Although there is no federal or state law barring physicians from providing health care services to themselves or their immediate family members including prescribing medication, there are limitations imposed by both applicable ethical rules and third party payor billing policies. For example, the American Medical Association ("AMA") has Ethics Opinion 8.19 which provides, in pertinent part, that: "physicians generally should not treat themselves or members of their immediate families" since their "professional objectivity may be compromised" and they may fail to: "probe sensitive areas when taking the medical history" or "perform intimate parts of a physical examination." AMA Ethics Opinion 8.19 does indicate that self-treatment or immediate family treatment may be appropriate in emergency circumstances or isolated settings where there is no other available qualified physician, however, it warns that controlled substance prescribing for themselves or immediate family members should only be done in emergencies. Michigan physicians should be aware that a violation of the AMA Ethics Opinion 8.19 could give rise to an administrative action against the physician's medical license under MCL 333.16221(b)(vi) which authorizes such action for lack of good moral character as evidenced by violation of the ethics opinion. It should also be noted that many third party payors have policies that bar claims for reimbursement for services rendered by physicians to themselves or their immediate family members. For examples, Blue Cross Blue Shield of Michigan does not cover services that health care providers render to themselves or any first-degree relatives, including parents, siblings, spouse and children. This bar covers not only controlled substances but all care services and does not provide for any exceptions. Thus, in the rare event that a Michigan physician does provide self-treatment or immediate family treatment, he or she should document the treatment using a S.O.A.P. format and indicate the emergency reason (which is required if prescribing a controlled substance) and/or isolated circumstances (if not prescribing a controlled substance). Moreover, in either case, the physician should not bill a third party payor for his/her services unless such payor allows such claims (which is unlikely).
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Recently, the National Practitioner Data Bank (NPDB) website revised both the content and appearance of its Frequently Asked Questions (FAQs) pages in order to provide more insight and better guidance to its users based upon its call center statistics and other customer feedback. The revised questions and answers are now organized into new categories by audience: Health Care Professionals, Organizations, and Other Topics. There is also a FAQ search bar that allows the user to type in a keyword to search for a topic. See: http://www.npdb.hrsa.gov/faqs/faqs.jsp
It was just released that Congress is contemplating whether Medicare will be able to restrict at-risk drug abuse beneficiaries to a limited number of pharmacies and providers when they seek narcotics. Currently, Medicaid and the Veterans Affairs (VA) are able to impose these restrictions, but Medicare is not.
If successful, this action will help prevent opioid abuse by averting doctor shopping and encouraging physicians and insurers to aid patients battling drug abuse.
With the fight against prescription drug abuse reaching an all-time high, health insurance plans are now taking a proactive role in attempting to reduce the quantity of some of the most abused drugs in the marketplace. As of September 2, 2014, Blue Cross Blue Shield of Michigan (BCBSM) commercial plans (non-Medicare) will implement new quantity limits for Oxycodone immediate release tablets and capsules (sold under the brand names of Roxicodone an OxyIR) and Oxymorphone immediate release tablets (sold under the brand name of Opana) of 180 per 30 days. These new limits apply to all strengths of the generic and brand-name versions of these drugs. Some pain management physicians have expressed concern that such limitations are an attempt by the health insurance companies to usurp the medical judgment of treating physicians due to cost containment measures while others believe that such limitations are helpful in reducing the potential for unsupervised use, misuse or abuse of prescription painkillers that can lead to addiction, hospitalization and even death. BCBSM will entertain a written request from a prescriber for an override of the limitation that includes documentation that the amount prescribed is medically necessary. A quantity limit override form is available from BCBSM on its website.
The attorneys at The Health Law Partners have a significant amount of experience in the defense of health care fraud investigations and pharmacy legal matters. For more information regarding such matters, please contact Robert S. Iwrey, Esq. at (248) 996-8510 or firstname.lastname@example.org.
