The environment today regarding the practice of medicine brings with it the increasing risk of adverse action or discipline by the Department of Health, (OPMC), Department of Education (OPD) and the New Jersey Office of the Attorney General (State Board of Medical Examiners.) Such risks might be as benign as the Practitioner Profile not being updated timely or more serious issues such as, audits by Medicare, Medicaid, commercial insurance companies, and complaints by patients for overbilling issues. All providers should constantly reassess his or her areas of potential risk and implement as many risk reduction measures as possible.
The following are brief suggestions to help reduce some risks. These recommendations should be implemented by every provider on an immediate basis.
Use Chaperones: Every provider should use chaperones, for his or her own self-protection, immediately. This, by itself, will prevent several false or unfounded complaints. Use of a chaperone should be documented in the office record.
Prescribing: Many adverse medical outcomes are caused by prescribing errors, a great deal of pressure has been brought to bear on state regulatory agencies to take stronger action to prevent it. As a result, we are seeing a tremendous increase in the number of investigations and disciplinary actions being commenced against providers related to prescribing. Pharmacists are being audited, reviewed, and pressured to report any questionable prescribing patterns or practices by providers. Accordingly, all providers should review the policies and guidance provided by the state to ensure they are in full compliance.
Patient Care Reviews: There is no such thing as an “informal” quality of care review, especially when performed by a hospital, insurance company, peer review organization, state or federal agency, insurance company or other institution. Each time a provider’s care is reviewed there are potentially dire consequences. As each review occurs, the provider should not respond without first reviewing the medical record in detail, obtaining, and analyzing the procedures, rules, by-laws, or regulations governing that specific review action. When responding, the response should always be neutral, calm, and objective, without emotion, or criticism, and respond directly and only to the issue under review. If the review is resolved favorably, or the complaint is withdrawn, the provider should obtain that disposition or decision in writing. At the minimum, if it cannot be obtained in writing, the providers should then write and confirm the successful resolution.
Provider’s Documentation: In order to avoid Medicare, Medicaid or commercial insurance audits a provider must ensure his/her medical records are reviewed and analyzed by counsel and a certified coder so that it can be determined whether the providers documentation supports the codes submitted. In the event that a provider’s documentation does not justify the codes submitted, the provider must rectify such billing deficiencies immediately. Once the records have been reviewed, the provider’s healthcare team, including attorneys and coding experts, will contact and negotiate with the insurance carrier.
Immediately Obtain Competent Legal Representation for any OPMC, OPD, Insurance Investigation: This is a serious matter and should be treated seriously. Obtain competent, experienced counsel to represent you from the beginning. By implementing the topics raised in this article, providers can dramatically reduce their risk of facing discipline from the DOH, OPMC, OPD, State Board of Examiners, Medicare, Medicaid or Commercial insurance carriers.
Mathew J. Levy is a Shareholder/Director of the Firm and co-chairs the Firms corporate transaction and healthcare regulatory practice. Mr. Levy has extensive experience in, defending healthcare professionals in actions brought by State licensing authorities and Federal agencies. Mr. Levy has successfully defended numerous healthcare providers in actions involving the US Attorney’s Office investigations, Medicare Fraud Waste and Abuse investigations, Medicaid Fraud Control Unit investigations, OPMC, OPD, Medicare, Medicaid as well as commercial insurance audits. Mr. Levy has successfully structured and negotiated joint venture agreements, private equity transactions, venture capital transactions, stock purchase agreements, asset sale agreements, shareholders agreements, partnership agreements, employment contracts, managed care agreements and commercial leases. Mathew Levy can be reached at 516-926-3320 or [email protected].
Weiss Zarett Brofman Sonnenklar & Levy, P.C. is a Long Island law firm providing a wide array of legal services to the members of the health care industry, including corporate and transactional matters, civil and administrative litigation, healthcare regulatory issues, bankruptcy and creditors’ rights, and commercial real estate transactions.
This article contains general advice that is not designed to apply to the reader’s specific situation and does not constitute the formation of an attorney-client relationship.
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