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CMS Proposes Eliminating Payment Reduction Under Two-Midnight Rule

April 20, 2016


After much pushback from industry stakeholders and from the judicial system, the Centers for Medicare and Medicaid Services (CMS) propose to eliminate the notorious payment reduction under the Two-Midnight Rule in its FY 2017 Medicare Inpatient Prospective Payment System (IPPS) Proposed Rule (Proposed Rule).  Though not slated to be finalized until the latter part of 2016, hospitals can be optimistic that the penalty under the Two-Midnight Rule may soon be a memory.


Changing Demographics in our Physician Workforce Supply, Demand and Assessment

April 13, 2016


According to a new report from the American Association of Medical Colleges (AAMC), the U.S. faces a shortage of physicians ranging between 61,700 and 94,700 over the next decade.  This report includes updated supply and demand data and refined medical school graduate data, and fully integrates the effects of the growing ranks of physician assistants.


Ransomware is a Serious Threat to Healthcare Systems

April 6, 2016


A few months ago most of us were blissfully unfamiliar with the word “ransomware.”  Now, after several large healthcare systems have been the victims of attacks, we are seeing and hearing the word everywhere.  Every provider that stores information on computers that can access the Internet should consider how best to protect itself against this type of malware.


Ready or Not Here They Come – The OCR HIPAA Phase Two Audits

March 30, 2016


The U.S. Department of Health & Human Services (HHS) Office for Civil Rights (OCR) announced the beginning of the 2016 Phase Two Health Insurance Portability and Accountability Act (HIPAA) Audit Program.  This program is designed to evaluate the compliance efforts of covered entities and their business associates (BA) with the HIPAA Privacy, Security and Breach Notification Rules (HPSBNR).


OCR Releases Guidance Regarding Patients’ Access to PHI

March 23, 2016


The U.S. Office for Civil Rights (OCR) has been actively releasing new information regarding the Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance, including releasing a frequently asked question (FAQ) aimed at clarifying the rules for fees charged to patients in need of access to medical records.


Bundled Payments Building Momentum

March 16, 2016


A bundled payment is defined as reimbursement to healthcare providers on the basis of expected costs for clinically-defined episodes of care.  It has been described as a middle ground between fee-for-service reimbursement and capitation.


A Setback for Health Data Transparency

March 9, 2016


Healthcare providers as well as health policy opinion leaders favor data transparency.  If detailed data about the costs and quality of healthcare are publicly available, the theory goes, we will be able to address matters of cost, quality and access through analysis of comprehensive payment information.  We will also have the information needed to foster competition on the merits instead of competition based on anecdotes, marketing and faith.


Improving Patient Satisfaction the Disney Way

March 2, 2016


Do you remember when you first discovered the magic of Disney?  Whether you’re a child or adult, chances are the Disney experience changed the perception of how a consumer should be treated.  Disney follows three philosophical tenants to ensure they consistently deliver the world-class service that consumers have become accustomed to receiving:


CMS Finalizes Rule Regarding Reporting and Returning Overpayments

February 24, 2016


The Affordable Care Act (ACA) established a new Section 1128J(d) as part of the Social Security Act (Act) requiring that a person who has received an overpayment to report and return the overpayment.  Failure to identify and refund overpayments exposes providers and suppliers to False Claims Act liability pursuant to 31 USC 3729.  In the February 16, 2012 Federal Register,1CMS published a proposed rule to implement the section in the Act.  Four years later, CMS finalizes its rule (Final Rule).2  Importantly, the Final Rule, further identifies when an overpayment exists, clarifies when it has been “identified,” explains how long providers and suppliers have to repay identified overpayments and revises how far back providers and suppliers must look-back for repaying overpayments.  Although the Final Rule takes effect March 14, 2016, both federal and state governmental bodies have been enforcing this statutory requirement since its enactment on March 23, 2010.


Telemedicine Trends and Opportunities

February 17, 2016


Telehealth is broadly defined as the use of telecommunications and other information technologies to deliver healthcare, health information or health education at a distance.  While telemedicine is most commonly used to improve access to medical services in rural areas where such services are not consistently available, Peter Rasmussen, MD, Medical Director of Distance Health at the Cleveland Clinic points out that the groundwork is being laid for a full virtual healthcare system meeting the needs of not only rural communities, but also busy patients unable to seek care in person, or unable to do so.  He foresees regular online outpatient visits with a care coordinator or nurse for health maintenance, and visits to a clinic or doctors’ office only for services requiring hands-on care such as eye examinations, throat cultures and comprehensive physical exams.


Patient Payment Liability Just Ain’t What it Used to Be

February 3, 2016


Baseball is America’s past-time and Yogi Berra was one of its most colorful heroes.  Berra was an 18-time All-Star, appeared in 14 World Series as a member of the New York Yankees and won 10 championships.  He was a sportswriter’s favorite because he had countless expressions and phrases that were memorable because most of them didn’t make any sense.  A warmhearted personality, he became famous for delivering brilliantly awkward sayings, such as:  “90 percent of the game of baseball is half mental” and “the future ain’t what is used to be.”


