Federal Out-of-Network Balance Billing Legislation: Context and Implications for Radiology Practices.

Out-of-network (OON) balance billing, commonly known as surprise billing but better described as a surprise gap in health insurance coverage, occurs when an individual with private health insurance (vs a public insurer such as Medicare) is administered unanticipated care from a physician who is not in their health plan's network. Such unexpected OON care may result in substantial out-of-pocket costs for patients. Although ending surprise billing is patient centric, patient protective, and noncontroversial, passing federal legislation was challenging given its ability to disrupt insurer-physician good-faith negotiations and thus impact in-network rates. Like past proposals, the recently passed No Surprises Act takes patients out of the middle of insurer-physician OON reimbursement disputes, limiting patients' expense to standard in-network cost-sharing amounts. The new law, based on arbitration, attempts to protect good-faith negotiations between physicians and insurance companies and encourages network contracting. Radiology practices, even those that are fully in network or that never practiced surprise billing, could nonetheless be affected. Ongoing rulemaking processes will have meaningful roles in determining how the law is made operational. Physician and stakeholder advocacy has been and will continue to be crucial to the ongoing evolution of this process. © RSNA, 2021.

Rules and Regulations Relating to Roles of Nonphysician Providers in Radiology Practices.

Nonphysician providers (NPPs) in radiology practices include nurse practitioners, physician assistants, and radiologist assistants. The number of NPPs has been increasing both within and outside of radiology departments. In order for leaders in radiology departments to incorporate NPPs effectively into their practice, they require nuanced knowledge of appropriate coding and billing for services these professionals render. Furthermore, the existing body of literature suggests that with a defined and appropriate scope of practice and proper supervision, NPPs can provide care that is at least equivalent to that provided by attending physicians for narrowly defined tasks. A broader understanding of the rapidly evolving NPP workforce both within radiology practices and throughout other health care specialties will inform practice leaders who are adapting to a health care system that is moving rapidly toward value-based incentive payment models. ©RSNA, 2018.

[Analysis of final judgements in cases of medical negligence occurred in Ukraine].

OBJECTIVE: Introduction: The peculiarities of the disadvantages of providing medical care in Ukraine are not well-known abroad. The aim: To study the peculiarities of court decisions in cases of unfavorable consequences of medical activity. PATIENTS AND METHODS: Materials and methods: The article analyzes the official data of the General Prosecutor's Office of Ukraine and the website of court decisions regarding criminal cases against medical practitioners. RESULTS: Review: Approximately 600 cases of alleged medical malpractice cases are registered annually in Ukraine. Only less than one percent of them are brought to the court. The guilt of medical practitioners was proven in majority (80,8%) of court decisions. Acquittals of defendants were pronounced in 5,9% of court verdicts. Obstetrics and gynecology, surgery, internal medicine and anesthesiology are in the top of high-risk medical specialties. CONCLUSION: Conclusions: Majority of medical malpractice litigations are sued in Ukraine baselessly. In cases of medical negligence majority of defendants are acquitted as usual.

Medical Malpractice Damage Caps and Provider Reimbursement.

A common state legislative maneuver to combat rising healthcare costs is to reform the tort system by implementing caps on noneconomic damages awardable in medical malpractice cases. Using the implementation of caps in several states and large database of private insurance claims, I estimate the effect of damage caps on the amount providers charge to insurance companies as well as the amount that insurance companies reimburse providers for medical services. The amount providers charge insurers is unresponsive to tort reform, but the amount that insurers reimburse providers decreases for some procedures. Copyright © 2015 John Wiley & Sons, Ltd.

Blundering into Liability: Unwitting Creation of Employment Contracts.

You think you are an employer at will. Think again! This article discusses how employers too often create binding contracts of which they are completely unaware-until the employee or former employee seeks to enforce the "contract" and collect on the liabilities the organization did not know it had. Such lack of awareness may lead to the creation of full-blown contracts of employment, or a variety of mini-contracts that can be enforced for smaller, specific issues, or huge liability for wages and commissions. It may even eliminate the ability to enforce the organization's work rules and discipline. This article focuses on the contract area.

