Billing

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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

On July 1, 2021, the Office of Personnel Management (“OPM”), the Internal Revenue Service (“IRS”), the Department of Treasury (“Treasury”), the Employee Benefits Security Administration (“EBSA”), the Department of Labor (“DOL”), the Centers for Medicare & Medicaid Services (“CMS”), and the Department of Health and Human Services (“CMS”) (collectively the “Departments”) jointly issued the Interim Rule – Requirements Related to Surprise Billing; Part 1 (hereinafter, the “Interim Rule” or the “Rule”). This Interim Rule is the first implementing regulation of the federal No Surprises Act (alternatively the “Act”) which was enacted on December 27, 2020 as part of the Consolidated Appropriations Act. Both this Interim Rule, and the Act, are effective applicable for plan years beginning on or after January 1, 2022.
Continue Reading Federal Guidance on Balance Billing: The No Surprises Act and its Interim Final Rule: Part I

Texas_157051216Rep. Dustin Burrows (Dist. 83, Lubbock) introduced H.B. 307, which could significantly impact facilities and practitioners that provide services on an out-of-network basis. Specifically, for services other than emergency services, H.B. 307 requires that a facility or practitioner provide a patient with the amount, including facility fees, that:

(1)  the patient’s health benefit plan will reimburse the facility or practitioner for the service, if the facility or practitioner is a participating provider under the patient’s health plan; or

(2) the facility or practitioner will charge for the service, if the facility or practitioner is not a participating provider under the patient’s health plan.
Continue Reading Texas 85th Legislature (2017) Legislation Update: Out-of-network billing limitations

The Texas Health & Human Services Commission’s (HHSC) final rules regarding physician billing for services provided by an APRN or PA became effective Jan. 1, 2015, and include limitations on such billing arrangements. See 39 Tex. Reg. 9884 (Dec. 19, 2014). The adopted rule requires that a physician billing for services provided by an APRN or PA under the physician’s Medicaid billing number must make a decision regarding the patient’s care or treatment on the same date of service as the billable medical visit and documented that decision in the patient’s record. See Tex. Admin. Code Tit. 1 §354.1062. If a physician billing for such services does not make a decision regarding the patient’s care or treatment on the same date of service, the physician must note on the claim that the services were provided by a supervisee. See Tex. Admin. Code Tit. 1 §354.1001.
Continue Reading Update: Texas Medicaid ‘incident to’ rule now in effect