Health Law

Accountable Care Organization (ACO) Proposed Regulations Released

Posted on March 31, 2011
Several federal agencies have just issued much awaited proposed guidance regarding Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program. The guidance includes the following: 1. The Centers for Medicare & Medicaid Services (CMS) has issued proposed regulations that would establish accountable care organizations (ACOs) under the Medicare Shared Savings Program...

Another Physician Sentenced to Prison for Medicare Fraud

Posted on March 29, 2011
Too many physicians still believe that federal and state fraud authorities are only interested in large health systems and pharmaceutical companies. As clear evidence to the contrary, however, the U.S. Department of Justice announced this week that Dr...

Physicians Begin Seeing Recovery Audit Contractor (RAC) Letters

Posted on March 28, 2011
We've known for a while now that the Medicare Recovery Audit Contractors ("RAC") program would eventually start impacting physicians and other Part B providers. That time has now come as medical practices and physicians are beginning to receive both audit and repayment letters from RACs...

$4.3 Million Penalty for HIPAA Violation

Posted on February 24, 2011
In case you thought that you didn't need to pay much attention to complying with the HIPAA Privacy Rule, a Notice of Final Determination issued by the Office of Civil Rights (OCR) of the Department of Health and Human Services this month should get your attention...

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100+ Arrested in National Medicare Fraud Bust

Posted on February 18, 2011
With what is likely to be one of the largest Medicare fraud take downs of its kind, the Federal Bureau of Investigation (FBI) announced yesterday that the Medicare Fraud Strike Force charged 111 defendants in nine cities for their alleged participation in Medicare Fraud schemes involving more than $225,000,000 in improper billing to the Medicare program...

OIG to Host Free Compliance Training Sessions

Posted on January 31, 2011
The Office of Inspector General (OIG) of the Department of Health and Human Services is hosting six free OIG compliance training sessions for local health care providers, compliance professionals, and their legal counsel. According to the OIG, the sessions are designed to help attendees: understand the law and the consequences of violating it...

Pennsylvania Physicians Required to Disclose Pathology Lab Charges

Posted on January 30, 2011
Under a new Pennsylvania law which took effect on January 22, 2011, physicians bill patients or third party payers for clinical pathology laboratory tests purchased from an independent laboratory are required to disclose on the bill the name of the laboratory from which the service was purchased, the amount paid by the physician to the lab and the physician's acquisition or processing (e...

Pennsylvania Adopts Physician Identification Badge Law

Posted on January 30, 2011
Physicians in Pennsylvania should be aware that a new Pennsylvania law requires physicians and their employees who provide direct patient care to wear a photo identification badge during work hours. The law became effective on January 22, 2011 and the Department of Health is required to publish regulations clarifying the law within 90 days...

Solo Doctor Guilty of Healthcare Fraud and Tax Evasion

Posted on January 24, 2011
As proof that no fish is too small for the wide health care fraud nets being cast by government authorities, a Columbus, Ohio internist has pleaded guilty to health care fraud and tax evasion arising out of health care services billed out of his medical practice between 2005 and 2007...

Physicians, Other Professionals Exempted from Red Flag Rules

Posted on December 21, 2010
At last, physicians and other professionals and service providers get some relief from proposed identity theft compliance obligations. On December 18, President Obama signed the "Red Flag Program Clarification Act of 2010" into law [Text, PDF]...

Hospital Pays $22M Settlement for Allegedly Improper Physician Professional Service Agreements

Posted on November 10, 2010
The United States Attorney's Office for the District of Maryland has announced that St. Joseph Medical Center in Towson Maryland will pay $22 million to settle allegations that it violated the federal False Claims Act, the federal anti-kickback statute and Stark by entering into several improper professional services contracts with a cardiology group, MidAtlantic Cardiovascular Associates that involved the payment of illegal remuneration...

Fee Schedule Clarifies PPACA Disclosure Requirement For In-Office MRI/CT/PET; Effective Date

Posted on November 09, 2010
The health reform law (PPACA) requires referring physicians who provide in-office MRI, CT or PET services to inform a patient in writing at the time of the referral that the patient may obtain the service from an alternative source and provide a list of suppliers who furnish the service in the area in which the patient resides...

More Medicare Cuts Looming for Physician in 2011 Physician Fee Schedule

Posted on November 09, 2010
The final Medicare Physician Fee Schedule for 2011 was placed on display at the Federal Register on November 2 , 2010.  Unwelcome to many physicians is the news that under the sustainable growth rate (SGR) formula, CMS is projecting a -24.9% decrease in physician fees unless Congress overrides the projected cuts as it has done each year since 2003...

OIG Advisory Opinions Shed Light on Marketing Activities

Posted on November 08, 2010
Two recent Advisory Opinions by the Office of Inspector General (OIG) shed some much needed light of the OIG's view of marketing by health care providers.  Last week the OIG published Advisory Opinions 10-23 and 10-24, both concerning a proposed arrangement between a sleep testing provider and a hospital...

HHS Secretary Sebelius Talks Fraud, Payment Reform At Summit

Posted on November 08, 2010
  HHS Secretary Kathleen Sebelius addressed the New York Health Care Fraud Prevention Summit on November 5 in Brooklyn and updated attendees on the government's efforts to rein in health care fraud. Significantly, she also indicated that CMS intends to squeeze out some of the excessive profit that is currently available to certain suppliers under Medicare...

OIG Publishes Physician Compliance "Roadmap"

Posted on November 05, 2010
Responding to input from medical school deans and residency program directors in a recent survey, the OIG has published a plain-English compliance summary for new physicians entitled Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse...

