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Bill Would Eliminate Several Certificate Of Need (CON) Requirements

Certificate of NeedGeorgia House Bill 1055 Would Eliminate “Certificate of Need” (“CON”) Requirements For Several Types Of Healthcare Facilities

Georgia House Bill 1055 would cause a substantial change in the way the state regulates healthcare providers. Georgia’s CON program is administered by the Department of Community Health (DCH). A CON is required for entities before building, acquiring or expanding healthcare services and facilities. Read the full bill here.

Roots of CON Requirements Almost 40 Years Old

Georgia first created its CON program in 1979 in response to the federal “Health Planning Resources Development Act” of 1974. The federal act was later repealed, but many states including Georgia continue to have CON requirements.

The goal of Georgia’s CON program was to “ensure access to quality health care services and to ensure that health care services and facilities are developed in an orderly and economical manner and are made available to all citizens and that only those health care services found to be in the public interest shall be provided in this state.” § 31-6-1. However, since then, the efficacy of CON programs has been questioned, and bills have been introduced seeking to change Georgia’s CON program one way or another nearly every year.

Larger Healthcare Providers Argue CONs Increase Barriers To Expanding

Larger hospitals oppose measures to weaken CON requirements which restrict potential competitors. Hospitals argue they need to use profits from surgical procedures to subsidize less profitable care they are required to provide to the uninsured. On the other hand, physicians and smaller healthcare facilities tend to advocate weakening or eliminating CON requirements because those requirements create barriers to offering services in certain healthcare areas. If House Bill 1055 passes, it would significantly reduce barriers for building multi-specialty surgery centers. Physicians contend changes like this would help lower healthcare costs.

Get Help With CON Requirements

Unless House Bill 1055 passes, Georgia’s CON program will continue to loom large for health care providers of all sizes. At Jeyaram & Associates, we have extensive experience with the CON process and related Letter of Determination and Letter of Non-Reviewability requirements and can help your practice. Contact DJ Jeyaram at DJ@Jeylaw.com  or Jonathan Anderson at Janderson@Jeylaw.com.

 

Champion Change for Special Needs Children: Sign the Katie Beckett Petition

Katie Beckett PeitionIn the early 1980’s a little girl named Katie Beckett was only 3 years old and suffering from a viral brain infection she caught a 5 months old that left her fighting for her life and permanently disabled. Her parents insurance was capped at one million dollars and they quickly surpassed that. Medicaid began covering her hospital stay. She was in the hospital for 3 years before her condition improved to where going home was even a possibility. BUT they faced a huge obstacle. While in the hospital Medicaid covered Katie’s needs. At home, her parents would not qualify. Her parents could not afford her care.

The dire situation of Katie Beckett got the attention of President Ronald Reagan. He too saw the absurdity. Her hospital stay was costing taxpayers more than providing Medicaid to her parents so they could provide her treatment at home. In 1981 Katie Beckett’s family was the first to receive the soon called Katie Beckett waiver and a week before Christmas Katie finally left the hospital with her new doll from the Reagan family in tow. In 1982 it was expanded to be a state plan option provision under Medicaid.

More than 30 years later, it is children in GA that now need help. Children who, like Katie, are severely affected by cognitive, developmental and physical disabilities. These children are in danger of losing the help they NEED and becoming wards of the state and institutionalized if they cannot receive the help their parents need to care for them at home. It is highly likely that Katie Beckett herself would not qualify for the waiver named after her if she were a child today living in the state of Georgia. Currently GA families are facing an unreasonable tightening and reevaluation of the requirements for those children receiving the Katie Beckett Medicaid Deeming Waiver.

The requirements are now stating that therapy/ nursing must be received 5 DAYS a week. While this requirement might not seem extreme, if enforced to this exact interpretation, thousands of children needing help would be denied and thousands of families would be forced with the agonizing decision of ripping apart their families and having their beloved children institutionalized in hospitals at great expense to the taxpayers of the state of Georgia. There is a provision in the guidelines that states that children with disabilities qualify regardless of ability to participate in therapy if they meet certain psychological testing guidelines.  This provision is being overlooked and children are routinely being denied. What are some of the problems?

