Tag Archive for: health care

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Feds paid $60 million in Medicare improper payments last year

Q: In 2016 the federal government paid out $60 million in “improper payments” to Medicare and Medicare Advantage plans. What are improper payments?

A: The prohibition against improper payments applies to Medicare and to the Medicare Advantage plans which stand in the place of Parts A and B but offer more choices to patients in the private insurance market. Most are HMOs, PPOs, and private fee-for-service plans. “Improper payments” refers to both underpayments and overpayments. The most common payment problems are traced to insufficient documentation of the care provided. Other problems are no documentation, failure to establish medical necessity and incorrect coding. Regulators tell us that the objective is to understand the ordering practitioner’s reasoning in evaluating and diagnosing a patient, in considering the alternative course of action and in selecting a specific treatment plan with the patient. Just as physicians have been trained to document robust informed consent, they are now being called upon to document their thought processes as a way of demonstrating the legitimacy of the treatment.

Q: What action can the federal government take once an improper payment has been identified by the Center for Medicare and Medicaid Services (CMS)?

A: The CMS is part of the Department of Health and Human Services and it has an investigative arm known as the Office of the Inspector General (OIG), which is the most robust of all federal agencies’ legal and investigative arms. The OIG can investigate a provider and refer the matter to the Department of Justice to bring a criminal or civil action against the provider that can result in repayments, penalties, and even incarceration. Such actions also ultimately can result in exclusion from federal payment programs and even loss of the provider’s clinical license to practice. A demand for repayment can be based on an extrapolation of a statistical sample of a provider’s claims submission and payment history.

Q: How can providers avoid making claims that result in improper payments? Are there certain kinds of providers who are at the greatest risk for coding errors?

A: In the face of this regulatory environment, providers would do well to engage in periodic preventive spot audits of their medical records documentation, coding and billing activity. Billing regulations are increasingly complex and require advanced training not only of the practitioner but also of his or her staff, billing company and supporting professionals such as accountants and attorneys. Continuing education, coding seminars and the like are the order of the day for persons with these responsibilities.

Q: What’s the potential impact of these billing errors on patients and on providers?

A: Improper documentation can be a result of mistakes, faulty documentation or fraud. Some documentation shortcomings can be traced back to the provider’s original training or education. Others relate to the electronic records formatting, which some experts argue fosters copying responses rather than creating medical record entries for each patient. Ideally, eliminating unnecessary claims benefits the health care system financially and so ultimately benefits the patient. However, in my experience, “false claims” often represent a failure on the business side of a medical practice or facility operations in a situation where quality services were actually performed. But once characterized as an overpayment, the amount paid by the Medicare contractor must be returned despite the fact that quality services were provided.

From NewsOK / by Paula Burkes
Published: September 29, 2017
Click to see full story – Feds paid $60 million in ‘improper’ Medicare payments last year

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NewsOK Q&A: FBI warns against doctors, dentists using ‘anonymous mode’ computer servers

From NewsOK / by Paula Burkes
Published: April 12, 2017
Click to see full story – FBI warns against doctors, dentists using ‘anonymous mode’ computer servers

Q: What attention has the FBI recently given to protect Protected Health Information (“PHI”) from cyber criminals?

A: Under a “Private Industry Notification” dated March 22, the FBI’s Cyber Division has provided guidance that’s applicable specifically to medical and dental providers and focuses on protection of sensitive, identifiable health information.

Q: What does the notice specifically recommend?

A: The notification recommends these health care providers request that their IT services personnel take steps to further secure the information from cyber threats by checking networks for File Transfer Protocol (“FTP”) servers running in anonymous mode. FTPs routinely are used to transport information between network hosts. This is the case, for example, when a covered entity such as a hospital or group practice transfers information to a business associate, such as a billing company or a third-party payer, for the purpose of submitting claims for services provided.

Q: What does “anonymous mode” mean and what threat does it represent?

A: “Anonymous mode” refers to the situation where an FTP server can be structured to permit users who are anonymous, doesn’t require a password to enter, and accepts common user names such as “anonymous” or “FTP.” The danger is that, in such circumstances, sensitive patient information stored on a server could be accessed with little or no security.

Q: Why does the FBI guidance focus specifically on health care?

A: Research conducted at the University of Michigan in 2015 resulted in a finding that more than one million FTP servers would allow such access. According to the FBI, some computer security researchers seek servers in anonymous mode as part of legitimate research, but others make such connections to facilitate nefarious activities such as launching cyber attacks, hacking, blackmailing, harassing and intimidating business owners. It’s the FBI’s purpose issuing this new guidance to both make health care business aware of the risks represented in their IT systems and to shore up weaknesses that pose cyber security risks. In addition to the precautions urged in the notice, the FBI has previously urged companies to buy and implement ransomware.

Q: Should additional actions be taken by medical and dental health care entities to provide additional protections against cyber crime?

A: The FBI encourages medical and dental health care entities to report suspicious or criminal activity to the local FBI field office (locate via www.fbi.gov/contact-us/field) or the FBI’s 24/7 Cyber Watch, CyWatch 855-292-3937 or CyWatch@ic.fbi.gov. Submitted reports must include available information regarding the date, time, location, type of activity, number of people and type of equipment used for the activity, the name and contact person for the entity submitting the report. Victim complaints can be filed with the internet Crime Complaint Center at www.ic3.gov.

 

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NewsOK Q&A: Advance directives provide care guidance for end of life

From NewsOK / by Paula Burkes
Published: April 28, 2016
Click to see full story – Advance directives provide care guidance for end of life

Q: What should we know about decision-making in the future to care for ourselves?

