Quality Fraud: What’s That?

Wednesday, November 15, 2023 1:00PM EST; 12:00PM CST; 11AM MST; 10AM PST

The predominant basis for federal fraud and abuse enforcement and settlements is the False Claims Act. While most of those enforcements and settlements turn on things like failing to perform services or under-documentation of the service billed, there are a host of requirements pertaining to clinical quality that can lead to false claims and other forms of fraud and abuse liability. In this crisp half hour program with a 17 page substantive handout and fifteen minutes for Q & A, Alice elucidates these little appreciated risks which merit focused attention from all providers.

  • Conditions of participation and the new risks associated with medical necessity
  • Quality reporting and pay for performance issues
  • Value-based arrangements and enterprises
  • Other forms of quality failures
  • Penalties including exclusions, sanctions, quality-based civil money penalties, quality-based corporate integrity agreements, false claims liability -- including caselaw
  • Government guidance
  • Practical steps

If you can’t join us live, you can pre-order the recording of the session.  $250 whether live or recorded.  CREDIT CARD ONLY

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Previous Teleconferences

Avoiding Modern Physician Compensation Pitfalls

It has been more than ten years since Alice Gosfield has done a teleconference focused specifically around physician compensation.  In this presentation with a 12 page handout (including links to 6 related more in-depth articles), she reviews 8 types of physician payment revenues from FFS to case rates, bundled payments, gainsharing and more.  She points out the perverse incentives of each, but also, what payer contract terms are essential to protect against pitfalls in each approach.

  • Brief review of the CMMI models as examples of the 8
  • Stark productivity payments, with illumination of what 'incident to' really means
  • Stark profit sharing and the overall profits requirements, clarifying how pods are allowed
  • Focusing on expenses instead of profit-sharing
  • Post-payment audits
  • Voluntary repayments

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Clarifying Questions About The No Surprises Act (NSA)

Many law firms are offering presentations on this confounding statute and regulations. We are taking a different approach. While the rules on balance billing are restricted to some providers, the rules on charge transparency for cash paying patients are far broader affecting physician practices and others besides hospitals.  Dan Shay will clarify 6 common questions about the NSA, including a 14 page handout, with practical guidance including:

  • The types of services to which the rules apply
  • The practice settings in which the rules apply
  • The differences between related documents: Notices, Consents, Disclosures, and Good Faith Estimates
  • The differences between “convening providers” and “co-providers” and their different duties
  • Tips to avoid ending up in disputes and arbitration.

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HIPAA in The Social Media Context

The Health Insurance Portability and Accountability Act (HIPAA) and its regulations have existed for over 20 years, but remain confusing for many health care providers. Since its inception, social media has become an ever-present aspect of modern life, for patients, physicians, and office staff alike. The risks in communicating by social media, even when patients initiate contact with PHI, is not well understood. Myths and misconceptions have arisen with respect to HIPAA in the online context, for all parties, both professionally and personally. Everyone who shares PHI needs to understand the particular problems that arise when they communicate with each otheT, with clinicians, with patients, and with office staff using social media. This thirty minute session with fifteen minutes of Q & A and a detailed, substantive handout will clarify the HIPAA rules and dispel misunderstandings, with a particular focus on their practical application to the social media and online setting. Suggestions will be offered regarding policies health care providers can implement to reduce their risk of HIPAA violations.

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Stark and AKS Teleconferences

We have now slogged our way through both the Stark and anti-kickback (AKS) massive sets of regulations and commentary. These regulations, while restrictive at their core, really do offer some opportunities for many players in the health care sector to work to improve the value of their care – improved quality with lowered costs. Even with a division of labor, just reading the material has taken us collectively 50+ hours. We know that larger firms are offering 1.5 hour webinars about these rules. We are taking a different and, we hope, more useful approach. The regulations themselves are a hodge-podge of issues, not all of which are connected to each other. Also, there are two topics which both sets address: EMRs and cybersecurity; and value-based arrangements. While Stark is a physician-only and Medicare and Medicaid-only statute regarding specific designated health services, AKS applies to everyone on the food chain of federal health care program payment. We think not everyone is interested in all the topics addressed.

Stark 1

Recorded January 19, 2021

Redefined financial terms: commercial reasonableness, volume or value; Permitted directed referrals; Group practices: profit shares, productivity bonuses; In handout only: decoupling from AKS, definitions of DHS, physician, remuneration.

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Stark 2

Recorded January 22, 2021

Fixing Problems: Isolated Transactions, period of disallowance, writing and signature requirements, limited remuneration to a physician; Fair Market Value Redefined Generally; Revised Fair Market Value Compensation Exception; In handout only: ownership or investment; rent of space and equipment; physician recruitment; payments by a physician; recruitment assistance for NPPs; updated obsolete references.

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Recorded January 26, 2021

Revised Safe Harbors: Personal Services and Management Contracts & Outcomes-Based Payment Arrangements: Increased flexibility in personal services/management contract safe harbor requirements, new outcomes-based payment arrangements sub-safe-harbor; Local Transportation: relaxed requirements and expanded geographic areas; New Safe Harbors: Arrangements for Patient Engagement and Support to Improve Quality, Health Outcomes and Efficiency, CMS-Sponsored Model Arrangements and CMS-Sponsored Model Patient Incentives; Civil Money Penalties: Telehealth Technology for Dialysis; In handout only: warranties, ACO beneficiary incentive payment.

