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.
Attorney Michael Silverman of the Florida Healthcare Law Firm will again team up with Matt Gruskin, Credentialing Director of BOC, to bring you an information packed event. This presentation has been designed to provide expert insights on the essential operational keys to success in the DME industry. Michael will cover an array of topics related to compliant operations, from corporate structure and post-transaction considerations to compliant marketing arrangements and more. Matt will share some tips related to accreditation, including a peek at the process and the maintaining the credential. This is a can’t miss for DME businessowners!
With the 2021 competitive bidding round on the horizon for durable medical equipment (DME) providers, both those that are established as well as those fairly new to the industry must take note of the potential pitfalls that may be encountered when competing to become a Medicare contract supplier.
The durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) competitive bidding program was first established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Under this program, DMEPOS suppliers submit bids (i.e. applications) and compete to furnish specific items in competitive bidding areas commonly referred to as CBAs. Additionally, suppliers are not just bidding for the rights to a particular CBA but also for a single payment amount that will replace the current Medicare fee schedule payment. The payment will be determined by using the bids submitted. As of December 31, 2018, all contacts have expired. As a result, there is currently a temporary gap period. The upcoming bidding process is loaded with requirements. Therefore, compliance with each requirement is crucial. Here are a few pitfalls to watch out for:
There are perfectly compliant ways to engage with healthcare marketers, and then there’s this; here are some of the latest real-life examples:
“DME BRACE CAMPAIGN – $40 to $150 PER LEAD PER BRACE”
“DME DIABETIC LEADS $40 PER LEAD, INSURANCE AND DOC INFO INCLUDED”
“PAIN CREAM/LIDOCANE LEADS FOR SALE, RX INCLUDED”
These marketers are seemingly holding auctions for the sale of federally protected patient health information out to the highest bidder! Couldn’t make this stuff up – if you’re in this industry, a quick gander at your (business) social media platforms will quickly confirm it.
Many DME suppliers purchase leads from marketing companies. The patients who respond to the marketing advertisements are generally not interested in travelling to their doctor’s office to obtain an order for braces, for example. This type of arrangement is seen often enough and so starts a potentially problematic arrangement with the DME company paying the marketing company. The marketing company may then use some of these dollars to pay a telehealth company. The telehealth company may then pay a telehealth physician for “telemedicine visit” with the patient. Ultimately, the telehealth/telemedicine physician issues and order for the braces or other supplies.The DME brace supplier then gets paid by Medicare Part C, or other healthcare plan for providing the supply to the patient.
The problem with this arrangement is that the sole source of the telehealth doctor’s reimbursement for the visit comes indirectly from the DME company. Essentially, the DME supplier is paying the ordering physician through the marketing company for the visit with the patient. This creates a prohibited kickback arrangement because the supplier is essentially paying the Teledoctor for the referral for braces. The telehealth company is acting as a virtual unregulated physician practice. Providers engaged in this type of practice are not in compliance with either Federal or Florida law.
Adding Durable Medical Equipment Prosthetics & Orthotics Supplies (“DMEPOS”) to a Chiropractic Practice is a great way to not only increase revenues, but most importantly it is a great way to increase overall patient satisfaction and care.
Providing patients with easy access to DMEPOS allows for more comprehensive care, enabling providers to help further stabilize injuries, maximize patient recoveries, and minimize patient down time. Many existing patients are already buying and utilizing DMEPOS such as back braces, so there is an opportunity to provide that additional supervision and care through an existing practice.
Examples of DMEPOS that would complement a Chiropractic Practice and which patients are likely already using:
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.
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.