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Paul Zimmerman
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Showing 35 posts in Reimbursement.

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Physician Alert: CA Balance Billing Legislation Signed Into Law

California Governor Jerry Brown has signed into law a bill that is meant to address the issue of balance billing patients when they receive non-emergency medical services from an out-of-network physician at an in-network facility. The bill, AB 72, has been on a fast track through the California legislature despite criticism from some segments of the medical provider community. Providers should be aware of this legislation, as it could significantly impact your business. (Read More)

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On the Clock: Physician’s Voluntary Engagement in Insurer's Internal Appeals Process Does Not Toll Statute of Limitations

An insurer’s optional appeals process does not toll the statute of limitations following unequivocal written denial of a claim. In Dev v. Blue Shield of California, a California appeals court held that the two-year statute of limitations applicable to claims for quantum meruit began to run when a health care provider received the “Explanation of Benefits” (EOBs), which constituted an unequivocal denial of payment. Out-of-network providers often appeal denied claims through an insurer’s internal appeals process. However, as laid out in the Dev decision, such appeals (and related correspondence) do not delay or otherwise suspend the statute of limitations – meaning that non-contracted physicians must be diligent in exploring and preserving their legal claims for fear of being time-barred at the conclusion of the optional appeals process. (Read More)

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Ninth Circuit: Manipulation of Risk Adjustment Data Subjects Insurers to False Claims Act Liability

The U.S. Court of Appeals for the Ninth Circuit has revived a whistleblower suit against Aetna, UnitedHealthcare and WellPoint for allegedly submitting false data for Medicare Advantage payments. Some of the nation’s largest health insurers must face a False Claims Act (FCA) suit accusing them of turning a blind eye to improper diagnoses. The unanimous Ninth Circuit opinion reversed a lower court decision to dismiss the suit. (Read More)

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Criminal Charges Brought in $1 Billion Alleged Medicare Fraud Scheme

If the June 2016 nationwide Medicare fraud takedown was not a sufficient indicator, today’s announcement that the U.S. Department of Justice (DOJ) has filed criminal charges against three Florida individuals alleging more than $1 billion in health care fraud, should make very clear that the federal government is cracking down on Medicare schemes.

The owner of more than 30 Miami-area skilled nursing and assisted living facilities, a hospital administrator and a physician’s assistant were charged with conspiracy, obstruction, money laundering and health care fraud involving numerous Miami-based health care providers. (Read More)

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Federal Government Sued Over Emergency Physician Reimbursement Policy

Emergency physicians have long alleged that health insurance companies are unfairly and inconsistently setting low out-of-network reimbursements for emergency care, and now they are imploring the federal government to do something about it. According to a complaint recently filed in federal court, an Affordable Care Act regulation related to emergency-care reimbursement fails to ensure reasonable payment to out-of-network providers. The case is American College Of Emergency Physicians v. Burwell et al. (case number 1:16-cv-00913), in the U.S. District Court for the District of Columbia. The American College of Emergency Physicians (ACEP) is targeting a final rule issued jointly in November in 2015 by the U.S. Department of Health and Human Services, the Department of Labor and the Department of the Treasury. (Read More)

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Health Care Providers Put On Notice As False Claims Act Penalties Are Doubled

Effective August 1, 2016, Health care providers will be subject to significantly increased penalties for improperly receiving reimbursements from or avoiding payment to the Federal government. The U.S. Department of Justice confirmed this week that civil penalties under the False Claims Act (FCA) will soon nearly double. Given that health care providers submit many thousands of claims each year, this increased penalty under the FCA could potentially result in huge liability. In light of the government’s enhanced statutory leverage, it is essential that providers maintain robust compliance programs that ensure best practices for billing and claim documentation. (Read More)

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Justice Department Announces Unprecedented National Health Care Fraud Takedown

In what is being billed as the largest coordinated Medicare fraud takedown in Justice Department history, Attorney General Loretta E. Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell have announced an unprecedented nationwide sweep led by the Medicare Fraud Strike Force. The result is criminal and civil charges against 301 individuals for their alleged participation in health care fraud schemes involving approximately $900 million in false billings. This is but the latest example of the government increasing its scrutiny of Medicare reimbursement claims, and using its considerable leverage, and the media, to tighten the screws on health care providers. (Read More)

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Health Care Provider Alert: Supreme Court Issues Landmark Ruling on False Claims Act

The Supreme Court has reached a significant decision that will substantially affect health care billing, but in an effort to breed uniformity, the Court appears to have actually facilitated even greater uncertainty. Last week, the United States Supreme Court issued its opinion in Universal Health Services v. Escobar, effectively approving the “implied false certification” theory of liability under the False Claims Act (FCA) and establishing a standard legal test in light of conflicting lower court decisions. Under the implied false certification theory, a provider that submits a claim for payment implicitly certifies compliance with all “conditions of payment,” potentially arising from statutory, regulatory, or contractual requirements. The Supreme Court adopted this theory, but with certain significant caveats. (Read More)

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Health Net Payments Trickle in to Addiction Treatment Centers as CA Regulators Investigate Insurer

As we have previously detailed, Health Net began directing a great deal of attention toward addiction treatment providers in early 2016. The payor (which has subsequently been acquired by Centene Corp.) started aggressively monitoring and investigating claims from substance abuse treatment facilities, and then dramatically expanded its attestation requests to smaller providers. Among other things, Health Net scrutinized referral practices, the medical necessity of services, and whether providers were waiving out-of-pocket payments from patients. Providers throughout California, as well as states like Arizona, Nevada and Texas, received attestation requests regardless of whether Health Net had any specific evidence of fraud and abuse. At the same time, providers found that Health Net payments stopped completely, including payments for previously-submitted claims that pre-dated the attestation letters.  Now, while some providers are beginning to receive reimbursements from Health Net, the California Department of Insurance (CDI) has reportedly opened an inquiry into the improper withholding of payments. (Read More)

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Physician Sues Blue Cross Over Narrow Provider Network

Some physicians find it quite challenging to gain acceptance into an insurer’s Covered California provider network. A few even take legal action to challenge the narrowness of such networks. For example, in a lawsuit recently filed in a California Superior Court, a Los Angeles dermatologist claims that Anthem Blue Cross intentionally restricts the number of physicians in its network in order to maximize its profits. The complaint alleges unlawful and unfair business practices, violation of common law fair procedure, and intentional and negligent interference with prospective economic advantage. (Read More)