Georgia's Trusted Healthcare
& Medical Provider Attorneys

GA’s City & Urban Hospitals Will Be Impacted By The American Health Care Act

Emergency Sign Healthcare LawPassage of the American Health Care Act in its current or proposed form with significant cuts to Medicaid and Medicare will not only impact rural hospitals and facilities, but city and urban hospitals as well. Here’s how.

Steep cuts to Medicaid and Medicare will result in many of Georgia’s 95 health clinics being unable to keep their doors open. These facilities serve a population that is often primarily at the poverty level, the elderly, unemployed and uninsured.

As a result, city and urban facilities could see a significant increase in uninsured and under insured patients as these patients do not have access to any other options for healthcare.

City & Urban Hospitals Need To Prepare for New Challenges

Hospitals will need to:

• Increase medical and administrative staffing to handle the influx of additional patients, especially for patients that may utilize ER services in place of what would have been primary care services prior to the cuts.

• Absorb the costs of an increase in patients and staffing as there will be little or no government money (or at best temporary money) to assist (Medicaid or Medicare).

• Review internal policies on how to handle additional patients and billing procedures for patients who cannot afford medical care.

It’s imperative for all hospitals to begin reviewing policies and procedures before an influx of patients occurs and the potential for lawsuits arises.

Experienced Healthcare Attorneys

Jeyaram & Associates has more than 50 years legal healthcare experience and has helped numerous city and urban hospitals conduct internal audits, write policies and procedures and ensure compliance with state and federal laws.

Contact Us

Free initial consults. Contact DJ at DJ@JeyLaw.com or 678.325.3872.

Healthcare Providers Need To Ensure Compliance Under Expansion of False Claims Act

False Claims Act Attorney The U.S. Supreme Court voted unanimously to allow False Claims Act (FCA) liability under the “implied certification theory.”

The implied certification theory means that submitting a claim to the government implies that the entity has complied with all contractual and regulatory requirements.

What The Supreme Court Ruling Means To Healthcare Providers

This decision could have profound repercussions for healthcare providers who bill federal healthcare programs. Healthcare providers must contend with the Stark Law and Anti-Kickback Statute (“AKS”). Violations of either the Stark law or AKS give rise to FCA liability. Healthcare cases make up approximately two-thirds of federal whistle-blower cases, which are enforced using the FCA.

The Supreme Court did not limit liability under the implied certification theory to conditions of payment. This ruling can potentially mean that a facially valid invoice can violate the false claims act case because of requirements that are not explicitly requirements for payment. If a regulation is a condition of participation but not a condition of payment, a violation can still give rise to FCA liability.

The Supreme Court did rule that liability is limited to “material” violations. Materiality may be shown if it is a provision for which the government routinely denies payment. The Court emphasized that the materiality test is “rigorous” and demanding….”

Healthcare Providers Need To Ensure Compliance 

Healthcare providers, and all contractors billing the government, should ensure they are compliant with all statutory, regulatory and contractual requirements.

Jeyaram & Associates’ attorneys have extensive experience in helping healthcare providers remain compliant with all state and federal regulations. Contact DJ Jeyaram at DJ@JeyLaw.com or Jonathan Anderson at Janderson@JeyLaw.com.

Georgia Department of Community Health Approves $140 million Medicaid Rate Increase

Georgia MedicaidGeorgia doctors, nursing home operators and other healthcare providers will soon see an increase in Medicaid reimbursements. The Georgia Department of Community Health (DCH) approved a reimbursement rate increase earlier this month that will go into effect July 1, 2016.

The increase addresses concerns that low Medicaid reimbursement rates have made it difficult for practices with high volumes of Medicaid patients to be profitable. The rate increases will most likely have the biggest impact on providers in rural Georgia communities, which serve a high Medicaid population. For some providers, the Medicaid reimbursement rate will go up by more than 50% for some procedures.

