Category Archives: Accountable Care Act

IS YOUR HEALTHCARE COMPLIANCE PROGRAM COMPLIANT?

Posted on August 26, 2016 by | Comments Off on IS YOUR HEALTHCARE COMPLIANCE PROGRAM COMPLIANT?

HEALTHCARE COMPLIANCE

10 RED FLAGS

Under current law, physicians are required to maintain an effective, comprehensive compliance program to detect, correct and prevent incidences of non-compliance with state and federal regulatory law.  Goals of a comprehensive compliance program is to prevent the significant criminal and civil penalties that might come with a violation of the False Claims Act, Stark, the Anti-Kickback Statutes, HIPAA and state law equivalents. Failure to comply might lead to exclusion from health payments. Here is a summary of the core components of a complete compliance plan:

#1  MISSING OR INCOMPLETE WRITTTEN POLICIES, PROCEDURES AND STANDARDS OF CONDUCT

#2  PEOPLE:   NO COMPLIANCE OFFICER OR COMPLIANCE COMMITTEE

#3  TRAINING:  THE FACILITY LACKS EFFECTIVE TRAINING AND EDUCATION

#4.  COMMUNICATION:  THE FACILITY LACKS

#5.  PERSONEL:  FAILURE TO PUBLISH DISCIPLINARY STANDARDS & TO EFFECTIVELY DISCIPLINE VIOLATORS

#6.  NO SYSTEM TO AUDIT AND MONITOR ORGANIZATION COMPLIANCE AND COMPLIANCE RISKS

 #7  FAILURE TO CREATE PROCEDURES TO PROMPTLY RESPOND TO IDENTIFIED ISSUES AND SELF DISCLOSURE OBLIGATIONS

#8.  LACK OF SUPPORT FROM PHYSICIANS AND LEADERSHIP OF THE ORGANIZATION

#9.  FAILURE TO INSTITUTE PRIVATE HEALTH INFORMATION POLICIES

#10. FAILURE TO MONITOR NEW LAW AND UPDATE COMPLIANCE ACCORDINGLY

By Matt Kinley,Esq., LLM, CHC

562.715.5557

             

 

                

 

 

 

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Posted in Accountable Care Act, Anti-kickback, healthcare compliance, Healthcare Regulatory Matters, HIPAA, Physician

COVERED CALIFORNIA TRANSITIONING TO VALUE PAYMENTS

Posted on May 18, 2016 by | Comments Off on COVERED CALIFORNIA TRANSITIONING TO VALUE PAYMENTS

HEALTHCARE PROVIDERS SHOULD PREPARE FOR END OF FEE FOR SERVICE PAYMENTS

Introduction

Medicare reimbursement has slowly changed from a system primarily based on fee for service to a system paying for treatment of a population.  Physicians and other providers who have relied on Medicare have seen payments reduced and general income levels decline as a result.

Covered California and Value Payments

Reinforcing the view that medical care can be less expensive if incentives are put in place for providers, Covered California has always promoted the utilization of value payments over fee for service for physicians and other healthcare providers.  They view it as a method to reward quality care and patient satisfaction, even though it is having the effect of reducing payments to providers, making medicine more corporate medicine and driving smaller practices out of business.  This has happened with similar Medicare reforms.

The Model QHP Contract

The Covered California Board has been considering its contract with Qualified Health Plans (“QHP”) for the coming years.  A review of the 2017 Qualified Health Plan Contract and Attachments shows that the Covered California Board is continuing its advance to reform payment models under the Healthcare Exchange.

The Qualified Health Plan Model Contract (“Model Contract”) is the agreement entered into between the Qualified Health Plans (“QHP”) and Covered California. The contract sets the terms for the QHP  operate under in order to participate in California’s healthcare exchange.  These contracts have become the major method by which Covered California promotes its major policy initiatives, such as appropriate healthcare networks and payment reform to healthcare providers.

The Model Contract specifically references federal policy on incentivizing quality by tying payments to providers by measuring performance. When providers meet specific quality indicators or enrollees make certain choices or exhibit behaviors associated with improved health, providers receive a higher level of payment.    Such policy requires quality reporting, care coordination; chronic disease management, patient-centered care, evidence based medicine and health information technology. (Quality Improvement Strategy: Technical Guidance and User Guide for the 2017 Coverage Year.)

