How to Make an Out of Network Appeal Count

Posted on January 11, 2017 by jlcohen

out of network appeal By: Karina Gonzalez

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 →

Medical Director Supervision Restrictions

Posted on February 17, 2015 by jlcohen

By: Karina Gonzalez

Medical Directors are used in an administrative capacity to oversee all medical services and care, specifically referring to substance abuse programs and services. Increasingly, commercial healthcare plans are targeting their role in addictions treatment facilities and denying payment of claims based on audit findings that Medical Directors in Florida may be responsible for far too many treatment facilities and too many patients.

Does Florida have any specific requirements or published guidance on the number of treatment facilities or number of patients for which responsibility falls to the Medical Directors in addictions treatment?

Florida’s Administrative Code directed to substance abuse programs and services does not have any directive which talks about a restriction on the number of facilities or patients recommended for oversight by a Medical Director. It specifies that addictions receiving facilities, detoxification, intensive inpatient treatment, residential treatment, day or night treatment with host homes and medication and methadone maintenance treatment must designate a Medical Director who oversees all medical services. This Medical Director must hold a current license in the state of Florida. Continue reading →

Protecting Your Practice Through Restrictive Covenants

Posted on January 14, 2015 by jlcohen

By: Charlene Wilkinson

The beginning of a new year is a great time to evaluate your medical practice and determine ways to protect its healthy growth for the future. The time, effort and dedication that it may take to build a successful practice may be quickly undermined without certain contractual protections in place. As you seek to establish or expand your practice, it is essential to protect your hard earned efforts from employees and consultants taking a portion of your patient base, employees and valuable proprietary business processes to compete against you.

One of the ways physicians seek to protect the investment that they have made in their practice is through the use of restrictive covenants. Restrictive covenant is an all-inclusive term used to refer to all contractual restrictions upon competitive practices; nonsolicitation; confidential information and use of trade practices. Restrictive covenants may be found in a number of documents related to your practice. A restrictive covenant may be found in your practice governing documents, such as the shareholder agreement, the partnership agreement of a partnership or the operating agreement of a limited liability company. A restrictive covenant is often included in an employment contract where it prevents an employee from engaging in certain competitive practices while they are an employee and for a period of time after their employment ends. There may be a restrictive covenant provision in a contract for the sale of a party’s interest in the practice. Continue reading →

The Affordable Care Act on Trial Again in King v. Burwell

Posted on January 13, 2015 by jlcohen

By: Jackie Bain

The Affordable Care Act is heading back to the Supreme Court this Spring. The issue presented to the Supreme Court on this occasion is whether the IRS is authorized promulgate regulations to extend tax credit subsidies for coverage purchased through Federal Government’s Health Care Exchange.

The Affordable Care Act allows individuals who purchased health coverage through State-established Health Care Exchanges to subsidize a portion of that coverage through the form of refundable tax credits. The United States treasury directly pays each eligible taxpayer to offset the cost of the taxpayer’s insurance premium. However, a majority of States (including Florida) have elected not to establish their own Health Care Exchanges. In order to provide coverage to persons in these States, the Federal Government set up its own Health Care Exchange marketplace. Continue reading →

Breaking Down Legal Buzzwords: Fair Market Value & Commercial Reasonableness

Posted on November 12, 2014 by jlcohen

By: Jackie Bain

Federal fraud and abuse laws often require that arrangements between health care providers are “fair market value” and “commercially reasonable.” And while these terms look like legalese and are easy to overlook, in fact, they are important. For example, the Federal Stark law requires strict compliance with its terms. A physician may enter into a prohibited arrangement with the intention that it falls within an exception to the law. If, however, the arrangement is not fair market value, the physician’s arrangement would violate the law, subject the physician to fines and risk the physician’s ability to participate in Medicare. Continue reading →

What Providers Need to Know Before They Balance Bill

Posted on August 13, 2014 by jlcohen

By: Karina Gonzalez

Balance billing occurs when a provider collects from a patient the difference between the amount billed for a covered service and the amount paid for that service. Balance billing does not apply when collecting deductibles, copayments or coinsurance.

Under Florida law, a provider may not balance bill a patient for any service, if an HMO is liable and responsible for payment. Contrary to what many people believe, this is true whether you are in-network or out-of-network. Even hospital based out-of-network physicians, such as anesthesiologists, pathologists, radiologists or emergency room physicians cannot balance bill HMO members where the hospital has a contract with the HMO or there was authorization given for an episode of care. Continue reading →

Phoning It In – Florida’s Brand New Telemedicine Law

Posted on March 12, 2014 by jlcohen

By: Jackie Bain

Until recently, the State of Florida has successfully avoided regulating telemedicine to account for advancements in technology. In 2003, the State issued standards for telemedicine prescribing practice for medical doctors and doctors of osteopathy, but has not formally revisited its position in light of increasingly common telemedicine practice in several states – until now.

Florida’s forestalling has officially come to an end. The State recently enacted new physician standards for telemedicine practice, and the State legislature is presently considering further regulation. These new standards do not impinge upon the prior standards for telemedicine prescribing practice, but are issued in conjunction to it. Continue reading →

Eye on the Regulations: The Argument Against ACO Exclusivity

Posted on February 10, 2014 by jlcohen

By: Jackie Bain

In an ACO, participating physicians, hospitals and other healthcare providers use a coordinated approach to provide improved care to beneficiaries. As an incentive to participate in ACOs, Medicare shares its savings when participating providers coordinate to provide quality care while spending Medicare dollars more wisely.

The Centers for Medicare & Medicaid Services (“CMS”) have determined that a certain amount of exclusivity is necessary for an ACO beneficiary to be accurately assigned to an ACO. Exactly how much exclusivity is necessary has been the topic of much debate. Initially, lawmakers envisioned that only primary care physicians were required to be exclusive to their ACOs. After the public had the opportunity comment on the proposed law, the rule was changed. Now, it is generally accepted that if CMS assigns an ACO beneficiary to an ACO because of primary care services previously supplied by the physician, then the physician must be exclusive to the ACO. This is true whether the physician is a primary care physician or a specialist who provides primary care services to a patient with no primary care physician. Continue reading →

Super Groups: The Most Important Factors When Considering a Merge

Posted on October 10, 2013 by jlcohen

By: Brian Foster, Guest Contributor

We shouldn’t be surprised that physicians still talk about banding together into “supergroups.” This has been a hot topic in South Florida for about 20 years. There are notable examples of large single-specialty groups that have succeeded – but unfortunately, there are many more groups that have crashed and burned, with many docs left considering how to get out. It’s an old joke, but getting doctors together really can feel like herding cats. The politics are tiring, expensive and time consuming. And there is no guarantee of success. Continue reading →