Thriving Under Medicare's Newest Pay-for- Performance Program: Making Sense of the Merit-Based Incentive Payment System And the Alternative Payment Models: Part I.

This is the first in a three-part series of articles intended to guide medical practice managers through the maze of the innovative,'yet complex regulations that will affect the amounts paid to healthcare providers by Medicare for at least the next three years. The goal of this series is to provide information to help practices optimize their payment potential from Medicare in 2019 based on their actions toward compliance for some portion of 2017 and to prepare to expand these behaviors as required in future years. Although there-are two pathways for participation in these new pay-for-performance programs, the series focuses more on actions required in the Merit-Based Incentive Payment System (MIPS). Approximately 85% of clinicians submitting Medicare Part B claims will participate in MIPS. The remaining 15% could assume risk in return for larger incentives while carrying out improvement activities similar to the MIPS requirements in frameworks known as Alternative Payment Models.

Avoiding Lawsuits for Wage and Hour Violations.

Due to the highly technical language in the wage and hour laws and regulations, employers often find that they have unknowingly violated the Fair Labor Standards Act (FLSA). This can occur because employers have improperly classified an employee as exempt or because employers do not realize that certain time should be paid in full. Improperly classifying employees as exempt or failing to compensate nonexempt employees for all time worked can lead to costly lawsuits, audits, or enforcement actions by the Wage and Hour Division of the Department of Labor. This article discusses the most common FLSA exemptions and provides best practices to avoid liability under the FLSA.

Practice Consolidation: Forces Not of Nature, but of Government, Demographics, Economics, and Technology.

The demand for healthcare services is increasing more rapidly than the supply of providers, while reimbursement levels ignore the free market law of supply and demand. The regulated healthcare environment in the United States fails to increase prices (i.e., reimbursement rates) as demand outstrips supply. Healthcare practitioners must find alternative methods in order to continue providing excellent patient care while at the same time maintaining an economically viable practice. Practice consolidation with the assistance of private equity healthcare investment is an extremely attractive solution to this imbalance.

Employee Absences and the Americans with Disabilities Act.

Under the Americans with Disabilities Act (ADA), a leave of absence may be a reasonable accommodation if it is likely to enable the employee to return to work. Employers should review their attendance and disciplinary policies to ensure that they are not violating the ADA when enforcing these policies. When an employee requests time off, the employer should determine the employee's rights under all of the relevant statutes if the request is related or possibly related to a disability. Importantly, the ADA is not a free pass for violations of an employer's attendance policy. Employers are within their rights to require doctor's note or other documentation to substantiate an employee's need for leave.

The False Claims Act: Increases in Investigations, Violations, and Penalties.

The False Claims Act is a tool used by the government, its contractors, and even employees of healthcare providers to recover overpayments and other improper reimbursements given to physicians for healthcare services provided to Medicare and other federal health program beneficiaries. In recent years, we have seen an increase in the number of False Claims Act cases filed against unsuspecting healthcare providers and practices. These cases have resulted in billions of dollars being paid back to the federal government. Knowing and understanding the requirements of the False Claims Act and implementing best practices and strategies to avoid violating any of these provisions will help practices to ensure that they do not become subject to the massive penalties imposed on violators.

Compliance Issues Facing Practices.

Healthcare fraud enforcement has increased exponentially over the past few years. Practice groups have seen increased enforcement specifically from the federal government. It has never been more important to ensure everyone in your organization understands the various compliance issues and the risks they present. This article highlights the top compliance issues to help your practice groups understand the risks related to healthcare fraud. Once everyone in your organization understands these issues, you can work toward developing effective compliance programs to limit the risks.

Why Practices Should Screen Against Every State Exclusion List.

