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.

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.

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.

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.

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.

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.

What Physicians Need to Know About the Stark In-Office Ancillary Services Exception

Stark LawThe Federal Stark Law generally prohibits physicians from referring Medicare/Medicaid payable Designated Health Services (DHS) to any organization in which they have a financial interest, including their own medical practice. Because the Stark prohibition applies when physicians refer their patients within their own practice to obtain DHS, such an arrangement must meet the requirements of an exception in order to comply with the law.

If you are a physician practice that intends to offer to your patients related services which are also DHS, for example, imaging or laboratory services, you might be able to rely upon the In-Office Ancillary Services (IOAS) exception. This exception is designed to protect the provision of Designated Health Services that are truly ancillary to the medical services being provided by your physician practice.

In order to take advantage of this exception, your practice must meet three specific requirements related to

  1. supervision
  2. location
  3. billing

Additionally, multi-physician practices must be considered a “group practice” as provided in the Stark Law.

Physicians providing MRIs, CT and PET scans through their medical practices must also provide a disclosure and notice to patients. Such notice must be in writing and provided at the time of the referral. The notice must disclose to the patient that he or she may obtain those services from other suppliers and provide a list of those suppliers in close proximity to the physician’s office.

Although this exception enables physicians to offer a number of ancillary services and still maintain compliance with the Stark Law, this exception is likely to be restricted in the future. The Department of Health and Humans Services’ (HHS) FY ‘16 proposed budget indicates that HHS intends to limit which practices may offer therapy services, advanced imaging, radiation therapy and anatomic pathology services. Only “clinically integrated” practices that demonstrate cost containment would be able to use the IOAS exception when offering such services.

Additional information on the HHS FY ‘16 Budget Proposal can be found at http://www.hhs.gov/budget/fy2016-hhs-budget-in-brief/hhs-fy2016budget-in-brief-cms-medicare.html.

If you have any questions about the IOAS exception or need legal advice with respect to offering ancillary services through your practice please contact DJ Jeyaram at DJ@jeylaw.com or Danielle Hildebrand at Dhildebrand@jeylaw.com.

Physicians’ Medicare Payments No Longer Tied To Economy

SRGAfter almost 20 years, Congress finally passed a law repealing the Sustainable Growth Rate (SGR ). Under SRG, Medicare payments to physicians were tied to the growth rate in the economy. Because of the sluggish economy during and after the Great Recession, the growth rate formula has resulted in either a reduction or inadequate increase in Medicare reimbursement rates. As a result, Congress recently passed last minute, short-term fixes to ensure that physicians receive the appropriate fees.

With the passage of the new law, physicians will finally see stabilization in Medicare payments. The statute provides for a 0.5% increase for the next five years. Then the government will transition to a new system in which payments will be based on quality, value and accountability – the Merit-based Incentive Payment System.

The repeal of SGR is good news for physicians treating Medicare patients. Because Medicare reimbursement rates have been so unpredictable for the last decade, physician practices  have had little opportunity to arrange for innovative care models. With the new law, physicians have the chance to come up with groundbreaking care delivery models while developing patient care protocols focused on quality and gearing up for the next phase in Medicare reimbursement.

If you are a physician with questions about Medicare reimbursement or enrollment, or need healthcare regulatory advice, please contact DJ Jeyaram at DJ@jeylaw.com or Danielle Hildebrand at Dhildebrand@jeylaw.com.