Legal Issues

With the federally mandated compliance date for the National Provider Identifier (NPI) quickly approaching, the Workgroup for Electronic Data Interchange (WEDI), of which the AMA is a member, and the Blue Cross and Blue Shield Association are offering a free introductory online education program. These on-demand audio and video Webcasts (meaning they can be viewed at any time) can help physicians understand how to obtain and implement their NPI by the May 23 deadline.

On June 19th, 2006, the U.S. Supreme Court declined to hear a law suit filed by several states, including Texas, Kentucky, Maine, Missouri, and New Jersey, challenging the “clawback” provisions of the Medicare Part D program of the Medicare Modernization Act (MMA). The Supreme Court did not comment on their decision, but indicated that the proper venue for disputes would be in lower courts. Under the “clawback,” states are required to make monthly payments to the federal government to help it cover the cost of providing prescription medication for dual eligibles (individuals covered by both federal Medicare and state Medicaid) who are enrolled in a Medicare prescription drug plan. Although state funding of the program is planned to be phased-down over a 10-year period, states argue the clawback causes them to lose the financial benefit of having shifted low-income beneficiaries from Medicaid to Medicare.

On Feb. 8, 2006, President George W. Bush signed into law the broad reaching Deficit Reduction Act (DRA).  Among its many provisions is an extension of CMS's moratorium on issuance of new provider numbers, or payment, to physicians with ownership-interests in specialty hospitals, until August, 2006.  On or before Aug. 8, 2006, CMS is required to issue a final report studying physician specialty hospital investment interests, including care provided to low-income patients at physician-owned specialty hospitals.  If CMS fails to issue a report in this time, the moratorium automatically extends until Oct. 8, 2006, at which time the moratorium will automatically expire.
 
The DRA also authorized limited pilot projects to study gainsharing arrangements between physicians and hospitals.  CMS is charged with soliciting for demonstration project participants, and must choose the projects by Nov. 1, 2006.

Significantly, the DRA also froze the scheduled 4.4 percentMedicare physician payment decrease that was to take effect at the beginning of the year.  Physicians will continue to receive payment at 2005 Medicare reimbursement levels.

On Jan. 3, 2006, the Center for Medicare and Medicaid Services (CMS) launched the Physician Voluntary Reporting Program (PVRP).  The program provides a means for physicians to report clinical performance measures to CMS through the existing Medicare claims submission administration.  The program will enable CMS to better analyze the quality of care provided to Medicare beneficiaries. 

Physicians who voluntarily elect to participate will provide information to CMS through a defined set of sixteen HCPCS codes (G-codes), supplemental to regular claims data.  CMS will provide feedback to participating physicians about submitted data starting in summer 2006.  The objective is for physicians to use such feedback to improve their data accuracy, reporting rate and clinical care. 

CMS intends to expand the preliminary set of measures as additional consensus-developed measures become available, and eventually replace the current means of clinical data collection with electronic submission through electronic health records.

The AMA continues to vigorously oppose the implementation of the PVRP as announced, and will continue to press CMS to address deficiencies in the program.

The Office of Inspector General (OIG) on November 16, 2005 released its Work Plan for fiscal year 2006.  The purpose of the Work Plan is to outline the areas the OIG believes represent vulnerabilities in DHHS’ programs and activities that need closer review. 

OIG plans involving physicians and other health care professionals include review of relationships between these individuals and billing companies, as well as evaluation of the impact of initial preventative physical examinations on Medicare payments and physician billing practices.  The OIG will also estimate the extent to which physicians excluded from federal health care programs continue to perform services for Medicare beneficiaries.

The Work Plan includes detailed plans for monitoring the massive drug-benefit program, Medicare Part D.  To monitor Part D, the OIG will assess the extent to which Medicare beneficiaries are aware of the program’s low-income subsidy, as well as the marketing of Part D benefits in rural areas.  In addition, the OIG plans to evaluate the coordination between Medicare Parts B and D in order to prevent duplicate payments for drugs.  Of particular concern to the OIG is fraud and abuse in the prescription drug card program. Accordingly, the OIG will train special agents to review potentially fraudulent arrangements and relationships under Part D.  

