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NEW STATE OF EMERGENCY PROVIDES HEALTHCARE PROVIDER FLEXIBILITIES

NEW STATE OF EMERGENCY PROVIDES HEALTHCARE PROVIDER FLEXIBILITIES

By Angie Cameron Smith with Burr & Forman, LLP

On July 6, 2021 Governor Kay Ivey allowed the State of Emergency in Alabama to expire.  She had previously proclaimed a State of Emergency due to the COVID-19 Pandemic effective March 13, 2020.  Along with that proclamation, came the invocation of Alabama’s Emergency Management Act.  When the state of emergency ended, so did the waivers or suspension of state regulatory requirements that were afforded to healthcare providers operating during the pandemic.  Due to the spike in COVID-19 cases, which appear to be related to the Delta variant, Governor Ivey proclaimed a new State of Emergency effective August 13, 2021.  Why does this matter?  Because many of the expired waivers that allowed for flexibilities for healthcare providers have now been renewed under the new State of Emergency.

Under Governor Ivey’s August 13 proclamation and pursuant to the authority granted to her under the Emergency Management Act, she cut “red tape for health care providers.”  The emergency proclamation removes barriers to allow additional healthcare providers and resources to address the surge in cases and is focused primarily on staffing at acute care hospitals.  The following apply to general acute care hospitals, critical access hospitals or specialized hospitals licensed by the Alabama Department of Public Health:  

  • A hospital’s chief of the medical staff or medical director may collaborate with or supervise an unlimited number of certified registered nurse practitioners (CRNP), certified nurse midwives (CNM); physician assistants (PA) and anesthesiology assistants (AA), and provide direction to an unlimited number of certified registered nurse anesthetists (CRNA);
  • CRNPs, CNMs, PAs and AAs working under the supervision of the chief of the medical staff at a hospital may implement the standard protocol and formulary approved by the Alabama Board of Medical Examiners;
  • CRNAs under direction of, and AAs under registration with, a hospital’s chief of the medical staff or medical director or his/her physician designee, are authorized to determine, prepare, monitor or administer legend and controlled medications for performance of anesthesia-related services, airway management (related or unrelated to anesthesia), and other acute care services within their scope of practice.
  • CRNPs, CNMs and CRNAs who possess an active, unencumbered nurse license or equivalent advanced practice approval issued by an appropriate licensing board of another state, the District of Columbia, or Canada, are authorized to practice in covered hospitals as if licensed in Alabama; and
  • Alabama’s Board of Pharmacy, Board of Nursing, Medical Licensure Commission, and State Board of Medical Examiners are authorized to adopt emergency rules to allow for expedited licensure and/or temporary permits for individuals possessing unencumbered licenses in other states.  At this time, this is limited to those practitioners providing care in inpatient units, emergency departments or other acute care units within acute care hospitals, critical access hospitals or specialized hospitals.

Another flexibility afforded under the Governor’s new proclamation is the authorization granted to the State Health Planning and Development Agency (SHPDA) to invoke the emergency rule passed last legislative session to allow for the issuance of emergency Certificates of Need.  This waiver was effective during the last Public Health Emergency to permit facilities to create alternate care sites.  Alternate care sites allow for a healthcare facility to convert parts of or entire facilities to provide care for which is not originally authorized.  For example, while hospitals struggle for placement of patients and surge capacities, these waivers would allow hospitals to create or use space not normally used for patient care or acute patient care.  Other healthcare providers may also seek waivers under the SHPDA Emergency Rule.  Under the previous health emergency skilled nursing facilities were able to transfer patients who did not require acute care but were in need of isolation and observation due to COVID to areas in a hospital not being used.  More information about alternate care sites can be found at https://www.alabamapublichealth.gov/covid19/assets/cov-adph-alt-care-site-app.pdf and http://shpda.alabama.gov/REQUEST%20FOR%20WAIVER%20Fillable%20Form.pdf.   

Another important aspect of the State of Emergency proclamation is the application of an alternative standard of care.  When evaluating whether a healthcare provider has breached the standard of care in a medical malpractice case, the analysis involves what a reasonable person would do in like or similar circumstances.  Under the alternative standards of care, if a provider has invoked its emergency operation plan in response to the public health emergency, it can implement alternative standards of care and those standards are “declared to be state-approved standard of care in healthcare facilities.” 

You may also recall that during the last legislative session there was an immunity statute passed to provide liability protections to healthcare providers and businesses during the COVID-19 pandemic.  This immunity statute should be unaffected by the gap between the last state of emergency ending on July 6, 2021, and the new state of emergency invoked on August 13, 2021.

The federal public health emergency (PHE) and the waivers under the U.S. Secretary of Health and Human Services Section 1135 declaration is also unaffected by the state of emergency.  The current federal PHE is set to last through October 18, 2021, with some indication from the federal administration that it will continue through the end of the year.

Angie Smith is a partner at Burr & Forman LLP and practices in the Healthcare Industry Group. Angie may be reached at (205) 458-5209 or acsmith@burr.com.

