Sunday, November 27, 2011
Thursday, November 17, 2011
Tuesday, November 15, 2011
November 2011
- November 10, 2011; U.S. Attorney; District of Maryland
- Salisbury Cardiologist Sentenced To Over 8 Years In Prison For Implanting Unnecessary Cardiac StentsClick here to review our disclaimersClick here to review our disclaimers Baltimore, Maryland - U.S. District Judge William D. Quarles, Jr. sentenced cardiologist John R. McLean, age 59, of Salisbury, Maryland, today to 97 months in prison followed by three years of supervised release for six health care fraud offenses in connection with a scheme in which Dr. McLean submitted insurance claims for inserting unnecessary cardiac stents, ordered unnecessary tests and made false entries in patient medical records, in order to defraud Medicare, Medicaid and private insurers. Judge Quarles also ordered that McLean pay restitution to Medicare and the other health insurance programs of $579,070. Judge Quarles also ordered McLean to forfeit $579,070 as proceeds of the crime.
- November 10, 2011; U.S. Department of Justice
- Fort Lauderdale-area Halfway House Owners Plead Guilty to Kickback Scheme
WASHINGTON - The two managers and operators of a Fort Lauderdale, Fla.-area halfway house company pleaded guilty today for their role in a Medicare fraud kickback scheme that funneled patients through a fraudulent mental health company, American Therapeutic Corporation (ATC), announced the Department of Justice, FBI and Department of Health and Human Services.
- November 8, 2011; U.S. Department of Justice
- Miami-Area Patient Recruiter Pleads Guilty in $25 Million Health Care Fraud Scheme
- November 8, 2011; U.S. Attorney; Middle District of Tennessee
- Vanguard Health Care, Vanguard Health Care Ancillary to Pay two Million Dollars to Settle False Claims Act Allegations
- November 4, 2011; U.S. Attorney; Middle District of North Carolina
- Area Dentist Pleads Guilty To Health Care Fraud
- November 3, 2011; U.S. Department of Justice
- Former "Most Wanted" Health Care Fraud Fugitives Sentenced to 14 Years in Prison for $9.1 Million Detroit Medicare Fraud Scheme
- November 3, 2011; U.S. Attorney; Southern District of West Virginia
- Federal Jury Convicts Man On Charges Related To Health Care Fraud Scheme
- November 3, 2011; U.S. Department of Justice
- Detroit-Area Man Arrested In Connection With $30 Million Medicare Home Health Scheme
- November 2, 2011; U.S. Attorney; Southern District of Texas
- Medical Equipment Business Owner and Manager Arrested for Health Care Fraud and Aggravated Identity Theft
- November 2, 2011; U.S. Attorney; District of Rhode Island
- R.I. Ambulance Company Owner Sentenced To 24 Months In Federal Prison For Health Care Fraud; Ordered To Pay More Than $700,000 In Restitution
- November 2, 2011; U.S. Department of Justice
- Brooklyn, N.Y., Medicare Fraud Strike Force Charges 12 Individuals for Participating in Health Care Fraud Schemes Totaling More Than $95 Million
- November 1, 2011; U.S. Attorney; Southern District of Texas
- Medical Equipment Business Owner and Manager Arrested for Health Care Fraud and Aggravated
Identity Theft
- November 1, 2011; U.S. Attorney; Southern District of Texas
- Home Healthcare Nurse Sentenced to Federal Prison
Switching to Outsourcing your Medical Billing in 2012
Outsourcing your medical billing claims to a third party partner may be one of the smartest business moves you make in 2012.
You may have had every intention of doing your own medical billing for your practice from the day you opened until the day you retired, however with the never ending changes and nuances in medical billing claims varying from cancelled codes to nonpayment of certain procedures because they simply weren't reported correctly - there comes a time when you need to look at your revenue flow from your reimbursements and decide it might be time to outsource your medical billing claims.
Another reason to outsource is the small fact that many practices are losing up to one solid forth of their revenue due to small inconsistencies in reporting. Medical billing codes can change, the way a particular carrier wants their medical billing claim reported can change and Medicare never seems to stop updating and changing their criteria for what constitutes a fully reimbursable procedure.
Your staff can spend valuable office time researching medical billing claims or you can outsource your medical billing and let your staff do what they do best : service your patients and help keep your practice running smoothly.
If you're ready to get away from the paper chase of never ending medical billing changes, consider outsourcing a proactive way to begin 2012.
