COVERED CALIFORNIA: WHAT’S A PROVIDER TO DO?

Posted on December 13, 2013 by | Comments Off on COVERED CALIFORNIA: WHAT’S A PROVIDER TO DO?

Several issues arise from the proposed agreements for providers from Qualified Health Plans (“QHP”) under Covered California. Some issues that physicians and other providers should be watching out for:

1. Payment Schemes. Initial contracts from the various QHP’s are offering low payment options, particularly the “80% of Medicare” option. Physicians should be wary of such agreements. Under QHP contacts with Covered California, the plans have agreed to work on value-based payments in the future, making future contracts even less attractive for providers.

2. Hospital Contracts. There still is no clarity on which hospitals will take part in Covered California and under what plans. Covered California has no listing of participating hospitals at this time. The prospect of narrow networks (fewer providers offered to consumers) makes it troublesome to predict the future on hospital participation.

3. Administrative Burdens. QHPs are imposing difficult and legally thorny administrative tasks on providers, particularly providing information about patients and payments.

4. Populations. Get information on the types of patients expected under contracts. The initial rounds of patients are predicted to be populations that are in fair to poor health. Since they are not used to traditional medical care, they are expected to have a large percentage of missed appointments and compliance issues.

5. Collections. What is the providers obligations to collect? Some Covered California plans leave high deductibles and copays for enrollees. Yet, the newest enrollees are not used to paying such amounts. Also, determine risk for patients who fail to pay premiums to Covered California QHPs. Providers may be on the hook.

With all the problems with exchange products, providers may want to sit out this first round

Several issues arise from the proposed agreements for providers from Qualified Health Plans (“QHP”) under Covered California. Some issues that physicians and other providers should be watching out for:

1. Payment Schemes. Initial contracts from the various QHP’s are offering low payment options, particularly the “80% of Medicare” option. Physicians should be wary of such agreements. Under QHP contacts with Covered California, the plans have agreed to work on value-based payments in the future, making future contracts even less attractive for providers.

2. Hospital Contracts. There still is no clarity on what hospitals will take part in Covered California and under what plans. Covered California has no listing of participating hospitals at this time. The prospect of narrow networks (fewer providers offered to consumers) makes it troublesome to predict the future on hospital participation.

3. Administrative Burdens. QHPs are imposing difficult and legally thorny administrative tasks on providers, particularly providing information about patients and payments.

4. Populations. Get information on the types of patients expected under contracts. The initial rounds of patients are predicted to be populations that are in fair to poor health. Since they are not used to traditional medical care, they are expected to have a large percentage of missed appointments and compliance issues.

5. Collections. What is the providers obligations to collect? Some Covered California plans leave high deductibles and copays for enrollees. Yet, the newest enrollees are not used to paying such amounts. Also, determine risk for patients who fail to pay premiums to Covered California QHPs. Providers may be on the hook.

With all the problems with exchange products, providers may want to sit out this first round of patients.

FORNIA: WHAT’S A PROVIDER TO DO?

Several issues arise from the proposed agreements for providers from Qualified Health Plans (“QHP”) under Covered California. Some issues that physicians and other providers should be watching out for:

1. Payment Schemes. Initial contracts from the various QHP’s are offering low payment options, particularly the “80% of Medicare” option. Physicians should be wary of such agreements. Under QHP contacts with Covered California, the plans have agreed to work on value-based payments in the future, making future contracts even less attractive for providers.

2. Hospital Contracts. There still is no clarity on what hospitals will take part in Covered California and under what plans. Covered California has no listing of participating hospitals at this time. The prospect of narrow networks (fewer providers offered to consumers) makes it troublesome to predict the future on hospital participation.

3. Administrative Burdens. QHPs are imposing difficult and legally thorny administrative tasks on providers, particularly providing information about patients and payments.

4. Populations. Get information on the types of patients expected under contracts. The initial rounds of patients are predicted to be populations that are in fair to poor health. Since they are not used to traditional medical care, they are expected to have a large percentage of missed appointments and compliance issues.

5. Collections. What is the providers obligations to collect? Some Covered California plans leave high deductibles and copays for enrollees. Yet, the newest enrollees are not used to paying such amounts. Also, determine risk for patients who fail to pay premiums to Covered California QHPs. Providers may be on the hook.

With all the problems with exchange products, providers may want to sit out this first round of patients.

