Physicians Legal Issues Conference

CHICAGO – The U.S. Department of Health & Human Service’s Office of Inspector General (OIG) is warning doctors to be wary of improper physician arrangements that could violate the federal Anti-Kickback Statute.

The federal law prohibits doctors from receiving any form of payment in exchange for past or future patient referrals under the Medicare or Medicaid programs.

The OIG recently reached settlements with 12 individual physicians who entered into questionable medical directorship and office staff arrangements. The agency stated money paid to the doctors was improper because the payments took into account volume or value of referrals and did not reflect fair market value for services provided.

Physicians sometimes enter into questionable physicians arrangements, such as medical directorships, without fully understanding if they are proper, said attorney Adrienne Dresevic, who spoke at a recent conference held by the American Bar Association.

In a video interview during the conference, Ms. Dresevic discussed common physician compensation arrangements that come under government scrutiny and how well-intentioned doctors can fall prey to Anti-Kickback Statute allegations. Ms. Dresevic, who practices health law in Southfield, Mich., also spoke about how physicians can avoid risky physician compensation arrangements.

[email protected]

@legal_med

CHICAGO – The U.S. Department of Health & Human Service’s Office of Inspector General (OIG) is warning doctors to be wary of improper physician arrangements that could violate the federal Anti-Kickback Statute.

The federal law prohibits doctors from receiving any form of payment in exchange for past or future patient referrals under the Medicare or Medicaid programs.

The OIG recently reached settlements with 12 individual physicians who entered into questionable medical directorship and office staff arrangements. The agency stated money paid to the doctors was improper because the payments took into account volume or value of referrals and did not reflect fair market value for services provided.

Physicians sometimes enter into questionable physicians arrangements, such as medical directorships, without fully understanding if they are proper, said attorney Adrienne Dresevic, who spoke at a recent conference held by the American Bar Association.

In a video interview during the conference, Ms. Dresevic discussed common physician compensation arrangements that come under government scrutiny and how well-intentioned doctors can fall prey to Anti-Kickback Statute allegations. Ms. Dresevic, who practices health law in Southfield, Mich., also spoke about how physicians can avoid risky physician compensation arrangements.

[email protected]

@legal_med

CHICAGO – The U.S. Department of Health & Human Service’s Office of Inspector General (OIG) is warning doctors to be wary of improper physician arrangements that could violate the federal Anti-Kickback Statute.

The federal law prohibits doctors from receiving any form of payment in exchange for past or future patient referrals under the Medicare or Medicaid programs.

The OIG recently reached settlements with 12 individual physicians who entered into questionable medical directorship and office staff arrangements. The agency stated money paid to the doctors was improper because the payments took into account volume or value of referrals and did not reflect fair market value for services provided.

Physicians sometimes enter into questionable physicians arrangements, such as medical directorships, without fully understanding if they are proper, said attorney Adrienne Dresevic, who spoke at a recent conference held by the American Bar Association.

In a video interview during the conference, Ms. Dresevic discussed common physician compensation arrangements that come under government scrutiny and how well-intentioned doctors can fall prey to Anti-Kickback Statute allegations. Ms. Dresevic, who practices health law in Southfield, Mich., also spoke about how physicians can avoid risky physician compensation arrangements.

[email protected]

@legal_med

CHICAGO – From Stark law to HIPAA violations to whistle-blower claims, clinicians face a litany of legal land mines in today’s practice landscape.

Not only that, but rules and regulations are constantly changing, and the government continues to increase its scope in some areas, said Michael E. Clark, chair of the American Bar Association Health Law Section.

Clinicians should be mindful of the new – and old – laws that impact them and take steps to prevent legal scrutiny, Mr. Clark advised during a conference held by the American Bar Association.

In a video interview at the conference, Mr. Clark discussed the most pressing health law issues for clinicians and ways in which they can avoid such risks. Mr. Clark, who practices health law in Houston, also shared his perspectives on what the future holds for upcoming legal dangers.

[email protected]

@legal_med

CHICAGO – From Stark law to HIPAA violations to whistle-blower claims, clinicians face a litany of legal land mines in today’s practice landscape.

Not only that, but rules and regulations are constantly changing, and the government continues to increase its scope in some areas, said Michael E. Clark, chair of the American Bar Association Health Law Section.

