On Tuesday, we discussed the history and basic elements of a violation of the False Claims Act. Today’s post will explore the penalties and enforcement of the Act.

The federal False Claims Act (“FCA”)[1] casts an incredibly long shadow, covering every transaction between the federal government and a private party seeking payment from it. Enacted at the height of the Civil War in 1863, the law was designed to keep military suppliers honest in their dealings with a government already strapped from fighting a war. Since then, the FCA has served as an almost nuclear deterrent to those who would attempt to defraud the government when requesting payment for services. In 2014, the Department of Justice managed to recover $5.69 billion under the law. False claims in federal healthcare programs accounted for $2.3 billion of that figure, which makes the FCA, as well as its interaction with other laws such as the Affordable Care Act, fraught with difficulty for unwary healthcare providers.

It was with the best of intentions that Congress passed the Federal Confidentiality of Alcohol and Drug Abuse Patient Records Law over forty years ago. The patient privacy regulations (“Part 2”) spawned by this law reflected a sensitivity to the stigma that can accompany substance abuse, preventing highly vulnerable patients in need from seeking appropriate treatment.[1] In the interim, however, the field of behavioral health care has experienced seismic shifts in coordinated patient care while the regulations concerning these patient records have failed to adapt to changing standards such as electronic health records or health information exchanges. Due to this inflexibility, providers and patients are now facing a host of impediments in the provision of behavioral healthcare.

Although supervising physicians are required to follow regulatory guidelines, it is also important that physician assistants (“PAs”) understand their role in the authority delegated to them and the specifics of regulatory compliance for supervision.

My last post focused on the discovery and investigation of a data security breach to determine if breach notification is needed. Today’s post now turns to the requirements of breach notification triggered by a data security breach.

As discussed in my prior post, recent massive data breaches at major retailers and health insurance providers paint a bleak picture of modern data and emphasize the importance of strong security safeguards and plans for handling suspected security breaches for electronic protected health information (“ePHI”). In the healthcare context, a security breach of a covered entity or a Business Associate’s (BA) data security system triggers the Security Rule and can trigger certain breach notification requirements under Health Insurance Portability and Accountability Act (“HIPAA”) and Health Information Technology for Economic and Clinical Health Act (“HITECH”). This post will discuss the investigation needed to determine whether a breach has taken place, while the next post will discuss the necessary notifications in the event of a breach.

The first part of this article discussed pharmacist provider status and argument both for and against it. Today’s post now turns to regulatory hurdles, developments towards provider status and the acknowledgment of changing roles in the pharmacist workforce.

While the passage of the Patient Protection and Affordable Care Act (“ACA”) ushered in a new era of access to health care, it only served to exacerbate a growing crisis in the provision of health care – lack of providers. As of April 2015, the Health Resources and Services Administration lists the population of the United States that lives within a health professional shortage area (“HPSA”) for primary care as 103,847,716, with 1,023,989 of those living in Kentucky.[1] This shortage calls for a reimagining of ways that non-physician providers can fill the care gap, and the debate surrounding the provider status of pharmacists with regard to federal health care programs is evidence of a changing mindset.

Tuesday’s post discussed the basics of Transitional Care Management (“TCM”), but today’s post will focus on five things that providers should know about TCM.

Similar to rules providing billing opportunities for chronic care management (as discussed in this McBrayer blog post), relatively new Medicare funds for Transitional Care Management (“TCM”) provide a new path for providers to supplement their Medicare practice with payment for services they may already provide. Beginning in 2013, Medicare, for the first time, allowed providers to bill for thirty days of TCM, incentivizing post-discharge care with an aim to prevent hospital readmission. The Center for Medicare and Medicaid Services (“CMS”) requires five specific elements of TCM to be met before provider reimbursement. Those elements merit review and brief discussion today, while Thursday’s post will discuss five important points of consideration with regard to TCM.