Attachment 7 to the QHP Model Contract

Attachment 7 to Covered California 2017 Model Contract provides the meat of the policy.  According to Attachment 7, QHPs are to work with Covered California to create healthcare networks that are based on value.   By working with Covered California, all QHPs will share data which they have received from providers across the state.  The plan also contemplates meetings where best practices are discussed.

QHPs Must Select Healthcare Providers Who Are Utilizing Quality Measurements

Under Attachment 7, all plans must include “quality” measurements in the selection and utilization of providers, including “clinical quality, patient safety and patient experience and cost.” Covered California will carefully monitor the plans to assure that that  QHPs only contract with providers and hospitals that demonstrate quality care.

QHPs are to ensure that providers which are serving enrollees with conditions that require highly specialized management have “documented special experience and proficiency based on volume and outcome data.”   Attachment 7 further specifically requires the submission of the Consumer Assessment of Healthcare Providers and Systems, developed by the Agency for Healthcare Research and Quality.  The CAHPS requests information from the consumer experience, including:

  Asking about aspects of care for which a patient or enrollee is the best or only source of information.

  Asking about the aspects of care that patients say are most important.

  Asking patients to report on the health care they receive.

  Reflecting input from a broad spectrum of stakeholders, including patients, clinicians, administrators, accrediting bodies and policymakers.

Finally, Attachment 7 promotes the use of Patient-Centered Medical Homes as well as integrated care models, with quality and patient satisfaction as key data points; population-based care, including integrated care; utilization of electronic health record technology, including utilization of data for results management and clinical decision support and patient support.

2017 continues the trend toward value added care.  Physicians and other providers should start preparing practices for this new payment models if they intend to continue in medicine.

By Matt Kinley,Esq., LLM, CHC

562.715.5557

 

 

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Posted in Accountable Care Act, Current Affairs, healthcare marketing, Medical Insurance, Medicare, physician compensation, Tredway, Lumsdaine & Doyle, LLP

INSURANCE COMPANIES SEEK TO DEFEAT THE SURGERY CENTERS

Posted on May 5, 2016 by | Comments Off on INSURANCE COMPANIES SEEK TO DEFEAT THE SURGERY CENTERS

Various news organizations (for example, Law360) reported on Aetna’s jury verdict against Northern California surgery centers for over-billing the insurer for out-of-network procedures. The jury determined that the surgery center should pay $37.4 million in damages.  The complaint by Aetna included allegations that surgery centers waived patient co-pays and other fees, sales of shares to physicians (who received substantial ROI) in addition to the physician’s own fee for service and other “fraud.”

Other lawsuits with similar allegations are pending. United Healthcare Services has a complaint against several Bay Area ASC’s claiming the ASCs’ bills are artificially inflated, that the providers utilizes different charges for different patients (out-of-network charges being the highest), that the ASCs failed to disclose waiver of co-pays, and inappropriate incentives to physicians for referring patients to the ASC.

The insurers in these cases are attempting to utilize the courts to stop out-of-network billings, especially for ASCs.   The conduct they are complaining about is a common issue of our medical landscape.  Surgery centers are typically physician owned and tend not to have insurance with the typical plans that exist.  Physicians will often promote the ASC as providing superior service, especially compared with alternative medical centers and hospitals.  In order to encourage the patient to have procedures at a facility which does not accept their insurance, the physician and the ASCs will often assure the patient that they will seek reimbursement from the out-of-network insurance provider and that any service received will be at no cost to the patient.  Freed from in-network contracts, these facilities seek their “reasonable fees” from the insurer.

The current litigation will certainly lead to appeals and opinions by courts that will alter the legal landscape. The facts in the Aetna case appear to include evidence of communications between physicians encouraging referrals to the surgery centers, which would appear inflammatory to the jury.