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EMR & Cybersecurity

Recorded January 28, 2021

AKS and Stark EMRs: changes to when recipients must pay 15% contribution, Areas of overlap between AKS and Stark; Differences and distinctions between revisions and their significance; AKS and Stark Cybersecurity, Areas of overlap between AKS and Stark, Differences and distinctions and their significance.

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Value-based Arrangements

Recorded February 2, 2021

What is permitted and encouraged; Why two sets of rules; Critical definitions: e.g. VBA, VBE, target population; 3 safety zones specified, Full financial risk, substantial downside risk, coordination and management of care: the small physician practice option; Excluded entities excluded how: e.g., pharma, lab companies, PBMs, DMEPOS; Limited technology participants; How to apply the rules.

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Two Fundamental Tuesdays

Recorded September 22 and September 29, 2020

Diagnostic testing is a critical element of physician practice billing. However, offering these crucial services to the public, physicians providers must navigate Medicare's regulatory maze. From the basic reimbursement and supervision rules, to Stark, to the Anti-Markup Rule, to distinguishing billing by IDTFs, the regulations can be confounding.

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Two Payment Thursdays

Recorded March 21, 2019 and April 4, 2019

The new Medicare Physician Fee Schedule introduces 4 entirely new ‘visit’ codes and 3 documentation changes effective immediately. There are also 3 new ‘visit’ codes for 2021 (with new payment) and new documentation options effective then. This session will focus on these issues only, which will challenge physician practices to manage effectively. We offer an 8 page handout with citations to the applicable policies and links to 4 additional free relevant articles.

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Inducing Beneficiaries: Do's and Don'ts

Recorded April 24, 2018

For many years, our solid legal guidance to physicians about what they could do to benefit their patients without running afoul of the fraud and abuse laws has been restrictive.

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Recorded October 26, 2017

Five years ago, we presented a teleconference on the pros, cons and practicalities of a group practice leasing itself to a hospital or health system, in lieu of employment. The group remains intact.

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Social Media and "BYOD": What Are Your Risks?

Recorded June 22, 2017

Social media usage is a fact of modern life. Facebook has over 1 billion active users, which undoubtedly includes physician practice employees. Physician practices also may want to establish there own social media presence, to connect with current and potential patients. 

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How Secure Do You Feel About Your HIPAA Compliance Plan?

Recorded December 6, 2016

The HIPAA Security Rule compliance stakes have risen. The Office of Civil Rights is currently enforcing against physician practices, and conducting audits of small practices and business associates alike.

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For Whom The Sixty Day Bell Tolls: Risk and Reward in Physicians Returning Overpayments

Recorded April 19, 2016

With less than a page of actual regulations, but 25 pages of discussion, the regulations addressing when and how to repay overpayments have some surprising elements. What triggers the obligation to report is now much broader than most people realize. 

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Beyond Face Time

Recorded February 2, 2016

Reports of the demise of fee for service are entirely premature. In fact, Medicare has introduced new codes to pay physicians for services that do not require that they have a face to face encounter with the patient.

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Is Your Group A Group?

Recorded May 5, 2015

The August, 2014 Stark settlement with the OIG and DOJ for $1.33 million dollars by a New York private practice cardiology group for its internal compensation practices should be seen as a call to arms.

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Unraveling The Knots: Stark and Medicare Reimbursement Principles and Intertwinings

Recorded July 15, 2014

Given the draconian impact of enforcement, it is clearly time to revisit some of the lurking pitfalls in the connection between the Stark law and Medicare reimbursement principles.

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Using Patient Safety Organizations to Bolster Clinical Integration

Recorded January 28, 2014

The demand for providers to change the way they deliver care to demonstrate more value is rampant. To make those changes requires clinical integration which centers, in essence, on analysis of data -- data that by definition demonstrates sub-optimal performance.

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Quality Fraud: What Is That?

Recorded February 14, 2013

This highly focused half hour of lecture with 15 minutes for questions will offer to hospitals and their compliance officers and physician practice groups a much better understanding of looming pitfalls which can be avoided with attention.

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Physician-Hospital Alignment Strategies

With health reform now moving inexorably forward, the implications of value-based payments, bundled payments, and reorganized care delivery - particularly for physicians - must be confronted.

  1. Leasing The Practice To The Hospital: Pros, Cons and Practicalities - (Sept. 11, 2012)
  2. A Physician's Perspective on Co-Management: Opportunities and Pitfalls - (Sept. 18, 2012)
  3. Governance and Contractual Issues Within Bundled Payment: The Physician Perspective - (Sept. 25, 2012)

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The Physician Compensation Challenge: Stark and Responding to The New Value Demands

Recorded June 19, 2012

This teleconference will explain the rules, debunk the myths and offer new information about how leading edge groups are increasingly moving to make their internal compensation models consistent with external demands for improved quality and value.

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