Health Coverage

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Evaluation and management (E/M) services have been called “the core” of healthcare billing.[1] E/M is a catch-all claim, allowing medical professionals to bill for diagnosing or treating nearly any illness or injury. E/M is also divided into fairly subjective levels depending on complexity, and the differences between levels is often merely a difference of opinion. While the DOJ has brought cases based on disputes over E/M services before, those cases are typically civil and part of a more complex upcoding or unbundling scheme.[2] This is because nearly everything involving some effort expended by a physician could arguably justify that physician believing the E/M service was proper, and therefore criminal cases requiring scienter evidence that proves the case beyond a reasonable doubt are incredibly rare.

Yet one of those rare cases went to trial this month.Continue Reading Physician Loses Rare Criminal E/M Fraud Trial

Distances in rural health care can be hard to fathom. A 2018 study found it took rural Americans, on average, 17 minutes to get to a hospital, but only 10 minutes in an urban center.[i] The distance between rural hospitals can be vastly further – in 2019, a National Institutes of Health study noted that hospitals in one rural state were generally at least 50 miles apart.[ii] These areas have been described (without meaning to be pejorative) as “health deserts.”[iii] Small populations, and a growing shortage of physicians in rural areas,[iv] often lead to hospitals in these areas having only one or two physicians in a particular specialty. Advanced health practitioners (AHP’s) with specialty training, such as psychiatric nurse practitioners or certified nurse midwives, can be an excellent way to preserve access to specialty care, particularly when lack of physician coverage would otherwise mean the hospital must divert or transfer emergency patients.Continue Reading It’s a Long Way From Here to There: Advanced Healthcare Practitioners, EMTALA’s Call Coverage Requirements, and Rural Hospitals

Large managed care plans have been squarely in DOJ’s crosshairs for years, but a late July 2023 Justice Department settlement agreement with one regional healthcare provider’s Medicare Advantage Plan offers a glimpse into an issue health systems and providers with their own managed care plans need to track.

This post examines the recent DOJ settlement, analyzes the trend towards enforcement of provider-owned managed care plans, and offers a prediction on what might be coming on the enforcement side.Continue Reading DOJ Continues Enforcement Efforts Against Provider-Owned Managed Care Plans

On June 14, 2023, a federal jury found that a Georgia physician knowingly violated the False Claims Act following a two-week trial on allegations that he made false claims to the Medicare Program. Now, despite just $1.1 million in improper payments stemming from false claims, a federal court is likely to impose a judgment that exceeds $27 million after adding statutory per-claim penalties and trebling the amount determined by the jury to be false.Continue Reading Georgia Physician Awaits $27+ Million Judgment Following False Claims Act Trial Loss

Healthcare Providers

Recently, CMS changed its process for approving provider transactions structured as equity transfers – which in Medicare’s eyes is generally classified as a change of information (“CHOI”).  Previously, the process for approving such a transaction was for the provider to submit the applicable 855 Enrollment Application as CHOI to the provider’s assigned Medicare Administrative Contractor (“MAC”) and the MAC would then approve the CHOI.  With this prior process, a provider only needed MAC approval for CHOIs. The CMS Regional Office only reviewed initial enrollments and changes of ownership (“CHOWs”).
Continue Reading Update on CMS’s Process for Approving Provider Transactions Structured as Equity Transfers (CHOI)