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McBrayer Blogs
Showing 31 posts from 2012.
Supreme Court Ruling on the ACA
Writing for the majority, in the Supreme Court of the United States’ decision upholding the health care law, Chief Justice John Roberts wrote, “[t]he Affordable Care Act is constitutional in part and unconstitutional in part.” The Court held that even though “[t]he individual mandate cannot be upheld as an exercise of Congress’s power under the Commerce Clause,” that “it is reasonable to construe what Congress has done as increasing taxes on those who have a certain amount of income, but (who) choose to go without health insurance. Such legislation is within Congress’s power to tax.” Roberts made a point of noting that he and the other justices “possess neither the expertise nor the prerogative to make policy judgments. Those decisions are entrusted to our Nation’s elected leaders, who can be thrown out of office if the people disagree with them. It is not our job to protect the people from the consequences of their political choices.” So, in other words, the Court held that Congress cannot require individuals to enter into an activity so that it could regulate it but that the individual mandate passed muster under the taxing power. The Court also held that the States cannot be coerced into expanding their Medicaid programs and that States are free to opt of the expansion, which is projected to add nearly 30 million more people to the insurance program for our nation’s indigent, if they choose. More >
The New Business of Prescribing Controlled Substances
Out of the heated debate between the Attorney General representing law enforcement and the Kentucky Medical Association representing physicians, the Legislature enacted Kentucky’s “Pill Mill Bill,” which is sweeping legislation designed to combat prescription drug abuse through increased regulation of pain clinics and greater scrutiny of prescribing practices by various agencies of state government. The Pill Mill Bill becomes effective on July 20, 2012 and imposes requirements not just for doctors practicing pain medicine, but for all practitioners who prescribe controlled substances. In addition to placing significant limits on who can own a pain clinic and how a pain clinic is operated, the legislation requires Kentucky’s licensing boards, including the Kentucky Board of Medical Licensure and the Kentucky Board of Nursing, to enact new regulations that impose standards for physicians, nurses and other practitioners when a Schedule II or Schedule III controlled substance is prescribed. Because the Pill Mill Bill imposes sweeping changes for pain clinics and prescribing practices, all health care providers and their patients will face new challenges as procedures change. Regardless of whether the legislation stops the shifting pattern of drug abuse from illicit to prescription drugs, physicians are at the center of the Pill Mill Bill and are now required to reduce the risk of diversion and abuse of prescription drugs when treating a patient’s pain. Whether the collateral effect of the Pill Mill Bill is the serious under treatment of pain is yet to be seen. More >
PRESCRIBERS BEWARE: KENTUCKY ENACTS PAIN CLINIC AND CONTROLLED SUBSTANCES LEGISLATION
In a Special Session, the Kentucky General Assembly enacted House Bill 1, sweeping legislation designed to combat prescription drug abuse through increased regulation of pain clinics and greater scrutiny of prescribing practices by various agencies of state government. Governor Beshear signed the legislation into law, and it will become effective in July, 2012. In addition to placing significant limits on the ownership of pain clinics and imposing a host of requirements governing the operations of pain clinics, the legislation also strengthens licensing standards for physicians and other practitioners and requires practitioners to take specific steps prior to prescribing or dispensing a Schedule II or Schedule III controlled substance. More >
HOSPITAL PAYMENT FOR PERFORMANCE: DRIVEN BY PHYSICIAN’S QUALITY
