Is this legal? Part 2

[Anonymous]

Stark Laws......I,II,III....and they keep getting tougher to discourage docs from financial benefits of prescribing products. Leads to overutilization. Reduces brand selection to highest bidder...BGS business typical case. Abuse and corruption.

A bone stim can only be Rx/paid for if patients meet certain criteria's. Abuse is using it on patients who don't need the device and don't meet the criteria. So to say there is abuse is stretching it....Your claim is false and not true.

 

[Anonymous]

A bone stim can only be Rx/paid for if patients meet certain criteria's. Abuse is using it on patients who don't need the device and don't meet the criteria. So to say there is abuse is stretching it....Your claim is false and not true.

sorry, you are 100% wrong on this.

say a clinic uses buy and bill and fits 15 patients per month with pysiostims. they are referring to themselves 100%, and making close to $30,000 for this practice. violation of the Starck laws. Once the doctors or dme crew get a taste of this sort of profit it spins out of control. Dme employees get bonuses for fitting more patients, office notes and dates start to get changed, and doctors are told what to write on the xray reports by the dme members so that the insurance companies or work comps pay up.
also think of all of the surgeons who let you fit patients in the hospital or OR setting. the units get billed to the hosp surg fees, patient ends up paying a portion in the long run. these are being used for acute fractures, bunionectomies and revisional surgeries of all kinds believe me.
additionally, what we all now know is that the orthofix reps have been doing is actually changing the dates on the office notes so that the device falls within guidelines. one specialty of the local rep is to fit an acute fracture, and then not submit the order for 90 days until they have some sort of office note that they can alter, unless their doc agrees to denote non-union for them at that time.

 

[Anonymous]

sorry, you are 100% wrong on this.

say a clinic uses buy and bill and fits 15 patients per month with pysiostims. they are referring to themselves 100%, and making close to $30,000 for this practice. violation of the Starck laws. Once the doctors or dme crew get a taste of this sort of profit it spins out of control. Dme employees get bonuses for fitting more patients, office notes and dates start to get changed, and doctors are told what to write on the xray reports by the dme members so that the insurance companies or work comps pay up.
also think of all of the surgeons who let you fit patients in the hospital or OR setting. the units get billed to the hosp surg fees, patient ends up paying a portion in the long run. these are being used for acute fractures, bunionectomies and revisional surgeries of all kinds believe me.
additionally, what we all now know is that the orthofix reps have been doing is actually changing the dates on the office notes so that the device falls within guidelines. one specialty of the local rep is to fit an acute fracture, and then not submit the order for 90 days until they have some sort of office note that they can alter, unless their doc agrees to denote non-union for them at that time.

well, I am not that versed on what ortho side is doing. I'm speaking regarding the spine stim side. So u may be right.

 

[Anonymous]

so you think that a group of sales reps who are forging doctors signatures, creating and changing office notes so that taxpayers are paying for physiostims for acute fractures, when there is no clinical proof there is any clinical benefit whatsoever is OK? making those poor patients pay $700 copays and wear the device for 3 hours a day to pay for your greed? that medicare is paying $3500 for each of these patients? that should go unpunished???

Of course Holder et al are corrupt but entirely a different story.

What if there is a corrupt Medicare official taking payments, which is how it all got approved in the first place....corrupt docs "clinically reviewing the product" and paid to evaluate and are public officials, deciding what gets approved and how much to pay. This could be rooted in corruption deeper into the game the big boys play. If that's the real truth, it is like the Holder story. Gov't protecting itself. Will someone please stand up and just call the BGS business what it is, a bunch of BS? Maybe they should just pay another $20M the next 30 days and think about it.

 

[Anonymous]

What if there is a corrupt Medicare official taking payments, which is how it all got approved in the first place....corrupt docs "clinically reviewing the product" and paid to evaluate and are public officials, deciding what gets approved and how much to pay. This could be rooted in corruption deeper into the game the big boys play. If that's the real truth, it is like the Holder story. Gov't protecting itself. Will someone please stand up and just call the BGS business what it is, a bunch of BS? Maybe they should just pay another $20M the next 30 days and think about it.

Well, I'm not in a position to speculate or comment on something that's not true or has not come out. At this point your comments are baseless and w/o facts. Something I'm not comfortable engaging in unless it was factual and had merit.