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Posted in Current Affairs, Healthcare Regulatory Matters, Medical Insurance, Tredway, Lumsdaine & Doyle, LLP, Uncategorized

New Ability to Prescribe

Posted on November 23, 2013 by | Comments Off on New Ability to Prescribe

This is third in a series of new 2024 laws affecting healthcare in California. 
SB 670: Physicians and Surgeons: Drug Prescribing Privileges

This new law wades into the increasing regulation over physicians for prescriptions, especially pain killers. The Medical Board of California has increased investigations in this area. One hurdle to such investigations has been getting access to patient records without the consent of the patient or the patient’s family.

SB 670 permits the Medical Board to inspect and copy a deceased patient’s medical records without authorization or court order solely for the purpose of determining whether death was in violation of MPA. The Medical Board must declare in writing that it has been unsuccessful in locating or contacting the deceased patient’s representative after reasonable efforts.

The legislation met with quite a few reservations and is watered down from the original version. The Medical Board still may not see the records when the representative refuses to allow access. It also has a provision that refusal of a physician to participate in a Medical Board interview can be deemed “unprofessional conduct.”

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HEALTHCARE LAW UPDATE, 2014: PHARMACISTS SEE MORE CLOUT

Posted on November 17, 2013 by | Comments Off on HEALTHCARE LAW UPDATE, 2014: PHARMACISTS SEE MORE CLOUT

This is second in a series of new 2024 laws affecting healthcare in California. 

SB 493: New Authority to Pharmacists

One of the key goals of the Accountable Care Act was to to increase utilization of professionals other than doctors.  One way to do that is to expand the authority of pharmacists to perform certain tests and to administer drugs.

This new law gives pharmacists new clout as “health care providers” who can now administer drugs by injection, provide training on drug therapy and disease management and prevention, furnish contraceptives, nicotine replacement products, medications recommended for travel outside the US, order certain tests, and initiate, adjust or discontinue drug therapy (but may not interfere with “as written”).

Devolving  physician authority to other professionals, including nurse practitioners, physician assistants and pharmacists, is an experiment with some risk.  It is clear that these professionals will be able to fill some gaps left by overly busy physicians.  However, there is likely to be less quality and the overall effectiveness of healthcare may follow.  The provision regarding the administration of international travel drugs will likely the pocket books of those physicians who derive economic benefit from this part of their practice.

 

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Posted in Current Affairs, Healthcare Regulatory Matters, Medical Licensing, Uncategorized

NEW CALIFORNIA HEALTHCARE LAWS: GAY AND LESBIAN DISCRIMINATION FOR FERTILITY TREATMENT

Posted on November 16, 2013 by | Comments Off on NEW CALIFORNIA HEALTHCARE LAWS: GAY AND LESBIAN DISCRIMINATION FOR FERTILITY TREATMENT

This is the first in a series of posts about new laws for 2014 affecting healthcare.

AB 460: Non-Discrimination for Homosexuals and Lesbians

Summary

This law requires coverage under the Knox-Keene Health Care Service Plan Act and a under a policy of health insurance that provides for coverage for the treatment of infertility.   If such coverage is offered and purchased, it must be provided without discrimination on the basis of age, ancestry, color, disability, domestic partner status, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex or sexual orientation.

AB 460 extended the idea of “non-discrimination” in this context to homosexuals and lesbians regarding fertility. If a health insurance plan is purchased that contains coverage for infertility, then the plan must not discriminate.  This statute is meant to help all people access to treatment of infertility.

Insurance plans are not required to carry such coverage.  There will be a violation of the statute only if the plan does offer such coverage and they attempt discrimination in the utilization of the coverage.

The law makes homosexuals and lesbians eligible for insurance coverage for “treatment of infertility, except in vitro fertilization, under those terms and conditions as may be agreed upon between the group subscriber or the group policyholder and the plan or the insurer.”

An interesting issue arises when the definition of infertility is considered. Under the new law, homosexuals and lesbians will be classified as “infertile” if they are unable “to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception.” Since most sexual relations in a homosexual and lesbian relationship do not result in pregnancy, the law effectively defines all homosexuals and lesbians as “infertile.” Surely this is an unintended result and new legislation will need to be considered in the near future.

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Posted in Current Affairs, Employers and Healthcare, Healthcare Regulatory Matters, Medical Insurance

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EMPLOYERS AND THE OCTOBER 1, 2013 NOTICE DEADLINE FOR THE ACA

Posted on September 30, 2013 by | Comments Off on EMPLOYERS AND THE OCTOBER 1, 2013 NOTICE DEADLINE FOR THE ACA

TOMORROW IS THE DAY THAT THE EXCHANGE OPENS UNDER THE AFFORDABLE CARE ACT – WHAT YOU NEED TO DO NOW!

SMALL BUSINESSES: NOTICE NOT REQUIRED!

By: Pamela Tahim, Esq.  and Matt Kinley, Esq.

