Outine
Table of Contents
DISCLAIMER
PREFACE : INTRODUCTION TO THE AMERICAN LEGAL SYSTEM
Chapter 1 ADA, DISCRIMINATION, AND THE NEVADA PHYSICIAN
INTRODUCTION
THE APPLICABLE FEDERAL LAW
Americans With Disabilities Act
Rehabilitation Act
PHYSICIAN EMPLOYERS
PATIENTS RIGHTS
NEVADA LAW
CONCLUSION
Chapter 2 ADVERTISING & SOLICITATION
INTRODUCTION
ADVERTISING CONCERNS
SOLICITATION & RESTRICTIVE COVENANTS OF EMPLOYMENT
CONCLUSION
Chapter 3 ANTITRUST
THE ANTITRUST LAWS
Prohibited Activity
Permissible Activity
Networks Outside the Safety Zone
Large Networks
WHAT PHYSICIANS CAN DO TO AVOID ANTITRUST PROBLEMS
PHYSICIAN GROUP MERGERS
Introduction
Basic Principles
Product Market
Issues
Other Court Decisions
Geographic Market Issues
Constraints Imposed by Outside
Sellers
Barriers to Entry
Efficiencies and Other Practical
Considerations
PHYSICIANS AND UNIONS
Definition of Physician Union
Self-employed Physicians’ Interest in
Union Formation
Employed Physicians’ Interest in
Union Formation
General State of Unions
Costs of Organizing a Union
The Labor Exemption from Antitrust
Laws, as Applied to Physicians
Employed Physicians
Self-employed Physicians
Self-employed Physicians Do Not
Qualify for Protection Under the
National
Labor Relations Act
Success of Physicians in Tucson,
Arizona
An AFL-CIO Affiliated Union May Not
Collectively Negotiate on Behalf of Any One Individual
AMA’s Position on Physicians and Collective Bargaining
ETHICAL OPINIONS
Chapter 4 BILLING – GENERALLY
INTRODUCTION
GENERAL PROVISIONS
RULES FOR HOSPITALS
CONCLUSION
Chapter 5 BILLING AND BUSINESS PRACTICES RELATING TO PHYSICIAN AND OTHER HEALTHCARE
PROFESSIONALS
FORM OF PRACTICE
Partnerships With Non-Physician
Healthcare Practitioners (HP)
Corporations Which Include
Non-Physician Shareholders and/or Employees
Physician Billing for the Services of
Another Healthcare Practitioner
MEDICARE REQUIREMENTS
Billing Medicare for Non-Physician
Healthcare Practitioner Services
“Incident to” Type of
Services
Billing for the Non-Employee
Billing Services Provided by a
Physician Assistant
Billing by Other Healthcare
Professionals
Determining How to Bill Medicare for
the HP’s Services
BILLING PRIVATE PAYORS
Health Insurers
Health Care Services Plans
Fee-splitting
ETHICAL CONSIDERATIONS
Ethical Problems With Associations
Between Healthcare Professionals
Chapter 6 BOARD OF MEDICAL EXAMINERS OF NEVADA: DISCIPLINE AND LICENSING
GROUNDS FOR BOARD DISCIPLINE
THE COMPLAINT
DISCIPLINARY PROCEEDINGS
SPECIFIC OFFENSES
Criminal Offenses
Offenses Related to a License to
Practice Medicine
Professional Incompetence
Prescriptions and Controlled
Substances
Misconduct Related to Patients
Financial Misconduct
Record Keeping
Misrepresentation and Related
Offenses
Miscellaneous Prohibited Conduct
BOARD OF MEDICAL EXAMINERS ENFORCEMENT AUTHORITY
LICENSING
Chapter 7 BUSINESS PROHIBITIONS (PERMITTED ACTIVITIES)
INTRODUCTION
CORPORATIONS
HOSPITALS & HMOs
INDIVIDUAL
PHYSICIANS
FEE SPLITTING
FORMING A BUSINESS RELATIONSHIP
WORKING FOR, EMPLOYING, OR SUPPORTING UNLICENSED HEALTH CARE PROVIDERS
MISCELLANEOUS PROHIBITIONS
