Healthcare Law Blog

CMS Rule on Medicare Overpayments? Don’t Hold Your Breath

Since the Center for Medicare & Medicaid Services proposed a rule three years ago suggesting that providers could be liable for returning Medicare overpayments going back ten years, providers have been anxiously awaiting a final ruling. Unfortunately, providers’ anticipation for a final ruling will have to continue. On February 16^th, CMS announced that it would delay the final rule on reporting and returning overpayment…by another full year! More >

Kentucky’s Evolving Behavioral Health Providers

One of the most important effects of the Patient Protection and Affordable Care Act (“ACA”) is the profound change in the coverage of behavioral health services. Building on the Mental Health Parity and Addiction Equity Act of 2008, the ACA requires both Medicaid and Medicare to provide far more robust behavioral health benefits, especially in the area of substance abuse. This expansion of benefits is not without growing pains - health care providers are waking up to the new reality of a vastly expanded need for substance abuse and other mental health services as well as providers. As state Medicaid programs struggle to finance these new benefits, the need for behavioral health care providers and clinicians has become acute. This is especially true in Kentucky, where access to substance abuse care is crucial due to the epidemic of prescription drug and heroin addictions. Fortunately, however, the Cabinet for Health and Family Services has taken proactive steps to strengthen and expand behavioral health infrastructure to meet the ACA’s directives. More >

HHS OIG RELEASES FISCAL YEAR 2015 WORK PLAN

Recently, the Office of Inspector General of the United States Department of Health and Human Services (“OIG”) released its Fiscal Year 2015 Work Plan summarizing its oversight and enforcement priorities for the 2015 Fiscal Year. Here are some highlights from the Work Plan. More >

Telehealth/Telemedicine: An Opportunity for Physicians and Providers to Add a New Line of Service

The cost effectiveness of providing health care via telemedicine or telehealth promises to be an effective tool to increase coverage and reimbursement of healthcare provided remotely or through telehealth. Towers Watson, a national consulting company, recently published a 2014 study that suggests that telemedicine could save $6 billion annually for the health care industry. "Achieving this savings requires a shift in patient and physician mindsets, health plan willingness to integrate and reimburse such services, and regulatory support in all states," according to Dr. Allan Khoury, a senior consultant at Towers Watson.[1] Recent studies have assigned significant cost savings generated by telehealth use that include cost savings of $537 million per year for emergency departments using telehealth to reduce transfers and spending reductions of 7.7% to 13.3% per person per quarter in the cost of care for chronically ill Medicare beneficiaries using a health buddy via telehealth. [2] As the cost effectiveness of providing services via telehealth and telemedicine is proven, Medicare, most state Medicaid programs and commercial insurers are increasing coverage as well as reimbursement for telehealth services. State law requirements for providing telehealth and coverage differ greatly. Consequently, physicians and health care providers should be aware of the complexity of providing telehealth and its requirements, but should also incorporate telehealth services into their practices as a new way of providing services and a new line of business. More >

Kentucky Rural Health Clinics and FQHC’s/Look- A-Likes with Low Rates—Don’t Overlook this Rate Increase!

Approved by CMS and effective July 1, 2014, Kentucky’s Medicaid Program may now pay certain Rural Health Clinics (“RHC”), Federally Qualified Health Care Centers (“FQHC”) and Look-a-Likes a higher rate. The Department of Medicaid Services (“Medicaid”) sought approval to pay RHCs, FQHCs and Look-A-Likes that have a low per visit PPS rate at a rate equal to 125% of the Medicare rate.  This means that Kentucky RHCs, FQHCs and Look-A-Likes with low Medicaid rates, just got a raise-- that is if they claim it! While the Medicaid State Health Plan Amendment provides that an “Alternative Payment Methodology” is now available, this really means that clinics with low rates can ask to be paid at a higher rate per visit without qualifying for a change in scope of service.   This increase in rate is supposed to be effective on July 1, 2014, but is based upon the Medicare Upper Payment Limit for RHCs as of September 30, 2014 and the rate as we calculate it is approximately $99.70. Essentially, this means that providers with rates below the $99.70 threshold may elect to be paid under the alternative payment methodology. More >

Part I Medicaid Webinar A Success – Register Now for Part II!

