Austin Texas Legal Issues Blog

The United States Centers for Medicare and Medicaid Services (CMS) recently released a publication outlining telehealth services that will be eligible for coverage in 2021. The agency’s list includes 39 telehealth-eligible services, such as:

• Preventive Care and Screening appointments for depression as well as child and adolescent Major Depressive Disorder suicide risk assessments
• Functional Status Assessments for hip and knee replacement procedures
• Primary care prevention intervention services provided by primary care physicians and dentists
• Childhood immunization status appointments
• Breast, cervical and colorectal cancer screening appointments
• Controlling high blood pressure appointments

The list, the Medicare Telehealth Service list, is subject to change.

Government authorities recently accused a former surgeon turned business owner of running a criminal enterprise in Texas. The physician transitioned from practicing medicine within the operating room to serving as the owner of an orthopedic and spinal disorder clinic in the Fort Worth area. During his time as a business owner, government authorities state he committed multiple acts of health care fraud.

How did the business owner commit health care fraud? Investigators claim to have evidence that from 2014 through 2017 the couple filed over 100,000 false claims with federal health care programs for physical therapy and pain management services that were not medically necessary. Ultimately, the government states the couple’s claims led to the fraudulent payment of over $5 million.

The Department of Justice (DOJ) recently announced a southern hospital system, Piedmont Healthcare, Inc., had agreed to pay $16 million to settle allegations of wrongdoing. Both parties intend the settlement to resolve two separate legal claims.

How did the case begin?

The case is a result of a qui tam action. The False Claims Act (FCA) includes a provision that allows citizens to move forward with a qui tam, or whistleblower, action. In this instance, a private citizen brought the case forward and will receive a portion of the settlement. The government has stated the individual that brought the claim forward in this case will get almost $3 million of the government's recovery.

The United States Department of Health and Human Services (HHS) issued a rule in November that requires hospitals to disclose the rates they negotiate with insurance providers. The rule requires hospitals begin to provide this information to the public in 2021. In response to the rule, the American Hospital Association, Association of American Medical colleges, Children's Hospital Association and Federation of American Hospitals filed a lawsuit against the HHS, stating the agency did not have the authority to require hospitals to make the disclosure.

Lawmakers state the required disclosure will result in increased information for the public, allowing patients to make better, more informed choices about their care. Hospitals counter, stating the rule results in an unreasonable burden. They also voice concerns about the timing of implementation of the rule, stating the impact of the coronavirus pandemic has already depleted their resources.