Posted in: Coronavirus, Legal Watch, MVP

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Training, Training, Training—The First Line of Defense When it Comes to HIPAA Compliance

Training, Training, Training—The First Line of Defense When it Comes to HIPAA Compliance

By: Kelli Carpenter Fleming with Burr Forman

When it comes to HIPAA compliance efforts, the first line of defense in ensuring that protected health information is secured appropriately and compliantly is training your practice’s employees. More often than not, when an inappropriate use or disclosure of protected health information occurs, it is because an employee made a mistake. For example, the employee may have faxed the information to the wrong patient, or released records before confirming that an authorization was on file, or clicked a link in an e-mail opening the door for bad actors to gain access to the system. One way to prevent these mistakes is to train your employees on HIPAA compliance efforts, as well as easy, practical steps they can take to prevent such mistakes. However, a lot of physician practices, especially smaller ones, do not routinely train their employees on HIPAA compliance efforts. 

HIPAA training should not occur in a silo. While employees should always be trained upon hire, they should also be trained periodically thereafter. I recommend that clients conduct routine, formal HIPAA training at least once a year. I also recommend implementing less formal monthly HIPAA reminders to ensure that HIPAA remains on the forefront of everyone’s minds. In addition, if an unauthorized use or disclosure occurs, the practice should conduct training related to that incident, at a minimum for the employees involved. If a policy or procedure is changed, training should also be conducted on the revised policy or procedure. 

Whenever training is conducted, whether internally or externally, the training must be documented. The documentation should include the date the training was conducted, the employees that were trained, the topics discussed, and a copy of any training materials that were utilized. This documentation becomes extremely important if there is a breach incident or an investigation by OCR.

All physician practices should strengthen their first line of defense when it comes to HIPAA compliance by ensuring that their employees are properly and periodically trained. 

Kelli Fleming is a Partner at Burr & Forman LLP and practices exclusively in the firm’s Healthcare Practice Group. Kelli may be reached at (205) 458-5429 or kfleming@burr.com.

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OSHA Issues COVID-19 Emergency Temporary Standard (ETS) for the Healthcare Industry

OSHA Issues COVID-19 Emergency Temporary Standard (ETS) for the Healthcare Industry

The Occupational Safety and Health Administration (OSHA) issued an Emergency Temporary Standard (ETS) for the healthcare industry on June 21, 2021.[1]

The Occupational Safety and Health Act (“the Act”) passed in 1970 and created OSHA to administer the Act. It has been thirty-eight years since OSHA issued its last ETS. That ETS was issued in 1983, covered asbestos, and was eventually struck down by a federal court.

The Act generally covers most employers, with some specific employers, such as “State(s) and political subdivision of a state,” being specifically excluded from OSHA’s jurisdiction.[2]  OSHA determined that COVID-19 causes health care industry employers and their employees to be in “grave danger,” which is the legal requirement allowing OSHA to issue an ETS.  Along with the ETS, OSHA issued General COVID-19 Guidance to most other workplaces, which followed the CDC’s guidance on COVID-19 in the workplace.  

The ETS generally applies to any workplace where employees provide healthcare services or healthcare support services, except for some specific exclusions such as retail pharmacies; home health care settings where all non-employees are screened prior to entry; healthcare support services not performed in a healthcare setting (e.g., off-site laundry); and telehealth services performed outside of a direct patient care setting.  Other exemptions include allowing employees to work from home and exemptions for those employees who cannot be vaccinated because of medical or religious reasons. One exemption could possibly apply to some physicians’ offices.  This exemption reads in full, “Non-hospital ambulatory care settings where all non-employees are screened prior to entry and people with suspected or confirmed COVID-19 are not permitted to enter those settings.”[3] More on this later.

It is clear that the ETS generally applies to physicians’ offices, as physician’s offices are used as examples in various parts of the ETS.[4]  However, employers with 10 or fewer employees have fewer requirements under the ETS.  For example, employers with more than 10 employees must have a written COVID-19 plan for each workplace. Employers with 10 or fewer employees must have COVID-19 plans, but the plan is not required to be in writing. OSHA’s plan is to include updates to the ETS as needed.  

The ETS covers the following subjects, as they relate to employment activities of health care workers in the health care industry:

COVID-19 Plan

Patient screening and management

Respiratory protection

Training

Ventilation of rooms and buildings

Health screening and medical management

Physical barriers

Physical distancing

Hand hygiene and cleaning

Record keeping

Reporting

Following is a brief discussion of each of the ETS requirements.

COVID-19 Plan.

Employers must have a plan to minimize the transmission of COVID-19 in the health care workspace.  Employers with more than 10 employees must have a written COVID-19 Plan.

Patient Screening and Management.

In settings where direct patient care is provided, employers must limit and monitor points of entry, screen and triage all non-employees entering the setting, and implement other patient management as necessary, including developing and implementing procedures regarding standard transmission-based precautions.

Respiratory Protections.

Employers must provide the personal protective equipment (PPE) necessary to protect employees, at no cost to the employees.

Training.

Employers must ensure and document that each employee receives training on the ETS, in a language and at a literacy level the employee understands.  Training should include various topics pertinent to COVID-19 safety measures, such as COVID-19 transmission and employer policies and procedures regarding COVID-19 transmission.

Ventilation of Rooms and Building.

HVAC systems should be operating at maximum efficiency, per the manufacturer’s recommendations.  Air filters that remove particles and aerosols that can transport the COVID-19 virus should be used where the HVAC system can accommodate the filters.

Health Screenings and Management.

