Contact Us
Categories
- Department of Health and Human Services' Office of Civil Rights
- Medical Residents
- EMTALA
- FDA
- Reproductive Rights
- Roe v. Wade
- SCOTUS
- Medical Spas
- medical billing
- No Surprises Act
- Mandatory vaccination policies
- Workplace health
- Coronavirus Aid, Relief and Economic Security Act
- Code Enforcement
- Department of Labor ("DOL")
- Employment Law
- FFCRA
- CARES Act
- Nursing Home Reform Act
- COVID-19
- SB 150
- Acute Care Beds
- Clinical Support
- Coronavirus
- Emergency Medical Services
- Emergency Preparedness
- Families First Coronavirus Response Act
- Family and Medical Leave Act (“FMLA”)
- KBML
- medication assisted therapy
- Department of Health and Human Services
- Legislative Developments
- Corporate
- United States Department of Justice ("DOJ")
- Employee Contracts
- Non-Compete Agreement
- Opioid Epidemic
- Sexual Harassment
- Health Resource and Services Administration
- Litigation
- Medical Malpractice
- House Bill 333
- Senate Bill 79
- locum tenens
- Senate Bill 4
- Physician Prescribing Authority
- Chronic Pain Management
- HIPAA
- Prescription Drugs
- "Two Midnights Rule"
- 340B Program
- Hospice
- Kentucky minimum wage
- Minimum wage
- Skilled Nursing Facilities (“SNFs”)
- Uncategorized
- Drug Screening
- EHR Systems
- Electronic Health Records (“EHR")
- ICD-10
- Mental Health Care
- Primary Care Physicians ("PCPs")
- Urinalysis
- Accountable Care Organizations (“ACO”)
- Affordable Insurance Exchanges
- Anti-Kickback Statute
- Certificate of Need ("CON")
- Compliance
- Department of Health and Human Services (HHS)
- Federally Qualified Health Centers (“FQHCs”)
- Fee for Service
- Fraud
- Health Care Fraud
- HIPAA Risk Assessment
- HPSA
- KASPER
- Kentucky Board of Medical Licensure
- Kentucky’s Department for Medicaid Services
- Office for Civil Rights ("OCR")
- Office of Inspector General of the United States Department of Health and Human Services (OIG)
- Part D
- Pharmacists
- Physician Assistants
- Qui Tam
- Rural Health Centers (“RHCs”)
- Stark Laws
- Telehealth
- Affordable Care Act
- Alternative Payment Models
- American Telemedicine Association (“ATA”)
- Centers for Medicare & Medicaid Services (“CMS”)
- Charitable Hospitals
- Data Breach
- Electronic Protected Health Information (ePHI)
- False Claims Act
- Health Information Technology for Economic and Clinical Health Act (HITECH Act)
- Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- Health Professional Shortage Area ("HPSA")
- Hospitals
- HRSA
- Kentucky Board of Nursing
- Limited Services Clinics
- Medicaid
- Medical Staff By-Laws
- Medically Underserved Area ("MUA")
- Medicare
- Mid-Level Practitioners
- Patient Protection and Affordable Care Act (“ACA”)
- Rural Health Clinic
- Telemedicine
- APRNs
- Criminal Division of the Department of Justice (“DOJ”)
- Health Care Fraud Prevention and Enforcement Action Team (“HEAT”)
- Hydrocodone
- Kentucky Pharmacists Association
- Qualified Health Care Centers (“FQHC”)
- United States ex. Rel. Kane v. Continuum Health Partners
- Webinar
- Agreed Order
- Chain and Organization System (“PECOS”)
- Chiropractic services
- Clinical Laboratory Improvement Amendments of 1988 (“CLIA”)
- Douglas v. Independent Living Center of Southern California
- Drug Enforcement Agency ("DEA")
- Emergency Rooms
- Enrollment
- Hinchy v. Walgreen Co.
