Mid-Atlantic Health Law TOPICS

Mandated benefits. Did you know that health insurance policies issued or renewed in Maryland after October 1, 1997, must provide coverage for bone mass measurement for the prevention, diagnosis and treatment of osteoporosis, and, under certain circumstances, prostate cancer examinations and prostate specific antigen blood tests for men 40-75 years old?

More Mandated Benefits. Did you know that medically appropriate diabetes equipment, diabetes supplies and outpatient self-management diabetes training and education, including medical nutrition therapy, must be covered under health insurance policies issued or renewed in Maryland as of January 1, 1998?

Health Plan Disclosure. Did you know that a Maryland health plan's enrollment materials must disclose, in layman's terms, how the plan reimburses its physicians? The plan also must disclose (in a pie chart or bar graph) how each $100 in premium dollars is divided between payment to providers and payment for the plan’s administration.

Experimental Medical Care. Did you know that Maryland insurers must establish a systematic, scientific process for evaluating emerging medical/surgical treatments, and must inform subscribers and providers of that process? Maryland insurers must file an annual summary with the Maryland Insurance Commissioner regarding the new clinical issues and diagnostic/therapeutic services evaluated by the carrier, and carriers must establish the patient selection criteria for an emerging medical or surgical treatment for which coverage will be provided.

Non-Participating Medicare Physicians. Did you know that physicians who do not accept Medicare assignment from their patients may not be entitled to appeal coverage determinations? A federal court in New York recently ruled that physicians who fail to accept assignment do not have the same appeal rights as physicians who do accept assignment.

Aggressively Collecting Co-Pays. Did you know that the fourth anti-kickback advisory opinion from the Office of the Inspector General (OIG) comes down hard on providers who do not make "reasonable collection" efforts to recover Medicare patient co-pays? The OIG characterizes this behavior as a violation of both the Medicare conditions of participation and the federal anti-kickback statute.

Taking Deficiency Citations to Court. Did you know that an appellate court in the State of Washington held that a nursing facility has a due process right to appeal a deficiency citation? Most survey and certification programs, including the federal and Maryland programs, do not provide such rights. However, if the Washington case is followed elsewhere, then all nursing homes would have such a right.