Clinicians should be mindful of the new – and old – laws that impact them and take steps to prevent legal scrutiny, Mr. Clark advised during a conference held by the American Bar Association.

In a video interview at the conference, Mr. Clark discussed the most pressing health law issues for clinicians and ways in which they can avoid such risks. Mr. Clark, who practices health law in Houston, also shared his perspectives on what the future holds for upcoming legal dangers.

[email protected]

@legal_med

CHICAGO – From Stark law to HIPAA violations to whistle-blower claims, clinicians face a litany of legal land mines in today’s practice landscape.

Not only that, but rules and regulations are constantly changing, and the government continues to increase its scope in some areas, said Michael E. Clark, chair of the American Bar Association Health Law Section.

Clinicians should be mindful of the new – and old – laws that impact them and take steps to prevent legal scrutiny, Mr. Clark advised during a conference held by the American Bar Association.

In a video interview at the conference, Mr. Clark discussed the most pressing health law issues for clinicians and ways in which they can avoid such risks. Mr. Clark, who practices health law in Houston, also shared his perspectives on what the future holds for upcoming legal dangers.

[email protected]

@legal_med

CHICAGO – From Stark law to HIPAA violations to whistle-blower claims, physicians face a litany of legal land mines in today’s practice landscape.

Not only that, but rules and regulations are constantly changing, and the government continues to increase its scope in some areas, said Michael E. Clark, chair of the American Bar Association Health Law Section.

Physicians should be mindful of the new – and old – laws that impact them and take steps to prevent legal scrutiny, Mr. Clark advised during a conference held by the American Bar Association.

In a video interview at the conference, Mr. Clark discussed the most pressing health law issues for doctors and ways in which physicians can avoid such risks. Mr. Clark, who practices health law in Houston, also shared his perspectives on what the future holds for upcoming legal dangers.

[email protected]

@legal_med

CHICAGO – From Stark law to HIPAA violations to whistle-blower claims, physicians face a litany of legal land mines in today’s practice landscape.

Not only that, but rules and regulations are constantly changing, and the government continues to increase its scope in some areas, said Michael E. Clark, chair of the American Bar Association Health Law Section.

Physicians should be mindful of the new – and old – laws that impact them and take steps to prevent legal scrutiny, Mr. Clark advised during a conference held by the American Bar Association.

In a video interview at the conference, Mr. Clark discussed the most pressing health law issues for doctors and ways in which physicians can avoid such risks. Mr. Clark, who practices health law in Houston, also shared his perspectives on what the future holds for upcoming legal dangers.

[email protected]

@legal_med

CHICAGO – From Stark law to HIPAA violations to whistle-blower claims, physicians face a litany of legal land mines in today’s practice landscape.

Not only that, but rules and regulations are constantly changing, and the government continues to increase its scope in some areas, said Michael E. Clark, chair of the American Bar Association Health Law Section.

Physicians should be mindful of the new – and old – laws that impact them and take steps to prevent legal scrutiny, Mr. Clark advised during a conference held by the American Bar Association.

In a video interview at the conference, Mr. Clark discussed the most pressing health law issues for doctors and ways in which physicians can avoid such risks. Mr. Clark, who practices health law in Houston, also shared his perspectives on what the future holds for upcoming legal dangers.

[email protected]

@legal_med

CHICAGO – Too often, physicians sign managed care contracts without negotiating or truly understanding all the terms. The complex clauses – or lack thereof – can come back to bite doctors in the form of delayed payments, sudden policy changes, and termination woes, health law attorney Mark S. Kopson warned at conference held by the American Bar Association.

To avoid these unwelcome surprises, prepare for contract discussions well before the conversation starts, Mr. Kopson advised.

Alicia Gallegos/Frontline Medical News

“Don’t go into any negotiation unless you know two things. The first is what your starting position will be and, equally if not more important, is what is your ultimate line in the sand?” said Mr. Kopson, who practices in Bloomfield Hills, Mich. “If you go in there not knowing those answers, you’re liable to give away the store or not get what you really need.”

One major “gotcha” is an insurer that does not reveal upfront that it is not the actual payer, Mr. Kopson said. Some national companies that enter into contracts with doctors are basically network aggregators that negotiate price discounts but then sell the network to the health insurance marketplace, he explained. Physicians later realize their contract states that the company is not responsible for paying claims and that the doctor does not have a contract directly with the payer.

