Category Archives: iMAX Medical Billing Insights

Ohio doctor pleads guilty to using his clinic to supply drugs, evading more than $3.5 million in taxes

“He got rich by feeding the addictions of hundreds and hundreds of people,” the DOJ said. An Ohio physician has pleaded guilty to drug, tax and fraud charges for using his clinic to supply drugs to addicts throughout the Midwest, and for his role in schemes to evade more than $3.5 million in taxes, the Department of Justice announced. Kevin B. Lake, 50, of Albany, Ohio will forfeit what’s left of the $29 million in proceeds from the clinic’s illegal activities. Lake owned and operated Columbus Southern Medical Center through corporate or trust entities in an effort to shield himself

Florida urologist to pay $3.8 million for allegedly ordering unnecessary medical tests

Meir Daller ordered more than 13,000 FISH tests for his Medicare patients, allegedly collecting bonuses based on tests. Meir Daller, a Fort Myers urologist, has agreed to pay $3.81 million to settle allegations he submitted claims to Medicare and Tricare for fluorescence in situ hybridization, or FISH, tests that weren’t medically necessary, a violation of the False Claims Act, the Department of Justice announced. FISH tests are performed on urine to detect genetic abnormalities associated with bladder cancer. They are not considered “reasonable or necessary” by Medicare unless it used to monitor for the recurrence of tumors in patients that

Surprise medical bills a costly problem for health plans, study says

Balance billing undermines competition between health plans and particularly harms plans offering narrower network products, authors say. Surprise, out-of-network bills hurt consumers, but two new studies show these bills undermine competition between health insurance plans and particularly harm plans that are trying to limit costs by offering narrower network products. Contracted, in-network providers agree to accept discounted reimbursement rates negotiated with health plans, and health plans typically charge patients lower cost-sharing liability for contracted services. However, 20 percent of emergency department visits and resulting admissions at in-network facilities involved an out-of-network physician, according to the studies published in Health Affairs

AMA calls for end to insurer prior authorization policy

Anthem, Cigna have already ended policy of prior authorization for medication assisted treatment for substance use disorders. The American Medical Association is urging attorneys general in all states to take the same action as recently taken by the New York AG in ending the insurance company policy of requiring prior authorization for medication-assisted treatment of substance use disorders. In addition, the AMA is calling on all insurers to end policies that require patients to repeat step therapy protocols or retry therapies failed under other benefit plans before qualifying for medication-assisted treatment coverage. The AMA made its requests in a Feb.

Is outsourcing the key to solving physician burnout?

Running a physician practice is a lot different—and substantially more challenging—than it used to be. Physicians and other practice staff are being asked to transform the way they deliver patient care while reducing costs and maintaining quality. They are having to navigate new payment structures—patient payments and risk-based payments, for example—while expanding their communication and collaboration with other care providers. As patients assume more payment responsibility, they are also demanding more from their physicians, looking for a highly service-oriented experience that includes responsive communication, cutting-edge technology and convenient access. Along with these shifting dynamics is an increasingly complex regulatory environment

Recent settlements show cost of HIPAA violations

The feds are constantly on the lookout for HIPAA violations – and one high-profile case involving a reality show filmed at a hospital shows just how costly they can be for facilities.  Last year, New York Presbyterian Hospital came under fire while it was in the midst of filming NY Med, a show chronicling the real-life efforts of providers to treat patients in its emergency department. According to an article in Bloomberg BNA, the show’s film crew ended up capturing the last moments of one patient’s life without his express permission, despite objections from a medical professional. It also filmed

Anthem Inc. Sets Aggressive Goals to Help Prevent Addiction, Increase Access to Care

Affiliated health plans aim to double number of members getting counseling More people in the United States are suffering from opioid addiction and dying from overdose than ever before. Anthem, Inc. has been identifying ways to help consumers better access treatment while also putting into place policy changes that help reduce opportunities for addiction. Anthem Inc. sets aggressive goals to help prevent #opioid addiction, increase access to care. Tweet this To help ensure consumers have access to comprehensive evidence-based care, Anthem is committed to helping its affiliated health plans double the number of consumers who receive behavioral health services as

Billers Convicted in Fraud Schemes

U.S. Attorney for the District of Maryland, Rod J. Rosenstein announced December 20 that Elma Myles pled guilty to defrauding Medicaid and other health benefit programs by conspiring to have durable medical equipment provider RX Resources and Solutions (RXRS) bill for supplies that were never provided or were medically unnecessary, and to overcharge for materials that were actually delivered. Myles, who worked for RXRS as a biller, admitted to conspiring with the company’s President and Chief Executive Officer, co-defendant Harry Crawford, and others in connection with the scheme, a press release said. An analysis of RXRS billing revealed that from

Anthem ends preauthorization requirement for medication-assisted substance use disorder treatment

The national policy change is part of a settlement with the New York Attorney General’s Office Anthem no longer will require preauthorization for coverage of medication-assisted treatment for opioid-related substance use disorders. Details of preauthorization rules change Anthem changed the policy as part of a settlement with the New York Attorney General’s Office that has nationwide implications. Anthem previously required physicians to answer various questions about an individual’s treatment and medication history before it would approve coverage for medication-assisted treatment. The New York Attorney General’s Office conducted an investigation that found Empire BCBS in 2015 and the first half of

CLIA Waived Tests Effective January 1, 2017

The Centers for Medicare & Medicaid Services (CMS) has tweaked the tests it says are waived from Clinical Improvement Amendment of 1988 (CLIA), releasing the list effective January 1, 2017. CLIA regulations require a facility to be certified for each test performed. To ensure that Medicare and Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are edited at the CLIA certificate level. The Current Procedural Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test; however, some