Hot Topics in Health Care - July 2022
AMA Provides a No Surprises Tool-Kit
As most health care providers know by now, the No Surprises Act (NSA) prohibits out-of-network health care providers from balance billing commercially insured patients, in certain circumstances. However, most physicians do not realize that uninsured patients and commercially insured patients who choose not to use their benefits are entitled to a good faith estimate (GFE) of charges from providers before the scheduled services are performed. If the actual charges by a particular provider exceed the GFE amount by more than $400, the patient is entitled to dispute the charges under an arbitration process.
Further, physicians’ responsibilities for the GFE differ depending on whether they serve as a “convening provider ” or a “co-healthcare provider.” A convening health care provider (or facility) is one that receives an initial request for a GFE or that is responsible for scheduling the primary service. A co-health care provider (or facility) is one, other than the convening provider or facility that furnishes items or services in conjunction with the primary service.
To help physicians navigate the NSA, the AMA has published a “tool-kit” for physicians to help them focus on three operational challenges that physicians need to address immediately: (1) non-emergency services at in-network facilities, (2) emergency services and post-stabilization care at hospitals and freestanding emergency departments and (3) good faith estimates for self-pay and uninsured patients.
Another Impactful Decision from The SCOTUS - It Is Something Other Than Abortion or Gun Control
On June 27, 2022, the Supreme Court of the United States (SCOTUS) heard an appeal emanating from a conviction of a doctor in Mobile, Alabama and a separate conviction of a doctor in Wyoming. The justices specifically examined convictions of Dr. Xiulu Ruan of Alabama and Dr. Shakeel Kahn of Wyoming, both serving prison sentences of more than 20 years.
In an important precedent-setting decision, SCOTUS ruled that prosecutions under the Controlled Substances Act for excessive prescribing of opioids and other addictive drugs must prove that doctors knew the prescriptions lacked a legitimate medical purpose. Specifically, SCOTUS held that the Department of Justice "must prove beyond a reasonable doubt that the defendant-doctor knew that he or she was acting in an unauthorized manner, or intended to do so," in order to secure a conviction for improper prescribing. The decision carries nationwide implications for criminal and civil cases related to sales and distribution of prescription narcotics.
The decision vacated the circuit court opinions upholding the underlying convictions and directed the lower courts to take a fresh look at the jury instructions given in the trial.
HHS Issues Updates - HIPAA Privacy Rule and Disclosures of Information Relating to Reproductive Health Care
On June 29, 2022, the Office for Civil Rights (OCR) updated its resource material regarding the HIPAA Privacy Rule and reproductive health care. OCR reiterated its position that the Privacy Rule supports access to health care services by giving individuals confidence that their PHI, including information relating to abortions and other sexual and reproductive health care will be kept private. The publication reviews various disclosures required by law and emphasizes that disclosures to law enforcement officials are narrowly tailored to protect an individual’s privacy and access to health services. Specifically, the update discusses and gives examples of (1) disclosures required by law, (2) disclosures for law enforcement purposes and (3) disclosures to avert a serious threat to health or safety.