CONCLUSION
Chapter 8 CLINICAL LABORATORIES DISCLOSURE AND BILLING
DISCLOSURE REQUIREMENTS
Federal Law
BILLING REQUIREMENTS
Federal Law
SPECIFIC REQUIREMENTS RELATED TO CYTOLOGIC SERVICES
Billing Prohibitions
Ethical Opinions
LICENSURE AND REGISTRATION OF CLINICAL LABORATORIES
Registration Requirements
Certificates
Standards and Inspections
Sanctions
Fees
Waived Tests
Tests of Moderate and High Complexity
Provider (Physician)-Performed
Microscopy Procedure
LABORATORY PERSONNEL
Laboratory Director
Persons Who May Perform Testing
SELF-REFERRAL AND FEE SPLITTING PROHIBITIONS
Self-Referral Prohibitions
Fee-Splitting Prohibitions
INTERACTION OF STARK AND CLIA
Chapter 9 CONSENT
INTRODUCTION
INFORMED CONSENT / CONCLUSIVE CONSENT
INFORMED CONSENT NOT REQUIRED – EMERGENCY CONSENT
Minors
General
Considerations
In Loco Parentis
Abuse of a Controlled Substance
Sexually Transmitted
Diseases/Communicable Diseases
CONSENT FOR SPECIFIC PROCEDURES / RELEASE OF INFORMATION
Abortion
Artificial Insemination
Breast Implant Surgery
Cancer
Donation of Blood
Genetics
Life Sustaining Treatment
Declarations
Qualified Patients
Patients No Longer Able to Give
Consent
Chapter 10 CRIMINAL LAW AND THE MEDICAL PROFESSION
INTRODUCTION
THE FEDERAL INVESTIGATION
INSURANCE AND WORKER’S COMPENSATION
FRAUD
MEDICARE AND MEDICAID “FRAUD AND ABUSE”
LAWS
SPECIFIC OFFENSES
Criminal Offenses
Civil Sanctions
ADDENDUM: THE “ADVICE OF COUNSEL” DEFENSE
Chapter 11 DISCLOSURE REQUIREMENTS OF NEVADA PHYSICIANS
INTRODUCTION
NEVADA LAW
Hospital Disclosure Requirements
Relating to Physicians
FEDERAL MEDICARE DISCLOSURE REQUIREMENTS
Disclosure of Ownership Arrangements
When Furnishing Medicare Services
Disclosure of Referring Physician on
Claims for Medicare Covered Services
Disclosure to Beneficiaries
Disclosure by Physicians and Other
“Disclosing Part B Providers”
Chapter 12 DRUG TESTING
INTRODUCTION
FEDERAL: DRUG-FREE WORKPLACE
NEVADA STATE EMPLOYEE PROGRAM & CONFIDENTIALITY
MISCELLANEOUS CRIMINAL ACTS – TESTING
Traffic
Firearms
DRUG TESTING IN THE PRIVATE SECTOR
CONCLUSION
Chapter 13 EMERGENCY TRANSFER LAWS
INTRODUCTION
Obligations for Physicians
Obligation to Screen
EMERGENCY
MEDICAL CONDITION
Women in Labor
OBLIGATION
TO TREAT UNTIL STABILIZED
Facility Capability
Futile Treatment
Application of Laws When Patient Is Not
Transferred
RESTRICTIONS
ON TRANSFER
Federal
Transfer Requirements
Nevada Admission; Transfer; and Discharge
Requirements
Certification that the Benefit of Transfer
Outweighs the Risk
PATIENT
REQUEST, REFUSAL, OR DEMAND FOR TRANSFER
Transfer or Discharge Against Medical
Advice
HOSPITALS
OBLIGATION TO ACCEPT TRANSFERS
NOTICE
AND RECORD-KEEPING REQUIREMENTS
MANDATORY
REPORTING REQUIREMENTS
LEGAL
PENALTIES
HOSPITALS
WITHOUT EMERGENCY DEPARTMENTS
BED
SHORTAGES
PRE-HOSPITAL
CARE
LEGAL
PROTECTION FOR PHYSICIANS
Federal
Immunities
Protection for Whistleblowers
MANAGED
CARE PATIENTS
Payment for Emergency Services
EMERGENCY
TRANSFER & MEDICAL STAFF ON-CALL REQUIREMENTS
Physician Obligations to Serve On-Call
Mandatory On-Call Policies
Potential Defenses to Alleged Violations
