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Showing 24 posts in Billing/Payment.

Government Intervenes in Affordable Care Act 60 day Rule Violation Allegation

Government Intervenes in Affordable Care Act 60 day Rule Violation AllegationIn 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

CMS Issues Proposed Rules for Medicaid Managed Care

medicaid managed careLast 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

New Legislation Makes Concierge Medicine a Viable Business Model In Michigan

concierge medicineThe 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

medicare hospice benefitOn 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, Medicare/Medicaid, News & Events

Health Plans Take Notice: Compliance with HIPAA Administrative Simplification Rules is still Required

hipaa administrative simplification rulesOn Jan. 2, 2014, the Department of Health and Human Services (“HHS”) issued a proposed rule related to the Administrative Simplification requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).  Specifically, it delayed the date by which health plans must certify compliance with certain operating rules imposed by the Affordable Care Act (“ACA”).   

The ACA required the Secretary of HHS to adopt operating rules related to claims status, eligibility, electronic funds transfers ("EFT") and health care payment and remittance advice transactions ("ERA").  Health plans (and other covered entities) were required to comply with the claims status and eligibility operating rules by Jan. 1, 2013 and the EFT and ERA operating rules by Jan. 1, 2014.  Additionally, health plans were required to file a statement with HHS certifying that the health plan is in compliance with the operating rules.  This certification statement was due by Dec. 31, 2013.  Read More ›

Categories: Billing/Payment, Compliance, Health Care Reform, HIPAA, Insurance, Privacy, Providers

Omnicare Settles Whistleblower Lawsuit Alleging Kickback Scheme With Nursing Homes

Omnicare Inc., the nation's largest dispenser of prescription drugs in nursing homes, announced on October 23, 2013, that it has agreed to pay $120 million to settle a whistleblower lawsuit alleging kickbacks to nursing homes.

The whistleblower in the case, an Ohio pharmacist named Donald Gale, worked for Omnicare from 1993 until 2010. The lawsuit, filed in federal court in Cleveland in 2010, accused Omnicare of giving discounts for prescription drugs to nursing homes for certain Medicare patients in return for referrals of other patients at higher prices paid for by the federal government. Read More ›

Categories: Billing/Payment, Fraud & Abuse, Medicare/Medicaid, Pharmacy, Providers

Blue Cross Changes on the Horizon?

blue cross changesChanges to the health insurance market in Michigan may soon be changing due to the Michigan House of Representatives’ approval of Senate Bills 1293 and 1294 (the “Senate Bills”) on December 6, 2012.  The introduction of the Senate Bills follow Governor Snyder’s proposed overhaul of BCBSM discussed here and directly address the corporate organization and continued operation of Blue Cross Blue Shield of Michigan (“BCBSM”) in our state.  In brief, the Senate Bills authorize BCBSM to establish, own, operate and merge with a nonprofit mutual disability insurer.  They also generally prohibit BCBSM from using “Most Favored Nation Clauses” in provider contracts beginning February 1, 2013.  While the Senate Bills are not final until Governor Snyder signs them into law, given his previous support it is likely he will give his approval. A more detailed analysis of the Senate Bills will be provided if the Governor does indeed sign them into law.

Categories: Billing/Payment, Insurance, Regulatory

Most Favored Nation Order Released by Michigan Insurance Commissioner

favored nation orderIn what appears to be a strong response to the most favored nation ("MFN")-related lawsuits filed against Blue Cross Blue Shield of Michigan by the U.S. Department of Justice and Aetna, the Commissioner of the Michigan Office of Financial and Insurance Regulation (“OFIR”) issued an Order dated July 18, 2012. The Order prohibits insurers, HMOs, and Blue Cross Blue Shield of Michigan from either using or enforcing MFN clauses in their provider contracts unless the MFN clause has been filed with and approved by the OFIR Commissioner.  This prohibition takes effect February 1, 2013.  To read the Order, see the Order posted on the Department of Licensing and Regulatory Affairs webpage.

Categories: Billing/Payment, Hospitals, Insurance

OIG Alert – Physicians May Be Liable for False Claims Submitted by Entities Receiving Reassigned Medicare Payments

Medical BillThe Office of Inspector General ("OIG") for the Department of Health and Human Services recently issued an alert, which warned that “physicians who reassign their right to bill the Medicare program and receive Medicare payments by executing the CMS-855R application may be liable for false claims submitted by entities to which they reassigned their Medicare benefits.”  The OIG stressed that physicians remain liable for claims submitted using their provider numbers, even when the claims for services are submitted by another party under a contractual arrangement.  The potential for liability also exists for other types of practitioners who enter into reassignment agreements. Read More ›

Categories: Billing/Payment, Compliance, Employment, Fraud & Abuse, Medicare/Medicaid, Physicians

Hot Off the Presses: Foster Swift Health Care Law Newsletter

health care lawThe latest edition of the Foster Swift Health Care Law Newsletter has just been released.  Topics include Electronic Health Records, Medicare Reimbursement for Resident Research and Hospital Community Needs Assessments.  In order to whet your appetite, below is a brief summary of the articles: Read More ›

Categories: Billing/Payment, Electronic Health Records, Health Care Reform, Health Insurance Exchange, HITECH Act, Hospitals, Medicare/Medicaid, Physicians

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Best Lawyers® 2021

Congratulations to the attorneys of the Health Care practice group at Foster Swift Collins & Smith, PC for their inclusion in the Best Lawyers in America 2021 edition. Firm-wide, 44 lawyers were listed. Best Lawyers lists are compiled based on an exhaustive peer-review evaluation and as lawyers are not required or allowed to pay a fee to be listed; inclusion in Best Lawyers is considered a singular honor. Health Care practice group members listed in Best Lawyers are as follows:

To see the full list of Foster Swift attorneys listed in Best Lawyers 2021, click here.