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Centers for Medicare & Medicaid Services (CMS) Zone Program Integrity Contractors (ZPICS) Guidance Print E-mail
Written by Troy A. Kishbaugh J.D. and Sarah Logan Mancebo J.D   
Friday, 17 February 2012 14:14

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 mandated that CMS, the federal agency that operates and administers the Medicare program, implement reform to phase out fiscal intermediaries and begin using Medicare Administrative Contractors. Further, because of this 2003 law, CMS now contracts with ZPICs that are private auditing contractors who investigate Medicare fraud and abuse on CMS's behalf. In 2008, CMS began contracting with ZPICs to identify and stop potential fraud to reduce improper Medicare payments for Part A and Part B. 

Specifically, ZPICs (i) identify cases of suspected fraud, (ii) develop them thoroughly and in a timely manner, and (iii) take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out to health care providers and that any mistaken payments are recouped. When necessary, ZPICs also make referrals to the Office of Inspector General (OIG), Office of Investigations field office (OIFO) for consideration and initiation of criminal or civil prosecution, civil monetary penalty, or administrative sanction actions.

ZPICs conduct its Medicare integrity audits in seven (7) geographical zones. For example, SafeGuard Services, LLC is the ZPIC that investigates Medicare fraud for Zone 7, which includes Florida, Puerto Rico and the Virgin Islands. ZPICs also report monthly statistics and data related to their program integrity activities, including ongoing investigations, case referrals, requests for information and administrative actions to CMS. CMS then monitors and analyzes the statistics. 

Thus, it is important for health care providers to ensure they are properly enrolled in Medicare, properly filing claims to bill Medicare and properly receiving Medicare payments to avoid the potential for fraud and a resulting investigation by ZPIC.

Mr. Kishbaugh and Ms. Mancebo  are healthcare attorneys at GrayRobinson.  For more information, please click Health Law Team.
Last Updated on Friday, 24 February 2012 11:55
 
Fraud & Abuse Enforcement Soars Sky High Print E-mail
Written by Jeffrey L Cohen   
Monday, 13 February 2012 00:00

Investigations and successful prosecutions for violation of laws like the Anti Kickback Statute ("AKS"), the Stark Law and the False Claims Act were dramatically up in 2011 and are expected to climb still higher in 2012. For instance 13 doctors were charged in December, 2011 with violating the AKS by receiving payment for referring patients to an MRI center. Physicians and other healthcare business people MUST have any suspect arrangement closely scrutinized by highly qualified counsel. A "suspect arrangement" is any arrangement between providers of healthcare services that involve, to any degree, the exchange or payment of anything of value, including money. The AKS is a criminal statute; and the risks of enforcement are now huge.

Business and arrangements which are designed at all to lock in physician referrals carry particularly large risks and require close scrutiny. For instance, surgery centers that received referrals from non-owner physicians viewed that as a great thing. Now, referrals from unaffiliated physicians are viewed as inherently suspect. "What," the regulator thinks, "is driving this referral? What wrongful conduct is being engaged in here?" This is especially so with any marketing arrangement as well.

Physicians and other healthcare business people would do well to recall that if even "one purpose" of the arrangement is to compensate (cash or anything of value) someone for a patient referral, the AKS is triggered. Moreover, where Safe Harbor Act compliance was recommended, many now find it necessary.

With almost 25 years of healthcare law experience following his experience as legal counsel for the Florida Medical Association, Mr. Cohen is board certified by The Florida Bar as a specialist in healthcare law. With a strong background and expertise in transactional healthcare and corporate matters, particularly as they relate to physicians, Mr. Cohen's practice involves him in regulatory, contract, corporate, compliance and other healthcare law related matters. As Founder of the Florida Healthcare Law Firm, Mr. Cohen can be reached at 888-455-7702 or online at jcohen@floridahealthcarelawfirm.com.

Last Updated on Sunday, 19 February 2012 13:48
 
New Appeals Court Decision Streamlines Stark Challenge Print E-mail
Written by Jeffrey L. Cohen   
Friday, 10 February 2012 09:13

Normally, challenges to healthcare related regulatory changes have to jump through an administrative hoop before they can file suit.  They can't just run to court.  They have to go through CMS first and allow CMS the opportunity to justify the new regulation.  A recent appellate court ruling changes this.

