Welcome to Alan S. Goldberg’s GoldbergLawyerBlog(sm)  HEALTHLAWYERBLOG(sm) for lawyers and law and other students for educational purposes only.

CV: About Alan S. Goldberg

Web site: http://www.GoldbergLawyer.com

Blogs: http://www.healthlawyerblog.com http://GoldbergLawyer.wordpress.com

Social networks:

http://twitter.com/GoldbergLawyer

http://www.linkedin.com/in/GoldbergLawyer

http://legalonramp.com/

DISCLAIMER: This blog is for lawyers and law and other students for educational purposes only and does not create a business or professional services relationship. This blog is provided upon the understanding that this blog does not constitute the rendering of legal or other professional services. While all reasonable attempts are made to ensure the accuracy of the information appearing in this blog, there are no express or implied representations or warranties regarding the accuracy of this information. This information may not be relied upon or used as a substitute for consultation with legal, accounting, tax, or other professional advisors. New York law requires a reminder that this is ATTORNEY ADVERTISING. Prior results do not guarantee a similar outcome. Virginia law requires a reminder that case results depend upon a variety of factors unique to each case; and case results do not guarantee or predict a similar result in any future case undertaken. Mr. Goldberg is not a Florida Bar board certified attorney in health law and is not certified as a specialist by any state bar or legal certifying organization. There is no procedure in Virginia for approving such certifying organizations.

___________________________________________________________________________

Alan S. Goldberg, Attorney & Counsellor-at-Law, 6845 Elm Street, Suite 205,
McLean, Virginia 22101

Admitted VA NY DC FL MA

© Copyright 2009, Alan S. Goldberg. All rights reserved.

http://www.medicare.gov/privacypractices.asp

Medicare program Notice of Privacy Practices for the Original Medicare Plan

http://www.inova.org/patient-and-visitor-information/pdfs/privacy-policy.pdf

INOVA NOTICE OF PRIVACY PRACTICES

http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/notice.pdf

Background - OCR publication regarding NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION [45 CFR 164.520]

Please also read the HIPAA Administrative Simplification statute:

http://aspe.hhs.gov/admnsimp/pl104191.htm

PUBLIC LAW 104-191

AUG. 21, 1996

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996

Public Law 104-191

104th Congress

Note please that the HIPAA Administration Simplification statute is affected by several subsequently enacted statutes, including most recently the The American Recovery and Reinvestment Act of 2009, Public Law 111-005 enacted February 17, 2009

http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h1enr.pdf

which includes the so-called HITECH Act found at pages 112 et seq.

TITLE XIII—HEALTH INFORMATION

http://www.healthlawyers.org/Resources/PI/Policy/Documents/Stark White Paper.pdf

OR

http://sn.im/sm3qq-drp

Please also see below for a hot link to a copy of the so-called Stark Law, which we also will study during our class on October 22, 2009.

http://sn.im/sm41e-aod

OR

http://www.ssa.gov/OP_Home/ssact/title18/1877.htm

and to the so-called health care civil monetary penalties false claims and antikickback statutes

http://www.ssa.gov/OP_Home/ssact/title11/1128A.htm

http://www.ssa.gov/OP_Home/ssact/title11/1128B.htm

And recall also that in a prior email, you were asked to study a recent OIG advisory opinion:

http://www.oig.hhs.gov/fraud/docs/advisoryopinions/2009/AdvOpn09-17.pdf

in anticipation of our discussion this week of seeking advisory opinions from the Office of Inspector General of the US Department of Health & Human Services.

Blick v. Connecticut

http://voices.washingtonpost.com/capitol-briefing/2009/10/senate_finance_committee_relea.html

http://www.washingtonpost.com/wp-srv/nation/documents/Americas_Healthy_Future_Act_amended_100209.pdf

Consider, as you peruse the above hot-lined materials, how, among others, members of Congress who are not physicians or hospital administrators, and physicians, and patients, will, or can, understand and apply changes in health care that would be implemented by detailed rules eventually to be published with policies to follow, pursuant to the current version of the bill referenced above.  Do you perceive any areas most likely to be subject to fraud and abuse, error, confusion, and undue complexity?

http://oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf

The file is 115 sheets or so long, so be patient with the downloading, please.  We'll study this material when we discuss fraud and abuse and related topics, please.

Recoupment Rule Change

quote

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 405

[CMS-6025-F]

RIN 0938-AN42

Medicare Program; Limitation on Recoupment of Provider and

Supplier Overpayments

AGENCY: Centers for Medicare & Medicaid Services (CMS),

HHS.

ACTION: Final rule.

SUMMARY: This final rule implements a provision of the

Medicare Prescription Drug, Improvement, and Modernization

Act of 2003 (MMA) which prohibits recouping Medicare

overpayments from a provider or supplier that seeks a

reconsideration from a Qualified Independent Contractor

(QIC). This provision changes how interest is to be paid to

a provider or supplier whose overpayment is reversed at

subsequent administrative or judicial levels of appeal.

This final rule defines the overpayments to which the

limitation applies, how the limitation works in concert with

the appeals process, and the change in our obligation to pay

interest to a provider or supplier whose appeal is

successful at levels above the QIC.

http://www.cms.hhs.gov/transmittals/downloads/R303PI.pdf

quoted snip

LCDs specify under what circumstances a service is generally considered to be reasonable and necessary. In rare and unusual circumstances during complex medical review MACs, FIs and carriers have the authority to apply an exception to the clinical criteria described in an LCD.

quote

Background:Local coverage determinations are determinations made by a fiscal intermediary, carrier, or MAC respecting whether or not a particular item or service is covered on an intermediary-, carrier-, or MAC- wide basis. LCDs specify under what circumstances a service is generally considered to be reasonable and necessary. In rare and unusual circumstances during complex medical review MACs, FIs and carriers have the authority to apply an exception to the clinical criteria described in an LCD.

In rare and unusual circumstances, contractors have the authority to apply an exception to the clinical criteria described in an LCD for individual claims

CERT RAC

6586.2

Contractors shall base their exceptions requests on a thorough review of the patient’s medical record and the relevant evidence in the medical literature.

CERT RAC

6586.3

Contractors other than RACs shall use this process for the purposes of approving or denying an individual claim. RACs shall only use the exception process to not deny an individual claim.

CERT RAC

6586.4

Contractors shall document in a log the individual claims that are approved or denied based on an LCD exception.