The Law Offices of Alejandro Mora, PLLCThe Law Offices of Alejandro Mora, PLLC2024-03-08T17:57:05Zhttps://www.morahealthcarelaw.com/feed/atom/WordPress/wp-content/uploads/sites/1604262/2023/05/cropped-ID-image-32x32.jpgOn Behalf of The Law Offices of Alejandro Mora, PLLChttps://www.morahealthcarelaw.com/?p=476252023-04-07T17:11:11Z2023-04-07T17:11:11Zrely on Medicaid and Medicare to pay for healthcare services. Although medical professionals want to provide medical care to those who need it, they may run into a few reimbursement challenges.
Compensation amount
One of the most significant issues medical providers face when they work with Medicaid and Medicare is the cost of care versus the amount of reimbursement. In fact, in 2020, the federal and state government underpaid medical providers by $75.6 billion. Unfortunately, many providers do not receive enough to cover their service costs because these insurance providers only pay 84 cents on every dollar, and they do not adjust enough for inflation, increasing the shortages.
Telehealth services
Today’s medical customers increasingly seek telehealth services. These services are especially valuable for those who live in rural areas and those who find it difficult to get to their appointments. However, Medicare and Medicaid site overuse, fraud, care quality and overpayment potential as reasons to avoid or reduce payments. Fortunately, the Consolidated Appropriations Act of 2023 extended telehealth payments for an additional two years.
Increasing denials
Although technology revolutionized healthcare services, payment software was not as beneficial. In fact, payers use software that results in increasingly more denials, and healthcare providers do not have the time to rework and resubmit these bills. In addition, health insurance companies, including Medicare and Medicaid, are for-profit organizations, so they receive incentives if they reduce their payouts.
Medical professionals should investigate all the relevant issues and develop strategies to address them to gain the best Medicare and Medicaid reimbursement results.]]>On Behalf of The Law Offices of Alejandro Mora, PLLChttps://www.morahealthcarelaw.com/?p=476242023-06-02T17:00:17Z2023-03-03T20:20:16Z1. Lack of training
Human error represents a leading cause of compliance issues. Changing technology paired with updates in policies and procedures means healthcare workers may easily find their knowledge outdated. If you manage a healthcare facility, providing training allows you a way of refreshing your staff's knowledge.
No matter what your role at work is, stay aware of changes that might alter what best practices you should use. Keep up on current Texas laws and regulations so you remain in the know even when things change.
2. Not considering compliance as a step in every process
While healthcare workers rightfully consider patient care as their first priority, regulatory compliance also requires consideration in everyday tasks. Often, employees think of compliance as someone else's job and fail in considering it until an issue arises. Having a plan in place for handling any potential breaches in compliance and fostering communication across departments creates a mindset focused on preventing issues throughout the facility.
The consequences of a compliance issue in healthcare range from fines to legal action against health professionals. While regulatory compliance involves careful attention to detail, revisiting the basics of staff training and communication helps reduce the likelihood of serious problems arising.]]>On Behalf of The Law Offices of Alejandro Mora, PLLChttps://www.morahealthcarelaw.com/?p=476232023-01-27T20:03:30Z2023-02-01T20:02:37ZExplaining the Anti-Kickback Statute
The AKS prohibits healthcare providers from giving or receiving rewards, also called remuneration or kickbacks, in exchange for promoting goods and services payable by Medicare or Medicaid, such as drugs and healthcare services.
For example, a doctor might prescribe a medication to a Medicare patient and receive money from the pharmaceutical company for doing so. This provider is acting in violation of the AKS and committing Medicare fraud.
The AKS applies to patients as well. For example, a provider may not give free services or waive copays to encourage patients to use his or her practice. Providers can still waive fees for patients who can not afford to pay.
Understanding the impact of kickbacks
Physicians and other healthcare providers wield a significant amount of influence. Patients trust them to recommend the most effective treatments, services and drugs. When providers accept kickbacks, it can affect their ability to make sound decisions about patient care.
Accepting remuneration for referrals also creates an unfair competitive advantage for the company that is paying for business and can drive up Medicare and Medicaid costs.
Potential consequences of violating the AKS can include fines, criminal penalties or the termination of the practice's Medicare contract.
