News You Can Use
As we previously observed, tele-dentistry is HERE! And – for its rewards and risks – it appears that even as COVID restrictions ease it’s here to stay. While we outlined the MANY rewards dental professionals and patients, alike, have experienced we also need to examine the risks that accompany online connectivity.
Coping with a genuine pandemic left every healthcare professional, their facilities and practices, scrambling to establish new protocols and means to continue providing quality medical care…ushering in the TRUE dawn of telemedicine! Many – such as surgeons, ophthalmologists and dentists – found themselves floundering amid the growing pandemic restrictions and patient reluctance. Yet, the insurance industry has actually had multiple billing codes for teledentistry available for years! So, the question begs to be asked: “How DOES one do dentistry ‘remotely’?!?
From Texas Health & Human Services,
The new Provider Management and Enrollment System (PMES) will consolidate and replace multiple enrollment processes and systems. The new system will benefit providers by reducing administrative burden and streamlining processes. The attached fact sheet includes a brief overview of PMES, its benefits, and an implementation timeline.
As the main users, it is essential HHSC works with providers to gain feedback throughout implementation, and encourages providers to submit initial input through the link below.
https://www.surveymonkey.com/r/PMES
There will be additional opportunities to discuss ideas and engage further beginning in May.
We’re going to start by saying just one word: AUDIT! Quick…what immediately went through your mind? Panic…Costs… or maybe, Confidence…or was it more of a physical reaction: Headaches…Gut Punch…Nausea…Sweating? That could all change very soon, thanks to several amendments recently proposed by the Texas Health and Human Services Commission!
So, what do these amendments mean for you? You know that feeling – if you've ever received a record request from a Medicaid MCO (Managed Care Organization), you know what a daunting task it can be to fulfill that request. And that’s assuming a best-case scenario! If you don't routinely audit your records, chart documentation and billed charges, we’re right back to sweating, nausea, stress...
And this could especially be true if you own a small practice. The standard request required you to first pull patient records for 50 CLAIM recipients, and THEN start the tedious review process, just to ensure all your ‘I’s are dotted and ‘T’'s are crossed before you even hand them over to the MCO – when the real tension begins. Depending upon the size of your existing patient base, this could amount to a complete internal review of up to 10-20 percent of your charts!
However, the OIG (Office of the Inspector General) has now proposed to cap the number of claims an MCO can request for a standard provider record audit. Based on this proposed amendment, an MCO would be able to request no more than 30 claims or 15 percent of a provider’s submitted Medicaid claims – whichever is the lesser number! This represents GREAT news for all providers, because it reduces a provider’s workload in preparation for an MCO review.
However, WellDent Compliance clients can skip the panic…nausea…well, you get the idea. We provide regular "in-house" audits of billed charges and chart documentation as part of our ongoing compliance services. And this makes it easier to spot “gaps” and allow you submit a corrected claim to show an act of provider good faith, and possibly mitigate or eliminate liability. However, if your practice does not have currently have protocols to routinely monitor these details, you should institute one immediately. And, if you DO have a system in place, these internal audits should continue to be routine within your practices. If any claims are found to be filed incorrectly, a corrected claim should be filed as soon as possible.
But, this new HHSC proposal could noticeably improve your life, when that inevitable MCO record audit request comes knocking at your practice door! FMI…see source article below.
by Joseph "Joe" Geraci, Jameson Sauseda | Husch Blackwell LLP
As provided in the Texas Register on March 22, 2019, the Texas Health and Human Services Commission (“HHSC”) has proposed several amendments to Title 1 of the Texas Administrative Code, which include amendments to the rules and procedures for preventing and investigating Medicaid fraud and abuse.
HHSC has proposed amendments to Sections 353.502 and 353.505 in effort to reflect the legislative changes as a result of House Bill 2379, which provided managed care organizations (“MCOs”) the ability to, under certain circumstances, retain a portion of the funds recovered by the HHSC Office of the Inspector General (“HHSC-OIG”) when fraud or abuse cases are referred to it by an MCO.
The proposed amendments include reducing the number of Medicaid recipient claims an MCO must review from 50 to 30 recipients or 15 percent of a provider’s claims. In addition, an MCO is required to notify HHSC-OIG of possible acts of waste, abuse, or fraud within 30 working days of the completion of an investigation. MCOs must also include specific documentation in their report to HHSC-OIG, including, among other documents, the provider’s credentialing documents, the complete investigative file as well as a summary of past investigations. The proposed amendments also attempt to simplify the existing language of Section 353.505 to improve coordination between MCOs and the HHSC-OIG regarding the referrals and recovery process of Medicaid fraud and abuse claims.
