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Out of Network Billing Under Increased Scrutiny

Out of network patient billing gives rise to many issues. As a result, some health care providers, including physician groups and ambulatory surgery centers, have struggled with the decision to participate or not to participate in various insurance plans. In addition to the political considerations that arise, various state and…

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Health Care Fraud Prevention and Enforcement Action Team Announced

The Health Care Fraud Prevention and Enforcement Action Team (“HEAT”)’s formation was announced today by US Attorney General Eric Holder and U.S. Secretary of Health and Human Services (“HHS”) Kathleen Sebelius. The purpose of HEAT is to assist in the crackdown on Medicare fraud. HEAT will be comprised of members…

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New ASC Conditions for Coverage Have Taken Effect

Ambulatory Surgery Centers (“ASCs”) need to take note of additional federal Conditions for Coverage (“CFCs”) governing patient rights that took effect May 18, 2009. The Amendments to these CFCs, which the Centers for Medicare and Medicaid Services (CMS) published on November 18, 2008, are codified at “Part 416 – Ambulatory…

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Michigan Recovery Audit Contractor (“RAC”) Provider Outreach Scheduled for April 10, 2009

The Medicare Recovery Audit Contractor Program (“RAC”) program has been made permanent and is expanding nationwide, pursuant to Section 302 of the Tax Relief and Health Care Act of 2006. Medicare providers and suppliers in Michigan are some of the first in the country that will experience RAC audits and…

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Stark, Anesthesia and the Federal False Claims Act

A recent Federal appeals court decision paved the way for a whistleblower to proceed with a False Claims Act (“FCA”) case involving allegations of Stark and Anti-kickback Statute violations regarding an exclusive anesthesia coverage agreement and pain management services arrangement. This case is important as it highlights how courts and…

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OIG, Medicare Payments and Pain Management Procedures

As part of the OIG 2008 Work Plan, the OIG reviewed Medicare payments for interventional pain management procedures in connection with Section 1862(a)(1)(A) of the Social Security Act, which requires that services must be medically necessary. The OIG noted that interventional pain management was a growing specialty and that Medicare…

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The Red Flag Rules and Health Care Providers

As the “Red Flag Rules” enforcement date of May 1, 2009 quickly-approaches, health care providers need to get prepared. The Red Flag Rules require financial institutions and “creditors” to develop and implement identity theft prevention programs that provide for identification, detection, and response to patterns, practices or specific activities (known…