All employees must be screened every day they work in a health care setting.  This can be accomplished by the employees answering questions before entering the workplace, or by the employee self-evaluating prior to entering the workplace. Where appropriate, employees must be kept from the workplace or removed from work (e.g., an employee develops a fever, cough and loss of the sense of taste while at work and is asked to leave). Employees must be informed of possible COVID-19 exposures (e.g., told of an employee (without giving their name) who has developed fever, cough and loss of the sense of taste at work, and is sent home). There are mandatory paid leave provisions for employees who develop COVID-19, or who must stay out of work because of a COVID-19 exposure, which are in addition to other employee paid leave provisions already in place for employers. Employees must be paid for the time they take while at work to be vaccinated against COVID-19, and for the day after receiving a vaccination, where there is a physical reaction to the vaccine.  

Physical barriers.

These include Plexiglas barriers when patients initially check in the office and between workers who must work at specific locations (e.g. computer billing) most of their workday.

Physical Distancing.

This is also referred to as “social distancing.”  Where there is room, employees should maintain at least six feet of distance between themselves and other employees (e.g., employee break rooms).

Hand Hygiene and Cleaning.

Hand hygiene and cleaning work together to reduce the spread of the COVID-19 virus. Offices and clinical spaces should be cleaned at least daily, and handwashing should occur between patient encounters.

Record Keeping and Reporting.

For employers covered by OSHA standards, there are already record-keeping requirements in place. Additional record-keeping and reporting are added by the ETS for employees who test positive for COVID-19 and employees who die because of a COVID-19 infection. Employers with more than 10 employees must keep a log of any employee diagnosed with COVID-19, whether or not the infection arose because of an occurrence at work.

This article began with an introduction to one of the exemptions that could possibly keep a physician’s office from having to comply with the ETS. That exemption reads “Non-hospital ambulatory care settings where all non-employees are screened prior to entry and people with suspected or confirmed COVID-19 are not permitted to enter those settings.”[5] Those physician’s offices that could operate under this provision — no suspected or confirmed COVID-19 patients or employers are allowed to enter the office — would be able to operate as they have in the past in regard to OSHA requirements. However, there are legal pitfalls with using this exemption to avoid compliance with the ETS.  For example, many surgeries require office follow-up. If a surgeon refused to see a patient who developed COVID-19 after surgery, but before the office follow-up, the patient could make a claim of abandonment.  There are other risks with this course of action, and many physicians could ill afford to refuse to see patients “suspected” of having COVID-19.  There may be ways to stay within the exemption; however, careful thought will need to be given for each patient in a similar situation. For instance, perhaps the post-surgery patient could be seen in a hospital ER, or evaluated/examined through a telehealth appointment, rather than in the surgeon’s office.  

Conclusion.

As is often the case, the ETS has been issued almost beyond the point of usefulness. Physician offices, health care facilities, and other health care providers are going on two years of their response to the COVID-19 pandemic. To mandate changes to their well-established COVID-19 precautions at this time is disruptive, to say the least; and it places additional administrative burdens on employers subject to OSHA, without adding much, if any, additional value. Nevertheless, physician’s offices and others are well-advised to take the ETS seriously because it will likely be the subject of complaints, investigations, and audits by OSHA. OSHA investigates complaints of violations of federal law based upon anonymous employee complaints and random “audits” of employer compliance and has indicated it will enforce the ETS using both of these methods.


[1] Occupational Exposure to COVID-19; Emergency Temporary Standard, 86 Fed. Reg. 32376, available at https://www.federalregister.gov/documents/2021/06/21/2021-12428/occupational-exposure-to-covid-19-emergency-temporary-standard.

[2] 29 U.S.C. § 652(5). 

[3] 29 C.F.R. § 1910.502(a) (2) (iii).

[4] 29 C.F.R. § 1910.502(a), n. 2.

[5] 29 CFR Section 1910.502(a) (2) (iii).

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Potential HIPAA Changes That Would Allow Healthcare Providers to Disclose Phi and Better Protect Patients

Potential HIPAA Changes That Would Allow Healthcare Providers to Disclose Phi and Better Protect Patients

by Lindsey Phillips, Burr & Forman

On December 10, 2020, the Office for Civil Rights (“OCR”) at the United States Department of Health and Human Services (“HHS”) announced proposed changes to the regulations implementing the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). The proposed changes, which are set out in the Notice of Proposed Rulemaking (“NPRM”), are a part of the broader initiative to promote value-based care, enable better coordination among healthcare providers, and facilitate patient autonomy and engagement. 

One key theme found in the NPRM that will likely enable better coordination among healthcare providers and potentially increase patient safety is expanded permission to disclose protected health information (“PHI”) to third parties in emergency situations. For example, under the proposed changes, covered entities would be allowed more flexibility to disclose PHI in emergencies like a mental illness and substance abuse crisis. The current standard for disclosure of PHI in an emergency or health crisis is based on the covered entity’s “professional judgment.” This standard has often left covered entities unsure as to when a disclosure is permitted. The proposed modification relaxes this standard slightly in that it would allow a covered entity to disclose PHI in an emergency situation or health crisis when the covered entity has a good faith belief that the disclosure is in the best interest of the individual. A good faith belief could be based either on direct knowledge of relevant facts or representations by a person who can reasonably be expected to know relevant facts. For example, OCR has provided the following scenarios:

Good faith would permit a licensed health care professional to draw on experience to make a determination that it is in the best interests of a young adult patient, who has overdosed on opioids, to disclose relevant information to a parent who is involved in the patient’s treatment and who the young adult would expect, based on their relationship, to participate in or be involved with the patient’s recovery from the overdose. Likewise, front desk staff at a physician’s office who have regularly seen a family member or other caregiver accompany an adult patient to appointments could disclose relevant information to the family member or caregiver as a way of checking on the welfare of the patient, when a patient misses an appointment, based on the staff’s knowledge of the person’s involvement and a good faith belief about the patient’s best interest.

