This document summarizes a presentation on legislative updates related to usual, customary and reasonable charges given by Ed Norwood. It discusses how health plan profits increased in 2008-2009 despite the economic downturn. It also summarizes regulatory efforts by the DMHC to audit health plans and providers who lower payment rates or have frequent complaints about payment. The presentation urges providers to help identify underpayments and file complaints to trigger DMHC reviews. It maintains that cost-to-charge ratios alone do not satisfy rules for determining reasonable reimbursement.
Short Thesis on Community Health Systems (CYH)Aaron Tan
Rural hospitals are shutting down across the country. Combined with Community Health System's over-leverage and mismanagement, this will lead to the company testing its debt covenants and eventual bankruptcy - which street analysts are not fully pricing in.
"Compliance: What Every Coder Needs To Know!"ctrapp
This document discusses the history of compliance efforts in Medicare, including the establishment of programs to investigate fraud and abuse like the Medicare Integrity Program. It notes the increasing demand for healthcare and costs have led to a crackdown on fraud to protect the Medicare Trust Fund, which is projected to become insolvent if costs continue rising. Various entities like RACs, ZPICs, and OIG play a role in ensuring compliance in coding, billing and care.
Re-Evaluating Your Managed Care Revenue Improvement Opportunitieschriskalkhof
Within your span of control are:
1) Preparing strategically through internal/external assessments and developing contracting/pricing strategies.
2) Negotiating effectively to optimize reimbursement, payment rules, and contracts.
3) Integrating agreements into revenue management operations through the revenue cycle.
The document summarizes Maryland's fiscal year 2013 budget and priorities under Governor Martin O'Malley. It highlights job creation, education funding, health care expansion, crime reduction, and maintaining a balanced budget through spending cuts and limited tax increases on high earners. Over $3.6 billion is allocated to capital projects focused on education, health, transportation, and economic development to support an estimated 52,000 jobs.
The document discusses incentives for hospitals to adopt electronic health records (EHRs) under the American Recovery and Reinvestment Act (ARRA). Hospitals can receive up to $15.9 million in incentive payments over 4 years if they demonstrate meaningful use of certified EHR technology. They must meet requirements like using EHRs to exchange health information and submit clinical quality measures. Hospitals that do not show meaningful use by 2015 will face Medicare payment reductions. States can also receive grants to help hospitals finance EHR purchases through loan programs.
The document summarizes the funding model of the NSW Ambulance Service. It provides details on:
- The sources of funding for the NSW Ambulance Service which include government appropriation, transport fees, ambulance subscription schemes, and bulk agreements.
- Government funding has failed to keep pace with increasing demand for ambulance services, resulting in a decrease in the cost recovery of the Service.
- Non-direct government funding such as transport fees and subscription schemes decreased significantly between 1999/2000 and 2003/04.
The summary provides an overview of the 2014 annual report of the Hawaii Health Connector. It discusses challenges faced in the initial launch in 2013 that persisted through 2014 open enrollment. Enrollment did not meet expectations and operational issues were the focus of 2014. However, improvements were made to processes and technology. The Connector was able to preserve Hawaii's Prepaid Health Care Act of 1974 and integrate it with the Affordable Care Act requirements. Three economic models are presented projecting enrollment numbers, revenues, expenses and surplus/deficit for the years 2015-2024 under a base, low and high case. The base case projects the Connector becoming self-sustaining by 2022. The report examines the potential economic benefits to Hawaii
Short Thesis on Community Health Systems (CYH)Aaron Tan
Rural hospitals are shutting down across the country. Combined with Community Health System's over-leverage and mismanagement, this will lead to the company testing its debt covenants and eventual bankruptcy - which street analysts are not fully pricing in.
"Compliance: What Every Coder Needs To Know!"ctrapp
This document discusses the history of compliance efforts in Medicare, including the establishment of programs to investigate fraud and abuse like the Medicare Integrity Program. It notes the increasing demand for healthcare and costs have led to a crackdown on fraud to protect the Medicare Trust Fund, which is projected to become insolvent if costs continue rising. Various entities like RACs, ZPICs, and OIG play a role in ensuring compliance in coding, billing and care.
