OIG Okays Provision of Free Services to Uninsured and Underinsured Patients

On October 15, 2013, the Office of Inspector General (OIG) released an Advisory Opinion concerning a community health services organization’s provision of free dental care to financially needy uninsured and underinsured patients that are not covered by Medicaid.

The organization was concerned that the free services violated two aspects of the Medicaid law: (1) the Social Security Act prohibits providers from billing Medicaid charges for items or services substantially in excess of the provider’s “usual charges,” and (2) the Anti-Kickback Statute prohibits providers from offering remuneration to Medicaid patients to induce them to receive services from the provider.

In the Advisory Opinion, the OIG stated that when a provider calculates its “usual charges,” it need not consider free or substantially reduced charges to uninsured or underinsured patients with financial need.  Therefore, the OIG would not seek to exclude a provider from the Medicaid program for providing discounts to financially needy uninsured and underinsured patients.

The OIG also stated that the organization’s provision of free services to financially needy uninsured or underinsured patients does not violate the Anti-Kickback Statute because the free services will not be provided to Medicaid patients.  The Anti-Kickback Statute would only be implicated if a provider used the free services as a means to induce Medicaid patients to order additional services that could be billed to the Medicaid program.

The bottom line is that providers may offer free services to uninsured or underinsured patients with financial hardship.  With that said, it is critical that providers have uniform eligibility criteria to determine whether such patients actually are financially needy.  In separate guidance released in 2004  the OIG outlined factors that providers should consider in determining financial need, including:

  • The local cost of living;
  • A patient’s income, assets, and expenses;
  • A patient’s family size; and
  • The scope and extent of a patient’s medical bills.

By applying these factors uniformly at all times, providers can ensure that their provision of free or discounted services meets OIG requirements.

If you would like more information please contact Casey Moriarty.

CA Surgeon Stripped of Medicaid Funding for Failure to Treat HIV Positive Patient

On July 18th, the U.S. Department of Health and Human Services announced that a California surgeon who refused to treat a patient based solely on the patient’s condition as HIV positive would lose Medicaid funding.  The surgeon had refused to perform necessary back injury and a resulting investigation by the HHS Office of Civil Rights found the surgeon had discriminated against the patient in violation of federal laws.  The violation ultimately resulted in an action to ensure compliance with federal civil rights laws and eventually the surgeon’s loss of the federal funding.

The determination underscores the need for health care providers to make best efforts to ensure patients and prospective patients who fall within protected classes receive the same treatment and standards of care as any other patient.  Failing to do so can jeopardize federal funding and also expose the provider to a range of potential claims for violations of federal and state workplace laws.

The fundamental steps to help avoid claims and liability are:

●             Have effective policies:  Providers should have written policies prohibiting discrimination and harassment.  Having an effective policy notifies all employees that discrimination and harassment will not be tolerated, and helps set a tone for conduct in the workplace.

●             Train up supervisors and staff:  All supervisors and staff should be fully aware of workplace discrimination and harassment laws and how to respond to potential problems.  Training helps prevent claims, allows problems to be identified and addressed early on, and provides vital potential evidence that the employer took reasonable steps to prevent improper behavior.

●             Familiarize yourself and staff with Medicaid rules:  Washington State Medicaid provider requirements obligate participating providers to provide all services without discriminating on the grounds of “race, creed, color, age, sex, sexual orientation, religion, national origin, marital status, the presence of any sensory, mental or physical handicap, or the use of a trained dog guide or service animal by a person with a disability.”  In addition, WA Medicaid allows termination of a provider relationship for discriminating in furnishing health care services as prohibited by federal statute.

For more information regarding avoiding such liability please contact Patrick Pearce.

OIG Launches New Online Submission Process for the Self-Disclosure Protocol

On July 8th, the Office of Inspector General (OIG) launched a new online submission process for the Self-Disclosure Protocol (SDP).  The SDP allows health care providers to voluntarily identify, disclose, and resolve instances of potential fraud involving federal health care programs, including Medicare and Medicaid.   The OIG has stated that individuals and entities that utilize the SDP will pay a lower amount of damages for violations than would normally be required in resolving a government-initiated investigation.

You can access the online submission process here.

