CMS announced this week that it is modifying its longstanding policy regarding the release of Medicare physician payment data in response to Freedom of Information Act (FOIA) requests. Since 1980, CMS’ policy has been that, for privacy reasons, it would not release Medicare payment data specific to individual physicians. However, according to a pronouncement in the Federal… Continue Reading
In recent months I have had a number of physician clients contact me to tell me that they have unexpectedly been dropped from one or more Medicare Advantage plans with which they have participated with no issue for, in some case, years. These physicians are left somewhat bewildered because these terminations are being done without cause and without explanation. A… Continue Reading
It is still evident to me that too many physician practices still do not have effective fraud and abuse compliance programs integrated into their practices. To date there has been no federal or state mandate that physicians implement a compliance program but such a mandate is coming. In fact, the Affordable Care Act of 2010… Continue Reading
As the implementation of the federal Affordable Care Act (ACA) continues in fits and starts, healthcare providers are scrambling to best position themselves to accommodate anticipated and developing payment models. Unfortunately no one really knows what these new payment models will look like or how they will ultimately work. It is apparent, however, that most… Continue Reading
Unless you’ve been living under a rock for the last several weeks, you are likely well aware of the budget sequester that took effect on March 1. The sequestration requires "across the board" cuts in federal spending. That, in and of itself, may not be such a bad news. However, what you may not be… Continue Reading
Physician Payment Sunshine Act
Yesterday the U.S. Department of Justice announced that it has entered into a $26M False Claims settlement with a dermatologist in Florida. According to the DOJ, this is one of the largest False Claims settlements against an individual in history. The physician was accused of allegedly accepting kickbacks from a pathology lab and billing for medically… Continue Reading
State’s “more stringent” Stark law restrictions upheld by court.
Last week the U.S. Department of Health and Human Services (HHS) released final regulations modifying existing HIPAA enforcement, privacy and security regulations.
OIG has announced its priorities for 2013 and some are of special interest to physicians.
It appears to be business as usual on Capitol Hill this New Year’s Eve. Once again, Congress has failed to fix the sustainable growth rate formula in the Medicare physician fee schedule. Unless at least a temporary "patch" is put in place to keep Medicare physician payment rates steady, physicians will experience a 27% cut… Continue Reading
With the emphasis placed on primary care under the federal Affordable Care Act, what will the federal government need to do to entice the best and the brightest to go into primary care?
It’s no secret that Medicare pays significantly more for certain services when they are performed in a hospital outpatient department than when they are performed in a physician office. In fact, this is one of the reasons privately practicing physicians have been folding up shop in favor of hospital employment. Hospitals can make more from these services than… Continue Reading
Recent press releases provide notice of activities that draw the government’s ire — and result in serious criminal consequences. Focusing on these issues is a helpful exercise for any physician trying to stay within the law.
A recent court decision concerns the method of rotating teaching physicians between multiple surgeries and billing Medicare for those services, and “whistleblower” claims when improperly done.
Health care fraud and abuse enforcement activity is at an all-time high yet many physicians and other providers lack a basic understanding of the key healthcare fraud and abuse statutes that apply to them. Although each state may have its own fraud and abuse laws, any healthcare provider that receives federal funds should be familiar… Continue Reading
Physicians who reassign their right to bill the Medicare program can still be liable for false claims
I have been speaking with physicians for years about the importance of developing effective fraud and abuse compliance programs in their practices and I often still get the same response: The government is only interested in the big fish like pharmaceutical manufacturers and hospitals -physicians are under the radar. Well, contrary to popular belief, it appears that there… Continue Reading
In June of 2011, I reported on this blog about a software program being launched by the federal Department of Health and Human Services to use a technology called predictive modeling to identify fraudulent and abusive billing practices on a prepayment basis. The program, known as the Fraud Prevention System, was funded through the The… Continue Reading
In a last ditch effort to salvage their Holiday vacation plans, the U. S. House of Representatives has approved legislation which will delay the 27% Sustainable Growth Rate (SGR) cut to the Medicare Physician Fee Schedule. The good news of course is that CMS will not need to put a hold on physician payments starting January 1 as they… Continue Reading
Federal prosecutors continue to focus their efforts on preventing health care fraud, as evidenced by a recent case arising in Texas. Earlier this year, a Houston doctor (Dr. Christina Clardy) was convicted of three counts of mail fraud, 14 counts of health care fraud and one count of conspiracy to commit health care fraud – all relating to over $45 million in false billings to Medicare and Texas’ Medicaid programs.
Physicians are feeling the economic burn of the down economy perhaps more than the average American. Not surprisingly, creative physician joint ventures are proliferating in the healthcare industry as a means of stabilizing revenue streams and referral patterns. Unfortunately, many of these arrangements may raise questions under applicable fraud and abuse laws. One such proposed… Continue Reading
This month, the Centers for Medicare and Medicaid Services (CMS) published a final rule for 2011 Electronic Prescribing Incentive Program. Importantly, for physicians who are in the process of becoming compliant but not quite there, the new rule pushed the deadline for seeking a hardship waiver from the applicable penalty to November 1, 2011. Unless… Continue Reading
HHS Proposed Regs Would Give Patients Direct Access to Lab Results