You may have had every intention of doing your own medical billing for your practice from the day you opened until the day you retired, however with the never ending changes and nuances in medical billing claims varying from cancelled codes to nonpayment of certain procedures because they simply weren't reported correctly - there comes a time when you need to look at your revenue flow from your reimbursements and decide it might be time to outsource your medical billing claims.
Another reason to outsource is the small fact that many practices are losing up to one solid forth of their revenue due to small inconsistencies in reporting. Medical billing codes can change, the way a particular carrier wants their medical billing claim reported can change and Medicare never seems to stop updating and changing their criteria for what constitutes a fully reimbursable procedure.
Your staff can spend valuable office time researching medical billing claims or you can outsource your medical billing and let your staff do what they do best : service your patients and help keep your practice running smoothly.
If you're ready to get away from the paper chase of never ending medical billing changes, consider outsourcing a proactive way to begin 2012.
Cuts threaten health care for seniors and the military
Thousands of physicians gather this week in New Orleans for the AMA's policy-making meeting. We're here to discuss the future of medicine, and we do so with the fear that on Jan. 1, a massive 27 percent cut will force many of us to limit the number of Medicare patients we treat.
This looming cut threatens access to care for nearly 678,000 Louisiana seniors in Medicare and 132,000 military family members in the TRICARE health program. The cut could not come a worse time. Medicare payments for physician services are so low that there is a 20 percent gap between payment updates and the increasing cost of caring for patients. Now, as millions of baby boomers enter Medicare and military families provide critical support to our armed forces, this massive cut could jeopardize access to the care they need and deserve.
The cause of this chronic problem is a broken physician payment formula that has destabilized Medicare. To stop cuts from this formula, Congress has repeatedly put in place short-term delays that have made the long-term problem worse. In 2005 the cost to repeal this formula would have been $48 billion. If Congress implements the same temporary fixes, the cost will escalate to $600 billion in five years. Clearly the formula needs to be repealed, and the cost will never be less than it is today.
The Joint Congressional Committee on Deficit Reduction has the opportunity to repeal this formula once and for all this month. The deadline for the deficit committee to act comes right before this devastating cut is scheduled to occur. Make your voice heard by contacting Congress at www.patientsactionnetwork.org. Tell your elected officials to repeal the Medicare physician payment formula, protect access to care for patients and stop the growth in cost for taxpayers.
Peter W. Carmel, M.D.
President, American Medical Association
Chicago, Ill.
This looming cut threatens access to care for nearly 678,000 Louisiana seniors in Medicare and 132,000 military family members in the TRICARE health program. The cut could not come a worse time. Medicare payments for physician services are so low that there is a 20 percent gap between payment updates and the increasing cost of caring for patients. Now, as millions of baby boomers enter Medicare and military families provide critical support to our armed forces, this massive cut could jeopardize access to the care they need and deserve.
The cause of this chronic problem is a broken physician payment formula that has destabilized Medicare. To stop cuts from this formula, Congress has repeatedly put in place short-term delays that have made the long-term problem worse. In 2005 the cost to repeal this formula would have been $48 billion. If Congress implements the same temporary fixes, the cost will escalate to $600 billion in five years. Clearly the formula needs to be repealed, and the cost will never be less than it is today.
The Joint Congressional Committee on Deficit Reduction has the opportunity to repeal this formula once and for all this month. The deadline for the deficit committee to act comes right before this devastating cut is scheduled to occur. Make your voice heard by contacting Congress at www.patientsactionnetwork.org. Tell your elected officials to repeal the Medicare physician payment formula, protect access to care for patients and stop the growth in cost for taxpayers.
Peter W. Carmel, M.D.
President, American Medical Association
Chicago, Ill.
5010 Compliance
Are you counting on an extension of the January 1, 2012 deadline for 5010 compliance? If you are, you will probably be very disappointed. With only a few weeks left to comply, it's very important for offices to realize that beginning in 2012, their claims are going to get rejected and it will cause cash flow problems unless they get up to speed quickly.
Fortunately, you can still take steps to prepare. If a practice hasn't done anything yet to comply with 5010, here's a quick checklist of things to do right away:
1) Call your software vendor to find out if they have completed the update for your billing software program to accommodate the required changes. If they have not, find out when it will be available because time is running out. If you are using a web-based "software as a service" vendor, they are likely to have already made the necessary changes, but verify this with them. If you use a billing service, find out what steps they have taken to comply. If you provide billing services, be prepared for your billing clients to ask what you’ve done to comply.
