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Settlements In my last Medicalaw I discussed the University of Florida being forced to pay the government in a whistleblower suit for billing for resident work. The University now concedes that they were told of the infraction and the doctors who reported were harassed. This is not only not a good idea but is actually stupid. An ophthalmologist is now suing the University for the harassment for complaining about the billing methods used. The plaintiff states he was asked to falsify records and time sheets. The accused harasser states he was cleared of any criminal wrongdoing by the DOJ, but this is a civil trial and different rules apply. In the largest settlement ever, Tap Pharmaceuticals agreed to a fine of $875 million and a 7 year Corporate Integrity Agreement (CIA). A handful of urologists have also been caught billing for Lupron samples. The federal government is getting back $8 for each $1 expended in combating fraud. Top Maryland fines insurers for not paying promptly. Aetna got hit with a penalty of $250,000 for continually not paying podiatrists properly. They were under an order to have the process done by a certain date, but didn't pay interest on the late claims. Aetna was also fined $600,000 for the late payment of claims. The next time Aetna gets disciplined their ability to accept new business would be removed. Aetna replied that they are now current and hope to remain that way. United has also been fined $300,000 for late payments, also under a previous agreement with the state. Magellan Behavior Health has been given a fine of $150,000 for prompt pay violations. I wonder how much these fines hurt the company since they obviously don't take it seriously until threat of removal from business in the state. They say they will improve but it doesn't seem to happen. What is the money they make on the float compared to the fine? Are the fines deductible as a business expense? California fined Health Net $100,000 for late payments to providers. They will also need to pay interest to the providers who were not paid timely. Also fined $50,000 was Heritage Provider Network. They were ordered to pay $200,000 in interest to the providers. In California the legal rate of interest is 10%. Top Tom Scully, the head of CMS, chastised hospitals for being too slow in devising and reporting quality indicators to the public. He states if they don't agree on their own standards soon, the government will do it for them. You all know how user friendly and helpful the government can be- see HIPAA. Scully also stated that Medicare +C is losing badly. The program is "dropping like a rock." He continues to see insurers dropping out and none begging to get in. He stated he can try to make the rules more flexible for the plans but can not give them more money. Top If medically necessary the government will pay for preoperative exams. The exam should not be part of the global fee nor routine screening and must be requested by the attending surgeon. This overrides local carriers that have been denying the charges. The coding necessary is left up to the direction of the physician with the usual oversight. Top California Governor Davis stating California has a severe
monetary crisis but not stating it is of his handling of the energy problem has
vetoed most laws that call for monetary expenditures. Some of the
important healthcare laws passed and signed are: Some of the bills vetoed: The OIG new work plan is for physician coding and documentation of EM codes, appropriateness of consultation services, ABN, hospital privileging within the context of Medicare's COP, one-day hospital stays, discharge and readmissions and consecutive inpatient stays. The OIG has also disclosed what to expect in site visits under a CIA. The visits will be by OIG attorneys and analysts and will last 1-3 days depending on the size of the organization inspected. The organizations will have a 2 week notice of the visit. The visit will look at disclosure logs, training programs and other documentation that center around the original problem. JCAHO dog & pony shows and employee prepping are discouraged. Many interviews are one on one with employees and the employee may have a company representative, not the compliance officer, present. Top South Carolina Limits OxyContin South Carolina is now making physicians call a state pharmacist for permission before prescribing OxyContin. It is ok to use the drug for cancer, sickle cell disease, or terminal illness. It is not OK to prescribe the drug for back pain etc. Most physicians are using other medication rather than wasting 10 minutes calling the pharmacist and answering the questionnaire. Top The IRS has stated that an emergency room is not required for a tax-exempt status. The community benefit potion necessary may be met in other ways, including using surplus revenue to improve facilities. There is a new manual to IRS auditors that has a 20 page section on tax-exempt organizations. The manual states that just having policies is not enough. A hospital must walk the walk which includes an open hospital medical staff, taking Medicare & Medicaid patients and following EMTALA. The hospital does not need to meet each and every component but only promote the health of the community as a whole. DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.
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