Most medical providers, including doctor’s offices, hospitals, pharmacies, and other types of medical professionals, provide services to patients and accept payments through Medicare or Medicaid. Providers must meet a variety of requirements when doing so, and the Centers for Medicare and Medicaid Services (CMS) is tasked with ensuring that providers are in compliance. CMS may conduct audits of providers based on billing irregularities, issues related to record-keeping, or other concerns about potential noncompliance. During these types of audits, providers will want to understand the process that will be followed and the requirements they must meet. Failure to comply with CMS requirements or cooperate during an audit could result in the provider being excluded from providing services through Medicare or Medicaid.

Steps Followed in a CMS Audit

The Medicare/Medicaid audit process has four phases:

1. Engagement and universe submission - Auditors will notify a provider of an audit and send an engagement letter that identifies the information that will be requested. This information will take the form of “universes,” which consist of data sets from a health plan, including Part C Organization Determinations, Appeals, and Grievances (ODAG) and Part D Coverage Determinations, Appeals, and Grievances (CDAG). After the provider submits the requested universes, auditors will assess the data provided and determine whether any other information is necessary. This phase will last six weeks.

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For many medical professionals, including doctors, surgeons, nurses, and physician assistants, the ability to provide services for patients in hospitals is crucial to their practice. Whether a person is a full-time staff member at a hospital or has courtesy privileges or surgical privileges, being able to see and treat patients at the hospital will ensure that they can provide quality medical care. This means that medical professionals will want to be aware of any issues that could lead to the loss of hospital privileges. By defending against this form of discipline, providers can avoid issues that may affect their medical license and their overall career.

Reasons for Loss of Hospital Privileges

In some cases, a person may face discipline to their hospital privileges due to issues involving the hospital. Accusations of substandard patient care or malpractice that occurred at the hospital may cause the hospital’s review board to take disciplinary action. These actions may involve a limitation on a person’s privileges, a temporary suspension of privileges, or a permanent revocation of the ability to see and treat patients at the hospital.

A hospital may also discipline a professional for issues such as violations of hospital policies or problems with other staff members. For example, a doctor who has acted abusively toward nurses or other members of a hospital’s staff, refused to accept constructive criticism or listen to suggestions from other providers, and publicly criticized the hospital and its staff members may be asked to explain this behavior by the hospital review board. The board may then choose to reprimand the provider and restrict or suspend their hospital privileges.

For more than a year, the COVID-19 pandemic has caused interruptions to many people’s daily lives and activities. Fortunately, an end to this situation is in sight as vaccines are administered to people throughout the United States. To ensure that as many people can be vaccinated as quickly as possible, officials are taking an “all hands on deck” approach, and multiple different types of medical professionals have been authorized to administer these vaccines. To avoid any issues that could affect a person’s medical license, it is important to understand what steps should be followed to obtain authorization to administer vaccines, and medical professionals will want to make sure they are following the correct procedures at all times.

Who Can Administer COVID-19 Vaccines in Illinois?

Governor J.B. Pritzker has declared a public health emergency in the state of Illinois and issued emergency orders to allow certain types of licensed professionals to administer COVID-19 vaccines. Those who are allowed to administer vaccines include:

• Licensed medical professionals - These include physicians, registered nurses (RNs), licensed practical nurses (LPNs), and advanced practice registered nurses (APRNs) with full practice authority, as well as APRNs and physician assistants who have a collaborative agreement with a licensed physician.
• Pharmacists and pharmacy technicians - Pharmacists must have completed a training course authorized by the Accreditation Council on Pharmacy Education (ACPE). Pharmacy techs must have completed an ACPE-approved practical training program, and they must work under the supervision of a pharmacist. Pharmacists and pharmacy techs must complete at least two hours of immunization-related continuing pharmacy education, and they must also be certified in CPR.
• Medical students - Medical residents can receive a temporary license allowing them to administer vaccines, and medical students who are enrolled in a medical college or who have recently graduated can administer vaccines under the direct supervision of a physician who is a faculty member of a medical college. Nursing students can administer vaccines if they are enrolled in a pre-licensure nursing program approved by the state of Illinois and are under the supervision of a qualified faculty member or a registered nurse preceptor. Physician assistant students who are enrolled in a pre-licensure program can administer vaccines while practicing under this program, and recent graduates who have not yet been licensed can administer vaccines under the supervision of a licensed physician assistant.
• Dentists - A dentist’s scope of practice may be expanded to administer vaccines if they complete a four-hour practical training program and are certified in CPR.
• Optometrists and veterinarians - These providers’ scope of practice may be expanded to administer vaccines if they complete a four-hour practical training program, have documentation of observation by a healthcare professional confirming their competency in administering injections, and are certified in CPR.
• Unlicensed persons - Within the setting of a medical office or practice, and as part of an established doctor-patient relationship, a physician can delegate vaccination tasks to people who are not licensed in Illinois as healthcare professionals, as long as the person has the appropriate experience and training.