On October 1, 2013, the new Health Insurance Exchanges under the Affordable Care Act will be open for enrollment.  Many businesses are still worried and have concerns about what this means for them.  There are two immediate steps that a business should take: 1) Provide notice to its employees by tomorrow of the Exchange; and 2) Contact your insurance broker. Your broker should be able to guide you through the issues posed by the Affordable Care Act.

Employer Exchange Notice Due to Employees by October 1, 2013

Fair Labor Standards Act (FLSA) § 18B requires that employers subject to the FLSA provide a notice to employees by October 1, 2013 and new hires thereafter. Most firms under $500,000 in annual dollars received from “sales made or business done” are exempt from the FLSA and thus exempt from the notice requirement other than those specifically included regardless of annual income, which are hospitals; institutions primarily engaged in the care of the sick, aged, mentally ill, or disabled who reside on the premises; schools for children who are mentally or physically disabled or gifted; preschools, elementary and secondary schools, and institutions of higher education; and federal, state, and local government agencies.

 The model DOL Exchange Notice for employers with a health plan is located at http://www.dol.gov/ebsa/pdf/FLSAwithplans.pdf.

 For employers with no health plan, the model notice is at http://www.dol.gov/ebsa/pdf/FLSAwithoutplans.pdf. Part B on the notice for employers with health plans is optional and complicated and many employers with health plans will not use it, preferring instead to customize the information on the Part B notice for employers with no health plans.

 If your company is covered by the Fair Labor Standards Act, it should provide a written notice to its employees about the Health Insurance Marketplace by October 1, 2013, but there is no fine or penalty under the law for failing to provide the notice. The notice should inform employees:

  1.   About the Health Insurance Marketplace;
  2.   That, depending on their income and what coverage may be offered  by the employer, they may be able to get lower cost private insurance in the Marketplace; and
  3. That if they buy insurance through the Marketplace, they may lose the employer contribution (if any) to their health benefits

For more information, feel free to contact us at 877.923.0971.

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Posted in Employers and Healthcare, Uncategorized

Quoted By AMEDNEWS.COM

Posted on August 12, 2013 by | Comments Off on Quoted By AMEDNEWS.COM

The American Medical Association publicaiton, Americn Medical News recently quoted Mr. Kinley in it's article, "Collaboration can save medical practices time, money and effort."

"Matt Kinley, a partner of Tredway, Lumsdaine & Doyle, LLP, a Southern California-based law firm, said some concerns were raised that ACOs would violate antitrust laws, leading to certain exceptions being made.

“With ACOs, physicians agree to a certain payment, but that payment is based on improved quality of care,” Kinley said. “The government is very interested in a system that improves quality of care and uses technology, which ACOs do.”

Kinley said it’s too early to tell if ACOs will replace IPAs."

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HIPAA Settlement Shows How To Comply

Posted on August 8, 2013 by | Comments Off on HIPAA Settlement Shows How To Comply

HHS’s Office of Civil Rights
recently completed an enforcement action against Wellpoint.  Wellpoint
suffered security breaches and settled with the Office of Civil Rights for $1.7
million.  Wellpoint self-reported the breach to HHS’s, which mitigates the
penalties that it agreed to pay.  The breach was leaving their database
open to unauthorized users over the Internet.  There is no evidence that
the database was accessed or information utilized.

What is
unique is that the OCR has published the actual settlement agreement with
Wellpoint.  From a providers point of view, the settlement shows what to avoid to be HIPAA compliant.  OCR
lists the violations of HIPAA law that caused the fine.  

What
this demonstrates is that it’s the “technical violation” that will get entities
into trouble. In this case, not having all the safeguards in place to safeguard
protected healthcare information (“PHI” or electronic protected healthcare
information, “ePHI”).

Quoting
from the agreement:

“2.
Factual Background and Covered Conduct

On
June 18, 2010, HHS received notification from WellPoint regarding abreach
of certain of its unsecured electronic protected health information (ePHI). OnSeptember
9, 2010, HHS notified WellPoint of HHS’s investigation regardingWellPoint’s
compliance with the Privacy, Security, and Breach Notification Rules.

HHS’s
investigation indicated that the following conduct occurred (“CoveredConduct”):

 (1) Beginning on
October 23, 2009, until March 7, 2010, WellPoint did not adequately
implement policies and procedures for authorizing access to ePHI
maintained in its web-based application database consistent with theapplicable
requirements of the Security Rule.

 (2) WellPoint did
not perform an adequate technical evaluation in responseto
a software upgrade, an operational change affecting the security of ePHI maintained
in its web-based application database that would establish the extent
to which the configuration of the software providing authentication safeguards
for its web-based application met the requirements of the Security
Rule.

