Tag Archives: Providers

Applicability of Fraud and Abuse Rules to the Marketplace Clarified … Somewhat

One of the lingering questions about the Health Insurance Marketplace created under the Affordable Care Act is whether plans on the Marketplace are considered part of a Federal health care program, thus opening up potential liability under the Anti-Kickback Statute. There was concern that the broad language defining a “Federal health care program” would apply to the Exchanges because of the federal tax subsidizes provided to individuals on the private market.  Under 42 U.S.C. 1320a-7b(f)(1), a “Federal health care program” is defined as “any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government.”  This presented the possibility that, by virtue of the inclusion of federal subsidy payments, even private insurance plans on the Marketplace and the state Exchanges would constitute Federal health care programs and necessitate compliance with the entire array of federal legal requirements.    Continue reading

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Filed under False Claims Act, Fraud and Abuse, PPACA

Jason Helgerson Makes MLTC Encounter Data a Priority

At a Managed Care Policy Meeting held last week with managed care plans, New York’s Medicaid Director, Jason Helgerson, spoke about the importance for plans to submit timely and accurate encounter data.  He noted that managed long term care plan submissions are particularly late.  He indicated that if the lack of reporting continues there is the possibility that Statements of Deficiencies (which can result in halting enrollments) will be issued and that the Department of Health will consider referrals to the OMIG for investigation and audit.  The plans responded by explaining that the challenge, in part, is that they are not receiving the required information from the providers (home care, nursing facilities, adult day health care, etc).  Continue reading

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Filed under Managed Long Term Care, Medicaid

Health Planning Committee of the Public Health and Health Planning Council Proposes Significant Certificate of Need Redesign

The Health Planning Committee of the Public Health and Health Planning Council is proposing a significant Certificate of Need (“CON”) redesign. The Committee and Council are expected to make twenty-two (22) recommendations to the Department of Health next week, affecting the CON process.  Five of the recommendations refer to an initiative to shift towards regional planning for CON applications.

New entities – called Regional Health Improvement Collaboratives (“RHICs,” pronounced “Ricks”) – would be responsible for increasing patient experience of care, decreasing the per capita cost of care, reducing the disparities in coverage, and more effectively managing the health of New York’s citizens.  Continue reading

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Filed under Announcements, Public Health and Health Planning Council

CMS Issues Section 1135 Waivers for New York and New Jersey

The Centers for Medicare and Medicaid Services (CMS) approved waivers for New York and New Jersey under Section 1135 of the Social Security Act.  The waivers ease certain legal requirements on healthcare providers who are serving those impacted by Sandy.  The Section 1135 waiver for New York is available here.  The waivers relax the rules for providers in areas like recordkeeping, patient relocation and billing in order to ensure that individuals enrolled in federal programs like Medicare and Medicaid receive the health care items and services that they need.  New York’s waiver is retroactive to Oct. 27. Continue reading

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Filed under Announcements, Medicaid

The danger of unencrypted protected health information: 55,000 patients’ PHI exposed.

An Indianapolis oncology group has disclosed that data concerning about 55,000 patients was stored on a stolen laptop computer.  A backup copy of the Cancer Care Group’s server was stored on the computer, which was stolen from a locked car.  Among the data stored on the device were patient names, addresses, Social Security Numbers, medical record numbers, and insurance information.  Several employees’ personal information was stored on the compromised device as well.

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Filed under HIPAA

OMIG Releases Compliance Alert for Medicaid Providers

The New York State Office of Medicaid Inspector General (“OMIG”) recently released a Compliance Alert that explains what types of Medicaid providers are required to have a compliance program and what steps those providers can take to ensure that they are meeting their obligations under the law.

The New York Social Services Law and its implementing regulations require certain Medicaid providers to develop, adopt, and implement effective compliance programs, which are designed to detect and prevent inaccurate billing and inappropriate practices in the Medicaid program (“Mandatory Compliance Law”).  N.Y. Soc. Serv. Law § 363-d; 18 N.Y.C.R.R. Part 521.