Re-Evaluating Your Managed Care Revenue Improvement Opportunitieschriskalkhof
Within your span of control are:
1) Preparing strategically through internal/external assessments and developing contracting/pricing strategies.
2) Negotiating effectively to optimize reimbursement, payment rules, and contracts.
3) Integrating agreements into revenue management operations through the revenue cycle.
The document summarizes Maryland's fiscal year 2013 budget and priorities under Governor Martin O'Malley. It highlights job creation, education funding, health care expansion, crime reduction, and maintaining a balanced budget through spending cuts and limited tax increases on high earners. Over $3.6 billion is allocated to capital projects focused on education, health, transportation, and economic development to support an estimated 52,000 jobs.
The document discusses incentives for hospitals to adopt electronic health records (EHRs) under the American Recovery and Reinvestment Act (ARRA). Hospitals can receive up to $15.9 million in incentive payments over 4 years if they demonstrate meaningful use of certified EHR technology. They must meet requirements like using EHRs to exchange health information and submit clinical quality measures. Hospitals that do not show meaningful use by 2015 will face Medicare payment reductions. States can also receive grants to help hospitals finance EHR purchases through loan programs.
The document summarizes the funding model of the NSW Ambulance Service. It provides details on:
- The sources of funding for the NSW Ambulance Service which include government appropriation, transport fees, ambulance subscription schemes, and bulk agreements.
- Government funding has failed to keep pace with increasing demand for ambulance services, resulting in a decrease in the cost recovery of the Service.
- Non-direct government funding such as transport fees and subscription schemes decreased significantly between 1999/2000 and 2003/04.
The summary provides an overview of the 2014 annual report of the Hawaii Health Connector. It discusses challenges faced in the initial launch in 2013 that persisted through 2014 open enrollment. Enrollment did not meet expectations and operational issues were the focus of 2014. However, improvements were made to processes and technology. The Connector was able to preserve Hawaii's Prepaid Health Care Act of 1974 and integrate it with the Affordable Care Act requirements. Three economic models are presented projecting enrollment numbers, revenues, expenses and surplus/deficit for the years 2015-2024 under a base, low and high case. The base case projects the Connector becoming self-sustaining by 2022. The report examines the potential economic benefits to Hawaii
This document provides information about filing individual income tax returns in Kansas for 2006. Some key points:
- The Kansas TeleFile program has been discontinued. Electronic filing options include WebFile and IRS e-File.
- Qualifying income limits for the food sales tax refund have increased. Refund amounts are $75 or $37 per exemption depending on income.
- New tax deductions and credits have been added, including donations to certain funds and long-term care insurance premiums.
- Filing requirements and who must file a Kansas tax return are outlined based on residency status and income levels. Standard deductions and exemptions are listed.
The document provides updates on various healthcare related topics including:
1) An OIG advisory opinion disapproving of proposed anesthesia arrangements with ASCs and approving a supermarket rewards program.
2) CMS announcing participants in the Independence at Home demonstration project and revising Medicare conditions of participation.
3) A large Medicare fraud takedown by the Strike Force involving over $452 million in fraudulent billing across seven cities.
This document summarizes a presentation given by Ben Hopkins of the Health Analysis Division to the International Microsimulation Association on December 2, 2021. The presentation discussed the methods used by the Congressional Budget Office (CBO) to construct synthetic firms in their health insurance microsimulation model HISIM2. Specifically, it described how CBO uses data from tax filings and health surveys to select traits like age, income, and health spending of synthetic coworkers for each individual modeled in HISIM2. This allows HISIM2 to realistically model employer decisions about offering health insurance based on the characteristics of their synthetic employee workforce.
Presentation by Alice Burns and Jaeger Nelson, analysts in CBO’s Budget Analysis Division and Macroeconomic Analysis Division, to the National Tax Association.