 (3) Beginning on
October 23, 2009, until March 7, 2010, WellPoint did not adequately
implement technology to verify that a person or entity seekingaccess
to ePHI maintained in its web-based application database is the one claimed.

(4) Beginning on
October 23, 2009, until March 7, 2010, WellPointimpermissibly
disclosed the ePHI, including the names, dates of birth,addresses,
Social Security Numbers, telephone numbers and healthinformation,
of approximately 612,000 individuals whose ePHI was maintained
in the web-based application database."

 

 ACTION ITEMS

Steps That
Covered Entities Can Take to Protect Against HIPAA Enforcement

  • Review
    relationships and the documentation of such relationships among and
    between Affiliated Covered Entities and other related entities with which
    they share PHI
  • Revisit
    risk analyses, especially following any changes to the underlying
    technology
  • Update
    policies and procedures as necessary to account for changes in technology
    or practices
  • Continue
    workforce training
  • Audit
    ongoing programs
  • Monitor
    security intrusions
  • Implement
    a breach response plan

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Posted in Current Affairs, Healthcare Regulatory Matters, HIPAA

BEST PRACTICES TO AVOID PAIN KILLER ABUSE BY PATIENTS IN THE MEDICAL OFFICE

Posted on August 1, 2013 by | Comments Off on BEST PRACTICES TO AVOID PAIN KILLER ABUSE BY PATIENTS IN THE MEDICAL OFFICE

This is the third in a series of articles on
avoiding fraud and theft in healthcare professionals’ offices.
The article is meant for medical professionals including physicians,
dentists, home nursing and mental health professionals. If you have any
questions about this series, feel free to contact attorney Matthew L. Kinley, a
healthcare lawyer in Long Beach, California at 562.901-3050

           Practices in California should be wary
of prescribing pain killers for their patients.
The Medical Board has told various audiences that they are reviewing
physicians who prescribe such medications, and will review patient files for
abuse.

           There is good reason for the Medical
Board to be concerned: There has been great abuse by patients who utilize pain
killers.  There has also been an epidemic
of deaths caused by such abuse.  One
estimate has it that American physicians prescribe enough pain killers to
medicate every American around the clock for a month.

           In order to avoid a visit by the
Medical Board, or to be prepared if they do visit,  and to make sure that your painkiller practice
is beneficial for patients, physician offices should adopt protocols to make
sure that patients actually need the painkillers you prescribe.  Such protocol will help keep prescribed drugs
making it on the black market.

 Action Items to Protect Your Practice:

 1. Carefully
document the patient chart.  Carefully
explain the side effects of the prescription, and for long term use, the
potential detrimental effects of potential addiction.

 2. Screen
and monitor for substance abuse and mental health problems.

 3. Be
vigilant for scams and identity theft.

 4. Prescribe
pain killers only after examining the patient.

           California Business and Professions
Code provides some guidance.  Section
2242 provides  that it is
“unprofessional conduct” to prescribe or furnishing dangerous drugs without
an appropriate prior examination and a medical indication.

 5.  Only prescribe painkillers after other treatments
have not been effective for pain.

 6.  Use legally required form. California Healt  & Safety Code section 11162.1 provides standards
for prescription forms for controlled substances. 

Limit the
number of pills prescribed. 

 7. The
quantity prescribed should be based on the expected length of pain.California
Health Safety Code section 11158 provides for limits on number of pills
(“may dispense directly to an ultimate user a controlled substance
classified in Schedule II in an amount not to exceed a 72-hour supply for the
patient in accordance with directions for use given by the dispensing
practitioner only where the patient is not expected to require any additional
amount of the controlled substance beyond the 72 hours. )

 8. Using
patient-provider agreements combined with urine drug tests for people using
painkillers long term.

 9.  Talking with patients about safely using,
storing and disposing of prescription of painkillers.  (www.cdc.gov/homeandrecrationalsafety/poisoning/preventiontips.htm)

 10.  Check the prescription monitoring programs with the California Attorney
General.

 

By Matthew L. Kinley, Esq.

Publish

 

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Posted in Healthcare Regulatory Matters, Medical Licensing

Seminar: Fraud in the Medical Providers Office

Posted on July 25, 2013 by | Comments Off on Seminar: Fraud in the Medical Providers Office
 
 

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Preventing Fraud in the Medical
Office Practice

Join
Tredway Lumsdaine & Doyle's Matthew L. Kinley along with
representatives from The Doctors Company and HMWC CPA's as they tackle
the topic of "Preventing Fraud in the Medical Office."

