The Wall Street Journal is reporting that virtual physician visits are on the rise, and more payors are viewing such visits as a way to reduce the cost of care while also making care more convenient for patients. UnitedHealth, Aetna, and most recently, WellPoint are now offering such services or will be soon.
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The California Supreme Court has agreed to hear a case to decide this issue (Fahlen v. Sutter Central Valley Hospitals, 208 Cal. App. 4th 557 (2012)). The case pits the sometimes adverse interests of physicians against the interests of hospitals when employment and practice privilege issues collide. Physicians who allege their privileges have been terminated in retaliation for blowing the whistle do not want to wait to file a whistleblower case until all administrative and judicial remedies concerning their clinical privileges are exhausted. On the flip side, hospitals do not want to fight physicians on two fronts: in court and in the hospital’s own peer review process with the potential for judicial review.
The hospital in the case, Sutter Central Valley Hospitals, declined to renew the physician’s privileges after peer review proceedings, and that determination was upheld by the hospital’s board. While the physician, Dr. Fahlen, might have been able to challenge that decision in court, he chose to file a lawsuit against the hospital with a number of claims, including claims under California’s whistleblower protection law (Cal. Health & Safety Code Section 1278.5, subd. (a)). Dr. Fahlen claims that he lost his privileges as retaliation for blowing the whistle on dangerous nurses.
The Office of Inspector General (OIG) of the Department of Health and Human Services has concluded that a per diem payment structure between a not-for-profit hospital and specialist physicians would not result in administrative sanctions under OIG’s civil monetary penalties law that relates to prohibited remuneration by the anti-kickback statute. According to an OIG Advisory Opinion that was posted this week:
Each year, [the hospital] allocates an aggregate annual payment amount per specialty for on-call coverage payments to participating physicians based on: (1) the likely number of days per month the specialty would be called; (2) the likely number of patients a participating physician would see per call day; and (3) the likely number of patients requiring inpatient care and post-discharge follow-up care in a participating physician’s office (OIG Advisory Opinion 12-15)
Once the aggregate amount per specialty is determined, the hospital divides this amount by 365 days to create the on-call coverage per diem fee to be paid to the specialty physicians. Notably, these physicians receive the per diem fee for each day of coverage under the arrangement even if they are not contacted by the emergency department to treat a patient.
Numerous elements of the particular arrangement at issue were highlighted by OIG as minimizing the risk of fraud and abuse. First, the per diem payment was certified by an independent consultant as commercially reasonable and within the range of fair market value for actual and necessary services. It was also calculated without regard to referrals or other business generated by the participating physicians. The OIG highlighted that the per diem amount was calculated annually in advance and was uniformly administered without regard to the individual physician’s referrals.
The FTC recently provided yet another warning to healthcare organizations that they must take the time to analyze potential antitrust implications when considering an acquisition or consolidation. On August 6, the FTC and Nevada Attorney General announced the filing of a lawsuit and proposed consent decrees settling litigation filed against Renown Health, the largest hospital provider in…
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With the passage of the ACA, the voluntary nature of compliance programs is about to change. Smaller healthcare organizations and other ancillary providers who have previously not established compliance programs will now be required to adopt formal programs. The ACA mandates providers and suppliers participating in federal health care programs to implement compliance programs with “core elements” as a condition of enrollment.
The HHS Secretary is responsible for setting a timeline to implement the new “core elements” for each health care sector and then setting a timeline for providers to adopt compliance programs. Details regarding the extent of the program have not yet been described or published. Skilled nursing facilities are the first providers required to implement an effective compliance program by March 23, 2013.
Our Insight. Your Advantage. By doing the work now, healthcare organizations can get ahead and avoid surprises when HHS eventually publishes the mandatory compliance program rules for other healthcare sectors. Many in the healthcare industry anticipate the OIG’s voluntary compliance program guidance will serve as an example to HHS as it determines which compliance program elements shall be required. As you prepare your compliance programs,
The Missouri Supreme Court has ended the debate over the constitutionality of statutory caps on non-economic damages in common law causes of action, including medical malpractice claims for personal injury. In a 4-3 decision returned on July 31, 2012, the court in Watts v. Lester E. Cox Medical Centers found that the right to a…
Husch Blackwell Healthcare Department Chair Curt Chase and his co-presenters explore common hospital/physician relationships that generate serious and complex compliance issues at HCCA’s 16th Annual Compliance Institute in Las Vegas, NV. They provide methods for effectively auditing, managing and conducting internal investigations and evaluate disclosure options and appropriate fixes.
To read the presentation, click below.
Husch Blackwell Healthcare Department Chair Curt Chase presented at the American College of Healthcare Executives’ 2012 Congress on Healthcare Leadership in Chicago, IL. Curt and his co-presenters discuss the various issues impacting successful hospital/physician integration efforts in light of healthcare reform and changes to reimbursement methodologies. They explore a full range of integration alternatives including…
CMS has, in the past, expressed concern regarding the use of concierge medicine by physicians treating Medicare patients. CMS has prosecuted some concierge care practices for charging concierge fees for “non-covered services” under Medicare. Despite this opposition, patients and physicians have increasingly implemented concierge-like relationships, including amenities that provide unlimited access to physicians via email,…