On Wednesday, August 20, the McBrayer Health Care Group, along with panelists from the Kentucky Primary Care Association and the Primary Care Centers of Eastern Kentucky, hosted a free webinar entitled, “Medicaid: Getting Paid & Keeping It.”

Part I of the webinar provided an overview of the Medicaid administrative appeal process, the Dispute Resolution Meeting (“DRM”), appeal of the DRM decision, and settlement. In addition, McBrayer attorneys weighed in on the “top issues” they encounter when helping providers work through the complicated reimbursement process. Attendees received real-world advice about what to challenge when an overpayment demand is received and saw examples of actual letters received by others in the industry.

Part II of the webinar is scheduled for Wednesday, August 27 from 12-1:30pm, EST. This session will discuss federal Medicaid audit authority, what to do if you’re contacted by a Medicaid Integrity Contractor (“MIC”), and opportunities to contest a MIC’s auditor’s adjustment/denials/identification of overpayment.

Attendees of Part I will automatically be enrolled in Part II. If you missed Part I, but would like to take part in next week’s webinar, sign up here: https://attendee.gotowebinar.com/register/6389912240505419777.

Services may be performed by others.

This article does not constitute legal advice.

DOJ Intervenes In Case Involving ACA’s 60-Day Overpayment Rule

Recently, the Department of Justice (“DOJ”) intervened in a qui tam whistleblower suit in the US District Court for the Southern District of new York, which involves Continuum Health Partners and several Mount Sinai-related hospitals. United States ex. Rel. Kane v. Continuum Health Partners, Inc. et al, (Civil Action, No. 11-2325(ER)). While DOJ intervention in whistleblower cases is not unusual, this case is significant because the DOJ’s complaint specifically alleges that the defendants failed to return Medicaid overpayments within 60 days, as required by the Affordable Care Act (“ACA”). The case is one of the first to explore the issues and interpret the requirements of the 60-Day Rule. More >

Medicare Part D Prescribers Must Act Now

On May 19, the Centers for Medicare & Medicaid Services (“CMS”) issued final regulations which require doctors prescribing drugs for Part D patients to enroll in Medicare. In addition, the regulations establish authority for CMS to revoke a doctor's Medicare eligibility for abusive prescribing practices, among other provisions. The regulations are part of the ongoing effort to curb fraud and abuse and to improve benefits and the quality of care for seniors and people with disabilities enrolled in these programs. More >

Tips for New Enrollment & Revalidation for Participation in Medicare & Medicaid

The new enrollment and revalidation requirements for providers and suppliers for Medicare/Medicaid participation was previously  detailed on this blog. As promised as a follow-up, this blog post will describe enrollment best practices and tips for ensuring that enrollment or revalidation is properly accomplished. Not only is initial enrollment now more onerous, but revalidation is required for all physicians and other providers/suppliers who were enrolled before March 25, 2011, which generally means that all physicians and physician groups must complete the re-enrollment process. A failure to re-enroll means that CMS will de-activate payment until a successful re-enrollment process is completed. In some cases, CMS may even revoke participation. Thus, it is crucial that physicians, providers, and suppliers get it right the first time. More >

Should Kentucky Physicians Follow California Physicians’ Lead In Challenging Medicaid Rates?

In recent years, Kentucky physicians have dealt with the state’s prescription drug abuse problem head-on – by adding substance disorder recovery services to their practices or establishing separate addiction recovery clinics. This trend has undoubtedly played a role in the 2013 decline of Kentucky deaths from overdoses of controlled substances – the first in many years. More >