 

[Anonymous]

What if there is a corrupt Medicare official taking payments, which is how it all got approved in the first place....corrupt docs "clinically reviewing the product" and paid to evaluate and are public officials, deciding what gets approved and how much to pay. This could be rooted in corruption deeper into the game the big boys play. If that's the real truth, it is like the Holder story. Gov't protecting itself. Will someone please stand up and just call the BGS business what it is, a bunch of BS? Maybe they should just pay another $20M the next 30 days and think about it.

No way. The truth is simpler, and well stated in this thread, more at the rep/clinic level so that thing get approved and reimbursed as above posters stated

 

[Anonymous]

This is complete BS, and probably a post from one of your scrambling, desperate pr people. or someone who just got hired and has no idea how the 'Firm' really operates.

orthofix specializes in the buy and bill model. your reps and managers, just like djo, hold a series of meetings with prospective clinics to pitch this, and then help them set up the billing system, go over guidelines, billing procedures, everything. orthofix of course endorses this. if not, how do you explain selling huge amounts of units at bulk pricing (~$1600) to all of your large clinics? these clinics do hundreds upon hundreds of units per year because they are earning up to $2000-3000 per patient. then the office gets in on the game of changing notes, changing dates so that the order bills properly, once they too realize just how easy that is.

All this is getting ready to Blow Up with some of the Blues who clauses in their contracts or WILL have a clause. This is an outrageous practice and will soon blow up and make a lot of clinics and hospitals very angry.

 

[Anonymous]

All this is getting ready to Blow Up with some of the Blues who clauses in their contracts or WILL have a clause. This is an outrageous practice and will soon blow up and make a lot of clinics and hospitals very angry.

We will see.....

 

[Anonymous]

All this is getting ready to Blow Up with some of the Blues who clauses in their contracts or WILL have a clause. This is an outrageous practice and will soon blow up and make a lot of clinics and hospitals very angry.

Clinics and hospitals are the greediest bastards on the planet, the worst, they milk companies like Orthofix and their employees dry and the reps take the jail time. fuck off, you whiney bitch.

 

[Anonymous]

What do you mean, "they milk" companies? Companies prices are outrageously Jacked Up, dude.

 

[Anonymous]

Clinics and hospitals are the greediest bastards on the planet, the worst, they milk companies like Orthofix and their employees dry and the reps take the jail time. fuck off, you whiney bitch.

Yes and Orthofix sells thousand of units per year at wholesale to these clinics so they can overcharge the insurance companies and they have absolutely no clue how that all works, eh? It is Ofx that is letting the reps take the fall- I hope you all realize this.

 

[Anonymous]

Yes and Orthofix sells thousand of units per year at wholesale to these clinics so they can overcharge the insurance companies and they have absolutely no clue how that all works, eh? It is Ofx that is letting the reps take the fall- I hope you all realize this.

Companies will sell out their employees 100% of the time to protect their corporate integrity, or in this case, their lack of it.

 

[Anonymous]

Seriously? Selling bone stims directly to clinics and hospitals at prices way below Payer remibursements will get you in trouble with the Insurance Companies eventually. BCBS is already doing audits because of their contract clauses. Come on People! Can't you play fair?

 

[Anonymous]

Poster #20 stated:

Stark Laws......I,II,III....and they keep getting tougher to discourage docs from financial benefits of prescribing products. Leads to overutilization. Reduces brand selection to highest bidder...BGS business typical case. Abuse and corruption.

In turn, Poster #21 stated:

A bone stim can only be Rx/paid for if patients meet certain criteria's. Abuse is using it on patients who don't need the device and don't meet the criteria. So to say there is abuse is stretching it....Your claim is false and not true.

Both are correct.

The Stark prohibitions on self-referral ONLY apply to Medicare, Medicaid, or other federally funded insurers, such as Tricare, Humana, or the BCBS Federal plans.

The Stark prohibitions are TOTALLY inapplicable, outside the federal arena, in regards to patients insured by, say Cigna, Aetna, or Anthem --- if the BGS is medically necessary, as set forth and promulgated by the commercial insurer's medical coverage policy, which sets forth the broad threshold coverage criteria. (e.g. for some commercial insurers, comorbid as a smoker, diabetic, or suffering from renal disease.)

