Health Law

Senate Bill Would Strengthen Anti-Fraud Efforts

Posted on November 17, 2009
While all eyes are on the health care reform debate, a new Senate bill would give the government improved tools for investigating and prosecuting fraud and abuse in both federal and private health insurance programs. One of the most significant proposed changes would authorize a qui tam whistleblower action under the False Claims Act based solely on allegations of a violation of the Anti-Kickback law...

Texas Hospital System Settles Sham Lease/Directorship Claims for $27.5 Million

Posted on November 16, 2009
A cautionary tale for physicians who lease space or provide medical director services to hospitals.  These common arrangements are coming under increasing scrutiny, and must be commercially reasonable to withstand challenge.   McAllen Hospitals L...

Red Flag Rule Enforcement Date Extended to June 2010

Posted on November 03, 2009
According to a Federal Trade Commission (FTC) press release, the FTC is once again delaying the "Red Flag Rule" identity theft enforcement date.  In its current form, the Red Flag Rule could apply to many physician practices.  The new enforcement date is June 1, 2010...

West Penn Allegheny Antitrust Suit Dismissed

Posted on October 30, 2009
According to a recent article in the Pittsburgh Post-Gazette, West Penn Allegheny Health System's federal antitrust lawsuit against University of Pittsburgh Medical Center and Highmark Inc., has been dismissed.  Filed in April of this year, the lawsuit alleged that UPMC and Highmark conspired to raise prices and squeeze out competition...

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No Long Term Fix for Medicare Physician Fee Cuts

Posted on October 22, 2009
Despite efforts by Senator Harry Reid to pass legislation which would have effectively frozen Medicare payment rates for physicians, it looks like Congress will once again look to freeze physician payment rates with a one-year patch. According to an article published by the Wall Street Journal, Senator Reid's proposed bill would have permanently prevented Medicare payment cuts to doctors...

Substantial Reduction in Medicare Payment Rates Under Baucus Bill

Posted on October 08, 2009
According to the Congressional Budget Office (CBO), the Chairman's mark for the Healthy Futures Act of 2009 proposed by Senator Max Baucus will be paid for, in part, through a reduction in Medicare payment rates.  Specifically, according to a blog post by the CBO,  the legislation would "substantially reduce the growth of Medicare's payment rates for most services"...

Doctor to Return to U.S. to Face Fraud Charges

Posted on October 07, 2009
According to an article in the News Tribune, the long arm of the federal government has tracked a Washington state doctor to Madagascar and brought him back to the U.S. to face fraud charges.  The doctor, who operated four clinics in Washington, will be charged with conspiracy to commit health care fraud following an audit of the doctor's Medicaid billing practices...

No More "Under Arrangements" Effective October 1, 2009

Posted on September 30, 2009
In case you somehow missed the news, effective October 1, 2009 (that's right, tomorrow), 'under arrangements' ventures involving Stark services are no longer permissible.  An under arrangements venture usually involves provision of a diagnostic or therapeutic service on a turn-key basis by an outside supplier (often a physician office) on behalf of a hospital...

OIG Blesses Chiropractic Referral Network

Posted on September 30, 2009
In the recently released OIG Advisory Opinion No. 09-16, the OIG found that participation by chiropractors in a referral network would not run afoul of the federal antikickback statute.  In AO 09-16, the OIG reviewed a proposed arrangement whereby chiropractors who are members of an association would each pay $200 per month to participate in a "network" that would advertise chiropractic services through internet, print, radio, or television advertising and provide referrals for such services...

Medicare Rules on Preventive Care Services

Posted on September 26, 2009
It is apparent that preventive care will take on greater importance in the "reformed " health care system and while Medicare historically did not cover routine or preventive screening services, the list of preventive services now covered by Medicare has grown in recent years...

Physician Owned Hospitals Targeted in Baucus Reform Proposal

Posted on September 25, 2009
The original Stark II regulations included an 18 month moratorium on an exception to Stark that would have permitted physician to invest in specialty hospitals. Since expiration of that moratorium some physicians seeking more control over their practice environments have embarked on a mission to develop specialty hospitals as an alternative to the traditional acute care hospital setting...