 

However existing law does not appear to support the insurers claims.  For instance, the Accountable Care Act actually requires discounting co-payments for out-of-network emergencies. (“Any cost-sharing requirement expressed as a copayment or coinsurance rate imposed with respect to a participant, beneficiary, or enrollee for out-of-network emergency services cannot exceed the cost-sharing requirement imposed with respect to a patient, beneficiary or enrollee if the services were provided in network.” 45 C.F.R. 147.138.)  The California Attorney General that waiver of copayments for out-of-network insurance companies was appropriate.  (Dentists routine waiver of co-pay appropriate. 64 Ops. Cal. Atty. Gen. 782 (1981).) Discounts to encourage patient referrals is not impermissible. (People v. Duz-Mor Diagnostic Laboratory, Inc. (1998) 68 Cal. App. 4th 654.)  Likewise, it is legal for physicians to refer to surgery centers where they have a financial interest. (California Business Code section 650(d).)

Providers who routinely bill to out-of-network providers should monitor these cases closely. The Courts will be making ground-making decisions in this area in coming months.

By Matt Kinley, Esq, LL.M.  Mr. Kinley represents health care clients in Southern California.

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Posted in Accountable Care Act, Healthcare Regulatory Matters, Medical Insurance, Physician

Los Angeles Medical Association: Navigating the Hornet’s Nest of Reimbursement

Posted on March 8, 2016 by | Comments Off on Los Angeles Medical Association: Navigating the Hornet’s Nest of Reimbursement

Matt Kinley Speaks to Los Angeles County Medical Association on March 23, 2016.  Contact Mr. Kinley at mkinley@tldlaw.com if your interested in attending.

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Posted in Accountable Care Act, Anti-kickback, Current Affairs, Healthcare Regulatory Matters, Medical Insurance, Medicare, Physician, Physician Assistant, physician compensation, telehealth, Uncategorized

PHYSICIAN OFFICE COMPLIANCE: PHYSICIANS SHOULD PREPARE

Posted on December 15, 2014 by | Comments Off on PHYSICIAN OFFICE COMPLIANCE: PHYSICIANS SHOULD PREPARE

Compliance in Physician Offices

Compliance guidance for physician practices was issued by the Office of Inspector General in 2000. Since that time, many physician practices, especially more complex specialty practices, have developed some sort of compliance plan. Compliance covers many areas of a healthcare practice.

Although compliance plans have not previously been mandatory, they have become “industry standard” as a way to minimize risks associated with health care regulations such as the Health Insurance Portability and Accountability Act of 1996, the Medicare and Medicaid Fraud and Abuse Laws, Anti- kickback Statute, Civil Monetary Laws, False Claims Act, the Clinical Laboratory Improvement Act and all other state and federal statutes, regulations and directives that apply to the operation of a complex physician’s practice.

The Patient Protection and Affordable Care Act of 2010, in section 6401, requires Health and Human Services and the Office of Inspector General to promulgate regulations that require most healthcare providers and suppliers to establish compliance programs. The compliance programs are intended to be “effective in preventing and detecting criminal, civil, and administrative violations” under the Medicare and Medicaid laws and other laws that govern operations.

Under the Affordable Care Act, physicians and group practices, will be required to establish compliance programs as a condition of enrollment in the Medicare program.HHS is required to issue regulations creating a timetable and basic core compliance program requirement.

Physician groups should begin the process of establishing compliance programs as soon as possible and not wait for final regulations. Compliance programs are a good way for physician practices to reduce risk associated with fraud and abuse and other legal matters that present risk to their operations. It makes sense for physicians to begin development now to provide ample time for creation of appropriately scaled policies and input from various personnel in the group.

It will not be sufficient to adopt pre-written compliance policies. Rather, physician offices must establish a continuing system of review for their office. Practices may need to be modified based upon their specialization. The seven core elements of effective compliance programs have been released by the Office of Inspector General, including the Physician Practice Guidelines.
A compliance program requires the physician to perform a risk assessment in their organization and document the outcomes of that assessment. The risk assessment could take many forms. Compliance professionals talk about a “gap analysis” which is an approach to help determine the vulnerabilities of your organization. Areas of risk provide emphasis to appropriate areas of risk that are identified through your risk assessment.
The seven areas of emphasis include:
1. Adoption of written guidelines and policies to promote the organization’s commitment to compliance;
2. Identification and appointment of a high ranking individual within the organization to serve as compliance officer;
3. Establishment of anonymous reporting systems, preferably through multiple pathways, to encourage individuals to make complaints regarding compliance items without fear of retaliation;
4. Effective education and training programs for all levels of employees and others with close relationships to the organization;
5. Ongoing auditing systems to assess the effectiveness of the compliance program and to provide input into areas that require additional emphasis;
6. Mechanisms to enforce the requirements of the compliance program and to discipline employees for violations of the organization’s commitment to compliance; and
7. An ongoing system of program modification based upon audit, feedback and experience that can further adapt the compliance policies to the specific issues faced by the organization.

