Why Prior Authorization Has Become a Breaking Point in Health Care

Why Prior Authorization Has Become a Breaking Point in Health Care

Episode Summary: In this episode of Gosfield and Shay on Health Law, Alice Gosfield, a renowned healthcare attorney, joins host LeAnn Lyon to delve into the complexities of prior authorizations in the healthcare system. They explore the historical context and recent scrutiny of prior authorizations, revealing how these processes have become a significant burden for physicians and patients alike. Alice discusses the role of pharmacy benefit managers and the controversies surrounding their practices, as well as the challenges posed by predictive algorithms and artificial intelligence in decision-making. The episode also covers Medicare Advantage's role in the prior authorization debate and the implications of new CMS rules aimed at increasing transparency and efficiency. Listeners will gain insights into the ongoing reforms and the potential for meaningful change in the healthcare landscape. Key Timestamps: 00:01 – Introduction 00:54 – The Rise of Prior Authorizations 01:09 – Burden on Physician Practices 02:22 – Role of Pharmacy Benefit Managers 03:36 – Industry's Response to Criticism 04:31 – Administrative Burden on Physicians 05:41 – Impact of Predictive Algorithms 06:42 – Medicare Advantage and Prior Authorization 08:11 – New CMS Rules and Their Impact 09:46 – State Regulations and Physician Rights 10:14 – Future of Prior Authorization Reforms About the Show: Gosfield and Shay on Health Law is a podcast dedicated to exploring the intricate world of healthcare law and policy. Hosted by healthcare attorney Alice Gosfield and LeAnn Lyon, the show offers insightful discussions on topics like Medicare, fraud and abuse, and healthcare regulations. With a focus on strategic clarity and practical guidance, the podcast aims to inform and empower physicians, healthcare professionals, and policymakers navigating the complex legal landscape of healthcare. Whether you're a seasoned professional or new to the field, this series provides valuable perspectives on the ever-evolving world of health law.

Physician Employment Agreements: Perspectives and Pitfalls from Both Sides

Episode Summary:  In this episode of Gosfield and Shay on Health Law, healthcare attorney Daniel Shay discusses the intricacies of physician employment agreements. Daniel delves into the evolution of compensation structures over the past decade, highlighting the shift from fixed salaries to productivity-driven models. The conversation covers the impact of industry consolidation, the role of private equity, and the pressures on employers to maximize productivity. Daniel also examines the challenges physicians face with non-compete clauses, termination provisions, and tail coverage obligations. By understanding these elements, physicians can better navigate their contracts and protect their interests. This episode provides valuable insights for healthcare professionals looking to negotiate favorable terms and avoid common pitfalls in their employment agreements. Key Timestamps: 00:01 – Introduction 00:10 – Evolution of Physician Employment Agreements 00:56 – Changes in Compensation Structures 02:14 – Productivity-Based Compensation Models 05:30 – Divergence of Expectations in Compensation 07:06 – Transparency in Compensation Calculations 09:02 – Non-Compete Clauses and Their Impact 12:25 – Termination Provisions and Their Implications 15:48 – Tail Coverage Obligations 18:12 – Employer Objectives in Employment Contracts 20:42 – Patterns in Contract Disputes About the Show:  Gosfield and Shay on Health Law is a podcast dedicated to exploring the complex intersection of healthcare and legal issues. Hosted by experienced healthcare attorneys, the show provides in-depth discussions on regulatory compliance, employment agreements, and the business realities of medical practice. Listeners gain practical insights into navigating the legal landscape of healthcare, with a focus on making complex rules accessible and actionable. Whether you're a physician, healthcare administrator, or legal professional, Gosfield and Shay on Health Law offers valuable guidance to help you stay informed and make informed decisions.

Why Medicare Enrollment Is Like Home Ownership (Because It Requires Constant Maintenance)

Episode Summary:  In this episode of Gosfield and Shay on Health Law, healthcare attorney Daniel Shay delves into the intricacies of Medicare enrollment, likening it to the ongoing responsibilities of homeownership. He highlights the necessity for constant updates and vigilance to maintain compliance, emphasizing the importance of responding to revalidation requests and updating application information within specified timelines. Daniel Shay discusses the consequences of failing to comply, such as deactivation and revocation of billing privileges, and provides real-world examples of how outdated information can lead to serious issues. He offers practical advice for healthcare practices to manage their enrollment processes effectively, ensuring they stay ahead of potential problems. Listeners will gain valuable insights into maintaining compliance and safeguarding their practice's financial health. Key Timestamps: 00:01 – Introduction 00:10 – Understanding Medicare Enrollment 00:47 – Ongoing Obligations for Providers 01:21 – Importance of Updating Information 02:01 – Types of Changes Requiring Updates 02:54 – Common Compliance Failures 03:41 – Deactivation vs. Revocation 05:41 – Impact on Billing and Cash Flow 06:32 – Revalidation Process Explained 07:52 – Consequences of Outdated Information 10:27 – Best Practices for Enrollment Management About the Show:  Gosfield and Shay on Health Law is a podcast dedicated to providing healthcare professionals with clear and practical insights into the complex world of health law. Hosted by experienced attorneys, the show covers topics such as regulatory compliance, Medicare, and emerging legal issues in healthcare. With a focus on making intricate legal concepts accessible, the series aims to empower medical practices to navigate legal challenges confidently and effectively.

Non Face-to-Face Services in Medicare: Risks and Rewards

Episode Summary: In this episode of *Gosfield and Shay on Health Law* attorney Alice Gosfield delves into the complexities and potential pitfalls of billing for non-face-to-face services under Medicare. She discusses the shift in Medicare payment policies, specific documentation requirements, red flags for federal auditors, and the challenges posed by remote physiologic monitoring. Alice also explores rules for split shared visits and the implications for physician compensation models, offering valuable insights for healthcare providers navigating Medicare reimbursement. Key Timestamps: 00:00 – Introduction 03:22 – Shift in Medicare payment policies 07:15 – Documentation requirements for non-face-to-face services 11:45 – Red flags for federal auditors 15:10 – Challenges of remote physiologic monitoring 19:30 – Rules for split shared visits 23:50 – Physician compensation models 27:40 – Special enforcement risks for billing codes About the Show: *Gosfield and Shay on Health Law* provides in-depth analysis and expert insights into the legal landscape of healthcare, focusing on compliance, fraud avoidance, and navigating complex regulatory frameworks in the industry. Hosted by healthcare attorney Alice Gosfield, the show aims to educate and empower healthcare professionals with the knowledge needed to thrive in an evolving healthcare environment.

Voluntary Repayments: How Voluntary Are They and How to Do Them

Episode Summary: In this episode of *Gosfield and Shay on Health Law*, healthcare attorney Alice Gosfield delves into the nuances of voluntary repayments in healthcare compliance. She highlights the importance of proactive auditing, the evolving definition of overpayments, common mistakes in calculating repayments, and the significance of proper documentation when returning money. Gosfield also emphasizes the implications of overpayments escalating to false claims and the hefty penalties providers face. Key Timestamps: 00:00 – Introduction 01:30 – Ongoing Internal Auditing for Compliance 04:15 – Definition Changes in Overpayment Rules 06:50 – Calculating Total Repayment Account 08:30 – Safest Way to Return Money 10:45 – Obligations of Healthcare Entities and Vendors 13:20 – Overpayments and False Claims 15:40 – Quality-Based Value Payments and Reporting About the Show: *Gosfield and Shay on Health Law* provides expert insights into Medicare reimbursement, fraud avoidance, and compliance strategies in the healthcare industry. Join for in-depth discussions with industry professionals and legal experts to navigate the complexities of health law.