2) Check with your clearinghouse to see if they have already have tested claims with any other users of your software. If they have, there is a good chance your software has an update available to accommodate the required changes. You need to begin testing claim as soon as possible. Be prepared to work through issues and re-test if necessary.
3) Contact your largest payers to find out if they have any issues you need to be aware of or if they have any contingency plans and what those might be. Even though CMS is telling payers they must reject 4010 claims after January 1, 2012, UHC confirmed during our conference that they could technically continue to accept 4010 claims. We don't know if they will, but the point was, they could and they were concerned that it could be a disservice to their insureds and providers to deny them.
Don't assume that your software vendor and clearinghouse will take care of testing for you. Doctors and other healthcare providers that have done nothing to comply with 5010 should prepare for cash flow issues. Even those that have tested and completed implementation should be prepared for technical glitches that might disrupt cash flow.
Consider submitting as many transactions as possible before December 31, 2011 using your current system. If you have any backlogs of claims, get them in now! Also, you may want to get a line of credit established with your lending institution. And finally, if you experience problems with testing or getting claims paid after the January 1st deadline, drop your claims to paper until the problem has been resolved.
Monday, November 14, 2011
Wednesday, November 9, 2011
Thursday, November 3, 2011
Purse Optimal Efficiency Strategies 5-6
Use six workflow strategies to improve your bottom line.
Strategy No.5:
Track Denials
Don't underestimate the importance of following up on denials. They often can ve reversed on appeal; even if they cannot, they can help identify flaws in upfront processes that can be fixed to prevent further denials. Typically, there are filing deadlines associated with appeals, so you should run denial reports daily to support quick identifications and response.
Strategy No.6:
Provide Effective Cross Training
Although it is a time-intensive endeavor, cross training can bring more to your practice that just staff coverage during illnesses or vacations. When done well, cross training promotes better patient service and improves financial performance by broadening the knowledges base of every employee.
Thoroughness is the key to good cross-training program. Offering front-desk staff only a high-level view of back office operations, for instance, is not enough. Instead, solid cross training should reveal in detail how front-desk tasks affect the back-end, and vice versa. An effective program will also:
* Engage the most experienced individuals in the "teaching" roles
* Map out specific learning objectives for each staff member
* Occur frequently (ideally, twice per year, or more frequently in instances of high staff turnover)
* Allow staff members to experience both morning and afternoon shifts during training, with no
department having more than one person cross- training at a time.
These workflow strategies require commitment and buy-in from everyone in your practice - including providers, administrators, and staff. While not always easy to implement, these strategies can enhance evenue cycle management and improve efficiency, ultimately helping your practice realize measurable financial gains.
Strategy No.5:
Track Denials
Don't underestimate the importance of following up on denials. They often can ve reversed on appeal; even if they cannot, they can help identify flaws in upfront processes that can be fixed to prevent further denials. Typically, there are filing deadlines associated with appeals, so you should run denial reports daily to support quick identifications and response.
Strategy No.6:
Provide Effective Cross Training
Although it is a time-intensive endeavor, cross training can bring more to your practice that just staff coverage during illnesses or vacations. When done well, cross training promotes better patient service and improves financial performance by broadening the knowledges base of every employee.
Thoroughness is the key to good cross-training program. Offering front-desk staff only a high-level view of back office operations, for instance, is not enough. Instead, solid cross training should reveal in detail how front-desk tasks affect the back-end, and vice versa. An effective program will also:
* Engage the most experienced individuals in the "teaching" roles
* Map out specific learning objectives for each staff member
* Occur frequently (ideally, twice per year, or more frequently in instances of high staff turnover)
* Allow staff members to experience both morning and afternoon shifts during training, with no
department having more than one person cross- training at a time.
These workflow strategies require commitment and buy-in from everyone in your practice - including providers, administrators, and staff. While not always easy to implement, these strategies can enhance evenue cycle management and improve efficiency, ultimately helping your practice realize measurable financial gains.
Pursue Optimal Efficiency Strategies 3-4
Use six key workflow strategies to improve your bottom line.
Strategy No. 3:
Seek Prior Authorization
This is critical because failure to obtain proper authorization can have a drastic affect on practice income. Insurers will not pay for procedures if they correct prior authorization is not received, and most contracts restrict practices from billing the patient in these situations.
