Healthcare Law Blog

Malnutrition Diagnosis Codes: The Compliance Danger You’re Not Taking Seriously Enough

It may seem like hair-splitting, but including the wrong diagnostic codes for malnutrition on hospital inpatient claims – using codes for severe malnutrition in place of other forms of malnutrition – is a costly mistake. The estimated overpayment as a result of these coding errors is a reported $1 billion. Because the payment error rate was so high at a colossal 31%, Medicare-Severity Diagnosis Related Group ("MS-DRG") applicable entities must take note and prepare for a marked increase in Department of Health and Human Services Office of Inspector General ("OIG") audits for these coding practices. The Centers for Medicare & Medicaid Services ("CMS") also plans to implement review practices for malnutrition coding on a sample of inpatient claims. The increased payer audits will result in severe financial damage for hospitals and other MS-DRG applicable entities if they do not mitigate coding and documentation risks. More >

Getting Long-Term Lost with Compliance for Long Term Care? OIG Has A Roadmap

Long Term Care (“LTC”) facilities have been a renewed area of focus for regulators in recent years, due to changes in Medicare and the potential for harm to a vulnerable population at the hands of bad actors. In April of 2019, for instance, the U.S. Department of Health & Human Services Office of Inspector General (“OIG”) put out a Data Brief with the ominous headline, “Trends in Deficiencies at Nursing Homes Show That Improvements Are Needed To Ensure the Health and Safety of Residents.” Unfortunately, this renewed focus exponentially increases the need for a push to instill compliance as a key tenet of a facility’s culture. Luckily, in 2000 and again in 2008, the OIG released a very clear roadmap for compliance that’s still reliable today. We’ll hit some of the highlights. More >

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.   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 >

Recap of the Webinar, "What Providers Should Know: Overpayments and the False Claims Act"

On May 24th and 25th, 2016, McBrayer held a webinar on what providers should know regarding overpayments and the False Claims Act.  Lisa English Hinkle and Chris Shaughnessy, McBrayer healthcare law attorneys, guided participants through the interplay between overpayments from various federal healthcare programs and violations of the False Claims Act that can accrue heavy penalties. For further information on this webinar, contact McBrayer’s Marketing Director, Morgan Hall.

Some of the information shared by the presenters is also summarized below. More >

The One Simple Rule for Practitioners to Avoid Overpayments and False Claims Act Penalties

In December, the Centers for Medicare and Medicaid Services (“CMS”) released its “Supplementary Appendices for the Medicare Fee-for-Service 2015 Improper Payments Report,”[1] an annual compilation of statistics from investigations into overpayments and other instances of fraud, waste and abuse in Medicare payments. What should shock Kentucky providers is that Kentucky has the seventh highest percentage of projected overpayments at 15.4%, or $897.7 million.[2] More than one out of every seven Medicare fee-for-service payments made in the Commonwealth is projected to be an overpayment in 2015, yet many of these problems could have been avoided by following one simple rule: document claims properly.

[1] U.S. Department for Health and Human Services, the Centers for Medicare and Medicaid Services. (2015). The Summary Appendices for the Medicare Fee-for-Service 2015 Improper Payments Report. Retrieved from  https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports-Items/Downloads/AppendicesMedicareFee-for-Service2015ImproperPaymentsReport.pdf

[2] Ibid. at 13. More >

Good News, Providers: A Mere Difference of Medical Opinion Does Not A False Claim Make

FINALLY, some good news for providers related to false claims. In a very important Alabama case, a federal trial court granted summary judgment to AseraCare, Inc., in a False Claims Act[1] action where it had been alleged that the hospice program had knowingly submitted false claims to Medicare for patients who were allegedly not terminally ill. In its opinion, the U.S. District Court ruled that the Government may not prove falsity for purposes of the False Claims Act based solely upon the opinion of one medical expert who disagrees with the certifying physician and the patient's treating physicians about whether the medical records reported eligibility for the hospice benefit. In a ruling that all health providers can cheer, the court held that "[a] mere difference of opinion between physicians, without more, is not enough to show falsity."[2]

[1] 31 U.S.C. §§ 3729–3733

[2] United States v. AseraCare, lnc., No. 2:12-CV-245-KOB (MD

Alabama March 31, 2016) at 2. More >

CMS finalizes the 60-day overpayment rule and providers can breathe a little easier

The wait is over – in February, the Centers for Medicare & Medicaid Services (“CMS”) released its Final Rule on identifying, reporting, and returning overpayments to the Medicare and Medicaid programs. This rule is the result of provisions in the Patient Protection and Affordable Care Act (“ACA”) which created a 60-day safe harbor during which providers can identify overpayments by the two major federal healthcare programs. If a provider fails to report an overpayment within 60 days of the date that it was identified, the overpayment may be considered a violation of the federal False Claims Act (“FCA” - for more information on the FCA, please read my earlier blog posts). The Final Rule implementing this provision became effective on March 14, 2016. 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 >

The Doctor’s Doctor: Professional Courtesy in an Age of Healthcare Regulation

For over 200 years, professional courtesy has been a hallmark of physician practice, a symbol of collegiality among doctors.  Historians describe its 18^th century beginnings as physicians providing charity care for the families of their deceased colleagues—an early form of health insurance for doctors’ widows and children.  Over the years, the concept of collegial care also became the preferred alternative to physicians treating themselves or their own family members.  In fact, the American Medical Association’s (“AMA”) first code of medical ethics created an obligation among doctors to reciprocate medical care and to extend the courtesy to physician family members as well. Today, the AMA recognizes professional courtesy as a “long-standing tradition” but not an ethical requirement.[1]  The federal government’s commentary about “the provision of free or discounted health care items or services to a physician or his or her immediate family members or office staff,” however, is far more cautious than nostalgic. [2]   The Department of Health and Human Services Office of Inspector General’s advice that physicians “consult with an attorney” before extending professional courtesy warns that certain arrangements for free or discounted medical care run afoul of fraud and abuse laws.[3] More >