With the regular changes affecting the health care system, urgent care providers are constantly facing regulatory and legal changes. Some of the issues facing urgent care services include fee splitting, audits, compliance with Medicare and Medicaid, accreditation and credentialing, and investigations of abuse and fraud. All of these issues fall within the realm of cases that urgent care lawyers deal with.
Urgent Care Regulations
The laws on urgent care differentiate it from emergency services. Urgent care applies to medical practitioners who treat minor traumas and acute episodic illnesses. Emergency services apply to major traumas, disabling or life threatening conditions.
Urgent care mainly deals with the following services:
- EKG and X-Ray
- Lab services and Phlebotomy
- Stitching minor laceration wounds
- Administration of sublingual, intramuscular, subcutaneous, intravenous, IV fluids, and respiratory medication
In New York, urgent care centers are supposed to use the term “urgent care”, on their signs, in their business name, and on their websites. Urgent care centers are prohibited from using the term “emergency” because emergency services use special government licenses.
Approval and Accreditation of Urgent Care Providers
In New York, an urgent care provider who is interested in offering urgent care service is required to apply and get the approval of the Department of Health. Health care providers such as nursing homes and hospitals, as defined in Article 28 of NY Public Health Law, who want to offer urgent care services should go through a review by the DOH. Private physicians as provided in Article 28 should only offer urgent care services after accreditation and certification by a DOH approved organization. Health providers who are not mentioned in Article 28 can only offer urgent care services after being accredited or certified by accrediting organizations that are authorized by DOH. An urgent care attorney can offer assistance in accreditation and approval issues.
Physician Contracting and Business Transactions
It is important to involve lawyers when drafting employment agreements to avoid problems with job contracts. There are certain issues that could pose great danger to your urgent care practice if not addressed during the drafting of contracts. These issues include assigning audit risk, non-compete provision, and non-solicitation.
There are various laws governing different areas of health care practices. DOH may prohibit certain services or limit some actions by urgent care providers. A lawyer can help you establish your practice in accordance with the DOH regulations on urgent care.
One of the areas that affect urgent care providers is self-referrals. The Stark Laws are meant to prevent referrals to a practitioner’s family or entities affiliated with the practitioner. Anti-Kickback laws prevent practitioners from soliciting money in exchange for referrals. A violation of the Stark and Anti-Kickback laws on referrals may result in penalties such as fines, jail term, and a revocation of the offender’s license. The counsel of a lawyer can help an urgent care practitioner provide services that comply with the Stark and Anti-Kickback laws.
Health Insurance Portability and Accounting
Urgent care centers are required to maintain a level of patient privacy in accordance with the Health Insurance Portability and Accounting laws. HIPPA provides that medical practitioners should not disclose patient information. However, there are certain exceptions to this law. An attorney can help clarify for you situations in which you are allowed to disclose patient information.
Overpayments, Medicare/Medicaid, and Commercial Payor Audits
The rising number of urgent care centers and increased treatments in these facilities is the reason urgent care is under close scrutiny by private payor auditors, Medicare, and Medicaid. Insurance audits lead to overpayment demands and can result in sanctions that include Medicare and Medicaid exclusion, and recoupment actions.
The Office of the Medicaid Inspector General performs Medicaid audits of billing documents that account for payments by urgent care services. The auditors mainly focus on:
- The use of wrong diagnosis codes
- Orders signed by unqualified practitioners
- Unsatisfactory explanation of services
- Wrong identification of a provider on the claim
- Billing for unauthorized services
- Billing for services that have been denied due to lack of medical urgency
The only way to avoid unintentional errors, improper billing, and legally questionable practices is by using an effective compliance strategy. Legal counsel can help create effective compliance plans and protect your urgent care services in times of Medicare, Medicaid, and payors audits.