But not only would covered entities be allowed more flexibility to disclose PHI when individuals are experiencing emergencies or health crises, they would also be allowed more leniency to disclose PHI to avert a threat to safety. While covered entities are currently allowed to disclose PHI to prevent threats to health and safety, the current standard is considerably more stringent in that it allows the disclosure of PHI to avert a threat to health or safety only when the threat is “serious and imminent.” Under the changes proposed in the NPRM, covered entities could make a disclosure when the threat is “serious and reasonably foreseeable.” OCR has stated that “[a]dopting a ‘serious and reasonably foreseeable’ standard can enable a health care provider to timely notify a family member that an individual is at risk of suicide, even if the provider cannot predict that a suicide attempt is ‘imminent.'” In addition, “[a]n emergency room doctor who sees an elderly patient with COVID-19 could contact the patient’s nursing home to alert them of the potential exposure of other residents and staff based on the serious and reasonably foreseeable threat of infection with COVID-19 without delay caused by the need to assess whether the threat is sufficiently ‘imminent’ to permit the disclosure.” 

These proposed modifications provide additional clarity regarding PHI disclosures that would assist in the Department’s initiatives to increase coordination among healthcare providers and ultimately improve patient safety. Both of these proposed changes would hopefully empower covered entities to disclose PHI in situations where there is a genuine belief that harm is likely without being fearful of HIPAA penalties because the harm was not imminent.

Lindsey Phillips is an associate at Burr & Forman LLP practicing exclusively in the firm’s Healthcare Industry Group. 

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Physician Recruitment Agreements – What You Need to Know

Physician Recruitment Agreements – What You Need to Know

by Howard E. Bogard

Both the federal Anti-kickback Statute and the Stark Law allow a hospital to provide certain financial assistance to aid a medical practice in its efforts to recruit and hire a new physician. Financial assistance can take many forms, including a collection guarantee, net income guarantee and/or payments with respect to a physician’s moving expenses, school debt and marketing.  A recruitment agreement reflecting financial assistance is typically signed by the medical practice, physician and hospital and is structured as a loan that is forgivable as long as the physician practices medicine in the hospital’s service area for a defined time period. The amount of financial assistance cannot take into account past or future referrals from the recruited physician (or medical practice) to the hospital.

In order for a hospital to provide a medical practice financial assistance to recruit and hire a new physician, the hospital must first determine that there is a documented need in the community for the physician’s specialty.  Once confirmed, the arrangement must be in writing and the physician must “relocate his or her medical practice” to the “geographic area served by the hospital” to become a member of the hospital’s medical staff. With some exceptions for hospitals located in rural areas, the geographic area served by a hospital is the area composed of the lowest number of contiguous zip codes from which the hospital draws at least 75 percent of its inpatients.  A physician will be considered to have relocated his or her medical practice if the physician moves his or her practice at least 25 miles and into the geographic area served by the hospital or the physician moves his or her practice into the geographic area served by the hospital and the physician derives at least 75 percent of revenues from patients not seen or treated by the physician at his or her prior medical practice site. There are also exceptions for residents or physicians who have been in practice one year or less or for physicians who meet other requirements.  The main point is that it is not permissible for a hospital to provide recruitment assistance with respect to a physician who is already working in the hospital’s service area.  

A common form of recruitment assistance is a collection or net income guarantee that runs for one or two years after the physician is first employed by the medical practice.   In either case, the recruitment agreement “guarantees” that the physician will generate a certain amount of revenue to satisfy a collection “target” or a net income “target”.  If the physician’s collections are not high enough in a particular month to meet the target amount, the hospital pays the difference.  With respect to a net income guarantee, the target is based on the physician’s collections after certain “direct expenses” are subtracted.  By law, direct expenses can only consist of new, incremental expenses incurred by the medical practice by virtue of the physician’s employment. Examples of new, direct expenses include the cost of the physician’s compensation and benefits, license fees and dues, malpractice insurance and other costs incurred by the medical practice to the extent that such expenses increase directly as a result of the physician’s employment.  Existing expenses, such as office rent and personnel costs, cannot be included as a direct expense. 

When reviewing a physician recruitment agreement, it is important to not only review the financial terms of the assistance but also to consider the following:

 Commitment Period – What is the length of time the recruited physician must practice in the hospital’s geographic service area for the recruitment assistance loan to be forgiven? The typical time period is one to three years after the financial assistance period ends.

   Repayment Obligations – It is important to review whether the medical practice, physician or both are obligated to repay the loan upon a default of the recruitment agreement.  Oftentimes, if the physician is the direct recipient of the loan proceeds, such as moving expense reimbursement and payments for student loans, the physician will be solely responsible. However, a collection or net income guarantee will often obligate both the physician and medical practice to repayment in the event of a default. A promissory note is often signed by the physician and sometimes the medical practice to secure the repayment of the loan.