Although neccessary, keeping track of prior authorization policies is challenging. Each health plan has its own set of requirements, which can change frequently. Some Medicaid payers, for instance, request one "blanket" referral authorization before patients see certain specialists; the specialist is not required to obtain prior authorization for every procedure. Other plans are much more restrictive, approving prior authorization for specified procedures only when certain criteria and diagnoses are met.
Here are three actions you can take to help navigate the prior authorization process:
1. Designate someone to oversee all authorizations.
This allows a particular individual to become knowledgeable about each payer's unique
requirements. This person should track the authorization allowed and used for procedure codes
and visits, and be diligent about obtaining authorizations. By gaining a more thorough underst-
anding of payer policies, this person can better fight inappropriate authorizations denials.
2. Open the line of communication. Two-way communication between physicians and
authorization staff is essential. Providers should document completely and tell staff why a
patient is being seen, so staff can inform providers about the treatment options the patient's
payer will accept. Providers can them make treatment decisions based on all relevant knowledge.
3. Leverage technology. It can be helpful to develop a spreadsheet listing the guidelines for payer
authorizations, including which specific codes require authorization. The spreadsheet should
explain what justifies medical necessity for each procedure, according to each payer. Using
this tool, you can quickly decide when to submit an authorization request. Note: Some payers
publish their pre-authorization guidelines on their website, while others require you to call and
request these.
Strategy No.4:
Ensure Timely Charge Entry
Lagging charge entry can delay payment and hinder accounts receivable (A/R) negatively affecting your practice's bottom line. An important way to improve the timeliness of charge entry is to ensure coding staff has a solid understanding of ICD-9, ICD-10 (prior to October 2013), CPT, and HCPCS Level II codes, and modifiers. Hold meetings once or twice a month for coding staff to discuss coding- related issues and new developments to make sure everyone is up to speed on current requirements.
Educate physicians on importance of timely charge entry as well. Such education may involve explaining the consequences of delayed charge entry, and how those consequences affect physicians directly.
Once coded, claims may be run through claim scrubbers, clearinghouses applications, or other tools that verify accuracy. By ensuring a clean claim upfront, your practice can avoid costly delays and reimbursement headaches from denials down the road.
Strategy No. 3:
Seek Prior Authorization
This is critical because failure to obtain proper authorization can have a drastic affect on practice income. Insurers will not pay for procedures if they correct prior authorization is not received, and most contracts restrict practices from billing the patient in these situations.
Although neccessary, keeping track of prior authorization policies is challenging. Each health plan has its own set of requirements, which can change frequently. Some Medicaid payers, for instance, request one "blanket" referral authorization before patients see certain specialists; the specialist is not required to obtain prior authorization for every procedure. Other plans are much more restrictive, approving prior authorization for specified procedures only when certain criteria and diagnoses are met.
Here are three actions you can take to help navigate the prior authorization process:
1. Designate someone to oversee all authorizations.
This allows a particular individual to become knowledgeable about each payer's unique
requirements. This person should track the authorization allowed and used for procedure codes
and visits, and be diligent about obtaining authorizations. By gaining a more thorough underst-
anding of payer policies, this person can better fight inappropriate authorizations denials.
2. Open the line of communication. Two-way communication between physicians and
authorization staff is essential. Providers should document completely and tell staff why a
patient is being seen, so staff can inform providers about the treatment options the patient's
payer will accept. Providers can them make treatment decisions based on all relevant knowledge.
3. Leverage technology. It can be helpful to develop a spreadsheet listing the guidelines for payer
authorizations, including which specific codes require authorization. The spreadsheet should
explain what justifies medical necessity for each procedure, according to each payer. Using
this tool, you can quickly decide when to submit an authorization request. Note: Some payers
publish their pre-authorization guidelines on their website, while others require you to call and
request these.
Strategy No.4:
Ensure Timely Charge Entry
Lagging charge entry can delay payment and hinder accounts receivable (A/R) negatively affecting your practice's bottom line. An important way to improve the timeliness of charge entry is to ensure coding staff has a solid understanding of ICD-9, ICD-10 (prior to October 2013), CPT, and HCPCS Level II codes, and modifiers. Hold meetings once or twice a month for coding staff to discuss coding- related issues and new developments to make sure everyone is up to speed on current requirements.
Educate physicians on importance of timely charge entry as well. Such education may involve explaining the consequences of delayed charge entry, and how those consequences affect physicians directly.
