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Showing 4 posts from August 2011.

ACO’s: An Alternative to Employment by a Hospital?

Posted In Health Care Law

With a backdrop of rising health care costs, 50 million uninsured Americans, and a health care system that spends more per person but has lower quality than 37 other developed countries, Congress passed a comprehensive health care reform law with the vision of doctors and hospitals joining forces, coordinating care to hold down costs for the prospect of earning government bonuses for controlling cots.1 While no one can foresee exactly how all the provisions of the new law will mesh with the current system, four of Kentucky’s largest hospital systems are negotiating mergers and many of the smaller systems are buying up other providers or seeking to enter into controlling systems, physicians and their groups are increasingly looking to hospitals as employers. It is a buyers market for hospitals with the financial reserves to buy physician practices, butnot every physician practice can be bought by a hospital nor does every physician want to be employed by a hospital. While this activity is being driven by decreases in reimbursement, it is also a product of the new health reform law, which encourages providers to create integrated health care delivery systems that can improve the quality of health care services and lower health care costs. Accountable Care Organizations (“ACO”) are the vehicles through which shared savings are to be passed along when certain quality performance standards are met. Hospitals and physicians must find ways other than employment relationships to align themselves as ACO’s. More >


Posted In Health Care Law

The peer review process is an important and necessary function of health care organizations, and the benefits it yields are unquestionable. Mandated by the Medicare's Conditions of Participation and the Joint Commission, peer review helps health care providers ensure that their patients receive safe care. Each of the fifty states, including Kentucky, have recognized the importance of the peer review process and passed statutes granting privileged status to information gathered during the peer review process. Kentucky's statute, however, has been rendered ineffective by a line of court cases. Though the language of Kentucky's statute states unambiguously that all materials generated during the peer review process "shall be confidential and privileged and shall not be subject to discover, subpoena, or introduction into evidence, in any civil action in any court,"1 Sisters of Charity Health Systems, Inc. v. Raikes, the Supreme Court of Kentucky held that this protection does not apply in medical malpractice suits.2 Kentucky healthcare providers may be able to reclaim at least some confidentiality and privilege for the type of information typically compiled during peer review through a Patient Safety Organization. More >


Posted In Health Care Law
One of the most important changes created by the Health Care Reform Act is the establishment of an explicit duty to refund Medicare and Medicaid overpayments within 60 days of identification.  While this “60 day rule” sounds simple, it is anything but, as all providers and suppliers struggle to determine both how and when this rule applies without regulatory guidance from the Centers for Medicare & Medicaid.  Physicians and provider groups should pay particular attention to the 60 day rule as billing responsibilities are generally delegated to staff. In the normal course of business, a physician may not even be aware that his or her office staff has received and deposited an overpayment due to a simple mistake in billing.  Failure to refund an overpayment within 60 days now constitutes an “obligation” under the Federal False Claims Act, which means that the overpayment may be considered to be a false claim.  False claims, of course, can be the subject of qui tam lawsuits, government investigations, MAC/RAC audits, among others, and, if liability is found, then damages can be assessed at three times the amount of the claim and civil monetary penalties. 
More >


Posted In Health Care Law

Medical school teaches physicians how to treat patients when they show up, but does not address how to treat patients when they do not.  No-shows are money losers and a frequent problem for physician offices.  Not only do missed appointments disrupt patient flow, but no-shows also equate to lost revenue.  Further, when a patient misses an appointment, the overhead related to that no-show remains on the books because the costs of office space, equipment, staff and supplies accumulate regardless of whether or not a patient is seen and treated.  Fortunately, there are ways to limit the loss caused by missed appointments. More >

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