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& Medical Provider Attorneys

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.

Congratulations To Jeyaram & Associates For Being Featured In The Business News Daily

Reprinted with permission from the Business News Daily
Special Needs Trusts

 

Owner DJ Jeyaram Esq. shared the story behind Jeyaram & Associates, a family-focused law firm that specializes in special needs trusts, wills, estate planning and healthcare legal services.

My son Kai, pictured in this photo, was born with a rare genetic condition called Williams Syndrome. He brings us an amazing amount of joy despite all of his challenges.

Soon after my son was born, we realized that we needed a plan to protect him in case anything happened to me or my wife, so we began offering special needs trusts, which help protect children’s current and future government benefits.

I started my business in 2007 after working at a large law firm. I realized that most special needs families could not afford my big firm rates and I was forced to refer these families to small firm attorneys that did not necessarily have the proper training to set up a special needs estate plan. Three months later, I hung out my shingle and have successfully been in business for more than 8 years. It’s been one of the best decisions I ever made.

One of the biggest challenges we face is limiting the number of pro bono cases we take every year. Because we have a special needs child and are ingrained in the special needs community, we meet a lot of families that need legal help but don’t have the necessary resources. We want to help everyone because we always think ‘That could be us.’

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

 

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.

Former DCH Attorney Joins Jeyaram & Associates

Screen shot 2015-06-26 at 2.55.32 PMMr. Harrison Kohler joins Jeyaram & Associates as counsel. Mr. Kohler brings extensive criminal defense and administrative hearing experience to the firm. He represented the Department of Community Health (DCH) for nine years in both administrative hearings and negotiations with attorneys for Medicaid providers.

Prior to joining DCH, Mr. Kohler served as an Assistant Attorney General, which included 10 years as a prosecutor in the Medicaid Fraud Control Unit. During that time, he had 90 jury trials, including both criminal and civil, in 15 different superior courts and two federal districts in Georgia.

Further, Mr. Kohler has orally argued approximately 50 appellate cases. He successfully argued Georgia v. McCollum, 505 U.S. 42 (1992), in the United States Supreme Court. In 1996 the Supreme Court Historical Society named Georgia v. McCollum as one of the most significant oral arguments heard by the United States Supreme Court between the years 1955 and 1993.

Prior to pursuing a legal career, Mr. Kohler  served three years in the United States Army, including a year in Vietnam. He was awarded the combat medical badge and the Army Commendation Medal with Oak Leaf Cluster. Mr. Kohler has also been recognized by his peers as he’s earned the AV Peer Review Rating, which identifies a lawyer with “very high to preeminent legal ability, is a reflection of the firm’s expertise, experience, integrity and overall professional excellence.”

Please help us welcome Harrison to the firm!

CMS Proposes Changes In Rules For CMOs

For the first time in more than a decade, the Centers CMOfor Medicare and Medicaid Services issued proposed changes in rules affecting Care Management Organizations

On June 1, 2015, the Centers for Medicare and Medicaid Services (“CMS”) published a proposed rule affecting Care Management Organizations (CMOs) that administer Medicaid benefits.  This is the first major overhaul of the managed care system since 2002.  Most believe these changes are long overdue as CMOs now cover approximately 74 percent of all Medicaid enrollees making managed care the dominant delivery system for Medicaid.

According to CMS, the Proposed Rule will “improve beneficiary communications and access, provide new program integrity tools, support state efforts to deliver higher quality care in a cost-effective way, and better align Medicaid and CHIP managed care rules and practices with other sources of health insurance coverage.”

The Rule targets seven main areas:

  • Improvement of the beneficiary’s experience
  • State delivery system reform
  • Quality improvement
  • Program and fiscal integrity
  • Managed long-term services and supports (MLTSS) programs
  • Children’s Health Insurance Program (CHIP)
  • Alignment with Medicare Advantage and Private Coverage Plans

Public comments are due July 27, 2015. CMS has published a Fact Sheet outlining the Proposed Rule that can be found here.

We urge CMOs to familiarize themselves with the Proposed Rule and take advantage of the time period for public comment. If you have any questions involving the Proposed Rule, please contact Kimberly Sheridan at 678.325.3872.

 

CMS Proposes New Quality Reporting Measures for Medicare Payment

MedicareThe Centers for Medicare and Medicaid Services (CMS) has proposed a rule regarding Medicare payments for inpatient rehabilitation facilities. Through this new rule, CMS introduces new quality measures that will be tied to reimbursement.

Such quality measures generally focus on overall performance with respect to specific components of the health status of patients, like new or worsening pressure sores, and certain events, such as falls causing major injuries.

A facility’s failure to submit the information regarding these quality measures would result in a reduction in Medicare payments to that facility.

In the CMS publication, the government estimates the new quality reporting requirements will cost inpatient rehab facilities around $24 million. However, because the rule also proposes a modest rate increase, the government estimates that the changes under the rule will result in $130 million increase in payments to those facilities.

The Proposed Rule can be found here.

If you have questions regarding these new quality reporting requirements, please contact DJ Jeyaram or Danielle Hildebrand at 678.325.3872.

Medicaid Fraud Investigations Continue But With Few Indictments

Medicaid FraudMedicaid Fraud Control Units (MFCUs) are responsible for investigating and prosecuting Medicaid provider fraud and patient abuse and neglect.  As part of its Medicaid plan, each State must establish a MFCU.  These Units are funded by both the Federal and State government with the Federal government reimbursing about 75% of the operating costs. MFCUs receive their referrals for investigation from a wide array of sources: program integrity divisions of the State Medicaid agencies; anonymous tips; whistleblowers; audits; and adult protective service agencies.

Each spring, the U.S. Department of Health and Human Services, Office of Inspector General, publishes an Annual Report summarizing the statistical data from the investigations and prosecutions conducted and reported by the 50 MFCUs nationwide. According to this Annual Report, in 2014, MFCUs reported 1,318 criminal convictions involving Medicaid providers; three-quarters of these convictions were for fraud. Recoveries in the criminal cases were close to $300 million, and 1,337 providers were excluded from Federal health care programs as a result of criminal conviction.

Out of the more than 1,000 criminal convictions:

  • 413 were Home Health Care Aides
  • 129 were Certified Nursing Aides
  • 64 were Physicians or Doctors of Osteopathy
  • 56 were Counselors/Psychologists
  • 33 were Durable Medical Equipment Suppliers

Nationwide, MFCUs investigated 13,192 cases of Medicaid Fraud but only indicted 1, 185 cases- roughly, 10%.  Of the 1,185 indictments, 956 resulted in convictions, almost 100% conviction rate.   From this data, it appears as if the trend in investigating often but indicting infrequently continued from 2013 to 2014 and that the high conviction rate also continued.

What about in Georgia?  Georgia MFCU was even less reluctant to indict than the nationwide trend but enjoyed the same success rate with convictions:  410 fraud investigations; 4 indictments for fraud and only 9 convictions.

If you are a Medicaid Provider, you very well may find yourself being investigated for fraud, but stay calm and call an experienced healthcare attorney. Remember, you have a very, very small chance of actually being indicted.

If you do  receive a subpoena or phone call from the Georgia Medicaid Fraud Unit, Jeyaram & Associates can help. Contact Kimberly Sheridan at ksheridan@Jeylaw.com or 678.325.3872.