No Surprise Act AKA Good Faith Estimates

The Centers for Medicare & Medicaid Services (“CMS”) effective January 1, 2022 has ramped up the new No Surprise Act (“NSA”) or often called the “Good Faith Law”. This law shall apply to group health plans, health insurers, health care providers and health care facilities (“Providers”). The NSA requires health care providers to be proactive and reactive as it relates to providing patients who are self-pay or shall receive out-of-network bills from their health insurance a pre-bill outlining the services they are intending to receive and could potentially receive.

Self-Pay

Self-Pay patients apply to a wide range of medical providers; therefore, the importance of this law is crucial for providers accepting cash patients. The provider will be required to transmit to patients itemized disclosures of the services offered at the facility, these disclosures are called “Good Faith Estimates”. A Good Faith Estimate will include various detailed terms that a patient must have upon request, or a provider will be required to inform a patient that said estimate is available to them when inquiring about services. The disclosure will be required at the front desk and on the providers website.

Out-of-Network

If a provider treats patients who have insurance coverage and is not in network with said insurance plan, the provider is subject to and will have to abide by the NSA.

The driving complaint by patients that lead to the institution of the NSA was surprise medical bills, which are essentially caused by balance billing. Balance billing occurs when a provider bills an amount or difference not covered by an insurance plan. Under the NSA, providers will have to implement the proper disclosure requirement of this practice, which must be presented to patients prior to the treatment. Providers will be required to obtain notice and consent forms signed by patients authorizing any additional billing not covered by the out-of-network coverage prior to providing said treatment.

Does Not Apply To

The NSA will not apply to vision or dental insurance plans which are solitary plans. However, if the vision and dental is an added benefit to a health plan it will be covered. The NSA will not apply to balance billing practices for those in the ground ambulance business. Providers who service Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE shall not apply to NSA.

Penalties for Non-Compliance

A patient shall be allowed to dispute any bill charge in excess of $400 personally or through an independent third party, a “dispute resolution entity”, which shall determine the amount owed by the patient. An email shall be sent to the provider stating that a dispute has arisen, and the provider will be required to upload certain documentation surrounding the dispute. During a dispute resolution period, providers will not be allowed to move the bill into collection or threaten collection, if collection is already ongoing it shall be paused, late fees on the unpaid bill shall not be collectable, and any threats of retaliation against the disputing patient shall not be permitted. However, providers shall have the option to settle the claim with a patient directly abiding by the above, upon executing a settlement form. Failure to adhere to the NSA shall result in penalties up to $10,000 per violation.

Understanding the Termination Upon Death or Disability Clause in Your Lease

So what exactly does a death and disability clause do? It protects you, your family and/or your estate from liability under your lease in the event of your death or disability. It allows you or the entity through which you lease space (the “tenant”) to be relieved of all obligations under the lease. Without including such language, the tenant will remain obligated to perform all the terms under the lease, including, for example, paying monthly rent and common area maintenance expenses.

Remaining obligated under the lease can cause undue hardship. For example, if you are your medical practice’s sole provider and you become disabled or your practice loses a critical employee due to death, your practice won’t make money, as the practice can’t see and treat patients.

Of course, landlords aren’t the biggest fans of death and disability clauses because such clauses don’t benefit them. Even in the case where a landlord allows for a death and disability clause, it likely will come with conditions. For example, a landlord may require you or your estate to pay for costs associated with reletting the leased space and pay rent until a new tenant leases the space. Or, if the landlord funds your tenant improvements and they are of a significant amount, the landlord may require a hefty termination fee upon your death or disability to recoup those improvements costs.

If your landlord refuses to allow for a death and disability clause, it’s important to have a plan that comes into play upon your death or disability. That may be by having an arrangement in place where you or your estate sells your practice and the lease transfers to the buyer. In such a case, it’s important to have language in the lease that expressly allows for such a transfer.

Article by: Amanda Howard

Protecting Your Medical Staff Privileges from Adverse Action

Ever consider why the ability to practice at a hospital is considered a “privilege” and not a “right”?  That is because the hospital granting those privileges has broad discretion to grant, modify, suspend, or revoke those privileges.  They are privileges, not rights, because the hospital has a duty protect itself and its staff and patients from the risks of the willful or negligent act of is medical staff.  The granting or refusal of privileges is therefore a duty of the hospital.  If the hospital fails to carry out that duty in an appropriate manner, it can be subject to liability for negligent credentialing.  Because of this, the hospital’s actions in granting, modifying, suspending, or revoking privileges receive deferential treatment at any subsequent level of review, whether at a hearing, on appeal, or in subsequent litigation.

