eClinicalWorks to pay $155 million to settle suit alleging it faked meaningful use certification
Electronic health records vendor eClinicalWorks has agreed to pay $155 million to resolve a False Claims Act lawsuit that alleged it gave customers kickbacks for publicly promoting its products.
“This resolution demonstrates that EHR companies will not succeed in flouting the certification requirements,” said Acting U.S. Attorney for the District of Vermont Eugenia Cowles.
Cowles was referring to the requirements EHR vendors must meet under the American Recovery and Reinvestment Act’s HITECH Act that their software satisfies criteria by an accredited testing body so that customers can use it to attest for EHR reimbursement under the meaningful use program.
“The government contends that ECW falsely obtained that certification for its EHR software when it concealed from its certifying entity that its software did not comply with the requirements for certification,” the DOJ statement said.
The DOJ alleges that eClinicalWorks opted to added the 16 drug codes necessary for certification into its software rather than enable the product to access those from a complete database, failed to accurately record user actions with audit log functionality, did not always accurately record diagnostic imaging orders or conduct drug-drug interaction checks and, finally, eClinicalWorks did not satisfy data portability requirements designed to enable doctors to transfer patient data to over vendor’s EHRs.
“As a result of these and other deficiencies in its software, ECW caused the submission of false claims for federal incentive payments based on the use of ECW’s software,” the Vermont DOJ said.
eClinicalWorks disputed the allegations that its customer program was unlawful but said it settled to avoid the expense of litigation.
“Today’s settlement recognizes that we have addressed the issues raised, and have taken significant measures to promote compliance and transparency,” said Girish Navani, CEO and co-founder of eClinicalWorks. “We are pleased to put this matter behind us and concentrate all of our efforts on our customers and continued innovations to enhance patient care delivery.”
Navani, along with CMO Rajesh Dharampuriya and COO Mahesh Navani are liable for the payment of $154,920,000, while developer Jagan Vaithilingam is on the hook for $50,000 and two project managers, Bryan Sequeira and Robert Lynes, each owe $15,000, the Vermont DOJ said.
The lawsuit was originally filed by whistleblower Brendan Delaney, who at the time was a software technician at the New York City Division of Health Care Access and Improvement. He will receive approximately $30 million as part of the resolution.
One-third of eClinicalWorks customers prepping to switch EHR vendors, KLAS says
Customers of eClinicalWorks are more or less of two minds about their EHR vendor’s recent legal settlement with the U.S. Department of Justice, says KLAS Senior Research Director Erik Bermudez.
Reaction ranges from, “Yeah, this leaves a bad taste in my mouth but I’m not really going to do anything about it,” to, “You know what, this news really pushed me over the edge to the point where I’m absolutely going to make a switch,” he said.
Actually, the eClinicalWorks’ client base is currently divided fairly equally into thirds, according to the KLAS report: Those planning to jump ship, those who “feel stuck in their contract but would like to switch and may do so when their contract expires,” and another third who are still satisfied with their customer experience.
Additional resources are available on the website. The Quality Payment Program Service Center may be reached at 1-866-288-8292 (TTY 1-877-715- 6222), available Monday through Friday, 8:00 a.m. – 8:00 p.m. ET or via email at QPP@cms.hhs.gov.
For the full proposed plan visit the web site listed above. The following is an excerpt.