Technical claims brief se - lord justice jackson civil litigation costs - m...QBE European Operations
Lord Justice Jackson published a final report in January 2010 that made recommendations to reform civil litigation costs in England and Wales. The report found current costs to be excessive and disproportionate. It recommended substantial changes to personal injury claims as well as other areas of civil litigation. Implementation of the recommendations will occur in phases, with some changes potentially being made by the end of 2010 through amendments to civil procedure rules, while other recommendations requiring legislation may not be fully implemented until 2012. The recommendations include increasing damages amounts, implementing fixed costs for certain claims, making success fees and insurance premiums unrecoverable, and other process reforms. However, the report notes the recommendations face challenges and may not be fully realized as envisioned.
(1) The document discusses different scenarios states may face in their health insurance markets following the Supreme Court decision on the Affordable Care Act.
(2) It outlines options for states like expanding Medicaid only to 100% FPL instead of 138% or buying low-income residents into the insurance exchange.
(3) The document provides data on who would be affected by different state choices, including demographic characteristics and estimates of churn between Medicaid and subsidized exchange plans.
This document discusses the federal tax treatment of employer-provided electric vehicle charging as a fringe benefit. Currently, employers face uncertainty around whether providing complimentary or discounted workplace charging constitutes a taxable fringe benefit. The document examines if workplace charging could qualify for two potential exemptions: as a de minimis fringe benefit or a qualified transportation fringe benefit. It outlines factors the IRS may consider like the value and frequency of the benefit. The IRS has not provided explicit guidance on the tax treatment of workplace charging.
The document provides a summary of proposed rules and regulations from federal and New Jersey sources:
1) At the federal level, CMS has proposed rules around reporting and returning Medicare overpayments within 60 days of identification, looking back 10 years. Joint regulations were also released outlining summary of benefits and coverage standards.
2) In New Jersey, DOBI has proposed substantive changes to new PIP regulations, including distinguishing hospital outpatient facility fees from ASC fees. Legislation has also been proposed to prohibit health care facilities from discharging unused medications into sewer systems.
3) The Department of Banking and Insurance additionally proposed new managed care regulations regarding provider networks and agreements.
This document discusses challenges facing rural healthcare providers. It notes that 62 million patients rely on rural providers who face unique population, geographic, cultural and healthcare delivery challenges. Rural providers and patients are disproportionately dependent on federal programs like Medicare and Medicaid. Recent federal policies have enacted Medicare cuts that negatively impact rural hospitals. The document examines characteristics of rural hospitals that have closed since 2010 and potential factors contributing to closures. It also reviews characteristics of rural hospitals that have merged with other providers and whether mergers improved financial performance. The document advocates policy solutions to stabilize rural hospitals and ensure their future viability.
The Department of Health Services has 4 principal functions: overseeing behavioral health programs and operating the Arizona State Hospital; operating the State Health Laboratory; administering public and family health programs; and licensing health care and child care facilities. For FY 2013, its total budget is $1.88 billion from various state and federal funds. The document discusses the department's budgets, programs, and proposed changes for FY 2012 and FY 2013.
This document discusses key aspects of state health insurance exchanges and the Affordable Care Act. It provides an overview of how exchanges are meant to increase access to affordable health insurance coverage by organizing the market and providing subsidies. It also addresses the Supreme Court decision on Medicaid expansion, costs to states of not participating, and new questions states may consider around expanding coverage and subsidizing premiums. Data on current insurance coverage and estimated subsidy amounts by income level are presented.
CBO’s work follows processes specified in the Congressional Budget and Impoundment Control Act of 1974 (which established the agency) or developed by the agency in concert with the House and Senate Budget Committees and the Congressional leadership.
CBO is strictly nonpartisan; conducts objective, impartial analysis; and hires its employees solely on the basis of professional competence, without regard to political affiliation. The agency does not make policy recommendations, and each report and cost estimate summarizes the methodology underlying the analysis.
Presentation by Keith Hall, CBO Director, at the 10th Annual Meeting of the OECD Network of Parliamentary Budget Officials and Independent Fiscal Institutions.