Required Response Time
Obligations of Physicians Taking Call for
Other Physicians
Obligations of Physicians to Accept
Transfers
Follow-Up Treatment
Standby Emergency Department
Chapter 14 EXPERT WITNESS TESTIMONY
INTRODUCTION
DUTIES
AND QUALIFICATIONS OF AN EXPERT WITNESS
USE
OF EXPERT WITNESSES
TESTIMONY
IN MEDICAL INJURY CASES
DEPOSITIONS
FEES
REVIEWING
FORMER/CURRENT PATIENTS RECORDS FOR THE DEFENSE
ETHICAL
OBLIGATIONS – AMA GUIDELINES
SAMPLE
EXPERT WITNESS AGREEMENT
Chapter 15 FORGOING TREATMENT
INTRODUCTION
DEFINITIONS
PATIENTS
RIGHT TO FORGO LIFE-SUSTAINING TREATMENT
REQUIRED
PROCEDURES
RIGHTS
& RESPONSIBILITIES OF THE PHYSICIAN
MISCELLANEOUS
PROVISIONS
DURABLE
POWERS OF ATTORNEY
CONCLUSION
Chapter 16 KICKBACKS AND FEE-SPLITTING PROHIBITIONS
KICKBACKS
AND FEE-SPLITTING
GENERAL
PROHIBITIONS
Nevada Law
Federal Medicare and Medicaid Law
Specific Activities that
Could Violate the Kickback and Fee Splitting Prohibitions
Billing Services
Clinical Laboratories
Drug Research
Employee Placement
Free Services
Goodwill Payments
Home Health
Hospital-Based Physicians
Joint Venture Arrangements
Leases, Loans, & Incentives
Marketing Compensation Arrangements
Percentage Arrangements
Promotional Activities
Waiver of Copayments and Other Beneficiary
Inducements
Ethical Limitations
Other Laws Used to Deter Payments for
Referrals
Safe Harbors
Summary of the Thirteen Safe Harbors
Issued
Chapter 17 MANAGED CARE – GENERALLY
INTRODUCTION
DEFINITIONS
ADMINISTRATION
OF MANAGED CARE ORGANIZATIONS
ACCESS
TO SPECIALTY CARE
QUALITY
ASSURANCE PROGRAM
FORMING
A MANAGED CARE ORGANIZATION
Requirements
COVERAGE
BY MANAGED CARE ORGANIZATIONS
SYSTEM
FOR RESOLVING COMPLAINTS OF INSUREDS
Written Notice to Insured
Time Within Which Plan Must Resolve
Complaints
Potential Penalties
Complaints Involving Potential Harm to
Patient
Further Rights of Complaint
EMERGENCY
SERVICES RENDERED
INDUSTRIAL
INJURIES
PROHIBITED
ACTS
Prohibited Interference of Communications
Prohibited Actions Against Providers Solely Because of
the Provider’s Advocacy
Prohibited Financial Incentives
Physicians Options When a MCO Refuses
to Authorize Referrals
CONCLUSION
Chapter 18 MANAGED CARE: POST-TERMINATION PHYSICIAN STRATEGY
INTRODUCTION
PHYSICIANS
RECOMMENDED STEPS UPON TERMINATION
Read your contracts termination clause
Determine the reason for termination
Was the termination retaliatory
Reinstatement and reconsideration of the
decision to exclude
Defamation
Termination rendering non-coverage of your
specialty
SAMPLE
LETTERS
Inadequate notice of termination
Request for a fair hearing
Requesting reason for termination
Requesting reinstatement
Termination due to malpractice claim
Termination due to quality of care
advocacy
Unlawful discrimination
Explanation to patients
Letter for patient to send to the plan
Patient letter to his/her employer
Request to colleagues
Colleague letter to plan
Request for a retraction by the plan
Retraction of letter stating physician has
retired
Explaining to the plan that they will lack
physician specialty
PROPER
PROCEDURE FOR TERMINATION OF A PHYSICIAN CONTRACT
