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Recent Blog Posts
New Federal Rules for Hospice Providers
The healthcare industry faces an ever-growing mountain of rules and regulations issued by the federal government that must be followed. Failure to adhere can result in fines, sanctions, and even a suspension or revocation of an individual’s professional license or the facility’s operating license. As new requirements issued for hospices as a result of the Consolidated Appropriations Act of 2021 go into effect in the fiscal year 2022, it is critical to understand what those requirements are.
Why the Change?
These new rules were created as a result of the findings of reports filed over the past several years that examined the results of hospice surveys by accreditors and regulators that found that at least 20 percent of these hospices had serious deficiencies. Some of the deficiencies cited in one report issued by the U.S. Department of Health and Human Services Office of the Inspector General (OIG) in 2019 included organizations that failed to manage patients’ pain, failure to make home visits, and even cited one incident where a patient’s feeding tube was infested with maggots.
Have You Been Notified Your Medical Practice Is Under a ZPIC Audit?
In the past 20 years or so, there has been a concerted effort by the federal government to crack down on the number of fraudulent claims that are submitted to Medicare by medical providers. One of the ways that the government prevents fraudulent claims is through prepayment audits. If your practice has been notified that you are the subject of a prepayment audit, you should contact an Illinois professional license defense attorney for legal assistance.
Zone Program Integrity Contactors
Prepaid audits fall under the bailiwick of the Centers for Medicare and Medicaid Services. The agency often employs Zone Program Integrity Contactors (ZPICS) to conduct these investigations into potential waste, abuse, and fraud. In some cases, ZPICS will use methods to mine the practices’ algorithms in an attempt to see if they can find any abnormalities in billing which could indicate fraud is taking place.
Defending Against HIPAA Violations in Illinois
In 1996, the federal government passed the Health Insurance Portability and Accountability Act (HIPAA). The law was created to establish national standards to protect sensitive patient health information from being disclosed to any other party unless the patient consents. In order to implement the requirements of the standards, the HIPAA Privacy Rule was established. Entities that are subject to the Privacy Rule include healthcare providers, health plans, and healthcare clearinghouses. Violations of HIPAA can result in hefty civil fines and even criminal charges.
Examples of HIPAA Violations
There are a number of actions that could result in a violation allegation. These include:
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The medical practice is a victim of a data breach.
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The medical practice fails to dispose of patient medical records properly. For example, if the practice replaces electronic equipment, the old equipment hard drives are not erased.
Are You an Illinois Nurse Accused of Committing a Medical Error?
According to data collected by John Hopkins patient safety professionals, medical errors are responsible for more than a quarter of a million deaths each year in this country. This major study used data collected over an eight-year period and put a spotlight on the dangers medical errors pose to patients. One of the most important factors in preventing these errors is the proper documentation by the nursing staff of the care provided to patients. Accusations of improper documentation by nurses can lead to disciplinary action or even suspension of your nursing license. The following are some of the more common documentation errors nurses are accused of making.
Illegible Writing
Although the majority of patient records are done electronically, there are still occasions where a nurse will need to handwrite patient information on a document or file. It is important that writing be done clearly and be legible for anyone who needs to read it.
Violations of the False Claims Act
In order to protect patients who are covered under federal health programs, such as Medicaid and Medicare, the federal government has put in place certain laws that medical providers are required to adhere to. The Department of Health & Human Services Office of Inspector General (OIG), the Centers for Medicare & Medicaid Services (CMS), and several other federal agencies are in charge of making sure these laws are followed, and to investigate and prosecute those who do not. We have discussed two of them – the Physician Self-Referral Law (Stark Law) and the Federal Anti-Kickback Statute (AKS) – in prior posts. In this third and final post about these laws, we will discuss the False Claims Act.
The False Claims Act
Violations of the Stark Law result in civil penalties, while violations of the AKS result in criminal penalties. The False Claims Act (FCA) has both criminal and civil penalties, depending on what the government thinks the intent of the individual being charged was.