A: The mechanism for providing guidance to your health care professionals and to your family at the end of your life is a legal document known as an “advance directive.” The process of completing your advance directive is an important one because it makes you think about yourself in various end-of-life situations. You are telling your providers, in advance, what you will allow them to do, to the extent possible.

Q: Is there a specific form for an advance directive in Oklahoma?

A: Advance Directive forms are available at the Oklahoma Bar Association at www.okbar.org/Portals/14/PDF/Brochures/advance-directive-form.pdf. The advance directive statute requires that you must be 18 or older, of sound mind, and have two witnesses 18 or older and who aren’t beneficiaries of your will. The advance directive needn’t be notarized. It’s effective when your health state is such that your physician and another physician conclude that you no longer are able to make your own health care decisions.

Q: What kinds of provisions can I make for myself with an advance directive?

A: Advance directives provide treatment and care directions for three different conditions. You can provide directions to your providers when your condition is determined to be terminal. A terminal condition is one which, in your physician’s opinion, will result in your death within six months. You also can provide directions about your care when you’re persistently unconscious, which means that your condition is irreversible and you aren’t aware of your environment or of yourself. You also can provide your wishes for your care when you’re in an end-stage condition or an irreversible condition, and medical care would be ineffective. An advance directive also gives you the option of directing future artificially-administered food and water if you’re unable to take those by mouth in the three conditions described. You also can provide for organ donation in the advance directive.

Q: What else should I know about advance directives?

A: These decisions aren’t easy and it’s helpful if you involve your family in your decision-making so that they understand your wishes. Second, keep copies of your advance directives in a number of places and let your family members and loved ones know where they are so that guidance will be readily accessible when needed. Finally, under Oklahoma law, an advance directive for mental health also is available.

Q: Is there a specific form for the advance directive for mental health?

A: The Oklahoma Advance Directive for Mental Health form is found in our Oklahoma statutes, Title 43A Section 11-106. This advance directive allows you to provide for an alternate decision-maker for your mental health treatment. For the seriously mentally ill, this is important in terms of facilitating care when needed, at moments of crises. The advance directive on mental health becomes effective if the attending physician or psychologist determines that the ability to receive and evaluate information and to communicate decisions is impaired so that one lacks the capacity to refuse or consent to mental health treatment. “Capacity” is a determination made by the health care provider.

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NewsOK Q&A: New health measures will require baseline screenings

From NewsOK / by Paula Burkes
Published: February 18, 2016
Click to see full story – New health measures will require baseline screenings, more data

Q: The Centers for Medicare and Medicaid Services (CMS) released core quality measures for physicians on Feb. 15. What does this mean for physicians and for patients?

A: Physicians currently are required to report multiple quality measures to a variety of entities, and this has been confusing for providers and difficult to report effectively. The quality measures, spearheaded for some time now by federal health care reimbursement programs and by commercial insurers, are being used to standardize care and to establish baseline performance for providers they reimburse for services provided to their beneficiaries. These measures are seen as a cost containment initiative and a way to facilitate provision of baseline quality services. It’s also envisioned as an opportunity to empower consumers to become informed decision-makers.

Q: How were these quality measures established?

A: CMS and America’s Health Insurance Plans came together, along with consumer groups, national physician organizations and employers, to form the Core Quality Measure Collaborative. The seven sets of core measures include: accountable care organizations, patient-centered medical homes and primary care; cardiology; gastroenterology; HIV and hepatitis C; medical oncology; obstetrics and gynecology; and orthopedics. CMS currently is using measures from each of these core sets. An example of a core measure for primary care (family practice) is control of high blood pressure by first obtaining a core set of data about the patient. Another primary care example for comprehensive diabetic care is performance of an eye exam.

Q: Does CMS intend to establish core measures for other medical practice “sets”?

A: The CMS news release of the Collaboration’s Core Quality Measures appears to be a single step in a process that will result in future proposed rules in additional clinical areas. Presumably CMS has stated that it will continue to engage in a multi-stakeholder collaboration including additional notice and public comment rulemaking. CMS isn’t newly committed to applying outcome metrics to payments for physicians and other providers. In fact, it’s not unusual for hospitals and other institutional providers to include baseline quality and performance metrics as a prerequisite to salary or bonus compensation in physician employment and other agreements.

Q: Are these additional regulations a win for Medicare, commercial insurers, physicians, patients?

A: The announcement of these regulations is thought to signal successful progress by Medicare and commercial insurers toward value-based purchasing. This is an effort to make the federal and private health care dollars go farther. Part of the federal health care agenda is based upon recouping financial savings by enabling a healthier population. For physicians, although this may initially seem like another layer of regulations tied to reimbursement, the standardized core measures are likely to simplify patient data the information that must be maintained and provided. For patients, although quality improvement is entirely positive, the logical extension of the efforts of the collaboration is to standardize care that will covered by these federal and commercial insurance programs. It’s possible that it will improve services provided to some patients while limiting that available to others.

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Attorney Mary Holloway Richard moderates webcast for OBA

Health Care Attorney Mary Holloway Richard hosted a webcast October 28 for the Health Law Section of the Oklahoma Bar Association.

“The presentation is entitled ‘Representing Vulnerable Populations: Behavioral Health Patients and Families,’ Richard said. “The webcast covers psychiatric diagnoses, emergency detention and involuntary admissions, confidentiality of information and other topics which will be useful to attorneys across the state called upon to represent behavioral health patients and their families.”

Richard served as moderator and presenter along with Judge Don Andrews, District Judge Oklahoma County formerly assigned to the Mental Health docket; Dr. Britta Ostermeyer, chairman Department of Psychiatry at the University of Oklahoma College of Medicine; and Dewayne Moore, general counsel of the Oklahoma Department of Mental Health and Substance Abuse Services.

The presentation was offered for Continuing Legal Education credit and will be made available by the OBA here.

 

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