Get Your COmments In the the 2010 Proposed Physician Fee Schedule

Posted on August 27, 2009
As reported previously on this Blog, the Centers for Medicare and Medicaid Services published the proposed Medicare Physician Fee Schedule CY 2010 on July 13, 2009 in the Federal Register.  Unless Congress takes action before the end of the year, physician payment rates with be reduced by an average of 21...

Hospital/Physician Employment Compensation May Run Afoul of Stark

Posted on August 26, 2009
The number of physicians seeking employment with hospitals seems once again to be on the rise and not surprisingly, physicians negotiating those arrangements will do their best to ensure that they are paid fairly for their services.  In light of the recent settlement of a federal False Claims case, however, physicians should be careful to ensure that their compensation - even as W-2 employees of a hospital - is consistent with fair market value and commercially reasonable...

Stuff You Didn't Know About Medicare: Physician Signature Requirements

Posted on August 25, 2009
With the rollout of the Recovery Audit Contractor (RAC) audit program in full swing, physicians should be paying close attention to their medical record documentation efforts.  One of the Medicare documentation requirement that many physicians don't fully appreciate is the requirement that all medical records be signed by the performing physician...

FTC Delays "Red Flags" Rule Compliance Date Until November 1, 2009

Posted on July 30, 2009
Citing lingering confusion over to whom the identity theft rules apply, the FTC announced yesterday that it is delaying the Red Flags Rule compliance date for a third time.  The compliance date, which was August 1, is now November 1, 2009.  The FTC intends to use the additional time to further educate industry about the rules and specifically to whom they apply...

Physician/Medical Device Manufacturer Financial Arrangements Continue to Draw Scrutiny

Posted on July 30, 2009
Physician/Medical Device financial arrangements continue to draw scrutiny by regulators. According to an article in the New York Times, Senator Charles Grassley has instituted an inquiry into payments between device-maker Medtronic and Dr. David Polly that Grassley says were not disclosed by Dr...

Insurance Department to Investigate the Blues in Pennsylvania

Posted on July 23, 2009
In what many Pennsylvania physicians feel is a long overdue move, the Pennsylvania Insurance Commissioner has announced that the Department of Insurance will investigate whether any of Pennsylvania's Blue Cross-Blue Shield insurers have engaged in anti-competitive behavior in violation of the Unfair Trade Practices act...

Proposed FY 2010 Medicare Physician Fee Schedule: The Rise of Primary Care

Posted on July 02, 2009
On July 1, 2009 CMS released a display copy of the Proposed FY 2010 Medicare Physician Fee Schedule. It is evident from a variety of the proposed policy changes that CMS intends to force primary care into a more prominent role – in some cases at the expense of specialists...

HITECH Act Fact Sheet

Posted on June 30, 2009
On February 17, 2009, President Obama signed the American Recovery and Reinvestment Act of 2009 (Recovery Act), which, among other things, created financial incentives for physicians and other providers to adopt and utilize electronic health records (EHR) and penalties for those physicians who do not...

Obama Administration Turns Up Heat On Medicare Fraud

Posted on June 25, 2009
According to a statement by Secretary of HHS Catherine Sebelius in a June 24 HHS Press Release, "the Obama Administration is committed to turning up the heat on Medicare fraud..."  As evidence of this commitment, the Press Release announced the indictment of 53 individuals, including physicians and health care executives, accused of various Medicare fraud offenses ranging from conspiracy to defraud the Medicare program, false claims anti-kickback statute violations...

Health Reform May Be Just Around The Corner - Details to Follow

Posted on June 04, 2009
According to a June 2, 2009 letter from President Obama to key Democrat Congressman, the President is pushing for major health care reform legislation by October 2009. Given that this is only a few months away, it is remarkable how little detail exists with regard to the President's plan for reform...

Are You 'Red Flag' Ready?

