Economy Indicators Stock Market Soared 58% since March 2008 Unemployment rate rose 9.8 to 10.2 % Leading indicators show recession bottoming out‘
Healthcare Reform Legislation on March 23, 2010 by President Obama Estimated cost of $938 billion over 10 years Key compromise: federal funds are not used for abortion services. Adds 16 million people to the Medicaid rolls Subsidizes private coverage for low- and middle-income people States and Attorney general challenges from Alabama, Florida, Nebraska, North Dakota, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Washington, Louisiana and Virginia.
Health Care Reform Pros PROSSocial welfare -- more Americans will have access to health insurance, includingpatients with preexisting conditions who could not get coverage previously.Primary care doctors and pediatricians who currently contract with lower-than-Medicare-rate insurers can see new Medicaid patients at Medicarereimbursement rates.Hospitals and the physicians who work in hospitals may receive more paymentfrom newly insured patients rather being unpaid for charity care.Potential new business opportunities exist for primary care doctors to practice ininner-city areas or locations where previously there were not many insuredpatients.More money will go toward training in medical schools to increase the number ofprimary care doctors.Business expansion is possible for doctors willing to hire more PAs and NPs tosee more patients.
Healthcare Reform Cons CONSMany say that the new budget cannot ultimately fund the healthcare reform.Money may have to come from additional taxes or some cuts to physicianpayments.A 3.8% tax will be levied on unearned income (ie, interest income and capitalgains) for individuals earning over $200,000 ($250,000 for married couples).Many doctors are in that category.For specialists, reimbursements for the newly insured Medicaid payments will notbe raised to Medicare levels.There is no tort reform provision, which will keep doctors practicing defensivemedicine.Cost-containment measures are not included.There are no incentives for patients to have accountability for their healthcareimprovement or to maintain wellness.
Healthcare trends Delay of primary and preventive care Increase of high deductible insurances People with high deductibles delaying payments BC/BS offering high deductible plans to its employees Increase in the number of bankruptcies from medical debt Increase utilization of ER Pending Medicare cuts (21.2%)
HITECH Act Purpose Of The HITECH Act "To improve the quality of our health care while lowering its costs, we will make the immediate investments necessary to ensure that, within five years, all of Americas medical records are computerized. This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests…But it just wont save billions of dollars and thousands of jobs; it will save lives by reducing the deadly but preventable medical errors that pervade our health- care system."
HITECH EMR Incentive Year Total 2011 $ 18,000 $ 12,000 $ 8,000 $ 4,000 $ 2,000 $ 44,000 2012 $ 18,000 $ 12,000 $ 8,000 $ 4,000 $ 42,000 2013 $ 15,000 $ 12,000 $ 8,000 $ 35,000 2014 $ 15,000 $ 12,000 $ 27,000 2015 $ 15,000 $ 15,000•Providers must be deemed to be “meaningful users” of EHR systems•Practices with multiple physicians will be eligible to receive incentive paymentsfor each provider.•Payments will be based on 75% of the correlating year’s Medicare andMedicaid charges.
HITECH Act - HIPAA Introduces patient notification of any unauthorized access, acquisition, or disclosure Define steps for breaches of information Number of patients Information exposed Report and retention requirements Business Associates increase liability and responsibility Patient Rights
HITECH Act - HIPAA Patient Rights Accounting of disclosure of PHI (Electronic records) Up to three years back Includes release for PTO Note: HIPAA allows for 6 years excluding PTO Restrict Access to PHI Must comply with patient’s request Allows patients to pay out of pocket for a health care item or service in full and to request that the claim not be submitted to the health plan. Note: Under present law patients can request restrictions but compliance to request is not required.
HITECH Act - Other Act permanently establishes Office of the National Coordinator for HIT (ONCHIT) Reinforces law protecting security and privacy of an individual’s health information Requires HHS to investigate complaints and impose fines where willful neglect exists Requires HHS to disclose in more detail how it resolves HIPAA privacy complaints Extends HIPAA rules to organizations that handle personal health information
HIPAA Changes HHS responsible for HIPAA Security Georgina Verdugo, HHS Civil Rights Director Maximum privacy right raised Civil fines raised from $25,000 to $1.5 million Effective Nov 30, 2009 Lack of knowledge not a plausible defense Enforcement authority granted to state attorneys general to enforce HIPAA
Fines and Penalties $15,000 per day: failure to provide timely access to the HHS Office of Inspector General (OIG) for audits, investigations, evaluations, or other statutory functions; $50,000 for each false record or statement: knowingly making, using, or causing to be made or used a false record or statement material to a false claim; $50,000 for each false statement, omission, or misrepresentation: knowingly making a false statement, omission, or misrepresentation on an enrollment application, bid, or contract; $50,000 for each order or prescription; ordering or prescribing items or services (including lab tests, drugs, durable medical equipment, etc.) during any period when the person ordering or prescribing has been excluded for participation in the program.
HIPAA 5010 Prerequisite for the implementation of ICD 10 Corrects the outdated transaction standard and enhance administrative data exchanges Includes four basic kinds of changes; front matter, technical, structural and data content improvements Note: HIPAA 5010 transactions go into effect in January 2012, Healthcare Reform will significantly change those transactions--and add new transactions--within just a few years.
