Wachler & Associates Health Law Blog

Blue Cross Blue Shield of Michigan (BCBSM) is auditing physicians who have conducted in-office Drug of Abuse (DOA) screening test. The purpose of these BCBSM audits is to determine whether the services, treatment, devices, and procedures that the physician billed to BCBSM conformed to Current Procedural Terminology (CPT) codes at the time of billing.

In auditing physicians who billed drug screening procedure codes, BCBSM is alleging that those physicians have incorrectly billed under current CPT codes for dates of services prior to the effective date of the current billing policies. In these cases, BCBSM sent notices to physicians enclosing current copies of the Physician Office Laboratory List (POLL) - a list of payable laboratory services allowed to be performed in the physician office setting - instead of the relevant POLL covering the audited time period. The drug screening procedure code at issue is CPT code 80101 [drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class], which is not listed on the current POLL. Instead, BCBSM states that codes 80104 and G0434 are the proper and payable drug screening tests when performed in the physician's office. BCBSM is seeking returns of alleged overpayments from these physicians who billed 80101 in the office setting, as opposed to billing the lesser-paying drug screening procedure codes.

BCBSM may not hold physicians retroactively accountable for recent changes in billing. We are currently representing a number of physicians that have been audited by BCBSM. Based upon our review, we believe these audits can be successfully defended and the amount for overpayment substantially reduced. If you have been audited by BCBSM, we believe we can help, as we are currently representing physicians in similar cases and have been successfully defending providers against BCBSM audits since 1980. For further information on BCBSM audits, please contact an experienced Wachler & Associates healthcare attorney at 248-544-0888.

Nearly a month after the federal government handed down indictments to defendants involved in one of Michigan's largest prescription drug schemes, the federal government indicted 18 more people allegedly involved in Medicare fraud schemes.  According to a Detroit Free Press article, the U.S. District Court indicted people for their alleged involvement in a number of different health care fraud operations.  One of the charges was handed down to a Troy doctor who allegedly billed for home health services when she was out of the country, as well as for certain services that were physically unable to be completed in a single day.  Another indictment was handed down to an owner of a Detroit company who is being accused of billing Medicare for psychotherapy for numerous beneficiaries who were no longer alive.  Combined, all 18 defendants are accused of billing Medicare for $28 million.

The Medicare Fraud Task Force has no charged 138 people in Detroit with allegations of fraudulent billings totaling nearly $150 million.  According to Maureen Reddy, a Detroit-based FBI special agent, home health fraud is currently the largest type of fraud in the Detroit area.  The recent indictments also establish that Medicare fraud investigations are also expanding to other areas of health care services, such as psychotherapy.

These indictments are another example of the government's focus on the Detroit area in Medicare and Medicaid investigations.  For more information on Medicare Fraud defense, or assistance with interpreting and understanding Medicare and Medicaid regulations, including the anti-kickback statute, please contact a Wachler & Associates attorney at 248-544-0888.

Those practices with electronic health record systems (EHR) in place appear to be very happy with the results. A survey conducted by the Medical Group Management Association found that 72% of practices with implemented EHR systems were "satisfied" with the results. Further, those practices which have optimized their EHR systems have reported an 82% level of satisfaction.

If you have any questions or concerns about the compliance or regulatory issues involved with the implementation of a EHR system, please contact an attorney at Wachler & Associates at 248-544-0888.

The proposed legislation would allow Michigan healthcare providers to apologize to patients without fear that those comments will be used against them in legal proceedings.  The law will not provide total immunity to comments, but allow for greater leeway when it comes to expressing remorse for procedures that did not achieve the desired result.  

The Detroit Free Press reported that the Detroit Medical Center has agreed to pay $30 million to the federal government to settle claims that involved violations of the Anti-Kickback Statute and Stark from improper financial relationships with referring physicians.  The majority of the relationships at issue in the DMC matter involved office lease agreements and independent contractor relationships that were either not consistent with fair market value or not in writing.  If you are a provider and would like to ensure that your relationships comply with Stark and the Anti-Kickback Statute, please contact Wachler & Associates. 

The proposed purchase of the Detroit Medical Center by Vanguard Health Systems Inc. has been conditionally approved by the Attorney General of Michigan Mike Cox.  This sale would bring a purported $1.5 billion in funding for the center.  The deal is tentatively set to take place on December 31, 2010 but there are still many issues that need to be worked out for the transaction to be completed.  One of the major issues still needing resolution before the final deal is the transferring of Medicare and Medicaid billing procedures from the nonprofit DMC to the for profit Vanguard.

For information on compliance issues associated with health care transactions please contact a Wachler & Associates attorney at 248-544-0888.

The U.S. Justice Department filed a lawsuit against Blue Cross Blue Shield of Michigan (BCBSM) on Monday, October 18.  The Justice Department alleges that BCBSM violated antitrust laws by using its strong presence in the market to increase prices for its competitors, which resulted in Michigan residents paying higher health care and health insurance costs.  Specifically, the Justice Department says that BCBSM required hospitals to charge competitors more.  The Detroit Free Press reported that the Michigan attorney general's office stated, "the investigation showed that Blue Cross increased its payouts to many hospitals to guarantee the hospitals would in turn charge all other insurers up to 40 percent more, pricing them out of the market and raising prices on all Michigan consumers." 

The Detroit Free Press reported that BCBSM adamantly refuted the allegations.  BCBSM stated that the lawsuit was without merit and that its responsibility in contracting with hospitals is to negotiate on behalf of its members and costumers, not to negotiate against other health care insurers.

For more information on Michigan health care news, please visit the Michigan Healthcare News section on the Wachler Blog. 