Contact an Illinois Medical Licensing Attorney

If you have questions about how administering COVID-19 vaccines will affect your medical license, or if you are facing any issues related to license renewal or disciplinary action, The Law Offices of Joseph J. Bogdan, LLC can provide the legal help you need. Contact our Illinois medical license defense lawyer today at 630-310-1267 to schedule your complimentary consultation.

Over the past decade, marijuana has been recognized as a substance that can provide patients with a number of medical benefits. Many states, including Illinois, have authorized the use of medical marijuana for patients with certain types of conditions. However, doctors, nurses, or other medical professionals will need to make sure they are following the correct procedures and meeting all requirements when certifying patients to use medical marijuana. Failure to do so could result in disciplinary action by the Illinois Medical Board, the Illinois Board of Nursing, or another division of the Illinois Department of Financial and Professional Regulation (IDFPR).

Health Care Professional Certifications for Medical Cannabis

Before applying for a medical cannabis registry identification card, patients in Illinois will need to receive a certification from a medical professional stating that they have a qualifying debilitating condition. Health care professionals that can provide this certification include medical doctors, doctors of osteopathic medicine, advanced practice nurses, physician assistants, and advance practice registered nurses with full practice authority.

Debilitating conditions that will allow a patient to qualify for the use of medical marijuana include HIV/AIDS, Parkinson’s disease, cancer, glaucoma, Hepatitis C, Crohn’s disease, migraines, seizures, rheumatoid arthritis, and traumatic brain injury. The Opioid Alternative Pilot Program also allows patients who could receive prescriptions for opioid painkillers to qualify for the use of medical cannabis.

Around 28% of all health care services in the United States are paid for through Medicare, Medicaid, or other federal programs. Because of this, health care providers need to comply with all applicable requirements, since being unable to provide services through these programs can eliminate a major source of revenue. The Office of Inspector General (OIG) for the federal Department of Health and Human Services (HHS) maintains a List of Excluded Individuals/Entities (LEIE), and any providers or organizations that are included on this list cannot receive payments from federal healthcare programs. Medical providers will want to understand the issues that could cause them to be included on this list and the actions they can take to prevent exclusion from Medicare or Medicaid programs.

Reasons for Exclusion

In many cases, a provider may face exclusion by the OIG due to charges of health care fraud or other offenses. The OIG has the discretion to issue a permissive exclusion if a provider is convicted of misdemeanor health care fraud or a misdemeanor related to illegal prescribing or dispensing of controlled substances or if their medical license has been suspended or revoked. Felony convictions for healthcare fraud or controlled substances, convictions related to abuse or neglect of patients, or any convictions for fraud against Medicare or Medicaid will result in a mandatory exclusion.

Effects of Being on the OIG Exclusion List

A provider who is on the LEIE will be barred from receiving payments for services through federal programs. If an excluded person submits a claim for payment through a federal program, they may face a civil monetary penalty (CMP) of up to $10,000 for each service furnished. In addition, an organization that employs or contracts with an excluded person may face a CMP if any services provided by the person were payable through Medicare or Medicaid. These services may include direct or indirect patient care, administrative services, or other prescriptions, items, or services provided at the direction of the excluded person. Because of these penalties, many hospitals and medical offices will not hire or contract with a service that employs a person who is on the LEIE.