As the fate of the Affordable Care Act is being determined by a divisive Supreme Court, the health care industry is being led or possibly dragged by the Department of Health and Human Services (“HHS”) and the Center for Medicare and Medicaid Services (“CMS”) into new payment systems that focus on quality of care, outcomes and individual provider performance rather than the traditional fee for service payment model. Even if the Supreme Court finds the Affordable Care Act to be unconstitutional, the change from a payment system focused upon individual services to payment focused upon the quality of the care and patient outcomes are being woven into the fabric of the Medicare reimbursement system. While change in the system is assured, whether the new models will actually bring about better and more efficient care or just reduce available reimbursement is unknown. Despite the unknown effect of paying for performance based upon quality, CMS is marching on with new programs and payment penalties. Physicians, whether employed by a hospital or in a private practice, should be aware of how quality is beginning to drive hospital reimbursement as well as the importance of the physician’s role in determining the quality of care provided by hospitals. By 2017, 6% of all DRG payments will be subject to quality measures through new CMS payment programs for hospital readmissions, value based purchasing and hospital acquired conditions. With these new programs determining a significant amount of payment, physicians must understand the programs and direct their services accordingly. Likewise, hospitals must develop ways to compensate physicians for providing high quality care in a manner that allows hospitals to earn performance payments. More >
PROPOSED PAIN CLINIC LEGISLATION WILL REQUIRE SIGNIFICANT CHANGES TO PROVIDER OPERATIONS AND INCREASE LEGAL SCRUTINY OF PRESCRIBING PRACTICES
The Kentucky General Assembly is currently considering sweeping legislation to combat prescription drug abuse through increased regulation of pain clinics and greater scrutiny of prescribing practices by various agencies of state government. House Bill 4 and the Free Conference Committee Report proposing to modify House Bill 4, if enacted and signed by Governor Beshear, will place significant limits on ownership of pain clinics and also impose a host of requirements governing the operation of pain clinics in the Commonwealth of Kentucky. More >
Federal Government Fight Against Health Care Fraud
FIFTEEN YEARS - $20.6 BILLION – NOT BAD!! More >
CMS Has Issued Proposed Rule Which Would Force Providers to Report Overpayments in 60 Days
The Centers for Medicare & Medicaid Services (“CMS”) released proposed regulations on Tuesday, February 14, 2012 proposing that providers and suppliers must report any self-identified overpayments within 60 days of the incorrect payment being identified or on the date when a corresponding cost report is due, whichever is the latter. More >
ON THE ENFORCEMENT RADAR: MEDICAID AUDITS AND THE 2012 OIG WORK PLAN
Unlike the Department of Health and Human Services Office of Inspector General (“OIG”) which publishes a Work Plan each year, the Department of Medicaid Services (“Medicaid”) generally does not publish guidance on the areas which it plans to investigate and/or audit. In fact, Medicaid’s website states … “Medicaid does not provide guidance on how companies should bill for services, but will direct you to applicable regulations. If you receive direction from staff about how to bill, the Department will not be bound by such instruction, unless it was given by a Director or Commissioner.” Because the federal integrity programs are now moving through the process, Kentucky Medicaid providers are starting to see lots of audit activities. Unlike the OIG audits, we don’t know the precise subject matter of the Medicaid audits, but the process for appeal is outlined below in addition to the areas announced for review by the OIG. More >
The Physician Employment Trend Continues
As healthcare reform continues to be implemented, the trend toward clinical integration and consolidation also continues and will be a defining characteristic of healthcare delivery in the years ahead. One critical component of clinical integration and consolidation has been health systems employing physicians to form large multi-specialty groups to serve the patient population. Physicians contemplating entering into an employment relationship with a hospital or health system must examine a number of critical issues before entering into an employment agreement. More >
ON THE ENFORCEMENT RADAR: THE 2012 OIG WORK PLAN
The Office of Inspector General of the United States Department of Health and Human Services (OIG) released its Work Plan for fiscal year 2012. At the beginning of each fiscal year, the OIG issues its annual Work Plan, which describes current audit, enforcement and evaluation activities and those the agency plans to initiate in the upcoming year. The Work Plan also provides a general view of the OIG’s investigative, enforcement and compliance activities. Basically, the Work Plan informs health care providers what is on the OIG’s enforcement radar in the coming year. Physicians should know what areas that the OIG is concerned about and review their own practices to ensure compliance with regulatory requirements. The following are some of the highlights from the FY 2012 Work Plan. More >