CONSULT
THE CONTRACT
Termination without cause
Reasons for termination & opportunity
for hearing required
Termination with cause
Notice to patients
Bankruptcy could prohibit termination
RIGHT
TO A HEARING UNDER FEDERAL LAW
ANTITRUST
CHALLENGES TO THE TERMINATION OF PHYSICIANS
Antitrust laws and challenging exclusion
from a plan
Differences between physician-controlled
and non-physician controlled plans
Plans with too many physician providers
may raise antitrust issues
Ability of the plan to prevent physician
practice within a geographic market
Group boycott of the applicant physician
Exclusion from a referral agreement and
antitrust consequences
Exhausting appeals
ANTITRUST
DOCTRINE AND THE NON-PHYSICIAN CONTROLLED PLAN
SUMMARY
OF ILLEGAL AND IMPROPER REASONS FOR TERMINATION
Termination due to unlawful discrimination
Termination for advocating patient care
Termination due to malpractice claims
Termination for lack of Board
Certification
ACTION
AVAILABLE TO THE PHYSICIAN WHO HAS BEEN EXCLUDED FOR LACK
OF BOARD CERTIFICATION
Address the credentialing committee
directly
Enroll the aid of patients
Look to under-served areas
Sue
LEGAL
CHALLENGES POSSIBLE
Challenge for lack of hearing
Challenge
on unfair business practice
grounds
Challenge for retaliation by managed care
plans
What the law does not change
Documentation
PRACTICAL
SUGGESTIONS TO ATTEMPT TO AVOID A LAWSUIT
Physicians
IPAs and other medical groups
Chapter 19 MANAGED CARE: UTILIZATION REVIEW AND MANAGEMENT
INTRODUCTION
COVERAGE BY MANAGED CARE ORGANIZATIONS
DENIAL OF NECESSARY MEDICAL SERVICES
Physicians Must Appeal Denials
Law Prevents Plans From Retaliating
Against Physicians
Entitlement to Competent Review of
Appeals
What to do if the Appeal Does Not
Attain Desired Results
Denials under Medicare
Right to Decision/Hearing
SANCTIONS
Sanctions Against HMOs
Sanctions Where Care was Warranted
and Federal Government is Responsible
EXPEDITED REVIEW
DENIALS OF CARE
Denial of Inpatient Care
Denial of Authorization for Hospital
Stays of Mothers and Newborns
Denial of Authorization of Mastectomy
and Related Services
Denial of Pain Management Medication
SAMPLE LETTER PROTESTING DENIAL OF SERVICES
SAMPLE FORM FOR DOCUMENTING DENIAL OF MEDICALL
NECESSARY SERVICES
SAMPLE LETTER DOCUMENTATION OF INFORMED REFUSAL AFTER
PLAN DENIAL
PATIENT CONSENT TO HOSPITAL DISCHARGE WITHIN 48 HOURS
OF VAGINAL DELIVERY OR 96 HOURS OF
CESAREAN SECTION
PHYSICIAN UTILIZATION PROFILES
Physician Data Which May Be Used
Methods of Profiling
Average Utilization Review Rates Should Be Viewed With
Caution
Chapter 20 MEDICAL PRACTITIONER DATA BANKS
THE NATIONAL PRACTITIONER DATA BANK
Data Bank Statistics
Querying the Data Bank
Access to the Data Bank
Required Queries
Controlling Access
Disputing, Correcting, or Changing
Reports
Physician Actions to Correct Data
Bank Reports
EXAMPLES OF REPORTABLE AND NON-REPORTABLE ACTIONS
THE HEALTHCARE INTEGRITY AND PROTECTION DATA BANK
Chapter 21 MEDICAL RECORDS
INTRODUCTION
DEFINITIONS
Patient
Provider of Health Care
Health Care Records
