On February 8, 2017, Florida Senator Jeff Clemens (Dem.) filed a bill entitled “Marketing Practices for Substance Abuse Services” (SB 0788). A sister bill was filed in Florida’s House of Representatives by Bill Hager (Rep.) on February 13, 2017 (HB 807).
In the most general sense, the bills propose the following:
creation of a marketing fraud statute specific to substance abuse treatment centers;
mandating that all recovery residences, even those owned by treatment centers, receive FARR certification prior to suggesting that patients reside there;
requiring lead generators, call centers and other web based marketing providers to make certain disclosures to consumers;
requiring lead generators, call centers and other web based marketing providers to be licensed by the State of Florida Bureau of Professional Regulations;
allowing the State Attorney’s office to prosecute patient brokering;
institutes and increases fines for convictions of patient brokering; and
expanding the definition criminal definition of “racketeering” to include patient brokering.
The bills also expand investigation and prosecution ability of the State and reduces substance abuse patient privacy in criminal investigations. If passed, the bill would grant law enforcement access to substance abuse patient records in criminal investigations. It also permits the State Department of Legal Affairs to investigate and prosecute patient brokering allegations.
CMS recently published a white paper entitled “Healthcare Payer Strategies to Reduce the Harms of Opioids.” The white paper was prepared by the Healthcare Fraud Prevention Partnership (“HFPP”), which is a voluntary public-private partnership between the federal government, state agencies, law enforcement, private health insurers, employer organizations and fraud units to reduce fraud, waste and abuse. The white paper gives information and provides insight on the way payors view addiction treatment.
HFPP identified five actions that should be considered for implementation by all payors as quickly as possible.
Train providers on Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain;
Promote access to and usage of Medication Assisted Treatment (MAT);
Promote the availability of Naloxone;
Encourage use of cross-payor data to identify fraudulent, wasteful or abusive practices associated with opioids in order to target corrective actions; and
Identify and disseminate effective practices across the healthcare sector.
We are seeing an increasing number of challenges to payors cost saving measures of retroactively changing the payment methodologies on unpaid claims for out-of-network providers involved with audit activity. For instance, if payors audited a 2015 claim and didn’t resolve the claim until 2017, the payor will pay 2017 rates instead of 2015 rates. More recently, payors have based their out-of-network rates on the benchmark set by Medicare, but have not explained the reduced reimbursements. The lack of payor transparency as reimbursements slide is frustrating to out-of-network providers who have little notice or opportunity to react.
For years, Ambulatory Surgery Centers (ASCs) have dabbled with the notion of overnight stay for late scheduled procedures or those that require extended recovery beyond the usual 23 hours period. The day of clarity may finally be upon us! HB 0145 and SB0222 in the Florida Legislature are both aimed at the notion of creating the concept of recovery care centers at which post surgical recovery of 24 hours (in the Senate Bill) or 72 hours (in the House Bill) can occur. If the bills pass both houses, it means ASC care can move to possibly more complex cases and at least later scheduled cases. Regardless, it certainly means greater ASC case volume and could be a boon to the industry.
You have a cause that you are passionate about. You have the drive and motivation to put your time and effort behind that cause. You have the dedication to use all of the aforementioned to create a 501(c)3 nonprofit organization. However, once you create the organization, you must also be diligent in protecting your organization’s tax-exempt status.
Like most people who start a non-profit organization, your focus and energy is probably directed towards serving the community rather than performing internal compliance checkups. However, you cannot serve your target community well if your nonprofit is not run in a manner that is compliant with the law.
What happens when the IRS revokes your organization’s nonprofit status? Here are some examples: Continue reading →
As many know, out-of-network providers have much different appeal rights with commercial plans than in-network providers. It is important to understand each health plan’s appeal procedure as well as time requirements for an appeal may vary. However, the appeal process is still one of the most important tools providers have to get paid in the current environment of reduced reimbursements, caps on the number and frequency of services, bundled payments based on specific codes, delayed payments, daily errors in claims processing leading to denied claims, claw backs, and the list goes on. Continue reading →
In the healthcare business, giving a patient a break on a health insurance copay is often viewed as suspicious. The reasoning for the suspicion is that the financial incentive may give one provider a competitive advantage over another, or persuade a patient to seek services that might not be medically necessary. Moreover, any person who interferes with a patient’s obligations under his/her health insurance contract may be viewed as tortuously interfering with that contract. However, in an advisory opinion issued on December 28, 2016, the OIG opined that, in certain instances, a non-profit, tax-exempt, charitable organization could provide financial assistance with an individual’s co-payment, health insurance premiums and insurance deductibles when a patient exhibits a financial need.
The party requesting the advisory opinion was a non-profit, tax-exempt, charitable organization that did not provide any healthcare services and served one specified disease. The non-profit, tax-exempt, charitable organization is governed by an independent board of directors with no direct or indirect link to any donor. Donors to the non-profit, tax-exempt, charitable organization may be referral sources or persons in a position to financially gain from increased usage of their services, but may not earmark funds and or have any control over where their donation is directed. Continue reading →