On January 15, 2013, Richard Behnan, DPM., a 56 year old podiatrist from Fenton, MI was sentenced by a federal judge to 55 months in prison and ordered to pay over $1.4 million in restitution to Medicare and nearly $200,000 to BCBSM for his participation in a $1.6 million fraudulent medical billing scheme. Dr.Behnan previously pleaded guilty on November 21, 2011 to one count of conspiracy to commit health care fraud. According to the plea documents, from approximately 2000 through 2010, Dr. Behnan, provided services to patients at various senior centers and assisted living facilities in Bay City, Flint, Detroit, and Lansing submitting claims to BCBSM and Medicare for nail avulsion procedures when he had merely trimmed and polished the patients' toenails. At times, Dr. Behnan submitted claims for nail avulsion procedures when he was traveling outside of the United States.
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.
On May 5, the Centers for Medicare and Medicaid Services (CMS) published in the Federal Register its final rule for telemedicine credentialing and privileging for hospitals and critical access hospitals (CAHs). Beginning July 5, 2011, hospitals and CAHs, will have the option of proxy credentialing distant-site physicians and practitioners pursuant to a written agreement. Currently, hospitals and CAHs must credential distant-site physicians and practitioners in the same manner as their on-site staff.
According to the Associated Press (March 6, 2011), an Indiana pharmacist, John D. Love (owner of the Terre Haute Prescription Shop) "faces a possible 10-year prison sentence if convicted of health care fraud and money laundering in a scheme that netted him more than $3.57 million, federal prosecutors say." The amount of the case qualifies it as the largest case of health care fraud and money laundering ever discovered in the Southern District of Indiana.
- Transferring the Bureau of Health Professions, the Bureau of Health Systems and the Controlled Substances Advisory Commission from the Department of Community Health to the DLRA;
- Creating an Office of Regulatory Reinvention tasked with reviewing all existing and proposed rules to ensure economic growth; and
- Creating the MI Administrative Hearing System, which is an independent agency that will centralize the state's administrative hearings.
Both executive orders are set to go into effect April 24, 2011.
Over $225 million in false billing, 111 defendants, and 9 cities across the country. The Medicare Fraud Strike Force charged doctors, nurses, physical and occupational therapists, healthcare company owners and executives and others in the largest Medicare fraud takedown ever. The defendants are accused of various healthcare fraud-related crimes, including conspiracy to defraud Medicare, criminal false claims, anti-kickback statute violations, money laundering and aggravated identity theft. According to the Department of Justice, the defendants allegedly submitted claims to Medicare for medically unnecessary services and for services that were not provided. Furthermore, the defendants allegedly paid patient recruiters kickbacks for supplying beneficiary information to providers to submit fraudulent billing to Medicare for services that were medically unnecessary or never provided. The charges are based on a number of alleged fraud schemes involving home health agencies, physical and occupational therapy, nerve conduction tests and durable medical equipment.
Among the nine cities that were included in the scheme were Detroit and Brooklyn. In Detroit 21 defendants were named--including three doctors, three physical therapists and one occupational therapist--charged with defrauding Medicare for more than $23 million and in Brooklyn 10 defendants were named--including three doctors and one physical therapist--charged with defrauding Medicare for $90 million in false claims billings for physical therapy, proctology services and nerve conduction tests.
Over the last two years, the number of anti-fraud Strike Force teams operating in fraud "hot spots" increased from two to nine, with Chicago and Dallas being the most recent additions. Since its inception in 2007, the Strike Force teams have charged nearly 1000 individuals who have falsely billed Medicare for over $2.3 billion.
Elizabeth L. Johnson, a former New York pharmacist was charged with grand larceny, offering a false instrument for filing and unauthorized practice for her allegations that she defrauded Medicaid out of approximately $191,000. While Johnson's license to practice as a pharmacist was suspended and she was excluded from participating in Medicaid, she allegedly continued to dispense prescriptions to Medicaid recipients for months. She was scheduled to appear in court on February 17.