The document outlines key aspects of valuing medical laboratories, including:
- What pathology is and the different types (clinical and anatomic)
- How laboratories generate revenue through billing payors like Medicare and insurance companies for procedures coded using CPT codes
- Details of the Medicare reimbursement process and fee schedules that determine payment amounts for laboratory services
- Sources of revenue for laboratories including referrals from physician offices and hospitals
- Factors that influence laboratory revenues such as Medicare spending trends and reimbursement rates
The document discusses the challenges self-employed individuals face in obtaining health insurance. It notes that one-third of self-employed individuals are currently uninsured due to the high cost of coverage. Between 2005-2008, the percentage of small businesses offering health insurance to employees dropped significantly from 46% to 18.6% as costs rose. The document then examines provisions of the Affordable Care Act that could help or hinder the self-employed, such as the creation of insurance exchanges but insufficient immediate cost savings. It argues that reform does not do enough to lower health care costs for small businesses and the self-employed.
The document discusses healthcare reform and what it means for providers. It notes rising healthcare costs and quality issues that reform aims to address. Key points of reform include accountable care organizations, value-based purchasing, bundled payments, and shared savings models that shift risk to providers. Reform goals include reducing readmissions and improving care coordination. The document outlines milestones and changes coming in 2010-2014, including payment cuts for high readmission rates. It discusses technology needs to manage reform including data analytics, EMRs, and outcomes reporting.
This document summarizes a session from the 2011 SMSF National Conference about what to expect when the Australian Taxation Office (ATO) audits self-managed superannuation funds (SMSFs). The ATO doubled the number of SMSF audits it conducted in 2011 and identified more funds as non-compliant. Top areas the ATO will target include loans to members or relatives, breaches of in-house asset rules, and administrative issues. The document provides examples of how the ATO determines if a loan is legitimate or an early release benefit, and when it may accept an enforceable undertaking for non-compliance issues.
Webinar: “Provider Relief Fund Payments – What We Know, What We Don’t Know, W...PYA, P.C.
The document provides information on the $100 billion Provider Relief Fund established by the CARES Act to reimburse healthcare providers for expenses or lost revenues attributable to COVID-19. It summarizes that $30 billion has been distributed based on providers' 2019 Medicare billings, with no repayment obligation. It outlines the attestation process to accept funds within 30 days and confirms that providers must comply with terms including using funds only for COVID-19 care and not balance billing uninsured patients. The document advises on accounting, compliance, and tax implications of the relief funds.
The American Nurses Association (ANA) is the largest nursing organization in the United States that represents the interests of over 3.1 million registered nurses. The ANA works to advance the nursing profession by promoting high nursing standards, protecting nurses' workplace rights, and advocating for nursing and healthcare issues. As the full-service professional organization for nurses, the ANA provides members with professional development resources, publications to stay informed, and opportunities to influence and guide the nursing profession.
The Robert Wood Johnson Foundation Executive Nurse Fellows Program
Linda Cronenwett, PhD, RN, FAAN
Co-Director
Distinguished Professor and Former Dean,
UNC-Chapel Hill School of Nursing
Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013
The document summarizes a meeting between ARNBC and BC nurses to discuss engaging nurses in policy discussions and identifying policy priorities. It outlines commitments to transparency, inclusion, and open consultation. It acknowledges tensions between regulatory colleges advocating for public safety and unions advocating for nurses' working conditions, and the need for a provincial nursing policy voice. Gaps in national nursing representation and health policy involvement are identified. The accomplishments of ARNBC in establishing itself are reviewed, along with a timeline of nursing organizations in BC. Leaving a legacy for students and connecting to international colleagues are discussed.
This document provides information about filing individual income tax returns in Kansas for 2006. Some key points:
- The Kansas TeleFile program has been discontinued. Electronic filing options include WebFile and IRS e-File.
- Qualifying income limits for the food sales tax refund have increased. Refund amounts are $75 or $37 per exemption depending on income.
- New tax deductions and credits have been added, including donations to certain funds and long-term care insurance premiums.
- Filing requirements and who must file a Kansas tax return are outlined based on residency status and income levels. Standard deductions and exemptions are listed.
The document provides updates on various healthcare related topics including:
1) An OIG advisory opinion disapproving of proposed anesthesia arrangements with ASCs and approving a supermarket rewards program.
2) CMS announcing participants in the Independence at Home demonstration project and revising Medicare conditions of participation.
3) A large Medicare fraud takedown by the Strike Force involving over $452 million in fraudulent billing across seven cities.
