"Dr. Michael Reilly's lawyer gave his client strong advice after reviewing a lucrative employment contract that the North Broward Hospital District offered him 15 years ago.
“I should throw this in the trash,” Reilly, a now-retired orthopedic surgeon, recalls the attorney telling him.
The contract, the lawyer said, had major problems, including that it violated the federal Stark law, which bars physicians from referring Medicare patients to hospitals, labs and other doctors that the physicians have financial relationships with unless they fall under certain circumstances.
Reilly didn't sign the contract.
That moment marked the beginning of Reilly's quest to hold North Broward Hospital District—a taxing district that operates five hospitals in Broward County in South Florida—accountable for alleged violations of the law. Reilly later filed a whistle-blower lawsuit against North Broward under the False Claims Act. In September, North Broward and the government settled the case for $69.5 million, with Reilly getting $12 million. North Broward did not admit to any wrongdoing. It declined to comment for this article.
Both plaintiff and defense attorneys predict that more False Claims Act cases alleging Stark violations are on the way, with whistle-blowers largely driving the U.S. Justice Department's enforcement—exponentially multiplying the government's regulatory eyes inside healthcare facilities. That's partly because two giant cases, involving Tuomey Healthcare System and Halifax Health, alerted potential whistle-blowers inside hospitals to the riches they could pocket by bringing such cases, some attorneys say.
In October, Tuomey in Sumter, S.C., agreed to settle with the government for $72.4 million, resolving allegations that it paid doctors in ways that rewarded them for referring patients to the hospital. Last year, Halifax in Daytona Beach, Fla., agreed to pay $85 million to settle allegations that it also had compensated physicians in illegal ways. Halifax did not admit to any wrongdoing. The whistle-blower in the Tuomey case got $18.1 million, while the whistle-blower in the Halifax case bagged $20.8 million."
Read more at Modern Healthcare
"Millennium Health LLC agreed to pay $256 million to resolve claims that it misrepresented the need for procedures and offered gifts to doctors in exchange for referrals.The biggest U.S. lab-testing company now plans to file for bankruptcy protection by Nov. 10, enabling it to turn over control of the business to its lenders, according to a person with knowledge of the matter.
The company has given the restructuring proposal to the holders of its $1.8 billion term loan and sent a copy to lawyers at the U.S. Department of Justice who are handling the settlement of the government’s case, said the person, who asked not to be named because the information isn’t public. Millennium will need to file its Chapter 11 petition with a bankruptcy court by Nov. 10, according to copies of resolved cases against the company that were unsealed Monday.
The payment will resolve allegations that Millennium violated the False Claims Act by having doctors order unnecessary urine, drug and genetic testing, according to a U.S. Department of Justice statement on Monday. The government accuses Millennium, a provider of urine-testing services to monitor prescription drug use and potential abuse, of misrepresenting to doctors the necessity of an $1,800 genetic test for pain management patients."
Read more at Bloomberg News
"The CMS says doctors tending to tens of millions of chronically ill Medicare patients aren't taking advantage of federal dollars aimed at improving care and reducing hospital readmissions and overall costs.
This year, Medicare began paying an average of $42 per patient per month for non-face-to-face chronic-care management services, such as consulting with other doctors caring for the same patient who might be dealing with dementia, heart disease or arthritis.
The CMS estimates 70% of Medicare beneficiaries—roughly 35 million—would be eligible, but CMS has only received reimbursement requests for 100,000 beneficiaries thus far, Kathy Bryant, a senior technical adviser in the Center for Medicare, said last week at an Advisory Panel on Outreach and Education meeting. She added that even that number may be too high as some could be duplicate claims.
One possible reason for the low interest is that doctors have to get permission from patients who are responsible for a 20% copayment each time their provider bills for the services.
“Getting bills for things when they haven't seen a doctor is not something they are used to,” Bryant said.
Others said the CMS didn't provide enough information on how to properly bill under the codes.
