Health Care Law Blog

CMS Issues Final Home Health Payment Rules for 2016

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 ›

Categories: Billing/Payment, Medicare/Medicaid

Department of Justice Enters Into Record-Breaking Stark Law Settlement

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 ›

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

DOJ Memo: Corporate Investigations to Focus on Individual Accountability

Recent guidance issued by the U.S. Department of Justice (“DOJ”) reveals the government’s renewed focus on individual accountability during corporate investigations. On September 9, 2015, Deputy U.S. Attorney General Sally Quillian Yates issued a memorandum to DOJ attorneys (the “Yates Memo”) that emphasizes the importance of seeking accountability from the individuals who are responsible for corporate wrongdoing.

The Yates Memo outlines six measures that should be taken by federal prosecutors during any investigation of corporate misconduct in order to hold accountable the individuals who are responsible for the conduct. A discussion of each measure appears below. Read More ›

Categories: Fraud & Abuse, Providers

Quality vs. Quantity: Accountable Care Organization Results Keep Coming, as Does Some Criticism

One of the primary ways that the Affordable Care Act seeks to reduce health care costs is through the formation of Accountable Care Organizations (ACO). ACOs are still a relatively new concept in the healthcare world, as they emerged in 2011 as a result of an initiative by the Centers for Medicare & Medicaid Services (CMS).

ACOs are generally groups of doctors, hospitals, and other health care providers, who voluntarily join forces for the purpose of providing coordinated care to Medicare patients (see other Foster Swift articles on ACOs). ACOs were established as a means of coordinating care in order to ensure that patients, especially the chronically ill, receive effective care while avoiding unnecessary duplication of services and preventing medical errors. ACOs that achieve cost saving from providing timely and accurate care that meet quality benchmarks share in Medicare savings. In short, ACOs are intended to encourage quality of care, not quantity of care, and ACOs that deliver care more efficiently are eligible for bonuses. Read More ›

Categories: Accountable Care Organizations, Health Care Reform, Medicare/Medicaid, News & Events, Providers

CMS Issues Final Rules for Fiscal Year 2016 Provider Payments

On July 31, 2015, the Centers for Medicare & Medicaid Services (“CMS”) issued final Medicare payment rules for federal fiscal year 2016 (the “Rules”). The Rules affect hospitals, hospices, psychiatric facilities, and rehabilitation facilities.  Read More ›

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

HHS Issues HIPAA “Basics” Fact Sheet

The Department of Health and Human Services (“HHS”) recently released a HIPAA overview called “HIPAA Basics for Providers: Privacy, Security, and Breach Notification Rules” (the “Overview”). The Overview is intended to provide HIPAA Covered Entities such as physicians, hospitals, and other health care providers with a basic overview of HIPAA’s rules and responsibilities. The fact sheet also provides an overview to Business Associates (such as law firms and accounting firms who receive protected health information ("PHI") from Covered Entities). The Overview can be found here.

The Overview explains that the HIPAA Privacy Rule protects individually identifiable PHI, which includes information such as an individual’s past, present, or future physical or mental health condition. Read More ›

Categories: HIPAA, News & Events, Privacy, Providers

Health Insurance Rate Increases Approved for 2016

On Tuesday, August 18, the Michigan Department of Insurance and Financial Services (“DIFS”) announced that it has approved health insurance rate increases that average 6.5 percent for the individual market and 1 percent for the small group market. 

Each year, DIFS is responsible for reviewing rate changes proposed by health insurers to determine whether such changes comply with state and federal laws. As part of its review this year, DIFS considered public comments that were submitted after the requested rate changes were posted. DIFS approved all rate changes as requested after determining that such changes were actuarially supported. Read More ›

Categories: Insurance, News & Events

Government Intervenes in Affordable Care Act 60 day Rule Violation Allegation

In a first-of-its-kind and closely followed case, a U.S. district court denied a New York health system's (Healthfirst’s) motion to dismiss the U.S. government's and State of New York's complaints in intervention under the federal False Claims Act (FCA) and New York state counterpart. This case represents the first time that the government has intervened in an FCA case based upon an allegation that a party violated the "60 day rule." The 60 day rule came into existence with the passage of the Affordable Care Act (ACA) in 2010 and subjects parties to FCA liability for failing to report and refund an overpayment within 60 days of identification, even if the defendant received the payment through no fault of its own.

The case, Kane ex rel. United States et al. v. Healthfirst et al., involves three hospitals that were part of the Healthfirst health system network and provided care to patients that were part of Healthfirst's Medicaid managed care plan. Healthfirst received payments from the New York State Department of Health (DOH) in return for services provided to Medicaid eligible enrollees.

The government's allegations stem from overpayments to Healthfirst as a result of a software glitch. Healthfirst was first questioned about the possible overpayments by the New York State Comptroller's office in 2010. The health system tasked Kane, an employee and the eventual whistleblower in the case, to look into the payments. Five months later Kane emailed Healthfirst management a spreadsheet listing over 900 claims totaling more than $1 million that contained an erroneous billing code that may have led to the overpayments. Read More ›

Categories: Billing/Payment, Fraud & Abuse, Health Care Reform, Hospitals, Medicare/Medicaid, News & Events, Providers

DOJ and State of Michigan Bring Antitrust Lawsuit Against Four Michigan Hospitals Three Settle Charges Immediately and One Vows to Fight

The U.S. Department of Justice (“DOJ”), together with the Michigan Attorney General (“AG”), recently filed a lawsuit alleging that four hospital systems located in Southern Michigan violated antitrust laws by agreeing not to compete with one another.

The civil lawsuit was filed in the U.S. District Court for the Eastern District of Michigan and alleged that the four hospitals agreed not to market or advertise themselves in each others’ territories, which constitutes “unreasonable restraints of trade that are per se illegal” under the Sherman Act and the Michigan Antitrust Reform Act. Read More ›

Categories: Hospitals, News & Events

Virginia Man Wins $500,000 After Recording Surgical Team’s Insulting Comments

Talk about adding insult to injury. A Virginia man woke up after his colonoscopy to learn that the surgical team had mocked, belittled and insulted him throughout the procedure.

Fearful that he would not remember the doctor’s post-op instructions, the man pressed record on his smartphone before receiving anesthesia. Upon listening to the recording after the procedure, he realized that the members of the surgical team began their rant as soon as he drifted off to sleep. Read More ›

Categories: Hospitals, News & Events, Physicians