This document summarizes a presentation given by Ben Hopkins of the Health Analysis Division to the International Microsimulation Association on December 2, 2021. The presentation discussed the methods used by the Congressional Budget Office (CBO) to construct synthetic firms in their health insurance microsimulation model HISIM2. Specifically, it described how CBO uses data from tax filings and health surveys to select traits like age, income, and health spending of synthetic coworkers for each individual modeled in HISIM2. This allows HISIM2 to realistically model employer decisions about offering health insurance based on the characteristics of their synthetic employee workforce.
Presentation by Alice Burns and Jaeger Nelson, analysts in CBO’s Budget Analysis Division and Macroeconomic Analysis Division, to the National Tax Association.
Technical claims brief se - lord justice jackson civil litigation costs - m...QBE European Operations
Lord Justice Jackson published a final report in January 2010 that made recommendations to reform civil litigation costs in England and Wales. The report found current costs to be excessive and disproportionate. It recommended substantial changes to personal injury claims as well as other areas of civil litigation. Implementation of the recommendations will occur in phases, with some changes potentially being made by the end of 2010 through amendments to civil procedure rules, while other recommendations requiring legislation may not be fully implemented until 2012. The recommendations include increasing damages amounts, implementing fixed costs for certain claims, making success fees and insurance premiums unrecoverable, and other process reforms. However, the report notes the recommendations face challenges and may not be fully realized as envisioned.
(1) The document discusses different scenarios states may face in their health insurance markets following the Supreme Court decision on the Affordable Care Act.
(2) It outlines options for states like expanding Medicaid only to 100% FPL instead of 138% or buying low-income residents into the insurance exchange.
(3) The document provides data on who would be affected by different state choices, including demographic characteristics and estimates of churn between Medicaid and subsidized exchange plans.
This document discusses the federal tax treatment of employer-provided electric vehicle charging as a fringe benefit. Currently, employers face uncertainty around whether providing complimentary or discounted workplace charging constitutes a taxable fringe benefit. The document examines if workplace charging could qualify for two potential exemptions: as a de minimis fringe benefit or a qualified transportation fringe benefit. It outlines factors the IRS may consider like the value and frequency of the benefit. The IRS has not provided explicit guidance on the tax treatment of workplace charging.
The document provides a summary of proposed rules and regulations from federal and New Jersey sources:
1) At the federal level, CMS has proposed rules around reporting and returning Medicare overpayments within 60 days of identification, looking back 10 years. Joint regulations were also released outlining summary of benefits and coverage standards.
2) In New Jersey, DOBI has proposed substantive changes to new PIP regulations, including distinguishing hospital outpatient facility fees from ASC fees. Legislation has also been proposed to prohibit health care facilities from discharging unused medications into sewer systems.
3) The Department of Banking and Insurance additionally proposed new managed care regulations regarding provider networks and agreements.
This document discusses challenges facing rural healthcare providers. It notes that 62 million patients rely on rural providers who face unique population, geographic, cultural and healthcare delivery challenges. Rural providers and patients are disproportionately dependent on federal programs like Medicare and Medicaid. Recent federal policies have enacted Medicare cuts that negatively impact rural hospitals. The document examines characteristics of rural hospitals that have closed since 2010 and potential factors contributing to closures. It also reviews characteristics of rural hospitals that have merged with other providers and whether mergers improved financial performance. The document advocates policy solutions to stabilize rural hospitals and ensure their future viability.
The Department of Health Services has 4 principal functions: overseeing behavioral health programs and operating the Arizona State Hospital; operating the State Health Laboratory; administering public and family health programs; and licensing health care and child care facilities. For FY 2013, its total budget is $1.88 billion from various state and federal funds. The document discusses the department's budgets, programs, and proposed changes for FY 2012 and FY 2013.
This document discusses key aspects of state health insurance exchanges and the Affordable Care Act. It provides an overview of how exchanges are meant to increase access to affordable health insurance coverage by organizing the market and providing subsidies. It also addresses the Supreme Court decision on Medicaid expansion, costs to states of not participating, and new questions states may consider around expanding coverage and subsidizing premiums. Data on current insurance coverage and estimated subsidy amounts by income level are presented.
