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Showing 8 posts from August 2012.

Compliance Plan – A Provider’s Defense

The Office of the Inspector General (“OIG”) has always encouraged Medicare and Medicaid providers to implement a compliance program. For 14 years, as a matter of fact, OIG has provided compliance guidance in 11 healthcare sectors (including: hospitals, nursing facilities, home healthcare, hospice and third-party billers). With the passing of the Patient Protection and Affordable Care Act (“PPACA”), compliance plans and programs are now mandatory for any provider enrolled in a Federal health care program, including Medicare. More >

Kentucky Health Cooperative Insurance, Available in 2014

The Supreme Court Decision of June 28, 2012 upholding the Patient Protection and Affordable Care Act (“PPACA”) in National Federation of Independent Business, et al., v. Sebelius , Secretary of Health and Human Services, et al., reignited the creation and implementation of Consumer Operated and Oriented Plan programs (“CO-OPS”).  CO-OPs are aimed at offering small businesses and individuals more affordable health insurance options, especially in states where there are a few insurance carriers capitalizing the market with plans that are not economically targeted at the smaller insurance market. More >

Fraud, Waste and Abuse Controls Under The Affordable Care Act

The Affordable Care Act (“ACA”) strives to improve our health care system in three main areas; by expanding consumer protections, strengthening Medicare and reducing health care costs.  One key way the government hopes to achieve these goals is through tougher fraud and waste controls. Given the focus on prevention, penalty and recovery, compliance plans are of the utmost importance for all health care providers. First we examine all of the elements incorporated in the ACA that pertain to fraud, abuse and waste before we can begin to develop a compliance plan for our facilities. The new law contains a host of tools aimed at enforcing fraud and waste prevention.  Let’s review: More >

Affordable Insurance Exchanges

Affordable Insurance Exchanges seek to ease the navigation and financial burdens of both individual and small business health insurance.  As part of the Affordable Care Act (“ACA”), State-based exchanges are a “one-stop-shop” to compare and find affordable health coverage in a competitive insurance market.  The transparency of Exchanges allows consumers to compare private and public health plans based on price and quality. The ACA created the notion, but on August 12, 2011 the Department of Health and Human Services and Treasury awarded establishment grants to 13 states and the District of Columbia, to facilitate the implementation of the exchanges. More >

Accountable Care Organizations Program Models

The Supreme Court’s decision upholding the Affordable Care Act supports The Centers for Medicare and Medicaid Services (CMS) different programs for the development of Accountable Care Organizations (ACOs).  In Kentucky, we are beginning to see these organizations emerge in different models. More >

Supreme Court Decision Legitimizes Accountable Care Organizations

With its decision upholding the Affordable Care Act, the Supreme Court has authorized the use of Accountable Care Organizations (“ACO”) as one of the principal tools for addressing health care costs and improving care.  When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely by reducing the rate of growth in the cost of health care, the ACO will share in the savings it achieves for the Medicare program.  The Centers for Medicare and Medicaid Services (“CMS”) announced the selection of 88 ACOs to participate in the first round of the Medicare Shared Savings Program. These ACOs will take responsibility for coordinating care for nearly 1.2 million Medicare beneficiaries in 40 states. Three ACOs have been approved for Kentucky and include Quality Independent Physicians (Louisville), Southern Kentucky Health Care Alliance (Smithsgrove), and Deaconess Care Integration (Serving Indiana and Kentucky). In late July, CMS announced 15 new ACOs to participate in the Advance Payment ACO Model Program including Jackson Purchase Medical Association PSC, which is an ACO that includes 6 physician practices in Paducah and Ballard County Kentucky that covers 6000 Medicare beneficiaries. This brings the total participation in the program to 20.   With the 32 systems approved to participate in the Pioneer ACOs Program in February 2012, CMS announced there are now 153 organizations participating in Medicare Shared Savings initiatives, serving over 2.4 million beneficiaries. More >


As the Kentucky Board of Medical Licensure’s (“KBML”) implementing regulations for House Bill 1 are now effective on an emergency basis for the next six months, physicians, nurse practitioners, and other licensed prescribers have specific statutory and regulatory requirements establishing when and how they may prescribe controlled substances.  These rules must be followed or physicians and others may face serious consequences that include criminal misdemeanor offenses, loss of prescribing privileges, and disciplinary actions against professional licenses. All practitioners must pay careful attention to these rules because even minor violations may create problems. Because the KBML’s regulations are more comprehensive than the requirements of House Bill 1, a great deal of confusion exists concerning what physicians and practitioners are required to do and when. Recognizing that compliance with its emergency regulations may mean major changes in the way physicians practice medicine, the KBML has announced that it expects full compliance by October 1, which creates a welcome grace period.   While the ambiguities and details will be worked out over the course of the next six months, physicians should take heed and incorporate these things into their practices. More >

Federal Medicaid Opt-Out Effect on Hospitals

The mandatory expansion of Medicaid was an important element of the Affordable Care Act as providing health care benefits to uninsured was intended to achieve equity.  The expansion of Medicaid rolls was also intended to reduce the cost of providing care for the uninsured and the need for disproportionate share hospital funding, which is an adjustment to account for the needs of hospitals serving a large number of low-income patients.  With the ability to opt out of the Affordable Care Act’s expansion of Medicaid eligibility (read more: The Federal Medicaid Apple:  Poison or the Cure?), the opt-out states may create financial problems for hospitals that depend on disproportionate share payments to cover part of their costs for providing non-reimbursed services to the indigent and uninsured.  The Affordable Care Act’s decrease in disproportionate share payments to hospitals is not changed by the Supreme Court’s ruling. More >

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