December 2012 Archives

December 26, 2012

Hospital Employment of Surgeons on the Rise

It seems like every ten years or so the pendulum swings towards or away from physicians seeking employment from hospitals as opposed to heading off on their own or joining existing private physician practices. Over the last few years, the pendulum has swung towards hospital employment. A number of factors have arguably led to this trend including the desire by many physicians to focus their attention on practicing medicine and shifting the burden of billing, third party payor audits, EMR and compliance with the new myriad of federal healthcare regulations (e.g., Patient Protection and Affordable Care Act a/k/a "Obama Care") to the hospitals that have the resources to employ administrative staff to address such matters. A recent study published this month in the Archives of Surgery confirms this shift for surgeons. According to the study, from 2006 to 2011, the number of surgeons in a full-time hospital employment arrangement increased by 32%. Moreover, according to the American Medical News,by the end of 2013, only 36% of the nation's projected 792,594 practicing doctors will have a practice ownership stake.

In November 2012, the American Medical Association ("AMA") House of Delegates issued new guiding principles for physicians entering into employment and contractual arrangements. The Principles expressly urge both the employer and the employee to "obtain the advice of legal counsel experienced in physician employment matters when negotiating employment contracts." All too often, well-respected attorneys who do not specialize in the field of healthcare fail to address important issues specifically related to physician employment due to their lack of expertise on the subject. Typically, the review of a proposed employment contract only involves a handful of billable hours, and the benefit of having such a review is immeasurable when considering the duration of a physician's career.

Continue reading "Hospital Employment of Surgeons on the Rise" »

December 26, 2012

CMS Releases Contractor Guidance on Applying the MPPR to Advanced Imaging Services Provided by Group Practices

On December 13, 2012, the Centers for Medicare and Medicaid Services ("CMS") released Transmittal 1104. This Transmittal is a one-time update that provides guidance to contractors on applying the Multiple Procedure Payment Reduction ("MPPR") to advanced imaging services provided for one beneficiary during one session by multiple providers in the same group practice. This transmittal was originally communicated to contractors on August 2, 2012, but was not released to the public at that time. Now that CMS has released the Final Medicare Physician Fee Schedule ("PFS") for CY 2013, the agency is re-communicating this Transmittal and has published it on-line for the public along with a Medicare Learning Network ("MLN") Article.

As confirmed in the final PFS, effective January 1, 2013, CMS will begin to apply the MPPR to the Technical Component ("TC") and Professional Component ("PC") of advanced diagnostic services provided by multiple physicians in the same group practice for the same beneficiary during the same session. The agency had originally proposed this rule in 2012 when it began to apply the MPPR to services provided by single providers. However, CMS delayed implementation of the rule for group practices in order to resolve technical issues.

Under the new rule and guidance, CMS will pay the full amount for the service with the highest payment under the PFS. Payments for any subsequent services provided by the same or another physician in a group practice performed on the same day for the same beneficiary will be at 75% for PC services and 50% for TC services. According to the guidance, CMS assumes that services provided for the same beneficiary on the same day are part of the same session. However, if the services are not part of the same session, the modifier 59 must be used and the MPPR will not be applied.

The transmittal includes an addendum with a list of the services subject to the MPPR.

Continue reading "CMS Releases Contractor Guidance on Applying the MPPR to Advanced Imaging Services Provided by Group Practices" »

December 12, 2012

PTA in Detroit Sentenced to 30 Months for Her Role in Multi-Million Dollar Home Health Care Fraud

On December 11, 2012, Hetal Barot, a physical therapy assistant from Westland, Michigan, was sentenced today to serve 30 months in prison followed by 2 years of supervised release after pleading guilty to 1 count of conspiracy to commit health care fraud. She was also ordered to pay $1,336,739 in restitution, jointly and severally with her co-defendants. Barot falsified medical documentation for home health agencies owned by her co-conspirators, creating evaluations, therapy revisit notes and other medical documentation to support physical therapy services that were billed but never rendered. From approximately May 2009 through September 2011, Medicare paid approximately $1,336,739 to four home health care companies for fraudulent physical therapy claims based on falsified files and notes signed by Barot. The four home health companies for which Barot worked were paid in total approximately $13.8 million by Medicare. With regard to Barot's co-defendants, 9 have pleaded guilty, 3 are fugitives, and 6 await trial.

Continue reading "PTA in Detroit Sentenced to 30 Months for Her Role in Multi-Million Dollar Home Health Care Fraud" »

December 11, 2012

Abby Pendleton, Esq. and Adrienne Dresevic, Esq. Interviewed and Featured in Motion Magazine's article, "In Good Health"

Abby Pendleton, Esq. and Adrienne Dresevic, Esq. were interviewed and featured in the December 4, 2012 issue of Motion Magazine in an article titled, "In Good Health". The article notes that: the firm's upward trajectory can be traced, in part, to a "strategic decision" to focus on complex health care matters, according to Dresevic and Pendleton. Health care, after all, accounts for one-sixth of our nation's spending, double the share of 30 years ago. "Health care law is a field that is becoming more complex all the time as government involvement increases," Dresevic says. "We have identified specific areas where we offer expertise....
To review the entire article, click here.