For healthcare professionals, accepting or offering kickbacks is never a wise decision.]]>On Behalf of The Law Offices of Alejandro Mora, PLLChttps://www.morahealthcarelaw.com/?p=476222022-12-28T19:51:32Z2022-12-30T19:50:31ZSeparate roles and responsibilities
No single staff member should be responsible for inputting patient record information, generating insurance company invoices and crediting payments. Divide these tasks between several employees to ensure a reasonable system of checks and balances. This prevents the lack of oversight that encourages fraudulent activity.
Require physician signatures on all check deposits and payments
Managing partner signatures must appear on any deposit records or payments made on behalf of the practice. This offers a management-level assessment of transactions as they happen so that you can audit and verify random samples.
Mandate background checks for all employees
Background checks can help raise red flags of concern with potential new hires. Conduct thorough background checks on everyone that you hire within the practice. This can help with malpractice and liability insurance as well because background checks help insurance carriers assess risk factors and determine premiums. With the additional inspection of those background checks, you have a sound defense with the board if issues arise.
Proactive steps to establish procedures, checks and balances within your practice can reduce the risk of insurance fraud and can minimize even the appearance of impropriety. Protect your practice from medical board review with strict safety measures.]]>On Behalf of The Law Offices of Alejandro Mora, PLLChttps://www.morahealthcarelaw.com/?p=476202022-12-06T15:45:29Z2022-12-06T15:45:29ZInvestigate possible abuse right away
If an employee suspects abuse directed at a nursing home patient by another employee, it is in everyone's best interest to investigate the situation immediately. Not only can abuse cases jeopardize a long-term care facility's license, but physical, emotional, sexual and financial abuse can cause lasting trauma to victims and their families. Employees can take the initiative to report and ensure a speedy investigation into anything they see that does not look right.
Comply with all safety standards
Maintaining a clean, safe environment for everyone is essential for ensuring healthy residents and the continued operation of the facility. One notable safety standard is having enough staff members present to provide each resident with the proper care and medical attention. Keeping a sanitary environment is another standard help to all medical facilities.
When staff do things that jeopardize a senior care facility's license, it is bad for everyone who comes into contact with the facility. Fortunately, adhering to some basic guidelines helps nursing facilities keep their licenses and keep their residents safe.]]>On Behalf of The Law Offices of Alejandro Mora, PLLChttps://www.morahealthcarelaw.com/?p=476182022-11-01T20:10:05Z2022-11-01T20:10:05Zpleaded guilty on Oct. 25 to a federal wire fraud charge for his involvement in a $54 million Medicare fraud scheme. Daniel R. Canchola of Flower Mound pocketed nearly $470,000 in kickbacks and bribes for prescribing unneeded and unprescribed medical equipment and cancer genetic tests to Medicare beneficiaries.
Telemarketing firms, health care vendors targeted beneficiaries
The crimes occurred during a nine-month period from August 2018 to April 2019 in which Canchola worked in tandem with telemarketing companies and health fair vendors. Telemarketers targeted unsuspecting Medicare beneficiaries who also became targets while attending health fairs.
These predators encouraged Medicare beneficiaries to agree to cancer genetic testing and receive medical equipment even though neither was necessary. Canchola then prescribed genetic cancer testing and durable medical equipment to patients he did not personally meet with, speak to or even treat.
Examples of durable medical equipment include hospital beds, canes, crutches, blood sugar testing strips, oxygen equipment and CPAP devices.
Sentencing is scheduled for March 15 at the U.S. Attorney’s Office for the Northern District of Texas in Dallas. Canchola faces up to 20 years in prison. In October 2019, the Texas Medical Board suspended Canchola’s license to practice medicine in the state.
Careers at risk
Medicare fraud remains a serious crime. Annually, many health care professionals put their careers at risk.]]>On Behalf of The Law Offices of Alejandro Mora, PLLChttps://www.morahealthcarelaw.com/?p=475452022-10-15T15:32:49Z2022-10-15T15:32:49ZThe PREP Act
The Public Readiness and Emergency Preparedness Act allows the Department of Health and Human Services to issue specific declarations during emergency situations that provide immunity from liability in areas of healthcare. One of the provisions of this act is the interstate practice of telemedicine in order to assist with a public health crisis or emergency. There are similar protections in place in certain states across the nation, but there are also specific requirements as to who can practice telemedicine.
