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Archives for July 2015

DCH’s “Engagement Process” Now Official

DCH Policy As of July 2015, the Department of Community’s Health’s “Engagement Process” became an official part of its Policy and Manual, section 402.5(b).

The “Engagement Process” offers providers an opportunity to discuss findings of an audit or other proposed adverse action and to possibly resolve the matter prior to any request for an Administrative Review during an Engagement Conference.

However, we strongly advise you to contact an attorney prior to requesting an Engagement Conference to help ensure the best possible outcome. 

Here is what you need to know:

  • PURPOSE: The purpose of the Engagement Conference is to discuss a proposed adverse action “with the goal of informally resolving the matter.”
  • WHO INITIATES: You. A provider may request an Engagement Conference following receipt of Initial Findings of Notice of Proposed Adverse Action letter
  • PROVIDER TIME DEADLINE: This request must be in writing within seven (7) calendar days of receipt; and submitted to Engagement@dch.ga.gov.
  • DCH TIME DEADLINE: The Engagement Conference must be held with twenty-one (21) calendar days of the receipt of the Request.
  • WAIVER: If you do not participate in the Engagement Conference and fail to provide the Department prior written notice of your absence, you waive your right to an Engagement Conference. Notice should be submitted to Engagement@dch.ga.gov. This waiver does not preclude you from requesting an Administrative Review.
  • SETTLEMENT:“The Engagement Conference is considered settlement talks, and therefore, is not admissible in any pending or future proceeding, including Administrative Review or Administrative Hearing.” This includes conduct during conferences, notes, and correspondence.
  • ACCEPTANCE/REJECTION: You have seven (7) calendar days from the date of the Conference to accept or reject the offer in writing.
    • Acceptance must be in writing and waives your right to an administrative review.
    • If you reject the offer, you have the Right to Request an Administrative Review pursuant to Policy and Procedures Manual Sections 402.6 and 505.

Remember to print a copy of any communication you have with DCH and always ask for a “read receipt” when you send an email to DCH.

If you have received a Proposed Adverse Action from the Department, please contact Kimberly Sheridan at ksheridan@jeylaw.com or 678-708-4703 for assistance.

What to Do When Your Special Needs Child Turns 18 | Financial Support

Special Needs Trust

The financial planning steps you take when your special needs child turns 18 will establish the foundation for your child’s support and well being for the rest of his or her life.

If you make the wrong decision during this transition, it could affect your child well into the future – often when we’re no longer here to care for him or her.

Therefore, as parents of special needs children, it’s important for us to understand our options when planning for our children’s financial future.

Most special needs planning begins with a look into whether a child needs and qualifies for Supplemental Security Income (SSI) for support. SSI is a means-based program for people with disabilities and provides a limited monthly cash benefit of about $733 a month, the exact amount depending on the state and whether the beneficiary receives housing or income from other sources.

In and of itself, this payment may or may not mean much for a child’s financial future, but SSI eligibility also comes with a much more important benefit — access to Medicaid. For this reason alone many families, especially those with children who have major medical expenses, pursue SSI benefits despite the program’s severe income and asset limits. SSI can also be the ticket into vocational training and group housing services.

Once a child reaches age 18, she qualifies for SSI based on her own income and assets. In order to receive benefits, the child must meet the government’s disability standard, have less than $2,000 in assets and receive minimal income. Each dollar of unearned income (including any direct payments of cash to a beneficiary, along with additional reductions for in-kind payment for food and shelter) and every two dollars of earned income reduces a beneficiary’s base SSI award by one dollar.

If the SSI benefit reaches zero because of this reduction, SSI coverage ends. Despite these restrictions, an SSI beneficiary needs only a $1 award in order to retain her Medicaid benefits, so careful planning in this realm carries great rewards.

A child who became disabled before reaching 22 years of age can also collect Social Security Disability Insurance (SSDI) based on a parent’s work record if either of his parents has worked enough quarters to collect Social Security and is already receiving Social Security benefits or has died. Under SSDI, the “adult disabled child” of the Social Security beneficiary receives a monthly benefit check, as long as he doesn’t perform substantial work, defined as earning more than $1,090 a month. After receiving SSDI for two years, the adult disabled child also begins to receive Medicare, a substantial benefit.

Often, adults who became disabled as children receive SSI benefits until their parents retire, at which point they transition to SSDI, which is usually preferred both because it may offer a higher monthly benefit and because the beneficiary no longer needs to be concerned about SSI’s strict rules on other sources of income and savings. On the other hand, the switch to SSDI can be problematic if it means that the adult child loses eligibility for Medicaid or other programs.

