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The Grassi Healthcare Advisor October 2009 - Information for the Health of Your PracticeTHE H.E.A.T. IS HERE A joint effort between the Department of Justice and the Department of Health and Human Services has recently been seen in Detroit and Miami. A new agency called H.E.A.T. (Healthcare Fraud Prevention & Enforcement Action Team) has made arrests already. In Detroit, 53 individuals were indicted for submitting more than $50 million in false Medicare claims. On June 26, 2009, 8 were indicted in a $22 million Medicare false claims scheme. If convicted, the charge of conspiracy to commit healthcare fraud carries a maximum sentence of 10 years. Paying healthcare kickbacks can carry a maximum sentence of 5 years. Conspiracy to launder healthcare fraud proceeds can carry a maximum sentence of 10 years per count. CENSUS
Each year, employees face double digit premium increases. Employers are being forced to apply increases to their employers. 16% of the middle-income families spend 10% of their yearly income on healthcare. Even the insured are not going to their physicians because they cannot afford the copayments, deductibles, coinsurance or prescriptions. In New York, reports show that 14% of the population is uninsured. 67% of these people are families who have at least one member working full time. Employers may not be offering health insurance, due to the high cost of this expense. It is a large issue for small businesses. Small businesses account for 81% of all businesses in New York. Only 50% of these businesses offer health insurance. Reports show that the quality of care in New York is AVERAGE. For the best city in the world, don't you think we'd hold higher standards? CIGNA CIGNA's membership is projected to grow to match Aetna in size in 2010. Based on signed contracts from employers, CIGNA's membership will be increasing substantially. If you are not credentialed with CIGNA, you may want to consider participation. CIGNA has picked up a number of large companies, including: NY Times, Con Edison, Siemens and Deutsch Bank. Consider becoming a part of CIGNA's network now. Applications can take 3 to 6 months to become an active participant. ALERT: OUT OF NETWORK NEGOTIATIONS
The letter states the patient's carrier and their offer. The letter clearly states a deadline to sign and the percentage the physician will receive. If you sign, you will only receive the amount specified in that letter; not the full amount that the patient should have paid. DO NOT sign these agreements. Out of network benefits exist for a reason. If your patient chooses to see someone out of network, they must pay their deductible and receive reimbursement from their carrier. Patients usually do not receive complete reimbursement, but that is what happens when you go out of network. Most patients should understand this concept. Don't let the insurance companies take advantage of your desire to speed cash flow. Make sure you are receiving the amount you deserve. W-9 REQUESTS: Medical practices must know what plans are accepted. A list should be readily available for patients and staff. It should be updated and accurate; verify the plans you accept. For example, you may accept BCBS PPO/HMO, but do not want to accept Medicaid. You must opt out of the Medicaid portion. If you receive a request for W-9 or a request to update demographic information for a plan you do not participate in, do not fill it out or sign it. Have it researched. If you send back the W-9 or provide demographic information, it may be considered as your agreement to participate. Once participating, it can take 60 to 90 days to terminate the contract. During the time leading up to termination, you are subject to participation rules and fee schedules. COMPLIANCE PROGRAMS The OMIG set the effective date for 7/1/09. All providers who receive $500k or more from Medicaid are subject to implementing a compliance program by 9/29/09. Certification is required yearly. The form for certification will be required by 12/09. For more information, please feel free to contact John Pellitteri, Partner & Healthcare Niche Practice Leader at (516) 336-2470 or via e-mail at jpellitteri@grassicpas.com. |
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The U.S. Census Bureau reports approximately 11.2 million people in New York receive health benefits from their employer. The average cost of a family healthcare plan is $13,791. A minimum wage full-time job does not cover this cost.
There is a saying that goes, "read before you sign." Do not sign letters from obscure companies just because the billing manager tells you. There are companies being hired by the major insurance carriers asking physicians to "act fast" to ensure they receive a percentage of their payments. Out of network physicians are being approached to sign agreements obtaining a percentage fee for a patient they have seen.