Posted on June 03, 2009
On Nov. 9, 2007, The Federal Trade Commission (FTC) created the Red Flags Rule requiring creditors to develop and implement written identity theft prevention programs within their organizations. The rule defines a 'Creditor' any person who regularly extends, renews, or continues credit; any person who regularly arranges for the extension, renewal or continuation of credit...

OIG Blesses Physician On-Call Compensation Arrangement

Posted on May 29, 2009
In its recent Advisory Opinion No. 09-05, the OIG reviewed a proposed arrangement whereby a hospital would compensate physicians for on-call services performed on behalf of the hospital's uninsured patients. The OIG concluded that while the Proposed Arrangement could potentially generate prohibited remuneration under the anti-kickback statute, if the requisite intent to induce or reward referrals of Federal health care program business were present, the Office of Inspector General ('OIG') would not impose administrative sanctions on the arrangement...

Local Podiatrist Gets Sentenced in Medicare Fraud Case

Posted on May 27, 2009
Major Medicare fraud and false claims settlements against large providers and pharmaceutical and device companies are reported in the news on a regular basis these days.  Unfortunately this trend may lead many physicians to believe that their billing and collection activities are under the radar of federal and state enforcement authorities...

Should You Consider Selling Your Practice to a Hospital?

Posted on May 20, 2009
Without a doubt, times are tough for physicians in private practice. Operating costs continue to rise at a staggering pace and reimbursements are simply not keeping up. Recruiting and retaining physician talent continues to be a challenge and as the regulatory landscape continues to change and become more complex, compliance is becoming ever-more important...

Proposed Pennsylvania Legislation Would Prohibit Physician Referrals for Ancillary Services

Posted on May 20, 2009
Pennsylvania physicians need to be aware that legislation (House Bill 1405) has once again been introduced in the Pennsylvania House which would severely limit the ability of physicians to refer to entities in which they have investment interests. As drafted, this Bill would create an outright prohibition on the referral by a health care provider of any patient to an entity in which the health care provider is an investor or has an investment interest for a provision of 'designated health services'...

Some Good News for Pennsylvania Physicians - Malpractice Claims Way Down

Posted on April 30, 2009
According to a statement by Governor Edward G. Rendell as reported by the PR Newsire, malpractice reform in Pennsylvania has been a dramatic success.  Governor Rendell noted that malpractice filings statewide declined by 41% between 2002 and 2008...

West Penn Allegheny Health System Inc. Files Anti-trust Lawsuit Against University of Pittsburgh Medical Center and Highmark Inc.

Posted on April 23, 2009
Things appear to be heating up between the lagest health system and the second largest health system in the Pittsburgh health care market.  West Penn Allegheny Health System Inc. has filed and anti-trust lawsuit against the University of Pittsburgh Medical Center and Highmark Inc...

Pennsylvania Gives Nurse Midwives Authority to Prescribe

Posted on April 14, 2009
The Pennsylvania Board of Nursing has published regulations implementing a 2007 law which gives nurse midwives the authority to prescribe, administer, and dispense drugs pursuant to collaborative agreement with a physician. The law and regulations also apply to medical devices, immunizing agents, and laboratory tests...

Independent Drug Education and Outreach Act Re-Introduced

Posted on April 07, 2009
Several Congressman, including Senator Ted Kennedy, are renewing their efforts to change the way physicians receive information about new prescription drugs.  Re-introduced in Bill form this month, the Independent Drug Education and Outreach Act would put an academic spin on the dissemination of drug information by providing grant money to organizations to produce educational materials on the safety, efficacy, and cost of prescription drugs...

Pennsylvania Qui Tam Case Highlights Dangers in Physician/Hospital Arrangements

Posted on March 25, 2009
A recent whistleblower case out of the federal 3rd Circuit in Pennsylvania highlights some of the dangers in not properly documenting financial relationships between physicians and hospitals. Specifically, in US ex. rel. Kosenske v. Carlisle HMA, Inc...

