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ICD-10 Gearing Up Again: One Year to Go—Hopefully!

October 1, 2014


The healthcare industry is expecting the October 1, 2015 conversion date to stick this time.  That is, unless for the third time, there is an unexpected delay.  Most Health Information Management (HIM), certified coders and billers felt blindsided when Congress legislatively decided last March that:


Tackling Crisis Management in an Era of Social Media: Hospitals Need to Evaluate Their Policies and Risks

September 24, 2014


It is a hard-hitting sport that generates lots of money and attention, both on and off the playing field.  Controversies involving football players, coaches, owners and referees have come and gone for the National Football League (NFL).  Fans have dealt with disputed championship wins as far back as 1925, teams relocating in the middle of the night, Michael Vick dog fighting and prior domestic abuse issues.  Yet Ray Rice, Adrian Peterson, Roger Goodell and all the others involved in the current NFL drama appear to be so blatantly inept at managing the growing controversy.


The New, Latest, Final Rule for Meaningful Use

September 10, 2014


In the final rule on Meaningful Use (MU) released August 29, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) finalized deadlines that could affect hospitals' and physicians' bottom line.  While some providers are breathing a sigh of relief, others are finding the changes and rules too confusing to draw any immediate conclusions.  In some cases it seems to resolve several challenges certain providers were having in receiving an Electronic Health Record (EHR) incentive in 2014.


Phase Three of the Hospital Readmission Reduction Program Slated for October 1, 2014

September 3, 2014


According to a 2009 study, nearly 20 percent of Medicare beneficiaries are rehospitalized within 30 days after discharge, at an annual cost of $17 billion.1  Causes of avoidable readmissions include:


American Hospital Association Turns up the Heat

August 27, 2014


The heat was turned up again last week by the American Hospital Association (AHA), the lobbying organization representing nearly 5,000 member hospitals, health systems and other healthcare organizations.  The AHA sharply criticized the audit methods used by the Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS), saying in a letter that the watchdog has been “grossly” inflating Medicare overpayment estimates.


Quality Management vs. Total Quality Excellence

August 20, 2014


This past week it is doubtful that any of us didn’t pause for a few minutes to reminisce about Robin Williams’ acting career.  From the voice of the genie in Disney’s Aladdin to Good Morning Vietnam, he will be remembered and missed.  For many, Robin Williams' favorite role was portraying John Keating in The Dead Poets Society.  Some readers may be scratching their heads and wondering where this article is headed but please indulge a fan.


CMS Issues Final FY2015 Rule on Inpatient Hospital Payments


On August 1, 2014 the Centers for Medicare & Medicaid Services (CMS) issued a final rule that will update fiscal year (FY) 2015 Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital Prospective Payment System (LTCH PPS).  The final rule, which applies to approximately 3,400 acute care hospitals and approximately 435 LTCHs, will generally be effective for discharges occurring on or after October 1, 2014.  Under the final rule, the operating payment rates for inpatient stays in general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users will be increased by 1.4 percent.  Beginning with FY 2015, those hospitals that do not successfully participate in the Hospital IQR Program and do not submit the required quality data will be subject to a one-fourth reduction of the market basket update (previously these hospitals received a two percentage point reduction).  Also, the law requires that the update for any hospital that is not a meaningful EHR user will be reduced by one-quarter of the market basket update in FY 2015, one-half of the market basket update in FY 2016, and three-fourths of the market basket update in FY 2017 and later years.  Total IPPS payments are projected to decrease by $756 million.  Medicare payments to LTCHs in FY 2015 are projected to increase by approximately 1.1 percent, or approximately $62 million.


HIPAA Updates

August 6, 2014


The Office of Civil Rights (OCR) recently released two reports required by the Health Information Technology for Economic and Clinical Health (HITECH) Act:  (i) the Annual Report to Congress on Breaches of Unsecured Protected Information (Breach Report); and (ii) the Annual Report to Congress on HIPAA Privacy, Security and Breach Notification Rule Compliance (Compliance Report).  Both reports covering calendar years 2011 and 2012 reveal some interesting details about data breach activity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as well as some helpful reminders and recommendations for covered entities and business associates.


Medicare Billing and Payment for Telehealth Services

July 30, 2014

Generally, for Medicare payments to be made for telehealth services under the Physician Fee Schedule (PFS) several conditions must be met.  Specifically, the service must be on the Medicare list of telehealth services and meet all of the following other requirements for coverage:


Off-Campus Provider-Based Departments May Get a New Modifier

July 23, 2014


The Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2015 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates proposed rule [CMS-1613-P] on July 3, 2014.  The proposed rule would update Medicare payment policies and rates for hospital outpatient department and ASC services, and update and streamline programs that encourage high-quality care in these outpatient settings.  This proposal would continue the progress made so far in moving the OPPS from what currently resembles a hybrid of a prospective payment system and a fee schedule, to a more complete prospective payment system.


CMS Issues Multiple Fact Sheets Addressing Proposed New Rules

July 16, 2014


July is a blockbuster month, if your job requires you to digest and prepare your organization for the ever-changing world of the Centers for Medicare & Medicaid Services (CMS) regulations.  CMS released eight Fact sheets since July 1st containing over 1,000 pages of proposed new regulations to various aspects of the Medicare program.  They cover proposed regulations for everything from the Physician Quality Reporting System (PQRS) to End-Stage Renal Disease (ESRD).  While the Fact sheets provide a good overview of the changes, determining what they really mean to your hospital or organization is, of course, in the details.  Many professional associations tend to spin the generalities and wait until the final regulations are released later this year rather than dive into the specifics of the proposed rules.  On the surface some of the proposed changes appear to be easy to deal with, e.g., plug in the new conversion factor or pull out the 73 PQRS measures that are being deleted. The chart below provides links to the various Fact sheets and the proposed rules.


