A physician's practice is not limited to the clinical side of medicine. Physicians cannot ignore the business, legal or effects that outside events have on their business.
Recent cases and guidance provide physicians with items to keep on their radar. Below is a list of a few items and events that physicians should take note of.
1. Medical necessity. On June 22, 2017, the Fifth Circuit Court of Appeals (Maxmed Healthcare Inc. v. Price) upheld a lower court's ruling that the extrapolation and sampling method utilized by the government to determine the Medicare provider's overpayment amount was proper and consistent with the Medicare Program Integrity Manual (MPIM). Maxmed was paid approximately $773,967 for providing home health services that were deemed not medically necessary. The government reviewed 40 claims and extrapolated the claims to 130.
2. Opioid epidemic. The Oklahoma Attorney General filed suit against 13 pharmaceutical manufacturers alleging fraudulent marketing, which, in turn, caused the state to pay millions of dollars in treating the opioid dependency. The basis for the claims is the state False Claims Act, consumer protection law and the Medicaid Program Integrity Act. Additionally, public nuisance, fraud and unjust enrichment were also claimed.
3. MACRA. On June 30, 2017, the Centers for Medicare and Medicaid Services (CMS) published in the Federal Register, a proposed rule to modify the provisions of the November 4, 2016 final rule. The November 2016 final rule became effective on January 1, 2017 and implemented quality based measures for reimbursement instead of the long standing fee-for-service model. The Merit Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (AAPMs) are the focus of the proposed rule's modifications.
For physicians, the takeaways regarding each of these events are as follows:
•Make sure that charts are adequately documented to establish medical necessity. In the event of a RAC or MAC audit, the government may use statistical methods to extrapolate a sample. In turn, this could impact the amount a practice has to return to the government.
•The opioid epidemic is everywhere in the news. Physicians are conduits to patients receiving prescription drugs. As such, the type, the dose, and the longevity of the prescription are going to be considered. Make certain that these prescriptions are medically necessary and appropriate for the condition being treated.
•MACRA is very complicated and physicians need to keep a close watch on the law because it relates to the livelihood of their practice. Importantly, physicians should focus on the four components of a MIPS final score (i.e., quality, cost, advancing care information and improvement activities) and the impact on their final score in determining upward, downward, or neutral payment.
In sum, there are a lot of issues to keep a pulse on. The ones included here all could have an adverse impact on revenue cycle and reputation. Therefore, physicians should stay informed and seek assistance if they do not understand how these current events could impact their practice.