HIPAA 5010 Initiatives to Consider ICD-10 – short term vs. long term CORE –Committee on Operating Rules and Efficiency. Through voluntary rules for payors, clearinghouses and providers around the exchange of eligibility information, CORE improves the usefulness of the eligibility transaction between payor and provider. Stimulus-Driven Electronic Health Records (EHRs) and Health Information Exchanges (HIEs)
HIPAA 5010 Additional Opportunities1. Practice Management System Upgrade vs. Replacement2. Re-examine Clearinghouse Utilization3. Revenue Cycle Re-engineering. Transactions that once seemed too challenging to implement should be reconsidered (real-time eligibility transaction and the electronic remittance advice).4. Transaction Exchange Infrastructure5. Quality Measure Reporting. Automated and widespread reporting of quality care and performance measures.6. Process Improvement (i.e. pre-admission, admissions and registration processes).
FERA, S. 386 Fraud Enforcement and Recovery Act of 2009, S. 386, (FERA) Signed into law May 20, 2009 Makes material changes to the civil False Claims Act (FCA) Primary tool used by the federal government to deter and sanction health care fraud
FERA Significant Changes Conspiracy. Includes Government subcontractors. Retention of Overpayments. Includes overpayments that may be knowingly and "improperly" retained/concealed. Expanded Whistleblower Protection. Extends protection from retaliation to contractors and agents. More Investigative Tools. DOJ can subpoena documents and depose witnesses before filing an FCA action. Allows the government to recover its costs from the defendant. Statute of Limitations. May be moved back to time of original third party (qui tam) complaint.
FERA Bottom Line Risk of Investigation and Liability Has Increased. Also, the cost of defense and settlement increases because defendants must pay the governments costs. Repayment Obligations Have Increased. Improper retention of an overpayment creates liability. Retaliation Exposure Has Increased. FERA expanded the non- retaliation provisions of the FCA to include independent contractors.
HEAT Health Care Fraud Prevention And Enforcement Action Team (HEAT) United States Department of Justice (DOJ) and the U.S. Department of Health & Human Services (HHS) team building upon and strengthen existing programs to combat fraud“, and "investing new resources and technology to prevent fraud, waste and abuse before it happens."
HEAT Actions Expansion of the Medicare Fraud Strike Force teams Improving data sharing between CMS and law enforcement Encouraging the American public to get involved Offering providers increased training and resources Strengthening program integrity activities related to Medicare Parts C (Medicare Advantage plans) and D (prescription drug coverage) compliance and enforcement
Recovery Audit Contractors (RAC) Medicare Modernization Act of 2003 established the Medicare Recovery Audit Contractor (RAC) The Tax Relief and Health Care Act of 2006, Section 302 makes program permanent By 2010, expansion to 50 state with 4 RACs New mechanism for detecting improper payments Duplicate payments Medical necessity and coding Fiscal intermediaries mistakes Payment based on a contingency fee
Red Flag Rule Regulations issued by the FTC Affects anyone providing services where the consumer is invoiced monthly or provides the consumer with a payment plan. Focuses on identity theft. Enforcement date to May 1, 2009. Modified Oct 20, 2009 Extended to Dec 1, 2010
Red Flag Requirements Develop and adopt policies and procedures Identify relevant red flags Develop/Identify procedures to detect red flags Define appropriate responses to red flags Perform periodic updating of the Program Administer the Program
The Genetic InformationNondiscrimination Act of 2008 (GINA) Applies to plan years beginning December 7, 2009 Prohibits collection of genetic information (i.e. family history) as part of wellness or health risk assessment if issues provides rewards New self-reporting and payment of excise tax if failure to comply with mandates
GINA Excise tax Amount of Tax. $100/day/per affected individual. Noncompliance Period. Begins on the day the failure first occurred and ends on the day the failure is corrected. If Discovered During Audit. $2,500 or the regular tax amount if discovered after the employer has received an IRS Notice of Examination If the failure is more than de minimis, $15,000 is substituted for $2,500. Maximum Tax for Unintentional Failures $500,000 or 10% of the aggregate amount paid No maximum on the amount of tax if intentional
ICD 10 Deadline October 1st, 2013 Basic reason for change ICD-9-CM is out of room. ICD 10 Benefits More accurately defined patient services More specific diagnosis and treatment information More comprehensive reporting of quality data More accurate payments for new procedures with fewer rejected claims
Comparison ICD9 vs. ICD 10 Issue ICD-9-CM ICD-10-CMVolume of codes approximately 13,600 approximately 120,000Composition of codes Mostly numeric, with E and V All codes are alphanumeric, codes alphanumeric. Valid codes beginning with a letter and with a of three, four, or five digits. mix of numbers and letters thereafter. Valid codes may have three, four, five, six or seven digits.Duplication of code sets Currently, only ICD-9-CM codes For a period of up to two years, are required . No mapping is systems will need to access both necessary. ICD-9-CM codes and ICD-10-CM codes as the country transitions from ICD-9-CM to ICD-10-CM. Mapping will be necessary so that equivalent codes can be found for issues of disease tracking, medical necessity edits and outcomes studies.
Document, Record, and DataManagement Organizations have a duty to preserve relevant evidence when litigation is pending or reasonably anticipated This duty can be satisfied by implementing litigation holds Demands to discontinue routine data destruction under an applicable document retention policy Knowledge of litigation or reasonable likelihood of litigation triggers the duty
Consequences of failing to preservedocuments can be severe Spoliation Adverse Inference Fines Dismissal of Case Obstruction of Justice
Basic Actions to follow Documentation is very important Documentation can and will most likely be used to show that the organization utilized their policy in good faith, and in a reasonable, consistent manner Develop Policies Follow policies Designate a responsible person to monitor the changes and implement as needed
Written Policies Not Enough Create and implement written policies and guidelines Establish your rights Policies must include sanctions Designate official to ensure compliance Time actions required and documentation Train employees Document Training Copies of lesson plans Attendance