Special Fraud Alert: Laboratory Payments to Referring Physicians

July 9, 2014


The Department of Health and Human Services Office of Inspector General (OIG) is warning clinical laboratories and physicians that providing remuneration to physicians to collect, process and package patients' specimens and/or establishing databases to collect patient testing data could violate federal anti-kickback law.


Challenging the United States to Win the World Cup in Health Care

July 1, 2014


World Cup fever has struck the United States (US) like never before. Last Sunday evening while navigating a busy airport, the thirty-foot wide hallway was cramped with fans trying to catch a glimpse of the US/Portugal game. Apparently, the game pulled in 20 million viewers, with another 1.4 million watching online on ESPN—figures which exceed the National Hockey League's Stanley Cup finals and are comparable with the NBA finals. It is exciting to see the interest grow for this sport. And when a big event comes up and the US has a fighting chance to compete with the power teams in the world, tens of millions of people will gather to watch. Face it, Americans like to win.


Hospitals Need to Recognize the Physician’s Role in the Revenue Cycle

June 25, 2014


Two recent articles highlight the importance of the physician in the revenue cycle.  The first is a report released several weeks ago by the Office of Inspector General (OIG) on documentation and coding problems with evaluation and management services (E/M).  Internet chatter has been high since the May 2014 release of Improper Payments for Evaluation and Management Services Cost Medicare Billions In 2010 which found that 55 percent of claims for E/M services in 2010 were incorrectly coded and/or lacking documentation.  Medicare inappropriately paid $6.7 billion for these claims, representing 21 percent of Medicare payments for E/M services in 2010.  In particular, 26 percent were upcoded and 15 percent were downcoded.  Let’s repeat the last part of that finding:  15 percent were downcoded at a cost of $1.8 billion in lost revenue!


Health and Human Services Renews Their Vision for an Interoperable Health IT Infrastructure

June 18, 2014


On June 5th the Office of the National Coordinator for Health IT (ONC) released a white paper outlining a 10-year plan to achieve an interoperable health IT infrastructure.  The paper—titled "Connecting Health and Care for the Nation:  a 10-Year Vision to Achieve an Interoperable Health IT Infrastructure”—recognizes the dramatic progress to date in laying a strong foundation of a health IT infrastructure across the United States.  Building on that foundation, ONC believes there is no better time than now to renew the focus on a nationwide, interoperable health IT infrastructure that among other goals, gives patients and providers access to appropriate health information that supports coordinated health management and improves the overall health of the nation’s population.  In short, ONC sees an interoperable health IT ecosystem as one that “makes the right data available to the right people at the right time across products and organizations in a way that can be relied upon and meaningfully used by recipients.”  ONC’s paper pays homage to the advancements made over the past decade, including:


The Link between Medicaid Expansion and Charity Care

June 11, 2014


According to the U.S. Department of Health and Human Services (HHS) more than one million people signed up for Medicaid in April, bringing the total growth since September to about six million.  In 47 states and the District of Columbia, overall Medicaid enrollment reached 65 million last month.  Enrollment for those same states back in September totaled 59 million, according to a report released last week by the Centers for Medicare & Medicaid Services (CMS).1


Hospitals and Physicians Receive a Reprieve With Meaningful Use Stage 2 Requirements

June 4, 2014

The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) announced a proposed rule, on May 20, 2014, that would allow providers more flexibility in how they use electronic health record (EHR) systems to meet meaningful use (MU) requirements and would formally extend the reporting requirements for Stage 2 of the Medicare and Medicaid EHR Incentive Programs.


CMS Issues Proposed Hospital Inpatient Payment Regulation

May 21, 2014


On April 30, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospitals Prospective Payment System (LTCH PPS) in Fiscal Year (FY) 2015.


Impact of the Telephone Consumer Protection Act on Healthcare Operations

May 14, 2014


To further protect consumers from unwanted autodial or prerecorded calls, often referred to as “robocalls,” the Federal Communications Commission (FCC) approved changes to its telemarketing rules, effective October 2013.  Widely viewed as a win for consumers, the FCC’s February 2012 Report and Order was designed to put an end to intrusive telemarketing calls that seemed to regularly occur during a consumer’s dinner hour.  The Order as adopted specifically protects consumers by:


Federation of State Medical Boards Passes Model Telemedicine Policy

May 7, 2014


On April 26, the Federation of State Medical Boards (FSMB) adopted its Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (Model Policy), which “provides guidance to state medical boards for regulating the use of telemedicine technologies in the practice of medicine and educates licensees as to the appropriate standards of care in the delivery of medical services direction to patients via telemedicine technologies.”  The aim of the Model Policy is to remove obstacles based in law and/or regulation to promote the appropriate adoption of telemedicine technologies.


Two Landmark False Claims Decisions

April 30, 2014


The Department of Justice (DOJ) is increasing enforcement on questionable physician arrangements.  Qui tam “whistleblowers” are steering them to new False Claims Act (FCA) cases daily.  Lately, there have been two landmark FCA decisions involving the Stark Law which has alarmed the hospital/physician community. First, was the $238 million award of damages after a jury trial against the Tuomey Healthcare System in South Carolina; and most recently, the tentative settlement with Halifax Hospital in Daytona, Florida.


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