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.
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.
In the broadcast and print media world PSA stands for public service announcement. In medicine PSA stands for prostate specific antigen. Along comes comedian/actor Ben Stiller who basically releases a public service announcement urging men to be tested for elevated levels of prostate specific antigen. This all sounds well and good but since the release of Stiller’s announcement live on the Howard Stern Sirius radio show in early October, there has been nothing but controversy. Continue reading →
Today’s workplace, like society has evolved into an extremely litigious environment that is plagued with legal duties and responsibilities that in years prior was never more than a passing thought.
Not only is much of the heartfelt bantering and jocularity between members of the work staff now forbidden, but now we have to investigate any and all allegations that may have resulted from what was thought to be innocent bantering. This obligation to investigate encompasses not only the aforementioned jesting, but pretty much anything that is taking place in the office setting. In the healthcare world, where compliance is taken to a dimension far greater that the average business setting, this duty to investigate is that much greater and involved.
There is only one thing worse than not conducting an internal investigation in your office when required. That is conducting an investigation which is plagued with bias and which was conducted in an unfair manner. Continue reading →
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 →
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 →
Regulatory issues in healthcare transactions have the potential to drive a transaction. A healthcare transaction is very different from your typical corporate transaction. This is so because the healthcare industry is highly regulated at many different levels, and the issues tend to be complicated and not necessarily intuitive. Whenever a provider is contemplating a sale of their healthcare business, they can expect a number of regulatory hurdles as they navigate the transaction. Typical regulatory issues in healthcare transactions include: (1) fraud and abuse; (2) compensation; (3) investigations and audits; (4) compliance; and (5) licensure. Of course, there are other regulatory issues that may arise, but these are, by far, the most common: Continue reading →