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McBrayer Blogs
Showing 8 posts from 2017.
Kentucky Supreme Court Addresses Negligent Credentialing
2017 has been a banner year for developments in healthcare litigation in Kentucky. While the focus has largely been on medical review panels, another issue of importance has been that of negligent credentialing claims brought against hospitals. Nationwide, states have been split on whether this cause of action is recognized. Lost in the recent rulings regarding medical review panels was the Kentucky Supreme Court’s quiet release of its opinion on November 2, 2017 striking down negligent credentialing as a separate and new cause of action against hospitals. This opinion provides clarity for hospitals facing claims of negligence related to physicians with staff privileges at their facilities and also provides guidance for counsel to properly defend cases with credentialing allegations. More >
2017 Legislation Muddies the Water for Kentucky Physicians and Providers
Kentucky’s 2017 legislative session has been described as the most productive regular session in modern history by Majority Floor Leader Damon Thayer. Over a hundred bills during the session addressed healthcare-related issues reflecting the priorities of Republican Leadership and its initiative to repeal the Affordable Care Act (Obamacare). While many bills failed to gain traction, several important new laws were enacted that not only require Kentucky physicians and providers to change their practices, but also offer possible protection from lawsuits. The following is a review of some of the most important new legislation resulting from the 2017 session. More >
CMS Executes About-Face on Pre-Dispute Arbitration Ban
The Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule on June 5, 2017, that serves as an effective course reversal on pre-dispute arbitration agreements in a long-term care (“LTC”) setting. This caps off an effort by many in the healthcare and nursing home industry to stop the prior rule, which banned such agreements, from taking effect. More >
Compliance Programs for Nursing Facility Providers
Nursing facilities are now required to develop and implement effective compliance and ethics programs under newly-created Section 483.85 of the Affordable Care Act (“ACA”) §6102. These programs must be in effect by November 28, 2017. These regulatory requirements are highly complex, especially the requirement of annual review and revision of the programs. More >
"Incident to" Billing - Easy to Get Wrong
Billing for medical services is never easy. Despite attempts by the Centers for Medicare & Medicaid Services (“CMS”) to simplify the rule regarding “incident to” billing for Medicare services, it remains misunderstood by a large swath of providers. This proves problematic, as incorrect billing practices may lead to overpayments and False Claims Act violations. Billing for “incident to” services is an important mechanism to reflect the actual value of mid-level services provided under the specific plan of a physician. When properly followed, the “incident to” rules allow physicians to bill for services provided by non-physician practitioners as if they were performed by the physician at physician reimbursement rates. Additionally, the non-physician provider can be an employee, an independent contractor or even a leased employee, provided that they are supervised by a physician and the requirements are met. Because of the confusing nature of allowing a physician to bill for services he or she did not directly provide to the patient, serious landmines exist that can create problems if the rules are not scrupulously followed and documented. More >
A New Day for Healthcare in Kentucky
Starting in July, practitioners may be asked to sign for mail from the Cabinet for Health and Family Services and open this to discover a “Proposed Complaint.” Thanks to a new and sweeping effort at reform in healthcare in the Commonwealth, Kentucky healthcare providers now need to know what to expect if they receive such a Proposed Complaint. More >
Kentucky’s HB 333 and Schedule II Drug Prescriptions – What Providers Need to Know
On April 10th, 2017, Gov. Bevin signed HB 333 into law, adding another tool to an ever-necessary arsenal to combat Kentucky’s opioid epidemic. While the new law should serve to help curb painkiller abuse, it adds new regulations to physicians in an already heavily-regulated area of practice. Providers must now understand the new restrictions and adjust their pain management practices to accommodate them. More >
Watch out MCOs--What to do with Medicaid Managed Care Organizations’ Payment Denials. Medicaid’s Findings of Alleged Overpayments—Relief?
With reported revenues in the billions of dollars and net profits not far behind, insurance companies providing a Medicaid Managed Care product are making huge profits on Kentucky’s Medicaid business. Across the country, lawsuits are being filed that go so far as to allege that these Medicaid Managed Care Organizations (“MCOs”) have been unjustly enriched and have made fraudulent misrepresentations, as well as negligent misrepresentations to providers and their staff. WellCare, in particular, is the subject of a new action in Florida based, in part, on its Kentucky Medicaid business. While these lawsuits create a very important way to address reimbursement issues, Kentucky providers have a new avenue to pursue claims against MCOs. In April of 2016, the Kentucky legislature directed that health care providers have a process by which a Medicaid MCO’s final decision denying a healthcare service or claim could be reviewed and appealed. Under the statute, providers could receive an independent, third-party review of denied Medicaid managed-care claims, as well as an administrative process for review. Prior to the new process in Senate Bill 20, the only avenue for appeal was to the MCO itself or through the Department of Insurance’s policy of reviewing claims regarding failure to make prompt payment, which was a process established by policy, not regulation. Finally, in December 2016, the final regulations implementing the statute and providing the process for appeal were promulgated by Kentucky’s Department for Medicaid Services (“DMS”), making available long-awaited relief for health care providers facing denied claims from Medicaid MCOs. More >