Physician Obligations – While the physician will need to remain on the medical staff of the hospital during the term of the recruitment agreement, it is important to determine if other obligations are imposed on the physician.  Often, during the term of the recruitment agreement the physician will be obligated to certain hospital call obligations and restricted from having an ownership interest in a provider that competes with the hospital. 

Security Interest – To secure the recruitment agreement loan sometimes the hospital will want a security interest in the medical practice’s accounts receivable generated by the recruited physician. These provisions must be carefully reviewed since medical practices often pledge their accounts receivable as collateral to a bank or other financial institution.

A physician recruitment agreement can provide a medical practice significant financial assistance with the recruitment and hiring of a new physician. However, the agreement may also impose significant financial restrictions and penalties on both the medical practice and physician if the terms of the agreement are breached.  Any recruitment agreement should be carefully reviewed and negotiated.

Howard Bogard is a Partner at Burr & Forman LLP and chairs the firm’s Health Care Practice Group. He can be reached at 205-458-5416 or at hbogard@burr.com.

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Are You Ready for Your PPP Loan Audit?

Are You Ready for Your PPP Loan Audit?

By: Jim Hoover, Burr & Forman

PPP loans received by individuals and businesses under the CARES Act will be audited (“reviewed”) by the SBA.  PPP loans of $2 million or more will automatically be audited by the SBA.  Many PPP loans of less than $2 million will also be audited.

Borrowers will often receive notification of the audit through their lending bank, but the SBA is directly notifying PPP borrowers as well.  The SBA is receiving support from the Internal Revenue Service and other federal agencies in these audits such as the Department of Justice.  There have been several criminal investigations resulting from these audits.

PPP loan audits request documents and information from the borrower, including income and employment tax returns, payroll records, financial statements, and bank account statements including deposit and payment information in order to verify information reported by the borrower on its PPP loan application.  However, the SBA PPP loan audits focus on much more.

SBA audits of PPP loans have thus far focused on whether the individual or business was eligible to receive a PPP loan, and whether the borrower correctly calculated its PPP loan amount.  Specific issues being reviewed by the SBA in these audits include “economic necessity” for a PPP loan, and “head-count” related issues including affiliation with other businesses, the appropriate “NAICS” code for the business, and whether the business counted all employees – full-time, part-time, and even temporary – in filing the loan application.  The SBA is also looking at other “business-specific” issues of the borrower.

The PPP loan application contains a borrower certification that “[c]urrent economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant“.  This same certification is also required in new PPP loan applications under the “Economic Aid Act”.  For borrowers that received PPP loans of less than $2 million, the borrower is deemed by the SBA to have made this “economic necessity” certification in “good faith.” As a result, the SBA may not be looking specifically at this issue for borrowers that received loans of less than $2 million.  However, for PPP loans of $2 million or more, borrowers are not eligible for this “good faith economic necessity presumption”, and the SBA is auditing this certification issue.

Without being an alarmist, false certifications is the keystone issue for most False Claims Act prosecutions.  Accordingly, it is important for borrowers to carefully review and gather the documentation that supports the certification.  

The SBA is beginning many audits by sending out a “Loan Necessity Questionnaire” (SBA Form 3509), which the SBA first sends to the lending bank and then the bank sends the questionnaire to the borrower.  The borrower has a limited amount of time, 10 days, to complete and return the questionnaire to the bank, and the bank then provides the completed questionnaire to the SBA.

If a borrower applies for forgiveness of a PPP loan, the forgiveness application may be separately reviewed by the SBA and, as a practical matter, if a borrower files for forgiveness this will likely trigger or at least accelerate a full SBA audit of the PPP loan.

Once an SBA PPP loan audit is completed, and where an adverse audit determination is made by SBA, including that the borrower may not qualify for the loan, the borrower then has administrative appeal rights within the SBA to have the audit determination reviewed, which can lead to a hearing before a federal administrative law judge. Those appeal rights are the subject of a future article.  

______________________

Jim Hoover is a partner at Burr & Forman LLP and works exclusively within the firm’s Health Care Practice Group and predominantly handles healthcare litigation. Burr & Forman has a dedicated team to counsel individuals and businesses in government audits, investigations and defense-related to the PPP under the CARES Act, and also new PPP loans under the Economic Aid Act. The PPP and CARES Act Audit, Investigations and Defense Team represents and advises clients in audits and investigations involving PPP loans and tax benefits that may have been claimed under the CARES Act. This multidisciplinary team combines more than 230 years of legal experience and attorneys with previous government positions, including attorneys with IRS Chief Counsel, the United States Department of Justice, and United States Attorneys’ Offices.  More information can be found at www.burr.com.

Posted in: Coronavirus, Legal Watch, Management, MVP

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Physician Compensation Models in Light of Recent Stark Law Changes

Physician Compensation Models in Light of Recent Stark Law Changes

by Kelli C. Fleming, Burr Forman

On December 2, 2020, the Centers for Medicare and Medicaid Services (“CMS”) finalized sweeping changes to the federal Physician Self-Referral Law, commonly known as the Stark Law. At least one such change may materially impact how physician group practices allocate profits from Stark Law designated health services (“DHS”).