Once coded, claims may be run through claim scrubbers, clearinghouses applications, or other tools that verify accuracy. By ensuring a clean claim upfront, your practice can avoid costly delays and reimbursement headaches from denials down the road.
Pursue Optimal Efficiency
Use six key workflow strategies to improve your bottom line.
Successful practices provide quality patient care while achieving good revenue cycle performance. They seek to be more efficent. From the front end of the office to the back, each employee finds ways to be more productive and ensure that the revenue stream is maintained.
In such practices, revenue cycle management is not haphazard, but involves specific workflow strategies that streamline processes, enhance productivity, and bolster patient satisfaction. Let's take a closer look at six specific workflow strategies to help your practice improve overall efficiency and, ultimately, strengthen your bottom line.
Strategy No 1:
Communicate Proactively with Patients
Share information proactively with patients about what they can expect from your practice - both clinically and financially - to help avoid misunderstandings, ehance patient satisfaction, and encourage repeat business. And, have an employee make courtesy calls prior to patients' visits to explain both payment policies and expectations and to help patients become aware of their out-of-pocket costs.
This call also provides the opportunity to address any potential payment problems early on, and avoid reimbursement issues on the back end. Informed patients improve morale because back-end staff spend less time chasing down payments and talking to patients who are dissatisfied because they did not fully understand their obligations to the practice.
Strategy No 2:
Verify Eligibility Upfront
To support proactive communication, revenue cycle staff must know a patient's insurance coverage, co-pay, and other financial details. Verifying this information prior to a patient's arrival at the practice allows staff to determine upfront whether a procedure is allowable through insurance; what the fee schedule is for the procedure; and the approxmate patient responsibility. This helps avoid unwelcome surprises, minimizing practice risk and preventing physicians from providing services for which they will not be paid.
Eligibility verification can be done manually or automatically. In a manual process, assigned staff members contact insurance providers via phone or website to verify patient benefits and eligibility. An automted process, which involves verification software, requires fewer staff resources and can lead to quicker eligibility verification. Either way, verification should be done prior to the patient visit.
Successful practices provide quality patient care while achieving good revenue cycle performance. They seek to be more efficent. From the front end of the office to the back, each employee finds ways to be more productive and ensure that the revenue stream is maintained.
In such practices, revenue cycle management is not haphazard, but involves specific workflow strategies that streamline processes, enhance productivity, and bolster patient satisfaction. Let's take a closer look at six specific workflow strategies to help your practice improve overall efficiency and, ultimately, strengthen your bottom line.
Strategy No 1:
Communicate Proactively with Patients
Share information proactively with patients about what they can expect from your practice - both clinically and financially - to help avoid misunderstandings, ehance patient satisfaction, and encourage repeat business. And, have an employee make courtesy calls prior to patients' visits to explain both payment policies and expectations and to help patients become aware of their out-of-pocket costs.
This call also provides the opportunity to address any potential payment problems early on, and avoid reimbursement issues on the back end. Informed patients improve morale because back-end staff spend less time chasing down payments and talking to patients who are dissatisfied because they did not fully understand their obligations to the practice.
Strategy No 2:
Verify Eligibility Upfront
To support proactive communication, revenue cycle staff must know a patient's insurance coverage, co-pay, and other financial details. Verifying this information prior to a patient's arrival at the practice allows staff to determine upfront whether a procedure is allowable through insurance; what the fee schedule is for the procedure; and the approxmate patient responsibility. This helps avoid unwelcome surprises, minimizing practice risk and preventing physicians from providing services for which they will not be paid.
Eligibility verification can be done manually or automatically. In a manual process, assigned staff members contact insurance providers via phone or website to verify patient benefits and eligibility. An automted process, which involves verification software, requires fewer staff resources and can lead to quicker eligibility verification. Either way, verification should be done prior to the patient visit.
Tuesday, November 1, 2011
New Online Application Fee Collection Process through PECOS
Medicare Learning Network (MLN) Matters Special Edition (SE) article 1130 changes Medicare's online application payment process and affects providers and suppliers. See MLN Matters SE1130 (www.cms.gov/MLNMattersArticles.Downloads/SE1130.pdf) for details.
AMA Releases CPT 2012 Category II Codes
The American Medical Association (AMA) has released new and revised CPT Category II codes, effective Jan. 1, 2012. Category II codes are supplemental tracking codes used for performance measurement (e.g., the Physician Quality Reporting System, www.cms.gov/PQRS/).