Physician Involvement in Medicare Fee Setting Questioned

Posted on October 28, 2010
Hot on the heels of the online article in the Wall Street Journal focusing on questionable physician billing practices and Medicare's Carrier Standard Analytic File database, another recent online Wall Street Journal article is now questioning the propriety of physician involvement in setting the relative values used to establish Medicare physician fees...

Wall Street Journal Article Criticizes Confidentiality of Medicare Physician Database

Posted on October 26, 2010
The recently enacted health reform law has ignited a great deal of public interest in rising health care costs and the underlying reasons for them.  Not surprisingly, fraud, waste and abuse in the system is a recurring theme.   Although of late the third party insurance companies and "corporate fatcats" have drawn most of the criticism in these cost discussions, at least one recent Wall Street Journal article suggests that abusive billing practices and fraud on the part of the Nation's physicians may be largely to blame...

Employed by a Hospital? Beware the New 3-Day Window Rule

Posted on October 18, 2010
Hospital-owned practices may take an unexpected hit in revenue under a new Medicare rule that bundles certain physician service fees into hospital payments. The so-called 'payment window' rule (sometimes referred to as 3-day/1-day window rule) requires a hospital (or an entity that is wholly owned or wholly operated by the hospital) to include on the claim for a beneficiary's inpatient stay, the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient nondiagnostic services that are furnished to the beneficiary during the three days before admission to a hospital, or one day preceding admission to a 'non-subsection (d) hospital,' (a hospital not paid under the IPPS: psychiatric hospitals and units, inpatient rehabilitation hospitals and units, long-term care hospitals, children's hospitals, and cancer hospitals)...

OIG Releases FY 2011 Work Plan

Posted on October 11, 2010
Physicians and other Part B providers should be aware that the Office of Inspector General of the Department of Health and Human Services has released its Work Plan for Fiscal year 2011. The Work Plan describes those area the OIG intends to review in the coming fiscal year and is a key tool for determining what 'risk areas' to focus on from a compliance standpoint...

Pennsylvania Adds 19 New Outpatient Surgery Centers

Posted on October 08, 2010
According to a new report from the Pennsylvania Health Care Cost Containment Counsel (also known as PHC4), 19 new ambulatory surgery centers (ASCs) opened up in Pennsylvania in the past year. This bring the total number of ASCs in Pennsylvania to 262...

October 5, 2010 Accountable Care Organization Workshop Agenda

Posted on October 04, 2010
One of the few true payment reform models built into the health care reform law passed earlier this year is the Accountable Care Organization (ACO). Unfortunately, absent final regulations implementing the ACO model, very little guidance exists for physicians who are interested in pursuing this model...

Failing To Update Medicare Enrollment Can Spell Bad News for Physicians

Posted on September 29, 2010
Many physicians are unaware that they are required to update their Medicare enrollment applications whenever key aspects of their practice change.  Changes in practice ownership, the addition or deletion of practitioners and the addition or deletion of office sites all require the filing of a completely new enrollment application...

CBO Estimates Medicare Doc Fix to Cost $330 Billion Over Ten Years

Posted on August 30, 2010
In years past, Congress was able with little fanfare to pass legislation forestalling the physician payments cuts under the Medicare Physician Fee Schedule Sustainable Growth rate (SGR) formula.  2009 was a far different story.  In fact, the SGR and the "doc fix" was a regular news headline for much of the first half of the year as the public was fixated on health care costs...

CMS Answers Frequently Asked Questions Regarding Electronic Health Record Incentives

Posted on August 24, 2010
In July, the Centers for Medicare and Medicaid Services (CMS) released the much-anticipated final regulations that providers are required to meet in order to receive the Medicare incentives for adoption of a certified electronic health record system. In those regulations, In the final rule, CMS set forth 15 core elements which must be met in order to qualify for 'meaningful use' of the EHR system...

Physician-Owned Enterprise Enters into $7.3 Million Settlement With OIG

Posted on July 30, 2010
Unfortunately, many physicians believe their activities are 'under the radar' when it comes to fraud and abuse enforcement. A recent settlement announcement by the Office of Inspector General (OIG) of the Department of Health and Human Services illustrates that this is not the case...

DOJ Announces Massive Health Care Fraud Crackdown

Posted on July 21, 2010
As further indication that health care fraud enforcement efforts are heating up in a big way, on Friday July 16, 2010, the Department of Justice announced the largest health care fraud crackdown in history.  According to Attorney General Eric Holder, raids were simultaneously conducted in multiple states including New York, Florida, Louisiana and Detroit...

Orthopedic Surgeons Sued in Whistleblower Suit

Posted on July 09, 2010
According to a recent article in the Chicago Tribune, a group of orthopedic surgeons and Rush University Medical Center have been sued in a federal whistleblower lawsuit.  The lawsuit alleges that the physicians and the medical center caused claims to be submitted to Medicare for surgeries performed by residents that failed to meet the Medicare teaching physician supervision rules...

CMS Proposes Regulations Clarifying Stark Imaging Disclosure Requirements

Posted on June 30, 2010
The Centers For Medicare and Medicaid Services (CMS) has published the CY2011 Proposed Medicare Physician Fee Schedule for public inspection.  The Proposed Fee Schedule includes a number of provisions which, if adopted, would implement the recently enacted Affordable Care Act (ACA)...

House Passes 6-Month "Doc Fix" Bill

Posted on June 25, 2010
On June 24, by a vote of 417-1, the House of Representatives passed a bill (H.R. 3962) impelmenting a six-month deferral of the automatic 21% cuts in the Medicare physician fee schedule retroactive to June 1.  This measure has already been approved by the Senate and is expected to be signed by the President...

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