Under the Stark Law, a medical practice with at least two physicians must qualify as a “group practice” in order to take advantage of the Stark Law in-office ancillary services exception, which is the exception often used to allow a physician owner or physician employee to order DHS from his or her own medical practice. As part of the group practice requirements, DHS profits must be distributed to all physicians in the group, or to a pool of five or more physicians in the group, in a manner that does not directly take into account the volume or value of a physician’s referrals for DHS.

Currently, many physician group practices, especially large or multi-specialty practices, allocate DHS profits to its physicians based on DHS categories. For example, profits from one DHS category (e.g., imaging services) may be allocated to certain physicians in the group practice while profits from a second DHS category (e.g., physical therapy) may be allocated to a different (or possibly overlapping) subset of physicians in the group practice.

However, under the new Stark Law rules, CMS has clarified that DHS profits can no longer be allocated based on DHS category. Instead, profits from all DHS categories for all physicians in the group practice (or a component of at least five physicians in the group practice) must be aggregated and then distributed to all physicians in the group practice (or a component of at least five physicians in the group practice) in a manner that does not directly take into account the volume or value of referrals. Using the example above, under this new clarification, DHS profits from both imaging services and physical therapy services ordered by physicians in the group practice (or a component of at least five physicians in the group practice) must be aggregated and then the total aggregated profits distributed to such physicians in a manner that does not take into account the volume or value of referrals.

CMS also clarified that if a physician practice has more than one pool of five physicians, each pool does not have to be treated in an identical manner. For example, one pool may utilize one distribution methodology and a second pool may utilize another distribution methodology, as long as the methodologies used are Stark Law compliant (i.e., not based on the volume or value of referrals).

CMS recognizes that its prior regulatory guidance on the distribution of DHS profits has led to confusion by industry participants. While the other recent changes to the Stark Law take effect on January 19, 2021, the changes with regard to the distribution of DHS profits take effect on January 1, 2022.

Kelli Fleming is a Partner at Burr & Forman LLP and practices exclusively in the firm’s Health Care Practice Group.

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CMS and OIG Issue Historic Revisions to the Federal Anti-Kickback Statute and Stark Law

CMS and OIG Issue Historic Revisions to the Federal Anti-Kickback Statute and Stark Law

By: Anthony Romano with Burr Forman

On November 20, 2020, the Centers for Medicare & Medicaid Services and the Office of Inspector General of the Department of Health and Human Services issued two significant final rules to reform the Anti-Kickback Statute and Stark Law in an aim to reduce regulatory barriers to coordination of patient care, and to accelerate the transformation of the health care system to value-based care (a value-driven health care system that pays for health and outcomes, as opposed to the traditional fee-for-service payment system which rewards providers for the volume of care provided).

The 1,000-page Anti-Kickback Statute final rule does this by implementing seven new safe harbors, modifying four existing safe harbors, and codifying one new exception under the Civil Monetary Penalty Law.  As you are probably aware, the Federal Anti-Kickback Statute provides for criminal penalties for whoever knowingly and willfully offers, pays, solicits, or receives remuneration to induce or reward, among other things, the referral of business reimbursable under any of the Federal health care programs, including Medicare and Medicaid. Health care providers and others may voluntarily seek to comply with statutory and regulatory safe harbors so that they have the assurance that their business practices will not be subject to sanctions under the Anti-Kickback Statute. To receive safe harbor protection, an arrangement must squarely meet each requirement of an applicable safe harbor. However, failure to fit in a safe harbor does not mean that an arrangement violates the Federal Anti-Kickback Statute. Arrangements that do not fit in a safe harbor are analyzed on a case-by-case basis, including whether the parties had the requisite intent. Congress intended the safe harbor regulations to be updated periodically to reflect changing business practices and technologies in the health care industry, and the new final Anti-Kickback Statute regulations accomplish this by, among other things, removing potential barriers to more effective coordination and management of patient care, and by removing potential barriers to the delivery of value-based care.   

The 627-page Stark Law final rule creates new exceptions for value-based arrangements, provides additional guidance to make it easier for physicians and other health care providers to comply with the Stark Law, and provides protection for non-abusive, beneficial arrangements. Unless otherwise specified in the rules, the new provisions go into effect January 19, 2021.  When the Stark Law was enacted in 1989, healthcare was paid for primarily on a fee-for-service basis and the Stark Law recognized that a profit motive could influence some physicians to order services based on their financial self-interest rather than the good of the patient. For this reason, the Stark Law prohibits a physician from making referrals for certain healthcare services payable by Medicare or Medicaid if the physician (or an immediate family member of the physician) has a financial relationship with the entity performing the service. There are statutory and regulatory exceptions, but in short, a physician cannot refer a patient to any entity with which he or she has a financial relationship unless an exception is satisfied.  The Stark Law also prohibits the entity from filing claims with Medicare or Medicaid for services resulting from a prohibited referral, and Medicare or Medicaid cannot pay if the claims are submitted. Although the regulations that interpret the Stark Law have been updated several times, the Stark Law has not been significantly updated since it was enacted in 1989, and all previous changes left in place a framework that is tailored to a fee-for-service environment.  The new Stark Law final rule includes a comprehensive package of reforms to modernize the regulations that interpret the Stark Law while continuing to protect the Medicare program and patients from bad actors.

Overall, these new rules will have a significant, and expected positive, impact on healthcare providers by easing burdensome regulatory restrictions.  With over 1,600 pages of new rules to digest, be on the lookout for more detailed and specific analysis in the near future.  In the meantime, please do not hesitate to contact us if you have specific questions regarding the impact of the new Anti-kickback Statute or Stark Law final rules on you or your practice. 