Massachusett's Regulations Ban Gifts to Physicians

Posted on March 12, 2009
Massachusetts has joined the small but growing list of states regulating gifts and payments by pharmaceutical and device manufacturers to physicians.  According to a Boston Globe article, Massachusetts regulators have adopted regulations banning gifts to physician and mandating disclosure of consulting/speaking payments to doctors in excess of $50...

Medical Device Company Settles with Feds over Alleged Kickbacks to Physicians

Posted on March 10, 2009
As yet another warning to physicians and the medical device industry, the Department of Justice has entered into a Deferred Prosecution Agreement with medical device maker Neuromtrix in connection with an alleged kickback arrangement with referring physicians...

Federal Authorities to Begin Prosecuting Physicians for Taking Money from Drug and Device Companies

Posted on March 06, 2009
Those of us in the health care industry are, by now, quite used to reading about major prosecutions and settlements by the federal government against drug and device companies for improper relationships with physicians.  It is far less common, however, to read about the physicians on the receiving end of those relationships...

Another Device-Maker To Disclose Physician Payments

Posted on February 26, 2009
Medtronic Inc. announced this week that beginning in 2011, it will start disclosing payments of more than $5,000 per year to physicians for consulting fees, royalties or honoraria.  According to an article by the Associated Press, Medtronic's decision comes in response to pressure from federal legislators to disclose the information...

The Obama Prescription For Health Care Begins To Take Shape: Doctors Get Ready to Tighten Your Belts

Posted on February 26, 2009
President Obama's prescription for health reform is beginning to take shape and the early prognosis is that physicians will be on the losing end.  According to an article in the Washington Post, Obama's Budget is going to include a $634 billion reserve fund as a downpayment on a $1 trillion health system overhaul...

Secretary of HHS: Daschle Is Out, But Who Is In?

Posted on February 19, 2009
Now that Tom Daschle is out of the running for Secretary of HHS, there's been much buzz about who President Obama's next choice will be.  Even Howard Dean's name has come up.  According to a recent New York Times article, however, it looks like it might be Gov...

Stimulus Bill and Health Care Reform

Posted on February 18, 2009
Yesterday President Obama signed the much touted stimulus bill into law.  Although not much is publicly being said about health care reform yet, sweeping changes to the health care system are quietly taking place. In fact, over $150 billion of the stimulus bill funds are earmarked for health care related projects...

IBC and Highmark Call Off Merger

Posted on January 21, 2009
In what is surely to be a bright spot for most physician in Pennsylvania, Independence Blue Cross and Highmark announced today that they are withdrawing their request to merge.  According to a report by the Philadelphia Inquirer this afternoon, the boards of two companies met today and decided they could not live with the condition that the Pennsylvania Insurance Department would have imposed on the merged entity...

Highmark Blue Shield and Independence Blue Cross Merger in the News

Posted on January 21, 2009
According to an article in today's Philadelphia Inquirer, the Pennsylvania Insurance Department has apparently unofficially informed Highmark Blue Shield and Independence Blue Cross of certain conditions it will place on the merger.  One condition, according to the Inquirer, would be that the combined company use only the Blue Shield trademark, but cease using the Blue Cross trademark so that another health insurer could compete statewide using the Blue Cross trademark...

What Does Obama's Healthcare Reform Plan Mean for Physicians

Posted on January 06, 2009
So much has been said and so little done over the last ten or more years about healthcare reform that many of us have stopped listening.  However, with the heavy emphasis placed by President-elect Obama on the issue of healthcare reform, and the astronomical rate at which health care costs are rising, it would seem that the chances of sweeping reform are greater now than ever before...

OIG Solicits Public Comment For New Anti-kickback Safe Harbors

Posted on December 17, 2008
pThe Office of Inspector General of the Department of Health and Human Services (OIG) published a notice today seeking proposals and recommendations for developing new and modifying existing safe harbor provisions under the Federal anti-kickback statutenbsp;and fornbsp;developing new OIG Special Fraud Alerts...