When a physician is faced with a potential threat of future action against his/her medical staff privileges, the physician should take immediate notice and action.  Such a threat is frequently because of a slow-brewing storm built on multiple components.  Whether the issue is disruptive behavior, quality concerns, administrative leadership changes or a backdrop of other political influencers, recognizing the issue and addressing it early is the best way to avoid a full-blown attack on your medical staff privileges and the need to defend yourself in a formal hearing process.Continue reading

Evaluating Hidden Pitfalls in Contracts

Contracts are a fact of life for all businesses.  But many businesses have in-house attorneys or contract specialists that manage the review and negotiation of the terms and specific conditions of each contract.  Smaller health care providers may not have the luxury of someone on staff to assist with contracting, someone who is particularly astute with contract language and pitfalls.

To evaluate and avoid some of the more common pitfalls, it is critical to review each contract in its entirety, whether the contract is to lease your office space, for internet service in your office, or rental of highly sophisticated medical equipment.  Having an attorney familiar with healthcare law review your agreement is certainly one way to identify and avoid the most common pitfalls.

Some common contracts that health care providers may encounter include:Continue reading

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

bribe

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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Weave Compliance Into Your Practice For 2021

fhlf regulatory compliance

fhlf regulatory complianceBy: Jeff Cohen

A recent Department of Justice $500,000 settlement with a cardiology practice underscores the need for ensuring tighter compliance by medical practices.  There, the practice billed Medicare for cardiology procedures for which interpretive reports were also required.  Medicare paid for the procedures, but upon audit, CMS could not find the requisite interpretive reports.  The False Claims Act case settled for $500,000, but it’s likely that (1) the reimbursement by Medicare was far less, and (b) the legal fees behind the settlement weren’t too far behind the settlement amount!  Had the practice self-audited each year, would they have found the discrepancy?

Medical practices have felt the weight of price compression and regulatory load more than probably any segment in the healthcare sector.  They are doing far more for far less.  And regulations expand faster than viruses!  Hence, many have a strategy of regulatory compliance that can best be characterized as a combination of facial compliance (“We bought the manual and put it on the shelf”) and hope (“They’re not really serious about this, are they?”).  Unless you’re part of a practice of more than 20 doctors, it’s likely that you can do more to ensure regulatory compliance.

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Physician Dispensing as it Relates to Injured Workers Clarified by the Florida Workers’ Comp Division

physician dispensing

physician dispensingBy: Zach Simpson

On March 31, 2020 the Florida Division of Workers’ Compensation (DWC) clarified that physicians are permitted to dispense medications to injured workers, and that an injured worker shall have full and free choice to utilize their physician for medication dispensing, as well as any other pharmacy or pharmacist.

It was declared by the DWC that it is not appropriate for employers/carriers to deny authorization or reimbursement for prescription medication solely because the medication is dispensed by the treating physician who is a licensed Florida dispensing practitioner instead of a pharmacist.

What Led to the DWC Bulletin?

A Florida dispensing practitioner was denied reimbursement for drugs dispensed out of their office to an injured worker in a recent reimbursement dispute claim. The physician asserted the claims administrator denied reimbursement for the dispensed medications because the physician was not authorized to dispense prescription medications. The Florida Department of Financial Services (DFS) ruled in favor of the physician – DFS Case No.: 20180824-007-WC – and subsequently issued DWC Bulletin DWC-01-2020 on March 31, 2020.

Details of the DWC BulletinContinue reading

Considering Compliance in Out of Network Physician Owned Specialty Hospitals

florida healthcare law firm physician owned hospital compliance info

florida healthcare law firm physician owned hospital compliance infoBy: Jacqueline Bain

Out of network physician owned specialty hospitals are unique in that there are less stringent legal requirements on the facility, but patient care obligations remain the same. This means that patient care must be prioritized over profits and all actions taken by the hospital and any physician investor must showcase that order of priority.