CMS Outlines Expansion of Audit Program to Medicare Advantage

January 20, 2016


Medicare's Recovery Audit Contractor (RAC) program was implemented nationwide for Medicare Parts A and B in January 2010.  The Affordable Care Act calls for the program to be expanded to cover Medicare Advantage plans, and last month CMS released a draft Scope of Work to “solicit comment on, and interest in CMS entering into a contract with RACs to identify underpayments and overpayments, and recouping overpayments associated with diagnosis data submitted to the Centers for Medicare & Medicaid Services (CMS) by Medicare Advantage Organizations.”  Up to now, CMS has conducted limited audits of MA Plans covering only about five percent of Medicare Advantage Organization Contracts.  The Scope of Work document outlines plans to significantly expand those audits by contracting with RACs, who currently audit only Medicare Part A & B payments.


Results from Medicare’s Hospital Acquired Conditions Reduction Program – 758 Hospitals Penalized

January 13, 2016


One of the Affordable Care Act’s tools for shifting from a volume-based to a value-based payment system is the Hospital Acquired Conditions (HAC) Reduction Program.  The HAC Reduction Program cuts payments by one percent for the hospitals that rank in the worst-performing quartile of all hospitals on risk-adjusted HAC quality measures.  The program took effect for discharges beginning on October 1, 2014 (FY2015).


Reducing Readmissions in 2016


Once patients are discharged from the hospital, they have no desire to return.  Hospitals also would prefer patients not be readmitted due to medical issues associated with their hospital stay.
Patient readmissions are a major problem plaguing the U.S. healthcare system and policymakers are taking steps to reduce them.  The efforts to reduce re-hospitalizations begin at the hospital and end with the transition of patients to their home and their community.  But while improving a patient’s transition from hospital to home is important, it is just one factor in preventing readmissions. 


CMS Proposes Revisions to Discharge Planning Requirements

December 30, 2015


In late October 2015, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule seeking to modernize the conditions of participation (CoP) related to its discharge planning requirements (Proposed Rule).  The Proposed Rule aims to bring the existing discharge planning regulations in line with current practice as well as improve quality of care and reduce avoidable complications. Although the Proposed Rule applies to hospitals, inpatient rehabilitation facilities, critical access hospitals and home health agencies, this alert focuses on some of the key changes to the hospital CoPs.


Being Prepared for Risk Assessment

December 16, 2015


In 2008, the following statement about our healthcare system appeared in the New England Journal of Medicine:


The OIG Work Plan for 2016

December 9, 2015

The Department of Health and Human Services’ Office of the Inspector General (OIG) released its Work Plan for Fiscal Year 2016 on November 2, 2015.  The Work Plan is published annually and describes OIG’s new and ongoing audit, compliance and enforcement priorities for the upcoming year.  It allows providers to identify corporate compliance risk areas and helps to focus providers’ ongoing efforts in connection with their compliance program activities, audits and policy development.  Compliance officers should be familiar with the Work Plan when preparing their own organizations’ compliance program priorities to ensure they include the pertinent risk areas identified by OIG for the year ahead.


Healthcare and the FCC Duke it Out Over the Telephone Consumer Protection Act

December 2, 2015


The Federal Communications Commission (FCC) issued a Declaratory Ruling and Order (Declaratory Ruling)1 on July 10, 2015 in response to 21 separate requests2 seeking clarifications to the Telephone Consumer Protection Act (TCPA).3  The Declaratory Ruling has acute implications for any organization that uses an autodialer or prerecorded messages to make non-emergency calls to wireless phones without obtaining the consumer’s prior express consent.


The Two-Midnight Rule is Here to Stay

November 25, 2015


In its 2016 Final Hospital Outpatient Prospective Payment System (OPPS Final Rule), the Centers for Medicare and Medicaid Services (CMS) reiterated its controversial Two-Midnight Rule (Rule), modified its existing exceptions to the Rule and revised its auditing methodology to have Quality Improvement Organization (QIO) contractors conduct reviews instead of Medicare Administrative Contractors (MACs).  Despite industry pressure, CMS rejected the notion of a One-Midnight Rule and also rejected requests to push back the enforcement date beyond January 1, 2016.


Protecting the Privacy and Security of Healthcare Data

November 18, 2015


A misplaced flash drive; a lost cell phone or laptop computer; a message forwarded to a personal email account; a database hacked by a cybercriminal.  While they implicate very different levels of severity, all are examples of cyber-security incidents that are in the news every day.


Health Insurance Company Mergers and Acquisitions

November 11, 2015


Health insurance companies are once again seeking to grow through consolidation.  The potential for a landscape dominated by just a handful of insurance behemoths is raising concerns across the industry.


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