Traditionally, the Office of the Inspector General for the U.S. Department of Health and Human Services (“OIG”) would take a hard stance on any arrangements that might involve some form of remuneration from a hospital to a referring physician, but the winds of change may be blowing. In Advisory Opinion 22-20, published in December of 2022, the OIG has given a green light, albeit in a limited context, to an arrangement in which a hospital may have its employee nurse practitioners perform some services traditionally performed by the patients’ primary care physicians. This is a small step in the direction of a more flexible OIG stance on the federal Anti-Kickback Statute (“AKS”), but it doesn’t completely sidestep risks.

It may seem like hair-splitting, but including the wrong diagnostic codes for malnutrition on hospital inpatient claims – using codes for severe malnutrition in place of other forms of malnutrition – is a costly mistake. The estimated overpayment as a result of these coding errors is a reported $1 billion. Because the payment error rate was so high at a colossal 31%, Medicare-Severity Diagnosis Related Group ("MS-DRG") applicable entities must take note and prepare for a marked increase in Department of Health and Human Services Office of Inspector General ("OIG") audits for these coding practices. The Centers for Medicare & Medicaid Services ("CMS") also plans to implement review practices for malnutrition coding on a sample of inpatient claims. The increased payer audits will result in severe financial damage for hospitals and other MS-DRG applicable entities if they do not mitigate coding and documentation risks.

The rapidly-evolving field of health care has been moving lately towards a single-minded goal – coordination of patient care in the name of efficiency and efficacy. Hospital systems are more and more often merging with other medical practices to better achieve the standards and goals of the Patient Protection and Affordable Care Act (“ACA”). The Ninth Circuit Court of Appeals, however, recently provided a stark reminder that the ACA isn’t the only law hospitals need to consider compliance with in these mergers.

The Affordable Care Act (“ACA”) took a big leap forward this month with the opening of the federally-facilitated and state-operated Exchanges. Here in Kentucky, 70,467 people reportedly participated in pre-screenings to determine qualifications for subsidies, discounts, or programs like Medicaid on the Health Insurance Exchange’s first enrollment day, October 1, 2013. The ACA is eventually expected to provide health coverage to as many as 30 million additional Americans. So, why are hospitals across the nation slashing jobs?

Earlier this week, I discussed CMS’ final rule on the prospective payment for acute care and long-term care hospital inpatient services for fiscal year 2014. The final rule provides guidance to physicians on how to designate a patient as inpatient or outpatient and the impact of the designation on Medicare Part A or Part B coverage. This blog will discuss the two midnight rule.

In August, the Centers for Medicare and Medicaid Services (“CMS”) announced a final rule regarding the prospective payment for acute care and long-term care hospital inpatient services for fiscal year 2014. This rule becomes effective on October 1, 2013.