Don’t Get Caught

We often write about healthcare fraud and list convictions or settlement agreements that show that healthcare fraud continues to be a serious problem.

Many of these fraud causes are clearly fraud that was intended to steal money by over charging, charging for medical services or goods that were never delivered and so on.  These are the obvious and easy cases and no physician, medical practice or hospital expects to be involved in such fraud.

Other cases appear to be situations where physicians either got caught up in someone else’s fraudulent activities or got into a detailed and difficult to understand area where simple mistakes in coding or billing lead to “fraud” charges.  For most hospitals, physicians and healthcare practices fraud claims can be avoided or at least significantly reduced by:

• Careful documentation of your care of patients.  It’s easy to become lax over time.  One of the significant advantages of using out sourced coding and billing is avoidance of casual or careless coding and billing.
• Use of periodic audits for evaluations to review your documentation, coding and billing.  This may be the single best way to not only ensure accurate coding, billing and documentation at the outset, but also to avoid falling into bad habits.
• Assuming that you follow the above steps for accurate clinical documentation and for accurate and effective coding, billing and auditing of those activities, the next recommendation we make to our clients is to listen to your employee concerns.  Employees sometimes misunderstand rules, regulations or procedures and sometimes their concerns are not accurate.  Often, their concerns are accurate and listening to your employees can not only improve your processes, but can avoid creating whistleblowers.  Use your employees to improve your practice.
• Be even more careful when your activities include high scrutiny areas.  These areas change from year to year but many of them are obvious if you stop and think-opioids, controlled substances, any payments from any other healthcare provider.  These are the cases we read about over and over again and therefore should be areas that involve extra scrutiny in your practice.
• Use effective advisers.  Most physicians and hospitals are busy doing what they do best-providing quality medical care.  Instead of trying to be all things, use attorneys, accountants and billing companies that are experienced and focused on providing ancillary services instead of trying to be your own attorney, your own accountant and your own billing company.

Dear Inspector General

The ranking democrat and republican members of the Senate Finance Committee have sent a letter dated April 8, 2019 to the HHS Inspector General.  The letter raises questions about Pharmacy Benefit Managers (PBMs) in this case in regard to state Medicaid programs.  Recent news articles and recent testimony before Senate committees has some of our elected representatives wondering why PBMs exist.  Cited in the letter is a report by the Kentucky Auditor General noting that PBMs in the State of Kentucky make $123 Million annually from the Kentucky Medicaid program solely through spread pricing practices.  Similar stories abound in other states.  With billions of dollars at stake and a significant impact on the sick and elderly, it will be interesting to watch the politics of PBMs over the next year.

Opioids Sometimes

In a letter dated February 28, 2019 but only released on April 9, 2019 from the CDC responding to the National Comprehensive Cancer Network, American Society of Clinical Oncology and the American Society of Hematology addressing concerns that the 2016 guidelines issued by the CDC attempting to curb opioid abuses was “misinterpreted” and had not meant to deny patients suffering from chronic pain the benefits of opioid pain relief.  The letter appears to be intended to deal with active cancer and sickle cell disease treatment and similar illnesses.

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.