This document discusses rising liability costs for long term care facilities in California. It notes that while claim frequency is decreasing, average claim sizes are increasing, with the average claim in California being $192,000. This is partly due to laws like the Elder Abuse and Dependent Adult Civil Protection Act that make it easier for plaintiffs to bring elder abuse claims. Proposed changes to lower the burden of proof in elder abuse cases may further increase costs. Additionally, claims alleging violations of patient rights are contributing to higher settlement amounts as these additional claims reduce plaintiff's risk. The document recommends facilities maintain thorough documentation of staffing and patient care to defend against such claims.
Health Reform Bulletin – Implementation Update: Women’s Preventive Health Se...CBIZ, Inc.
The women’s health services component of the Affordable Care Act’s (ACA) preventive services mandate continues to evolve. As background, the ACA requires non-grandfathered plans to provide specified preventive services at no cost to plan participants. These preventive services require coverage of certain women’s health services including contraceptive coverage. Recent challenges to this requirement have reached the Supreme Court.
Health Reform Bulletin – Implementation Update: Women’s Preventive Health Se...CBIZ, Inc.
The women’s health services component of the Affordable Care Act’s (ACA) preventive services mandate continues to evolve. As background, the ACA requires non-grandfathered plans to provide specified preventive services at no cost to plan participants. These preventive services require coverage of certain women’s health services including contraceptive coverage. Recent challenges to this requirement have reached the Supreme Court.
Importance of insurance eligibility verification during COVID-19Jessica Parker
Insurance Eligibility Verification is the procedure of verifying a patient’s insurance with regards to Eligibility status, Coverage status, and Inactive or Active status. In simple words the process of checking patients.
This presentation will help you understand the strategies for patient enrollment & navigation and there by reduce the risk of caring for the uninsured.
"Will Congress Fix The Stark Law Disclosure Dilemma?"amnonwitten
This article describes the dilemma facing health care providers that discover Stark Law violations. It also discusses proposed legislation to solve the dilemma. The article was originally published in BNA Health Law Reporter, in December 2009.
Presentation made by Dr. Carolyn A. (Cindy) Watts on the 5th of November, 2012 during the live webinar hosted by VCU Department of Gerontology (discussion moderated by Dr E. Ayn Welleford) - review recording of webinar at http://www.alzpossible.org/wordpress-3.1.4/wordpress/alliedhealth/
This chapter examines the U.S. health care system—specifically, the organization of medical services; key governmental health programs such as Medicare and Medicaid; the crisis in health care, including attempts to curb health care costs; the large numbers of uninsured people; the impact of the American Medical Association on health care; and that of managed care in the American health care system. The chapter also surveys various proposals designed to ameliorate the problems in U.S. health care and considers how medical services are organized in Great Britain, Canada, and Australia.
Criança, infantil, juvenil com desenvolver comprometedor síndrome de disgenes...Van Der Häägen Brazil
O estrogênio em baixas doses aumenta a velocidade de crescimento, enquanto estrogênios em altas doses a suprime. Mesmo que a velocidade de crescimento seja aumentada, no entanto, a estatura adulta não é aumentada com esse tratamento. O tratamento da síndrome de Turner com GH aumenta com sucesso a estatura da idade adulta. Durante a infância estas meninas devem ser regularmente rastreadas para estrabismo, perda auditiva e doença autoimune da tireóide.
Importance of insurance eligibility verification during COVID-19Jessica Parker
Insurance Eligibility Verification is the procedure of verifying a patient’s insurance with regards to Eligibility status, Coverage status, and Inactive or Active status. In simple words the process of checking patients.
This presentation will help you understand the strategies for patient enrollment & navigation and there by reduce the risk of caring for the uninsured.
"Will Congress Fix The Stark Law Disclosure Dilemma?"amnonwitten
This article describes the dilemma facing health care providers that discover Stark Law violations. It also discusses proposed legislation to solve the dilemma. The article was originally published in BNA Health Law Reporter, in December 2009.
Presentation made by Dr. Carolyn A. (Cindy) Watts on the 5th of November, 2012 during the live webinar hosted by VCU Department of Gerontology (discussion moderated by Dr E. Ayn Welleford) - review recording of webinar at http://www.alzpossible.org/wordpress-3.1.4/wordpress/alliedhealth/
This chapter examines the U.S. health care system—specifically, the organization of medical services; key governmental health programs such as Medicare and Medicaid; the crisis in health care, including attempts to curb health care costs; the large numbers of uninsured people; the impact of the American Medical Association on health care; and that of managed care in the American health care system. The chapter also surveys various proposals designed to ameliorate the problems in U.S. health care and considers how medical services are organized in Great Britain, Canada, and Australia.
Criança, infantil, juvenil com desenvolver comprometedor síndrome de disgenes...Van Der Häägen Brazil
O estrogênio em baixas doses aumenta a velocidade de crescimento, enquanto estrogênios em altas doses a suprime. Mesmo que a velocidade de crescimento seja aumentada, no entanto, a estatura adulta não é aumentada com esse tratamento. O tratamento da síndrome de Turner com GH aumenta com sucesso a estatura da idade adulta. Durante a infância estas meninas devem ser regularmente rastreadas para estrabismo, perda auditiva e doença autoimune da tireóide.