In accordance with SB 313, passed by the Texas Legislature during the 85th Legislative Session, several changes will take effect on September 1, 2017:
Click on this link to review the text of SB 313.
Earlier this summer, our family took a mini-vacation to the beach for a little rest and relaxation. Although this was only a 4-day trip, it was special because we took the whole family… including our 18-month-old Maltese. We rarely get to take him on trips, so we thought he’d love new surroundings at the condo and beach. When we arrived, one of the FIRST places we decided to hit was the swimming pool. With excitement gleaming, my wife and daughter decided to go out and scout the resort and report back, while I unwound from the long drive.
One of the first things they said, when they got back, was our dog couldn’t go to the pool. They had a “No Pets Allowed” sign posted in the pool area. This meant we couldn’t even have him on the deck around the pool. Bummer! He was NOT happy, and cried as we left him behind in a strange and unfamiliar place. All I could think about, while at the pool, was how I wished he could join us in the sun.
My wife mentioned if he were certified as a service dog, he would be allowed in the pool area. She said she knew someone who certified their cat as a service animal, to relieve their social anxiety disorder. After arrivinghome from our trip, I began to research registering our dog as a service animal. I found out, that for $70-$140, we could have him certified. Seemingly easy – but odd – since nothing required any proof of a disability. In good conscience, I was unable to go through with it, since no one in our family has an “official diagnosis” of a listed disability for an emotional support dog.
Let’s fast forward to today. Coincidentally, one of my clients just happened to send me a text message asking if service dogs were allowed in the Dental operatory. Based on my earlier personal research into service dog certification, I informed them they had to allow it. Because the Dental office, including the operatory, is “a place of public accommodation” they have to permit the use of a service animals for people with disabilities.
The American Disabilities Act (ADA) says it is against federal law for anyone to ask for proof of an animal’s certification, training or licensing. Even if the office has a “no pets allowed” policy, a service animal is STILL allowed, unless the doctor can show why permitting the service animal in that area would pose “a significant health risk.” Only service animals displaying vicious behavior toward or posing a direct threat to the health and safety of patients, patrons or employees, may be excluded from the facility.
Their question made me think back to our little trip andthe dilemma we had with our dog earlier this summer. I thought to myself, he’ll just have to be happy with our trips to Home Depot! Now let me see, what’s next on my “honey do’ list?
Will McGowan
(Americans with Disabilities Act Title III Technical Assistance Manual, 4.2300)
From the Texas Dental Association:
As a part of ongoing efforts to prevent potentially devastating “rebalancing” of Medicaid dental fees, the Texas Dental Association (TDA) will meet with Health and Human Services officials in the coming weeks to discuss each of the codes individually and make recommendations about appropriate fee adjustments for each code. The recommendations will balance the state’s budgetary concerns with creating a dental rate reimbursement methodology that represents the most logical and best use of state funds to improve dental access for Medicaid children.
TDA’s advocacy efforts on behalf of its Medicaid participating dentists was instrumental in securing this meeting prior to Tuesday’s rate hearing and last Wednesday’s Health and Human Services Committee hearing. HHS Executive Commissioner Charles Smith confirmed that the agency will wait to receive TDA’s feedback before making any final decisions.
The state’s top legislative and agency decision makers seek the TDA’s presence and guidance. This is only one of many examples of the Association’s strong advocacy program on behalf of dentistry in Texas. TDA is only as strong as its membership. I urge all dentists, if not already, to become members of the Texas Dental Association in an effort to continue its long-standing efforts of being advocates for the dental professions and the patients we treat.
Dr. Joey Cazares
President – Texas Dental Association
(from August 2017 TDMR Publication)
The amount of opioids prescribed in the United States peaked in 2010 and then decreased each year through 2015, but remains at high levels and varies from county to county in the U.S., according to the latest Vital Signs report by the Centers for Disease Control and Prevention (CDC).
In 2015 six times more opioids per resident were dispensed in the highest-prescribing counties than in the lowest-prescribing counties. This wide variation suggests inconsistent prescribing practices among healthcare providers and that patients receive different care depending on where they live.