For example, see the Cigna Medical Coverage Policy for a BGS, ultrasound or electrical:
http://www.cigna.com/assets/docs/he...gepositioncriteria_electrical_stimulators.pdf

In regards to Aetna, see:
http://www.aetna.com/cpb/medical/data/300_399/0343.html

In regards to Anthem, see:
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050280.htm

The reason Orthofix got a spanking by the DOJ is solely because the wrongdoings were perpetrated on Medicare patients.

As a disclaimer, I do not, nor have I ever, sold or rented a BGS; and, I do not work for, nor have I ever worked for, the players in the BGS market, such as Orthofix, S&N, or DJO.

There are many who mistakenly believe that the Stark prohibitions apply across-the-board, even to patients insured by commercial insurers who are not federally funded. NOT SO.

Outside of Medicare, Medicaid, Tricare, Humana, or federally funded BCBS plans, the Stark tiger has no teeth.

This is a huge distinction, with a difference. If you don't believe me, ask an attorney who specializes in health care law.

As a caveat, there may be contractual prohibitions for the physician who is a participating provider --- but from my experience as a paralegal who has made a living off providing practice management solutions for many physicians over the past two decades, contractual prohibitions for participating physicians are as rare as hens teeth.

Generally speaking, there may indeed be moral and ethical considerations --- as it can be safely assumed that the physician who profits from dispensing a BGS he has prescribed, will most probably over-utilize dispensing a BGS for profit --- but it is LEGAL, as long as the physician is not prescribing and dispensing to a Medicare, Medicaid, Tricare, Humana, or federally funded BCBS insured patient --- if medically indicated by the commercial insurer's own guidelines.

Now that the ACA, commonly known as "Obamacare," has been upheld by the Supremes, and we will be seeing many commercial insurers further spiking their premiums while concurrently reducing reimbursement to physicians on a regular basis, be prepared to see many more physicians looking for ways to legally increase their profits by prescribing, dispensing, and billing the commercial insurer for many more BGS units.

 

[Anonymous]

Poster #20 stated:



In turn, Poster #21 stated:



Both are correct.

The Stark prohibitions on self-referral ONLY apply to Medicare, Medicaid, or other federally funded insurers, such as Tricare, Humana, or the BCBS Federal plans.

The Stark prohibitions are TOTALLY inapplicable, outside the federal arena, in regards to patients insured by, say Cigna, Aetna, or Anthem --- if the BGS is medically necessary, as set forth and promulgated by the commercial insurer's medical coverage policy, which sets forth the broad threshold coverage criteria. (e.g. for some commercial insurers, comorbid as a smoker, diabetic, or suffering from renal disease.)

For example, see the Cigna Medical Coverage Policy for a BGS, ultrasound or electrical:
http://www.cigna.com/assets/docs/he...gepositioncriteria_electrical_stimulators.pdf

In regards to Aetna, see:
http://www.aetna.com/cpb/medical/data/300_399/0343.html

In regards to Anthem, see:
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050280.htm

The reason Orthofix got a spanking by the DOJ is solely because the wrongdoings were perpetrated on Medicare patients.

As a disclaimer, I do not, nor have I ever, sold or rented a BGS; and, I do not work for, nor have I ever worked for, the players in the BGS market, such as Orthofix, S&N, or DJO.

There are many who mistakenly believe that the Stark prohibitions apply across-the-board, even to patients insured by commercial insurers who are not federally funded. NOT SO.

Outside of Medicare, Medicaid, Tricare, Humana, or federally funded BCBS plans, the Stark tiger has no teeth.

This is a huge distinction, with a difference. If you don't believe me, ask an attorney who specializes in health care law.

As a caveat, there may be contractual prohibitions for the physician who is a participating provider --- but from my experience as a paralegal who has made a living off providing practice management solutions for many physicians over the past two decades, contractual prohibitions for participating physicians are as rare as hens teeth.

Generally speaking, there may indeed be moral and ethical considerations --- as it can be safely assumed that the physician who profits from dispensing a BGS he has prescribed, will most probably over-utilize dispensing a BGS for profit --- but it is LEGAL, as long as the physician is not prescribing and dispensing to a Medicare, Medicaid, Tricare, Humana, or federally funded BCBS insured patient --- if medically indicated by the commercial insurer's own guidelines.