Trump immigration plan explained by an immigration attorney including deportation of undocumented workers, Muslims ban, executive powers, and the wall.
Chapter 2Fraud and Abuse StarkPhysician Self-Referral and EstelaJeffery653
Chapter 2
Fraud and Abuse: Stark/Physician Self-Referral and Anti-Kickback
Learning Objectives
Physician Self-Referral (Stark) Law and Anti-Kickback Statute (AKS)
Services, individuals, organizations, and transactions affected by these laws.
Specific behaviors prohibited.
Exceptions and “safe harbors” for avoiding liability.
Anticipating and preventing violations.
Physician Self-Referral Law (Stark)
Initial law (Stark I) sponsored by Congressman Pete Stark enacted in 1989 and applied only to clinical laboratory services.
Omnibus Budget Reconciliation Act of 1993 (Stark II) expanded law to additional 10 types of clinical services.
Patient Protection and Affordable Care Act of 2010 added restrictions on physician-owned hospitals and required the issuance of a self-referral disclosure protocol.
Stark Prohibition
“... If a physician (or an immediate family member of such physician) has a financial relationship with an entity ..., then the physician may not make a referral to the entity for the furnishing of designated health services for which payment otherwise may be made” under Medicare (also applicable to Medicaid). (underlining added).
“Physician”
The person making the referral may be a(n)
MD
Osteopath
Dentist
Podiatrist
Optometrist, or
Chiropractor
“Immediate family member”
Besides the referring physician herself, this person may be a
spouse;
parent, child, or sibling (by birth or adoption);
stepparent, stepchild, step-brother, or step-sister;
father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law;
grandparent or grandchild; or
spouse of a grandparent or grandchild.
“Entity”
The entity with which there is a financial relationship must be one that bills CMS for designated health services (DHS) or that furnishes all or most of the components of the DHS.
This includes the person or entity that actually performs the DHS, or presents a claim for DHS services to the Medicare program.
7
“Financial relationship”
Direct or indirect ownership of an entity:
Equity stock, interest in a limited liability company, holding debt in an entity.
Direct or indirect compensation from an entity:
Physician’s compensation from an entity, lease between physicians and health care facilities, medical director agreements, and independent contract with physicians.
“Designated health services” (I)
Clinical laboratory services.
Physical therapy services.
Occupational therapy services.
Outpatient speech-language pathology services.
Radiology and certain other imaging services.
Radiation therapy services and supplies.
“Designated health services” (II)
Durable medical equipment and supplies.
Parenteral and enteral nutrients, equipment, and supplies.
Prosthetics, orthotics, and prosthetic devices and supplies.
Home health services.
Outpatient prescription drugs.
Inpatient and outpatient hospital services.
Penalties for Stark Violations
Payment for services in response to prohibited referral must ...
This new publication, Cyber Claims Insight from Aon Benfield’s Cyber Practice Group, empowers readers with the resources and tools they need to understand the cyber landscape, including legal trends, claims and insurance coverage disputes.
Commercial Payor Behavioral Health Audits: How to Avoid Getting Wiped OutEpstein Becker Green
The number of commercial payor audits of behavioral health facilities has been steadily rising, forcing closures of multiple treatment facilities, straining resources, and setting up an increasingly contentious conflict between treatment providers and payors.
This webinar will examine the most common issues arising in payor audits (including medical necessity; patient financial responsibility; and other issues asserted to constitute fraud, waste, or abuse) and the common arguments used as grounds for the nonpayment or recoupment of fees by insurers. The presenters will also review responsive strategies in commercial payor audits and examine defensive strategies and best practices to avoid fraud, waste, and abuse.
Presented by:
Paul D. Gilbert – Member, Epstein Becker Green
John A. Mills – Partner, Nelson Hardiman
Part of a "first Thursdays" fall webinar series hosted by Behavioral Health Association of Providers, Epstein Becker & Green, P.C., and Nelson Hardiman, LLP.
More info: https://www.ebglaw.com/events/how-to-avoid-getting-wiped-out-by-the-wave-of-commercial-payor-behavioral-health-audits-medical-necessity-and-waivers-of-co-insurance-and-deductibles/
These materials have been provided for informational purposes only and are not intended and should not be construed to constitute legal advice. The content of these materials is copyrighted to Epstein Becker & Green, P.C. ATTORNEY ADVERTISING.
Independent healthcare in house lawyers' forum, March 2018, LondonBrowne Jacobson LLP
In our first independent healthcare in house lawyers' forum for 2018 we cover the following topics:
- claims and liabilities update - including vicarious liability for the acts of non-employees and the post Paterson inquiry
- inquests and other regulatory liabilities
- capacity, consent, and how to not get sued.
Webinar: “Making It Work—Physician Compensation During the COVID-19 Pandemic”PYA, P.C.
What to do with your physician compensation plan in the face of the COVID-19 pandemic? It’s a question that leaves administrators searching for answers.