“The amount of opioids prescribed in the U.S. is still too high, with too many opioid prescriptions for too many days at too high a dosage,” said Anne Schuchat, M.D., acting director of the Centers for Disease Control and Prevention. “Healthcare providers have an important role in offering safer and more effective pain management while reducing risks of opioid addiction and overdose.”
CDC researchers analyzed changes in annual prescribing measures from 2006 to 2015 and found that while there have been declines in the amount of opioids prescribed, more can be done to improve prescribing practices. For example, between 2006 and 2015 the amount of opioids prescribed peaked in 2010 at 782 morphine milligram equivalents (MME) per person and decreased to 640 MME in 2015. (MME is the amount of opioids in milligrams, accounting for differences in opioid drug type and strength.)
Daily MME per prescription remained stable from 2006 to 2010 and then decreased 17 percent from 2010 to 2015 (from 58 MME to 48). However, the average days’ supply per prescription increased 33 percent from 13 days in 2006 to almost 18 days in 2015. The amount of opioids prescribed per capita in 2015 was still approximately three times as high as in 1999.
County-level opioid prescribing patterns vary
For this Vital Signs report, CDC analyzed retail prescription data from QuintilesIMS to assess opioid prescribing in the United States from 2006 to 2015, including rates, amounts, dosages, and durations prescribed. CDC examined county-level prescribing patterns for the years 2010 and 2015.
County-level factors associated with higher amounts of opioids prescribed include:
“While some variation in opioid prescribing is expected and linked to factors such as the prevalence of painful conditions, differences in these characteristics explain only a fraction of the wide variation in opioid prescribing across the United States,” said Deborah Dowell, M.D., M.P.H., chief medical officer in the Division of Unintentional Injury Prevention at CDC’s National Center for Injury Prevention and Control. “This variation highlights the need for healthcare providers to consider evidence-based guidance when prescribing opioids.”
Ensuring access to safer, more effective pain treatment
In 2016, CDC published the CDC Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. These recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than three months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care. The Guideline includes recommendations such as:
Healthcare providers should also use state-based prescription drug monitoring programs (PDMPs), which help identify patients at risk of addiction or overdose.
The Guideline can also be used by health systems, states, and insurers to help ensure appropriate prescribing and improve care for all people. Tools and resources are available to help providers and patients discuss the risks and benefits of opioid therapy for chronic pain to improve the safety and effectiveness of pain treatment and to reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death. For more information about preventing opioid overdose: www.cdc.gov/drugoverdose.
Vital Signs is a CDC report that typically appears on the first Tuesday of the month as part of the CDC journal Morbidity and Mortality Weekly Report. The report provides the latest data and information on key health indicators. These are cancer prevention, obesity, tobacco use, motor vehicle injury prevention, prescription drug overdose, HIV/AIDS, alcohol use, healthcare-associated infections, cardiovascular health, teen pregnancy, and food safety.
Centers for Disease Control & Prevention
This month we look at a case involving a HIPAA privacy violation. This case is particularly important (and unusual) because it illustrates two points: 1) a person can get jail time for a HIPAA violation (even a misdemeanor violation), and 2) ignorance of the law does not protect you.
Dr. H was in his mid-40's when he took a research position with a large, well-known health system in a major city. The research position was not what Dr. H wanted, but he had a family to support, and had to take whatever employment he could. In his native country of China, Dr. H had been a cardiothoracic surgeon, but since immigrating to the United States a few years ago, his job options had been limited. Although he felt that the research position was beneath him, he also felt he had no choice, at least until his English became more fluent and he obtained the requisite licensing to perform surgery again. His wife also worked, but they had three small children to support, and they were living in an expensive part of the country.
Dr. H's frustration with the position was apparent to many of his colleagues, and his discomfort with speaking English meant that he tended to be a loner. His performance reviews were poor, and in less than a year he was given notice that he was going to be terminated from the job. His employer had an appeal process, and a grievance hearing regarding his termination was set. In the meantime, Dr. H began idling away his remaining days at the health system by looking at patient records for entertainment. The day he was notified of his termination, he accessed the first one – his immediate supervisor. Over the next few weeks, Dr. H browsed the medical records of many of his colleagues. He also viewed the records of the health-system's many high-profile patients, including well-known movie stars, television personalities, and people in public office.