NURSING:

  • It is very hard for families of medically fragile children to qualify and/or afford in-home nursing care for their children. In fact, the Department of Community Health is removing access to nursing care of these medically fragile, vulnerable children.
  • The majority of private insurance companies do not cover in home, private duty nursing care. In many instances, there are not enough nurses to staff the hours and days, particularly for highly specialized care.
  • A parent may choose to become their child’s unpaid 24/7 nurse for their child after being trained and given oversight by qualified personnel. Because they do not have “skilled nursing hours” they can be denied Katie Beckett with these stricter requirements.

THERAPY:

  • A parent may receive a prescription for therapy 5 or more sessions a week from their doctor which is the amount of therapy that is medically necessary for the child. Many times it is impossible for children to be able to receive it. Lack of availability of therapists and therapy centers.
  • There are not enough therapy centers or therapists to accommodate the growing list of children who now need 5 sessions of therapy a week in order to keep the Katie Beckett Deeming Waiver.
  • If a parent is lucky enough to find such a center, there is then usually a wait list for afternoon hours. Many children attend school during the day and many parents try to have therapy later in the day so the child misses the least amount of school.
  • Most primary insurance plans have limitations on amount of therapy or what type is covered. Many families cannot afford it and may not be enrolled in therapy when they apply for Katie Beckett. Medicaid rarely covers five days per week of therapy for any child, even the most severe.
  • Lack of therapy services and providers in the school setting. Across the state, the majority of children receiving therapeutic services at school through their IEPs are enrolled in group therapy. Many schools only offer this due to limited funding, time, and staffing. While there is NOTHING in the Medicaid guidelines stating that this type of therapy cannot be provided or counted, they are now not being allowed to count this as a session of therapy by the state of Georgia. Furthermore, the majority of these children are not able to continue their therapies at school over the summer and are getting penalized as not having enough therapies because of this.
  • Only physical, occupational, and speech therapies are being counted as counted therapies. This excludes other medically researched, peer reviewed proven therapies like Applied Behavioral Analysis (ABA) and music therapy that have greatly improved the quality of life and health of these children.
  • Stamina and health issues of medically fragile children: Some children are too immune compromised to attend a therapy center and/or miss therapy frequently due to hospitalizations, illnesses, medical procedures/appointments.
  • Many parents do not have the means to safely transport their medically complicated or child with severe physical disabilities 5 sessions a week, and parents have had an extremely difficult time finding therapists to come to their homes. They will be DENIED Katie Beckett for this reason.

Please help us to send a clear message to our lawmakers in GA, that we must help these children who cannot help themselves. Without this waiver, more children will be placed in the care of the state of Georgia and be placed in institutions at a cost that can be six times the cost of caring for the child at home which Georgia taxpayers will be paying!

The state of Georgia will be forced to place many of these children in pediatric facilities like Children’s Healthcare of Atlanta for long-term care creating a bed shortage, and ANY sick child across the state of Georgia will suffer due to a lack of treatment space. This policy will cost the state of Georgia more in the long run than any savings it may gain in the short term!

Please sign this petition and let us remind our Governor, Representatives, and those who oversee the Katie Beckett Medicaid Deeming Waiver that this vulnerable population of children matter. We must be the voice of these children who are unable to speak for themselves.

LETTER TO
Governor of Georgia Governor Nathan Deal (Governor of Georgia)
Chair Health & Human Services – Georgia House of Representatives Representative Sharon Cooper
Georgia House of Representatives Speaker Representative David Ralston
and 15 others
Leutenant Governor of Georgia Leutenant Governor Casey Cagle
Chair Senate Health and Human Services Committee Senator Renee Unterman
Department of Community Health – Office of Communications & Legislative Affairs Janice Abrams
Department of Community Health – Office of Communications & Legislative Affairs Jeremy Arieh
Department of Community Health – Director, Office of Communications and Legislative Affairs Lisa Marie Shekell
Department of Community Health – Constituent Services Constituent Services
CBS 46
WSBTV
Atlanta Business News – Atlanta Business Chronicle
AJC
Fox 5 News
11 Alive News
Newnan Times Herald
Georgia Advocacy Office
Children’s Healthcare of Atlanta CHOA Social Media

