On March 31, 2016, the United States District Court for the Northern District of Alabama granted summary judgment for AseraCare in one of the largest False Claims Act (FCA) lawsuits against a hospice provider. In this whistleblower case, the government sought over $200 million, alleging that defendant AseraCare overbilled Medicare for hospice services by falsely certifying that patients were eligible for hospice care.
The litigation began when six AseraCare employees in Alabama, Wisconsin and Georgia (the "relators") filed whistleblower cases under the FCA. The employees alleged that AseraCare knowingly submitted false claims to Medicare by falsely certifying that patients met the Medicare eligibility requirements for the hospice benefit. In order to be eligible for the Medicare hospice benefit, a patient's physician must certify that "the individual's prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course." 42 C.F.R. § 418.22(b)(1). The Department of Justice (DOJ) intervened in January 2012. Read More ›
The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) recently announced that it reached resolution agreements and corrective action plans with two health care entities - a health system and a research institution - in connection with alleged violations of the Health Insurance Portability and Protection Act of 1996 (HIPAA). These cases underscore the importance of ongoing HIPAA compliance vigilance by covered entities and business associates, particularly in light of OCR’s recent announcement that it has commenced Phase 2 of its audit program. Read More ›
The Michigan Health Insurance Claims Assessment Act is back for reconsideration before the United States Court of Appeals for the Sixth Circuit. The act imposes a tax on paid health care claims that is used to fund the state share of Michigan’s Medicaid program. The act had been upheld by the federal appeals court in 2014 against an ERISA preemption challenge brought by an organization representing self-insured group health plans and third-party administrators.
The Supreme Court recently remanded the case to the federal court of appeals for reconsideration in light of a decision holding that a Vermont all-payers claim database statute interfered with the uniform administration of ERISA plans and was therefore preempted. Read More ›
Modern Health Care has reported that hospitals often lose approximately $176,000 a year per each employed physician.
While this initially seems like a surprising statistic, it is understandable that hospitals lose money when they employ physicians. Physicians in private practice often pay their staff less than comparable hospital employees. When a hospital buys a physician’s practice, the benefit costs typically increase if the staff receives the hospital’s fringe benefit package. Moreover, hospital overhead is typically higher than a private physician practice with regard to HR costs and other support services.
Many systems claim that the only way to manage the health of a given population (which is what ACO and other similar payment structures are requiring) is to be fully integrated with employed physicians, so covering the losses incurred by employing physicians is the necessary cost of preparing for the new paradigm. The ugly, and legally problematic, truth is that most health systems look beyond the income generated by physicians for treating patients but also at income from physician ancillary referrals to justify the economic losses caused by acquiring physician practices. This raises concerns under the Stark law. Read More ›
On February 11, 2016, the Centers for Medicare & Medicaid Services (“CMS”) issued its long-awaited Final Rule on Reporting and Returning of Overpayments (the “Final Rule”). The Final Rule, which will become effective on March 14, 2016, implements section 1128J(d) of the Affordable Care Act (“ACA”). This Section of the ACA requires that Medicare providers report and return Medicare overpayments by the later of (A) the date that is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due, if applicable (the “60-day rule”). According to CMS, the purpose of the Final Rule is to provide “needed clarity and consistency in the reporting and returning of self-identified overpayments.”
CMS issued a Proposed Rule on Reporting and Returning of Overpayments (the “Proposed Rule”) on February 16, 2012. The Final Rule includes some important changes to the provisions of the Proposed Rule. A summary of the major provisions of the Final Rule appears below. Read More ›
The Office of Civil Rights (“OCR”) recently issued new guidance (“Guidance”) concerning the right of individuals to access their protected health information (“PHI”) under the HIPAA Privacy Rule. The OCR explained in the Guidance that based on its enforcement experience and recent studies, individuals continue to have difficulty accessing information - even from entities required to comply with the HIPAA Privacy Rule. This is also despite improvements in technology that make access more readily available. Bottom line is that individuals must have access to their PHI and health providers need to be providing such access.
However, the Guidance further clarifies a number of issues, including permissible charges for providing information to patients, security issues, submission of requests for information, and the manner for providing access to information. Read More ›
As part of the continuing transition toward a physician payment system based more on quality than quantity, the Centers for Medicare & Medicaid Services (“CMS”) recently released a draft Quality Measure Development Plan (the “Plan”). The Plan is authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”), which mandated that CMS post a draft plan for the development of quality measures by January 1, 2016. The Plan explains how CMS will support the transition to the new Merit-Based Incentive Payment System (“MIPS”) and Alternative Payment Models (“APMs”). Read More ›
In the last few days of 2015, the Internal Revenue Service ("IRS") published welcomed relief for employers who are struggling to understand their reporting obligations under the Affordable Care Act ("ACA"): extended deadlines. Read More ›
On October 29, 2015, the Centers for Medicare & Medicaid Services (CMS) issued the final home health prospective payment system (PPS) rule for calendar year (CY) 2016. CMS projects that the impact of the final rule will result in a 1.4 percent (or $260 million) reduction in Medicare payments to home health agencies (HHAs) from 2015 payment levels. Read More ›
The U.S. Department of Justice (DOJ), and a handful of states, recently reached a settlement agreement with Adventist Health System (Adventist), resolving Stark Law issues, as well as allegations in two separate qui tam actions that included false claims. Generally speaking, the Stark Law limits physician referrals of designated health services or “DHS” for Medicare and Medicaid patients in instances where the physician - or an immediate family member of the physician - has a financial relationship with the DHS entity. Read More ›