By Matt Kinley, Esq

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Posted in Accountable Care Act, Anti-kickback, Criminal Prosecution, Current Affairs, Healthcare Regulatory Matters, HIPAA, Home Healthcare, Home Nursing, Medicare, Uncategorized

TLD Partner Matthew Kinley Speaks with Healthcare Risk Management on Corporate Negligence

Posted on November 17, 2014 by | Comments Off on TLD Partner Matthew Kinley Speaks with Healthcare Risk Management on Corporate Negligence

As my firms healthcare practice chair,  I had the chance to share my insights with American Society for Healthcare Risk Management on the role of corporate negligence in medical malpractice cases.

You can read the full article posted by Healthcare Risk Management here:  TLD – Healthcare Risk Management 11-2014

Source: Healthcare Risk Management, published by AHC Media, Atlanta. Phone: (800) 688-2421. Email: customerservice@ahcmedia.com. Web

 

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Posted in Accountable Care Act, Employers and Healthcare, Healthcare Regulatory Matters, Physician, Tredway, Lumsdaine & Doyle, LLP

What’s the difference: Physician Assistant v. Nurse Practioner

Posted on June 25, 2014 by | Comments Off on What’s the difference: Physician Assistant v. Nurse Practioner

As the need for health care has expanded, there has been an increase in demand for employees and professionals in the medical field. Therefore, there are a variety of health care jobs and careers. Two key positions in the health care field that have contributed to addressing the looming physician gap are Physician Assistants and Nurse Practitioners. Because both job descriptions have notable similarities, there can be some confusion between the differences in purpose and the roles between a Physician Assistant and Nurse Practitioner. However, there are notable differences.

In California, both Physician Assistants and Nurse Practitioners are regulated according to state regulations. The main difference between a Physician Assistant and Nurse Practitioner is the education received. Physician Assistants are trained more similarly to that of a Physician where a Nurse Practitioner skills are advanced under the nursing-centric education model. Physician Assistants get extensive training in treatment and diagnosing ailments for patients and conversely, the nursing-centric education model that Nurse Practitioners are exposed to focuses on a holistic approach to management of patients.

A Physician Assistant is a medical professional who has been authorized to practice medicine. Specifically, a Physician Assistant can conduct physical examinations, diagnose patients, provide treatment including setting broken bones, obtain medical histories, perform procedures, assist in surgery, and make regular rounds in hospitals and nursing homes. Physician Assistants must be certified to practice. Generally, masters programs for Physician Assistants are modeled on the medical school curriculum combining both classroom lectures and clinical training. Physician Assistants must be supervised by a Physician as established by Title 16 of the California Code of Regulations Section 1399.545. Moreover, a Physician Assistant may only provide medical services in which they are competent to perform and which are consistent with their education (Cal. Code Regs. tit. 16, § 1399.540).

On the other hand, a Nurse Practitioner is a registered nurse with an advanced education—usually a masters degree in nursing. A Nurse Practitioner specializes in disease prevention, promotion of health and education, and diagnosis and management of chronic diseases. Nurse Practitioners utilize a holistic approach to management of patients and overall care. Title 22 of the California Code of Regulation Section 51170.3 requires that Nurse Practitioners be licensed and certified under the Board of Registered Nursing. Moreover, Nurse Practitioners can further specialize and hold themselves out as family or pediatric Nurse Practitioners (Cal. Code Regs. tit. 22, § 51170.3). Unlike that of a Physician Assistant, in California, Nurse Practitioners do not need to be under direct supervision of a Physician.

As the demand for medical treatment grows, the importance of mid-level practitioners including Physician Assistants and Nurse Practitioners increases. It is apparent that there are overlapping skills between the two careers, however, a Physician Assistant concentrates on medical treatment whereas a Nurse Practitioner provides overall care management for patients.

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Posted in Accountable Care Act, Current Affairs, Healthcare Regulatory Matters, Medical Licensing, Nurse Practioner, Physician Assistant, Tredway, Lumsdaine & Doyle, LLP