Please help Georgia’s children with disabilities and preserve the Katie Beckett Deeming Medicaid Waiver created by President Ronald Reagan! These children are in danger of losing the help they NEED and becoming wards of the state and institutionalized if they cannot receive the help their parents need to care for them at home. It is highly likely that Katie Beckett herself would not qualify for the waiver named after her if she were a child living in Georgia today. Currently GA families are facing an unreasonable tightening and reevaluation of the requirements for those children receiving the Katie Beckett Medicaid Deeming Waiver. Without this waiver, more children will be placed in the care of the state of Georgia and be placed in institutions at a cost that can be six times the cost of caring for the child at home which Georgia taxpayers will be paying! The state of Georgia will be forced to place many of these children in pediatric facilities like Children’s Healthcare of Atlanta for long-term care creating a bed shortage, and ANY sick child across the state of Georgia will suffer due to a lack of treatment space. This policy will cost the state of Georgia more in the long run than any savings it may gain in the short term! Please fix this problem started by President Reagan for the sake of these children and the taxpayers of Georgia.

Jonathan Anderson Joins Jeyaram & Associates

Jonathan AndersonPlease help us welcome Jonathan Anderson to our legal team!

Mr. Anderson is an associate attorney specializing in healthcare law. Prior to joining Jeyaram & Associates, Mr. Anderson worked as a legal intern on the Disability Integration Project for the Atlanta Legal Aid Society.

Mr. Anderson provided legal support to individuals with disabilities to help them remain in or move back the community rather than live in institutions. He also worked extensively with state Medicaid waivers including appealing the State’s decisions to terminate benefits of disabled individuals.

Mr. Anderson also served as an intern for the Health Law Partnership (HeLP) which serves clients whom meet certain income requirements and have a treatment relationship with Children’s Healthcare of Atlanta (CHOA). He conducted interviews, drafted briefs for Supplemental Security Insurance, and researched how changes in Supplemental Security Insurance regulations affected HeLP clients.

Legal Expertise

  • Medicaid Waivers
  • Medicare
  • Mediation

Jonathan can be reached at janderson@jeylaw.com.

Even If Your Child Doesn’t Receive SSI Or Medicaid, You May Still Need To Set Up A Special Needs Trust

special needs trustSocial Security Disability Insurance (SSDI) is a federal program that typically provides cash stipends to people who have paid into the Social Security system and who can’t work due to disability.  (In some cases, it is possible to receive SSDI even if you haven’t worked.) In most cases, when someone has been eligible for SSDI benefits for two years, the individual also receives Medicare, even if he or she is under age 65.

From a special needs planning perspective, SSDI benefits are fairly easy to deal with because the program does not have an asset limit or a restriction on unearned income, like interest or dividends.  This means that a millionaire who meets the program’s requirements can receive SSDI benefits alongside a completely impoverished person. It also means that from a purely financial perspective, a person with resources doesn’t need to shelter her assets in a special needs trust in order to qualify for SSDI benefits as she would have to do if she were receiving means-tested government benefits like Supplemental Security Income (SSI) or Medicaid.

But this does not mean that SSDI beneficiaries should not have special needs trusts. In fact, there are many benefits to having a special needs trust that go far beyond the ability to maintain eligibility for SSI or Medicaid. For instance, a person with a mental illness may be unable to manage money. A special needs trust would allow that person’s funds to be invested and spent appropriately by a qualified trustee.  In another case, a person with special needs may be able to handle her personal finances but she might live in an environment where she is susceptible to mistreatment by others. In this situation, a special needs trust would provide an appropriate buffer between the beneficiary and the people who would otherwise take advantage of her.

When it comes to special needs planning, you never want to take anything for granted.  Just because an SSDI beneficiary might not need Medicaid and SSI now, it doesn’t mean she won’t qualify for, or require, services from those programs in the future. For instance, an SSDI beneficiary may rely on private health insurance and Medicare, but if she loses her insurance and Medicare doesn’t cover certain medications, it might be incredibly important for that beneficiary to receive Medicaid, which could make a special needs trust essential.

Finally, there is one particular type of special needs trust, called a first-party special needs trust, that is specifically designed to hold the beneficiary’s own assets. In most of the examples above, this is the type of special needs trust that would be required. Unfortunately, only a parent, grandparent, guardian or court can establish a first-party special needs trust for the beneficiary, even if she is completely competent to create a trust on her own. Therefore, if the parent or grandparent of a person who receives SSDI has the capability, it is probably a good idea for him to create the trust for his child or grandchild, on the off-chance that it will have to be used later, instead of relying on an expensive and time-consuming court process.