Custodian of Medical Records
Confidential Communication
PATIENTS RIGHT TO PRIVACY WITH REGARD TO MEDICAL RECORDS
Patients’ Bill of Rights
Privilege
Rules Regarding the Medical Records
of Mental Health Patients
EXCEPTIONS TO PRIVACY – RELEASE OF MEDICAL RECORDS
Subpoenaed Records
Compliance With the Subpoena
Investigations
GENERAL PROVISIONS
Disciplining Physicians
Recording Determination of Terminal
Condition & Declaration
Transfer of Records
Health Care Record Retention
Examination of Health Maintenance
Organization
Business Relationships
Chapter 22 MEDICAL REPORTING REQUIREMENTS OF PHYSICIANS
REQUIRED REPORTING TO THE NEVADA BOARD OF MEDICAL
EXAMINERS
Change of Address/Closing Office or
Practice
Physician Competence
Grounds for Initiating Licensure
Disciplinary Action
PHYSICIAN REPORTING TO THE DEPARTMENT OF MOTOR VEHICLES
Blindness and Visual Impairment
Epilepsy
PHYSICIAN REPORTING TO LAW ENFORCEMENT
PHYSICIAN REQUIRED REPORTING TO STATE REGISTRAR
Birth
Hospital Births
Out of Hospital Births
Registration of Stillborn Children
Failure or Refusal to File a
Certificate of Birth
Death
Cause of Death Statement
Death – Attended
Pronouncement of Death by a
Registered Nurse
Autopsy on the Body of a Minor
Removal of Body to Another
Registration District
Penalties
Neglect or Refusal to Execute the
Medical Certificate of Death
False Certification of Cause of Death
Signature of Uncompleted Certificate
of Death
PHYSICIAN REQUIRED REPORTS TO STATE HEALTH OFFICER
Cancer Reporting
Types of Neoplasms Requiring
Reporting
Exceptions for Reporting
Reporting Procedures
CONFIDENTIALITY
PHYSICIAN REQUIRED REPORTING TO THE HEALTH AUTHORITY
(DISTRICT HEALTH OFFICER OR, IF NONE,
STATE HEALTH OFFICER)
Incidence Reporting
Urgent Reporting Requirements
Content of Report
COMMUNICABLE DISEASES
Sexually Transmitted Diseases
Patient Instruction – Prevention and
Treatment
Ensuring Adequate Treatment
Consent for Treatment of Minors
Tuberculosis
Reporting Requirements
Treatment of Patient for Control
Measures
Records Inspection of a Facility
ENFORCEMENT
Grounds for Prosecution
CONFIDENTIALITY
REFERENCES
Chapter 23 MEDICAL STAFF
INTRODUCTION
ACQUIRING STAFF PRIVILEGES
DUTIES OF THE MEDICAL STAFF
RESTRICTING ACCESS TO THE MEDICAL STAFF
LIABILITY CONCERNS
CONCLUSION
Chapter 24 MEDICARE
INTRODUCTION
MEDICARE ELIGIBILITY
SERVICES COVERED BY MEDICARE
PREVENTIVE SERVICES PROGRAM BENEFITS
MEDICARE EXCLUSIONS
PARTICIPATION AGREEMENTS
PROSPECTIVE PAYMENT
REIMBURSEMENT
NEVADA MEDICAID
Chapter 25 MEDICARE COMPLIANCE
MEDICARE CARRIERS
THE AUDIT PROCESS
Selection for an Audit and Avoiding
an Audit
Notice of the Audit
The Audit
POTENTIAL DEFENSES
OTHER AUDIT ISSUES
MEDICARE REASSIGNMENT
RELATED ASSIGNMENT ISSUES
Independent Contractors
Billing Companies
Partnerships
SIDE AGREEMENTS WITH PATIENTS
The Requirements of the Written
Contract
The Affidavit Requirement
Limited Exception for Emergency or
Urgent Treatment
The Effect of Opting Out of Medicare
Compliance, Termination, and Partial
Opt-Outs
SAMPLE LETTER TO OBTAIN INFORMATION AND EVIDENCE THAT
WILL BE USED DURING AN AUDIT