Given the amount of scrutiny placed in physician owned specialty hospitals in the past two decades, these facilities are well served to identify and implement a process to remedy compliance concerns. Even when a facility does not submit claims to any Federal health insurance provider and is out of network with all commercial insurance companies, it is still required to follow the laws of the state where it is located.

The best plan for surviving scrutiny in such situations is to have a plan. Proactively seek out applicable laws and regulations, and determine how your hospital will abide by them. Compliance can be tailored to fit your facility.

Overutilization and Self-Referrals

A physician who shares ownership in a hospital may have a financial incentive to refer patients for services if he or she receives a percentage of the revenue generated. Laws including the Federal Stark Law and Anti-Kickback Statute were promulgated to combat unnecessary referrals. A 2003 study by the Department of Health and Human Services concluded that physician-investor referrals to hospitals in which they have an investment interest are similar to those physicians without investment interests. Nevertheless, the fear of overutilization and unnecessary self referral remains at the forefront of the regulators’ minds at both the State and Federal level.Continue reading

More Relief on the Way: H.R. 266 – Paycheck Protection Program and Health Care Enhancement Act Signed by the President

HHS Stimulus Payment action required on Second Round

HHS Stimulus Payment action required on Second RoundBy: Susan St. John

The newest relief for small business and health care providers was passed by the Senate on April 21st, by the House on April 23rd, and became law on April 24, 2020. This new Act, provides for $484 billion in additional relief to small businesses and healthcare providers. $100 billion of the relief has been allocated to the Department of Health and Human Services and of that amount $75 billion is earmarked “to reimburse health care providers for health related expenses or lost revenues that are attributable to the coronavirus outbreak.” The remaining $25 billion will be used for expenses to research, develop, validate, manufacture, purchase, administer, and expand capacity for COVID-19 test to effectively monitor and suppress COVID-19.

The $75 billion provided under the Act will remain available until expended and will be used to prevent, prepare for, and respond to coronavirus to reimburse necessary expense or lost revenues incurred as a result of COVID-19. However, if a health care provider has already had expenses or lost revenues incurred due to COVID-19 reimbursed from other sources or that other sources are obligated to reimburse (like the CARES Act), any funds received from the $75 billion cannot be used as a “double dip” by that health care provider.

A big difference for health care providers with this Act, is that unlike the CARES Act that provided a direct deposit to health care providers based on Medicare fee for services reimbursement, no application necessary, this Act requires the health care provider to apply for relief funds. Eligible health care providers include public entities, Medicare or Medicaid enrolled suppliers and providers, profit and not-for-profit entities that provide diagnoses, testing, or care for individuals with possible or actual cases of COVID-19 (so as to accommodate the “lost revenues” provision, this could mean any patient treated since January 31, 2020, and is not necessarily limited to patients treated for COVID-19 symptoms without testing confirmation). Health care providers should act quickly and apply for funds as soon as possible as the HHS Secretary will review applications and make payments on a rolling basis. Payment may be a pre-payment, prospective payment, or a retrospective payment as determined by the HHS Secretary. Health care providers must submit an application that includes statements justifying the need of the provider for the payment. The provider must have a valid tax id number (could be an individually enrolled physician). As with the CARES Act, HHS will have the ability to audit how relief funds are expended and must start reporting obligations of funds to the House and Senates Committees on Appropriations within 60 days from the date of enactment of this Act. Reporting will continue every 60 days thereafter.Continue reading

Stark Law waived to facilitate COVID related medical services

stark law waiver

stark law waiverBy: Jeff Cohen

The Secretary of Health and Human Services issued blanket waiver of the Stark Law on March 30th in order to facilitate COVID related medical services.  The waivers apply only to financial relationships and referrals related to COVID.  The circumstances and conditions under which the waivers apply are strictly and narrowly described.  Moreover, the waivers have no impact in the presence of fraud or abuse.  With respect to physicians wanting to provide designated health services (e.g. clinical lab services) related to COVID detection and treatment, for instance–

  1. the federal requirement that the DHS be provided in the same building as the physician office is waived; and
  2. the financial relationship limitations between the physician (or family member) and the DHS provider is waived.

The waiver also contains specific examples of waived interactions between providers and hospitals, including—Continue reading