Anthony Romano practices with Burr & Forman LLP in the firm’s Health Care Industry Group. Anthony may be reached at aromano@burr.com or (205) 458-5210.

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The Perfect Storm for Litigation Resulting From the Paycheck Protection Program (PPP) and Coronavirus Aid, Relief and Economic Security (CARES) Act

The Perfect Storm for Litigation Resulting From the Paycheck Protection Program (PPP) and Coronavirus Aid, Relief and Economic Security (CARES) Act

By: Jim Hoover

Millions of American businesses and self-employed individuals applied for and received Paycheck Protection Program (PPP) loans authorized by the CARES Act. PPP loans are obtained from a bank and guaranteed by the Small Business Administration (SBA). The processes for obtaining loans and loan forgiveness are ripe for many types of possible litigation including administrative, civil, and criminal. 

Businesses and individuals were required to provide documents and information and make important certifications to their bank when they applied for a PPP loan. The certifications included the eligibility of the business or individual for a PPP loan meeting the many requirements of the CARES Act. In a PPP loan application a borrower also had to certify that “[c]urrent economic uncertainty make this loan request necessary to support the ongoing operations of the Applicant.” 

The CARES Act also allows PPP loans to potentially be forgiven subject to many conditions. Businesses and individuals seeking PPP loan forgiveness must provide additional documents and yet more certifications through an application filed with their PPP lending bank. It is the responsibility of the borrower to provide an accurate calculation of loan forgiveness and to attest to the accuracy of its reported information.

PPP loans under the CARES Act will be audited. The Department of the Treasury announced that all PPP loans over $2 million will be audited; other PPP loans will also certainly be audited.  For example, borrowers that seek forgiveness of a PPP loan increase their likelihood of being audited, and not limited just to forgiveness, but eligibility of the borrower for the loan and the accuracy of certifications made by the borrower in the borrower’s PPP loan application. 

The SBA also reserves the right to review and audit all PPP loans and related loan issues, including eligibility, borrower certifications, and forgiveness. The SBA may review whether a borrower calculated its loan amount correctly and whether the borrower used loan proceeds for allowable purposes. The SBA issued guidance stating that a borrower who received a PPP loan of less than $2 million will be deemed to have made this required certification in good faith. For borrowers who received a PPP loan of $2 million or more, the borrower may have to prove that its application was based on current economic uncertainty and that the PPP loan was necessary to support ongoing operations of the borrower.  If the SBA determines in the course of its audit/review that a borrower lacked an adequate basis for the required certification concerning the eligibility of the loan request, the SBA will seek repayment of the outstanding PPP loan balance and determine that the borrower is not eligible for loan forgiveness. If the borrower repays the loan after receiving notification, the SBA has announced that it will not pursue administrative enforcement or make referrals for enforcement to other agencies. 

Applicable to forgiveness, the SBA states that, to receive loan forgiveness, a borrower must complete and submit the Loan Forgiveness Application (or equivalent bank form) to the PPP lending bank (or the lender that is servicing the PPP loan). The bank will review the application and make a decision regarding loan forgiveness. Banks are expected to perform a good-faith review, in a reasonable time, of the borrower’s calculations and supporting documents concerning amounts eligible for loan forgiveness. The lender must issue a decision to the SBA regarding a loan forgiveness no later than 60 days after receipt of a completed loan forgiveness application.

That decision may take the form of an approval (in whole or in part), denial, or (if directed by the SBA), a denial without prejudice due to a pending SBA review of the loan for which forgiveness is sought. In the case of a denial without prejudice, the borrower may subsequently request that the bank reconsider its application for loan forgiveness, unless the SBA has determined that the borrower is ineligible for a PPP loan. If the bank determines that the borrower is entitled to forgiveness of some or all of the amount applied for, the SBA will, subject to any SBA audit or review of the loan or loan application, remit the appropriate forgiveness amount to the bank. If the bank denies forgiveness, in whole or in part, the bank must notify the borrower in writing that the lender has issued a decision to the SBA denying the loan forgiveness application. The SBA reserves the right to review the bank’s decision in its sole discretion. Within 30 days of notice from the bank, a borrower may request that the SBA review the bank’s decision.

In the event the SBA reviews or audits a borrower’s PPP loan, the SBA will notify the bank, who is required to notify the borrower in writing within five (5) business days of receipt of notice from the SBA and to request information from the borrower. The SBA may also request information directly from the borrower. A borrower’s failure to respond to the SBA may result in a determination that the borrower was ineligible for a PPP loan or ineligible to receive the loan amount or loan forgiveness.

If the SBA determines in the course of its audit or review that the borrower was ineligible for a PPP loan, the loan will not be eligible for forgiveness. If only a portion of the loan is forgiven, or if the forgiveness request is denied, any remaining balance due on the loan must be repaid by the borrower on or before the two-year maturity of the PPP loan. 

The CARES Act created the new “Office of the Special Inspector General for Pandemic Recovery,” whose task is to “conduct, supervise, and coordinate audits and investigations” of the financial assistance programs for businesses. Administrative appeal remedies from disputed PPP audits, including resulting litigation, are presently unclear. While adverse decisions of the Office of Hearings and Appeals are appealable to federal courts, more guidance from the SBA concerning PPP audits and appeal remedies will be issued. 