Now that the ACA, commonly known as "Obamacare," has been upheld by the Supremes, and we will be seeing many commercial insurers further spiking their premiums while concurrently reducing reimbursement to physicians on a regular basis, be prepared to see many more physicians looking for ways to legally increase their profits by prescribing, dispensing, and billing the commercial insurer for many more BGS units.

Problem is: Many BCBS and other Commerical Payers have clauses in their DME contracts AGAINST this practice. So, is it worth losing your contract with some of the highest commercial Payers? Audits are already happening.

A Commercial Payer can decide NOT to contract with a DME company or any other vendor if they so choose.

 

[Anonymous]

Problem is: Many BCBS and other Commerical Payers have clauses in their DME contracts AGAINST this practice. So, is it worth losing your contract with some of the highest commercial Payers? Audits are already happening.

A Commercial Payer can decide NOT to contract with a DME company or any other vendor if they so choose.

Spine stim is alive and well. Everyone gets on here and says......you wait and see....or it's going to rental. You can all write books on your BS opinion on what you want to have happen but SS is alive and well. Guess what on Monday, Medicare, BCBS and many other private insurers will approve and pay for hundreds of BGS. SO EAT SHIT.

 

[Anonymous]

Hi, I'm poster #36.

Poster #37 stated:

Problem is: Many BCBS and other Commerical Payers have clauses in their DME contracts AGAINST this practice. So, is it worth losing your contract with some of the highest commercial Payers? Audits are already happening.

A Commercial Payer can decide NOT to contract with a DME company or any other vendor if they so choose.

Poster #37, you must have posted your thoughts while I was still composing mine. As I alluded to in my post above, some commercial insurers do have contractual language that forbids the contracted participating provider (physician/clinic) from providing DME. Specifically, this would be BCBS, but only in a few States.

However, I am not seeing retro audits being conducted by BCBS, as their software is able to ascertain whether the physician/clinic is a contracted participating provider when the billing is received, either electronically or on paper. If the NPI number of the physician/clinic matches up in the BCBS database as a contracted participating provider, no payment is issued, and a denial is issued instead --- based on the physician/clinic providing services that is outside of its contract with BCBS.

From my experience, it is only BCBS that will refuse to reimburse a contracted participating provider physician/clinic for the provision of DME, and again, only in a few States.

It has also been my experience that BCBS will not cancel their contract with the participating provider physician/clinic that has prescribed and dispensed the DME prescribed --- but instead, BCBS will simply not pay the bill for the DME --- and, the contract forbids the contracted participating provider physician/clinic from balance-billing the patient for the full amount (or even a partial amount) of the DME that has been disallowed on a contractual basis.

I have never seen this with United Health Care, Cigna, or Aetna.

Poster # 37, you also mentioned that "A Commercial Payer can decide NOT to contract with a DME company or any other vendor if they so choose."

I agree. However, this will, generally speaking, not result in a refusal to reimburse, but instead, reimbursement will be at a lower percentage of the allowed amount.

As an example, if the insurer is Aetna, and the provider is an in-network participating provider, Aetna will reimburse at, say, 80% of the allowed amount. But, if the provider is out-of-network, Aetna will only reimburse at 60% of the allowed amount, leaving their insured (usually the patient) financially responsible for the increased co-pay or co-insurance. This is akin to the insurer punishing the insured for obtaining treatment or DME out-of-network --- and it is a further financial incentive for the insured patient to only obtain treatment or DME from an in-network provider.

I will acknowledge that some insurers offer what I call a "strict" PPO policy, that only allows their insured to treat with in-network physicians/clinics. But, from my experience doing practice management nationwide, the percentage of patients with "strict" PPO policies that will only reimburse for treatment or DME provided by the in-network physician/clinic is very small, number wise. (e.g. maybe 5%)(In my view, the "strict" PPO policy is similar to an HMO policy that will only reimburse for treatment, or DME, provided by its in-network HMO providers --- unless the treatment is provided on an emergent basis, such as an unexpected ER visit at a non-participating and non-contracted hospital or trauma center.)

