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NAVIGATING THE HEALTHCARE MINEFIELD

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Title: Group Practice & Cultural Changes Subject: Chiropractic practice challenges Author: John C. Peick Keywords: Chriopractic, group practices, associates – PowerPoint PPT presentation

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Title: NAVIGATING THE HEALTHCARE MINEFIELD


1
NAVIGATING THE HEALTHCARE MINEFIELD
  • John C. Peick, J.D.
  • PEICK BOYER LAW GROUP, P.S.
  • Bellevue, Washington
  • www.peicklaw.com
  • 425-462-0660

2
INTERFACES
3
AVOIDING MISSTEPS
  • Avoiding Contract Mistakes
  • Group Practices
  • Escalating Regulatory Compliance Demands
  • Billing
  • False Advertising
  • Sexual Misconduct
  • Rewarding Referral Sources

4
COMMON PROVIDER CONTRACT MISTAKES
  • Billing for non-credentialed providers
  • Billing for unbundled services
  • Billing wrong codes for services
  • Billing higher time codes without supporting
    documentation
  • Collecting discount balances from patients for
    covered services (P.I.)

5
COMMON PROVIDER CONTRACT MISTAKES(cont)
  • Billing services under inappropriate provider
  • No or little documentation of services
  • No or little documentation of medical necessity
  • No or little documentation of reasonableness

6
GROUP PRACTICES
  • Misery Loves Company
  • OR
  • The More the Merrier

7
What is Group Practice
  • Group Practice is generally defined as three
    or more providers who deliver patient care, make
    joint use of equipment and personnel, and divide
    income by a prearranged formula.
  • Group Practice may be single discipline or
    multidisciplinary.

8
Legal Structure of Group Practices
  • Sole Proprietor with Associates
  • Partners (with or without Associates)
  • Shareholders in Professional Service Corporation
    (with or without Associates)
  • Members in Professional Limited Liability
    Company (with or without Associates)
  • Combination of Above Entities

9
PROFESSIONAL COMBINATIONS
  • GROUP I
  • Acupuncturist, Mental Health, Podiatrist, DC,
    Dental Hygienist, Opticians, Hearing Aid,
    Naturopathic, Midwifery, Optometry, Ocularist,
    Osteopathy, D.O. Assistant, Pharmacist, M.D.,
    P.A., Nurses, Psychologist, Respiratory, LMP,
    Dieticians, Nutritionists
  • GROUP II
  • Physical Therapists
  • Occupational Therapists

10
Advantages of Group Practice
  • Increased Economies of Scale in Use of Equipment
    Technology
  • Reduces Per Provider Staff Overhead
  • Increased Marketing Capabilities Resources
  • Generates Stable Income Stream
  • Enables Practice to Maximize Utilization of
    Associates

11
Disadvantages of Group Practice
  • Requires Uniformity in Staff Procedures Billing
  • Individual Practice Variations Will Come Under
    Scrutiny for EO Exposure
  • Increased Financial Accountability
  • A General Sense of Loss of Control
  • Requires Team Player Skills

12
MultiDisciplinary Group Practice Advantages
  • Same economies of scale as single discipline
    groups.
  • Breadth of healthcare expertise is a marketing
    strength to consumers - One Stop Shopping
  • Marketing advantage to MCOs
  • Opportunity to deliver more comprehensive health
    care solutions with better patient outcomes

13
Traps for the Unwary
  • Failure to incorporate as professional services
    corporation or PLLC
  • Failure to understand scope of practice
    limitations
  • Failure to delineate services provided
  • Failure to bill separately
  • Failure to document reasons for intercompany
    referrals

14
REGULATORY COMPLIANCE
  • WHERE THE BIG STICK CAN SMASH THE OUT OF
    YOUR LIFE

15
REGULATORY COMPLIANCE
  • WHY SHOULD I CARE?

16
LOMPOC
17
CAMP SHERIDAN
18
SOURCES OF RISK
  • EMPLOYEES
  • PATIENTS
  • COMPETITORS
  • CME/IME REVIEWERS
  • ATTORNEYS
  • REGULATORS
  • PAYERS
  • YOU

19
WHAT CAN HAPPEN
  • Professional Discipline
  • Criminal Investigation
  • Insurance Company Audits
  • Civil Claims by Patients

20
FEDERAL HEALTHCARE CRIMINAL LAWS
  • Healthcare Fraud under HIPAA
  • False Statements relating to Healthcare
  • Medicare Patient Protection Act
  • Anti-Kickback Self-Referral (Stark I II)
  • False Claims Act
  • Mail Wire Fraud
  • Obstruction of Justice

21
STATE HEALTHCARE RELATED LAWS
  • Anti-Rebating (Ch. 19.68 RCW)
  • Healthcare Insurance Claim Trafficking (Ch.
    48.30A RCW )
  • False Insurance Claims (RCW 48.30.230)
  • Healthcare Fraud (Ch. 48.80 RCW)
  • Criminal Profiteering (RCW 9A.82.010)

22
STATE LAWS (cont.)
  • Healthcare Disciplinary Act (RCW 18.130.180)
  • Self-Referral Prohibitions (DSHS)
  • Medical Records Privacy (Ch. 70.02 RCW)