As discussed in section V.C. of this proposed rule, for the 2020 payment year based on Advanced APM participation in 2018 performance period, we estimate that approximately 180,000 to 245,000 clinicians will become QPs, and therefore be exempt from MIPS and qualify for lump sum incentive payments based on 5 percent of their Part B allowable charges for covered professional services. We estimate that the total lump sum incentive payments will be between approximately $590 and $800 million for the 2020 Quality Payment Program payment year. This expected growth in QPs between the first and second year of the program is due in part to reopening of CPC+ and Next Generation ACO for 2018, and the ACO Track 1+ which is projected to have a large number of participants, with a large majority reaching QP status.Start Printed Page 30018
Under the policies in this proposed rule, we estimate that approximately 572,000 eligible clinicians would be required to participate in MIPS in the 2018 MIPS performance period, although this number may vary depending on the number of eligible clinicians excluded from MIPS based on their status as QPs or Partial QPs. After restricting the population to eligible clinician types who are not newly enrolled, the proposed increase in the low-volume threshold is expected to exclude 585,560 clinicians who do not exceed the low-volume threshold. In the 2020 MIPS payment year, MIPS payment adjustments will be applied based on MIPS eligible clinicians’ performance on specified measures and activities within three integrated performance categories; the fourth category of cost, as previously outlined, would be weighted to zero in the 2020 MIPS payment year. Assuming that 90 percent of eligible clinicians of all practice sizes participate in MIPS, we estimate that MIPS payment adjustments will be approximately equally distributed between negative MIPS payment adjustments ($173 million) and positive MIPS payment adjustments ($173 million) to MIPS eligible clinicians, as required by the statute to ensure budget neutrality. Positive MIPS payment adjustments will also include up to an additional $500 million for exceptional performance to MIPS eligible clinicians whose final score meets or exceeds the additional performance threshold of 70 points. These MIPS payment adjustments are expected to drive quality improvement in the provision of MIPS eligible clinicians’ care to Medicare beneficiaries and to all patients in the health care system. However, the distribution will change based on the final population of MIPS eligible clinicians for CY 2020 and the distribution of scores under the program. We believe that starting with these modest initial MIPS payment adjustments is in the long-term best interest of maximizing participation and starting the Quality Payment Program off on the right foot, even if it limits the magnitude of MIPS positive adjustments during the 2018 MIPS performance period. The increased availability of Advanced APM opportunities, including through Medical Home models, also provides earlier avenues to earn APM incentive payments for those eligible clinicians who choose to participate.
Out-of-Network providers seem to have increasing audits by payers. The following is a “Out-Of-Net ” Provider regulations guidelines review.
An Out-of-Network provider is a person or company that offers healthcare services to patients, but the provider is not contracted with the patient’s insurance. Usually the patient has a larger out of pocket cost when seeking treatment with a Out-of-Network provider. However Out-of-Network providers allow the patient to have a choice of who their treating provider will be.
In comparison to an HMO or contract plans that may dictate where the patient has to get care. More Out-of-network providers also offer alternative care, the patient has more choices in their healthcare, such as non-evasive treatment, or supplements instead of drugs.
Out-of-Network providers are not bound by payer contract agreements.
A benefit of not being contracted is reimbursement times. For example, many contracts with insurance companies state payment will not be made until 60 days from the date billed. Such contracts could cause disruption in the practice cash flow. An out-of-network provider, when submitting claims electronically to the payer will receive payment of claims with-in an average of 15 days from the date billed.
If the provider submitted paper claims, the average reimbursement is 45 days. Medicare has a 10 day payment delay penalty mandated for paper claims.
Out-of-Network providers must follow judicial rules and regulations. The provider may elected to not be contracted with a plan, but they must follow the laws that govern capitalism commerce policy. The following are three areas that may promote an audit from a commercial or government payer.
• Sending patients a balance bill
• Completing a ABN form for Medicare patients.
While compliance is voluntary, if a provider is audited the absence of compliance policy and procedures will work against the provider.
Compliance has a focus on self-governance. This includes having written policies and procedures in place. Internal auditing for quality control making sure HIPAA regulations are followed and a system of risk mitigation and disciplinary protocol are in place.
• Sending statements for balance due to patients.
Federal law regulations state ” There must be an attempt by the medical provider documented that there was an attempt to collect the patient’s deductible and co-pays. There is no requirement to show that funds were collected. Sending a statement to the patient fulfills this requirement.
