and acting more like “when”. It costs everything to be ill-prepared and it costs very little to be well-prepared. The following preparation can prevent much of the uncertainty that arises in these cases.
POLICIES AND PROCEDURES
First and foremost, make sure you have well-developed policies and procedures for what to do in such instances. You should review these policies and procedures with your employees regularly, focusing on the importance of compliance. Out of fear and uncertainty, employees can do things that create unnecessary challenges. Educating them as to what their rights and responsibilities are will mitigate those risks. Make sure your policies and procedures include the designation of who is in charge (“person in charge”) when the government does show up. read more
Pharmacies and their pharmacists are in a very tough spot in the current regulatory enforcement environment. This is particularly true with dispensing controlled substances. Headlines like the below are commonplace:
DEA RAIDS PHARMACY AS PART OF LOCAL DRUG SWEEP
PHARMACY PAYS $500,000 IN PENALTIES FOR CONTROLLED SUBSTANCES ACT VIOLATIONS
MAN ARRESTED USING DOCTOR’S PRESCRIPTION PAD TO WRITE FRAUDULENT RX’S
So, how do you avoid filling a fraudulent prescription for controlled substances? Before getting into the nitty gritty, it is important to lay the foundation of standard of care and the corresponding responsibility so pharmacies and pharmacists can evaluate what steps are most likely to mitigate these risks.
As background, federal law states that the primary responsibility for prescribing controlled substances rests with the prescriber. However, that same law places a “corresponding responsibility” on the pharmacist to assure each prescription is written for a legitimate medical purpose pursuant to a valid patient-prescriber relationship. 21 CFR §1306.04(a).
Under Florida law:
A pharmacist may not dispense a Schedule II-IV controlled substance to any patient or patient’s agent without first determining, in the exercise of her or his professional judgment, that the prescription is valid. F.S. §893.04 (2)(a).
A prescriber or dispenser must consult the prescription drug monitoring system, eForce, to review a patient’s controlled substance dispensing history before prescribing or dispensing a controlled substance.S. §893.055
Once you have a clear understanding of a pharmacist’s liability, you can then consider ways to mitigate the inherent risks in filling controlled substance prescriptions. read more