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The “60-Day Refund Rule” A Federal District Court Defines How Quick is Quick Enough

August 19, 2015


The “60-Day Refund Rule” is a provision applicable to Medicare and Medicaid overpayments that was added as part of the Affordable Care Act (ACA).  The False Claims Act (FCA), as amended in 2009 by the Fraud Enforcement and Recovery Act (FERA), imposes liability on any person who “knowingly or improperly avoids or decreases an obligation to pay or transmit money or property to the government.”  Pursuant to the ACA, an “obligation” carrying liability under the FCA arises when the recipient of an overpayment fails to “report and return” it to the government within 60-days of the “date on which the overpayment was identified.”1


Security Standards Challenges are Universal

August 5, 2015


Last week National Security Agency (NSA) contractor Edward Snowden was back in the news when the White House officially responded to a petition requesting the Obama administration pardon Mr. Snowden for revealing widespread government surveillance on millions of Americans.  Instead of constructively addressing these issues, “Mr. Snowden's dangerous decision to steal and disclose classified information had severe consequences for the security of our country and the people who work day in and day out to protect it,” the White House response reads.1  The official response recommends that rather than disclose sensitive information to the press, Mr. Snowden should have taken the issue up with the proper U.S. government channels:  “Challenge it, speak out, and engage in a constructive act of protest.”


GAO Report Identifies Vulnerabilities in CMS’s Enrollment Process

July 29, 2015


To enroll in Medicare, providers and suppliers must use the Provider Enrollment, Chain and Ownership System (PECOS).  According to CMS, as of December 31, 2014, there were about 1.8 million healthcare providers and suppliers enrolled in PECOS and, in fiscal year 2014, Medicare paid $554 billion for healthcare and related services.1  Moreover, CMS estimates that roughly 10 percent of the monies paid were paid improperly.  Because of such high expenditures and potential for improper payments, the government is continuously looking closely at the program to minimize opportunities for fraud, waste and abuse.  As such, it should come as no surprise that the Government Accountability Office’s (GAO) recent June 2015 report:  Additional Actions Needed to Improve Eligibility Verification of Providers and Suppliers (http://www.gao.gov/products/GAO-15-448) (Report), has identified some areas of vulnerability in the CMS enrollment processes that could be contributing to the 10 percent of improper payments.


Doctors Dealing with the High-Deductible Dilemma

July 22, 2015


Hospitals and physician groups are carefully watching the growing popularity of high-deductible health plans (HDHP) which result in patients taking on more of a financial responsibility for their healthcare.  HDHPs and health savings accounts (HSA) are meant to incentivize consumers to manage the costs of their healthcare.  For 2015, the Internal Revenue Service’s definition of high-deductible is $1,300 for an individual and $2,600 for a family. Maximum out-of-pocket expenditures are $6,450 and $12,900 for individuals and families, respectively.  Many, but not all, HDHPs include preventive care such as annual physicals or immunizations, as a no-cost benefit.


A Busy Breaking News Week for Physicians

July 16, 2015


A few weeks ago, the healthcare industry, along with most Americans, was waiting for breaking news from the Supreme Court regarding the Affordable Care Act (ACA) and several other pending decisions. Since then, the Centers for Medicare and Medicaid Services (CMS) has been rolling out press releases faster than ever. Some of the breaking news like the recent compromise with the American Medical Association (AMA) on ICD-10 is final (or as final as CMS has ever been regarding anything dealing with ICD-10), whereas other announcements concern proposed rule changes. CMS rolled out several significant test balloons in the 800-page Proposed 2016 Medicare Physician Payment and Fee Schedule Rule. These include:


Modify, Not Eliminate, 2-Midnight Rule

July 8, 2015


The 2-midnight rule was effective October 1, 2013 and from the start it was contentious. The Centers for Medicare and Medicaid Services (CMS) has over the past few years attempted to explain, clarify and respond to the ongoing assault from the American Hospital Association (AHA) to eliminate the policy. A week before it was adopted, Rich Umbdenstock, President and CEO, AHA called the regulation fundamentally flawed.1 In the ensuing months, the AHA filed a lawsuit. The CMS offered various settlements and postponement of enforcing the rule.