OIG Blesses Physician Employment Arrangements

Posted on December 15, 2008
In response to an unusually straightforward fact pattern, the OIG today released an advisory opinion blessing certain part-time physician employment arrangements. The advisory opinion comes in response to a nonprofit, tax-exempt corporation’s proposal to employ two physicians on a part-time basis to perform endoscopies on the requestor’s own premises...

Changes In Medicare Enrollment Rules

Posted on December 09, 2008
Physicians enrolling in the Medicare program should be aware that Medicare recently changed the rules applicable to when a physician's enrollment is deemed to take effect. Specifically, the FY 2009 Medicare Physician Fee Schedule establishes that the effective date of billing for physicians and non-physician practitioners is the later of: (1) the date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor; or (2) the date an enrolled physician or non-physician practitioner first started furnishing services at a new practice location...

Changes to Medicare Anti-Markup Rules Effective January 1, 2009

Posted on December 02, 2008
Does your practice bill Medicare for diagnostic tests? If so, you have until January 1, 2009 to make sure your arrangements comply with the now very complicated anti-markup rule. The Centers for Medicare and Medicaid Services (CMS) published the Final Medicare Physician Fee Schedule for 2009 in the Federal register on November 19, 2009...

Physician Detailing By Pharmaceutical Manufacturers: The Winds of Change Continue to Blow

Posted on October 21, 2008
It's pretty clear that the good old days of detailing prescribing physicians with freebies are gone.  Lavish golf trips and expensive meals have gone the way of the dinosaurs (for the most part), and it looks like even more change is likely to come...

Highmark/IBC Merger Ruling Delayed

Posted on October 21, 2008
According to a recent article in the Philadelphia Business Journal, the Pennsylvania Insurance Department will not issue a ruling on the merger until early next year.  This is because the Insurance Department must wait 105 days from the end of the public comment period...

Medicare Updates Overpayment Interest Rate

Posted on October 21, 2008
Under Medicare regulations,  the interest rate that may be charged on Medicare overpayments and underpayments is the higher of the current value of funds rate (five percent for calendar year 2008) or the private consumer rate as fixed by the Department of the Treasury...

Physicians Need to Make Sure Their Stark Arrangements Are In Order ASAP

Posted on October 14, 2008
Physicians, Do you have financial relationships (think joint venture, medical director stipends, lease arrangements, AS&T agreements) with a hospital? If so, your referrals to that hospital for inpatient and outpatient services may violate the federal Stark self referral law unless they fall within one of the exceptions to Stark...

The Office of Inspector General (OIG) Releases FY2009 Workplan

Posted on October 02, 2008
The Office of Inspector General (OIG) of the Dept of Health and Human Services released its FY2009 Workplan yesterday. The Workplan outlines the initiatives and audits that the OIG expects to undertake in the coming fiscal year.  Below are some of the key initiatives that the OIG expects to undertake with regard to physicians...

More Changes to the Stark Self-referral Regulations

Posted on September 30, 2008
For those of you who have not been watching your Stark radar screen closely, be aware that CMS recently made a number of substantial changes to the Stark self-referral regulations that may affect your practice arrangements. Some of these changes will not take effect until October 1, 2009, but others changes will take effect on October 1, 2008...

Altering Medical Records: What Not To Do When Being Audited By Medicare

Posted on August 08, 2008
Document, document, document! is the cry of health care attorneys and consultants across the Country when asked what physicians can do to protect their practices from fraud and abuse liability.  But what happens if you receive a Medicare audit request and you find out that your documentation isn't so good or even non-existent?  Many physicians when faced with this prospect are tempted to recreate or alter medical record documentation...

Some Physicians Elect Not To Accept Gifts From Industry

Posted on May 21, 2008
It is no secret that the federal government is very interested in the connection between gifts and other remuneration from drug and device manufacturers and physician decision-making when it comes to ordering those items.  At least one Senator has gone so far as to introduce legislation which would require disclosure of these financial relationships...

Meet the New Doc: Researchers Develop Computerized Anesthesiologist

Posted on May 14, 2008
Canadian researchers may have solved the looming physician shortage crisis -- at least as it would apply to the administration of  surgical anesthesia.  According to an article in the Canadian Press, scientists at McGill University in Montreal have developed a software system that administers anesthesia during surgery...

