Health Care Law Blog

Michigan Doctor Sentenced to 45 Years for Cancer Fraud Scheme

Dr. Farid Fata was sentenced to 45 years in a federal prison by U.S. District Judge Paul Borman. The sentence was greater than the 25 years that the defense advocated for, but well under the 175-year maximum requested by the prosecution. Dr. Fata, who had built an empire of upscale cancer clinics, intentionally misdiagnosed patients and illegally billed Medicare for the treatment. He grossly over-treated, under-treated, and misdiagnosed hundreds of patients by telling them they had cancer when they did not, giving too much or improper treatment to others who did have cancer, and continuing to give chemotherapy to terminal patients who no longer needed it.  Read More ›

Categories: Fraud & Abuse, News & Events

CMS Issues Proposed Rules for Medicaid Managed Care

Last month, for the first time in over a decade, the Centers for Medicare & Medicaid Services (CMS) published proposed revisions to the Medicaid managed care regulations. According to CMS, the proposed rule aims to reflect the changes in delivery systems, strengthen the system’s ability to serve diverse populations, and promote greater alignment of Medicaid managed care policies with those of other payers. A summary of the key provisions of the proposed rule appears below. Read More ›

Categories: Billing/Payment, Medicare/Medicaid, News & Events

Tuomey Health Loses Appeal, Facing $237 Million in Fees and Damages

A very long legal battle may be nearing its final chapter after the U.S. Court of Appeals for the Fourth Circuit upheld a $237 million judgment against Tuomey Healthcare System in South Carolina. The judgment is an enormous sum for the regional health system and hospital, with even one of the Court of Appeals judges calling it a "death sentence." A three-judge panel heard the case at the Court of Appeals, so Tuomey could still seek reconsideration from all the judges of that Court or take the case to the U.S. Supreme Court. It may also opt to find a new partnership to keep the hospital afloat. Read More ›

Categories: Compliance, News & Events, Physicians, Providers

Joint Guidance for Health Care Boards Released by HHS OIG and Industry Leaders

One of the most important responsibilities that governing boards of healthcare organizations (“Boards”) have is carrying out their compliance oversight obligations. Recently the U.S. Department of Health and Human Services Office of Inspector General (OIG) released a new guide to assist Boards in carrying out their compliance duties. The guide is titled “Practical Guidance for Health Care Governing Boards on Compliance Oversight” (“Guidance”) and was developed in collaboration with the American Health Lawyers Association (AHLA), the Association of Healthcare Internal Auditors (AHIA) and the Health Care Compliance Association (HCCA).  Read More ›

Categories: Compliance, News & Events

The US Supreme Court's Ruling on the Affordable Care Act will not Change Employers' Responsibilities

On June 25, 2015, the Supreme Court of the United States issued a ruling related to the Patient Protection and Affordable Care Act (the "Act") in the case of King v Burwell. The issue that the Court addressed was whether tax credits were available to individuals who purchased health insurance coverage through a Health Insurance Exchange ("Exchange") that was established by the Federal government.

An Exchange serves as a marketplace where individuals can compare various health insurance plans and ultimately purchase health insurance coverage. The Act requires an Exchange to be established in each State. If a State fails to establish its own Exchange, the Federal government is required to step in and establish the Exchange for that State. The Court's decision had the potential to preclude tax credits for individuals purchasing insurance through the Federal Exchanges in 34 States, including Michigan.

This issue was of significant importance because of its implications for the Act's Employer Mandate, which generally requires large employers to offer health insurance coverage to their full-time employees. The tax credits provided under the Act serve as the lynchpin for liability under the Employer Mandate. Despite the fact that a large employer may fail to offer health insurance coverage to its full-time employees, it will not be penalized if those employees do not obtain coverage through the Exchange and receive a tax credit. Therefore, large employers located in States that have a Federal Exchange could arguably avoid penalties for their failure to offer coverage to their full-time employees; such employees would not receive a tax credit when purchasing health insurance coverage on the Exchange and would not trigger the penalty. Read More ›

Categories: Employee Benefits, Health Care Reform, Health Insurance Exchange, News & Events, Tax

