Little Health Law Blog

A New Prospective Payment System for Federally Qualified Health Centers

May 13, 2014 | Little Health Law

Medicare payments to community health centers are expected to increase by as much as $1.3 billion over the next five years, according to Bloomberg News, based on a new prospective payment system. On April 30, 2014, the U.S. Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) rendered a Final Rule that, among other things, implements methodology and payment rates for a prospective payment system (PPS) for federally qualified health centers (FQHC), effective October 1, 2014. The Final Rule stems from the Affordable Care Act’s (ACA) provisions to establish a new payment system for FQHC services under Medicare Part B (supplemental medical insurance) based on prospectively set rates.
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Primer on Whistleblowing in Healthcare

May 5, 2014 | Little Health Law

What are whistleblower lawsuits?

Whistleblower lawsuits and settlements are on the rise and in the news. From January 2009 through September 2013, the federal government recovered $17 billion in false claims alone. Of course, most healthcare providers are honest and work diligently to improve the health of their patients and contribute to the lawful operation of a healthcare business. It is in the best financial interests of physicians and other healthcare providers who comply with the law that fraudulent schemes to unlawfully obtain government funds be deterred and remedied. The federal and many state governments have determined that a crucial means of combatting healthcare fraud is by incentivizing those who are aware of fraud to report it as a “whistleblower.”¹ In light of spiraling healthcare costs and with state and federal governments’ roles as third party payors, healthcare whistleblowing protects law-abiding taxpayers, healthcare professionals and consumers.

As this article explains, many federal and state whistleblower laws provide legal causes of actions for employees, officials and others who suspect or discover violations of law, waste or abuse within government or fraudulent practices by companies doing business with government. A person with knowledge of a violation or fraud, known as a whistleblower or “relator,” may bring a lawsuit to expose the fraud or abuse and recover damages on the government’s behalf. In many cases, whistleblowers are entitled to a percentage of the recovery for their efforts in uncovering fraud and assisting in the recovery.
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Price Transparency In Healthcare: What Am I Paying For?

April 28, 2014 | Little Health Law

Shopping savvy largely derives from the discomfort of parting with money. If health insurance pays all (or most) of the bill for healthcare services, why should the patient care what the cost of the healthcare is, how such cost is calculated, or how cost might be reduced? But as a patient begins to spend money out-of-pocket for healthcare, his attention to cost and his interest in how cost is determined and what alternatives might save money quickly increase. When his money is spent, he tends to want to know more about his medical bills, what the details are and, ultimately, how price is calculated. Historically, how healthcare is priced has been all but impossible for consumers to ascertain. Now, there is a push in the healthcare industry toward greater pricing transparency, which may dovetail well with increasing financial responsibility placed upon patients for their healthcare costs. Many experts argue that greater price transparency will lead to more intelligent “shopping” by patients for their healthcare, which in turn may (at least theoretically) put downward pressure on healthcare costs.
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April 23, 2014, Article co-authored by Kevin Little and Jay Brownstein, Primer on WhistleBlowing in healthcare, Published by The Ambulatory M&A Advisor.

April 23, 2014 | Little Health Law

Article co-authored by Kevin Little and Jay Brownstein, Primer on WhistleBlowing in healthcare, Published by The Ambulatory M&A Advisor.

STARK Whistleblowing Case Leads To Record $85 Million False Claims Act Settlement Between Florida Hospital System And The Government

April 22, 2014 | Little Health Law

Halifax Hospital Medical Center and Halifax Staffing, Inc. (Halifax), on the day of jury selection, agreed to pay $85 million and made other concessions as part of a settlement with the federal government to resolve allegations that Halifax violated STARK prohibitions and the False Claims Act (FCA). The settlement amount is the largest STARK sanction to date against a hospital system for STARK law violations.

The case is styled United States ex rel v. Halifax Hospital Medical Center, et al., No. 09-cv-1002 (M.D. Fla). The government’s allegations stemmed from Halifax’s financial relationships with a group of oncologists. The case was initiated by a compliance officer of the hospital, and the Justice Department agreed to take the case pursuant to the FCA.
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March 19, 2014. Our firm’s article Financial Ramifications for Physician Practices of ACA Deductibles: Getting Paid for “Affordable Care,” Published by The Ambulatory M&A Advisor

March 19, 2014 | Little Health Law

Our firm’s article Financial Ramifications for Physician Practices of ACA Deductibles: Getting Paid for “Affordable Care,” Published by The Ambulatory M&A Advisor

