Some states have no laws regarding balance billing or surprise billing to healthcare users. Some states have laws but they may be of limited effectiveness. As I have reported earlier, patients are outraged by the seemingly arbitrary nature of balance/surprise billing not only for everyday healthcare, but particularly for emergency patients and out of network billings.
A bi-partisan group of Senators last week introduced a plan to protect patients from surprise bills and high charges from hospitals or doctors who are not in their insurance networks. One of the areas covered by the bill is a particularly insidious balance/surprise billing situation where a patient goes to an in-network hospital but receives treatment from a “out of network” doctor. The other situations covered by this bill involve treatment at out of network facilities and hospitals. Not only is this a concern for patients with standard insurance, but also for health plans offered by companies and unions that are self-funded. Current federal law does not prohibit balance billing to these self-funded plans which can be stunning amounts to employers.
Among the sponsors are Indiana’s own Todd Young and Claire McCaskill of Missouri. Expect this bill will be modified from its introductory format since emergency rooms and out of network hospitals are only two of the sources of balance/surprise billing.
The Beat Goes On
I have discussed previously unimaginable problems for veterans in receiving the healthcare we promised them. The latest is an OIG report on VA disability claim backlogs. In a shocking finding to no one, the OIG found that claims 125 days or older which required a rating decision were not considered by the VA to be a part of their backlog. Ultimately the OIG found that the VA reported less than 80% of claims that were 125 days or older and required a rating.
Do The Right Thing
Dr. John Janek of Port Charlotte, Florida received a sentence of five months in prison for obstructing a Medicare audit. He is also required to pay over $118,000.00 in restitution. Apparently, Dr. Janek lied to a program integrity contractor auditing his medical group and made false claims about who was paying rent for office space utilized by his wife. Even worse, his wife used access to sensitive patient data to generate referrals from Dr. Janek to her employer without regard for HIPAA or medical necessity. His wife had previously pled guilty to healthcare fraud charges in another case and she awaits sentencing.
As noted before, the fines for obstructing an audit and lying to enforcement officials are often much worse than the penalty would have been for the conduct being investigated.
The Ohio State Auditor recently charged that pharmacy benefit managers (PBM) charged Ohio a spread of more than 31% for acquisition of generic drugs. The spread is the difference between what PBMs pay pharmacies to dispense generic drugs and what the PBMs are paid by the State of Ohio. The Ohio Department of Medicaid had recently stated there was no urgent need to make a change from the PBM-spread-pricing model but after reviewing a draft of the Ohio State Auditor’s report, indicated they would abandon the PBM-spread-pricing model.
The benefit from the PBM model has been questioned before, but the urgency and detail of recent questions indicates the PBM model’s continued existence may be in jeopardy.
Streamlining Medicare Compliance
CMS’s latest proposed rule has the potential for benefiting physicians and health systems. The rules appear to recognize that many health systems have fairly uniform rules across their system for integrated quality assessment and will allow the hospital systems to certify those programs on a system-wide basis rather than the current rule which requires a hospital by hospital certification.
The changes would also ease requirements on organ transplant centers, for hospitals and ambulatory surgery centers conducting physicals and collecting patient histories ahead of procedures and create a simpler process for providers to order portable x-rays.
One of the more likely controversial parts of the proposed rule would eliminate a requirement for critical access hospitals to disclose people with a financial interest in that critical access hospital. While CMS states it obtains that information outside of compliance, it does not appear to provide an adequate method for patients of critical access hospitals to have that information readily available.
It is likely this rule will not be finalized in 2018, but it is worth watching for 2019 along with other streamlining measures.
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 firstname.lastname@example.org.