SAMPLE PRIVATE CONTRACT BETWEEN A PHYSICIAN AND A
MEDICARE BENEFICIARY
SAMPLE AFFIDAVIT FOR A PHYSICIAN ENTERING INTO A PRIVATE
AGREEMENT WITH A MEDICARE BENEFICIARY
MEDICARE ADVANCE BENEFICIARY NOTICE
BENEFICIARY AGREEMENT
THE FALSE CLAIMS ACT
Chapter 26 MENTAL HEALTH LAWS
INTRODUCTION
DEFINITIONS
CIVIL COMMITMENT
Voluntary Commitment
Involuntary Commitment
PATIENTS RIGHTS
MINORS
GUARDIANSHIP
MENTAL HEALTH PARITY
CONCLUSION
Chapter 27 PEER REVIEW
INTRODUCTION
PEER REVIEW – GENERALLY
THE “PEER REVIEW STATUTE” – PRIVILEGE
CONCLUSION
Chapter 28 PHYSICIAN ASSISTANTS AND THE SUPERVISING PHYSICIAN
PHYSICIAN ASSISTANT (PA) LICENSING, DUTIES, AND
RESPONSIBILITIES
Definition of a physician assistant
Education and licensure requirement
Degree requirement
Interim or temporary license
PHYSICIAN ASSISTANT SCOPE OF PRACTICE
Limits on scope of practice
PA identification
Prescriptions
Surgery
Advertising as physician
PHYSICIAN SUPERVISION RESPONSIBILITIES
Requirements of the supervising
physician
Use of protocols
Board authorization of the
supervising physician
PA examination of patient prior to
physician
Discipline of supervising physician
OTHER PROCEDURES BY PA
Physician Assistants in Podiatry
Acupuncture
Laser depilatory
Orthopaedic PA
Osteopathic PA
Chapter 29 PHYSICIANS DUTY TO WARN
INTRODUCTION
DUTY TO WARN THE PATIENT
PHYSICIANS DUTY TO WARN THIRD PARTIES
CONCLUSION
Chapter 30 PRESCRIBING AND DISPENSING DRUGS
INTRODUCTION
DEFINITIONS
PRESCRIBING AND DISPENSING DANGEROUS DRUGS
Dangerous Drugs
Who May Possess, Administer, and
Dispense Dangerous Drugs
Requirements for Prescriptions
Recording and Inspection Requirements
Hypodermic Devices
PRESCRIBING AND DISPENSING CONTROLLED SUBSTANCES
Registration Requirements
Prescription Requirements
Recording and Storage Requirements
Appetite Suppressants
PAIN MANAGEMENT
Adopted Regulation of the Board of
Medical Examiners R007-99
Sample Mailing List request letter
PENALTIES FOR PRESCRIPTION AND DISPENSING VIOLATIONS
MISCELLANEOUS
Record Keeping
Silicone
Supervising Physician’s
Responsibilities
Chapter 31 PROFESSIONAL LIABILITY
INTRODUCTION
SOURCES OF LIABILITY
SUBMISSION OF CLAIMS
THE SETTLEMENT CONFERENCE
STANDARDS OF PROOF
DAMAGES
CONCLUSION
ALTERNATE DISPUTE RESOLUTION (ADR)
APPENDIX A – MODEL CONTRACTUAL ARBITRATION AGREEMENT
Chapter 32 PROFESSIONAL PRACTICE ARRANGEMENTS
INTRODUCTION
CAPITALIZATION
Overview
Financial Advisors
The Business Plan
Sources of Capital
Conclusion
THE PRACTICE CONSULTANT
Introduction
Finding the Practice Consultant
Hiring the Practice Consultant
NEVADA LAW RELATED TO MEDICAL PARTNERSHIPS
Liability Concerns of Partnerships
NEVADA LAW RELATED TO PROFESSIONAL ASSOCIATIONS
Overview
Who May Participate in a Professional
Association
Liability Issues for the Professional
Association
NEVADA LAW RELATED TO PROFESSIONAL CORPORATIONS
Overview
The Medical Professional Corporation
“One Purpose” Rule of
Professional Corporations
Who May Participate in a Professional
Corporation
Liability Concerns of the
Professional Corporation
THE INDEPENDENT CONTRACTOR ARRANGEMENT
Overview
