The government and insurance carriers are becoming highly vigilant about patient information and claim requirements. At the same time more and more people are being covered by health benefit providers like Medicare and Medicaid, without due consideration to any eligibility criteria. This not only complicates financial management for medical practitioners but also expose them to some serious legal issues. With increasing stress on details of medical billing practices, stringent security regulations regarding patient data and complex procedures pertaining to claim filing, legal issues are bound to spring up due to even minor oversights.
In such a demanding scenario, handling every aspect of an independent medical practice can prove almost impossible for a physician whose prime focus is supposed to be patient care and being well versed with latest medical practices.
Some of the most recurring and expensive legal complications that a medical practitioner is expected to face are–
- Breaches and violation of HIPAA and the HITECH act –
The privacy, security and breach notification rules as per the HIPAA and the HITECH acts, necessitate meticulous handling of technical violations and actual breaches done by medical practitioners. Cases where it is mandatory to send notification to the HHS and physicians have overlooked the requirement; have resulted in settlement costs of as high as $1 million.
- CMS penalties and rewards –
The CMS conducted a nationwide survey on quality of care and readmission rates in hospitals, shifting from quantity based reimbursements to quality based payments by Medicare, Medicaid and other insurance carriers. Re-hospitalizations related to congestive heart failure, acute myocardial infarction and pneumonia, within a 30 day period will cause the CMS to reduce payments to the hospital in case. The reforms are beginning from January 2013 and additional conditions will be added by 2015
- Recovery Audits –
Since 2010, adherence to Recovery Audit Contractor Program has been effective and consistent efforts are being made towards lowering claim submission error rate and identifying overpayments. With automation and digitization of review process as well as auditors accessing medical records for thorough reviews, more transparency and vigilance is expected in the audit process.
- Collection of overpayments –
Fiscal Cliff bill signed in January 2013 has revised the statute of limitations for non fraudulent Medicare overpayments to five years, thereby allowing Medicare contractors to recoup overpayments from physicians and hospitals dating back to 2007.
- Post deadline appeal for a claim – The concept of ‘Equitable tolling’ is catching on allowing healthcare providers to appeal a claim even after the 180 day deadline, under special circumstances.
Medical billing experts at medicalbillersandcoders.com can help medical practices adhere to regulatory requirements such as encryption, business associate agreements and risk assessments thereby avoiding any litigation for breach or violation. We can also help appeal a claim past deadline, manage overpayments and supervise readmission rates as per the standards expected by the CMS. So our clients using our services can focus on patient care and medical aspect of their practice with a free mind.