Borrowers must also be aware of the Federal False Claims Act (“FCA”).  Under the FCA, a claim generally means any request or demand, whether under a contract or otherwise, for money or property that–(i) is presented to an officer, employee, or agent of the United States; or (ii) is made to a contractor, grantee, or other recipient, if the money or property is to be spent or used on the Government’s behalf or to advance a Government program or interest, or (iii) will reimburse such contractor, grantee, or other recipient for any portion of the money or property which is requested or demanded.  31 U.S.C. § 3729.  Federal courts have ruled that loan applications are “claims” for FCA purposes.  Thus, a PPP loan and any corresponding forgiveness is subject to the “False Claims Act.” In fact, government authorities are beginning to focus substantial resources on CARES Act fraud and abuse. Although the U.S. Department of Justice began indicting borrowers in connection with PPP fraud as early as May of this year, on September 10, 2020, federal authorities charged 57 people in jurisdictions across the U.S. with “stealing” $175 million from the PPP.  Additionally, a government report issued in September found “tens of thousands of loans could be subject to fraud, waste, or abuse.” The U.S. Government Accountability Office further reported to the U.S. House of Representatives that the SBA’s fraud hotline had received more than 42,000 reports of alleged fraud. 

Because of the many types of litigation, it is important that recipients of PPP loans and other financial assistance programs, carefully review their applications and requests for forgiveness to ensure they have met all of the programs’ requirements. 

Jim Hoover practices with Burr & Forman LLP and works exclusively within the firm’s Health Care Industry Group and primarily handles healthcare litigation and compliance matters.

Posted in: Coronavirus, Legal Watch, Management

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Five Things to Consider When Selling Your Practice to a Private Equity Firm

Five Things to Consider When Selling Your Practice to a Private Equity Firm

By Howard Bogard, Burr Forman

A growing number of physicians are selling their medical practices to private equity firms in order to “monetize” their practice, as well as to access capital and obtain operational efficiencies. In the Southeast, we are seeing consistent private equity activity in the specialties of anesthesiology, gastroenterology, dermatology, ophthalmology, oncology, ENT, and internal medicine, as well as others. 

 Private equity firms generally use capital from wealthy individuals, pension funds and university endowments to invest in various industries with the goal of obtaining a return on investment of 20% or more.  To start, the private equity firm will purchase a large, well-managed (“platform”) medical practice and thereafter will acquire additional practices in order to increase the number of employed physicians throughout a defined geographic area.  The goal is to grow revenue and decrease cost and then sell the practices within three to seven years of acquisition.

 If you are considering a sale to a private equity firm, there are several things to consider:

  1. Valuation of the Practice.  A private equity firm generally determines the purchase price for a medical practice based on a multiple of EBITDA (earnings before interest, taxes, depreciation, and amortization) as a measure of the operating performance of the practice. The multiple can run anywhere from 4 to 12 times EBITDA, with a platform or larger practice obtaining a multiple on the higher end of the range.
  2. Payment of the Purchase Price.  The purchase price is typically a combination of cash plus “roll-over” equity in the buyer from 10% to 30% of the total purchase price.  For example, if the total purchase price is $10 million, $8 million could be paid in cash at closing and $2 million paid as equity in the buyer.  When the buyer sells, the physicians receive a return on their roll-over equity.  A portion of the purchase price may also be paid by a promissory note with payment contingent on the physicians meeting certain revenue benchmarks.  
  3.  Expect a Change in Compensation. After closing, the physicians will become employees of the private equity buyer. In return for a large up-front purchase price, typically a physician will be paid less in annual compensation as compared to pre-closing compensation amounts, although “guaranteed” salaries for a period of time can be negotiated.  Compensation is based on a variety of factors, including collections from personally performed services, plus a percentage of ancillary revenue and/or a percentage of overall profits. Physicians considering a private equity sale should analyze and compare their expected compensation over a three to five year period in private practice versus the same period under a private equity model, to include the up-front payment.
  4. Penalties for Early Departure.  Typically, a private equity firm will require the selling physicians to sign a five-year employment agreement. In the event a physician leaves employment for certain reasons within a defined time period, the departing physician will be required to repay some of the purchase price he or she received (a “claw-back”).  Typically, the claw-back period runs from three to five years after the start of employment, with more money repaid in the first year of the claw-back as compared to the last year. In addition, the selling physicians are required to sign non-compete and non-solicitation/no-hire agreements that restrict the physician’s ability to compete with the private equity buyer in the event the physician leaves the practice.
  5. Loss of Control.  One of the benefits of being in private practice is that the physician owners make the decisions.  If a practice sells to a private equity firm, a management company (owned by the private equity firm) will manage the practice and will have authority to make essentially all operating decisions, other than clinical/medical decisions, which remain within the control of the physicians.  Oftentimes, there is a clinical management board or committee comprised of physicians and private equity representatives that has authority to address certain issues.  However, if the practice is well run and profitable (hence the reason the private equity firm is interested in the practice), in my experience, the private equity firm does not make significant changes without first consulting with the physicians.

Howard Bogard is a Partner at Burr & Forman LLP and chairs the firm’s Health Care Practice Group.  Howard can be reached at 205-458-5416 or at hbogard@burr.com.

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