If a child has more than $2,000 in assets when he reaches age 18, rendering him ineligible for SSI, a parent, grandparent or court has the power to create a special trust, known as a “(d)(4)(A) ” or “first-party supplemental needs” trust to hold his savings. Any assets held by the trust do not count against the $2,000 asset limit for SSI, allowing him to qualify.

One requirement of such trusts is that when the beneficiary dies, any funds remaining in the trust must be used to reimburse the state for medical care the trust beneficiary received during his life. Because of this payback provision, planners often encourage trustees to pay for a child’s supplemental needs from a (d)(4)(A) trust before using other assets, in order to limit the state’s collection later on.

Finally, many families create trusts known as “third-party” supplemental needs trusts in addition to (d)(4)(A) trusts.  As long as families fund these trusts with their own assets (never with their child’s funds) and give the trustee complete discretion to distribute the funds for a beneficiary’s care, the funds held in the trust will not count as the child’s assets. Furthermore, these trusts do not have to contain a payback provision, allowing families to place significant amounts of money into the trust without worrying that the government will receive a large portion later on. The trusts can then provide a child with special needs with services and care he may not receive from other sources throughout his life.

You don’t want to wait to plan for your child’s transition out of childhood. We can help you start planning for the future today. Contact DJ@Jeylaw.com or 678-325-3872.

CMS Proposes 2 New Stark Exceptions

drIf adopted, the new exceptions will provide physicians with more options when setting up financial arrangements with hospitals.

On July 15, the Centers for Medicare & Medicaid Services (CMS) published several proposed changes to the Stark regulations as well as two new exceptions. The changes made pursuant to the proposed rule would clarify certain requirements which must be met for many of the Stark Law exceptions.

One notable change would impact several Stark exceptions (e.g., office space and equipment rental, personal service arrangements, physician recruitment arrangements, etc.) which require that an arrangement be either “in writing” or memorialized in a “written agreement.” If adopted, the proposal would make the writing requirement uniform throughout by replacing “written agreement” with “in writing.” CMS’s comments further clarify that a formal contract is not required. Rather, if under the circumstances it is appropriate, the writing requirement may be satisfied with a collection of “contemporaneous documents evidencing the course of conduct between the parties.”

CMS also provides clarification on how to satisfy Stark exception requirements that are conditioned on having an arrangement that lasts at least one year. According to CMS, a “formal contract or other document with an explicit ‘term’ provision is generally not necessary to satisfy the [one-year-term] element.” An arrangement that lasts at least one year satisfies the requirement.

The two new Stark Law exceptions involve payments related to employment of non-physician practitioners and timeshare arrangements for the use of office space, equipment, supplies, etc. The first exception would allow hospitals, Federally Qualified Health Centers and Rural Health Centers to subsidize physicians for the cost to employ physician assistants, nurse practitioners, clinical nurse specialists and certified nurse midwives up to a certain amount. The goal of the proposed exception is to promote the expansion of access to primary care services.

The other proposed exception would protect timeshare arrangements if certain requirements are met. Such arrangements would need to be between a hospital or physician organization (licensor) and a physician (licensee) for the use of the licensor’s premises, equipment, personnel, items, supplies, or services. Additionally, the licensed premises, equipment, personnel, items, supplies, and services would need to be used predominantly for evaluation and management services to patients of the physician.

If adopted, the new exceptions will provide physicians with more options when setting up financial arrangements with hospitals. However, CMS also clarifies and broadens certain limitations — the percentage of a hospital that may be owned by physicians will now encompass all physician owners, regardless of whether a physician owner refers patients to the hospital.

The CMS publication can be read here.

If you have any questions about the CMS guidance and proposed changes, our attorneys can help. Please contact Danielle Hildebrand at dhildebrand@jeylaw.com at 678-325-3872

 

What To Do When Your Special Needs Child Completes High School

ClassroomPictPart I: The Path To Employment

As our children begin to enter into early adolescence, many of us begin to realize that many – if not all – of the services and programs that our child relies on for care will soon disappear and be replaced by radically different benefits.

Most of these new benefits abruptly come into play once our children leave the public education system. This may happen at any time between the ages of 18 and 23, depending on the state you live in and your child’s particular needs.

One of the most important aspects of this transition is securing employment services for our children. According to the National Collaborative on Workforce and Disability, one-quarter of all adults with disabilities work at either a full- or part-time job.

Some of the remaining three-quarters are unable to work at all due to their disability; but a large number of disabled adults who aren’t employed don’t have a job because they lack the skills necessary for gainful employment. Several federal laws address this situation with the goal of providing vocational education to a wider segment of the population with disabilities.

