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The Five Levels of The Medicare Appeal Process

May 11th, 2021 by

medicare appeals pricessBy: Zach Simpson

There might be times when Medicare denies coverage for an item, service, or test that you or your company provided. In the event this occurs you have the right to formally disagree wit the decision and encourage Medicare to change it. Therefore, understanding the appeals process for Medicare claims is vital for all providers. The aim of this article is to give providers a better understanding of the five (5) levels of the Medicare Appeal process, and what must occur at each level.

The Medicare Fee-For-Service (FFS) has five levels in the claims appeal process:

Level 1 – Redetermination by a Medicare Administrative Contractor (MAC)

Level 2 – Reconsideration by a Qualified Independent Contractor (QIC)

Level 3 – Disposition by Office of Medicare Hearings and Appeals (OMHA)

Level 4 – Review by the Medicare Appeals Council (Council)

Level 5 – Judicial review in U.S. District Court read more

6 Essential Questions For Audit Preparedness

May 5th, 2021 by

medical practice auditBy: Zach Simpson

As you train your staff on the changes that were recently made regarding evaluation and management coding it is very important to ensure that your staff understands the auditor’s perspective as well. There are four distinct portions of an auditor’s tool when evaluating the documentation guidelines for office/outpatient evaluation and management (E/M) services (99202-99215). The four distinct portions are diagnoses, data, risk, and calculation of medical decision making (MDM).  In order to ensure that a provider’s progress note is complete in the auditor’s eyes the provider should ask themselves the following six questions to create the best chances of successfully meeting the auditors expectations:

  1. Does my progress note contain a medically appropriate history and examination?
  2. Were my diagnoses addressed appropriately?
  3. Did I document all orders and data reviewed?
  4. Were other professionals included in my documentation that I worked with?
  5. Was an independent historian used?
  6. Does the documentation support the level of risk I chose?

For the remainder of the article, I am going to dive deeper into each question above so that you, as providers are able to recognize insufficient areas in a provider’s E/M documentation when you perform a self audit to better your practice. read more

Permissible Payments For Referrals Under The Federal Anti Kickback Statute

April 28th, 2021 by

anti kickbackBy: Karen Davila

The term “payment for referral” strikes fear in the hearts of health care providers throughout the country because of the significant prohibitions under the federal Anti-Kickback Statute (AKS).  And, Florida’s Patient Brokering Act (PBA) casts an even bigger shadow over arrangements involving payment in exchange for referrals.  There are other statutory restrictions as well, which may apply depending upon the services for which a referral is being made.  Those include but are not limited to statutes prohibiting physician fee-splitting and the federal Eliminating Kickbacks in Recovery Act (EKRA) (applicable to referrals to recovery homes, clinical treatment facilities, or laboratories in an effort to stave off growing opioid-related fraud), and the potential collateral damage of a false claim under the federal False Claims Act (FCA) if any of the above statutes are violated.

So, is there any scenario where a payment may be made by a health care provider in exchange for referrals?  The answer is yes- there is a safe harbor under the AKS (42 U.S. C. §1320a-7b(b)) specifically for such arrangements.  This safe harbor is not commonly used and likely means revision to existing arrangements to come into compliance with its specific requirements.  But it may be worth considering if the referral (and payment for that referral) is not otherwise prohibited as noted above. read more

Drug Waste A Big Money Issue & How Providers Can Recoup The Cost of Unused Drugs on Medicare Part B Claims

April 21st, 2021 by

drug wasteBy: Zach Simpson

In today’s practices there are many circumstances that call for the discarding of unused portion of drugs, and because of this drug waste can be a big-money issue for many practices. A perfect example is Botox which must be used within five hours of reconstitution, and if it is not used within that timeframe the only option a provider has is to discard the unused supply. What many providers may not be aware of though is that money can be recouped for drugs that have been discarded. The aim of this article is to educate providers that when applicable they may report drug waste in addition to the drug and its administration for Medicare Part B claim reimbursement.

How to Properly Report

For a provider to recoup and report the drug waste they must report the administered drug using the appropriate HCPCS Level II supply code, and the correct number of units in box24D of the CMS-1500 form. As a second line-item providers will want to enter all of the wasted units. It is very important to ensure that the provider documentation verifies the exact dosage of the drug injected, and the exact amount of and any reason for waste. Be aware If the provider did not assume the cost of the drug or administer the drug to the patient they may not bill for the unused portion.

In addition to listing the wasted units as a second line-item certain local contractors may require you to use the modifier JW Drug amount discarded/not administered to any patient to identify an unused drug from single-use vials or single-use packages that are appropriately discarded. Be aware that is inappropriate to use the modifier JW with an unlisted drug code. Therefore, it is imperative to be aware of the local contractor requirements, and appropriate drug codes. read more

3 Ways a Florida Medical License Attorney Can Save Your Practice

April 9th, 2021 by

Chances are, you hope you’ll never need the help of a Florida medical license lawyer. You just want to serve your patients with dignity and honor, without ever taking a break to deal with a lawsuit or legal complaint.

