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OCR Issues Final HIPAA Breach Notification Rule

January 23, 2013

On August 24, 2009, the OCR issued its Breach Notification Interim Final Rule. After nearly three-and-a-half years later, on January 17, 2013, the Office for Civil Rights of the US Department of Health and Human Services (OCR) issued its long-awaited Modifications to the HIPAA Privacy, Security, Enforcement and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act (Final Rule). The Final Rule is to be published in the Federal Register on January 25.


Hospital Payments of Performance-Based Bonuses to Physician Groups Viewed Favorably by OIG

January 16,2013

In its most recent Advisory Opinion (No. 12-22), the Office of Inspector General (OIG) viewed favorably an arrangement wherein a cardiology group’s compensation from the hospital comprised, in part, a performance-based bonus (Arrangement). The performance bonus is based on certain patient service, quality and cost savings measures associated with procedures performed at the hospital’s cardiac catheterization laboratories.


2013: What to Expect on the Road Ahead

January 9, 2013

While 2012 left the healthcare world spinning, 2013 does not show promise of slowing down anytime soon. As healthcare providers position themselves for a new year, they should bear in mind some of the following, which are expected to send waves through the industry this year.


ICD-10—Despite Delays in the Implementation Deadline, Planning and Preparation Now Are Key to Future Success

January 2, 2013

ICD-10 implementation and the need for preparation has been discussed for years. However, the repeated delays in deadlines for the transition from ICD-9 has provided the false sense of security that it is possible to continue to postpone the steps necessary for implementation. Due to the complexity of ICD-10 implementation and the time necessary to coordinate the steps for a successful go-live date by October 1, 2014, organizations cannot wait to see if the Department of Health and Human Services (“HHS”) will again postpone the ICD-10 deadline.


Incident-To Services: A Recap

December 26, 2012

The issue of “incident to” billing arises when physicians and certain other practitioners seek to be paid for services that are furnished incident to their services. The purpose of this alert is to review the requirements for incident-to billing both in the non-institutional and institutional settings.


Medicare Secondary Payer—Navigating the Trenches

December 19, 2012

Understanding what to do when a patient presents with multiple payers can be an administrative and billing nightmare. Fortunately, the Centers for Medicare and Medicaid Services (CMS) recently issued a Medicare Learning Network Fact Sheet entitled Medicare Secondary Payer for Provider, Physician, and Other Supplier Billing Staff wherein it clarified billing for services furnished to patients that have health insurance coverage in addition to Medicare.


Approaching the “Cliff” Regarding the Quickly-Approaching Fiscal Cliff

December 12, 2012

It is difficult to avoid hearing or talking about the fiscal cliff—an impending tax-hike-and-spending-cut disaster that is set to take effect in less than one month. While Washington appears to be dancing to a familiar routine, the rest of the country is sitting on the edge of its seat wondering when it will see the end of this number and what it will bring. Generally, Republicans propose severe cuts to spending and limited, if any, tax increases, while Democrats propose limited spending cuts and steep tax hikes for upper income earners. Amidst all of this debate, it is hard to discern where healthcare fits into the picture. Unfortunately, while navigating through the labyrinth of information, we find little concrete guidance.


Could Pre-Payment Audits for EHR Incentive Payments Be on the Horizon?

December 5, 2012

Since 2011, over 84,000 physicians and hospitals have claimed about $4 billion in incentive payments for meaningfully using certified electronic health record (EHR) programs. Estimates revealed that the government will be paying eligible physicians and eligible hospitals nearly $7 billion in total incentive payments by 2016. Because the aggregate incentive payments are so great, the Office of Inspector General (OIG) conducted an audit and issued a report, Early Assessment Finds that CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program (Report), which analyzes the fraud and abuse vulnerabilities in the EHR inventive program. The Report focused on the Medicare incentive payments and did not discuss Medicaid incentive payments.


HIPAA: De-Identified Health Information Explained

November 28, 2012

By now, most individuals involved in the healthcare industry have a familiarity with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As a brief refresher, HIPAA requires covered entities to maintain the privacy and security of protected health information (PHI) held or transmitted by them. A covered entity is defined as a healthcare provider that conducts certain administrative and financial transactions electronically, a healthcare clearinghouse, or a health plan.


Does Your Facility Use Templates in Documenting Clinical Information? If So, CMS Has Issued Guidance for You.

November 21, 2012

Many healthcare providers utilize templates (either hardcopy or electronic) to increase the efficiency of clinical documentation. Oftentimes, these templates contain check boxes or other similar time saving-elements, which assist providers in maintaining an efficient practice. On November 9, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 438 (Transmittal), which, in part, provides some insight into CMS’s position on the use of templates in medical record documentation, the risks, as well as some guidance.