Category II codes are not required for correct coding and should not be used in place of Category I codes. They describe clinical components that may: typically be included in evaluation and management (E/M) or clinical services; result from clinical laboratory or radiology tests and other procedures; or identify processes intended to address patient safety practices or services reflecting compliance with the state or federal law.
For 2012, four Category II codes are deleted and replaced by newer codes:
* 4002F Statin therapy, prescribed (CAD) is deleted and replaced by 4013F Statin therapy
prescribed or currently being taken (CAD).
* 4006F Beta-blocker therapy prescribed (CAD,HF) is replaced by 4008F Beta-blocker
therapy prescribed or currently being taken (CAD, HF).
* 4009F Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy prescribed (HF, CAD, CKD), (DM) is replaced by 4010F Angiotensin converting
enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy prescribed or
currently being taken (CAD, HF).
* 4275F Hepatitis B vaccine injection administered or previously received (HIV) is replaced by
4149F Hepatitis B vaccine injection administered or previously received (HEP C, HIV) (IBD).
Several dozen new codes have been added in clinical areas such as angina, tobacco use, neuropsych-
iatric symptoms, and more.
For a full list of revisions to Category II codes (as well as a sneak peak at some 2013 codes), see "Update to List of Category II Codes" dated Sept. 14, 2011.
Category II codes are not required for correct coding and should not be used in place of Category I codes. They describe clinical components that may: typically be included in evaluation and management (E/M) or clinical services; result from clinical laboratory or radiology tests and other procedures; or identify processes intended to address patient safety practices or services reflecting compliance with the state or federal law.
For 2012, four Category II codes are deleted and replaced by newer codes:
* 4002F Statin therapy, prescribed (CAD) is deleted and replaced by 4013F Statin therapy
prescribed or currently being taken (CAD).
* 4006F Beta-blocker therapy prescribed (CAD,HF) is replaced by 4008F Beta-blocker
therapy prescribed or currently being taken (CAD, HF).
* 4009F Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy prescribed (HF, CAD, CKD), (DM) is replaced by 4010F Angiotensin converting
enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy prescribed or
currently being taken (CAD, HF).
* 4275F Hepatitis B vaccine injection administered or previously received (HIV) is replaced by
4149F Hepatitis B vaccine injection administered or previously received (HEP C, HIV) (IBD).
Several dozen new codes have been added in clinical areas such as angina, tobacco use, neuropsych-
iatric symptoms, and more.
For a full list of revisions to Category II codes (as well as a sneak peak at some 2013 codes), see "Update to List of Category II Codes" dated Sept. 14, 2011.
Patient Referral Act Ethics
Stark Law (42 U.S.C. $ 1395nn), effective for referrals made after Dec. 31, 1994, states that if a physician (or an immediate family member of such physician) has a "financial relationship" with an entity, the physician may not make a refferal to that entity for the furnishing of "designated health services" for which payment is sought under Medicare and Medicaid. Nor may the entity present a claim or bill to any individual, third-party payer, or other entity for designated health services. The following services/items are defined as designated health services (enumerated by CPT codes):
* Clinical Laboratory services
* Physical therapy services, speech language pathology services
* Occupational therapy services
* Radiology or other diagnostic services, including magnetic resonance imaging (MRI) computed
tomograghy (CT) scans and ultrasound services.
* Radiation therapy services and supplies
* Durable medical equipment and supplies
* Parenteral and enteral nutrients, equipment and supplies
* Prosthetics, orthotics, and prosthetic devices and supplies
* Home health services
* Outpatient prescription drugs
* Inpatient and outpatient hospital services
* Nuclear medicine services and supplies
All six elements of Stark must be present to implicate the statute. If all six elements are present, the referral will be protected only if an applicable exception applies. There are four general exceptions, two ownership/investment exceptions, and seven compensation exceptions.
Protential self-referral violations include:
* A physician refers all blood specimens to a clinical laboratory in which he has an ownership
interest.
* A physician has a compensation arrangement (without a written agreement) with a diagnostic
facility to which he or she refers radiation therapy patients.
In cases where the physician or a group practice has billed and collected for designated health services in violation of the Stark Law, the physician or group is required to refund such amounts on a timely basis. The Office Of Inspector General (OIG) also may impose upon any person a civil penality of up to $15,000 for each improper service provided by the person who knew, or should have known, the service was rendered in violation of the Stark Law; and up to $100,000 for each scheme to cirumvent the Stark Law.