CBO’s work follows processes specified in the Congressional Budget and Impoundment Control Act of 1974 (which established the agency) or developed by the agency in concert with the House and Senate Budget Committees and the Congressional leadership.
CBO is strictly nonpartisan; conducts objective, impartial analysis; and hires its employees solely on the basis of professional competence, without regard to political affiliation. The agency does not make policy recommendations, and each report and cost estimate summarizes the methodology underlying the analysis.
Presentation by Keith Hall, CBO Director, at the 10th Annual Meeting of the OECD Network of Parliamentary Budget Officials and Independent Fiscal Institutions.
The document outlines key aspects of valuing medical laboratories, including:
- What pathology is and the different types (clinical and anatomic)
- How laboratories generate revenue through billing payors like Medicare and insurance companies for procedures coded using CPT codes
- Details of the Medicare reimbursement process and fee schedules that determine payment amounts for laboratory services
- Sources of revenue for laboratories including referrals from physician offices and hospitals
- Factors that influence laboratory revenues such as Medicare spending trends and reimbursement rates
The document discusses the challenges self-employed individuals face in obtaining health insurance. It notes that one-third of self-employed individuals are currently uninsured due to the high cost of coverage. Between 2005-2008, the percentage of small businesses offering health insurance to employees dropped significantly from 46% to 18.6% as costs rose. The document then examines provisions of the Affordable Care Act that could help or hinder the self-employed, such as the creation of insurance exchanges but insufficient immediate cost savings. It argues that reform does not do enough to lower health care costs for small businesses and the self-employed.
The document discusses healthcare reform and what it means for providers. It notes rising healthcare costs and quality issues that reform aims to address. Key points of reform include accountable care organizations, value-based purchasing, bundled payments, and shared savings models that shift risk to providers. Reform goals include reducing readmissions and improving care coordination. The document outlines milestones and changes coming in 2010-2014, including payment cuts for high readmission rates. It discusses technology needs to manage reform including data analytics, EMRs, and outcomes reporting.
This document summarizes a session from the 2011 SMSF National Conference about what to expect when the Australian Taxation Office (ATO) audits self-managed superannuation funds (SMSFs). The ATO doubled the number of SMSF audits it conducted in 2011 and identified more funds as non-compliant. Top areas the ATO will target include loans to members or relatives, breaches of in-house asset rules, and administrative issues. The document provides examples of how the ATO determines if a loan is legitimate or an early release benefit, and when it may accept an enforceable undertaking for non-compliance issues.
Webinar: “Provider Relief Fund Payments – What We Know, What We Don’t Know, W...PYA, P.C.
The document provides information on the $100 billion Provider Relief Fund established by the CARES Act to reimburse healthcare providers for expenses or lost revenues attributable to COVID-19. It summarizes that $30 billion has been distributed based on providers' 2019 Medicare billings, with no repayment obligation. It outlines the attestation process to accept funds within 30 days and confirms that providers must comply with terms including using funds only for COVID-19 care and not balance billing uninsured patients. The document advises on accounting, compliance, and tax implications of the relief funds.
The American Nurses Association (ANA) is the largest nursing organization in the United States that represents the interests of over 3.1 million registered nurses. The ANA works to advance the nursing profession by promoting high nursing standards, protecting nurses' workplace rights, and advocating for nursing and healthcare issues. As the full-service professional organization for nurses, the ANA provides members with professional development resources, publications to stay informed, and opportunities to influence and guide the nursing profession.
The Robert Wood Johnson Foundation Executive Nurse Fellows Program
Linda Cronenwett, PhD, RN, FAAN
Co-Director
Distinguished Professor and Former Dean,
UNC-Chapel Hill School of Nursing
Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013
The document summarizes a meeting between ARNBC and BC nurses to discuss engaging nurses in policy discussions and identifying policy priorities. It outlines commitments to transparency, inclusion, and open consultation. It acknowledges tensions between regulatory colleges advocating for public safety and unions advocating for nurses' working conditions, and the need for a provincial nursing policy voice. Gaps in national nursing representation and health policy involvement are identified. The accomplishments of ARNBC in establishing itself are reviewed, along with a timeline of nursing organizations in BC. Leaving a legacy for students and connecting to international colleagues are discussed.
