The waiver of coinsurance and deductibles owed by patients treated by physicians and other health care providers has come under increased scrutiny recently. Although there are no clear legal prohibitions, commercial health insurers have aggressively pursued out-of-network provides who fail to collect or waive amounts owed by their insureds under different statutory regulations.
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Author Archives: Breazeale Sachse
Psychiatric Medical Emergency Policies and the Largest EMTALA Penalty Ever
Most hospitals are intimately familiar with the application of the Emergency Medical Treatment and Labor Act (EMTALA) in medical cases. It becomes more complex and challenging when an individual presents to a hospital’s emergency department (ED) with symptoms of a psychiatric disturbance. We are seeing increased focus on these types of cases by healthcare regulators. Multiple recent enforcement actions include two settlements – $360,000 and $1.3 million – that are far afield from the “usual” $50,000 penalty (or $25,000 for smaller hospitals). From these settlements, we see how problematic practices can significantly compound penalties, particularly in psychiatric emergency cases. Continue reading
Additional Challenges for Off-Campus Provider-Based Hospital Departments
Proposed Reduction of Payment Rates for Non-excepted Off-campus Provider-Based Hospital Departments Paid Under the Medicare Physician Fee Schedule
Medical facilities owned by hospitals but located off-campus are facing new challenges on both the state and federal levels. CMS recently proposed a rule updating certain payment policies and rates for the Medicare Physician Fee Schedule (Proposed Rule). Among other provisions, the Proposed Rule slashes payment rates for non-excepted off-campus provider-based hospital departments that are now paid according to the Medicare Physician Fee Schedule. The Proposed Rule will be published in the Federal Register on July 21, 2017; the comment period will close on Sept. 11, 2017. Continue reading
Conducting Required Reviews Can Save Your Facility from Embarrassment – and Worse!
Even though we know the old saying “an ounce of prevention is worth a pound of cure,” background checks on on personnel can sometimes fall through the cracks. Here are a few examples of times that make us wish we would have double-checked to be sure they were getting done:
- A state surveyor is on-site investigating and advises that the allegation of neglect or abuse is against a tech who was convicted for beating up his father a year before he was hired.
- In employing a favorite PRN nurse who has been around for a couple of years, you learn that she never obtained a license when she moved here from Texas. You realize there may now be returnable overpayments, because she is not appropriately licensed to perform the services in our state.
- You want to impress your new venture partner, and cringe when they discover in due diligence that your team has not checked the excluded provider or debarred contractor lists in a few years.
CMS Urged to Recoup and Audit EHR Incentive Payments
According to a report released by the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) on June 12, 2017, the Centers for Medicare and Medicaid Services (CMS) overpaid an estimated $729 million in Medicare electronic health record (EHR) incentive payments to participating providers. (The full report is available at https://oig.hhs.gov/oas/reports/region5/51400047.asp). The OIG reviewed whether CMS’ oversight of the Medicare EHR incentive program was sufficient and whether eligible professionals (EPs) nationwide met Medicare incentive payment program requirements and received appropriate incentive payments. Alarmingly, the OIG urged CMS to recoup and audit these incentive payments based on its findings. Participating EPs and hospitals should be cognizant of the ramifications of CMS’ recommendations, including the potential for an audit and recoupment. Continue reading
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