“Physicians are leery about using them because they don't know if they are doing so correctly,” said Regina Mixon Bates, founder and CEO of the Physicians Practice S.O.S. Group, a healthcare consulting and education firm. Another reason could be the lengthy process on electronic health-record systems."
Read more at Modern Healthcare
"A new survey from The Commonwealth Fund and The Kaiser Family Foundation asked primary care providers—physicians, nurse practitioners, and physician assistants—about their experiences with and reactions to recent changes in health care delivery and payment. Providers’ views are generally positive regarding the impact of health information technology on quality of care, but they are more divided on the increased use of medical homes and accountable care organizations. Overall, providers are more negative about the increased reliance on quality metrics to assess their performance and about financial penalties. Many physicians expressed frustration with the speed and administrative burden of Medicaid and Medicare payments. An earlier brief focused on providers’ experiences under the ACA’s coverage expansions and their opinions about the law"
Read more at The Commonwealth Fund
"Darren Gold had a stomach virus the first time he used an app called Heal to summon a doctor to his Beverly Hills home. He liked the Stanford-trained doctor who showed up so much that he called Heal again when his 2-year-old son had a fever, and again when the whole family had colds.
The charges—$99 each for the first two visits; $200 for the family—weren’t covered by insurance, but Mr. Gold, who owns a corrugated-box company, says that was still a bargain compared with taking time off work to go to the doctor. “Now, whenever my son bumps himself, he says, ‘Daddy, we need to get the doctor here,’ ” Mr. Gold says."
Read more at The Wall Street Journal
"Traditionally, medical students haven't been taught how to talk with their patients about the costs of treatments and medications. The thinking was that doctors should offer their best advice to all patients, regardless of their insurance or ability to pay.
But in a huge departure from the past, the vast majority of the country's medical schools now integrate discussions of cost, value and effectiveness into their curricula.
It's "a dramatic change," says Dr. Janis Orlowski, chief health care officer for the Association of American Medical Colleges, which helps medical schools develop curricula."
Find more at KPCC
"The CMS lowered its final increase for hospitals rates in 2016 to a scant 0.9%, down from the 1.1% increase it proposed in April. The move will heighten pressure on the nation's 3,400 acute-care hospitals to rein in costs and reduce unnecessary spending.
The 435 long-term care hospitals certified by Medicare will see a 4.5% cut in their payments in fiscal 2016, which begins Oct. 1. The CMS on Friday posted a final rule that said long-term care hospitals can expect to see a decrease in payments by $250 million next year.
The inpatient prospective payment system is meant to create incentives that encourage efficiency and reduce unnecessary costs in U.S. hospitals that offer care to Medicare beneficiaries. The changes outlined will further those goals, the CMS says, while maintaining the financial viability of the hospital industry and ensuring access to high quality healthcare for Medicare beneficiaries."
Read more at Modern Healthcare
"Three separate pay-for-performance programs affect the amount of Medicare payment for inpatient services to about 3,400 US hospitals. These payments are based on hospital performance on specified measures of quality of care. A growing share of Medicare hospital payments (6 percent by 2017) are dependent upon how hospitals perform under the Hospital Readmissions Reduction Program, the Value-Based Purchasing Program, and the Hospital-Acquired Condition Reduction Program. In 2015 four of five hospitals subject to these programs will be penalized under one or more of them, and more than one in three major teaching hospitals will be penalized under all three. Interactions among these programs should be considered going forward, including overlap among measures and differences in scoring performance."
Read full PDF at healthaffairs.org
"It’s one of the grand ideas that is supposed to revolutionize U.S. health care: reward doctors who keep patients well with fewer tests, procedures, and appointments.
That might register as barely profound to most of us, but it is a radical shift in the incentives that doctors and hospitals face. Under the Affordable Care Act, some doctor’s groups and hospitals have banded together in accountable care organizations to treat Medicare patients under this new philosophy. If the patient stays healthier with fewer appointments, the providers get a share of the cost savings.
But a new study published Monday in the Annals of Family Medicine examined how doctors have been making money in this brave new world vs. the status quo, and found pretty negligible differences."
Read more on Washington Post