The OIG hopes that the online submission tool for the SDP will streamline the process for providers that want to resolve violations without the time and expense of a government-directed investigation.  With that said, we suggest that providers have an attorney analyze any potential SDP issues prior to completing the online form.  As always, the health law attorneys at OMW are happy to help.

For more information about the SDP online submission process please contact Casey Moriarty.

Medicaid Disallows Reimbursement, Requires Reporting for Provider Preventable Conditions

Starting  July 1, 2013, the Washington Medicaid program will not pay a provider for the health care costs of treating conditions that the provider could have prevented.  The rule, WAC 182-502-0022, contains a long list of such conditions and adds a few more acronyms to health care speak, including:

(1) PPC – provider preventable conditions that include hospital and non-hospital acquired conditions;

(2) OPPC – other provider preventable conditions that are a PPC subset of conditions identified in WAC 246-302-030, and;

(3) HCAC – health care acquired conditions that are also a PPC subset occurring in an inpatient hospital setting.

Providers, including inpatient hospitals, must report any PPC to the Health Care Authority even if there is no intent to bill for services related to the PPC.  Health care professionals or designees responsible for or associated with a PPC involving a Medicaid patient must notify the Health Care Authority within forty-five (45) calendar days of confirming the PPC.

A similar reporting requirement applies to hospitals for OPPC.  And, of course, Medicaid patients are not liable for payment of an item related to a HCAC or an OPPC and must not be billed for any item or service related to a PPC.

For information about this new rule or Medicaid reimbursements please contact Greg Montgomery.

New Court of Appeals Decision Provides Guidance on Medicaid Spenddown Requirements

The recent appellate decision in Multicare v. State of Washington Department of Social and Health Services (DSHS) sheds light on how hospitals should use a patient’s “spenddown” in the billing process for the Medicaid Medically Needy (MN) program.

The MN program assists low-income families with medical costs.  A family can qualify for the MN program if its income is less than a certain amount during a specific base period.  A family that exceeds the maximum income level can still qualify for the program if it pays medical expenses in an amount equal to or over the excess income.  For example, if a family’s income is $500 over the maximum level, it can still qualify for the MN program if it spends $500 on medical expenses.  This process of using excess income is called the “spenddown.”

In the Multicare case, DSHS alleged that the hospital billed the MN program without deducting the spenddown liability of patients.  According to DSHS, this billing practice resulted in overpayments to the hospital. The hospital argued that the spenddown requirements were an enrollment qualification, not a deduction from DSHS’s payments.  The Washington State Court of Appeals, however, sided with DSHS and found that hospitals must factor in a patient’s spenddown to determine DSHS’s payment obligations.

The Court provided examples of how to use a patient’s spenddown, including the following:  A patient has a spenddown liability of $500 and total hospital charges of $450.  The total charges would apply to the spenddown liability, resulting in a new spenddown of $50.  Since a spenddown remains, the patient is not enrolled in the MN program and DSHS has no payment obligations for the services provided by the hospital.  Instead, the patient would owe the Hospital the $450.

Hospitals should review their Medicaid billing policies to ensure compliance with the Multicare decision.  You can view the decision here.  If you have questions or would like to follow-up, please contact Don Black or Casey Moriarty.

OIG Approves Electronic Interface Arrangement

In a recent advisory opinion, the Office of Inspector General DHHS (“OIG”) approved an arrangement under which free access to an electronic computer interface is provided by a hospital to local physicians.  The opinion provides an important contemporary analog to earlier guidance published by the OIG as part of the preamble to the Federal anti-kickback statute safe harbor regulations (see 56 Fed. Reg. 35952, 35978, July 29, 1991).   At the same time, the OIG reinforced its long-standing position that in order for such arrangements to pass muster under the Federal anti-kickback statute, the parties must validate that the technology is limited to facilitating hospital-physician communications, and that it will not have independent value to the physicians. 

Please contact David Schoolcraft  (dschoolcraft@omwlaw.com or 206.447.7000) you have any questions about the scope and applicability of this OIG advisory opinion.

