Emergency room physicians or health care providers are a discrete breed – whales in a sea of fish. Emergency room doctors have – for the most part – been overlooked by the RAC auditors or TPE, ZPIC, or MAC auditors. Maybe it’s because, even RAC auditors have children or spouses that need ER services from time to time. Maybe it’s because ER doctors use so many different billers. Normally, an ER doctor doesn’t know which…

A sneaky and under-publicized matter, which will affect every one of you reading this, slid into common law last year with a very recent case, dated Jan. 9, 2020, upholding and expanding the findings of a 2018 case, Lucia v. SEC, 138 S. Ct. 2044 (U.S. 2018). In Lucia, the Supreme Court upheld the plain language of the U.S. Constitution’s Appointments Clause. The Appointments Clause prescribes the exclusive means of appointing “officers.” Only the President, a court…

Extra, extra, read all about it: Breaking News! In a 2-1 decision issued December 18, a Fifth Circuit panel held that the individual mandate under the Affordable Care Act (ACA) is unconstitutional after Congress zeroed out the penalty in tax reform legislation. Although the ruling was a victory for the 18 Republican-led states that initiated the challenge to the ACA, the appeals court side-stepped the critical issue of severability—i.e., whether other parts of the sprawling…

Effective Jan. 2, 2019, the Centers for Medicare & Medicaid Services (CMS) radically changed its guidance on the use of extrapolation in audits by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), and the Supplemental Medical Review Contractor (SMRC). Extrapolation is a veritable tsunami in Medicare/Medicaid audits. The auditor collects a small sample of claims to review for compliance, then determines the “error rate” of the sample. For example, if…

As Virginia Medicaid behavioral health care providers are being terminated, the question remains, is it legal? Virginia behavioral health care providers that accept Medicaid are under statewide blanket fire. Without warning or provocation, the Managed Care Organizations (MCOs) recently began a mass firing, terminating all Medicaid behavioral health care providers “without cause.” Since the terminations involved multiple MCOs that were not ostensibly connected by business organization, involving providers across the state, it became immediately clear…

As a Medicare/caid health care provider, you have a property right to your reimbursements for services rendered that were medically necessary. Why does it matter if your Medicare/caid reimbursements constitute property rights? If you have a property right to something it cannot be taken from you without due process of law. Due process equals a fair hearing and notice. If you have a property right in something then it cannot be usurped from you. For…