One of the business entities, with whom I am contracted to provide practice management, is a DME company. This particular DME company is a non-participating provider, who is out-of-network, with all commercial insurers, nationwide. They are getting paid regularly for the DME provided, albeit, at a reduced percentage of the allowed amount.

This particular DME provider does seek the co-pay and/or co-insurance from the insured patient --- but sometimes they do waive it, on a case-by-case basis, if the insured patient can demonstrate and document that it would be a "financial hardship" to reimburse the DME company the co-pay or co-insurance. Also, with some insured patients who cannot afford to pay the full amount of the co-pay or co-insurance today, this DME company will work out a payment plan --- allowing the financially strapped insured patient to pay over time.

Just because "A Commercial Payer can decide NOT to contract with a DME company or any other vendor if they so choose," does not mean the PPO insurer will refuse to reimburse the DME company without a contract with that insurer, unless of course the particular policy issued by the commercial insurer is a "strict" PPO plan.

Accordingly, Poster #37, most respectfully, I disagree with your quote at the beginning of this post.

In summation, I am not seeing retrospective audits by BCBS, as their software is able to separate contracted participating physician/clinic providers, whose contract disallows DME services to be provided the insured patient, and billed to BCBS in some States --- from non-contracted DME physician/clinic providers.

Also, I am not seeing any commercial insurer, refuse to reimburse the non-contracted physician/clinic for provision of "medically necessary" treatment or DME. (Unless, as indicated above, the insured patient's policy is a "strict" PPO.) Instead, the commercial PPO insurer simply reimburses that provider at a reduced amount, leaving the insured patient financially responsible for a higher percentage of co-pay or co-insurance, just because the treatment or DME was provided by a non-participating provider.

Last, in regards to the response from Poster #38, there was no need to resort to offensive and foul language to make your point. I see these type of responses frequently here on CP, which is a shame. One can agree to disagree, without being disagreeable.

We all know that come Monday, and every day of the week, many BGS units will be provided and billed out to commercial insurers. However, I would admonish any physician/clinic treating the patient whose bill is being paid by Medicare, Medicaid, Tricare, or other federally funded plan, such as the one offered by BCBS to federal employees, to not prescribe, then dispense and bill for a BGS unit. As sure as the sun will rise tomorrow, that physician/clinic is in violation of Stark, and inevitably, there will be an investigation and audit by CMS/DOJ, resulting in either being placed on the "do not pay" list, or worse, being indicted.

 

[Anonymous]

Don't take it personal just tired of reading your novels, and your hypotheticals and what you want to happen. It's just a bunch of babble. Has no merit and is irrelevant because Medicare, BCBS and private insurers are paying for it. Now that's factual information. So, for you to write your thesis on something that hasn't happened is a waste of time. Now if it does happen then you have something to write about. Until then what are you trying to prove???

 

[Anonymous]

Don't take it personal just tired of reading your novels, and your hypotheticals and what you want to happen. It's just a bunch of babble. Has no merit and is irrelevant because Medicare, BCBS and private insurers are paying for it. Now that's factual information. So, for you to write your thesis on something that hasn't happened is a waste of time. Now if it does happen then you have something to write about. Until then what are you trying to prove???

Thank you......99% of physicians buying SS are not dealing with Medicare.

 

[Anonymous]

This sounds like someone from the PR department is doing some desperate, defensive posting to distance themselves from the buy and bill practice. Incredible.

Hi, I'm poster #36.

Poster #37 stated:



Poster #37, you must have posted your thoughts while I was still composing mine. As I alluded to in my post above, some commercial insurers do have contractual language that forbids the contracted participating provider (physician/clinic) from providing DME. Specifically, this would be BCBS, but only in a few States.

However, I am not seeing retro audits being conducted by BCBS, as their software is able to ascertain whether the physician/clinic is a contracted participating provider when the billing is received, either electronically or on paper. If the NPI number of the physician/clinic matches up in the BCBS database as a contracted participating provider, no payment is issued, and a denial is issued instead --- based on the physician/clinic providing services that is outside of its contract with BCBS.

From my experience, it is only BCBS that will refuse to reimburse a contracted participating provider physician/clinic for the provision of DME, and again, only in a few States.