- Jimmo v. Sebelius
- Kentucky Senate Bill 7
- Maintenance Standard
- Medicare Part D
- Minors
- Ophthalmological services
- Overpayments
- Physician Compare website
- Re-validation
- Texting
- Vitas Innovative Hospice Care
- 2014 Medicare Physician Fee Schedule (“PFS”)
- 501(c)(3)
- Affinity Health Plan
- All-Payer Claims Database ("APCD")
- Appeal
- Cadillac tax
- Centers for Disease Control and Prevention
- Chronic Care Management
- Community health needs assessment (“CHNA”)
- Compliance Officer
- Compounding
- CPR
- Denied Claims
- Dispenser
- Drug Quality and Security Act (“DQSA”)
- Essential Health Benefits
- Federation of State Medical Boards (“FSMB”)
- Food and Drug Administratio
- Form 4720
- Grace Period
- HealthCare.gov
- House Bill 3204
- ICD-9
- Individual mandate
- Kentucky Medical Practice Act
- Kindred v. Cherolis
- Kynect
- Long-term care communities
- Mobile medical applications ("apps")
- Model Policy for the Appropriate Use of Social Media and Social Networking in Medical Practice (“Model Policy”)
- National Drug Code ("NDC")
- National Institutes of Health
- New England Compounding Center ("NECC")
- Nonprofit hospitals
- Outsourcing facility
- Physician Payments
- Ping v. Beverly Enterprises
- Power of Attorney ("POA")
- Prescriber
- Qualified Health Plan ("QHP")
- Social Media
- Spousal coverage
- State Health Plan
- Sustainable Growth Rate (“SGR”)
- UPS
- "Plan of Correction"
- Advanced Practice Registered Nurses
- Arbitration
- Audit
- Business Associate Agreements
- Business Associates
- Call Coverage
- Condition of Participation ("CoP")
- Daycare centers
- Decertification
- Department of Medicaid Services’ (“DMS”)
- Division of Regulated Child Care
- Doe v. Guthrie Clinic
- EHR vendor
- Employer Group Health Plans
- Employer Mandate
- ERISA
- Fair Labor Standards Act (FLSA)
- False Billings
- Group Purchasing Organizations ("GPO")
- Health Professional Shortage Areas (“HPSA”)
- Health Reform
- Home Health Prospective Payment System
- Home Medical Equipment Providers
- Hospitalists
- House Bill 104
- Inpatient Care
- Intermediate Sanctions Agreement
- Kentucky Health Benefit Exchange
- Kentucky House Bill 217
- Licensed practical nurses (LPN)
- Licensure Requirements
- List of Excluded Individuals and Entities
- LLC v. Sutter
- Long-Term Care Providers ("LTC")
- Low-utilization payment adjustment ("LUPA")
- Meaningful use incentives
- Medicare Administrative Coordinators
- Medicare Benefit Policy Manual
- Medicare Shared Saving Program (MSSP)
- Network provider agreement
- Nonroutine medical supplies conversion factor (“NRS”)
- Nurse practitioners (NP)
- Office of the National Coordinator for Health Information Technology (“ONC”)
- Part A
- Part B
- Patient Autonomy
- Patient Privacy
- Payors
- Personal Health Information
- Personal Service Entities
- Physician Recruitment
- Physician shortages
- Provider Self Disclosure Protocol
- Quality reporting
- Registered nurses (RN)
- Residency Programs
- Self-Disclosure Protocol
- Senate Bill 39
- State Medicaid Expansion
- Statement of Deficiency ("SOD")
- Trade Association Group Coverage
- Upcoding
- “Superuser”
- Autism/ASD
- Center for Disease Control
- Compliance Programs
- Critical Access Hospitals (“CAHs”)
- Essential Health Benefits (“EHBs”)
- Genetic Information Nondiscrimination Act ("GINA")
- Healthcare Information and Management Systems Society (HIMSS)
- Kentucky House Bill 159
- Kentucky Primary Care Centers (“PCCs”)
- Managed Care Organizations (“MCOs”)
- Medicare Audit Improvement Act of 2012
- Occupational Safety and Health Administration (“OSHA”)
- Recovery Audit Contractors (“RAC”)
- Senate Finance Committee Report
- Small Business Health Options Program (“SHOP”)
- Sunshine Act
- Abuse and Waste
- Consumer Operated and Oriented Plan programs (“CO-OPS”)
- Employee Agreement
- Free Conference Committee Report
- Health Care Fraud and Abuse Control Program
- House Bill 1
- House Bill 4
- Kentucky Cabinet for Health and Family Services
- Kentucky Health Care Co-Op
- Kentucky Health Cooperative (“KYHC”)
- Kentucky “Pill Mill Bill”
- Pain Management Facilities
- Health Care Law
- Health Insurance
- Healthcare Regulation
McBrayer Blogs
Compliance is Crucial
This article appeared in the December edition of MD-UPDATE, available at http://www.md-update.com/wp-content/uploads/2018/12/MD-Update-Issue-118/#?page=8
In the current legal enforcement environment, it is crucial that healthcare providers prioritize compliance initiatives and programs in order to avoid illegal practices that may result in large financial penalties and both criminal and civil liability.