The Council for Urological Interests (CUI) is a national organization of physician-owned joint ventures.  As many readers know, "under arrangement" lithotripsy services, for instance, are a common joint venture type business for urologists to be engaged in.  The CUI filed suit in response to 2008 changes to the Stark Law, which would have interfered with certain urology-centered joint venture businesses, but the lower court dismissed the suit because the CUI was first required to go through "administrative review" required by the Medicare Act.  The appellate court disagreed and agreed to hear the CUI suit.  The case should make it easier to file legal challenges in response to regulatory changes, like Stark Law developments.

The case is also important because the Stark Law change in 2008 (effective in 2009) made it difficult (impossible in some instances) for physicians to act as service providers to hospitals.  These "under arrangement" transactions were ok because the hospitals billed for the "designated health services," not the doctors.  The Stark Law change, effective in October, 2009, interfered with such relationships (between physicians and hospitals) by determining that the "under arrangement" providers were actually providing the service (even though the hospital, not the doctor entity, billed for the service).

Though the jury is still out on the substance of the CUI lawsuit (whether the Stark changes are unlawful), the case will pave the way for more legal challenges of this type.

With almost 25 years of healthcare law experience following his experience as legal counsel for the Florida Medical Association, Mr. Cohen is board certified by The Florida Bar as a specialist in healthcare law. With a strong background and expertise in transactional healthcare and corporate matters, particularly as they relate to physicians, Mr. Cohen's practice involves him in regulatory, contract, corporate, compliance and other healthcare law related matters. As Founder of the Florida Healthcare Law Firm, Mr. Cohen can be reached at 888-455-7702 or online at jcohen@floridahealthcarelawfirm.com

 Click HERE  to view Mr. Cohen's Blog page.
Last Updated on Monday, 13 February 2012 09:21
 
CMS Issues Proposed Rule Implementing the "Federal Sunshine Law" Reporting Requirements Print E-mail
Written by MWE.com   
Tuesday, 17 January 2012 00:00

The U.S. Centers for Medicare & Medicaid Services (CMS) released a proposed rule implementing the "Sunshine" provisions of the Affordable Care Act (ACA) that requires annual public reporting by certain drug and device manufacturers of payments made by them to physicians and teaching hospitals and of physician ownership interests in such manufacturers.  The "Sunshine" provisions of the ACA also require group purchasing organizations to make annual public reports of physician ownership interests in such organizations.  CMS is accepting comments on its proposed rule through February 17, 2012.
 
 Read the full article here.  
Last Updated on Monday, 23 January 2012 10:20
 
Congress Scrutinizing Physician Owned Distributorships Print E-mail
Written by Jeffrey L. Cohen   
Monday, 16 January 2012 12:51

PODS Make Waves

Physician owned distributorships (PODs) have been the source of considerable controversy for years, but now they've caught the attention of Congress!

PODs distribute various things, most commonly surgical implants and devices, that are reimbursed by insurers. A patient needs a spinal rod, a surgical implant/device company makes it and a distributor rep distributed it. Device/implant companies usually contract with distributorships to sell their products. Distributorships contract with reps who are paid commissions for sales. Surgeons who actually order the devices sometimes think "Since I'm the one doing the surgery and ordering all this stuff, why don't I make something from the selling of it?" PODs are one way for physicians to financially benefit from the sales of devices and items their patients need, but they have never been more controversial than now.

Conceptually speaking, PODs are controversial because government regulators think physicians who have an economic stake in health care items or services will tend to over utilize them. Moreover, there is a specific concern that allowing physicians to profit from the devices their patients need violates federal anti kickback laws or the Stark prohibition on compensation arrangements.

Click HERE to read more.

With almost 25 years of healthcare law experience following his experience as legal counsel for the Florida Medical Association, Mr. Cohen is board certified by The Florida Bar as a specialist in healthcare law.  With a strong background and expertise in transactional healthcare and corporate matters, particularly as they relate to physicians, Mr. Cohen's practice involves him in regulatory, contract, corporate, compliance and other healthcare law related matters.  As Founder of the Florida Healthcare Law Firm, Mr. Cohen can be reached at 888-455-7702 or online at jcohen@floridahealthcarelawfirm.com.

Last Updated on Monday, 30 January 2012 18:54
 
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