By: Karina Gonzalez
Effective July 1, 2018, Florida’s recent legislation SB 622 repeals the entirety of Chapter 483, Part I of the Florida statutes, and removes the state licensure requirement for clinical laboratories operating in-state and out-of-state. Section 97 of SB 622, approved by the Governor on March 19, 2018, repeals the entirety of Chapter 483, Part I of the Florida statutes, and so eliminates section 59A-7.024(1).Continue reading
By: Karina Gonzalez
Healthcare practitioners are excited about the expansive geographic scope of practice in Telemedicine. A licensed Florida physician can provide services in other states provided the physician is also licensed in the state where the patient is receiving the services. There are no geographical limitations if the delivery platform of technology provides voice and vision and where necessary videos for the Telemedicine/Telehealth visit.
As more and more physicians practice and contract to provide Telemedicine visits, one of the legal challenges we are facing is how to draft a restrictive covenant. The traditional reasonableness standards used to evaluate non-compete agreements just do not apply. What are you trying to restrict when the physician lives in Florida but has telemedicine practice with patients 500 miles away?Continue reading
By: Karina Gonzalez
A recent whistleblower action (by UnitedHealthcare Medical Director, Tina Groat) against Boston Heart (laboratory) was brought under the federal False Claims Act and deals with medical necessity issues. As part of the analysis, the Court reviewed whether a laboratory [or supplier like DME] must determine the medical necessity of the ordering physician. Boston Heart contended that a doctor, not a laboratory, determines the medical necessity of a test. Boston Heart argued that when a laboratory bills Medicare for testing ordered by a physician, it must only maintain documentation it receives from the ordering physician and ensure that the information that it submitted with the claim accurately reflects the information it received from the ordering physician. It noted that the CMS-1500 form certification does not require that the billing lab to make the medical necessity determination. The lab certifies that the services are medically necessary by relying on the clinical determination of the treating physician.Continue reading
By: Karina Gonzalez
Telehealth law Florida is constantly evolving The latest example is found with Florida’s Department of Children and Families (DCF) recent proposed rule change which now includes a definition of Telehealth as a delivery system in substance abuse. Telehealth can be used in treatment or prevention services through electronic communications from one site to another. However, it does not include delivery of services using only the audio on a telephone, or e-mails, text messages, fax transmissions, US mail or other parcel service. Proposed Rule 65D-30.0031 (83) Definitions.
Telehealth services can be used in intensive outpatient, day or night treatment, day or night treatment with community housing, outpatient, interventions, aftercare, and prevention. If a substance abuse provider plans on including telehealth services it must submit to DCF detailed procedures outlining which services it intends to provide. The provider will be responsible for the quality of the equipment and technology used in the telehealth service. Proposed Rule 65D-30.004 (20) Common Licensing Standards.Continue reading
By: Karina Gonzalez
Most commercial health plans require that prior to admission to a substance abuse treatment facility, patients must have a face-to-face individual assessment by a licensed behavioral health clinician 72 hours prior to admission, to determine if the admission is both medically necessary and clinically appropriate. Many potential patients reside in states outside of Florida (or a given destination), so complying with a face-to-face requirement when a patient is in another state before admission is a challenge. Telehealth is being increasingly utilized to evaluate these out-of-state patients and perform the necessary face-to-face evaluation in advance of arrival at a given facility. However, as with anything healthcare, there is a right way and a wrong way to implement this technology. In the coming weeks, we’ll be discussing many of the facets involved from telemedicine claims overpayments to Medicare telehealth law issues.
By: Karina Gonzalez
The US Department of Health and Human Services, Office of Inspector General (OIG) reports that as part of its 2017 Work Plan it will be reviewing Medicare Part B payments for telehealth services. These services support rural access to care and Medicare pays telehealth services provided through live, interactive videoconferencing between a Medicare beneficiary located at an origination site and a healthcare provider located at a distant site.
The OIG is reviewing Medicare claims that have been paid for telehealth services that are not eligible for payment because the beneficiary was not at an originating site when the consultation occurred. A beneficiary’s home or office is not an originating site, an eligible originating site must be a practitioner’s office or a specified medical facility.Continue reading
By: Karina Gonzalez
With the opioid epidemic in South Florida at crisis levels, there is an increasing demand on local hospital emergency departments for screening and evaluations of drug overdoses, considered a medical emergency. Addiction treatment law evolves with EMTALA updates. Many patients receiving substance abuse treatment in this community are coming from out-of-state. Many are young, under 35 years and a majority receive outpatient services. Overdoses are occurring more frequently as patients deliberately misuse opioid prescriptions such as Fentanyl or an illicit drugs such as heroin. If the patient possesses and or uses an illicit drug while in treatment, the policy in many facilities is to terminate treatment and discharge the patient. But if the patient has overdosed, the facility will place a call to 911 and that patient will end up with a visit to a local emergency department. A discharged patient will often continue using and end up in the emergency department, taken there by paramedics or some other individual.
Local emergency departments now play a pivotal role in the next steps that an overdosed patient may take. Is the patient receiving their EMTALA rights (Emergency Medical Treatment and Labor Act), a federal law requiring anyone coming to a hospital emergency department to be screened and examined? If an emergency medical condition exists, treatment is provided to relieve or eliminate the emergency medical condition within the service capability of the hospital, a difficult task with substance abuse. Continue reading
By: Karina Gonzalez
Most of the commercial payors are paying PHP (Partial Hospitalization Plan) and IOP (Intensive Treatment Plan) at a bundled daily rate. Many of the plans are now adding urine drug screens to the bundled daily rate and imposing a cap on the number of screens that can be done during an admission. Plans are paying rates that are much nearer to a Medicare rates. Payments based on a reasonable percentage of a provider’s charge are becoming harder to find, as the calculation of what is a usual and customary rate of payment continues to decline.
Yet, a great portion of substance abuse facilities are operating with more clinical staff, at a higher level through licensure, with better Electronic Medical Systems, more programs to combat some of the symptoms of addiction and with a greater awareness of compliance with state and federal guidelines. Even with these necessary improvements, reimbursements continue to decline.Continue reading
By: Karina Gonzalez
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.
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