William McDonald

  • Providers, Take Note: Cigna Increases Its Recovery Efforts

    By William McDonald, Esq. Email Bill March 30, 2017 Long Island medical providers have learned that Cigna is once again striving to “recover” payments made to them. Cigna’s investigation focuses primarily on out-of-network providers, since it believes that its contract language with self-funded ERISA plans entitles it to recover payments made for out-of-network services. Cigna employs a classic flanking maneuver to box in the targeted providers.  It begins by sending letters to its members who have received services at out-of-network providers. The letter asks about services provided, the dates such services were provided, and whether the member paid any co-pay or co-insurance payment to ...

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    Wednesday, March 29th, 2017

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  • Disclosure of Protected Health Information: It’s Not All About HIPAA

        Published in the Suffolk Lawyer, January 2017 By William McDonald, Esq. Email Bill December 20, 2016 Anyone who’s had a doctor’s appointment in the past 20 years is familiar with the Health Insurance Portability and Accountability Act (known affectionately—or not—as HIPAA).  Undoubtedly, if your business collects and shares protected health information, you and HIPAA are old friends.  However, many healthcare providers don’t realize that HIPAA isn’t the only game in town.  It’s also critical to analyze all of your statements to consumers together and ensure that your disclosures are not deceptive under the Federal Trade Commission (FTC) Act. As a refresher, the HIPAA Privacy Rule empowers ...

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    Monday, December 19th, 2016

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  • OMIG Update: December 31 Certification Requirement for Compliance

          OMIG Update December 21, 2016 The New York State Office of the Medicaid Inspector General: Reminder of Certification Requirement for Compliance Programs and DRA Obligations As a reminder for Medicaid providers subject to New York’s mandatory compliance program obligation in Social Services Law section 363-d and 18 NYCRR Part 521, the December Annual Certification period expires December 31, 2016 at 11:59 p.m. Additionally, New York’s Medicaid providers subject to the Deficit Reduction Act of 2005 must complete their DRA Annual Certification by December 31, 2016 at 11:59 p.m. For OMIG compliance questions year-round, please contact Bill McDonald, chair of our Healthcare practice group, at (631) 738-9100.

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    Monday, November 21st, 2016

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  • Overthinking Overpayments from Medicare

        Published in Nassau Lawyer, June 2016 By William McDonald, Esq. E-mail Bill June 15, 2016 Since passage of the Affordable Care Act, compliance officers and attorneys have struggled to comply with the new rule requiring notification and repayment of Medicare overpayments within 60 days.  The two large questions that remain unclear are what constitutes an “overpayment,” as well as what it means to “identify” an overpayment. Section 6402(a) of the Affordable Care Act (“ACA”) created a new section 1128J(d)(1) of the Social Security Act (the “Act”), which addresses overpayments.  Section 1128J(d)(2) requires an overpayment to be reported and returned “by the later of (A) the date ...

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    Wednesday, June 15th, 2016

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  • A Refresher On Medicare Exclusions From The Office Of Inspector General

    By William McDonald, Esq. December 21, 2015 As we near the end of the year, the government will report on how much money it has recovered from healthcare entities for improper Medicare billing.  It is important to remember that, while monetary penalties are serious consequences, egregious overbilling violations may result in the Office of the Inspector General for Health and Human Services (“OIG”) issuing an order excluding a provider from participating in Federal Health Care programs.  This sanction is in effect a civil death penalty, since an excluded provider may not bill for services reimbursed by any Federal Health Care program during ...

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    Friday, December 18th, 2015

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  • Healthcare Providers with Health Republic Patients Must Act Now to Protect Ability to Receive Payment

    By William McDonald, Esq. Healthcare providers must proactively pursue timely payments under New York’s Prompt Pay Law and conduct credentialing verification to protect their income in the wake of the Health Republic insurance company closing. In October 2015, the New York State Department of Financial Services (DFS) announced that Health Republic would halt coverage at the end of November 2015 due to its risk of insolvency.  This announcement started a scramble among healthcare providers.  The state Healthcare Association, an industry group representing hospitals, estimates that hospitals alone are owed at least $160 million from Health Republic. Newsday reported that the DFS has told ...

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    Friday, November 20th, 2015

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  • Medicare Providers: Don’t Let Identity Theft Cost You Money!

    By William McDonald, Esq. October 20, 2015 Medicare providers face an alphabet soup of entities seeking to recover “overpayments” from them on behalf of Medicare.  Commonly referred to as Recovery Audit Contractors (“RACs”), these entities include Zone Program Integrity Contractors (“ZPICs”), and they have an aggressive mandate to recover Medicare “overpayments” to providers. We recently represented a physician from whom a RAC sought $850,000 in overpayments for services billed to Medicare.  The liability arose because our client did not have any documentation to support the $850,000 in billed services.  However, our client did not have the supporting documentation because she never performed or ...

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    Tuesday, October 20th, 2015

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  • Medicaid Providers: Keep Your Money. Prepare For an OMIG Audit.

    By William McDonald, Esq. August 26, 2015 Governor Cuomo announced that New York recovered a record-breaking $851 for the Medicaid program in 2013, which led the nation. but such results are not ...

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    Wednesday, August 26th, 2015

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  • Center for Medicare & Medicaid Services (“CMS”) Announces Guidelines to Ease ICD-10 Implementation

    By William McDonald, Esq. July 15, 2015 Beginning October 1, 2015, physicians will be required to utilize ICD-10 for claims.  ICD-10 will replace the 35-year old ICD-9 diagnostic system.  According to Acting CMS Administrator Andy Slavitt, “ICD-10 will set the stage for better identification of illness and earlier signs of epidemics, such as Ebola or flu pandemics.” The task of converting to ICD-10 has proven nothing less than gargantuan for medical practices, and spurred intense lobbying from the American Medical Association (“AMA”) and other physician interest groups. As a result, on July 6, 2015, the CMS and AMA jointly released an announcement detailing ...

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    Wednesday, July 15th, 2015

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  • Court Strikes Down CMS Prohibition on ‘Per-click’ Equipment Rentals, Upholds ‘Under-Arrangements’ Prohibitions, Under Stark Law

    By William McDonald, Esq. June 22, 2015 Freddy Kreuger from Nightmare on Elm Street, Jason from Friday the 13th, and The Exorcist.  This triumvirate struck fear in me as a kid and caused many sleepless nights.  Fast forward to present, and the Stark Law invokes similar fears, with its strict liability and draconian punishments for even inadvertent violations.  The Stark Law prohibits a physician from billing any federal healthcare program for items or services provided by another entity with whom the physician has a financial relationship, unless the arrangement falls within a statutory exception.  See generally, 42 U.S.C. 1395nn. The Secretary for Health ...

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    Monday, June 22nd, 2015

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