Healthcare Law Blog

Healthcare Practitioners – Three Ways to Use KASPER to Protect Your Practice

Prevention and compliance best practices for healthcare providers are a hot topic, and this isn’t likely to change, maybe ever. As the opioid crisis continues to grow and healthcare providers come under increasing scrutiny, one tool is emerging as a resource for prescribing providers, and it’s probably not what you would expect: KASPER, Kentucky’s prescription reporting database. Below are three ways to get the most out of KASPER to keep your practice in compliance. More >

With Great Power, Comes Great Liability?

As medical advancements and patients in need of medical care continue to increase, the role of mid-level practitioners becomes even more crucial.  While there have been many turns of phrase for these medical professionals, the term “mid-level practitioner” is meant to encompass those non-physician providers, which include advanced practice nurses and physician assistants, among others. In Kentucky, there has been a shortage of primary care providers, which is particularly problematic in the state’s many rural areas.  This in turn has led to the push for more autonomy to these integral medical providers. While there are many reasons why this development is an improvement for patients and providers alike, this also leads to more liability exposure.  More >

Healthcare Entities: How is Your Cyber Security?

In an evolving world of cyber terrorism where individuals such as Edward Snowden grab headlines by stealing national secrets, it should come as no surprise that protected healthcare information (“PHI”) kept by providers has become a “target rich environment” for foreign governments and individual hackers alike. In addition to threats from outside entities, healthcare providers must also realize and appreciate that state and federal regulatory and statutory requirements govern the creation, maintenance and protection of PHI, including through but not limited to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Health Information Technology for Economic and Clinical Health (“HITECH”) Act.  Failure to abide by these complex and stringent rules can lead to significant penalties.  More >

Compliance: Include Prescribing Practices!

Since the implementation of House Bill 1 in 2012, the restrictions on prescribing controlled substances have become more and more stringent, which is a response to the opioid epidemic sweeping Kentucky and the nation. The Cabinet for Health and Family Services, the Kentucky Board of Medical Licensure, the Kentucky Board of Nursing, and the Kentucky Board of Pharmacy are vigilant in policing prescribing practices and have tools through KASPER to closely monitor the prescribing practices of physicians and other practitioners. With the addition of new medications like Gabapentin to the controlled substances hit list, practitioners must be particularly careful to ensure that their prescribing is consistent with regulatory requirements, particularly when patients have been on this medication previously.   Physicians and practitioners must continually monitor compliance as even a minor violation can give rise to investigations, complaints and regulatory penalties.  Assessment of regulatory penalties, even when characterized as “Agreed Orders,” can have devastating consequences for physicians and practitioners’ practices and ability to maintain provider contracts, including Medicare and Medicaid. More >

Compliance Programs for Nursing Facility Providers

Nursing facilities are now required to develop and implement effective compliance and ethics programs under newly-created Section 483.85 of the Affordable Care Act (“ACA”) §6102. These programs must be in effect by November 28, 2017. These regulatory requirements are highly complex, especially the requirement of annual review and revision of the programs.   More >

"Incident to" Billing - Easy to Get Wrong

Billing for medical services is never easy. Despite attempts by the Centers for Medicare & Medicaid Services (“CMS”) to simplify the rule regarding “incident to” billing for Medicare services, it remains misunderstood by a large swath of providers. This proves problematic, as incorrect billing practices may lead to overpayments and False Claims Act violations. Billing for “incident to” services is an important mechanism to reflect the actual value of mid-level services provided under the specific plan of a physician. When properly followed, the “incident to” rules allow physicians to bill for services provided by non-physician practitioners as if they were performed by the physician at physician reimbursement rates. Additionally, the non-physician provider can be an employee, an independent contractor or even a leased employee, provided that they are supervised by a physician and the requirements are met. Because of the confusing nature of allowing a physician to bill for services he or she did not directly provide to the patient, serious landmines exist that can create problems if the rules are not scrupulously followed and documented. More >

Watch out MCOs--What to do with Medicaid Managed Care Organizations’ Payment Denials. Medicaid’s Findings of Alleged Overpayments—Relief?