Continue reading "Abby Pendleton, Esq. and Adrienne Dresevic, Esq. Interviewed and Featured in Motion Magazine's article, "In Good Health"" »

December 11, 2012

CMS Releases Report on Recovery Audit Statistics

CMS has posted on its website the latest RAC statistics. The statistics for the 4th quarter of FY 2012 show CMS collected $648 million in alleged overpayments and returned $46.5 million in underpayments. CMS' report on the total amounts collected and returned from October 1, 2009 through September 30, 2012, indicates that $3.16 billion in overpayments were collected and $268.2 million in underpayments were returned. The top issue for each of the four RAC regions remains whether inpatient hospitalizations (rather than outpatient stays) were medically necessary.

For FY 2012, CMS collected $397.7 million in the 1st quarter, 588.4 million in the 2nd quarter, 657.2 million in the 3rd quarter and $648 million in the 4th quarter for a total of $2,291.3 billion in FY 2012.

Continue reading "CMS Releases Report on Recovery Audit Statistics" »

December 11, 2012

2 Brooklyn Physicians Pay the Price for Medicare Fraud

On Monday, December 10, 2012, Boris Sachakov, MD, a colorectal surgeon, was sentenced to serve 30 months in prison for Medicare and private insurance fraud for billing for procedures such as hemorrhoidectomies that he never performed. On June 13, 2012, Dr. Sachakov was found guilty by a jury of one count of health care fraud and five counts of health care false statements after a 2-week trial in federal court. At trial, 11 of his patients testified that they never received the surgeries and medical services for which Dr. Sachakov had billed their insurance companies. In addition, when confronted by 2 of the insurance companies for allegations of billing for services not rendered, Dr. Sachakov sent letters to his patients asking them to falsely certify that they did receive the surgeries. Dr. Sachakov was charged with submitting more than $22.6 million in false claims and receiving more than $9 million from those claims.

In addition, on December 10, 2012, Ho Yon Kim, M.D. plead guilty to conspiracy to commit health care fraud. Dr. Kim admitted that he conspired with others in 2 Brooklyn clinics to induce Medicare beneficiaries to allow the clinics to bill their Medicare numbers for services that were never rendered or medical unnecessary in exchange for a variety of spa services (e.g., facials, massages), lunches and dance classes.

Continue reading "2 Brooklyn Physicians Pay the Price for Medicare Fraud" »

December 6, 2012

ELECTRONIC MEDICAL RECORD USAGE RISES TO 40%

Nearly 4 in 10 office-based physicians are now using an electronic health-record system with a basic level of functions, according to the latest estimates from an annual federal survey, up from about 1 in 3 a year ago.

A basic system was defined as an EHR that could be used for all of the following: record a patient history, patient demographics, problem lists, clinical notes, medications and allergies; write prescriptions; and view lab and imaging results.

Of physicians surveyed, 2 in 3 indicated that they either intended to--or already had applied for--either the Medicare or Medicaid incentives under the EHR incentive payment program.

Continue reading "ELECTRONIC MEDICAL RECORD USAGE RISES TO 40%" »

December 6, 2012

Feds Collect Record Amount Under False Claims Act

Led by a record-breaking legal settlement with drugmaker GlaxoSmithKline, federal collections from civil False Claims Act prosecutions and settlements exceeded all previous years, topping $4.9 billion in the most recent fiscal year.

The biggest single chunk--more than $3 billion--came from healthcare companies accused of defrauding Medicare and other government healthcare programs. Fiscal 2012 marked the first time that healthcare tallies topped $3 billion.

The False Claims Act is a federal statute designed to encourage whistle-blowers to file lawsuits when they have insider knowledge of companies defrauding the government. The act was overhauled in 1986, and has since become the most powerful tool that the Federal government has to deter and redress fraud.

The law carries significant financial penalties, including $11,000 per violation and up to triple the original damages to the government. It also allows whistle-blowers who come forward with non-public information to collect up to 30% of the total settlement. Most FCA cases are brought by whistle-blowers on behalf of the government.

Continue reading "Feds Collect Record Amount Under False Claims Act" »

December 5, 2012

AMA Issues Physician Employment Guidelines

On November 13, 2012, the American Medical Association ("AMA") House of Delegates issued new guiding principles for physicians entering into employment and contractual arrangements. The six principles issued by the AMA are intended to provide physicians with guidance as to how to handle potentially problematic aspects of the employer-employee relationship and include addressing: (1) conflicts of interest; (2) patient advocacy; (3) contracting; (4) hospital medical staff relations; (5) peer review and performance evaluations; and (6) payment agreements. With regard to contracting, the Principles provide that physicians should be able to freely enter into contracts with hospitals, health care systems, medical groups, insurance plans and other entities as permitted by law and medical ethics without coercion and such arrangements should be negotiated in good faith. The Principles expressly urge both the employer and the employee to "obtain the advice of legal counsel experienced in physician employment matters when negotiating employment contracts." All too often, well-respected attorneys who do not specialize in the field of healthcare fail to address important issues such as covenants not to compete and/or solicit patients or malpractice insurance when drafting and/or reviewing employment contracts due to their lack of expertise on the subject. Typically, the review of a proposed employment contract only involves a handful of billable hours, and the benefit of having such a review is immeasurable when considering the duration of a physician's career.

Continue reading "AMA Issues Physician Employment Guidelines" »