Recently there was a great deal of hoopla in the news when it was revealed that the manufacturer of the long time well known life-saving device, the EpiPen, had raised its price by five thousand percent since 2010. This was the lead story on nearly all the major and minor news outlets for about a week. Then, as is routinely the case with most news cycles, and certainly with a variety of abusive pharmaceutical pricing stories, the reports seemed to vanish. In the weeks that have ensued since the breaking story, Mylan, the drug giant behind he EpiPen, has done very little to rectify this seemingly outrageous rip-off of the American health care consumer. But now these poster-bad-boys of the industry are quietly taking things to an even more egregious level.
Last month the New York Times reported that Mylan is lobbying all involved parties, in particular the United States Preventive Task Force, to get EpiPen placed on the federal preventive list. By law, when a drug is positioned on this sacred list, most families would have very little or no out of pocket costs. Under the Affordable Care Act, recommendations from this task force must be adopted by all health insurance companies. Continue reading →
In 1986 President Ronald Reagan signed the Emergency Medical Treatment and Active Labor Act (EMTALA) into law. Since then, the application of the law has been expanded and refined. It was one of the first laws giving the government the authority to dictate certain operations of a hospital. While other laws and regulations such as the Anti-Kickback Statute and the Stark Law have become more of a focus for health care providers, EMTALA remains an area of active enforcement. All providers with hospital privileges should therefore be aware of its application.
The policy behind the law is fairly straightforward. Hospitals with emergency departments should not be able to turn away patients needing care because of their inability to pay (no more “wallet biopsies” as part of triage). Likewise, hospitals should not be able to “dump” patients on other facilities for reasons other than for advanced care.
The requirements of the law are also very basic. If a patient comes to an emergency department and requests an examination or treatment for a medical condition, the hospital must provide an appropriate medical screening exam, within its capability, to determine whether or not the patient has an emergency medical condition. The screening provided goes beyond simple triage, and must be performed by a clinical provider such as a physician, nurse practitioner, or physician’s assistant. Continue reading →
Earlier this year, the Florida legislature passed prohibitions against balance billing by out-of-network providers for emergency services and where the patient goes to a contracted facility but does not have an opportunity to choose a provider such as emergency room physicians, pathologists, anesthesiologists and radiologists.
Specific reimbursement requirements went into effect on October 1, 2016 for certain out-of-network providers of emergency and non-emergency services, where a patient has no opportunity to choose the provider.
Under these circumstances, an Insurer must pay the greater amount of either:
(a) The amount negotiated with an in-network provider in the same community where services were performed;
(b) The usual and customary rate received by a provider for the same service in the community where service was provided; or
If you’re not satisfied with your medical care at the Pennsylvania based Geisinger Health System you now have a recourse not often found in traditional medical practice. You can ask for a refund. And thanks to technology you can conduct the entire transaction through an app on your smartphone and the money will come back to you in three to five business days.
This novel step in the world of medical practice is perhaps the latest consequence of the corporatization of medicine and the transition of patients into consumers. In fact in numerous published articles, Geisinger CEO Dr. David Feinberg repeatedly suggests that delivering medical care is not very different from buying a coffee at Starbucks. “If you don’t like the cappuccino, they don’t sip it and say, ‘We made it right, we’re not giving you a new one,’” was Feinberg’s quip in a recent edition of Healthcare IT News in defense of his refund policy, which started as a pilot in November of 2015 and now is in full swing. Continue reading →
Earlier this year, CMS (Centers for Medicare and Medicaid Services) released its final rule related to reporting and returning identified Medicare and Medicaid overpayments for Medicare Part A and B. The rule is referred to as the “60-day rule” and it governs when an “identified” overpayment must be repaid to the government before it will be subject to liability under the federal False Claims Act (FCA), Civil Monetary Penalties Law and exclusion from the federal health care programs.
The Final Rule went into effect on March 14, 2016
An overpayment is “identified” for the purposes of reporting and overpayment under the 60-day rule when a provider or supplier “has or should have, through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment.” Continue reading →
Recently, a Florida-based physician practice specializing in pain management was ordered to pay the Federal Government $7.4 after it was determined that the group’s physicians were ordering medically unnecessary drug screens and billing Medicare for those tests. Federal prosecutors contended that the group’s physicians had appropriately ordered initial drug screens on many patients, but had inappropriately ordered more extensive (and more expensive) follow up tests nearly 100% of the time. Moreover, patient medical records did not reflect the need for more extensive testing. Continue reading →
Healthcare professionals and businesses are routinely barraged with people who claim to be able to generate business for them. The business of healthcare is like none other in its abhorrence of anything that even smells like payment for patient referrals, so professionals and businesses alike have to be extremely cautious and well advised in crafting marketing and related business-enhancing relationships.
The key here is to realize that, while the laws haven’t changed, what regulators are doing with them has! The environment of healthcare marketing has never been more treacherous than it is today. So what’s changed? How about:
Commission based marketing and sales involving federal or state payers, even those that arguably comply with the personal services arrangement and management contract safe harbor, are detested by federal regulators;
The regulators will look to pierce any enterprise, including those consisting of multiple tax ID entities, in hopes of making the case that commercial based marketing payments were in exchange for even one drop of federal/state payer money;
Both health insurers and large providers (e.g. labs, pharmacies) work hand in hand with federal regulators to pursue suspicious activity, the result of which is to support the large provider; and
Targets of enforcement activity who have obtained good legal advice often pay just to put an end to the enforcement because there’s a risk of losing and “winning” can feel like losing when one considers the enormous defense costs.