Make Your Voice Heard: A Beginner's Guide to Lobbying (Advocating) to Congres...Matthew Taber, M.S.
Learn how to lobby (advocate) Congress for your physician (pediatrician, internist, family practitioner, gynecologist, etc), nurse, medical practice (primary care, specialty, dental, etc), and hospital. In this video, you will learn the following:
What is Lobbying (advocacy)
The make up of the U.S. Congress
Identification of Congressional Healthcare Committees
Identification of Nurses and Physicians in Congress
The Anatomy of a Congressional Office
The Anatomy of a Congressional Committee
The Lobbying (Advocacy) Process
Please visit http://medicalaccessusa.com or http://medicalaccessforamerica.com for more information
The Alliance to Reduce Disparities in Diabetes
http://ardd.sph.umich.edu/
The Alliance is working to improve communication between patients and health care providers. Effective communication among providers, patients and their family members is a critical component of efforts to promote optimal care outcomes, enhance prevention and management of diabetes and reduce disparities in care.
Driving APRN Policy: A Legislative Success
James LaVelle Dickens, DNP, FNP-C, FAANP
Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013
Nurses can affect policy outcomes through political involvement and exercising influence in various areas like the workplace, community, and government. While nurses are respected professionals interested in others' welfare, they often lack knowledge of the political process and do not address larger issues due to workload and misunderstanding how to influence policy. For nurses to gain power and political influence, they must educate themselves, develop leadership skills, and take collective action. However, structural constraints like blocked opportunities and tokenism have historically limited women's influence due to existing power imbalances.
1. Nurses can have a significant impact on health systems through decisions made in practice and by driving transformational change in delivery of services from policy to practice.
2. Key priority areas for nurses include adoption of digital technologies, demonstrating quality care through a holistic and evidence-based approach, and developing systems leadership.
3. Nurses must develop personal and organizational resilience by maintaining their own health, improving skills, and making strong networks across health systems to optimize their contributions at all levels of health policy and services.
Nursing Leaders influencing politics and acting as patient advocatesMarian Mj
This document discusses politics, economics, and collective bargaining in human services. It covers several key points:
1) Politics exists because resources are limited and some people have more power than others. Nurses can influence various areas including the workplace, community, professional organizations, and government.
2) Nurses advocate for patients by ensuring their rights are protected, they are informed and involved in their care, and their needs are communicated.
3) Collective bargaining allows employees to negotiate wages, benefits, and working conditions as a group through a union. It can benefit workers but may also reduce individual flexibility and decision making power. Managers must understand labor laws and represent both worker and organizational concerns during unionization.
The document describes a medieval model called the Wheel of Life that illustrates the emotions experienced during periods of change. The Wheel of Life depicts four positions - happiness, loss, suffering, and hope. It is used to explain that people naturally experience anxiety, sadness and stress when changes occur but can regain optimism and contentment by successfully working through the transition. The document also outlines several types of changes, common reasons for resisting change, and a six step process for managing change.
Care of Sickle Cell Disease Patients: Process Improvement & Change with NursesTosin Ola-Weissmann
The document discusses implementing a Sickle Cell Vulnerability Assessment (SCVA) to improve care for sickle cell disease patients. It notes disparities in care for this vulnerable population and cites regulatory drivers and benchmarks supporting standardized assessment. A proposed SCVA methodology would assess medical history, vulnerabilities, and pain for individualized care plans. Implementing the SCVA using Lewin's change model and PDCA cycles is outlined over six weeks, with strategies including staff education and surveys to evaluate outcomes.
Sharon Pearce provides an overview of political lobbying for nurses. She discusses that lobbying involves educating legislators about issues in order to influence their thinking. The most effective types of communication are constituent meetings, calls, and personal letters. It is important to lobby before, during, and after legislative sessions by building relationships with legislators and their staff based on trust and being an expert on issues. Nurses can lobby wherever opportunities arise, including socially and in their districts. The goal is to advocate for the nursing profession and influence the legislative process through political involvement.