MCARE Abatement Program Still A Political Football

Posted on May 12, 2008
According to a recent article in the Patriot News, Governor Rendell has outlined the costs associated with his plan to provide health insurance for Pennsylvania's uninsured population.  The plan calls for increases in taxes on tobacco products and would tap into the MCARE fund to cover the health insurance costs...

Feds Challenge Physician/Hospital Cardiology Arrangement

Posted on May 07, 2008
The federal government was apparently not kidding when it said it planned to take a closer look at physician/hospital arrangements.  According to a recent Department of Justice Press Release, the DOJ has elected to intervene in a whistle-blower lawsuit against Christ Hospital and the Ohio Heart Health Center, a large cardiology group in Ohio...

Free Rent, False Claims and Self-Disclosures

Posted on April 15, 2008
Proving the theory that no good deed goes unpunished, according to a March 17, 2008 Department of Justice press release, Hardeman County Memorial Hospital in Texas agreed to pay the federal government a total of $398,230 to resolve allegations that it violated the federal False Claims Act by submitting improper claims for payment to the Medicare program for healthcare items and services that were provided as a result of improper physician referrals...

Appeals Court Clears Way for Physician Lawsuit Against MCO

Posted on April 15, 2008
Under a recent decision by the U.S. Court of Appeals for the 11th Circuit, a case brought by a group of physicians against a PPO discount card company and a managed care company for appropriation of the doctors’ names and identities in connection with a plan to market and sell medical discount cards will be permitted to proceed in court...

CMS Withdraws Stark Physician/Hospital Survey

Posted on April 15, 2008
As previously reported on this blog, the Centers for Medicare and Medicaid Services (CMS) had announced in 2007 that they intended to send requests for information to all Medicare participating hospitals for details regarding the investment/ownership and compensation arrangements between those hospitals and physicians to determine whether the arrangements were in compliance with the federal Stark statute...

Healthcare in the Workplace - Walgreen Announces Plans

Posted on March 18, 2008
According to a recent online Wall Street Journal article, Walgreen Co. is taking definitive steps to expand further into the workplace health center arena. Specifically, Walgreen has announced its plans to acquire two worksite health-center companies in an effort to build its business as a manager of on-site health centers at large companies...

Medicare Issues New Advance Beneficiary Notice (ABN) Form

Posted on March 12, 2008
According to a recent alert on the Centers for Medicare and Medicaid Services (CMS) website, physicians and other providers are required to begin using a new ABN form when services are expected to not be covered by medicare.  According to the alert, beginning Monday, March 3, 2008, physicians may use the revised ABN for all situations where Medicare payment is expected to be denied...

Be On the Lookout for Better Educated Patients

Posted on March 12, 2008
According to an article in the New York Times, Aetna will soon begin offering a new service to help enable patients to research their own specific medical conditions. Specifically, Aetna’s SmartSource Service will allow patients to link online research with their own medical records and claims data...

Medical Society Predicts Doctor Shortage in Pennsylvania

Posted on March 07, 2008
More not-so-good news for Pennsylvania: according to an article in the Times Tribune, Pennsylvania Medical Society officials are predicting a shortage of physicians in Pennsylvania in the foreseeable future.  Citing the Society's recently released demographic report (See The State of Medicine in Pennsylvania), the article suggests that Pennsylvania could be short 10,000 doctors within 10 years...

Supreme Court Decides in Favor of Medtronic

Posted on February 21, 2008
Medtronic (and by default, all medical device manufacturers) scored a huge win on Wednesday when the U.S. Supreme Court held that medical device manufacturers cannot he held liable in tort actions for medical devices that have gone through FDA pre-market approval...

Physicians Called Upon to Identify Patients with Pre-Existing Conditions

Posted on February 18, 2008
According to an article in the Los Angeles Times, a dispute is brewing in California over what one insurer is calling an “outreach effort” but others are calling an attempt to pit physicians against their patients. Specifically, Blue Cross of California has sent letters to physicians with a copy of patient insurance coverage applications, asking the physicians to identify patients who had pre-existing conditions at the time insurance coverage was extended to them...