The rate increases means $140 million in increased reimbursements for Georgia providers. The increase was funded by the General Assembly earlier this year, but the Department of Community Health did not approve the rate increase until the beginning of May. The total will be paid for in part out of the Georgia budget with about two thirds of the increase coming from the federal government.

Jeyaram & Associates is a full service healthcare law firm committed to helping doctors, nurses, hospitals, nursing homes, adult day care facilities, pharmacies, and Medicaid and healthcare providers. Contact DJ at DJ@Jeylaw.com or 678.325.3872.

Work In Healthcare? You Could Face Steep Fines Or Jail Time For Healthcare Fraud

Healthcare FraudNewly Released Health Care Fraud Report shows that HHS/DOJ Enforcement Efforts Remain Strong

The Department of Health and Human Services (HHS) and the Department of Justice (DOJ) recently released their annual joint report outlining the results of their healthcare fraud enforcement efforts throughout FY 2015.

The Report shows that during that period the DOJ opened 983 new criminal health care fraud investigations and over 800 new civil health care fraud investigations. Additionally, HHS investigations resulted in 800 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 667 civil actions, CMP settlements, and administrative recoveries related to provider self-disclosure matters.

Over the course of the year, the government won or negotiated over $1.9 billion in health care fraud judgment and settlements.

High Number Of Fraud Convictions

The Report also highlights the activity of the Medicare Fraud Strike Force whose efforts resulted in over 300 guilty pleas and 48 defendant convictions throughout the year, and over 260 defendants going to jail. The Report summarizes several successful enforcement actions by the Strike Force including:

  • 2 physicians owners of a mental health clinic were each sentenced to 10+ years in prison for certifying that certain Medicare patients qualified for partial hospitalization services when they did not and paying kickbacks to group home operators and patient recruiters in exchange for referring Medicare patients;
  • An owner of a DME company was sentenced to 84 months in prison for paying kickbacks to medical clinics for fraudulent prescriptions for DME which the patients did not need; and
  • 2 home health directors were sentenced to over 10 years in prison and ordered to pay $18.6 million in restitution after pleading guilty to conspiracy to commit fraud and payment of kickbacks in exchange for Medicare referrals and home health service prescriptions.

You Could Personally Be Fined Or Go To Jail

The government is clearly cracking down and the healthcare industry should heed the warning. The Report indicates that any individual in the healthcare realm, whether physician or hospital CFO, could incur steep fines, penalties and even serve jail time for violating the Federal Anti-Kickback Statute, Stark Law and False Claims Act.

Jeyaram & Associates can help you assess and minimize your risk under these healthcare fraud and abuse laws. If you have any questions please contact Danielle Hildebrand at Dhildebrand@jeylaw.com or 678.325.3872.

To review the Report it is available here.

Congratulations! Jeyaram & Associates Opened Its Doors 9 Years Ago Today!

DJHeroCongratulations to Jeyaram & Associates’ Owner and Founder DJ Jeyaram for hanging out his shingle 9 years ago today!

With 50% of startups failing in the first five years, Jeyaram & Associates is not only defying the odds, but it’s successfully helping physicians, nurses, hospitals, nursing homes, adult day care facilities, pharmacies, Medicaid and healthcare providers as well as individuals and families in the special needs community.

To celebrate Jeyaram & Asssociate’s 9 year anniversary, we’ve created a super hero figure of DJ Jeyaram as he relentlessly and tirelessly fights for the underdog and individuals who often do not have a voice or are overlooked.

Jeyaram & Associates is a four (4) attorney firm offering extensive legal expertise in healthcare corporate, regulatory and fraud matters; special needs estate planning and guardianship; and Katie Beckett and NOW/COMP appeals. The firm is AV rated and a certified Minority Business Enterprise.

“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.

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.