Employee vs. Independent Contractor
IRS Safe Harbor Provision
Fraud and Abuse
Self-referral prohibitions
Pension plan issues
Malpractice coverage
Medicare assignment issues
Anti-trust issues
Obligations of being self-employed
EMPLOYMENT CONTRACTS
Overview
The Employer
The Employee
Negotiation
Selected Contract Terminology
FAMILY MEDICAL LEAVE ACT
APPENDIX A – Model Contractual Arbitration Provision
APPENDIX B – Model Consultancy Agreement
Chapter 33 REIMBURSEMENT: HMOS & OTHER PRIVATE PAYORS
INTRODUCTION
ASSIGNMENT OF BENEFITS
Failure to Pay Despite Assignment of
Benefits
When Services Rendered Are Not
Covered Benefits
Denial Or Reduction Of Claims
Non-Assignable Benefits
OBTAINING PAYMENT FROM AN INSURER OR MCO IN
FINANCIAL DISTRESS
Overview
Disadvantages To Termination
Litigating Claims
Reorganization Under Chapter 11 of
the U.S. Bankruptcy Code
The Role of Creditors in Bankruptcy
Proceedings
Arbitration Clauses Generally
Unenforceable in Bankruptcy
Proceedings
Notification to Creditors of Pending
Bankruptcy
Filing a Proof of Claim
Payment for Services Rendered After
Filing for Reorganization
Accepting New Plan Patients During
Reorganization
Termination of the Contract During
Bankruptcy Proceedings
Communication with Patients is
Protected
IPAs in Distress
BILLING FOR COVERING PHYSICIAN OR NEW PHYSICIAN
Billing Medicare for Covering
Physician or New Physician
Managed Care Contracts and Billing
for Covering/New Physician When
the Covering
Physician is not a Party to the Contract
Billing for New Member Physician of
Medical Group
COORDINATION OF BENEFITS
Managed Care Organization Contracts
Coverage of Dependents
Married Couples
Divorced or Separated Couples
Order of Coverage Not Determinable
AUTHORIZATION OF PAYMENT FOR EMERGENCY SERVICES
Emergency Services Defined
Payment for Emergency Services
Billing Issues
ERISA Plans
Definitions
Billing ERISA Plans
State Remedies Preempted By Federal
Law
Standards of Review
LATE PAYMENT
Interest
Requirement of Notice for Contested
Claims
Medicare
Discounts for Timely Payment
Electronic Claim or Payment
Procedures
Recourse for Non-Timely Payment
MULTIPLE FEE SCHEDULES
Federal Medicare & Medicaid Law
Contractual Obligations
“Usual, Customary, and
Reasonable Fees” Clauses
“Most Favored Nation”
Clauses
Prohibitions Against Fraud
Different Fee Schedules Without
Contractual Agreement
Non-HMO Physicians Accepting HMO
Rates
Medicare and Medicaid
PAYMENT DENIAL AFTER OBTAINING ELIGIBILITY VERIFICATION
OR TREATMENT AUTHORIZATION
ERISA Plans
Other Plans
Non-Payment Where Authorization or
Confirmation Obtained
PAYMENT DENIALS BY MCOs AND IPAs
Reason for Denial Must Be Disclosed
Non-Payment for “Not Medically
Necessary”
Billing Patients
Failure to Comply with Billing
Requirements
Non-Covered Services
Denial of Payment for Urgent Care
Because Outside of Service Area
Failure to Use a Contracting Lab
OVERPAYMENT OF CLAIMS AND REQUEST FOR REFUND
Eligibility Verified by Mistake
Multiple Payments
Automatic Deductions for Overpayment
by the Payor
Statute of Limitations
HEALTH PLAN SPECIAL CLAIMS REVIEW