Violations of the Federal Anti-kickback Statute
There are several federal laws that have been put in place in order to protect patients by ensuring that there are no financial incentives or other conflicts of interest regarding referrals by healthcare providers. In our last post, we discussed the seriousness any accusations of violating the Physician Self-Referral Law (Stark Law) can have on a physician’s career. In this post, we will address the Federal Anti-Kickback Statute.
Federal Anti-Kickback Statute
Unlike the Stark Law, in which any violations are met with civil penalties, the Anti-Kickback Statute (AKS) is a criminal law, meaning that if a provider is found guilty of violating the statute, they now have a criminal record and could even face jail time depending on the circumstances of their case. Any criminal charges are classified as a felony.
Violations of the Stark Law
There are many federal and state laws that physicians are required to abide by, including laws that address fraud and abuse. According to the Office of Inspector General, U.S. Department of Health and Human Services (OIG), the most serious of these laws include the Physician Self-Referral Law (Stark Law), the Anti-Kickback Statute (AKS), and the False Claims Act (FCA). Violations of these laws can result in severer penalties, including exclusion from federal health care programs, civil fines, loss of medical license, and even criminal penalties. In our next few posts, we will discuss each of these laws and how they may affect your practice. In this post, we will look at the Stark Law.
The Physician Self-Referral Law
The Physician Self-Referral Law, referred to as the Stark Law, bans doctors from referring patients to other medical providers for services that will be paid by Medicare, Medicaid, or other programs if the referring doctor or a member of their immediate family has any type of financial relationship with the medical provider they are referring. Basically, a doctor cannot refer a patient in exchange for receipt from that provider of anything of value. They also cannot present claims to Medicare or other healthcare program for referred services.
PBM Audits for Black-Market Diabetic Test Strips
In the healthcare industry, pharmacy benefit managers (PBMs) serve a pivotal role. In fact, a pharmacy would be unable to operate without having a contract with a PBM. The PBM serves as an intermediary between the pharmacy and the insurance company, negotiating rates and processing the majority of all prescriptions.
Under these contracts, the PBM also has the right to conduct an audit of the pharmacy to make sure that all terms of the contract and proper guidelines are being met. Any discrepancies found during the audit could result in not only the pharmacy being required to pay back funds they have received, but could also result in the PBM contract being terminated. One product PBMs have been laser focused on recently is the number of pharmacies purchasing diabetic testing strips from unauthorized sources.
Black Market Diabetic Testing Strips
There are currently more than 30 million patients diagnosed with diabetes in this country. Patients who have the condition are required to test their glucose levels each day. One of the most common ways to test is by using diabetic test strips. It is so common revenues from these test strips surpasses $8 billion a year.
Illinois Creates New License Process for Midwives
Over the past few decades, the experience of labor and delivery for women has undergone dramatic changes. The process used to be a very clinical one, ending in a birthing experience that involved drugging the mother from the moment she arrived at the hospital and keeping the newborns in the nursery instead of with their mothers for the majority of their extended hospital stays.
The attitude about the birthing process has all changed to a much more family-intimate experience. This has also led to many women choosing to entrust their care to midwives instead of obstetricians. Some women even decide to have their babies born at home, whether by choice or because of the astronomical expense of a hospital delivery.
However, until recently, only those who were certified as nurse-midwives could provide Illinois women with this type of care, but a new law recently signed by the governor will create a new license process for midwives that does not require a nursing degree.
Do Medical Professionals Have to Report Arrests to Medical Boards in Illinois?
No matter where you are in life or what your profession is, anyone can find themselves dealing with some kind of legal issue, whether it has to do with being charged with a DUI, stealing medications, fraud, or domestic violence. While these criminal accusations are serious for any individual, they can have even more dire consequences for an individual who holds a professional license. If you are a licensed professional in the state of Illinois and have concerns or questions regarding what you are required to notify the licensing board that oversees your profession, you should speak with an Illinois professional license defense attorney.
What Charges Need to Be Disclosed?
When a person who holds a professional license is charged with a crime, one of the first factors that need to be examined is whether the crime is related in any way to their profession. In the case of a medical professional stealing prescription medications from patients, that relation is pretty clear. There are other charges that are not so clear. For example, if a doctor is arrested for drunk driving, they may not feel this is something they need to report because it was not connected to their position.
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