Many physician practices believe it is enough to screen their employees against the Office of Inspector General's (OIG's) List of Excluded Individuals and Entities upon employment, and perhaps annually thereafter. Although this may have been an acceptable practice in years past, the OIG's Updated Advisory Bulletin on the Effect of Exclusions, the Centers for Medicare & Medicaid Services mandates to state Medicaid programs on screening, and the rules and regulations issued by the states themselves in response to these initiatives have broadly and significantly increased providers' exclusion screening obligations. This article discusses the nature of the expanded screening requirements for providers, and why the risks of noncompliance are too great to ignore.

Is the swiss health care system a model for the United States?

Both supporters and critics of the Patient Protection and Affordable Care Act (ACA) have argued that it is similar to Switzerland's Federal Law on Health Insurance (LAMal), which currently governs Swiss health care, and have either praised or condemned the ACA on the basis of this alleged similarity. I challenge these observers on the grounds that they overlook critical problems with the Swiss model, such as its inequities in access, and critical differences between it and the ACA, such as the roots in, and continuing commitment to, social insurance of the Swiss model. Indeed, the daunting challenge of attempting to impose the tightly regulated model of operation of the Swiss model on mega-corporations like UnitedHealth, WellPoint, or Aetna is likely to trigger no less ferocious resistance than a fully public, single-payer system would. I also conclude that the ACA might unravel in ways unintended or even opposed by its designers and supporters, as employers, confronted with ever-rising costs, retreat from sponsoring insurance, and workers react in outrage as they confront the unaffordable underinsurance mandated by the ACA. A new political and ideological landscape may then ensue that finally ushers in a truly national health program.

Your EHR license agreement: critical issues.

This article discusses several key provisions and concepts in software license agreements for electronic health records. It offers insight into what physician practices can expect to find in their license agreements, as well as practical advice on beneficial provisions. The article examines contractual language relating to term and termination, technical specifications and support, and compliance with governmental programs.

The health of healthcare, Part VI: Be prepared!

We who work in healthcare need to know our future. The following are virtually assured consequences of Patient Protection and Affordable Health Care Act: expansion of both the bureaucracy and its complexity; government restrictions on what physicians are allowed to do medically; more underinsured Americans; greater focus on outcomes; the death of private practice; more hospital closings; less available liability insurance; and an increase in medical tourism. We must--as the Boy Scouts advise--"Be Prepared"!

Business associates gone bad: five tales of woe and ways to prevent them from happening to you.

Liability for confidentiality of protected health information extends beyond the walls of a medical practice. Studies show a significant number of breaches occur via the actions or inactions of third-party entities/business associates. These business associates are trusted with patient information to assist a medical practice and can include collection agencies, third-party billing firms, transcription services, etc. Medical practices can be legally liable for the breaches of their business associates. This article provides an overview as to proper methods of retaining and monitoring business associates in an effort to minimize exposure from these firms.

Is your practice at risk for medical identity theft?

Medical identity theft has become increasingly prevalent. Medical practices need to take action and have policies and procedures in place to prevent data breaches. This will protect both the patient and the practice from medical identity theft.

Eleven essential steps to purchasing or selling a medical practice.

Based on our experience in representing more than 100 doctors and medical specialists in practice sales and acquisitions, we have identified 11 key considerations important to a deal. There are several issues to consider while going through the process of buying or selling a practice including the implementation of a "letter of intent" as a first step rather than drafting a contract, securing a lease, and verifying the property is not in violation of the local zoning requirements. There are also considerations with regard to the patients, which range from how will the accounts receivable at the time of the closing be handled to who is responsible for the handling of continued treatment in an ongoing case after a deal is finalized. This article details these considerations and more.

Using patient safety organizations to further clinical integration.

This article addresses why in the current context of driving toward improved value, physician groups ought to consider developing a patient safety evaluation system and reporting to a patient safety organization. The fundamental challenge to physicians to succeed in the future is to clinically integrate within their own practices, standardizing to the evidence base, and measuring their performance. In addition, it is increasingly clear that the physician office practice is a source of patient safety issues. The Patient Safety and Quality Improvement Act provides two powerful protections for data that will support and bolster clinical integration and patient safety. The protections and how to deploy them are presented.