Health Care Trends

Rural hospitals across the United States struggling to stay open

According to the National Rural Health Association, approximately 50 hospitals in the rural United States have closed since 2010. The number of annual closures is growing. Congressional healthcare budget cuts and policy changes significantly affect rural hospitals because rural hospitals often have a disproportionate number of patients who are covered under Medicare, Medicaid or who are uninsured. A number of factors affect and pose challenges to rural hospitals. One challenge is the difficulty of attracting talent, which often means paying more to healthcare professionals in order to recruit them for employment at a rural hospital.  Other challenges facing rural hospitals include:

  • changing demographics;
  • advances in medical practice that the hospital may be unable to implement;
  • new federal regulations and standards that create additional compliance related pressure; and
  • lower reimbursement rates for Medicare and Medicaid.

Closures of rural hospitals may force individuals to travel long distances for medical care, which may lead to an increase in mortality rates. The closures may discourage business ventures in rural areas due to the increased costs associated with not having a healthcare facility nearby. Metropolitan hospital closings have increased recently, but the existence of medical care alternatives in metropolitan areas typically reduces the effects that closures have on patients.  Read More ›

Categories: Health Care Reform, Hospitals, Insurance, News & Events, Physicians, Tax

New Legislation Makes Concierge Medicine a Viable Business Model In Michigan

The Affordable Care Act ("ACA") authorizes the innovative payment model referred to as direct primary care, and more commonly known as “concierge medicine.” Under the direct primary care model, patients can access comprehensive coverage of basic healthcare services for a flat monthly fee.  Such services generally include guaranteed same-day or next-day visits with no waiting times. Concierge medicine is becoming increasingly popular in states where it is allowed. Read More ›

Categories: Billing/Payment, Health Care Reform, Insurance, Providers

CMS Proposes Rule to Update Wage Index and Payment Rate for the Medicare Hospice Benefit

On April 30, 2015, the Centers for Medicare & Medicaid Services (“CMS”) issued a proposed rule that would update fiscal year (“FY”) 2016 Medicare payment rates and the wage index for hospices serving Medicare beneficiaries (the “Proposed Rule”). CMS estimates that the Proposed Rule would result in a 1.3 percent ($200 million) increase in hospice payments for FY 2016. The highlights of the Proposed Rule are summarized below.  Read More ›

Categories: Billing/Payment, Long Term Care, Medicare/Medicaid, News & Events

The Updated April 2015 National Practitioner Data Bank Guidebook has been Released

The DHHS Health Resources and Services Administration (“HRSA”) has finally published the new National Practitioner Data Bank (“NPDB”) Guidebook.  The original Guidebook had not been updated since September 2001. 

The updated April 2015 NPDB Guidebook is available here.

The new Guidebook extensively covers the changes resulting from the 2013 merger of the NPDB and the Healthcare Integrity and Protection Data Bank (“HIPDB”).  The HIPDB was a separate data bank that received and disclosed reports of final adverse actions by federal and state agencies and health plans against practitioners, entities, providers, and suppliers.  After the merger, there were significant changes in the entities eligible to query and report, as well as the individuals and entities subject to reports.  Read More ›

Categories: Criminal, Hospitals, Licensing, News & Events, Physicians, Providers

Peer Review Protections Apply to Objective Facts in Incident Reports

The Michigan Supreme Court has issued an important decision on the scope of peer review protection. In Krusac v Covenant Med Ctr, Inc, the court held that “objective facts gathered contemporaneously with an event” are protected when “contained in an otherwise privileged incident report.” Krusac overruled a Court of Appeals opinion, Harrison v Munson Healthcare, which ruled that peer review protection only applied to the evaluative content in an incident report. Krusac reinforces the broad protections for “records, data and knowledge” that is collected by or for peer review committees.

While Krusac clarifies the scope of the statutory protection, it also highlights the need for hospitals and health facilities to carefully structure and properly document their peer review processes. It will be especially important in litigation to establish that a committee or individual has been assigned a peer review function and that information is being collected for the purpose of reducing morbidity and mortality and improving patient care.

Richard Kraus of Foster Swift filed an amicus curiae brief on behalf of the University of Michigan Health System in Krusac.

Categories: Hospitals, News & Events