The
program is intended to provide information, education, and case
examples to illustrate risks associated with fraud in documentation,
prescriptions, billing, collections, physician and employee conduct,
and the internal controls necessary to reduce your risks.

Should
you have any questions, please contact Matthew
L. Kinley.

DATE/TIME:

·       
Tuesday, July 30, 2013

·       
6:00 PM – Dinner

·       
6:30-8:00 PM – Seminar

For
more details and to register, please click here.
 
 

 
   
         
 

©2013 Tredway Lumsdaine
& Doyle LLP
www.TLDLAW.com

Please contact Matthew L. Kinley at
mkinley@tldlaw.com or 562-901-3050.

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BEST PRACTICES TO AVOID FRAUD AND THEFT IN THE MEDICAL OFFICE: PROTECTED HEALTH INFORMATION, IDENTITY THEFT AND THE LAW PRACTICE

Posted on July 25, 2013 by | Comments Off on BEST PRACTICES TO AVOID FRAUD AND THEFT IN THE MEDICAL OFFICE: PROTECTED HEALTH INFORMATION, IDENTITY THEFT AND THE LAW PRACTICE

IDENTITY THEFT, PROTECTED HEALTH INFORMATION EMRs and OTHER FEDERAL REGULATORY ISSUES

This is the second in a series of articles on
avoiding fraud and theft in healthcare professionals’ offices.
The article is meant for medical professionals including physicians,
dentists, home nursing and mental health professionals. If you have any
questions about this series, feel free to contact attorney Matthew L. Kinley, a
healthcare lawyer in Long Beach, California at 562.901-3050. 

Medical providers store all sorts of private information.  Patients give medical providers virtually every identifying fact about themselves possible.  Records kept in the office include information about the health of the patient.  Billing records have banking and other important financial contacts.

Medical providers have an obligation to protect private health infomration.  Federal and state laws impose specific obligations to protect information provided to medical providers. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and related regulations, the Health Inforamtion TEchnology for Economic and Clinical Health  (HITECH) and realated regulations, and the California Business and Professions Codes and related regulations are all laws designed to protect patient’s privacy and to require providers to keep information private.

Medical providers, if they expect payment from Medicare, Medicaid (Medi-Cal in California) or from private payors, will have Electronic Medical Rerords systems in place.  This expansion of electronic records require medical providers to institute plans to follow complicated regulations to make sure they are able to survive government audits and in order to make sure that medical records are safe.  Failure to do so may result in penalties and fines.

ACTION ITEMS:

What to do to protect electronic information?

1.  Hire competent people. 

Take the time to carefully research people you hire.  Check their references.  Make sure they are not on the Office of Inspector Generals Excluded Persons list. (Persons on this list have been found by the OIG to be involved in some sort of fraudulent scheme.)

2.  Prepare a HIPAA Compliance Plan.  Every medical provider, no matter how small, should prepare such a plan.  Failure to do so can result in serious fines and penalties, even if no information is leaked.  The basics of such a plan include:

a.  Appointment of a privacy officer.  Takes charge of the office’s privacy efforts.

b. Security Rule Analysis.  This is the first part of preparing a HIPAA plan.

c.  Prepare a Breach Policy.  This is what to do if there’s a breach and confidential helath information is made public.

d.  Training of your employees.  All employees need to be trained in basic patient privacy.

e.  Privacy Notice.  The law requires every health provider to have and have published a Privacy Notice.

f.  Business Associate Agreements.  The provider is required to protect all information if using other entities to help with collections or other information gathering.

g.  Policies relating to release of information.   When can a patient’s information be released?  To whom can the information be released?  How is such information sent (internet? e-mail?).

Some of the nuts and bolts of your plan will include:

a. Negotiating Leases.  Make sure your landlord does not have access to protected health information.  Most leases allow the landlord to enter the premises, either upon notice or during emergencies.  These entrances into the medical space should be limited.

b. Patient sign-in sheets don’t disclose protected medical information.

c. Patient schedules can’t be seen.

d. Confidential discussions can’t be overheard.

e. Computers have proper encryption and passwords.

f.  Computer monitors can’t be seen by passersby

g. Internet use is secure.

h. Filing cabinets are locked.

i.  Use encryption.  Monitor lap tops and portable storage devices to make sure they are not lost.

e. Keys and access items are retireved from former employees.

Modern electronic information requires that all medical providers comply with the law and institute privacy procedures.  Our office provides guidance on such matters for a flat fee.  You can call for a no cost consultation at any time.

By: Matthew L. Kinley, Esq.

 

 

 

 

 

 

 

 

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Posted in Healthcare Regulatory Matters, HIPAA