Access to Patient’s Medical Records
Appealing Imposition of Special
Claims Review
Alternatives to Special Claims
Reviews
APPENDIX A
A.1 Sample Assignment of Benefits
A.2 Sample Billing Letter for
Covering Physician
A.3 Sample Demand Letter for Payment
and Interest
A.4 Sample Appeal of Payment Denial
for Lack of Medical Necessity
A.5 Sample Appeal of Payment Denial
for Failure to Comply with
Billing
Requirements
A.6 Sample Appeal of Payment Denial
for Failure to Use
Contracting Lab
Chapter 34 REIMBURSEMENT – MEDICAL LIENS & BILLING COMPANIES
BILLING COMPANIES
Hiring a Billing Company
The Billing Contract
Other Contract Provisions
Legal Issues Concerning Billing
Services
Special Rules Concerning Medicare
MEDICAL LIENS
Entering a Medical Lien Agreement
How Medical Liens Operate
Contents of the Lien Agreement
Medicare Patients
SAMPLE LIEN AGREEMENT
LETTER TO DEFENSE ATTORNEY WHERE A MEDICAL LIEN
IS INVOLVED
Chapter 35 REIMBURSEMENTS FROM PATIENTS
BILLING FOR NON-COVERED SERVICES
Services Deemed Not Medically
Necessary
Other Non-Covered Services
A Recent Case that May Be Useful to
Patients Whose Care is Not Covered
BILLING AND COLLECTING FROM PATIENTS
Missed Appointments
Missed Medicare Appointments
Timeliness of Bills
Cash Payments
Collection Activities
Collection Agencies
Major Hospitals
Extending Credit to Patients
Patients Billing Physicians for Time
Spent Waiting
WAIVER OF COPAYMENT
Medicare Copayments
Nevada Law
Ethical Obligations
SAMPLE GENERAL NOTIFICATION OF NON-COVERED SERVICES
SAMPLE AGREEMENT TO PAY2
Chapter 36 REPORTING ABUSE & NEGLECT
INTRODUCTION
REPORTING REQUIREMENTS
METHOD OF REPORTING
PENALTIES FOR FAILURE TO REPORT ABUSE & NEGLECT
CONCLUSION
Chapter 37 UNPROFESSIONAL CONDUCT
INTRODUCTION
CRIMINAL ACTS
“IMMORAL” ACTS
BUSINESS RELATED ACTS
VIOLATION OF MEDICAL PRACTICES
Quality of Care
Negligent Practices
Administrative Errors/Omissions
CONCLUSION
Chapter 38 WORKERS COMPENSATION
INTRODUCTION
TREATING PHYSICIANS
“Managed Care” Physicians
Non-Managed Care Physicians
Physicians’ Responsibilities Under
the Workers Compensation System
REPORTING INJURIES & CLAIMS FOR COMPENSATION
FEES & BILLING
ILLEGAL ACTS
Fraud & Misrepresentation
Improper Acceptance of Benefits &
Referral Fees
CONCLUSION
Chapter 39 MEDICAL AND LEGAL INTERNET SITES
INTERNET ADDRESSES GENERALLY
Some Popular Search Engines
MEDICAL INFORMATION WEBSITES
Physician Information
Medicare
Patient and Consumer Information
Medical Trade Associations
Alternative Medicine
HEALTH LAW WEBSITES
Health Website Search Engines and
Jumpsites
Government Health Statistics
LAW RELATED WEBSITES
Law Search Websites
Nevada Law Websites
Other Important Nevada Websites
Nevada Local Government Websites
FEDERAL LAW WEBSITES
Congress
Executive Branch
United States Statutes and
Regulations
United States Government Sites
UNITED STATES COURTS
U.S. Court Rules
U.S. Supreme Court
U.S. Courts of Appeal
U.S. District Courts
U.S. Bankruptcy Court, Nevada
Court Administration and Bar
Associations
LAW SCHOOLS AND LAW LIBRARIES
LEGAL FORMS AND DO-IT-YOURSELF SOURCES
HOW TO FIND PEOPLE ON THE INTERNET