Possible Delay of the Affordable Care Act’s Individual Mandate

March 12, 2014 | Little Health Law

House Republicans gained the support of 27 Democrats and passed The Suspending the Individual Mandate Penalty Law Equals Simple (SIMPLE) Fairness Act (H.R. 4118), a bill that would delay for one year the Affordable Care Act (ACA) individual mandate penalty tax for those failing to buy health insurance before the deadline this month. As reported recently in the Washington Post, while destined to fail in the Democratic-controlled Senate, this Bill nonetheless underscores mounting pressure upon the Administration and Democrats in an election year, as the troubled healthcare law struggles to get traction in its implementation and with voters. Republicans want mileage in November from increasing public confusion and disenchantment about the ACA. They seize upon much publicized trouble spots of ACA implementation, such as the disastrous rollout of the website, cancelled policies, patients unable to stay with the doctor they prefer, and higher insurance premiums.

Insurers and proponents of the ACA view the individual mandate as critical to the financial mechanics of the health insurance reform intended by the ACA, namely expansion of insurance coverage to most Americans irrespective of health conditions and without lifetime or annual caps on benefits. With the new law’s imposition upon insurers of a requirement that they insure all Americans — even the most high-cost patients — it is important that the young and healthy, whether they need insurance or not, pay insurance premiums to help fund the insurers’ cost of paying for the health care of unhealthy Americans. Hence the law’s controversial individual mandate that everyone obtain coverage and pay insurance premiums or, alternatively, pay a penalty tax based on household income. The penalty is to begin this year, phased in at 1 percent of taxable income, then 2 percent in 2015, and 2.5 percent in 2016.
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Navigating Troubled Waters: Five Tips for Physician Practice Breakups and Departures

February 24, 2014 | Little Health Law

Medical practice breakups and physician departures are inevitable. Some are the result of professional or personal disputes, and others are simply the result of practical or economic realities or life events (disability, death, retirement, etc.). Whatever the circumstances, failing to carefully execute a plan for the breakup can quickly result in financial, legal, and emotional complications. All physicians and physician practices should anticipate the inevitable conclusion of any professional relationship.

1. Have a Good Contract

When a business relationship fails or otherwise ends, not having a properly done contract that fairly, accurately and precisely sets forth the parties’ respective rights and obligations will be a painful mistake, financially and otherwise. At the beginning of the marriage (or at least during the period that it is happy), the parties should carefully and thoughtfully construct a written agreement that states their meeting of the minds. That contract should also specifically set forth in reasonable detail a road map for the parties to separate when it is time for the relationship to conclude.

2. Carefully Document the Termination of the Relationship

Whether or not the practice had proper preparation before a breakup or departure, both parties should carefully document the final resolution in writing. This is especially the case if the resulting departures necessitate any post-employment obligations such as unfinished payments, restrictive covenants, confidentiality agreements, etc. Important practice contracts and documents should be marshalled and carefully reviewed to determine what the parties’ respective rights and obligations will be in concluding the relationship, including:
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February 20, 2014. Kevin Little speaks to physicians. Financial Ramifications for Physician Practices of ACA Deductibles. In Health Consulting & Educational Services National Tele-Class Series.

February 20, 2014 | Little Health Law

Kevin Little speaks to physicians. Financial Ramifications for Physician Practices of ACA Deductibles. In Health Consulting & Educational Services National Tele-Class Series.

Medical Practice Compliance 101

February 18, 2014 | Little Health Law

Patients tend to see physicians only as providers of care — meeting their medical needs. The reality is that a physician’s efforts to stay compliant with regulations and laws may consume as much or more time than actually rendering care. With consequences for regulatory violations ranging from financial to criminal, compliance is a subject of the utmost importance for any physician practice.

The best way to avoid penalties is to have a serious compliance program in place to prevent, detect, and respond to any possible violation. With regulations always changing on both a federal and state level, especially now with the implementation of the Affordable Care Act (ACA), having a compliance program in place is critical. The benefits of creating an effective compliance program range from better sleep, higher ethical standards, satisfying government auditors and regulators’ requirements, and ensuring that business operations align with proper legal protocol. Given all the possible problems that may derive from doing otherwise, the absence of a strong compliance program invites problems.

To create an effective compliance program, physicians must first understand that there is no one-size-fits-all model. Compliance programs must be adaptable to each practice’s unique structure, services, and personnel. An experienced consultant and/or healthcare attorney should be considered to help set up or review the program and minimize particular risks applicable to your specific type of practice. You must also keep in mind that an effective compliance program will require time and resources to set it up properly and to modify it as needed to adapt to changes in our regulatory environment.
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