Archive for the ‘Health’ Category

U.S. Supreme Court hears Health Reform case

Tuesday, March 27th, 2012

This week is a landmark week for the U.S. Supreme Court.  The Court will be hearing 6 hours of argument (spread over 3 days) relating to the Affordable Care Act (aka Health Reform Law, Obamacare).

Here’s the schedule for the arguments: (links will be added as they become available)

Monday, March 26 10:00am-11:30am–Anti-Injunction Act  (link to audio or transcript of hearing)

Tuesday, March 27 10:00am-12:00pm–Individual Mandate  (link to audio or transcript of hearing)

Wednesday, March 28 10:00am-11:30am–Severability (link to audio or transcript of hearing)

Wednesday, March 28 1:00pm-2:00pm–Medicaid Expansion (link to audio or transcript of hearing)

Pill Mills in Florida & Unintended Consequences

Thursday, March 8th, 2012

Florida pill mills have come under close scrutiny from investigators since new laws went into effect last year.  In fact, it has been reported that over 400 Florida pain clinics have been shut down or closed in the last year.

But are the new regulations too broad?  Do these regulations make it difficult for patients with legitimate pain issues to get treatment? Also, how do these regulations interfere with a physician’s legitimate practice?

While looking into some of these issues, I came across a video of a medical director being interviewed about the unintended consequences of the pill mill laws.  Toward the end of the interview, he discusses what changes he had to make to his website/advertising and how this change may make it harder for patients dealing with chronic pain to seek treatment.


(Disclaimer: This post is not intended as legal advice nor does it create an attorney-client relationship.)

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New Health Law Legislation in Florida

Tuesday, December 13th, 2011

If you follow health law news in Florida, you may be interested in the following 3 bills.


HB 0863  Relating to Emergency Medical Services Training Programs in Pinellas County (Full text can be read here.)

Provides that majority of field internship experience provided for paramedic students by paramedic program located in Pinellas County may be done aboard advanced life support permitted vehicle other than ambulance if certain other requirements are met.

HB 0895  Relating to Sale or Lease of a County, District, or Municipal Hospital (Full text can be read here.)

Provides for sale or lease of county, district, or municipal hospital is subject to approval by CFO or registered voters; requires hospital governing board to determine by certain public advertisements whether there are qualified purchasers or lessees before sale or lease of such hospital; requires board to state in writing specified criteria forming basis of its acceptance of proposal for sale or lease of hospital; requires board to pay costs associated with petition for approval unless party contests action; provides for deposit, appropriation, & use of proceeds from sale or lease; authorizes special hospital or other health care taxing district to tax or appropriate funds to county economic development trust fund in order to promote economic growth in such district & county.

HB 0901  Relating to Health Insurance (Full text can be read here.)

Requires individual accident or health insurance policies, group, blanket, or franchise accident or health insurance policies, & health maintenance contracts to provide specified coverage for orthoses, prostheses, orthotics, & prosthetics benefits; specifies deductible & copayment requirements; authorizes insurers & HMO’s to specify benefits limitations; provides for nonapplication to specified policy & contract coverages.

All three bills were filed on December 5, 2011.

~At Matthews Law Firm, P.A., we practice criminal defense & health law.~

(Disclaimer:  This post is not intended as legal advice nor does it create an attorney-client relationship.)

New OIG Advisory Opinion 11-18

Monday, December 12th, 2011

The OIG has released its most recent Advisory Opinion (#11-18).  This Opinion was issued on November 30, 2011 and was posted on December 7, 2011.

The Opinion deals with the legalities of an online service that would facilitate the exchange of information between health care practitioners, providers, and suppliers.

In the end, the opinion concludes that although the Proposed Arrangement could potentially generate prohibited remuneration under the anti-kickback statute if the requisite intent to induce or reward referrals of federal health care program business were present, the OIG would not impose administrative sanctions in connection with the Proposed Arrangement.

Hospice Care and the 2012 OIG Work Plan

Tuesday, October 18th, 2011

Those working in hospice settings will want to take notice of the 2012 OIG Work Plan.  Here are 5 ways the Work Plan affects hospice care:

1.  Acute-Care Hospital Inpatient Transfers to Inpatient Hospice Care

The government will review Medicare claims for inpatient stays for which the beneficiary was transferred to hospice care and examine the relationship, either financial or common ownership, between the acute-care hospital and the hospice provider and how Medicare treats reimbursement for similar transfers from the acute-care setting to other settings.

