Physicians’ Participation in the Open Payments Program: As if the Anti-Kickback Statute Wasn’t Enough !

sunshine act scope

sunshine act scope

 

By: David Hirshfeld

By now we are all too familiar with the commandment “Thou shaltneither pay nor receive, nor solicit the payment or receipt, of anything of value in exchange for referring an individual to a person for the furnishing of an item or service for which payment may be made by a Federal health care program.”  Many of us have restructured, redefined, contorted and construed our arrangements so that they fit neatly within a statutory Safe Harbor to the anti-kickback legislation.  Then, in the name of “Patient Protection,” comes the Open Payments Program (also known as the “Physician Payment Sunshine Act”).

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The 8 Ways to Save Money or Make Money in 2014

2014

      2014Now that we’re on other side of the holidays and solidly planted in 2014, it’s a great time to chart a new course.  Here are 8 things you can do that will make you money or save you money:

  1. Hire someone.  If you are a solo practitioner, are responsible for generating the revenue and also for leading your business, you will learn one clear thing:  it’s impossible!  It’s simply impossible to do both.  In business, if you are not growing, you’re sinking.  There is no such thing as maintaining the status quo.  If you can’t see how you can afford to do it, then you need to meet with your financial advisors, since at least some part of the work of your new hire will come off your plate.  It may even make sense to ask a local hospital to assist you in bringing in a new doctor.   Continue reading

Super Groups: The Most Important Factors When Considering a Merge

Final ACO Rules

supergroup doctorsBy: 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

Kill H.R. 2914

Background

H.R. 2914 is a bill filed by Congresswoman Speier that is intended (among other things) to prohibit medical practices providing the following sorts of medical services (“Non-ancillary Services”) to their own patients—

*The technical or professional component of (i) surgical pathology, (ii) cytopathology, (iii) hematology, (iv) blood banking, or (v) pathology consultation and clinical lab interpretation services

*Radiation therapy services and supplies

*Advanced diagnostic imaging studies (which include for instance MR and CT)

*Physical therapy services

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Is The End of Stark (and IOAS) Near?

false claims act

gavel

Background

Since its passage in 1989, the now ubiquitous federal law known as the Stark Law has driven the business behavior of health care providers of many kinds.  Recent developments, however, make us wonder whether the end of Stark is near, and if so, whether that’s a good thing.

By way of background, the Stark law has two components:  part one, a self referral prohibition, generally forbids physicians from referring to a provider of any “designated health service” (DHS) (e.g. MRI, PT, clinical lab) if the physician or his/her immediate family member has a financial relationship (including ownership interest) with the provider of the service.  Part two mandates that certain compensation arrangements between healthcare providers meet certain requirements.  Things like medical director agreements, management agreements, employment and independent contractor arrangements have been regulated by the law since its inception.  Most notably, for purposes of this article, one provision (the “In Office Ancillary Services” exception or “IOAS”, also known as the “Group Practice Exception”) has allowed medical practices to provide all sorts of “ancillary services” to their own patients.  That is the key aspect of the law that is lately coming under serious attack.Continue reading

Hospital Physician Alignments are Tenuous

DME operation

integration1Hospitals, particularly those heading ACO development efforts, are quick to say things like “One day, all physicians will be employed by hospitals.”  Though there is clearly some wisdom under that statement, it’s also a remarkable leap of faith.

Three things are clear in this era of healthcare reform:  (1) healthcare will be provided to more, but with less; (2) there will be a growing move over time to pass financial risk to providers; and (3) those businesses in a position to control both costs and quality (and some say patient satisfaction) are in a position to both survive and even do better than ever.

This leaves the door wide open as to the form of the business that can succeed.  Is it a single specialty mega practice?  Is it a multi specialty medical practice?  How about a hospital?Continue reading

Healthcare Reform Doesn't Have to be All or Nothing

terminating a patient

By: Jeff Cohen

pulling hairHealthcare professionals today are constantly faced with views of what’s changing in healthcare, and all of them seem equally convincing.  “One day, everyone will be employed by a hospital” is one of the favorites.  Not surprisingly, the proponents of that perspective tend to be….hospitals.  “Everyone has to merge their practices” is another favorite.  The proponents?  Large super practices, of course.

How does one sort through this?  Who’s right?  The truth is that everyone is seeing part of the whole and is “right.”  But being “right” doesn’t mean right for you.  My opinion?Continue reading

Ordering and Referring Providers: CMS Just Won’t Take No for an Answer. Form 855-O.

By: David Hirshfeld, Esq.

More and more of our seasoned clients are opting out of Medicare, and the younger ones are simply not enrolling.  The scale seems to have finally tipped so that the potential liability of being a Medicare provider outweighs the benefits.  So many providers are avoiding Medicare participation, that the Affordable Care Act and CMS have implemented the issuance of “Ordering and Referring Provider Numbers” through CMS Form 855-O.

As of May 1, 2013, physicians and other providers (collectively “Providers”) who bill Medicare must list the NPI of the ordering/referring Provider on their claim forms in order to be paid for the technical component of imaging services, the technical component of clinical laboratory services, durable medical equipment and/or home health services.  An issue arises when the referring/ordering Provider does not participate with Medicare, and does not have an active NPI.

The Affordable Care Act provides a solution by allowing Providers to enroll in Medicare for the sole purpose of ordering or referring covered services for their Medicare patients, even though the ordering/referring Provider cannot bill Medicare for the services (s)he provides.  This limited enrollment is accomplished through CMS Form 855-O.

Providers who have opted-out of Medicare by filing the required affidavit and entering into acceptable patient contracts do not have to submit Form 855-O as they have NPIs, even though they are not allowed to bill under them during their opt-out period.

The Preventionists Are Coming!

healthcare legal news fast updates medical law firm

paul-revereThe popular conception in healthcare is that (1) a new law was passed, (2) it changed everything, and (3) in a bad way.  Over time, however, it should get clearer that, while there was a law passed, the law alone is not driving changes to our healthcare system: it’s our own demographics and behavior.  Most of the tax dollars currently fueling our healthcare system (and arguably our economy) are tied to an aging Boomer population that are soon to drop off the income producing cliff into the Medicare population.  Bye bye income earners; hello ridiculous public healthcare expenditures.  Though it is true that the timing for expanding public spending on healthcare (with the federal mandates aimed at employers and Medicaid eligibility expansion) could not be more poorly timed, the situation is more of a “Perfect Storm” than a surgical strike.

The financial stress of our changing population and of a historic utilization based healthcare system is causing our healthcare system to morph in every way.  “Health insurance,” with increasing cost, copays and deductibles and reduced benefits, is quickly ceasing to look like your father’s 80/20 major medical plan and starting to look more like catastrophic coverage.  Fee for service compensation is fast becoming “spoken” out of existence.  There are more “pay for performance,” “case rate” and other outcome and risk based compensation models than you can shake a stick at.  The simple truths are: payers have to deliver more with less; and patients have to bear more and more of their healthcare expenses.Continue reading