“This is a really big issue that I’ve been seeing more and more frequently,” Mr. Kopson said at the meeting. “If you don’t have a direct contract with the payer, you have the possibility of not being able to force payment obligations against the responsible party.”

Specify in your contract that the plan must require the payer to pay, he said. That way, if a payer fails to pay, the plan has breached its contract obligation.

Contract terms that involve medical necessity also can lead to frustration if not properly negotiated. In some cases, the fine print states that medical necessity will be determined by the plan’s medical director or otherwise will be ultimately decided by the payer. Instead, include language specifying that a treating physician’s professional opinion will be entitled to great deference if medical necessity comes into question, Mr. Kopson said.

The process surrounding clean claims is often overlooked by physicians during contract negotiations, he added. The “gotcha” occurs when a plan retains full control over how contested claims are handled.

“If you don’t adequately address this in the contract, you wind up with the payer taking multiple bites of the apple,” Mr. Kopson said.

Make sure to clarify parameters for how long insurers have to request additional information about a claim and whether they must pay a portion of the claim that is being contested, he advised. Include a firm time line of when payers must complete their review and address payment after the requested information is provided.

Another critical issue: changes to the contract. In some cases, doctors enter into a contract with a plan and then the plan decides some details aren’t working out and makes changes. The physician later learns that the contract language allowed the plan to make unilateral changes. In other instances, a plan institutes new products and doctors learn that they had only a certain timeframe to opt out.

To avoid these situations, specify during contract negotiations that policies in conflict with the contract are prohibited, that contract changes can only be made bilaterally, and that unless you directly opt-in to new products, you will not participate.

Mr. Kopson encouraged physicians to have a solid exit strategy in their contracts and to ensure terms regarding contract termination are clearly understood. Clearly defined criteria around “cause” for termination are imperative, he said. Additionally, if a plan alleges a termination breach, require it to send a written notice to a specific person/title and ensure that the notice also is provided to counsel.

The bottom line: To avoid trouble later, strongly negotiate at the start of a managed care contract, Mr. Kopson said.

“If you don’t ask, if you don’t negotiate it in there, you’re not going to have that weapon,” he said.

[email protected]

On Twitter @legal_med

CHICAGO – Too often, physicians sign managed care contracts without negotiating or truly understanding all the terms. The complex clauses – or lack thereof – can come back to bite doctors in the form of delayed payments, sudden policy changes, and termination woes, health law attorney Mark S. Kopson warned at conference held by the American Bar Association.

To avoid these unwelcome surprises, prepare for contract discussions well before the conversation starts, Mr. Kopson advised.

Alicia Gallegos/Frontline Medical News

“Don’t go into any negotiation unless you know two things. The first is what your starting position will be and, equally if not more important, is what is your ultimate line in the sand?” said Mr. Kopson, who practices in Bloomfield Hills, Mich. “If you go in there not knowing those answers, you’re liable to give away the store or not get what you really need.”

One major “gotcha” is an insurer that does not reveal upfront that it is not the actual payer, Mr. Kopson said. Some national companies that enter into contracts with doctors are basically network aggregators that negotiate price discounts but then sell the network to the health insurance marketplace, he explained. Physicians later realize their contract states that the company is not responsible for paying claims and that the doctor does not have a contract directly with the payer.

“This is a really big issue that I’ve been seeing more and more frequently,” Mr. Kopson said at the meeting. “If you don’t have a direct contract with the payer, you have the possibility of not being able to force payment obligations against the responsible party.”

Specify in your contract that the plan must require the payer to pay, he said. That way, if a payer fails to pay, the plan has breached its contract obligation.

Contract terms that involve medical necessity also can lead to frustration if not properly negotiated. In some cases, the fine print states that medical necessity will be determined by the plan’s medical director or otherwise will be ultimately decided by the payer. Instead, include language specifying that a treating physician’s professional opinion will be entitled to great deference if medical necessity comes into question, Mr. Kopson said.

The process surrounding clean claims is often overlooked by physicians during contract negotiations, he added. The “gotcha” occurs when a plan retains full control over how contested claims are handled.

“If you don’t adequately address this in the contract, you wind up with the payer taking multiple bites of the apple,” Mr. Kopson said.

Make sure to clarify parameters for how long insurers have to request additional information about a claim and whether they must pay a portion of the claim that is being contested, he advised. Include a firm time line of when payers must complete their review and address payment after the requested information is provided.