Dr. H never shared the information he saw in the records. He didn't talk about it with his wife, or try to sell the information about the celebrity patients to the tabloids. He knew he shouldn't be looking at records of patients who were not his, but believed that as long as he didn't share the information he gained, it wasn't a problem. Thus, he didn't believe that he had committed a federal offense.
After losing his job, Dr. H was hit with another shock – he was charged by the government with violating the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which imposes a misdemeanor penalty on a person who knowingly and in violation of the act obtains individually identifiable health information relating to an individual.
Dr. H immediately hired a defense attorney, who told him that although there was information that Dr. H had illegally accessed patient records over 300 times, the government was only charging him with four counts, instances which had taken place after he was no longer working at the health system.
“But I didn't do anything wrong,” said Dr. H. “I never sold the information or told anyone about it.”
“They aren't charging you with selling the information,” said the attorney. “If they were, you would be facing a felony and a lot of jail time. They are charging you with simply accessing identifiable health information without a valid reason for doing so. You were not treating any of those patients. And in the last several instances, you weren't even working for the health system anymore.”
“But I didn't know that was a crime…” said Dr. H.
The attorney made a motion to dismiss the case, seeking to have the charges against Dr. H dropped. The court denied the motion. Then the defense attorney sought to have the court issue jury instructions telling the jury that elements of the case required that the defendant knew that obtaining the personal medical information was a violation of criminal laws. The court refused. Faced with what appeared to be a losing proposition, Dr. H entered a conditional plea of guilty, reserving his right to appeal his original motion to dismiss the case. Dr. H was sentenced to four months in prison, followed by a year of supervised release, and a $2,000 fine. Dr. H appealed the case.
Legal Background
On appeal, the Ninth Circuit held that the plain text of the statute does not limit its application to people who knew their actions were illegal. Rather, the court stated, “the misdemeanor applies to defendants who knowingly obtained individually identifiable health information relating to an individual, and obtained that information in violation of HIPAA.” The key language, according to the court, was “knowingly and in violation of this part.” Dr. H wanted it to be interpreted as “knowingly, in violation of this part” – therefore presuming that knowledge that it was a violation was necessary for conviction. The court, however, disagreed, saying that if the statute did not contain the word “and,” Dr. H's argument might be more persuasive. “However, we cannot ignore ‘and' because its presence often dramatically alters the meaning of a phrase,” wrote the court in its decision. “Without ‘and,' the Second Amendment would guarantee ‘the right of the people to keep bear arms,' Leo Tolstoy would have published ‘War Peace,' and James Taylor would have confusingly crooned about ‘Fire Rain.'”
The court went on to say that “HIPAA's legislative history indicates that Congress intended broadly to apply this misdemeanor criminal penalty,” and that “our conclusion is supported by Congress's decision not to require willfulness as an element of the crime.”
The court refused to dismiss the case, and Dr. H's conviction stood.
Protecting Yourself
Criminal penalties for HIPAA violations are rare, but not unheard of. Civil penalties (fines) are far more common. In this case, Dr. H's employer faced civil HIPAA violations due to its employee's actions. The health system ended up paying over $800,000 in civil fines related to this case.
This case stands for the proposition that ignorance of the law is no excuse.
Criminal penalties for HIPAA violations can be severe. In Dr. H's case, he was facing a fine of up to $50,000 and a year in jail. If the offense were committed under false pretenses, a perpetrator could be fined up to $100,000 and imprisoned for up to 5 years. And finally, if the offense is committed with intent to sell, transfer, or use the health information for personal gain or to harm someone, a perpetrator may be fined up to $250,000 and imprisoned for up to ten years.
Protecting yourself is not difficult – avoid, at all costs, accessing medical records which you have no legitimate medical purpose to be viewing. Patient privacy is paramount – treat it that way.
by Ann W. Latner, JD
www.empr.com
A proposal to eliminate health insurance companies and guarantee government-funded health care for all California residents is moving forward.
The Senate Health Committee voted Wednesday to send the measure to the Appropriations Committee. The vote came after hundreds of nurses clad in red held a rally in Sacramento, marched to the state Capitol and packed into a committee room.
The proposal is promoted by the state's powerful nursing union and two Democratic senators who say California should create a national model for providing health care for everyone.
Critics say the measure would disrupt the health care used by millions of Californians, would require high taxes and would likely create longer waits to see a doctor.
Associated Press, KXTV