PYA Principal Angie Caldwell and Senior Manager Katie Culver introduced several key considerations for provider compensation during and after the COVID-19 pandemic. In PYA’s complimentary webinar, they:
Summarized the current environment impacting physician compensation associated with the pandemic.
Provided an overview of the Stark Blanket Waivers and opportunities created for physician compensation.
Described restoration and recovery strategies for physician resources.
PYA hosted this one-hour webinar Tuesday, April 28, 2020, at 11 a.m. EDT in conjunction with the Florida Hospital Association.
Corpus Christi Health Insurance Not An Attractive Option For Many Small Busin...jthorn4
Rick Thornton, a Corpus Christi health insurance agent, said that small businesses aren’t required by law to provide health insurance to employees, and rising premiums could lead them to drop coverage altogether.
Potential factor of rising health care cost. Presentation will drive around introduction,facts, statistics, tactics and solutions regarding fraud & abuse. I would like to thank Imran Bhai for his suggestions
1. www.wrotenlaw.com
SERVING THE UNIQUE NEEDS OF HEALTHCARE PROFESSIONALS
5510 Trabuco Road ∙ Irvine ∙ CA ∙ 92620∙ (949)788‐1790 ∙ www.wrotenlaw.com
THE INCREASING NUMBER OF CLAIMS FOR THE VIOLATION OF
RESIDENT'S RIGHTS AND ITS IMPACT ON LIABILITY COSTS
by: Regina A Casey, JD, CHC
A recent study by Aon Risk Solutions, in partnership with the American Health Care Association,
found that long term care liability costs are rising as a result of the average claim size increasing
despite the fact that claim frequency is decreasing. In its study, Aon found that the average claim size
has increased four percent, and nationwide, liability claims have risen from an average of $125,000 in
2005 to $153,000 in 2010. This increase in claim size is important to long term care providers,
especially when coupled with the uncertainty of Medicare and Medicaid funding and reimbursement.
In California, the liability cost for long term care facilities is higher than the national average.
California has a projected loss rate per occupied long term care bed of $2,020 in 2011, which is the
fourth highest loss rate in the study. The projected average liability cost for 2011 is $192,000.
Why are liability costs in California among the highest in the country when California caps
noneconomic damage awards at $250,000? One reason is California’s elder adult protection law.
Enacted in 1991, The Elder Abuse and Dependent Adult Civil Protection Act (EADACPA, Cal.
Welfare & Institutions Code Sections 15657-15657.7) provides a tool for the plaintiffs' bar to
circumvent the limitation on the recovery of non-economic damages in individual cases of elder abuse
by placing an emphasis on the "custodial" rather than the "professional" nature of long term care,
thereby enabling plaintiffs to get around the protections normally afforded healthcare providers.
Now comes proposed legislation SB 558 (Simitian), which will fundamentally change the way juries
decide elder abuse cases by establishing a lesser standard of proof from "clear and convincing" to a
"preponderance of the evidence" by amending EADACPA. Not only has tort reform in California
been ineffectual in protecting the long term care industry, but recent legislation is increasing the
burden for providers to defend themselves.
Another reason claim severity may be increasing in California is the recent rise in claims for alleged
violations of resident rights, as Health and Safety Code Section 1430(b) creates a civil cause of action
for these violations. In addition to claims for elder abuse and negligence, now plaintiffs are including
separate causes of action for violating resident rights under 22 C.C.R. Section 72527. In addition to
alleging that defendants failed to keep plaintiff free from mental and physical abuse; failed to provide
good personal hygiene; and failed to treat plaintiff with dignity, thus violating his or her rights,
plaintiffs are routinely claiming defendants failed to employ, train and/or supervise an adequate
number of staff violating 22 C.C.R Section 72527(a)(24) and Health and Safety Code Section
1599.1(a).
With the lesser burden of preponderance of the evidence, plaintiffs will simply need to present
testimony of a family member that the resident was allowed to lay in soiled sheets for long periods of
time to persuade a jury to conclude the resident's rights were violated.
2. www.wrotenlaw.com
If staffing is below 3.2 PPD at any time during the plaintiffs residency, plaintiffs counsel will be
confident they will be able to recover attorney fees and costs under Health and Safety Code Section
1430(b), even if elder abuse is not established, thus reducing counsel's risk of taking a case to trial.
Therefore, if a long term care facility finds itself in the unfortunate circumstance of having elder
abuse litigation levied against it, reaching a reasonable settlement will be more challenging when
violations of residents rights are raised.
How do you prevent plaintiffs counsel from inflating the settlement value of a case by arguing
insufficient staffing? If staffing appears to be below minimum statutory requirements, then shift the
focus of the case from statistical staffing ratios to the actual care that was provided. Emphasize the
care documented in the chart that clearly shows the resident's needs were met. If documentation is
poor, then rely on the testimony of the various care providers to establish that appropriate care was in
fact given.
The best approach to preventing the upward spiral of liability costs is to maintain good documentation
of the care provided in the facility record as well as maintain documentation of sufficient staffing and
training of personnel to counter claims of violations of resident rights and substandard care.
To learn more about Wroten & Associates visit www.wrotenlaw.com
To contact Regina Casey directly email her at rcasey@wrotenlaw.com