Legal advice for signing agreements

• Referral process: If you did not self-refer, you need to confirm if a licensed health professional, health licensing board or the Department of Licensing and Regulatory Affairs (DLRA) did the referral. The HPRP should not accept confidential or anonymous referrals.
• Evaluation: The referred practitioner needs to undergo evaluation for the HPRP to know their condition and determine if they’re eligible to join the program. Evaluators must be qualified professionals.
• Safety agreement phase: Before the completion of the monitoring agreement, the HPRP may offer a safety agreement. The temporary contract requires a participant to abstain from substances and submit to random drug tests. The contract’s validity should not exceed 60 days.
• Treatments and monitoring: The participant and HPRP will enter into a monitoring agreement that lasts from one to three years. The contract should give details on the treatments, random drug tests, therapies, reporting schedules, medical supervision and limits on their medical practice.
• Completion and release: Once the participant completes the monitoring agreement, the HPRP must commit to destroy their records after five years unless readmission happens.

The road to recovery

Billing fraud

• Upcoding: Charging for a more expensive service than what was provided.
• Phantom billing: Billing for services or procedures that were never performed.
• Unbundling: Billing separately for services that should be billed together as a package deal.
• Prescription fraud: Occurs when providers unlawfully obtain prescription drugs or submit false claims for reimbursement.

Medicare fraud

• Phantom Billing for Medicare services.
• Fraudulent Medicare claims for unnecessary medical equipment or services.
• Medicare Identity Theft: Using stolen Medicare information to submit fraudulent claims.

Unintentional coding errors

Prescription errors

Misrepresentation of credentials

Understanding the CON is vital for healthcare providers, administrators and policymakers because it influences decisions regarding developing and distributing healthcare resources. By requiring healthcare providers to obtain approval before making significant changes or additions, the program aims to promote equitable and cost-effective healthcare service delivery.

Purpose of certificate of need

A CON regulates the healthcare market. It mainly focuses on controlling costs and ensuring that new services or facilities are necessary for community health. The program's primary goal is to avoid the duplication of healthcare services, which can lead to underutilization and increased costs. It also seeks to ensure that all community members have access to adequate healthcare services and are distributed equitably, particularly in underserved areas.

How the certificate of need process works

Obtaining a CON involves applying to a state health care agency or commission. Applicants must demonstrate the need for the proposed service or facility in their community. This includes assessing the demand for the service, its potential economic impact, its contribution to community health outcomes and its alignment with state health planning goals.

The CON is a crucial mechanism in healthcare regulation that ensures the appropriate development of healthcare facilities and services in line with community needs. While it brings benefits in terms of cost control and equitable access, it can be a complex undertaking to receive the documentation necessary. Working with someone familiar with this aspect of healthcare law is crucial because compliance is vital.

A diagnosis was never made

The wrong diagnosis was made