New Jersey - Volume XV, Number 1 - January, 2006

HEALTH CLAIMS AUTHORIZATION, PROCESSING & PAYMENT LAW ENACTED:

The Health Claims Authorization, Processing & Payment Act (the Act) was signed into law by outgoing Acting Governor Codey earlier this month. The Act changes some provisions of current law regarding the processing and prompt payment of health care claims. Among other things, the Act limits to 18 months the time frame in which a payor can seek reimbursement from a provider for overpayment of a claim, except in cases of fraud. Likewise, a provider has 18 months in which to seek reimbursement for underpayment of a claim. A payor’s offset of an overpayment against future payments can only occur under specified circumstances. The Act also requires that a payor respond to a physician’s request for authorization of service by either approving or denying the request based on a utilization management decision made by a State-licensed physician, communicated to the physician within set time frames or the request shall be deemed approved. Payors are required to maintain an Internet website with information describing the payor’s utilization management and claim processing and payment policies, 30 days before the policies become effective. The Act becomes effective in July 2006.

UMDNJ ACCEPTS MONITOR; DEFERS HEALTH CARE FRAUD PROSECUTION:

The University of Medicine and Dentistry of New Jersey has agreed to complete a series of financial, management and personnel reforms and to reimburse the state and federal governments at least $4.9 million for its double-billing of Medicaid. In return for the successful completion of those reforms over 2 to 3 years, the institution will avoid criminal prosecution for health care fraud under terms of a Deferred Prosecution Agreement. A federal monitor has been appointed to oversee UMDNJ’s compliance with the Agreement. The Agreement does not protect or absolve any individuals who may have been involved in criminal conduct and the criminal investigation is continuing. UMDNJ is required to cooperate fully with all federal and state law enforcement and regulatory agencies.

FTC ORDER BARS IPO FROM JOINT PRICE NEGOTIATIONS:

In a unanimous decision, the Federal Trade Commission (FTC) has ruled that an independent physician organization (IPO) engaged in illegal price-fixing in its negotiations with payors over non-risk sharing contracts. The FTC found that the IPO, consisting of 480 primary care and specialty physicians, engaged in prohibited conduct designed to enhance the collective bargaining power of its members, including the use of information from member polls on prospective fees, refusals to deal and to forward payor offers to members, and restricting independent negotiations with payors by individual physicians. The IPO also used collective withdrawal from payor networks in order to coerce agreements from payors.

PHYSICIANS WITH EXPIRING FLORIDA LICENSES CAN NOW RENEW ONLINE:

If you are one of the many NJ physicians with a Florida license expiring on January 31st, you should have already received your renewal packet. If you have not, you should call (850) 488-0595, ext. 3, or renew online at www.doh.state.fl.us/mqaservices. Don’t forget that physicians renewing their license after the first time need to have completed 40 hours of CME (i.e., from February 1, 2004 to date). Many out-of-state physicians are disciplined by the Florida Board each renewal cycle for failing to have taken a sufficient number of CME hours in the required subjects. The required hours and subjects are: 1 hour of Florida-approved category I in HIV/AIDS; 1 hour of category I or II in Domestic Violence; and 2 hours of category I or II in Preventing Medical Errors. Those interested in retiring their Florida license can do so for a one-time fee of $50.00. Contact KACS’ Bob Conroy, a licensed Florida attorney with Florida Board experience, if you have any questions about Florida licensure.

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