On October 8, U.S. District Judge George Steeh refused to grant an injunction that would prevent the implementation of the federal health reforms enacted through the Affordable Care Act.  Judge Steeh also dismissed several substantive portions of the suit, determining that Congress did not exceed its constitutional authority by requiring most people to buy health insurance.  The lawsuit was brought by the Thomas More Law Center, an Ann Arbor-based Christian legal center and four plaintiffs.  The Detroit Free Press reported that an attorney for the law center, Robert Muise, stated that the plaintiffs will appeal the decision.

The Michigan lawsuit is one of several lawsuits filed challenging provisions of the Affordable Care Act.  Another lawsuit filed by several attorney generals, including Michigan Attorney General Mike Cox, is in the appeals process with oral arguments scheduled for December 16.

For more information on federal healthcare reform, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888. 

The Detroit Medical Center (DMC) recently announced that it has saved more than $5 million in costs in 2009 due to its system-wide Electronic Medical Records (EMR).  This is the second consecutive year that the DMC has experienced cost-savings due to the EMR system. 

Physicians Health Plan will be the insurer to offer subsidized health coverage for chronically-ill Michigan residents.  The insurer, based in Lansing, will offer health coverage through the health insurance pool that was created to provide an avenue for the uninsured chronically ill to buy coverage until state exchanges are active in 2014 as set forth in the health care reform legislation.  To qualify for the pool individuals must provide proof of U.S. citizenship and Michigan residency, certification by a physician that the individual is chronically ill and evidence that an insurer has refused, for health reasons, to cover the individual within the previous six months.  Physicians Health Plan will start enrolling members August 31 for coverage that becomes effective October 15. 

For more information on Michigan health care news or health care reform, please visit www.wachler.com or contact a Wachler & Associates attorney 248-544-0888. 

The Detroit Free Press reported that a Michigan doctor was sentenced to 14 years in prison for Medicare fraud.  In addition to the prison sentence, the doctor will owe $9.4 million in restitution payments and is eligible for a three-year supervised release after his prison sentence.  According to the Department of Justice (DOJ), the doctor and a co-conspirator wrote prescriptions for controlled drugs in exchange for the patients' Medicare numbers.  The co-conspirator would then bill for fictitious rehabilitation and home health services using the Medicare numbers.  Medicare reimbursed the conspirators $9.4 million for fake services.

For more information on Michigan healthcare legal news, or for assistance with a Medicare audit or investigation contact a Wachler & Associates attorney at 248-544-0888. 

As part of the Patient Protection and Affordable Care Act (PPACA), i.e., health care reform, states received more than $46 million in grants from the U.S. Department of Health and Human Services (HHS).  Crain's Detroit Business reported that Michigan has received $1 million of grants from HHS to go towards improving oversight and review of proposed health insurance premium increases.  Although the Michigan Office of Financial and Insurance Regulation (OFIR) will ultimately use the grant for this purpose, OFIR first must obtain additional legislative authority to enforce consumer protections in the federal bill.  This will require the Michigan Legislature to amend the Michigan Insurance Code to incorporate the specific consumer protections.  At this time, the OFIR only has the authority to review, investigate, examine and encourage compliance from health insurance companies. 

Crain's Detroit Business also reported that Michigan plans to use the $1 million grant to:

(1) Contract with consulting actuaries for targeted, in-depth analysis and review of health insurance premium filings made by HMOs and commercial carriers.

(2) OFIR also plans to conduct a study on the feasibility of posting health insurance rate information on a website that will also create a forum for access to consumer friendly information.

For more information on Michigan healthcare legal news, or the implications of health care reform, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.

Michigan's Attorney General Mike Cox announced a community forum to be held next week regarding the proposed sale of the Detroit Medical Center to Vanguard Health Systems, Inc.  Earlier this year, DMC signed a purchase agreement that would require Vanguard to make $850 million in capital improvements over the next five years.  The forum will take place from 5:00-7:00pm on August 18 at the Cadillac Place in Detroit.  It will provide the public with an overview of the proposed sale, explain the Attorney General's review process for the transaction and provide the public an opportunity to comment and question representatives of DMC and Vanguard.

For more Michigan healthcare legal news, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888. 

The Detroit Free Press reported that an effort to give Michiganians a constitutional right to opt-out of participation in the Federal healthcare program failed to obtain enough signatures to place the proposal on the November ballot. The group, Michigan Citizens for Healthcare Freedom, estimated that it turned in between 145,000-170,000 signatures. A total of 381,000 signatures were necessary for the proposal to be included on the November ballot. The state director of the National Federation of Independent Business, Charles Owens, reported that the effort collected more signatures in less time than any other all-volunteer drive. He indicated that this fact demonstrates the widespread disagreement with the healthcare reform law.

For more information on Michigan healthcare legal news, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.

Last week, Michigan's Governor Jennifer Granholm announced that Michigan could have a $560 million budget gap if Congress does not provide the funding promised in last year's stimulus package. The Detroit News reported that Governor Granholm was concerned that without the mandated Medicaid funding programs and services would have to be cut. This would seriously impact Michiganians that rely upon Medicaid.

Governor Granholm's announcement follows her visit to Washington D.C. with the Governors of New York and Pennsylvania. The Bloomberg News reported that the three governors traveled to the nation's capital to appeal to the Senate to approve the extra financing for Medicaid. Last week, the Senate failed to approve $16 billion in extra financing for Medicaid and extended jobless benefits. The Senate Republicans opposed the measure because it added to the national deficit.

For more information on Michigan health care or to contact a Michigan Health Law attorney, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.