Medicare Tracks Provider Inquiries

Posted on February 05, 2008
If you have a question about Medicare coverage or how a particular service is to be billed, who do you call? Many physician practices don’t hesitate to pick up the phone and call their Medicare carrier provider representative for guidance. While this can be an effective way of getting certain kinds of questions answered, practices should be aware that their calls to the carrier are being tracked and can be used by the carrier for a variety of things, including initiating audits...

Diagnostic Imaging Centers Continue to Struggle

Posted on January 24, 2008
As was predicted by many, the Deficit Reduction Act is continuing to cause a major shake-out in the imaging center industry.  According to the Florida Business Journal, a major Florida-based imaging center company has filed for Chapter 11 reorganization and will close 5 of its 17 centers...

CMS Delays Anti-Markup Rules until January 1, 2009

Posted on January 03, 2008
Citing the need for additional clarification of what constitutes the "office of the billing physician" under the final anti-markup regulations issued as part of the 2008 Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) issued another regulation today postponing the effective date of the anti-markup regulations until January 1, 2009...

WHAT PHYSICIANS NEED TO KNOW ABOUT THE HIGHMARK CLASS ACTION SETTLEMENT

Posted on December 27, 2007
(By William H. Maruca, Esq. - Posted with permission of the Allegheny County Medical Society )  A tentative settlement has been reached in a class action brought on behalf of a group of affected physicians against Blue Cross and Blue Shield plans which alleged that the plans engaged in certain misconduct that resulted in the denial or downcoding of physician claims...

Pennsylvania Governor Softens Position on MCare Subsidies

Posted on December 17, 2007
Much to the chagrin of practicing Pennsylvania physicians, the issue of MCare premium subsidies became a political football earlier this month when Governor Ed Rendell said he would not approve the 2008 MCare subsidy until Pennsylvania lawmakers acted on his proposal to expand the state insurance program to uninsured adults...

Major Changes are Afoot at Centers For Medicare and Medicaid Services

Posted on December 11, 2007
The Centers for Medicare and Medicaid Services (CMS) issued a final rule on November 26, 2006 enacting Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. Section 911 of the MMA required the (CMS) to replace the current fiscal intermediary and carrier contracts for the administration of Medicare benefits with new contracts with Medicare Administrative Contractors (MACs) who will administer both Part A and Part B...

Medicare Changes Diagnostic Testing Rules and IDTF Rules

Posted on November 28, 2007
The much awaited 2008 Medicare Physician Fee Schedule has finally been formally published in the Federal Register (click here to read it).  The proposed Fee Schedule published in June of 2007, included a number of proposed changes to the Stark regulations as well as certain regulatory changes to the diagnostic testing rules and IDTF conditions of participation...

Oops! Medical Device Company Identifies Wrong Physician

Posted on November 08, 2007
Earlier this week, a number of major orthopedic medical device companies, as part of an anti-kickback settlement agreement, began posting on their websites the names of physicians to whom the companies have paid consulting fees.  Now, as a perfect example of why this "transparency" is a danger to all physicians, a Michigan newspaper is reporting that one of the companies, Smith and Nephew, incorrectly identified a physician on its website...

Physician Orthopedic Consulting Fees Made Public

Posted on November 06, 2007
Several weeks ago I posted an entry on this blog about a major federal anti-kickback settlement agreement entered into by the five largest orthopedic device companies: Zimmer Inc., Depuy Orthopaedics, Inc., Smith & Nephew Inc., Biomet Orthopedics, Inc...

CIGNA Reaches Settlement on Doctor Ranking

Posted on October 30, 2007
Several month ago I posted an entry on this Blog about a lawsuit the New York Attorney General was threatening to file to prevent United Healthcare from ranking its participating physicians.  Well, according to an article on USAToday...

