Compliance Update

CMS Issues Proposed Rule Implementing the "Federal Sunshine Law" Reporting Requirements Print E-mail
Written by   
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

Last Updated on Monday, 30 January 2012 18:54
More Evidence of Hard Working Bureaucrats Print E-mail
Written by Jeffrey Herschler   
Tuesday, 10 January 2012 00:00

The OIG recently released a report entitled:


The key finding was that "Contrary to Federal law, CMS accepted some PDE data submitted by sponsors for prescriptions written under the Part D program by excluded providers and used these PDE data to adjust Medicare Part D payments to sponsors at the end of the plan year. Of approximately $185 billion in gross drug costs included in sponsors' PDE data for calendar years 2006 through 2008, CMS accepted PDE data with gross drug costs totaling $15,079,608 for prescriptions written by excluded providers. Furthermore, CMS accepted PDE data with gross drug costs totaling an additional $1,985,315 for prescriptions that may have been written by excluded providers."

Citing "inadequate internal controls", the OIG recommends several procedural changes at CMS to correct the problem. Click HERE to view the report.
Last Updated on Wednesday, 11 January 2012 06:52
CMS' 2012 OPPS Final Rule Revises Physician Supervision Requirements Print E-mail
Written by   
Thursday, 29 December 2011 00:00

The U.S. Centers for Medicare & Medicaid Services (CMS) further revised its physician supervision policy by finalizing the federal Advisory Panel on Ambulatory Payment Classification Groups as the independent review body to evaluate and recommend physician supervision levels to CMS, and by defining personal supervision and general supervision for all hospital outpatient therapeutic services

Read the full article here           

Last Updated on Thursday, 05 January 2012 06:38
Transitioning to HIPAA 5010 Print E-mail
Written by Todd Demel, MBA   
Tuesday, 20 December 2011 20:05

The deadline for changing to a new mandatory standard format for submitting electronic claims information is fast approaching. Providers must transition by January 1, 2012 or face potential delays in reimbursement since payors may not be able to process claims submitted in the current format.

This federally mandated change will impact health plans, clearinghouses, as well as providers and requires these entities to follow new standards in electronic healthcare administrative transactions that are fundamental to daily revenue cycle operations. Among the factors contributing to the need for change are administrative and technical challenges, inconsistencies, ambiguities, and limitations with the current 4010A1 format.

The upgrade from the current HIPAA 4010A1 transaction standards to the new X12 standard 5010 version has the following objectives:

·         Support for the additional codes associated with the new ICD-10 code set

·         Streamline reimbursement transactions

·         Increase transaction uniformity

·         Support electronic referral certification and authorization

·         Enhance overall capabilities

·         Improve tracking methods

·         Remove unnecessary information

·         Support Pay for Performance

Broader motivational factors driving the change include the government's goal of improving quality of care while lowering costs within the healthcare system. For example, premium dollars spent on administration associated with manual processes could be reduced, while overall healthcare costs would likely substantially decrease as well.

In addition, there is a widely recognized need for a comprehensive electronic data exchange environment that enables sharing of information, and accommodates the expanded ICD-10 code set transition coming in 2013. So, the 5010 upgrade should bring about a more uniform billing and reimbursement system and thereby simplify the reconciliation process required of providers.   

With the looming deadline just around the corner, healthcare organizations need to finalize the process of upgrading and testing current claims management systems in order to accommodate 5010 and reduce the likelihood of operational disruptions. Not surprisingly, while healthcare practices are faced with a barrage of substantial and seemingly simultaneous changes, many have put off implementation of new transaction software that is compatible and required for the upgrade. However, the time to initiate the change is now and the necessary workflow modifications must be made and testing performed. Physician practices need to plan for training of functional and technical staff and anticipate that productivity may decrease during the transition period. The new processes may require changes to ongoing daily billing procedures and the goal should be minimizing the impact to your practice and ensuring the transition occurs as seamlessly as possible.

ABOUT THE AUTHOR: Mr. Demel is Senior Executive of Physician Management Services at MF Healthcare Solutions. Possessing both operational and financial backgrounds, the MF Healthcare Solutions management team has vast experience in a range of healthcare industry settings. Combined expertise enables the firm to offer specialized physician practice management services. For more information, please visit: or contact Todd Demel at (954) 475-3199.

Last Updated on Wednesday, 11 January 2012 06:54
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