There are lots of reasons to have a special needs trust beyond merely qualifying for government benefits.  If you or a loved one receives SSDI and doesn’t have a special needs trust, our attorneys can help you determine the best estate planning option to meet your needs. Contact DJ Jeyaram at DJ@Jeylaw.com or 678.325.3872.

Jeyaram & Associate Medicaid Fraud Expert Interviewed On “Mostly Medicaid”

Medicaid FraudJeyaram & Associate attorney Kimberly Sheridan was interviewed about Medicaid fraud.

The segment originally aired today on the national site “Mostly Medicaid.”

To hear the interview, click here.

 

Two Things Every Special Needs Parent Should Know

Free workshop hosted by Jeyaram & Associates

Jeyaram & Associates is hosting a free workshop on how to win an appeal if you’ve been denied Katie Beckett and how to protect your special needs child’s benefits with a special needs trust.

DJ Jeyaram, Esq. is the leading Katie Beckett appeals expert in Georgia and the father of a special needs child. Mr. Jeyaram has intimate knowledge of the Katie Beckett appeals process and is a former administrative law judge.

After the presentation, Mr. Jeyaram will answer questions about appeal Katie Beckett denials and how to protect special need children’s benefits – now and in the future.

Special Needs Trust

  • Who: Special needs parents and caregivers
  • What: Free workshop presented by DJ Jeyaram, Esq.
  • When: October 22nd at 6:30 p.m.
  • Where: Kidspeech in Lawrenceville, GA

***Space is limited. Must RSVP to Lheyward@jeylaw.com by 10/17***

“Two Midnight Rule” Clarifies Reimbursements For Hospitals

Hospital ReimbursementIn 2013, the Centers for Medicare and Medicaid Services (CMS) announced the so-called two-midnight rule in an attempt to clarify when a patient should be designated to inpatient status versus outpatient status.

Hospitals are paid differently for treating inpatients versus outpatients. The rule addressed when surgical procedures, diagnostic tests and other treatments are generally considered appropriate for inpatient hospital admission under Medicare Part A.

The two-midnight rule attempts to set a bright line test: only patients that doctors expect to spend two nights in the hospital are considered inpatient.

Although the rule was set to take effect on October 1, 2015, CMS recently announced that it would postpone the enforcement on inpatient status reviews. The rule will now go into effect December 31, 2015.

Additionally, CMS proposed that it will consider stays a physician expects to last less than two midnights to be an inpatient admission relying on the judgment of the physician and the documentation justifying the stay on a case-by-case basis. For many in the healthcare industry, this appears to be a small step in the right direction.

Lastly, CMS announced that it will shift the responsibility of educating physicians and enforcement of the two-midnight rule to quality improvement organizations (QIO) from recovery auditors.

If you have questions about the Two Midnight Rule, please contact Kimberly Sheridan at ksheridan@jeylaw.com or 678-708-4702

Need Proof As To Why You Need To Conduct HIPAA Risk Assessments? Read On

HIPAAAn employee’s stolen laptop with unencrypted files led to a HIPAA investigation and ultimately a $750,000 settlement

The Department of Health and Human Services (HHS) recently issued a press release announcing a settlement with a 13-physician radiation oncology practice related to HIPAA violations. Cancer Care Group, P.C. settled allegations of HIPAA noncompliance for an amount of $750,000. One of the major factors that led HHS to conclude that Cancer Care was in widespread non-compliance with the HIPAA Security Rule was the practice’s failure to conduct a proper risk analysis.

HHS investigated the practice because of a HIPAA breach that occurred in 2013. The breach occurred when a laptop bad was stolen from an employee’s car. The laptop contained unencrypted files which included patient Protected Health Information (PHI) such as names, addresses, birth dates, Social Security numbers, and clinical information.

HHS notes that if Cancer Care had conducted an enterprise-wide risk analysis, they could have identified the removal of unencrypted backup media as an area of significant risk to Cancer Care’s ePHI and adopted policies and procedures to reduce such risk. HHS Office of Civil Rights Director, Jocelyn Samuels emphasizes that “organizations must complete a comprehensive risk analysis and establish strong policies and procedures to protect patients’ health information.”