CMS Issues 3 FAQs on Stage 2 Rules and the Medicaid EHR Incentive Program

CMS has responded to several questions following the issuance of its Stage 2 Meaningful Use Final Rule.  Along with publishing new meaningful use guidelines, the Final Rule adds new provisions regarding the calculation of patient volume for Medicaid providers.  CMS has recently published these new FAQs, some of which take effect immediately, while others will start in 2013, giving the states some time to update their guidance.  These new rules will affect all eligible professionals, regardless of their stage in participation in meaningful use.  To see additional FAQs click here.

Medicaid changes to patient volume calculations 

Q: The EHR Incentive Programs Stage 1 Rule stated that, in order for a Medicaid encounter to count towards the patient volume of an eligible provider, Medicaid had to either pay for all or part of the service, or pay all or part of the premium, deductible or coinsurance for that encounter.  The Stage 2 Rule now states that the Medicaid encounter can be counted towards patient volume if the patient is enrolled in the state’s Medicaid program (either through the state’s fee-for-service programs or the state’s Medicaid managed care programs) at the time of service without the requirement of Medicaid payment liability. How will this change affect patient volume calculations for Medicaid eligible providers?  

A: Importantly, this change affecting the Medicaid patient volume calculation is applicable to all eligible providers, regardless of the stage of the Medicaid EHR Incentive Program they are participating in. Billable services provided by an eligible provider to a patient enrolled in Medicaid would count toward meeting the minimum Medicaid patient volume thresholds.  Examples of Medicaid encounters under this expanded definition that could be newly eligible might include: behavioral health services, HIV/AIDS treatment, or other services that might not be billed to Medicaid/managed care for privacy reasons, but where the provider has a mechanism to verify eligibility.  Also, services to a Medicaid-enrolled patient that might not have been reimbursed by Medicaid (or a Medicaid managed care organization) may now be included in the Medicaid patient volume calculation (e.g., oral health services, immunization, vaccination and women’s health services, telemedicine/telehealth, etc.).

Providers who are not currently enrolled with their state Medicaid agency who might be newly eligible for the incentive payments due to these changes should note that they are not necessarily required to fully enroll with Medicaid in order to receive the payment.

In some instances, it may now be appropriate to include services denied by Medicaid in calculating patient volume.  It will be appropriate to review denial reasons.  If Medicaid denied the service for timely filing or because another payer’s payment exceeded the potential Medicaid payment, it would be appropriate to include that encounter in the calculation.  If Medicaid denied payment for the service because the beneficiary has exceeded service limits established by the Medicaid program, it would be appropriate to include that encounter in the calculation.  If Medicaid denied the service because the patient was ineligible for Medicaid at the time of service, it would not be appropriate to include that encounter in the calculation.

Further guidance regarding this change will be distributed to the states as appropriate.

CHIP patients eligible to be included in Medicaid patient volume totals
Q: The Stage 2 Rule describes changes to how a state considers CHIP patients in the Medicaid patient volume total when determining provider eligibility. Patients in which kinds of CHIP programs are now appropriate to be considered in the Medicaid patient volume total?  

A: States that have offered CHIP as part of a Medicaid expansion under Title 19 or Title 21 can include those patients in their provider’s Medicaid patient volume calculation as there is cost liability to the Medicaid program in either case (under the Stage 1 Rule, only CHIP programs created under a Medicaid expansion via Title 19 were eligible). Patients in standalone CHIP programs established under Title 21 are not to be considered part of the patient volume total (in Stage 1 or Stage 2). This change to the patient volume calculation is applicable to all eligible providers, regardless of the stage of the Medicaid EHR Incentive Program they are participating in.

Changes to the base year of the Medicaid EHR Incentive Program for hospital incentive payment calculation 
Q: Are there any changes to the base year for the Medicaid EHR Incentive Program hospital incentive payment calculation?

A: Yes. Previously Medicaid eligible hospitals calculated the base year using a 12 month period ending in the Federal fiscal year before the hospital’s fiscal year that serves as the first payment year.  In an effort to encourage timely participation in the program, §495.310(g)(1)(i)(B) of the Stage 2 Rule was amended to allow hospitals to use the most recent continuous 12 month period for which data are available prior to the payment year. This change went into effect upon publication of the Stage 2 Rule.  Only hospitals that begin participation in the program after the publication date of the Stage 2 Rule (i.e., program years 2013 and later) will be affected by this change.  Hospitals that began participation in the program prior to the Stage 2 Rule will not have to adjust previous calculations.