Unfortunately, even with the best Florida physician malpractice insurance program available, you may need legal help to save your business.

Here are just three ways in which a Florida medical license lawyer could help you:

1. Prevent Common Problems

Medical errors are unfortunately common. More than 250,000 deaths due to medical errors happen in the United States each year. Some aren’t preventable, but others are.

You may experience moments of uncertainty, where a choice could cause an error. A Florida medical license attorney might help if you’re dealing with:

  • Contract issues. Are you working long hours with no breaks? Is a lack of sleep impacting your work?
  • Interpersonal problems. Is workplace harassment impacting your ability to care for patients?
  • Licensing concerns. Are you able to attend continuing education classes to stay abreast of the latest developments?

Addressing any of these issues could keep common malpractice issues from occurring.

2. Represent Your Interests in Court

If you are facing a case, you’ll need a Florida medical license attorney more than ever. The consequences can be severe.

For example, one Florida pharmacist faced penalties of up to 20 years in prison and a $250,000 fine. A lawyer could help defend you in a case like this and ensure you’re not punished for something you just didn’t do.

3. Clear Your Name

Plenty of websites allow consumers to search for malpractice claims against doctors. Presumably, the sites allow these patients to get better, safer care. As a doctor, they can ruin your reputation.

A talented medical license lawyer can work hard to defend your good name, so a frivolous lawsuit won’t stall your practice for a lifetime.

At Florida Healthcare Law Firm, we have a team of talented lawyers waiting to help you. Contact us to find out more.

A Quick Refresher On Medicare’s Requirements For Self-Reporting & Returning Overpayments

April 8th, 2021 by

By: Zach Simpson

With the current healthcare environment many providers looked to alternative methods of treating patients and achieving outcomes this past year due to the pandemic. To meet the needs of their patients, and their financial obligations many providers implemented services that were not customary to their practice, or their billing departments. As is the case for any office that begins to provide something new there is always the potential for error in any aspect of the practice involved with the patient or claim. Therefore, I believe it is a great time to refresh providers on the procedures for reporting and returning Medicare overpayments as they are discovered moving forward.

As many of you are aware in 2016 the Centers for Medicare and Medicaid Services (CMS) published a final rue pursuant to Section 1128J(d) of the Social Security Act (the Act), as amended by the Affordable Care Act, that requires Medicare Parts A and B health care providers to report and return overpayments 60 days after the date an overpayment is identified, or the due date of any corresponding cost report, if applicable, whichever is later. If credible information indicates that an overpayment exists, the rule requires that a reasonably diligent inquiry must be performed.

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5 Easy Steps To Implement An ABN Into Your Practice’s Standard Procedures

April 7th, 2021 by

adding abn to your medical practiceBy: Zach Simpson

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

Can I Provide in-home or mobile IV Therapy?

March 24th, 2021 by

By: Chase Howard

IV hydration therapy has many applications and purposes. In the most common cases, the purpose is for post-surgery recovery or wellness optimization. IV therapy businesses that want to offer a more concierge type of service by offering mobile or in-home services, need to be aware of Florida home health agency laws and regulations.

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PLLC v. LLC: What’s The Difference?

March 24th, 2021 by

healthcare business llcBy: Chase Howard

In most cases, the limited liability company, or LLC, is the preferred business structure for a wide variety of healthcare businesses. If you’re a licensed professional, you can also use the professional limited liability company, or PLLC for your healthcare practice or business. While generally these two entity types are the same, there’s a small difference to be aware of when organizing the company.

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FMV (Fair Market Valuation) Heads Up

February 26th, 2021 by

By: Jeff Cohen

FMVs are at the heart of healthcare regulatory compliance when money or anything of value changes hands in a healthcare business setting.  Why?  Two reasons:

  1. Healthcare laws (Stark, the Anti Kickback Statute and the Patient Brokering Act) all target money changing hands in the healthcare business space; and
  2. There are clear exemptions and exceptions that have as an essential ingredient that the compensation (or pricing) is consistent with “fair market value.”

How it Goes—A Six Part Process

Locking down an externally performed FMV (part of the “gold standard” in regulatory compliance) is a process.  Here’s what it should look like:

Step 1.  The healthcare business person or his/her advisors (often accountants) find someone who specializes in performing FMVs for the specific matter (e.g. compensation, price of a business to be acquired);

Step 2.  The LAWYER for the healthcare business is immediately involved in the process BEFORE the FMV firm is engaged;

Step 3.  The LAWYER engages the FMV firm on behalf of the healthcare business client;

Step 4.  The parties (including the lawyer) get on the phone or in a meeting with the “FMV guy” and has a very extensive conversation re the project;

Step 5.  Once the FMV process done, a DRAFT FMV study is prepared and discussed interactively with the healthcare business and the lawyer;

Step 6.  Once finalized, an execution copy is prepared and provided to the lawyer. read more