By SARAH HILLEGONDS, ESQ.
Targeted probe and educate (TPE) audits are the latest type of audits facing Medicare providers and suppliers (collectively referred to as “providers”). TPE audits are unique in that providers may be subject to up to three rounds of record reviews. If a provider fails to improve the accuracy of their claims after three rounds, the provider will be referred to CMS for possible further action.

The Centers for Medicare and Medicaid Services initially launched TPE as a pilot program in one Medicare Administrative Contractor (MAC) jurisdiction limited to certain types of claims. In October 2017, CMS expanded TPE audits to all MACs for all Medicare providers and [Read More]

By ALLAN DOBZYNIAK, MD
One of the drivers of increasing health insurance policy premiums, and especially ACA policies, is the so called “community rating.” This is the concept that requires health insurance companies to offer policies within a given territory at the same price to all persons without medical underwriting, regardless of their health status. This does not account for all premium increases such as coverage mandates and increasing provider costs (almost exclusively attributable to hospitals), but it has become increasingly consequential. For the ACA, as the premiums increase fewer healthy people, particularly the younger, can afford the increasing premiums, or they may voluntarily choose not to purchase the more expensive [Read More]

By FEDERICO MARIONA, MD
The Michigan voters recently approved Proposal 1 by a margin of 56 to 44 percent. Retail for-profit sales of marijuana and related products is now the law in Michigan. Our state is the first state in the Midwest to take this step. Our neighbor Canada already has this in place. There are no neighboring states that have approved the use of marijuana for retail sales, yet.

Marijuana is a product from the flowers, stems, leaves and seeds of the plant (Phyto cannabinoids), and is the most common illicit drug used in the United States. Phyto active elements [Read More]

By THOMAS MILES, ESQ. & REESA N. BENKOFF, ESQ
On Nov. 26, 2018, the Office for Civil Rights (OCR), a division of the U.S. Department of Health and Human Services, announced that it had entered into a settlement agreement with Allergy Associates of Hartford, P.C. regarding alleged violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. The settlement requires Allergy Associates to pay the OCR $125,000 and enter into a two-year Corrective Action Plan. Allergy Associates, a physician practice with four office locations in Connecticut, is comprised of four physicians and two mid-level providers. Despite the seemingly low settlement figure, this fine relates to [Read More]

By SERJ MOORADIAN
Healthcare providers balance their time and resources between providing the best possible care to patients and keeping up with their ever-changing regulatory landscape. Providers are often at the mercy of the federal and state agencies that administer healthcare programs, which have significant discretion in interpreting statutes, promulgating rules and guidance that implement those statutes, and their enforcement. Due to the sheer number of applicable requirements, any provider that regularly bills a government healthcare program is likely to have an enforcement action brought against it by a government agency at some point, no matter how strong the provider’s compliance program is.

When an administrative agency takes [Read More]

By PAUL NATINSKY
Governor-elect Gretchen Whitmer has her work cut out for her. Despite historic gains for Democrats and women in Michigan and national midterm elections, Michigan’s legislature retains its Republican majority, and thus presents the new governor with an uphill challenge on all of her initiatives, including her healthcare plan, titled, “Get It Done: Healthy Michigan, Healthy Economy.”

The 19-page document covers a full range of issues facing a state that has low to middling marks on health status, access to care and the cost of healthcare services.

“The state of Michigan has invested very little in public health—just enough to meet what is needed to draw down federal funding,” stated Whitmer [Read More]

By EMMARIE HUETTEMAN
For the first time since passing the Affordable Care Act, Democrats will soon control the House of Representatives and its powerful health committees. But Republicans’ tightened grip on the Senate means those hoping for another round of dramatic, progressive reforms may be disappointed.

Empowered by voters outraged over Republican attempts to chip away at the law’s protections for the sick, Democrats owe much of their midterm takeback to health care issues. And Democratic leaders say they are ready to get back to work, this time training their sights on skyrocketing drug prices, among other policy conundrums, with a majority of House votes and a slate of new committee chairmanships [Read More]

By EWA MATUSZEWSKI
At this risk of entertaining numerous strategic partnership requests following the publication of this blog, I want to explore the benefits of partnerships that may or may not have financial benefits, yet bring the strengths of two or more parties together for the greater good.

What has me thinking of partnerships in general is the soon-to-be launched integrated primary care clinic our PO is opening at the Warren location of the Judson Center. Judson Center provides autism programs, behavioral health services, child and family services including foster care and adoption, and disability support services throughout Southeast Michigan. With the opening of the clinic, they can add primary care to [Read More]

By SARAH HILLEGONDS
In August, the Provider Reimbursement Review Board released 90 pages of updated rules governing its appeals process. The rules were issued with immediate effect and apply to all pending and future appeals. If a provider fails to comply with these new rules, the PRRB has discretion to dismiss the appeal.1 Because appeals before the PRRB are typically high-value cases, it is critical that attorneys and providers that have cases before the PRRB understand the rule changes.

As background, the PRRB is an independent adjudicating body of the United States Department of Health and Human Services to which a Medicare Part A provider may appeal if dissatisfied with a “final [Read More]

By GREGORY W. MOORE & ALEXANDRA A. HALL
Forty-eight thousand Americans were lost to opioid overdoses in 2017. Michigan opioid-related deaths and overdoses rank 18th-highest in the nation. Over the last year, significant attention was dedicated toward combating this widespread issue on both a federal and state level.

Michigan

Recently enacted Michigan opioid laws were executed with the intent to save lives and decrease misuse of controlled substances. In effect, the laws have imposed significant administrative hurdles and led to some confusion among prescribers, pharmacists, and patients.

The new laws impose substantial obstacles for prescribers prior to writing a prescription for opioids. Among such obstacles include the requirement that when a prescriber [Read More]