Another critical issue: changes to the contract. In some cases, doctors enter into a contract with a plan and then the plan decides some details aren’t working out and makes changes. The physician later learns that the contract language allowed the plan to make unilateral changes. In other instances, a plan institutes new products and doctors learn that they had only a certain timeframe to opt out.

To avoid these situations, specify during contract negotiations that policies in conflict with the contract are prohibited, that contract changes can only be made bilaterally, and that unless you directly opt-in to new products, you will not participate.

Mr. Kopson encouraged physicians to have a solid exit strategy in their contracts and to ensure terms regarding contract termination are clearly understood. Clearly defined criteria around “cause” for termination are imperative, he said. Additionally, if a plan alleges a termination breach, require it to send a written notice to a specific person/title and ensure that the notice also is provided to counsel.

The bottom line: To avoid trouble later, strongly negotiate at the start of a managed care contract, Mr. Kopson said.

“If you don’t ask, if you don’t negotiate it in there, you’re not going to have that weapon,” he said.

[email protected]

On Twitter @legal_med

CHICAGO – Too often, physicians sign managed care contracts without negotiating or truly understanding all the terms. The complex clauses – or lack thereof – can come back to bite doctors in the form of delayed payments, sudden policy changes, and termination woes, health law attorney Mark S. Kopson warned at conference held by the American Bar Association.

To avoid these unwelcome surprises, prepare for contract discussions well before the conversation starts, Mr. Kopson advised.

Alicia Gallegos/Frontline Medical News

“Don’t go into any negotiation unless you know two things. The first is what your starting position will be and, equally if not more important, is what is your ultimate line in the sand?” said Mr. Kopson, who practices in Bloomfield Hills, Mich. “If you go in there not knowing those answers, you’re liable to give away the store or not get what you really need.”

One major “gotcha” is an insurer that does not reveal upfront that it is not the actual payer, Mr. Kopson said. Some national companies that enter into contracts with doctors are basically network aggregators that negotiate price discounts but then sell the network to the health insurance marketplace, he explained. Physicians later realize their contract states that the company is not responsible for paying claims and that the doctor does not have a contract directly with the payer.

“This is a really big issue that I’ve been seeing more and more frequently,” Mr. Kopson said at the meeting. “If you don’t have a direct contract with the payer, you have the possibility of not being able to force payment obligations against the responsible party.”

Specify in your contract that the plan must require the payer to pay, he said. That way, if a payer fails to pay, the plan has breached its contract obligation.

Contract terms that involve medical necessity also can lead to frustration if not properly negotiated. In some cases, the fine print states that medical necessity will be determined by the plan’s medical director or otherwise will be ultimately decided by the payer. Instead, include language specifying that a treating physician’s professional opinion will be entitled to great deference if medical necessity comes into question, Mr. Kopson said.

The process surrounding clean claims is often overlooked by physicians during contract negotiations, he added. The “gotcha” occurs when a plan retains full control over how contested claims are handled.

“If you don’t adequately address this in the contract, you wind up with the payer taking multiple bites of the apple,” Mr. Kopson said.

Make sure to clarify parameters for how long insurers have to request additional information about a claim and whether they must pay a portion of the claim that is being contested, he advised. Include a firm time line of when payers must complete their review and address payment after the requested information is provided.

Another critical issue: changes to the contract. In some cases, doctors enter into a contract with a plan and then the plan decides some details aren’t working out and makes changes. The physician later learns that the contract language allowed the plan to make unilateral changes. In other instances, a plan institutes new products and doctors learn that they had only a certain timeframe to opt out.

To avoid these situations, specify during contract negotiations that policies in conflict with the contract are prohibited, that contract changes can only be made bilaterally, and that unless you directly opt-in to new products, you will not participate.

Mr. Kopson encouraged physicians to have a solid exit strategy in their contracts and to ensure terms regarding contract termination are clearly understood. Clearly defined criteria around “cause” for termination are imperative, he said. Additionally, if a plan alleges a termination breach, require it to send a written notice to a specific person/title and ensure that the notice also is provided to counsel.

The bottom line: To avoid trouble later, strongly negotiate at the start of a managed care contract, Mr. Kopson said.

“If you don’t ask, if you don’t negotiate it in there, you’re not going to have that weapon,” he said.

[email protected]

On Twitter @legal_med