Two Significant Healthcare Laws Celebrate Anniversaries Despite Their Initial and Ongoing Adversaries

July 1, 2015


On July 30, 1965, President Lyndon B. Johnson signed into law legislation that established the Medicare and Medicaid programs. For 50 years, these two programs have been protecting the health and well-being of millions of American families. Enacted under Title VIII of the Social Security Act, Congress created Medicare for Americans beginning at age 65. Medicare also authorized coverage for Americans who became disabled. The Affordable Care Act (ACA) commonly known as Obamacare, is a United States (U.S.) federal statute signed into law by President Barack Obama on March 23, 2010. The law provides health insurance to any U.S. citizen through newly formed State agencies called insurance exchanges. According to the White House, over 10 million Americans have signed up for coverage under the ACA statute. Both laws were not passed without brisk debates from adversaries lead by politicians, providers of care, and the populist.


False Claims Act and Kickback Cases Prompt New OIG Fraud Alert

June 17, 2015


The number of False Claims Act (FCA) cases predicated on violations of healthcare laws continues to grow as it has in recent years. The $2.3 billion in healthcare fraud recoveries in fiscal year (FY) 2014 marks five straight years the Department of Justice (DOJ) has recovered more than $2 billion in cases involving false claims against federal healthcare programs such as Medicare, Medicaid and TRICARE, the healthcare program for the military. From January 2009 through the end of the 2014 FY, the DOJ recovered $14.5 billion in federal healthcare dollars under the FCA. One area of growth has been FCA cases based on violations of Medicare and Medicaid Anti-Kickback and self-referral laws. The self-referral laws (also known as the Stark Law) generally prohibit hospitals or physicians from referring patients for certain “designated health services” to persons or entities with whom the hospital or physician has a financial relationship. In addition, the Anti-Kickback Statute (AKS) prohibits soliciting or receiving any remuneration in exchange for the purchase or lease of federally funded goods or services. With the increased enforcement under these laws and the growing return on investment for the government for prosecuting such cases, it should come to no surprise that the Office of Inspector General (OIG) has released yet another fraud alert, this time regarding medical directorships.


CMS Finalizes Rules for Medicare Shared Savings Program

June 10, 2015


On June 11th the Centers for Medicare & Medicaid Services (CMS) released the final Rules updating the Medicare Shared Savings Program to encourage the delivery of high-quality care for Medicare beneficiaries and build on the early successes of the program and of the Pioneer Accountable Care Organization (ACO) Model.  The revisions are intended to strike a balance between maintaining the program's rigorous requirements and making sure providers continue to participate.


New Medicare Data Available to Increase Transparency on Hospital And Physician Utilization

June 3, 2015


Perhaps the greatest support for expanded collection and reporting of health data comes from the Patient Protection and Affordable Care Act (ACA) signed into law on March 23, 2010.  The key provisions requiring more transparency of healthcare data are:


Medicare Recovery Audit Contractor Program A Costly Burden to Hospitals

May 27, 2015


The American Hospital Association (AHA) recently released the results from a September 2014 survey of the Medicare Recovery Audit Contractor (RAC) program.  The report, “The Real Cost of the Inefficient Medicare RAC Program" is based on responses from 402 hospitals that participated in the survey.  In addition, the AHA reviewed Fiscal Year 2013 RACTrac data submitted in all four quarters by 547 hospitals.


OIG: Practical Guidance for Health Care Governing Boards on Compliance Oversight

May 20, 2015


As the government continues to dedicate substantial resources to combat fraud and abuse in the healthcare industry, and the number of private whistleblower suits continues to increase, the need for a robust compliance program with appropriate board-level oversight is greater than ever.  On April 20, 2015, the Office of the Inspector General of the U.S. Department of Health and Human Resources (OIG), in collaboration with the American Health Lawyers Association, the Association of Healthcare Internal Auditors and the Health Care Compliance Association published Practical Guidance for Health Care Governing Boards on Compliance Oversight (Guidance) directed in particular at healthcare organizations’ boards of directors and trustees regarding compliance oversight.