Unfortunately, some providers agree to only accept what the insurance pays. And then do not send a statement to the patient. This is a violation.
Of course, the provider has the option to give the patient discounts. There is no cause to tell the payer about your agreement. But the provider does have to show an “attempt to collect the deductibles and co-payments” .
• Advance Beneficiary Notice of Non-Coverage (Medicare)
When providing a service to a Medicare patient there are limiting charges to consider and having the patient to sign a formal ABN form when the service is expected to not be covered by Medicare.
Any service over $250 and is expected to not be covered by Medicare requires the beneficiary to sign an ABN as an acknowledgement of financial responsibility. The ABN can be downloaded in English or Spanish from the CMS we site.
Additional restrictions of the Medicare program include
Medicare Assignment of benefits. Carrier “Participating Providers”
are paid at 100 percent of the physician fee schedule and must
accept assignment (must accept program payment as payment in full, except for any unmet deductible and coinsurance). “Non-participating providers” are paid at 95 percent of the physician fee schedule and may accept assignment on a claim-by-claim basis.
Assignment is mandated for the following claims:
Clinical diagnostic laboratory services and physician lab services;
Physician services to individuals with dual entitlement to Medicare and Medicaid;
Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers,
Anesthesiologist assistants, and mass
immunization roster billers.
The provider type Mass Immunization Roster Biller can only bill for influenza and pneumococcal vaccinations and administrations. These services are not subject to the deductible or the 20 percent coinsurance
Ambulatory surgical center services;
Home dialysis supplies and
equipment paid under Method II;
Drugs and biologicals
The carrier system must be able to identify (and update) the codes for those services subject to the assignment mandate.
Please note if you are a non-participating Medicare provider you are allowed to only charge patients 115% of the Medicare non-participating allowed amount. providers who may be subject to the nonparticipant fee schedule amount, if they elect not to participate for a calendar year.
The limiting charge equals 115 percent of the nonparticipant fee
schedule amount. For the facility setting differential, the limiting charge is 115 percent of the nonparticipant fee for the differential amount.
Medicare and Medicaid are the largest payers of healthcare in the US, Approximately 40%. These plans have shifted to a more active role of verifying service rendered and that regulatory guidelines are met to substantiate reimbursement expenditures. Recently Commercial payers have follow suit with auditing for refunds.
Understanding your responsibility as a healthcare provider can save the practice from hours of audits and insurance payer financial re-coupments.
By Martha Sims-Green, Executive Director Health Tec Systems a remote compliance firm. http://www.healthtecsystems.org.
Follow this link to an interactive map that allows you to see ARRA funding opportunities by state.
ARRA Related Links and Resources:
o this is a key resource for all things related to the ARRA including how, when and where the money is spent
o this site allows you to search all Recovery Act available funding
o U.S. Department of Health and Human Services, Office of Recovery Act Coordination
on this site you can track the progress of HHS activities funded through the ARRA
o U.S. Department of Health and Human Services, Health Information Technology home
this is where the government will list more specifics related to the initial set of HIT
standards, implementation specifics and certification criteria
you can also find information on the Office of the National Coordinator (ONC) here as
o Centers for Medicare & Medicaid Services (CMS) this is where the Secretary will post a
list of names of eligible hospitals that become “meaningful users”
o The National Alliance for Health Information Technology (NAHIT)
NAHIT identifies and develops strategies and best practices around the use of EHRs and
other technology. It has been said they hope to evolve into the government’s HIT
Standards Committee however that is still to be determined.
o Healthcare Information Technology Standards Panel
o Congressional Budget Office
The CBO provides objective, nonpartisan, and timely analyses to aid in economic and budgetary decisions on the wide array of programs covered by the federal budget including the ARRA. You can view the report “Estimated Macroeconomic Impacts of the American Recovery and Reinvestment Act of 2009” which estimates more than expected spending in healthcare IT.
o HIMSS Analytic s