Good News for IUSME

CMS announced a recent change to rules for billing by medical students.  CMS had required teaching physicians to verify and re-document notes on physical exams and medical decisions for Medicare patients.  Now while teaching physicians must still be involved in the performance of physical exams and continue to handle decision making, the teaching physicians no longer have to fully re-document those claims but can simply verify the student documentation.  This should be good news for all medical education locations that perform actual exams upon patients, including Evansville’s new location of the IU Medical School.

The Suit Goes On

CareFirst was sued by persons affected by its 2014 data breach.  Since suit was filed, CareFirst has attempted to get the lawsuit dismissed on the basis that the Plaintiffs could not show an immediate dollar based harm.  After an appeal to the DC Appeals Court and now the Supreme Court, the suit goes on.  The Supreme Court chose not to become involved which should allow the suit to go to trial.  In essence, the Supreme Court decided to let the lower Courts wrestle with questions relating to data breach cases.  However, the Supreme Court’s decision not to become involved also signals to lower Courts that the decisions to allow such cases to proceed to trial and determination of damages by juries has some approval.  Previously, such suits were immediately struck down leaving the persons who were affected by the breach with little or no recourse against CareFirst or other recent breachers of large amounts of data.

Whistleblown

Two whistleblowers filed suits in Federal Court in Pittsburgh against Horizons Hospice, LLC and its owner/CEO, John Rezk.  A settlement was announced where Horizons and Rezk will pay the US $1,240,000 to settle allegations that Horizons had billed fraudulently for hospice services.  The billings went to Medicare and Medicaid.  Apparently, the fundamental facts relating to the false claims were that the patients for whom false claims were submitted did not have a life expectancy of six months or less.  Most Federal programs only pay for hospice care when patients have a life expectancy of less than six months related to an illness.  A secondary claim regarded the defendants preparing false records to support the false claims.  Not surprisingly Horizons has decided to change its name and is now known as 365 Hospice, LLC.

There had been prior settlements regarding hospice billings for patients who had either no prognosis relating to a terminal illness being billed through hospice or patients with life expectancies far exceeding six months even with a Sunday terminal illness.  Providers should take notice of these settlements and these accusations because they tend to identify those areas where our government is targeting enforcement.  Even though this is a whistleblower law suit, there have been enough hints from prior enforcement actions to give fair warning to make your billing compliant.

No ER for You

Anthem faces push back if not outrage over its ER program policy.  Anthem decided it would review ER charges and decide, after the fact, whether such ER visits will be covered by Anthem.  Currently, the ER policy applies to Indiana, Georgia, Kentucky, Missouri, New Hampshire and Ohio for commercially insured patients.  Note, it does not apply to Medicare or Medicaid patients.

Anthem has adjusted its policy slightly so it will not, after the fact, refuse to pay where a patient is directed by a healthcare provider to go to the ER, the patient is under 15 years of age, the patient is traveling out of state or the patient received surgery, IV fluids, IV medications or an MRI or CT scan.

While doctors and hospitals have been understanding of Anthem’s wish to not pay for avoidable ER visits, this policy is far from mature and, according to them, needs many more adjustments.  Anthem assumes if you don’t go to the ER you should go to an urgent care.  However, urgent care is not available 24 hours in many locations.  They also questioned whether Anthem’s basing payment on final diagnostic codes and their after the fact review, causes those with no medical training or experience to decide whether or not they should go to the ER.  Some believe this potentially violates some state and federal laws.  There is also great concern since it is rumored that others, including UnitedHealthcare, are reviewing similar policies.

This is likely to be a news item for many months or even years.  Certainly hospitals and Anthem need to cut unnecessary and avoidable ER treatments.  On the other hand, there is no infrastructure in place that allows an insured to review their options and understand what their healthcare needs are, particularly in a time of stress or illness.  Until this structure is in place, it is likely Anthem’s policy will be challenged by healthcare providers and likely by state or federal legislators.

This newsletter is edited by Paul Wallace of Jones • Wallace, LLC, a member of the American Bar Association Healthcare Law Section and the American Health Lawyers Association who has been representing physicians and healthcare practices for over 25 years.  Mr. Wallace assists physicians, practices and hospitals in contract items, federal legal compliance, practice entity creation, estate and wealth planning and similar issues.  Please feel free to call if you have any questions on this newsletter or legal matters at (812) 402-1600 or pwallace@joneswallace.com.