Archive for category Let’s help Congress do their job.
In 1996 we had Kennedy-Kassebaum which was intended to fix the health care problem. It gave self employed the Medical Savings Account, a forerunner to the newer Health Savings Account. “They” were paranoid too many self employed would take advantage of this new tool, so they capped the number at 700,000 eligible participants in the country.
We never got near that much participation initially and they have tinkered with it ever since.
There are so many rules and regulations that continue to bog down “the system” and make it so honest men can’t comply.
MANAGED CARE March 1997. ©1997 MediMedia USA
Kennedy-Kassebaum Law Means Greater Fraud Scrutiny
BY NEIL CAESAR, J.D.
On Aug. 21, President Clinton signed the Health Insurance Portability and Accountability Act of 1996 into law. HIPA is extremely significant for physicians and managed care organizations. I’m not referring to the portions of HIPA that gained the most press coverage–namely, the creation of an entitlement to (and mechanisms for) more affordable and portable health insurance. Rather, HIPA creates perhaps the most substantial and dramatic change to health care fraud-and-abuse laws since this category of legislation was created.
As we begin to explore these sweeping changes and their implications, I predict that we will draw three conclusions. First, HIPA makes the government more intrusive than ever in its commitment to seeking out health care fraud, and also makes the government more eager than ever to probe potentially unethical or illegal actions. Even when no fraud is found, the costs and burden from government and payer inquiries and investigations will be substantial for physicians, other providers and managed care organizations subjected to scrutiny. HIPA also creates an incentive for the government to seek financial settlement from many of the providers and managed care organizations that it investigates, even in circumstances where it previously would have walked away from the investigation because it was not likely to be worth the cost and effort of continued probing and/or prosecution.
Second, HIPA demonstrates that the federal government has become more responsive to the growth of creative and alternative systems and structures for delivery of health care services. Among these are alliances, management services organizations and integrated delivery systems. Some of this recognition, you will note, takes the form of new rules and means to fight fraud by these new systems and entities. Other rules reflect the converse: The government realizes that approaches that differ from “tried and true” methods do not necessarily indicate improper intent or encourage fraudulent activity.
The third conclusion reflects the first two: Every health care provider and managed care organization must put into place an appropriate health care fraud and abuse compliance program. At a minimum, every physician or physician group and managed care organization must undergo prompt and regular legal and financial analysis of its health care compliance activities, must correct deficiencies identified in that analysis and must implement a program to reduce the likelihood of these sorts of problems occurring. Period.
The question no longer is whether you can afford a health care fraud and abuse compliance program. Rather, it is whether you can afford not to have one.
Anyone may blow the whistle
Let’s start with one example. Section 203 of HIPA requires the secretary of health and human services to implement a program that will encourage people to report information about health care fraud. The program is quite broad. It encourages reports of improper activity in the past, even when it has stopped. It encourages people to report improper activity involving kickbacks, false claims, mail fraud, false billings or almost any other activity that relates to penalties under the Office of Inspector General’s areas of authority.
Longtime readers of this column know that one of my recurring themes is that our behavior is influenced by rewards, whether financial, egotistic, spiritual or other. HIPA also recognizes this observation about human behavior. It authorizes payment of a reward to anyone who reports information that leads to the collection of at least $100 under any of its law enforcement provisions except for the anti-kickback law. My understanding is that this reward program will be modeled on the Internal Revenue Service rewards for tax fraud tip-offs. IRS pays up to 10 percent of the amount recovered. When fine and penalty are added to overpayment, this can easily be very lucrative.
The new HHS program is dis- tinct from provisions of the federal false claims act that permit health care “insiders” who are aware of fraud in their organizations to undertake a lawsuit against the allegedly fraudulent providers on behalf of the government and collect part of the proceeds. The new HIPA incentive program, in contrast, permits any individual to obtain a reward. A beneficiary is eligible, a competitor is eligible and a health care adviser is eligible. (Note that the attorney-client privilege requires lawyers to maintain confidentiality about wrongdoing by their clients. But this does not apply to other health care business advisers!) Basically, if you are aware of the possibility of past or present fraud, you may receive a reward regardless of who you are.
Also, note that the law pays a reward simply for reporting information that leads to the collection of funds. The person does not have to sue the fraudulent provider. A physician would not, for example, need to risk becoming an outcast in the medical community, viewed as disloyal or greedy. Indeed, the reporter often will have no involvement beyond the initial conversation(s) with the government. And since the primary mechanism for this reporting will probably be some sort of hot line, the person may not even have to meet directly with government agents.
Are you your brother’s keeper? You betcha! And a darned lucrative job it can be, too!
Required: attention to detail
I don’t mean to be flippant. This system can go a long way to encourage people to report fraud that would otherwise never be reported. But I have had many clients suffer the burdens of government scrutiny without having engaged in fraudulent activity. This is especially true now that the government asserts that repeated billing errors may constitute a pattern of fraud. Thus, inattention to detail can easily subject a provider to a fraud investigation. HIPA will increase that danger.