Final 2013 Medicare Physician Fee Schedule Issued

November 14, 2012

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) issued its 2013 Final Physician Fee Schedule (Final PFS). Included within the Final PFS is discussion about the omnipresent Sustainable Growth Rate (SGR) formula, increase in payments to primary care physicians (PCP), an expansion of the multiple procedure payment reduction (MPPR) policy, and revisions to the new value-based payment modifier proposal.


The OIG’s Most Recent Guidance Regarding Compensation for On-Call Physician Coverage

November 7, 2012

Hospitals often face challenges related to on-call coverage by their specialist physicians. In fact, fears of violating State and Federal fraud and abuse laws typically steer hospitals away from putting systems in place to encourage call coverage by their specialists. However, the Department of Health and Human Services Office of Inspector General (OIG) issued an Advisory Opinion last week (No. 12-15) wherein it viewed favorably an arrangement involving per diem compensation for on-call coverage.


Payors and Private Parties Take Action Against Providers That Routinely Wave Patient Coinsurance and Deductibles

October 31, 2012

In the October 4, 2012 Alert, we cautioned against the policy of routinely waiving patient co-insurances and deductibles because of the various laws that have been enacted by the Federal and State governments to deter such practices. While much of the recent emphasis has been on the government’s actions, insurance companies, competitors and private individuals are also taking the initiative by filing civil actions against providers who attempt to attract business by offering discounts, including the waiver of patient co-insurance and deductibles.


The Medicare Audit Improvement Act of 2012—Is There Hope for Part A Providers Facing Medicare Audits?

October 24, 2012

On the heels of our last alert, a new bill was introduced by Rep. Sam Graves (R-Mo.) along with Reps. Todd Akin (R-Mo.), Billy Long (R-Mo.) and Adam Schiff (D-Calif.) in the US House of Representatives, the Medicare Audit Improvement Act of 2012 (HR 6575). HR 6575 aims to put forth a more structured process for recovery audit contractors (RACs) while also holding their feet to the fire when certain program requirements are not met. Even as we discussed the audit appeals process last week, in light of this recent bill, it may be beneficial to take one step back and look at the current RAC process (which is the precursor to the appeals), and focus on the proposals of this new bill.


Appealing Claims Denials Under the Medicare Program

October 17, 2012

The Centers for Medicare and Medicaid Services (CMS) has a number of audit tools at its disposal to protect the integrity of State and Federally-funded healthcare programs. Included in those tools are Program Safeguard Contractors and Zone Program Integrity Contracts, which identify fraud, abuse and waste in the Medicare program; Medicare and Medicaid recovery audit contractors, which identify improper payments (e.g., overpayments and underpayments) made to providers and suppliers; and Medicaid Integrity Contractors, which identify fraud, abuse and waste in the Medicaid program. With the increased focus on compliance and fraud and abuse, providers and suppliers are finding that, even with effective and appropriate compliance programs in place, they still experience audits by CMS contractors and claim denials. However, providers and suppliers should be aware that claims denials may be successfully appealed through the appeals process. This alert describes the five levels of appeal a provider or supplier could face when appealing a claim denial under the Medicare program.


The Office of Inspector General (OIG) 2013 Work Plan: The OIG’s Upcoming Initiatives

October 10, 2012
Each year, the Department of Health and Human Services (HHS) OIG issues a Work Plan wherein the OIG summarizes new and ongoing reviews and activities that it intends to pursue with respect to HHS programs and operations during the upcoming fiscal year. On October 2, the OIG issued its Work Plan for 2013 and in it included both a renewed focus on existing reviews as well as new efforts for 2013.


Seven Serious Concerns with Routine Waiver of Patient Coinsurance Amounts

October 4, 2012

At the 2012 American Health Lawyers/Health Care Compliance Association Fraud and Abuse Conference recently held in Baltimore, Maryland, it was surprising to learn that this issue is still resulting in confusion and concerns. Some physicians are being approached by “companies and health care entities” that do not participate in specific insurance programs. As a result, when the physician works at their facility they request that the physician accept any health insurance payment received on the professional side as payment in full. These types of arrangements may be considered abuse and potentially implicate the anti-kickback rules. Here are seven reasons to say no to these requests.


New HIPAA Rules Coming Soon

September 27, 2012
Health care providers will soon be receiving major updates to the Health Insurance Portability and Accountability Act (HIPAA) that were created by the Health Insurance Technology for Economic and Clinical Health Act (HITECH). The new HIPAA Rule is expected to be finalized and published to the Federal Register sometime later this year and contains key provisions that need to be incorporated into all health care entities HIPAA compliance program. Some of these anticipated changes include:


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