With reported revenues in the billions of dollars and net profits not far behind, insurance companies providing a Medicaid Managed Care product are making huge profits on Kentucky’s Medicaid business.  Across the country, lawsuits are being filed that go so far as to allege that these Medicaid Managed Care Organizations (“MCOs”) have been unjustly enriched and have made fraudulent misrepresentations, as well as negligent misrepresentations to providers and their staff. WellCare, in particular, is the subject of a new action in Florida based, in part, on its Kentucky Medicaid business.  While these lawsuits create a very important way to address reimbursement issues, Kentucky providers have a new avenue to pursue claims against MCOs.  In April of 2016, the Kentucky legislature directed that health care providers have a process by which a Medicaid MCO’s final decision denying a healthcare service or claim could be reviewed and appealed.  Under the statute, providers could receive an independent, third-party review of denied Medicaid managed-care claims, as well as an administrative process for review. Prior to the new process in Senate Bill 20, the only avenue for appeal was to the MCO itself or through the Department of Insurance’s policy of reviewing claims regarding failure to make prompt payment, which was a process established by policy, not regulation.   Finally, in December 2016, the final regulations implementing the statute and providing the process for appeal were promulgated by Kentucky’s Department for Medicaid Services (“DMS”), making available long-awaited relief for health care providers facing denied claims from Medicaid MCOs.  More >

The One Simple Rule for Practitioners to Avoid Overpayments and False Claims Act Penalties

In December, the Centers for Medicare and Medicaid Services (“CMS”) released its “Supplementary Appendices for the Medicare Fee-for-Service 2015 Improper Payments Report,”[1] an annual compilation of statistics from investigations into overpayments and other instances of fraud, waste and abuse in Medicare payments. What should shock Kentucky providers is that Kentucky has the seventh highest percentage of projected overpayments at 15.4%, or $897.7 million.[2] More than one out of every seven Medicare fee-for-service payments made in the Commonwealth is projected to be an overpayment in 2015, yet many of these problems could have been avoided by following one simple rule: document claims properly.

[1] U.S. Department for Health and Human Services, the Centers for Medicare and Medicaid Services. (2015). The Summary Appendices for the Medicare Fee-for-Service 2015 Improper Payments Report. Retrieved from  https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports-Items/Downloads/AppendicesMedicareFee-for-Service2015ImproperPaymentsReport.pdf

[2] Ibid. at 13. More >

Primary Care Providers – Are you feeling the pinch?

It was nice while it lasted – due to a provision of the Patient Protection and Affordable Care Act (“ACA”), services furnished by certain primary care providers (“PCPs”) were subject to an enhanced payment rate for Calendar Years 2013 and 2014. These PCPs had to have (a) been Board certified in the specialty designation of family medicine, general internal medicine or pediatric medicine or have a subspecialty designation recognized by specific boards or associations, or (b) furnished more than 60% of claims in specific evaluation and management or vaccine administration services under certain codes to have been eligible for these enhanced payments.[1] The payments were raised to the level of the Medicare Part B fee schedule rate (unless the actual billed charge for the service was lower), and providers had until April 1, 2013 to self-attest to being eligible.[2] The increase applied to both fee-for-service and managed care Medicaid plans. More >

RHCs and FQHCs – It’s time to take a second look at Alternate Payment Methodology

In July of 2014, Kentucky Medicaid established an Alternate Payment Methodology (“APM”) for all Federally-Qualified Health Centers (“FQHCs”) and Rural Health Clinics (“RHCs”) as an alternative to the all-inclusive encounter rate per patient under the standard prospective payment system (“PPS”) of 42 U.S.C. 1369a(aa). The APM allows for qualified centers to be reimbursed at a rate of 125% of the 2014 Medicare Upper Payment Limit for RHCs in place of the PPS system ($99.75 per covered visit). There are more advantages to APM than meet the eye, however, and qualified centers currently using PPS method should at the very least reevaluate APM, as proposed changes will make APM even more attractive and potentially risk-free. More >