The telemedicine statute in Texas is the Texas Occupations Code, Chapter 111. This sets the standard of care for the health care provider and guidance on the advisability of telemedicine services in a particular situation.
State-level guidance
In Texas, there are strict guidelines in place for patient privacy and informed consent, much like one would find at an in-person visit. There are also requirements for a protocol related to abuse or fraud. While the physician needs to establish continual communication with the patient, the physician must have the appropriate medical license or authorization from the medical board in the state where the patient lives.
In Texas, a healthcare provider licensed to practice medicine in Texas may engage in telehealth services within Texas. However, Texas participates in the Interstate Medical Licensure Compact which allows one application for licensing in several states.]]>On Behalf of The Law Offices of Alejandro Mora, PLLChttps://www.morahealthcarelaw.com/?p=475432022-09-17T15:51:22Z2022-09-17T15:51:22ZEducation and training
Educating and training staff to regulate compliance is essential to a cohesive compliance plan. The main objectives include ensuring each employee understands compliance practices and how failure to comply can affect employment.
Monitoring compliance
You can designate a compliance officer to audit and monitor your plan. Outline your monitoring guidelines and ensure you are up-to-date on changes within federal programs. Additionally, you may benefit from conducting these audits at least once per year.
Communication
Help establish relationships between administrative staff and medical personnel to foster collaboration. Opening the lines of communication in your office creates a workplace culture that makes medical staff and other personnel feel comfortable discussing possible compliance issues. You can also establish a way for employees to report issues anonymously.
Enforcing discipline
It is important for your staff to understand the disciplinary action they may face for noncompliance. Include an element in your employee handbook about the discipline you will enforce in the event of a compliance issue. Some disciplinary actions you may invoke include:
Giving a formal warning
Placing an employee on probation
Enforcing suspension for continued violations
Applying a demotion
Even with your best efforts, you cannot monitor or control all the actions of your staff. However, creating an environment where employees feel like a family helps garner a sense of collective responsibility.]]>On Behalf of The Law Offices of Alejandro Mora, PLLChttps://www.morahealthcarelaw.com/?p=475412022-08-26T01:56:21Z2022-08-26T01:56:21ZSeeing billing for services never rendered
One of the most common ways that healthcare providers commit fraud is to charge a client or insurance company for services that they never provided in the first place. If you see a bill for yourself or a loved one that looks suspicious or higher than usual, call someone at the nursing facility and have them explain the bill and provide you with an itemized receipt of services rendered.
Encountering improper diagnoses
Sometimes, healthcare facilities will provide an incorrect diagnosis in order to obtain more money from a patient's Medicare provider. Caregivers can spot this in many ways, including by looking closely at the billing codes on a statement. Again, communicating with as many people as possible, including doctors, nurses and technicians, is key to getting to the bottom of an improper diagnosis.
Financial scams and fraud, unfortunately, hit older adults at higher rates than the rest of the population, and this includes scams occurring in nursing homes. By knowing what to look for, professionals can help prevent Medicare fraud in their workplace.]]>On Behalf of The Law Offices of Alejandro Mora, PLLChttps://www.morahealthcarelaw.com/?p=471052022-07-15T14:45:53Z2022-07-15T14:45:53Ztelltale signs of fraud at your practice, it is important to take action immediately.
1. Incorrect billing
Some hostile individuals in the medical field might believe that elderly patients with Medicaid benefits are easy to trick. That is why it is unfortunately common for fraud perpetrators to bill patients for services they do not receive or duplicate bills for a single service.
2. Overtreatment
Performing costly procedures that are unnecessary for a patient's condition is an example of overtreatment. In a similar vein, prescribing medications that a patient does not need is also an example of illegal fraud.
3. Accepting kickbacks
When a hospital or other medical facility pays to solicit referrals from out-of-network professionals, it is an example of a "kickback." This behavior can occur in areas where medical practices are particularly competitive against one another, but it is disingenuous and a clear sign of bad faith that may go against the best interests of patients with a dire need for proper care.
Sometimes fraud can occur as a one-off honest mistake that calls for corrective action and nothing more. However, such behavior can be indicative of malicious intent and the start of a pattern that can be disastrous for the future of your medical practice.]]>