HEALTH LAW AND ETHICS

FIND THE REGULATIONS THAT APPLY FOR EACH AND CITE THEM

1. You are a physician in a four doctor group practice. You would like the group to purchase an X-Ray machine as an ancillary diagnostic service to their medical practice. The group agrees but insists that all fees for the technical component billed to Medicare for the X-Rays should be split up based solely upon who ordered the test. (The technical component is the charge for the X-Ray itself and is not for the professional part of the radiologist or other doctor who reads or interprets the X-Ray.) Also, there is not enough space at the office building where the group practices to house the MRI machine so they want to lease space in the building next door for the MRI. What is your response to these proposals.

(I suggest looking to the fraud and abuse regulations to find support for your answers i.e. Stark and the Anti-Kickback Act. First, determine whether the laws apply and then see if there is a Stark exception or Anti-Kickback safe harbor that addresses this ancillary service and if the proposals are compliant with those exceptions or safe harbors. If not, why not?)

1. You are the compliance officer of a Medicare certified hospice. In reviewing this month’s claims submitted for payment to Medicare you discover that of the 15 new hospice admissions, for the first 90 days of hospice coverage, the medical records contain 10 written certifications of terminal illness signed by the hospice medical director within 48 hours of the initiation of service; 2 were written and signed but only after 5 days from the initiation of service and 3 have no written certifications at all, however, your staff confirms that for those last three, each of the patient’s attending physician verbally certified the terminal illness. All of the written certifications state the time frame for life expectancy for the newly admitted patients, however, the staff forgot to verify the time frame of life expectancy in their verbal conversations with the 2 attending physicians who gave verbal certificates. You decide to call the two attending physicians. What time frame of life expectancy do you need to confirm? Also, of these 15 new claims, how many do you think could be denied for payment by Medicare and why?

(This problem requires a careful analysis of the Medicare reimbursement coverage issues).

1. You sister would like to start a new personal care attendant healthcare business. A personal care attendant (“PCA”) business is licensed by the State of Louisiana as part of the Home and Community Based Service Providers. Essentially, a PCA company provides direct service workers to go to people’s homes who have disabilities to help them with Activities of Daily Living, and some very basic medication management. Your sister has asked you to help her with some licensing questions, as follows:
2. Is it OK to base the company out of her home until she makes enough money to rent an office?
3. She can secure financing from her bank through a line of credit but only for $50,000, is that enough?
4. Your sister would like for her boyfriend to be a co-owner, he has a prior misdemeanor conviction for possession of marijuana. Would that prohibit him from being an owner?
5. Once the PCA company starts making money and she moves it into a new office, she would like to sell her home and establish residency in Bay St. Louis, Mississippi, just across the border. She doesn’t mind the commute and plans to continue to serve as the PCA company’s administrator. She has a college degree and use to work for five years for the Council for the Aged in Slidell providing service to the elderly. Is that OK?

(I suggest looking to licensing regulations to find support for your answers).

1. You are the hospital administrator of one of three large hospitals in Metropolis, Louisiana. You would like to institute a new policy to help the city’s ambulance company by replenishing the ambulances that transport patients to your hospital’s emergency room with drugs, linens and other supplies that the ambulance EMT crew may have used in stabilizing the patient prior to transfer. You need to establish a policy that is compliant with the Anti-Kickback Act to avoid having a problem with Medicare should the other hospitals complain that you are giving the ambulance company a kickback to steer patients to your emergency room. Draft a policy to replenish the ambulances that is compliant with the Anti-Kickback Act.

(This is obviously a Federal Healthcare Program Anti-Kickback problem. Is there an applicable safe harbor?)

1. You are psychologist. Your last patient just left your office. She had just been fired from her position as a school counsellor and she was extremely bitter. During the therapy session she said that she wanted to “get even” with the school administration and “make them pay” for firing her which she believes was completely unjustified. You were unable to get any more details regarding her feelings about being fired. Can you disclose what she said and if so, to whom?

(Consult the Privacy Rules under HIPAA, and determine what one must do under the law in a case like this).