Special report on reimbursement. Medicare and Medicaid false claims prosecutions: your clerk's mistake can subject you to criminal penalties!

A number of steps are available to individual and institutional providers to minimize exposure under the new wave of enforcement activity. The first is education: learn what rules apply in your setting and share that knowledge with management and line employees. Second, undertake an independent compliance review to identify and resolve any existing exposure, including voluntary disclosure to the authorities, if appropriate. Third, institute an ongoing program to communicate to all employees not only the content of applicable rules, but also the genuine commitment of management to ensure continuing compliance above other concerns.     

Special report on reimbursement. Medicare program abandons 1986 malpractice rule

Hospitals with claims "properly pending" before fiscal intermediaries or in the courts need do nothing in order to obtain corrected reimbursement for fiscal years so pending. However, to speed processing of corrected reimbursements for fiscal years pending in appeals before the PRRB, hospitals should request that the Board determine its jurisdiction and remand to the fiscal intermediary for payment as soon as possible. It will be helpful to include with any such request a copy of the notice of program reimbursement and the original appeal letter for each fiscal year under appeal. Despite the fact that HCFA Ruling 91-1 effectively concedes that HCFA has applied an invalid regulation to all fiscal years since May 1, 1986, HCFA counsel have stated that HCFA will not permit reopening of closed cost reports to correct the inappropriate apportionment of malpractice insurance costs. Nevertheless, hospitals that do not presently have a claim or appeal pending have several options. Under the Provider Reimbursement Manual, HIM-15, sections 2930-2931, fiscal intermediaries are required to reopen cost reports filed within the three-year reopening period to correct errors. Accordingly, should a fiscal intermediary deny a provider's reopening request, the provider should seriously consider taking an appeal to the PRRB. The PRRB's jurisdiction to review fiscal intermediary denials of requests to reopen cost reports was affirmed by the United States Court of Appeals for the Ninth Circuit, see State of Oregon v. Bowen, 854 F.2d 346 (9th Cir. 1988), a decision that is controlling in California, Oregon, Washington, Nevada, Arizona, Montana, Idaho, Hawaii, Alaska, Guam, and the Northern Mariana Islands.(ABSTRACT TRUNCATED AT 250 WORDS)     

Special report on reimbursement. HCFA enacts new enforcement remedies covering nursing facilities

While the regulations are revolutionary in their use of "substantial compliance," the interpretation and application of HCFA's new remedial scheme are still uncertain, as states are given broad discretion in defining important terms and in applying and interpreting the criteria to select remedies. Further complicating the issue is the fact that some states, including California, intend to seek waivers from HCFA to substitute their own state enforcement systems for most, if not all, of the new federal system. Based upon these uncertainties, the enforcement of nursing facility standards will likely be in a state of flux for some time to come.     

Special report on reimbursement. Final Medicare fraud and abuse safe harbors are published

There has been great concern in the health care industry that business arrangements that do not comply with the Safe Harbors will automatically be deemed illegal. HHS has confirmed that this is not so; the commentary to the Regulations expressly states that "The failure of a particular business arrangement to comply with these provisions does not determine whether or not the arrangement violates the statute because...this regulation does not make conduct illegal. Any conduct that could be construed to be illegal after the promulgation of this rule would have been illegal at any time since the current law was enacted in 1977....This regulation is intended to provide a formula for avoiding risk in the future." 56 Fed. Reg. at 35955. In the final analysis, the majority of transactions will fall outside the Safe Harbors and thus will continue to be judged by the standards established by the Medicare antifraud statute enacted 14 years ago. Under these standards, as HHS states, "the degree of the risk [in any particular transaction] depends on an evaluation of the many factors which are part of the decision-making process regarding case selection for investigation and prosecution." Id. at 35954. Providers that are mindful of these criteria should therefore still be able to accomplish, with relative safety, transactions that do not qualify for Safe Harbor protection.     

Special report on reimbursement. HCFA publishes proposed rule establishing new payment system for physicians

Whether any or all of these effects actually occur is presently a matter of conjecture. Over the long term, however, it is likely that RBRVS will lead to new opportunities to structure relationships between hospitals and physicians. In practical effect, DRG payments to hospitals, coupled with RBRVS fee schedules, are designed to promote patient care in outpatient settings. This means there will be new opportunities for joint ventures and practice/management arrangements between hospitals and physicians. As these new arrangements come to fruition, both hospitals and physicians must be aware of the financial implications of the new RBRVS codes.     

Special report on taxation. Prepare for impending legislation that could threaten your tax-exempt status!

With impending federal action, and the likelihood of "copycat" legislation at the state and local levels if a federal statue is adopted, nonprofit hospitals need to ensure that they will be in compliance if a mandatory charity care bill were to become law. Such facilities should take the initiative now, by clearly articulating their charity care policies and by describing their other undercompensated or uncompensated activities that are maintained in order to benefit their communities. They should also ensure that all of their activities that could be counted as charity care or community benefit are fully documented and quantified. Financial consultants and counsel may be helpful in this process. Exempt facilities also should, of course, closely monitor the progress of the bills discussed above. Most importantly, they should continue to test their charity care and community benefit statistics on a regular basis to determine if their facilities meet the thresholds specified in the bills as they proceed through Congress.     

Publication of the OIG's provider self-disclosure protocol--Office of Inspector General (OIG), HHS. Notice

This Federal Register notice sets forth the OIG's recently-issued Provider Self-Disclosure Protocol. This Self-Disclosure Protocol offers health care providers specific steps, including a detailed audit methodology, that may be undertaken if they wish to work openly and cooperatively with the OIG to efficiently quantify a particular problem and, ultimately, promote a higher level of ethical and lawful conduct throughout the health care industry.     

见义勇为行为的民法透视

见义勇为的行为是民法无因管理行为的种类之一 ,属事实行为。又有别于无因管理 ,具有自身特点 ,见义勇为行为的发生引起了民事上的几种请求权 ,负有义务的各方当事人应履行各自的义务 ,由此形成的债权债务关系 ,构成了见义勇为行为所引发人与人之间的人身和财产利益的法律机制。受益人向救助者给付酬谢金是民法债务关系的新创见。这有利于弘扬当今社会有难相助 ,大义大勇的高尚精神     

Damned if they do, damned if they don't: the need for a comprehensive public policy to address the inadequate management of pain

Amy Dilcher examines the need for a comprehensive pain policy and argues that opioids--highly effective drugs for pain management--should be legally and practicably accessible to medical professionals and their patients, as and when needed to provide relief from pain. The article synthesizes a number of perspectives regarding the regulation of pain management and demonstrates that the inadequate treatment of pain stems from a multitude of barriers. After reviewing Congressional action on the topic, Ms. Dilcher concludes with recommendations for a more comprehensive pain policy that would enhance the management of pain.