CMS Issues Advisory Opinion on Physician Recruitment Arrangement

Posted on October 09, 2007
In a recent Stark law Advisory Opinion (CMS-AO-2007-01), the Centers for Medicare and Medicaid Services (CMS) found that a hospital could not change the terms of an existing physician recruitment assistance agreement where that change would effectively result in additional compensation to the recruited physician...

Medical Device Companies Enter into Major Settlement Agreement

Posted on October 05, 2007
According to a recent DOJ Press Release, five medical device companies (comprising approximately 95% of the hip and knee joint implant market) have settled kickback allegations relating to payments to surgeons by agreeing to pay a total of $311 million and entering into five-year Corporate Integrity Agreements...

Microsoft Launches "HealthVault"

Posted on October 05, 2007
Just when physicians thought it was safe to start investing in electronic medical records systems, Microsoft may be changing the ground rules altogether.  On October 4, 2007, Microsoft took a giant leap into the health information arena by announcing the launch of it's new web site "HealthVault"...

Medicare Audit Program Could Be Costly

Posted on September 17, 2007
According to a recent article in the Seattle Times, the Medicare contractor audit program which was launched in three states on a trial basis in 2005 and is expected to expand to all 50 states by 2010 could end up costing the public dearly, with potentially very little to show for the efforts...

Payors Looking to Better Manage Imaging Services

Posted on August 22, 2007
According to a recent article published on AIS Health.com, Blues plans are increasingly turning to radiology management firms to help manage costly imaging services.  This is a new twist on the old "managed care" concept and, once adopted by the Blues, other major payors can be expected to follow...

Forbes Identifies Top Paying Jobs

Posted on July 30, 2007
So it's stressful, expensive and the hours stink -- accordingly to an article on Forbes.com, medicine is still a pretty good gig.  In what will undoubtedly add fuel to the already raging debate over who is responsible for the high cost of health care, health care-related occupations fill the top 15 slots on Forbes' list of the top 25 best paying jobs in the nation...

Dems' Medicare Bill Would Prohibit Physician Investment in Hospitals

Posted on July 27, 2007
Much has been in the news lately about the Children's Health and Medicare Protection (CHAMP) Act of 2007 recently introduced by the House democrats.   The Bill's proponents claim that if enacted it will provide insurance coverage for millions of children and improve and strengthen Medicare for America's seniors and people with disabilities...

New Jersey Department of Insurance Fines Aetna

Posted on July 25, 2007
The New Jersey Department of Banking & Insurance has issued an order stopping Aetna's practice of limiting non-participating physician reimbursement to 125% of Medicare.  The Department has also fined Aetna almost $10,000 for violations of state insurance laws...

CMS Terminates Florida HMO Plans

Posted on July 25, 2007
According to a recent article in the Florida Sentinal, the Centers for Medicare and Medicaid Services has taken the unprecedented step of terminating the Medicare HMO plans run by America's Health Choice in Florida due to quality of care issues.  According to the article, termination of the plan was the result of patient complaints about delays in and denials of authorizations of care...

Pennsylvania Dept. of Insurance Elects not to Raise Malpractice Insurance Requirements

Posted on July 22, 2007
You may recall from a July 2 posting on this blog that the Insurance Department was considering changing the required level of malpractice coverage Pennsylvania physicians must maintain (before MCARE coverage) from $500,000 to $750,000.  Pennsylvania doctors can breath a sigh of relief, at least for now...

Physician Alert! CMS to Require Hospitals to Disclose Physician Compensation Arrangements

Posted on July 18, 2007
In accordance with the Deficit Reduction Act, the Department of Health and Human Services (“HHS”) is undertaking an initiative to require all hospitals participating in a Medicare program to provide information to HHS on a periodic basis concerning their investment and compensation relationships with physicians...

Watch Out for Physician Rating Systems

Posted on July 17, 2007
More and more payors are instituting rating systems for their participating physicians and at least one state attorney general has taken issue with the practice.  According to a recent article on CNNMoney.com, the New York Attorney General has threatened an injunction against United Healthcare if it implements a physician rating system in New York...