Incidentally, note that Section 203 also requires physicians and other providers to give beneficiaries an “explanation of Medicare benefits” form for every item or service, even if there is no deductible or coinsurance payment required of the beneficiary. At present, EOMBs are issued only where the beneficiary will pay for part of the service.
This means that Medicare beneficiaries will know all charges claimed by health care providers. In theory, this will alert them to potential fraud. In practice, it will probably lead to a lot of complaints about $40 bedpans and $10 Ace bandages.
Are you getting a bit nervous? In another column, we will explore additional ways HIPA will affect you.
Neil B. Caesar is president of The Health Law Center (Neil B. Caesar Law Associates, PA), a national health law/consulting practice in Greenville, S.C.
If you could stick together, as 87 Proud Patriotic Americans, committed to old fashion values, and not sell out for cash and power, would you?
We have that group right now in our new freshman congressmen.
We must return to the vision that Benjamin Franklin showed us when he gave away money to a university, to hold and manage for 100 years before they used it. He was brilliant, to show us compounding interest grows geometrically. But so does debt, and we all know that lesson now.
We all need to brush up on our history lessons. My son’s 8th grade school paper is a perfect start. The world actually runs at about a 10th grade level these days. Are you smarter than a 10th grader? America has invested in its EDUCATIONAL system.
JFK was brilliant to launch the space program because it fine tuned our focus and helped us apply ourselves as a group. The most incredible technology has come out of NASA and the space programs, and it has enriched our lives in SO many levels you would be amazed.
Let’s help the Gang of 87 do their job with public support for serious REFORM. Start with the mayor in the local town, and help the Chamber of Commerce create viable businesses without over regulation and complication. Let us be creative at the local level, and the state level using what we know about the welfare state se feel. The money is in the budget already, just being spent in inefficient ways.
As a planner, you see the future and work to create it. How can we come off the “oil” based forms of transportation we use? Can we use other means to create a efficient community and people mover? Can we use something as simple as a roller coaster to move people around? The UNIVERSITY system is an asset America has built. We need to grow around our educational system into vibrant local economies. We can make things here in America, and use them locally.
Retirement villages are needed for the time span of age 65 to 100. We know our people will live long, and they can be a part of society long past their prime. Let us. Build those communities around your existing infrastructure. Create and revitalize your downtown area and clean up the place.
Nurture the arts, and the artists. Creative people bring value to society and they always have. A vibrant community always includes the churches, the charities and the arts. Get back to basics.
We need the food banks and the soup kitchens but we also need the Camps to help rehabilitate people back into usefulness. When you fail financially and emotionally you may require help to get back on your feet.
The famous “Hoover Towns” of the 1930′s were evident when the money supply was too constrictive, and it didn’t flow in a free banking market. You must remove some of the regulatory challenges that were brought upon the Insurance and Banking industry, so that they work to help the people grow once again.
The solutions that the Gang of 87 can present to Congress should be the will of “We the People.”
If we hold Congress out to the FIDUCIARY standards they would see that they are working with Our Money, not their money.
We the People, in order to form a more perfect Union.
Not, We the Government are going to form more perfect people.
Let’s help the Gang of 87 stand firm, even if they don’t get reelected.
Let the old ways go buy up cheap real estate somewhere and retire.
Pick up a penny and the American punchline is apparent.
The likeness of Abraham Lincoln and the words “In God We Trust.”
Faith to trust is American. Having the rights of the Constitution and the Bill of Rights is a beautiful thing. America should be a Nation of bright, creative, kind people. We should try to be “Man Kind.” It comes from within and manifests in others. We take care of our family, our community, our State and our Country.
Here was a story I liked about a wealthy man who knew the value of a penny.
You always hear the usual stories of pennies on the sidewalk being good luck, gifts from angels, etc. This is the first time I’ve ever heard this twist on the story. Gives you something to think about.
Several years ago, a friend of mine and her husband were invited to spend the weekend at the home of her husband’s employer.
My friend, Arlene, was nervous about the weekend. The boss was very wealthy, with a fine home on the waterway, and cars costing more than her house.
The first day and evening went well, and Arlene was delighted to have this rare glimpse into how the very wealthy live. Her husband’s employer was quite generous as a host, and took them to the finest restaurants. Arlene knew she would never have the opportunity to indulge in this kind of extravagance again, so was enjoying herself immensely.
As the three of them were about to enter an exclusive restaurant one evening, the boss was walking slightly ahead of Arlene and her husband..
He stopped suddenly, looking down on the pavement for a long, silent moment.
Arlene wondered if she was supposed to pass him. There was nothing on the ground except a single darkened penny that someone had dropped, and a few cigarette butts. Still silent, the man reached down and picked up the penny.