Any physician or entity entering into an arrangement or scheme in violation of the self-referral ban may also be subject to an assessment of not more than twice the amount claimed for each designated health service rendered in violation of the ban, and may also be excluded from participation in all state and federal health care programs.
Section 6409 of PPACA requires self-disclosure protocols to be developed by the Center for Medicare & Medicaid Services (CMS). CMS' instructions must include the procedures for self-disclosure, the affect of self-disclosure on Corporate Integrity Agreements, and information regarding possible reductionin penalties for self-disclosure of Stark Law violations.
Because there is an increased likelihood that an enforcement agency may request records or perform a site visit at your practice, your practice will benefit greatly if you can identify these potential issues in advance and bring such conduct inot compliance with the law.
Christopher A Parrella J.D CHC, CPC CPCO is with the Health law off of Anthony C Vitale in Miami Fla. He is a member of AAPCs legal Advisory Board and can be reached at (305) 258-4500 or at cparrella@vitalehealthlaw.com
* Clinical Laboratory services
* Physical therapy services, speech language pathology services
* Occupational therapy services
* Radiology or other diagnostic services, including magnetic resonance imaging (MRI) computed
tomograghy (CT) scans and ultrasound services.
* Radiation therapy services and supplies
* Durable medical equipment and supplies
* Parenteral and enteral nutrients, equipment and supplies
* Prosthetics, orthotics, and prosthetic devices and supplies
* Home health services
* Outpatient prescription drugs
* Inpatient and outpatient hospital services
* Nuclear medicine services and supplies
All six elements of Stark must be present to implicate the statute. If all six elements are present, the referral will be protected only if an applicable exception applies. There are four general exceptions, two ownership/investment exceptions, and seven compensation exceptions.
Protential self-referral violations include:
* A physician refers all blood specimens to a clinical laboratory in which he has an ownership
interest.
* A physician has a compensation arrangement (without a written agreement) with a diagnostic
facility to which he or she refers radiation therapy patients.
In cases where the physician or a group practice has billed and collected for designated health services in violation of the Stark Law, the physician or group is required to refund such amounts on a timely basis. The Office Of Inspector General (OIG) also may impose upon any person a civil penality of up to $15,000 for each improper service provided by the person who knew, or should have known, the service was rendered in violation of the Stark Law; and up to $100,000 for each scheme to cirumvent the Stark Law.
Any physician or entity entering into an arrangement or scheme in violation of the self-referral ban may also be subject to an assessment of not more than twice the amount claimed for each designated health service rendered in violation of the ban, and may also be excluded from participation in all state and federal health care programs.
Section 6409 of PPACA requires self-disclosure protocols to be developed by the Center for Medicare & Medicaid Services (CMS). CMS' instructions must include the procedures for self-disclosure, the affect of self-disclosure on Corporate Integrity Agreements, and information regarding possible reductionin penalties for self-disclosure of Stark Law violations.
Because there is an increased likelihood that an enforcement agency may request records or perform a site visit at your practice, your practice will benefit greatly if you can identify these potential issues in advance and bring such conduct inot compliance with the law.
Christopher A Parrella J.D CHC, CPC CPCO is with the Health law off of Anthony C Vitale in Miami Fla. He is a member of AAPCs legal Advisory Board and can be reached at (305) 258-4500 or at cparrella@vitalehealthlaw.com
Primer on Anti-kickback Statue and Stark Law
Understanding government fraud and abuse laws is your best defense.
As the Obama administration further reinforces its federal and state health care fraud and abuse enforcement budgets, it is essential for practice managers to have a basic understanding of tow of the biggest fraud and abuse tools within the government's arsenal: the anti-kickback statue (AKS) and the Stark Law:
The Federal Anti-kickback Statue
The AKS (42 U.S.C $1320a-7b(b) (1-3)) prohibits the offer, soliciation, payment, or receipt of any remuneration, in cash or in kind, in return for, or to introduce, the referral of a patient for any service that is covered by a federal health care program (most notably, Medicare and Medicaid).
Reward in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or item reimbursed under a federal health care program is also prohibited.
Example for potential kickback violations include:
* A physician who offers a patient recruiter $100 per patient
* A manufacturere of Medical devices offering gifts and educational programs in exotic locales
to physicians who prescribe its products.
* A pharmacy that pays for a patients' groceries and cleaning service in return for patient's
continued loyalty.
