Reprinted with Permission from the Birmingham Medical News
If the 2017 healthcare environment could be summed up in one word, it would be “uncertainty.” With the largely unexpected election of Donald Trump as President, the multiple, unsuccessful attempts by the Republican controlled Congress to repeal and replace the Affordable Care Act (“ACA”), and the recent Executive Orders by President Trump that could destabilize the health insurance markets, payers, providers and patients are trying to plan for an uncertain future. In addition, Alabama healthcare providers of all sorts and sizes face increased cyber security threats, a new Medicare Administrative Contractor beginning the first quarter of 2018, and changes to Medicare payment and performance initiatives. In these uncertain times, I present to you my top ten healthcare developments of 2017 for Alabama healthcare providers.
10. Physician Practice Settles with the Government for Failure to Return Credit Balances. On October 13, 2017, it was announced that First Coast Cardiovascular Institute, P.A. (“First Coast”), a Florida physician practice, had agreed to pay $448,821 to resolve allegations that it violated the False Claims Act by knowingly delaying repayment of more than $175,000 in credit balances owed to Medicare, Medicaid, TRICARE, and the Department of Veterans Affairs. The settlement stemmed from a qui tam lawsuit brought by a former employee of First Coast. While the total dollar amount of the settlement is relatively small compared to other False Claims Act cases, the application of a 2.5x multiplier of single damages is on the high end. It is widely expected that the government will increase its investigation and prosecution of providers who fail to return credit balances or other overpayments owed to federal payers. Pursuant to the ACA, a provider or supplier who has received an overpayment from a federal payer must return the overpayment within the latter of: (1) 60 days after the date on which the overpayment was “identified,” or (2) the due date of a corresponding cost report, if applicable (the so-called “60-Day Rule”). An overpayment is “identified” once a provider or supplier has or should have, through “reasonable diligence,” quantified the overpayment. This investigation period cannot exceed six months from receipt of credible information of the overpayment, absent extraordinary circumstances.
9. Alabama Pill Mills. As a by-product of the Opioid Crisis (see paragraph 2 below), the government has stepped up its investigation and prosecution of physician practices that prescribe narcotics for illegitimate purposes, so called “pill-mills”. In March of this year, two pain management physicians in Mobile, Alabama were convicted of running a pill-mill following a seven-week trial. The physicians received lengthy prison sentences and forfeited virtually all of their personal assets, including several houses, beach condos, and 23 luxury cars. In addition, each physician was ordered to pay a $5 million judgment to the government, as well as $15 million in restitution. A few months after the conviction, U.S. Attorney General Sessions announced a nationwide takedown of 120 doctors, nurses, and pharmacists, entitled “Operation Pilluted,” who were charged with various federal offenses related to their alleged “unlawful distribution of opioids and other prescription narcotics.” Recently, a special prosecutor has been assigned to the Northern District of Alabama in Birmingham for the sole purpose of investigating providers that illegally prescribe narcotics.
Download the full article, “2017 Healthcare Year in Review” written by Howard E. Bogard.