23
REBATING - State
RCW 19.68.010(1) It shall be unlawful for any
person to pay, or offer to pay or allow,
directly or indirectly, to any person licensed by
the state of Washington to engage in the practice
of medicine and surgery, drugless treatment in
any form, dentistry, or pharmacy and it shall be
unlawful for such person to request, receive or
allow, directly or indirectly, a rebate, refund,
commission, unearned discount or profit by means
of a credit or other valuable consideration in
connection with the referral of patients to any
person, firm, corporation or association, or in
connection with the furnishings of medical,
surgical or dental care, diagnosis, treatment or
service, on the sale, rental, furnishing or
supplying of clinical laboratory supplies or
services of any kind, drugs, medication, or
medical supplies, or any other goods, services or
supplies prescribed for medical diagnosis, care
or treatment.
24
FALSE CLAIMS - State
48.80.030. Making false claims, concealing
information--Penalty--Exclusions   (1) A person
shall not make or present or cause to be made or
presented to a health care payer a claim for a
health care payment knowing the claim to be
false. (2) No person shall knowingly present to
a health care payer a claim for a health care
payment that falsely represents that the goods or
services were medically necessary in accordance
with professionally accepted standards. Each
claim that violates this subsection shall
constitute a separate offense. (3) No person
shall knowingly make a false statement or false
representation of a material fact to a health
care payer for use in determining rights to a
health care payment. Each claim that violates
this subsection shall constitute a separate
violation.
25
FALSE CLAIMS cont.
4) No person shall conceal the occurrence of any
event affecting his or her initial or continued
right under a contract, certificate, or policy of
insurance to have a payment made by a health care
payer for a specified health care service. A
person shall not conceal or fail to disclose any
information with intent to obtain a health care
payment to which the person or any other person
is not entitled, or to obtain a health care
payment in an amount greater than that which the
person or any other person is entitled. (5) No
provider shall willfully collect or attempt to
collect an amount from an insured knowing that to
be in violation of an agreement or contract with
a health care payor to which the provider is a
party. (6) A person who violates this section is
guilty of a class C felony punishable under
chapter 9A.20 RCW. (7) This section does not
apply to statements made on an application for
coverage under a contract or certificate of
health care coverage issued by an insurer, health
care service contractor, health maintenance
organization, or other legal entity which is
self-insured and providing health care benefits
to its employees.
26
PRIVACY, SECURITY ACCESS
  • HIPAA covered entity status governs HIPAA vs.
    UHCIA
  • UHCIA has parallel features but less complex
  • HIPAA has both privacy aspects and electronic
    security
  • HITECH amendments to HIPAA increase security
    breach sanctions but also place direct HIPAA
    responsibility on Business Associates

27
HIPAA-HITECH COMPLIANCE
  • Encrypt your computers email containing PHI
  • Conduct a HIPAA risk assessment review
  • Create training for staff on HIPAA
  • Review data safeguards for your PHI
  • Create and distribute your Notice of Privacy
    Practices
  • Have you made provisions for reporting any breach
    of HIPAA?

28
SEXUAL MISCONDUCT
  • A healthcare provider shall not engage, or
    attempt to engage, in sexual misconduct with a
    current patient, client, or key party, inside or
    outside the health care setting.

29
KEY PARTY
  • 'Key party' means immediate family members and
    others who would be reasonably expected to play a
    significant role in the health care decisions of
    the patient or client and includes, but is not
    limited to, the spouse, domestic partner,
    sibling, parent, child, guardian and person
    authorized to make health care decisions of the
    patient or client.

30
DEFINITIONS
  • Twenty one separate offenses which constitute
    sexual misconduct (WAC 246-16-100(1)
  • Suggesting or discussing the possibility of a
    dating, sexual or romantic relationship after the
    professional relationship ends.
  • Terminating a professional relationship for the
    purpose of pursuing a relationship.
  • Any behavior, gestures, or expressions that may
    reasonably be interpreted a seductive or sexual.

31
TERMINATION
  • The healthcare provider shall not engage, or
    attempt to engage, in the activities listed in
    (1) of this section with a former patient, client
    or key party within two years after the
    provider-patient/client relationship ends.

32
POST TWO YEARS?
  • After the two year period, a health care provider
    shall not engage in the (1) activities, IF
  • There is a significant likelihood that the
    patient, client or key party will seek or require
    additional services from the provider.
  • There is an imbalance of power, influence,
    opportunity and/or special knowledge of the
    professional relationship.

33
DEFENSE
  • 'Legitimate health care purpose' means activities
    for examination, diagnosis, treatment, and
    personal care of patients or clients, including
    palliative care, as consistent with community
    standards of practice for the profession. The
    activity must be within the scope of practice of
    the health care provider.

34
MANDATORY REPORTING
  • There has always been some reporting
    requirements, particularly courts and insurance
    companies.
  • In May 2008, the reporting requirements were
    broadened to require licensees to report on other
    licensees and to self report their own defined
    acts or omissions.

35
EMPLOYMENT CHALLENGES
  • Employee vs. Independent Contractor
  • Whether the staff person is an employee or an
    independent contractor is determined in large
    part as a matter of employer control of work,
    finances and behaviors. What your employer
    designates you is not the determining factor it
    is control.

36
CONSEQUENCES OF MISCHARACTERIZATION
  • Employer tax penalties and fines from IRS, ESD
    DOLI
  • Labor Industries imposition of liability upon
    employer for not insuring workers
  • Worker vulnerability to unfunded tax liabilities
    and injury
  • Employer liability to employee for insufficient
    payment of minimum wage, if any.

37
QUESTIONS
  • John C. Peick
  • PeickBoyer Law Group, P.S.
  • 3633 136th Pl. SE 205
  • Bellevue, Washington 98006
  • 425-462-0660
  • Visit www.peicklaw.com
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