Description

Balance billing and the waiver of copays and deductibles can lead to criminal and/ or civil government enforcement actions. The False Claims Act is one area of potential liability that providers should be aware of because it could also lead to being excluded from participation in government programs such as Medicare and Medicaid. Various cases and the November 2023 HHS OIG Compliance Guidance document will be highlighted.

Additionally, the No Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021 and became effective on January 1, 2022, is critical for providers accepting private insurance. There have been recent developments regarding the independent resolution process (IDR) and some notable court cases over the past two years.

The purpose of the presentation is to provide a semblance of the current landscape and to provide practical suggestions for compliance programs to implement in order to reduce the likelihood of legal, financial, and reputational damages.

Learning Objectives

• Explain balance billing
• Appreciate when it is permissible and when it is not
• Learn the American Medical Association’s position on balance billing
• Appreciate False Claims Act liability and how exclusion from being a Medicare provider may result
• Learn about recent case law
• Understand the evolution of the healthcare system that led to the No Surprises Act (NSA)
• The key aspects of the No Surprise Act (NSA)
• The recent proposed rules to the IDR
• Cases impacting the implementation of the No Surprise Act (NSA)
• The importance of an adequate compliance program

Areas Covered in the Session

• Copay versus Deductible
• OIG Special Bulletin
• Balance Billing
• ABA Article
• Professional Courtesy
• Professional Courtesy & Stark Law
• Healthcare Industry Billing, Coding, and Claims Overview
• U.S. Healthcare System History
  • New York 1933
  • Blue Shield
  • Health Maintenance Organizations (HMOs)
  • Kaiser
• Medicare and Medicaid
• Medicare Part D, CHIP & ACA
• HMO v. PPO v. POS
• HIPAA Requirements
• Claims Forms
• Coordination of Benefits
• No Surprises Act – Enacted as Part of the Consolidated Appropriations Act
• Surprise Billing
• The 17 states that don’t offer any surprise billing protections
• Consolidated Appropriations Act
• No Surprises Act
• Air Ambulance Service
• Cost Sharing & Payment Methodologies
• Patient Cost Sharing Responsibilities
• The Multi-Agency Interim Final Rule
  • 86 Fed. Reg. 36895
  • Federal Register
• Five Areas Addressed in the Interim Rule
• Cost Sharing
• Emergency Services
• Emergency Medical Condition
• The NSA’s Independent Dispute Resolution Process
• IDR Process
• IDR Final Rule
• CMS – No Surprise Act Items
• Relevant Case – False Claims Act, AKS and Stark
• Fraud Enforcement: The False Claims Act
• MDTN False Claims Act Case – Copay Waivers
• SDNY False Claims Act Case – Copay Waivers
• False Claims Act Case – Balance Billing
• Concluding Thoughts

Suggested Attendees

• Healthcare CEOs, CFOs & COOs
• Physician and Physician Assistants
• Billers and Coders
• Revenue Cycle Specialists
• Government Organization
• Defense Counsel
• Relator’s Counsel
• Compliance Officers
• Healthcare Attorneys
• Cybersecurity Professionals & Consultants
• Anyone in Healthcare