Holland & Hart Healthcare Law Blog

THE “MASSIVE REDISTRIBUTION OF WEALTH” AND 31 OTHER INTERESTING STATISTICS AFFECTING THE HEALTHCARE REFORM.

 The United States has undergone a massive redistribution of wealth in the last 30  years. In 1980 the top 1 percent of taxpayers reported 8.5 % of the nations reported income to the Internal Revenue Service. In 2008, the top 1 percent of taxpayers reported receiving 20% of the nation’s income. This and the following 31 other statistics provide an interesting foundation to review the PPACA and its alternatives.

ARMENIAN GANGSTERS RIP MEDICARE FOR $35 MILLION DOLLARS PLUS.

 

 

Is this a great country or what?  Newly arrived immigrant gangsters from Armenia have helped themselves to the largess of Medicare to the tune of $35 million dollars and more by creating a loose network of false health clinics, staffed by real physicians and patients whose identities had been stolen.  The gang operated 118 of the non-clinics in 25 states.  In matching the stolen identities of physicians with the stolen identities of patients the thieves were able to bilk the federal government of millions by submitting false claims that were paid without pre-verification, which is the way Medicare works.

 

THE GREAT NURSE ANESTHETIST “OPT OUT” DEBATE

 

 

Under Medicare rules Certified Registered Nurse Anesthetists (“CRNAs”) must be supervised by a physician, typically an anesthesiologists or perhaps by a surgeon in rural areas where anesthesiologists are not available.  Medicare has a state “opt out” provision which permits CRNAs to practice without supervision of a physician.  To date, 15 states have chosen to opt out and others like Colorado are considering doing the same.  Anesthesiologists are compensated for supervising CRNAs and can supervise up to 3 at a time because they are not required to be in the same room.

PROVIDER INTEGRATION AND THE ADVENT OF ACCOUNTABLE CARE ORGANIZATIONS (“ACOs”)

    Can financial incentives and physician practice structures be enlisted o enhance the quality and reduce the cost of healthcare?  Health Care Reform supporters believe they can and the new Patient Protection and Affordable Care Act ("PPACA")  signed into law by the President recently,  provides incentives for the development of ACOs for Medicare patients. ACOs have been described as HMO’s on steroids, but many wonder whether they will meet the same fate as the managed care systems of the past that focused on blind leveraged cost reductions and favorable beneficiary selection to achieve profits.

    

CMS ISSUES MEMORANDUM REGARDING HOSPITAL EMTALA OPTIONS IN EVENT OF H1N1 FLU PANDEMIC.

On August 14, 2009, CMS issued a memorandum on requirements of hospitals under the Emergency Medical Treatment and Labor Act (“EMTALA”) in the event of a surge in hospital emergency room visits for H1N1 influenza treatment. EMTALA requires all hospitals to provide an appropriate medical screening examination on presentation to determine whether the patient has an Emergency Medical Condition. If it determines that one exists, the hospital must treat and stabilize the patient within its capacity or transfer a patient to a hospital that has a capability and capacity to stabilize the condition. In anticipation of a surge in emergency room visits CMS issued additional guidance for hospitals to comply with EMTALA.

GENERAL COUNSEL LIABILITY IN HEALTH CARE ETHICS AND COMPLIANCE OVERSIGHT.

It is not easy being General Counsel for a health care system and growing more difficult with the advent of Corporate Integrity Agreement and Public Securities Obligations.  It is also dangerous and unwise to accept responsibility for Chief Compliance Officer as well as Chief Legal Officer. The ongoing travails of Christi R. Sulzbach, Esq. former Executive Vice President and General Counsel and Chief Compliance Officer of Tenet Healthcare Corporation is a case in point. Ms.Sulzbach, who resigned her position at Tenet in 2003, settled a case brought against her by the Securities Exchange Commission. arising out of a Tenet scheme to defraud Medicare by over reporting its costs so as to increase Medicare payments under its enhanced payment program for “Outlier” patient conditions.  Tenet settled for 10 Million Dollars several years ago. 

Greg Piche' and Joan Ditges RAC Audit Audioconference Scheduled for June 18, 2009

Greg Piche' and Joan Didges, R.N. will present an audioconference on RAC Audits captioned "How to Guard Your Practice from Medicare RAC Audits." on June 18, 2009 at 1:00 P.M. ET. The Webinar is sponsored by Part B News and Decsion Health.  Further Information can be found at

http://www.decisionhealth.com/conferences/A1799/home.html

TWENTY-FIVE STEPS IN DEFENSE OF RAC AUDITS.

Recovery Audit Contractors (RACs) are in the process of saddling up for the nationwide roll out of their Medicare payment recoupment mission. Here are twenty-five recommended proactive steps to circle the wagons and defend the RAC threat.

1. Develop and implement a written audit defense plan- the government bounty hunters are coming your way and they will be looking for the  low lying fruit.

2. Select an audit team or responsible persons depending upon the size of your organization. Including if appropriate internal audit, billing and coding, medical records, risk management and the CFO.

3. Assign specific team member responsibilities in dealing with anticipated audit issues.

4. Consider running an internal pre-audit to identify vulnerabilities such as “medical necessity” and “duplication of services.”

RAC AUDITS AND NEW FEDERAL FALSE CLAIMS ACT EXPOSURE.UNDER THE FRAUD ENFORCEMENT RECOVERY ACT OF 2009 (“FERA”).

The federal squeeze of health care providers is underway. Federal Medicare recovery “bounty hunters,” the Recovery Audit Contractors (“RAC”), are marshalling resources for the anticipated, algorithm primed, data mining hunt for Medicare overpayments from hospitals, physicians, DME companies, hospices and other providers, which is likely to bloom in the second half of this year. Those that attempt to mislead the government or its computer toting agents in order to limit the harvest are facing additional potential exposure under the Federal False Claims Act, 31 U.S.C. §3729-3733 (“FCA”).

CHILD MEDICARE SUIT MAY PROCEED IN SOUTH CAROLINA

Senior U.S. District Judge Malcolm Howard recently ruled that a motion to dismiss a class action brought by the defendants in McCartney v. Lanier Cansler, Secretary North Carolina Department of Health and Human Services, No 7:08-CV-57-H(3), must be denied. The plaintiffs claim that they were denied access to mental health and developmental disability benefits without a prompt hearing and that the defendant failed to adopt reasonable standards for implementation of its Medicaid program.  The three minor plaintiffs through their parents as next of kin brought the class action to restore the children’s rights prospectively. They are not suing form damages.