He held it up and smiled, then put it in his pocket as if he had found a great treasure.
How absurd! What need did this man have for a single penny? Why would he even take the time to stop and pick it up?
Throughout dinner, the entire scene nagged at her. Finally, she could stand it no longer. She casually mentioned that her daughter once had a coin collection, and asked if the penny he had found had been of some value.
A smile crept across the man’s face as he reached into his pocket for the penny and held it out for her to see. She had seen many pennies before! What was the point of this?
“Look at it,” he said.. “Read what it says.”
She read the words, ” United States of America .”
“No, not that. Read further.”
“No, keep reading.”
“In God we Trust?”
“And?. . .”
“And if I trust in God, the name of God is holy, even on a coin. Whenever I find a coin, I see that inscription. It is written on every single United States coin, but we never seem to notice it! God drops a message right in front of me telling me to trust Him. Who am I to pass it by? When I see a coin, I pray. I stop to see if my trust IS in God at that moment. I pick the coin up as a response to God; that I do trust in Him. For a short time, at least, I cherish it as if it were gold. I think it is God’s way of starting a conversation with me. Lucky for me, God is patient and pennies are plentiful!”
When I was out shopping today, I found a penny on the sidewalk. I stopped and picked it up, and realized that I had been worrying and fretting in my mind about things I cannot change. I read the words, “In God We Trust,” and had to laugh. “Yes, God, I get the message!”
It seems that I have been finding an inordinate number of pennies in the last few months, but then, pennies are plentiful! And, God is patient.
Photo (cc) by dawnzy58
Seeing out to 2020 should be clear. Transportation, and getting people around. Living without cars, using bikes, walking and mass transit are part of the future. But what does that look like?
Monorails and Airplanes work together to bring communities closer. Technology makes the big world smaller, and a local economy and its’ people matter. A trip to Dallas/Fort Worth Airport will show you how well it is working! That’s a beautiful use of technology and planning. How can we use that some more?
The local Chamber of Commerce works together, with the Mayor and the downtown to create a local economy. Complete with jobs, lifestyle, community and character! Every State should have its’ own flavor! Lots of small economies. Not one big Federal one!
The Great Park should be where baby boomers retire in comfort, as we re-inspire and lead active lives, travel, and create a theme for the World, right here in Orange County. Education, wellness and fitness, in a business friendly environment with great food, culture and the arts!
We were promised the Jetsons! Let’s put this technology to work and jump right over $5 a gallon gasoline! The creative minds are here and we can do it!
Schools need to provide educations and teach kids critical thinking skills. Education is in, even when school is out! The flavors of America are many, and together we make up a fabulous soup! That is the gift we bring to the table. Our diversity is a good thing.
Irvine is the melting pot of America. I’ve been here for 30 years and I’ve seen it firsthand, we are a more colorful bunch now! But our flavors are terrific, and the character of the community is enhanced by our differences and similarities as humankind.
Build it all along a great coastline, with nice weather and creative thinking people, we are living the American dream.
Let’s see the future more clearly for the community, the state, the federal government and the world. Go World!
It helps us see the future and that even on a penny are the words “In God we Trust.”
Let us all pick up a penny, and know that it truly is Gold.
One of the things a mother learns to do is advocate for others. As we raise up our babies we look out for their best interests. We encourage their success and nurture their way. We must learn to transfer the power from us as parents to them as children, and raise them up to be independent and confident. That’s our job.
We do this in a fiduciary capacity. That is a person who is under an obligation to act in another’s interest to the exclusion of the fiduciary’s own interest. We owe to another the highest duty of care, good faith, trust, confidence and candor based on the relationship. It is the relationship of one person to another, where the former is bound to exercise rights and powers in good faith for the benefit of the latter.
So I ask you this: Do you think your Congress Person has the responsibility of acting as a FIDUCIARY for you and our country as they review the finances, budgets, taxes and laws? Should this be thier standard of care?
Definitions of fiduciary on the Web:
- a person who holds assets in trust for a beneficiary; “it is illegal for a fiduciary to misappropriate money for personal gain”
- relating to or of the nature of a legal trust (i.e. the holding of something in trust for another); “a fiduciary contract”; “in a fiduciary capacity”; “fiducial power”
- A fiduciary duty is a legal or ethical relationship of confidence or trust between two or more parties, most commonly a fiduciary and a principal. …
- One who holds a thing in trust for another; a trustee; One who depends for salvation on faith, without works; an antinomian; Related to trusts and trustees
- One who owes to another the highest duty of care, good faith, trust, confidence and candor based on their relationship.
- Undertaking to act as executor, administrator, guardian, conservator, or trustee for a family trust, authorized trust, or testamentary trust, or receiver or trustee in bankruptcy.
- A person holding a position of trust; agents, trustees, attorneys, etc.