The Individuals with Disabilities Education Act (IDEA) mandates that special education plans begin transition planning when a child turns 14. At this point, a written transition plan must be incorporated into a child’s Individual Education Plan (IEP), outlining the steps a school will take to help a child with special needs acquire skills necessary for an eventual move into the workforce.

By the time the child turns 16, the special education team must steer the child towards development programs keyed towards the child’s individual vocational preferences. The law also mandates periodic measurement of the child’s progress to ensure that he receives attention from the proper vocational advocates.

Once your child reaches 18 and receives either Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) payments, the Social Security Administration (SSA) offers several programs to encourage your child to work. The best-known program, Ticket to Work, is a somewhat complicated program designed to offer beneficiaries a way to begin a career without having to worry about losing their SSI or SSDI benefits.

SSI beneficiaries, on the other hand, must conform to very strict income and asset limits. Often, beneficiaries who could hold a job do not pursue one because they are worried that they will lose their SSI benefits once they earn too much. While this is certainly a concern, the benefits of employment may outweigh the loss of SSI. Furthermore, the government provides specific incentives for SSI beneficiaries to work. For instance, if a person with disabilities is under 22 and at school or in a vocational training program, $1,780 of his monthly income does not count against his SSI benefit, up to a yearly limit of $7,180.

The Social Security Administration also offers the PASS (Plan for Achieving Self Support) program for SSI beneficiaries who would like to work. Under this program, a beneficiary presents the SSA with a detailed plan for obtaining a specific type of employment. Once the SSA approves the plan, a beneficiary sets aside income and assets towards achieving her goal without having those funds count against her benefit. Funds can be used for things like childcare, transportation, books and supplies, and additional education and training.

Many programs are available for people with special needs to seek employment if they would like to do so. Unfortunately, the rules for most of these programs are complicated and the SSA is often not very good at explaining them.

Beginning to plan well before your child completes high school – with the assistance of local vocational agencies and qualified special needs planners – is your best chance for successfully navigating the maze of educational opportunities for your child.

 

 

ICD-10 Deadline Less Than 3 Months Away – Need Help?

CMS Announces Measures To Help Ease Transition

The countdown to the ICD-10 has begun in earnest, and the Centers for Medicaid & Medicare Services (CMS) has made it clear that it will not back down on the deadline of October 1, 2015. However, CMS announced on July 6, that it is adopting policies to help ease the transition to ICD-10.

The ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code. ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims.

Although the American Medical Association (AMA)  has long opposed the ICD-10 conversion, it issued a joint press release with CMS on July 6. The press release addresses some of the AMA’s concerns and offers some concessions by CMS. To assuage concerns from healthcare providers about inadvertent coding errors that could lead to audits and penalties, CMS has named a CMS ICD-10 Ombudsman to triage and answer questions about the submission of claims. The ICD-10 Ombudsman will be located at CMS’s ICD-10 Coordination Center. CMS has also released provider training videos and an outline of its implementation plan.

Additionally, CMS has announced that for one year past the Oct. 1, 2015, deadline, it will reimburse for incorrectly coded claims as long as that erroneous code is in the same broad family as the right one.

Providers should note that claims for services provided on or after the compliance date will need to be submitted with ICD-10 diagnosis codes; but claims for services provided prior to the compliance date should be submitted with ICD-9 diagnosis codes.

It is important for providers to have their practices ready to implement ICD-10 on October 1, 2015. If you need help with the ICD-10 transition and implementation, call Jeyaram & Associates’ Kimberly Sheridan at 678-708-4703.

Physicians Need To Be Prepared For Increased Medicare & Medicaid Fraud Scrutiny

doctor-in-handcuffs-caption-1HHS increases resources to root out and penalize fraud:  Review existing financial arrangements NOW

On June 30th the federal Department of Health and Human Services Office of the Inspector General announced that it has created a specialized unit comprised of attorneys focused on Medicare and Medicaid fraud. This announcement comes on the heels of the OIG Special Fraud Alert reminding physicians of anti-kickback liability for illegal compensation related to arrangements with healthcare institutions.

Physicians should be prepared for increased scrutiny and an uptick in enforcement actions for kickback violations. According to OIG official Lisa Re, the new unit will be targeting kickback cases and will be going after not only the individual or organization paying the kickbacks but also the recipient of the kickbacks, e.g., the physicians.

Physicians who have financial arrangements that violate the Federal Anti-Kickback Statute would not only be subject to fines in the form of Civil Money Penalties, but could also be excluded from the Medicare and Medicaid programs.

Now is the time for physicians to review existing or proposed financial arrangements to ensure that they do not pose any risk of violating the Anti-Kickback Statute.

If you have any questions about a particular arrangement our attorneys can help. Please call Danielle Hildebrand or DJ Jeyaram at 678-325-3872 for legal counsel.