It has also been my experience that BCBS will not cancel their contract with the participating provider physician/clinic that has prescribed and dispensed the DME prescribed --- but instead, BCBS will simply not pay the bill for the DME --- and, the contract forbids the contracted participating provider physician/clinic from balance-billing the patient for the full amount (or even a partial amount) of the DME that has been disallowed on a contractual basis.

I have never seen this with United Health Care, Cigna, or Aetna.

Poster # 37, you also mentioned that "A Commercial Payer can decide NOT to contract with a DME company or any other vendor if they so choose."

I agree. However, this will, generally speaking, not result in a refusal to reimburse, but instead, reimbursement will be at a lower percentage of the allowed amount.

As an example, if the insurer is Aetna, and the provider is an in-network participating provider, Aetna will reimburse at, say, 80% of the allowed amount. But, if the provider is out-of-network, Aetna will only reimburse at 60% of the allowed amount, leaving their insured (usually the patient) financially responsible for the increased co-pay or co-insurance. This is akin to the insurer punishing the insured for obtaining treatment or DME out-of-network --- and it is a further financial incentive for the insured patient to only obtain treatment or DME from an in-network provider.

I will acknowledge that some insurers offer what I call a "strict" PPO policy, that only allows their insured to treat with in-network physicians/clinics. But, from my experience doing practice management nationwide, the percentage of patients with "strict" PPO policies that will only reimburse for treatment or DME provided by the in-network physician/clinic is very small, number wise. (e.g. maybe 5%)(In my view, the "strict" PPO policy is similar to an HMO policy that will only reimburse for treatment, or DME, provided by its in-network HMO providers --- unless the treatment is provided on an emergent basis, such as an unexpected ER visit at a non-participating and non-contracted hospital or trauma center.)

One of the business entities, with whom I am contracted to provide practice management, is a DME company. This particular DME company is a non-participating provider, who is out-of-network, with all commercial insurers, nationwide. They are getting paid regularly for the DME provided, albeit, at a reduced percentage of the allowed amount.

This particular DME provider does seek the co-pay and/or co-insurance from the insured patient --- but sometimes they do waive it, on a case-by-case basis, if the insured patient can demonstrate and document that it would be a "financial hardship" to reimburse the DME company the co-pay or co-insurance. Also, with some insured patients who cannot afford to pay the full amount of the co-pay or co-insurance today, this DME company will work out a payment plan --- allowing the financially strapped insured patient to pay over time.

Just because "A Commercial Payer can decide NOT to contract with a DME company or any other vendor if they so choose," does not mean the PPO insurer will refuse to reimburse the DME company without a contract with that insurer, unless of course the particular policy issued by the commercial insurer is a "strict" PPO plan.

Accordingly, Poster #37, most respectfully, I disagree with your quote at the beginning of this post.

In summation, I am not seeing retrospective audits by BCBS, as their software is able to separate contracted participating physician/clinic providers, whose contract disallows DME services to be provided the insured patient, and billed to BCBS in some States --- from non-contracted DME physician/clinic providers.

Also, I am not seeing any commercial insurer, refuse to reimburse the non-contracted physician/clinic for provision of "medically necessary" treatment or DME. (Unless, as indicated above, the insured patient's policy is a "strict" PPO.) Instead, the commercial PPO insurer simply reimburses that provider at a reduced amount, leaving the insured patient financially responsible for a higher percentage of co-pay or co-insurance, just because the treatment or DME was provided by a non-participating provider.

Last, in regards to the response from Poster #38, there was no need to resort to offensive and foul language to make your point. I see these type of responses frequently here on CP, which is a shame. One can agree to disagree, without being disagreeable.

We all know that come Monday, and every day of the week, many BGS units will be provided and billed out to commercial insurers. However, I would admonish any physician/clinic treating the patient whose bill is being paid by Medicare, Medicaid, Tricare, or other federally funded plan, such as the one offered by BCBS to federal employees, to not prescribe, then dispense and bill for a BGS unit. As sure as the sun will rise tomorrow, that physician/clinic is in violation of Stark, and inevitably, there will be an investigation and audit by CMS/DOJ, resulting in either being placed on the "do not pay" list, or worse, being indicted.