The staggering success of the Federal government’s recoupment efforts is easily recognizable. In FY 2017, the Department of Justice (“DOJ”) recovered a total of $3.7 billion in settlements and judgments from civil fraud and False Claims Act cases.[1] Specifically, $2.4 billion was recovered through settlements and judgments from civil cases involving healthcare providers who defrauded the government.[2] Since Congress strengthened the civil False Claims Act in 1986, the Federal government has recovered an astounding $56 billion from providers defrauding the government.[3] Given the increased penalties that the Federal government can pursue as of January 1, 2018, a healthcare provider can be liable for fines ranging from $11,181 to $22,363, per false claim, plus triple the amount of damages. For every $1 invested in enforcement activities, the government earns $4 in return.
Whether it is the Federal government directly bringing an action under the False Claims Act, an action by a relator (a whistleblower) through a Qui Tam suit (type of lawsuit filed on behalf of the government), or an insurance company’s special investigation unit recouping from their contracted providers for fraudulent practices, healthcare providers must identify and implement the most efficient way to prevent compliance issues and fraudulent billing practices. Simply put, by establishing clear expectations and promoting a culture of compliance, healthcare providers can implement tools that allow its employees to operate in a compliant manner without compromising patient care and treatment.
Compliance is in a healthcare provider’s financial best interest. Healthcare providers looking to either establish a compliance program or reevaluate the effectiveness of an existing program should seek to:
- 1) operate with concise policies and procedures.
- 2) establish a commitment to reasonable and attainable compliance expectations 3) ensure the autonomy of a compliance program within the healthcare provider’s strategic initiatives.
- 4) conduct meaningful training for all employees on an ongoing basis.
- 5) establish a “hotline” that allows employees to report compliance issues in confidence and without the fear of repercussions.
- 6) test both employees’ and management’s ability to recognize and address real-world compliance problems.
Compliance is an important tool in the war against opioids. As a result of the astounding number of opioid-related deaths across the nation and particularly in Kentucky, the Federal government is ramping up operations to combat the opioid crisis, which was declared a Public Health Emergency in October 2017. In 2018, the DOJ established the Prescription Interdiction Task Force, and, as a result, Kentucky is now one of 12 states nationwide that has been assigned additional Federal prosecutors solely focused on investigating and prosecuting healthcare fraud related to opioid prescribers and pharmacies.
The use of the False Claims Act as a tool to combat the opioid epidemic has already been successful. In 2017, two pharmacies paid $11.75 million and $2.75 million, respectively, to settle False Claims Act allegations concerning opioids. Similarly, medical providers have been convicted and sentenced to long prison terms for accepting kickbacks relating to the prescription of opioid products, falsifying patient records to fraudulently bill insurers, and prescribing fentanyl-based pain medication for non-legitimate uses. In August 2018, the DOJ announced a $225 million settlement with Insys Therapeutics, Inc. concerning its sub-lingual spray fentanyl-based opioid. The settlement was based on violations of the False Claims Act and the Anti-Kickback Statute. Insys Therapeutics, Inc., was accused of not only targeting non-cancer patients to market its fentanyl-based opioid for off-label uses, but also inducing and paying medical providers to use the fentanyl-based opioid while knowingly causing Medicare and other Federal healthcare programs to pay for non-approved uses.
As the opioid epidemic continues to evolve, healthcare providers and federal, state and local governments are filing lawsuits against pharmaceutical companies seeking compensation for services related to treating opioid users. Also, the Federal government and insurance companies are utilizing available resources to seek recoupment against healthcare providers to offset the economic burden caused by opioid misuse, which is estimated to cost approximately $78.5 billion a year. With increasing enforcement and recovery efforts, healthcare providers should ramp up compliance efforts to include review of documentation, prescribing patterns, and billing records for opioid-related treatments.
To ensure your healthcare providers’ compliance, please contact Lisa English Hinkle at lhinkle@mcbrayerfirm.com or call 859-231-8780.
Services may be performed by others.
This article does not constitute legal advice.
[1] Department of Justice– Office of Public Affairs Press Release December 21, 2017.
[2] Id.
[3] Id.