The Tenth Amendment & Telehealth Expansion Opportunities: State-by-State within the United States

May 15, 2015


Healthcare is a global industry. We have medical devices and pharmaceuticals being developed in Europe and Asia.  We have coding and billing being performed in India, Philippines and other foreign countries. The rapid evolution of technology has given us treatments hardly conceivable ten years ago.  The Affordable Care Act (ACA) moved the United States forward in providing healthcare to all its citizens. Yet, many aspects of how that care is delivered and reimbursed are based on State regulations.


The Affordable Care Act Impact on Medicaid Programs

May 6, 2015


As of March 2015, twenty-eight states and the District of Columbia had implemented the expansion of Medicaid under the Affordable Care Act (ACA) to cover adults under age 65 with incomes up to 133 percent of the Federal Poverty Level.  There is no deadline for when a state must decide whether to expand Medicaid and states continue to consider their options.  The enrollment impact of the Medicaid expansion varies; some of these states had expanded coverage to parents and other adults at income levels above the level required under federal law before the ACA.  Many other states previously covered parents only at the minimum required income levels and often did not cover other adults without disabilities who are under age 65.


Provider-Based Departments are on the Radar

April 22, 2015


For the second time in six months, a hospital has settled a case over alleged violations of Centers for Medicare and Medicaid Services (CMS) provider-based regulations. Hospitals are vulnerable in this area because of the many technical requirements for provider-based status.


Point-of-Service Collections Benchmarking

April 15, 2015


The Association of Healthcare Access Management (NAHAM) promotes best practices, standards and subject matter expertise to their members to influence and promote high quality delivery of Patient Access Services.  In early January 2015, NAHAM released 22 standard patient access key performance indicators (KPIs) called the NAHAM AccessKeys®.  The AccessKeys are available to NAHAM members and provide a better way to track and measure the performance of patient access.  AccessKeys were created for six key areas: Collections, Conversions, Patient Experience, Process Failure and Resolution, Productivity and Quality.  Prior to the establishment of the NAHAM’s recognized standards, it was difficult to produce an accurate comparative benchmark because patient access departments lacked a level of standardization in terms of definitions and measurements in use at their facility.  The NAHAM AccessKeys definitions of what is or isn’t included in certain processes will further assist patient access departments in determining how well various functions are being performed in comparison to other hospitals.


April is National Workplace Violence Prevention Month

April 8, 2015


Healthcare and social service workers face a significant risk of job-related violence. The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.”1 According to the Bureau of Labor Statistics (BLS), 27 out of the 100 fatalities in healthcare and social service settings that occurred in 2013 were due to assaults and violent acts.2


Coverage and Reimbursement for Genetic Testing

April 1, 2015


There is an adage that things happen in three.  Whether they are good or bad luck, rare finds or everyday bargains, it seems that when something happens three times in a row, people tend to pay attention to it.  Angelina Jolie's announcement of her additional proactive surgery to prevent cancer based on the BRCA1 and BRCA2 genes identified through genetic tests was my recent number three.  The first occurrence happened the week before on a Park City ski lift when a young man identified himself as a biomedical researcher working for a Salt Lake City company that does BRCA testing.  The second occurrence was over the weekend when a friend shared her recent breast cancer diagnosis following a 12-month period in which both her mother and sister were also diagnosed.  Then the news broke about Jolie’s decision.  Within a span of ten days, breast cancer and genetic testing were staring me, and likely many consumers, providers and payers in the United States (U.S.), in the face.


It’s a Yellow Brick Road Journey to a Shared Nationwide Interoperability Roadmap

March 25, 2015


The Office of the National Coordinator for Health Information Technology (ONC) recently laid out their draft vision for a future health information technology (IT) ecosystem where electronic health information (EHR) is appropriately and readily available to empower consumers, support clinical decision-making, inform population and public health and value-based payment, and advance science.


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