Whether the remuneration atucally results in a referral is immaterial because it's sufficient that the reward may induce someone to refer or recommend. Under Greber (United States v Greber, 760 F.2nd 68, 71 (3rdCir.), cert, denied, 474 U.S. 988 (1985)), it is also irrelevant if there are other legitimate reasons for remuneration. If one purpose is to induce referrals, then the AKS may be violated.
The AKS contains exceptions protecting parties form criminal liability for conduct that would otherwise violate the statute. Similarly, the AKS permits the Department of Health & Human Services (HHS) secretary to promulgate "safe harbors," which identify referral arrangements that do not violate the AKS ( see 42 CFR 1001.952). If the requirements of the Safe Harbor are strictly complied with, individuals and entities can insulate themselves from prosecution under the AKS for conduct that would otherwise violate the statute. There are 25 exceptions and nine safe harbors.
A violation of the AKS constitues a felony criminal offense. Sanctions include imprisonment of up to five years, criminal fines of up to $25,000, civil money penalties of $50,000 per act, and/or exclusion from all federal and/or state health care programs. Sanctions apply to all parties to the transaction- he who "offers/pays" and "solicits/receives."
The Patient Protection and Affordable Care Act (PPACA) is a federal statute that was signed inot law on March 23, 2010. The statute, among its many provisions clarifies the intent standard of the AKS by requiring there be a "knowing" and "willful" intent element to sustain a conviction. The law provides that a person need not have actual knowledge that the alleged activity violates the AKS itself, or that there be a specific intent to commit a violation of the AKS, so long as the defendant committed the act (knowingly) with the knowledge that such conduct was unlawful.
The PPACA also makes a violation of AKS a basis for False Claims Act (FCA) violation.
As the Obama administration further reinforces its federal and state health care fraud and abuse enforcement budgets, it is essential for practice managers to have a basic understanding of tow of the biggest fraud and abuse tools within the government's arsenal: the anti-kickback statue (AKS) and the Stark Law:
The Federal Anti-kickback Statue
The AKS (42 U.S.C $1320a-7b(b) (1-3)) prohibits the offer, soliciation, payment, or receipt of any remuneration, in cash or in kind, in return for, or to introduce, the referral of a patient for any service that is covered by a federal health care program (most notably, Medicare and Medicaid).
Reward in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or item reimbursed under a federal health care program is also prohibited.
Example for potential kickback violations include:
* A physician who offers a patient recruiter $100 per patient
* A manufacturere of Medical devices offering gifts and educational programs in exotic locales
to physicians who prescribe its products.
* A pharmacy that pays for a patients' groceries and cleaning service in return for patient's
continued loyalty.
Whether the remuneration atucally results in a referral is immaterial because it's sufficient that the reward may induce someone to refer or recommend. Under Greber (United States v Greber, 760 F.2nd 68, 71 (3rdCir.), cert, denied, 474 U.S. 988 (1985)), it is also irrelevant if there are other legitimate reasons for remuneration. If one purpose is to induce referrals, then the AKS may be violated.
The AKS contains exceptions protecting parties form criminal liability for conduct that would otherwise violate the statute. Similarly, the AKS permits the Department of Health & Human Services (HHS) secretary to promulgate "safe harbors," which identify referral arrangements that do not violate the AKS ( see 42 CFR 1001.952). If the requirements of the Safe Harbor are strictly complied with, individuals and entities can insulate themselves from prosecution under the AKS for conduct that would otherwise violate the statute. There are 25 exceptions and nine safe harbors.
A violation of the AKS constitues a felony criminal offense. Sanctions include imprisonment of up to five years, criminal fines of up to $25,000, civil money penalties of $50,000 per act, and/or exclusion from all federal and/or state health care programs. Sanctions apply to all parties to the transaction- he who "offers/pays" and "solicits/receives."
The Patient Protection and Affordable Care Act (PPACA) is a federal statute that was signed inot law on March 23, 2010. The statute, among its many provisions clarifies the intent standard of the AKS by requiring there be a "knowing" and "willful" intent element to sustain a conviction. The law provides that a person need not have actual knowledge that the alleged activity violates the AKS itself, or that there be a specific intent to commit a violation of the AKS, so long as the defendant committed the act (knowingly) with the knowledge that such conduct was unlawful.
The PPACA also makes a violation of AKS a basis for False Claims Act (FCA) violation.
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