This Mandatory Compliance Law applies to Medicaid providers operating under Articles 28 or 36 of the Public Health Law or Articles 16 or 31 of the Mental Hygiene Law, or who are newly enrolled in the Medicaid program.  It also applies to providers of care, services, and supplies for which the Medicaid program is or reasonably should be expected to be a “substantial portion of their business operations.”  The regulations define a “substantial portion” as ordering, billing or claiming $500,000 or more from Medicaid during a 12-month period.  The $500,000 threshold applies whether the provider receives the reimbursement directly or indirectly from Medicaid funds.    Continue reading

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Filed under Announcements, NY Office of Medicaid Inspector General

HIPAA: Conversion to Version 5010

As of January 1, 2012, all healthcare providers were required to transition from version 4010/4010A to version 5010 standards for submitting electronic transactions, and the failure to comply may result in claim denials or a government investigation. CMS has repeatedly postponed enforcement, but it appears the agency will begin to enforce civil monetary penalties against non-compliant medical practices, hospitals and other healthcare entities as of July 1, 2012.

If you are compliant, you may have noticed that not all public and private payors are currently compliant and able to accept transactions in version 5010 standards. This means that you will have to continue submitting transaction forms in both version 4010/4010A and version 5010 standards until all payors complete the transition.  It is important that you contact each payor and establish a relationship with their HIPAA compliance department to determine their compliance level and promote a fluid transition to version 5010 standards.

If you are not currently in compliance, it is imperative that you begin to develop a transition plan to incorporate the steps your practice will take to become compliant by the enforcement date.  In developing your plan, you should be in contact with your payors to provide you with valuable assistance. Continue reading

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Filed under Adult Homes, HIPAA, Home Health Agency, Laboratories, Nursing Homes

United States HHS OIG Reviewing Self Disclosure Protocol for Federal Health Care Programs

The federal government’s Office of the Inspector General (“OIG”), part of the United States Department of Health and Human Services, is considering revising its self-disclosure protocol to provide additional guidance to federal health care program providers.  The OIG is soliciting comments from all sources on the process by which health care providers can report overpayments and potential fraud.

The current OIG self-disclosure protocol was issued in 1998 and is available here.  The OIG Provider Self-Disclosure Protocol established the process by which providers self-reported overpayments and potential fraud thereby satisfying their obligation to do so under federal law. Continue reading

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Filed under Announcements, Medicaid Fraud

Gov. Cuomo Announces Agreement on Justice Center Legislation to Protect People with Special Needs and Disabilities

Today, Governor Andrew M. Cuomo, Senate Majority Leader Dean Skelos, and Assembly Speaker Sheldon Silver announced an agreement on legislation that will establish a new Justice Center for the Protection of People with Special Needs, which will change how the state protects New Yorkers in state-operated, certified, or licensed facilities and programs.

As we previously reported, Governor Cuomo first proposed the “Protection of People with Special Needs Act” on May 7, 2012.

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Filed under Announcements

New York Attorney General Settles Balance Billing and Overpayment Disputes

New York State Attorney General Eric Schneiderman announced on Tuesday that it had reached settlements with Group Health Inc. (“GHI”) and a New York City health care provider regarding overpayments to consumers.

GHI has agreed to repay consumers for approximately three years of overbilling.  GHI purportedly charged its assureds out-of-network rates for certain medical providers, including radiologists, pathologists, and anesthesiologists.  This practice was contrary to GHI’s policy.  Reportedly, GHI assureds sometimes paid in the thousands of dollars for services that GHI should have covered.  Attorney General Schneiderman’s office reached an agreement with GHI to return the overbilled amounts, which are thought to total nearly $500,000.  GHI has also agreed to pay a penalty, assist consumers who were subject to debt-collection as a result of GHI’s overbilling, and train its employees to avoid this practice in future. Continue reading

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Filed under Announcements