With respect to Medicare hospitals, the OIG will address issues such as whether hospitals are receiving appropriate reimbursement for new technologies, and whether reimbursements accurately reflect audit adjustments for graduate medical education.  

In addition to the programs outlined in the Work Plan, the OIG intends to review DHHS relief programs in hurricane-affected areas.  

The new Bankruptcy Abuse Prevention and Consumer Protection Act of 2005, which went into effect on Oct. 17, 2005, amends the Federal Bankruptcy Code, and affords broad new protections to patients affected by health care bankruptcies. The Act amends the Code with respect to health care business (i.e.,  including, but not limited to, physician medical practices) bankruptcies in four significant ways. First, where there are insufficient funds to store medical records, patients are to be given written notice that the records will be destroyed if unclaimed in one (1) year. Second, within thirty (30) days of bankruptcy filing, a patient care ombudsman is to be appointed to monitor patient care, who is to file periodic reports and, if there is a decline in the quality of care, file a motion with notice to all interested parties. Third, the Act provides that the Trustee may claim as an administrative expense the costs incurred in closing a health care business in bankruptcy. Fourth, the Act indicates that bankruptcy does not preclude HHS from excluding the debtor physician from participation in Medicare or other Federal programs.

As of October 1, 2005, the Centers for Medicare and Medicaid Services (CMS) will be returning non- Health Insurance Portability and Accountability Act (HIPAA) compliant claims to the filer for resubmission in compliant format, thus terminating the contingency exception which has permitted covered entities to submit non-compliant transactions since October 16, 2003.  CMS expects that the HIPAA claim submission standards will bring administrative efficiencies and cost savings.

On Feb. 16, 2006, the Department of Health and Human Services (HHS) published the Final Enforcement Rule for the Heath Insurance Portability and Accountability Act (HIPAA).  This final rule extends the existing privacy regulation noncompliance enforcement procedures to the other HIPAA administrative simplification regulations.  The new regulations clarify investigation procedures under HIPAA and set forth rules for the imposition of civil monetary penalties on covered entities.  It also clarifies and expands upon bases for liability, grounds for waiver, conduct of hearings and the appeals process.  The Final Rule is effective March 16, 2006.

On Oct. 6, 2005, the U.S. Department of Health and Human Services (HHS) awarded three contracts totaling $17.5 million to public-private groups that will promote the adoption of health information technology in health care. Award recipients included the American National Standards Institute (ANSI), the Certification Commission for Health Information Technology (CCHIT), and the Health Information Security and Privacy Collaboration (HISPC), a new partnership focused on privacy and security practices. The awards were spurred by the loss and destruction of medical records by Hurricanes Katrina and Rita, and will help to achieve the President's goal of widespread interoperable electronic health records within ten years.

The contract recipients will create and evaluate processes for harmonizing health information technology standards; develop criteria to certify and evaluate electronic health record (EHR) products; and develop solutions to address challenges to interoperability posed by variations in privacy and security standards under state law and business policies.

The Litigation Center is a coalition of the American Medical Association and the state medical societies. Its purpose is to represent the medical profession in the courts, in accordance with AMA policies. Specialty societies may and do request assistance from the Litigation Center.

Cases are selected according to a variety of criteria, including their importance to the medical profession and their precedential value. Since Jan. 1, 2000, the Litigation Center has become involved with 150 cases representing the interests of physicians and patients, ranging from the level of the state trial courts to the United States Supreme Court. Click here to learn about some of the more notable cases in which the Litigation Center has been recently or is now currently involved.

Summaries of current legal issues, court decisions, and products available by the legal group.

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Summaries of current legal issues, court decisions and products available by the legal group.

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Summaries of legal issues, court decisions and products available by the legal group.

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Summaries of legal issues, court decisions and products available from the legal group.

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Summaries of legal issues, court decisions and products available from the legal group.

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