2.  Hospice Marketing Practices and Financial Relationships with Nursing Facilities

The government will review hospices’ marketing materials and practices and their financial relationships with nursing facilities. Medicare covers hospice services for eligible beneficiaries under Medicare Part A. (Social Security Act, § 1812(a).) In a recent report, OIG found that 82 percent of hospice claims for beneficiaries in nursing facilities did not meet Medicare coverage requirements. MedPAC, an independent congressional agency that advises Congress on issues affecting Medicare, has noted that hospices and nursing facilities may be involved in inappropriate enrollment and compensation. MedPAC has also highlighted instances in which hospices aggressively marketed their services to nursing facility residents. They will focus their review on hospices that have a high percentage of their beneficiaries in nursing facilities.

3.  Medicare Hospice General Inpatient Care

The government will review the use of hospice general inpatient care from 2005 to 2010. They will assess the appropriateness of hospices’ general inpatient care claims and hospice beneficiaries’ drug claims billed under Part D. Federal regulations address Medicare CoPs for hospice at 42 CFR Part 418. They will review hospice medical records to address concerns that this level of hospice care is being misused and to determine the extent to which drugs are being inappropriately billed to Part D.

4.  Duplicate Drug Claims for Hospice Beneficiaries (Medicare Part D)

The government will review the appropriateness of drug claims for individuals who are receiving hospice benefits under Medicare Part A and drug coverage under Medicare Part D. They will determine whether payments under Part D are correct, supported, and not duplicated in hospice per diem amounts. They will also determine the extent of any duplication found and identify controls to prevent duplicate drug payments. Medicare Part D drug plans should not pay for drugs that are covered under the Part A hospice benefit. CMS publishes hospice payment rates, which include prescription drugs used for pain relief and symptom control related to the beneficiary’s terminal illness. (Medicare Claims Processing Manual, Pub. No. 100-04, ch. 11, § 30.2.) Hospice providers are paid per diem amounts, which include payments for these drugs. A drug prescribed for a Part D beneficiary shall not be considered for payment if the drug was prescribed and dispensed or administered under Part A or Part B.

5.  Hospice Services: Compliance With Reimbursement Requirements

The government will determine whether Medicaid payments for hospice services complied with Federal reimbursement requirements. Medicaid may cover hospice services for individuals with terminal illnesses. (Social Security Act, § 1905(o)(1)(A).) Hospice care provides relief of pain and other symptoms and supportive services to terminally ill persons and assistance to their families in adjusting to the patients’ illness and death. An individual, having been certified as terminally ill, must elect hospice coverage and waive all rights to certain otherwise covered Medicaid services. (CMS’s State Medicaid Manual, Pub. 45, § 4305.) In FY 2010, Medicaid payments for hospice services totaled more than $816 million.


(Disclaimer–This post is not intended as legal advice nor does it create an attorney-client relationship.)



HIPAA Loophole–Are law firms “covered entities”?

Monday, October 17th, 2011

Recently, a Baltimore medical malpractice law firm lost a portable drive that contained medical records for 161 stent patients, patient names, addresses, dates of birth, social security numbers and insurance information.  It appears as though the law firm represented a cardiologist being sued for alleged malpractice.

According to a Baltimore Sun article, the portable hard drive was “taken home nightly as a security precaution in case of fire or flood…though the portable information was not encrypted–among the most stringent security precautions that is standard practice for health professionals dealing with medical records.”

The law firm employee lost the hard drive while traveling on the Baltimore light rail.  She returned for it within 10 minutes but it was already gone.

HIPAA & Covered Entities

The protection of patient information is regulated by HIPAA, which applies to “covered entities”.  Under HIPAA, a “covered entity” is defined as being:

  • a health care provider that conducts certain transactions in electronic form (called here a “covered health care provider”)
  • a health care clearinghouse
  • a health plan

Here’s the legal question: Should law firms be included in the definition of covered entities?


(Disclaimer: This post is not intended as legal advice nor does it create an attorney-client relationship.)


~At Matthews Law Firm, P.A., we practice health law~

Cost for Mental Health & Substance Abuse Hospital Stays

Thursday, October 13th, 2011

Included in the September 2011 edition of HealthLeaders magazine is some information on hospital costs for mental health and substance abuse (MHSA)  issues.  Here are some interesting statistics:

“Over the past decade, the average length of stay for MHSA diagnosis has dropped about 10%, but the number of discharges with a principal MHSA diagnosis has increased about 14%.”