HHS also notes that Cancer Care should have had a comprehensive device and media control policy in place. Failure to have a policy that outlined employee responsibilities when removing devices containing ePHI from the facility contributed to the breach.

This settlement is another reminder that health care practices should not ignore their obligation to conduct periodic comprehensive risk assessments. Failure to do so might put practice patient information at risk of breach and could be costly for the practice if it is investigated by HHS.

The full HHS Press Release is available here, and the Cancer Care Settlement Agreement is available here.

Please contact Danielle Hildebrand at dhildebrand@jeylaw.com or (678) 325-3872 if you have questions about conducting a risk assessment for your practice.

CMS Considers ICD-10 Test Run A Success

ICD 10 Success

With less than a month to go until the October 1 deadline for implementation of ICD-10 codes, many providers are nervous and wary of the readiness of the Centers for Medicare and Medicaid Services (CMS) systems.

According to CMS, there is little to worry about. CMS recently released the results of its July ICD-10 end-to-end testing and announced a success rate of 87%.

Approximately 1,200 voluntarily providers participated in the test.  

  • Of the 29,286 test claims received, 25,646 were accepted. (This is an 87% success rate.)
  • 1.8% of the test claims were rejected due to invalid submission of ICD-10 diagnoses or procedure codes.
  • 2.6 % of test claims were rejected due to invalid submission of ICD-9 diagnosis procedure code.  
  • Zero rejects due to front-end CMS issues.

If you are a provider, these statistics should be comforting. However, the 13% error rate is still a cause for concern. Add that number to that fact that the ICD-10 codes will have 68,000 diagnosis and procedure codes FIVE times the number of ICD-9 codes, and it can be a bit overwhelming.

Remember that that upon implementation, ICD-10 codes will be required for all HIPAA covered entities.  

Please contact Kimberly Sheridan at ksheridan@jeylaw.com or 678-708-4702 if you have questions about ICD-10 implementation.

Medicare & Medicaid Deadline For Overpayment Clarified

60 Days Medicaid and Medicare RuleFederal Court Finds Sixty Day Rule Deadline Begins to Run When Put on Notice of Potential Overpayments

When the Affordable Care Act (ACA) was passed, a new requirement for reporting overpayments was created. This new obligation, often referred to as the ‘Sixty Day Rule’ requires providers who receive an overpayment of Medicare or Medicaid funds to “report and return” the overpayment to the government.

According to the statute, an overpayment must be reported and returned within sixty days of the “date on which the overpayment was identified.” Failing to do so is a violation of the False Claims Act.

Although Centers for Medicare and Medicaid Services (CMS) has provided some guidance on when an overpayment is “identified” within the context of Medicare, now a New York Federal Court has weighed in on the meaning and application of the ACA sixty-day rule as it applies to Medicaid.

In a case before a New York Federal Court, the U.S. Department of Justice asserted that a hospital improperly billed Medicaid in 2009 and 2010 and violated the FCA by delaying the return of overpayments. Such overpayments were the result of a billing system software glitch. The case was brought with the assistance of a former employee who had investigated the issue. Such employee had provided to hospital administrators a list of around 900 claims that were likely affected by the glitch which was subsequently ignored by the hospital.

The Court had to decide how to define the key term in the statute – “identified.” In the case, the former employee had not conclusively proven the identity of any overpayments. As it turned out, hundreds of the claims he listed had not actually been overpaid. However, he did recognize nearly five hundred claims that did in fact turn out to be overpaid as worthy of attention.

After looking at the legislative history and purpose, the Court concluded that the 60-day clock begins ticking when a provider is put on notice of a potential overpayment, rather than when the overpayment is conclusively ascertained. This holding is in line with CMS’s patchwork of guidance for Medicare overpayments.

As a result, providers facing a potential overpayment must take action immediately to meet the 60 day deadline and avoid False Claims liability. Every health care practice should have a protocol in place to ensure that possible overpayments are investigated in a timely manner and such investigation is documented appropriately. Failure to report overpayments within that time frame could subject providers to huge penalties.  

If you have any questions about the 60-day rule or need assistance with investigating and reporting a potential overpayment contact Danielle Hildebrand at dhildebrand@jeylaw.com.