Free Introductory Home Health Visits Don’t Violate Anti-Kickback Law

Anti-Kickback StatuteInspector General: No Kickback violation for free home health introductory visits

The Office of the Inspector General issued an advisory opinion clearing the way for home health providers who provide “introductory” home visits to individuals who eventually become their clients. The OIG advised that home healthcare providers who contact  patients after being selected by that patient and provide information to those patients about their services, do not violate the federal Anti-Kickback statute.

The Federal Anti-Kickback law makes it a criminal offense to knowingly and willfully offer, pay, solicit or receive anything of value in exchange for inducing or rewarding referrals of items or services reimbursable by a Federal health program

The OIG’s office stated that the “primary purpose of the Introductory Visit is to facilitate the patient’s transition to home health services in an effort to increase compliance with the post-acute treatment plan.” In addition, the OIG”s noted that during the “Introductory” visit, the health care provider ‘”does not provide any type of  any federally reimbursable diagnostic or therapeutic services during the Introductory Visits,” which occur where a patient is receiving care whether it’s a physician’s office, hospital or personal home. Further, the home health provider is not involved in any way in the patient’s selection process and “Introductory Visits” do not provide any actual or economic benefit to the patients. .

It’s important to reiterate, that healthcare providers should not contact the patient prior to receiving notification from the  patient that they have been selected nor can the “Introductory Visits” be a covered service under Medicare or Medicaid, or reimbursed by third-party payors. These actions could violate the Anti-Kickback statute.

To read the full opinion, click here.

For more information, please contact Kimberly Sheridan at 678-708-4703.

Avoid Being A Target Of HIPAA Audits | Here’s How

HIPAA AuditPhase 2 OCR HIPAA Audits Are Here – What Providers Should Do to Prepare

The Office of Civil Rights (OCR) has taken the first step in the next round of HIPAA audits.

OCR has begun to send out surveys in order to collect information from providers, health plans, and clearinghouses in preparation for phase 2 of their HIPAA audits. From the hundreds of entities receiving surveys, OCR will select over 200 providers and over 100 health plans to be audited.

It is more important than ever to make sure that you have complied with the HIPAA Rules. Here are the top 3 areas every provider should address:

1. When was the last time you conducted a Risk Assessment? If it has been more than a year or two, you should conduct a comprehensive Risk Assessment now.

If you are a small to medium sized office you can take advantage of HHS’s security risk assessment tool available on their website: HHS.gov SRA Tool

2. Have you recently reviewed your HIPAA policies and procedures to ensure that they are up to date and are being followed? There are three main areas that need to be addressed in your policies: Security Standards, Privacy Standards and Breach Notification Standards.

    • Security Standards – focus on how you keep Protected Health Information (PHI) secure, whether it is stored and/transmitted electronically or in some other form. Your practice must have appropriate safeguards in place (for example, requiring the use of secure passwords to access electronic health records and encrypting all devices that might contain e-PHI).
    • Privacy Standards – do you conduct periodic trainings for personnel regarding privacy practices? Do you have records that such trainings have been completed by all personnel? Is your Notice of Privacy Practices current and made available to your patients?
    • Breach Notification Standards – do you have a policy in place that outlines the steps for identifying and reporting a breach? Such a policy should address steps to take to investigate and contain the problem, as well as a means for identifying how many people were affected, who those individuals are, and how to send out breach notices. Keep in mind that under the Breach Notification Rule, providers must provide notice of a breach within a certain time frame. Your procedures for responding to a breach should allow for adequate time to meet this deadline.

3. Keeping track of your Business Associates and Business Associate Agreements – During the audit process OCR might ask for a list of business associates and their contact information. All providers should have this readily available. It is also important to have written Business Associate Agreements that are up to date and can be made available to OCR upon request.

If you have any questions about any HIPAA requirements or the approaching OCR audits our attorneys can help. Please contact Danielle Hildebrand at dhildebrand@jeylaw.com.

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The information on this site should not be construed as formal legal advice and is not intended to create or constitute a lawyer-client relationship.