Average Cost of a Hospital Stay

Schizophrenia/other psychotic disorders……………………….$7,500

Attention-deficit/conduct/disruptive behavior disorders…$7,200

Bipolar Disorders…………………………………………………………….$5,600

Alcohol-related disorders………………………………………………..$5,000

Drug-related disorders……………………………………………………$4,900


Anxiety disorders……………………………………………………………$4,500

Pregnancy-related MH disorders…………………………………….$3,500

Adjustment disorders…………………………………………………….$2,800

(Source: U.S. Dept. of Health & Human Services, Agency for Healthcare Research and Quality, HCUP Facts and Figures, 2008, exhibit 5.10.  Costs reflect all costs associated with stay, not solely those associated with the principal diagnosis.)


~At Matthews Law Firm, P.A., we practice health law~

Nursing Home Compliance Plans

Friday, October 7th, 2011

Nursing homes should now have increased motivation to draft and implement a compliance plan. The reason?  Nursing home compliance plans are now listed in the 2012 OIG Work Plan, and will be a target for enforcement.  Specifically, the provision states in full:

Nursing Home Compliance Plans (New)

We will review Medicare and Medicaid-certified nursing homes’ implemention of compliance plans as part of their day-to-day operations and whether the plans contain elements identified in OIG’s compliance program guidance. We will assess whether CMS has incorporated compliance requirements into Requirements of Participation and oversees provider implementation of plans. Section 6102 of the Affordable Care Act requires nursing homes to operate a compliance and ethics program, containing at least 8 components, to prevent and detect criminal, civil, and administrative violations and promote quality of care. The Affordable Care Act requires CMS to issue regulations by 2012 and SNFs to have plans that meet such requirements on or after 2013. OIG’s compliance program guidance is at 65 Fed. Reg. 14289 and 73 Fed. Reg. 56832. (OEI; 00-00-00000; expected issue date: FY 2013; new start; Affordable Care Act)

As you read, according to the Work Plan, a nursing home (and skilled nursing facility) compliance plan should have at least 8 components.  And just what ARE the 8 components?  For that answer, we look to Section 6102 of the Affordable Care Act.  That law states the 8 components are:

REQUIRED COMPONENTS OF PROGRAM —The required components of a compliance and ethics program of an operating organization are the following:

(A) The organization must have established compliance standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under this Act.

(B) Specific individuals within high-level personnel of the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures and have sufficient resources and authority to assure such compliance.

(C) The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in criminal, civil, and administrative violations under this Act.

(D) The organization must have taken steps to communicate effectively its standards and procedures to all participation in training programs or by disseminating publications that explain in a practical manner what is required.

(E) The organization must have taken reasonable steps to achieve compliance with its standards, such as by utilizing monitoring and auditing systems reasonably designed to detect criminal, civil, and administrative violations under this Act by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents could report violations by others within the organization without fear of retribution.

(F) The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense.

(G) After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including any necessary modification to its program to prevent and detect criminal, civil, and administrative violations under this Act.

(H) The organization must periodically undertake reassessment of its compliance program to identify changes necessary to reflect changes within the organization and its facilities.

And remember, having a compliance plan is not merely having written policies.  Anyone could copy and paste the 8 components into a document and call it their “compliance plan”.  A compliance plan is a living, breathing document that should be implemented and followed everyday.  It is a “way of life” for an organization, from top administration, to full-time staff members, to part-time employees, and even to third-party business associates.  A compliance plan includes not only talking the talk, but walking the walk.  In order to be compliant, an organization needs to do both by talking it AND walking it.

~At Matthews Law Firm, P.A., we help clients draft & implement compliance plans that suit their needs~

(Disclaimer: This post is not intended as legal advice nor does it create an attorney-client relationship.)

2012 OIG Work Plan

Thursday, October 6th, 2011

The 2012 OIG Work Plan has been released!  Click here to access the full document. (Beware, the Work Plan is 165 pages long…may take a second to download.)

For those that are unfamiliar with this document, the OIG Work Plan comes out every October and explains what types of activity the government will be monitoring and reviewing for the next year.  Basically, it works as a “cheat sheet” to those involved in healthcare as to what to expect with government enforcement and audits.  From an attorneys perspective, the Work Plan helps in advising clients as to what areas to pay particular attention to in regards to compliance for the next year.

Happy reading everyone!

~At Matthews Law Firm, P.A., we practice health law.~

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Tuesday, September 27th, 2011

CMS has posted an update to “amount in controversy” for appeals

On September 23, CMS posted a notice in the Federal Register to announce the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process.

The calendar year 2012 AIC threshold amounts are $130 for ALJ hearings and $1,350 for judicial review. This will be the third straight year that ALJ threshold amounts remain at $130, while the threshold amount for judicial review has increased by $50.00.

Click here to view the notice in the Federal Register.