This document discusses the problems caused by overcrowding and inadequate nurse staffing in healthcare institutions, and proposes solutions to address these issues. Specifically, it notes that overcrowding leads to dangerous nurse workloads and compromised patient care. It recommends legislating nurse-patient ratios and implementing dynamic staffing models determined by nursing expertise as ways to match patient needs with appropriate staffing levels. The document advocates engaging nurses in care decisions at all levels and enforcing accountability to ensure staffing supports safe, quality patient care.
Nursing Informatics and Healthcare Policyawalker625
This document discusses a pre-conference workshop on nursing informatics and healthcare policy. It provides an agenda and introduces the thought leaders who will speak, including Amy Walker. Walker polls attendees on how policy correlates to various nursing issues. Her biography outlines her experience in nursing leadership, informatics, consulting, and entrepreneurship. The workshop will cover creating public policy, the goals of being involved in policy, and strategies for nurses to exercise influence, communicate, educate and support policy decision making.
This document discusses nurses' involvement in politics through various levels of participation. It describes how Florence Nightingale effectively influenced British parliament through political activism. There are three levels of political involvement for nurses: as citizens through voting, speaking out, and joining organizations; as activists by contacting officials, fundraising, and lobbying; and as politicians by running for office or seeking appointments. The document argues that nurses should be politically active to influence their profession's future and develop leadership skills.
The document discusses power, politics, and influence in nursing. It begins with objectives and outlines different topics that will be covered, including power, types of power, empowerment, developing a powerful image, and personal power strategies. Nurses must be skilled in exercising power to shape the future of healthcare. Power is the ability to influence others to achieve goals. Nurses regularly exercise power through patient teaching and coaching colleagues. Empowerment involves sharing power with others to help them make decisions. Developing a powerful self-image and strong communication, networking, and mentoring skills can help nurses effectively exercise power.
Collective bargaining is a process of negotiations between employers and employee representatives, usually unions, to determine working conditions and terms of employment. It aims to reach binding agreements on wages, hours, benefits, grievance procedures, and other aspects of work. The document discusses the history and objectives of collective bargaining, how it works, advantages and disadvantages, and its role in the nursing profession specifically. It provides definitions of key terms, the differences between professional associations and unions, and factors that influence successful negotiations.
This document summarizes a regulatory review presentation on home health and hospice issues. Key points include:
- Medicare has four jurisdictions for home health and hospice administrative contractors.
- Providers need to stay up to date with contractor instructions by signing up for newsletters.
- New rules assign providers a screening level of limited, moderate or high risk for fraud based on their category.
- The hospice benefit policy manual and conditions of participation were updated. Hospices received new comparative billing reports to examine their practices.
This report provides an overview of key provisions of the two separate comprehensive health reform bills passed by the five committees of jurisdiction in the U.S. Congress: the Finance Committee and the Health, Education, Labor, and Pensions (HELP) Committee of the Senate, and the Ways and Means, Education and Labor, and Energy and Commerce committees of the House of Representatives. While the general frameworks of the bills are very similar—all bills include provisions intended to improve and expand coverage and all would create a comprehensive and coherent strategy for improving health care quality—they differ in a few key respects. Most important, the Senate Finance Committee bill does not include a public plan option or a requirement that employers offer coverage, nor does it reform for more than one year Medicare’s formula for setting physician fees; the House bill includes all of these features.
Clermont County 2018 Horan Renewal Update - Commissioners PresentationClermont County, Ohio
The document provides an agenda and updates on Clermont County's 2018 benefits renewal. It summarizes 2015-2016 financials and claims data, provides 2017 financials year-to-date, and projects 2018 medical and dental renewals. UHC and Humana were selected as finalists for medical based on cost and plan details. UHC offered higher pharmacy rebates and potential savings from plan changes. Dental was projected to be flat, with DCP selected over MetLife due to network match. Other benefits were noted to be under rate guarantees.
The document discusses the history and future of "doc fixes" - legislative actions to prevent cuts to Medicare physician payments resulting from the Sustainable Growth Rate (SGR) formula. It notes that while the SGR failed to control costs, doc fixes have led to over $165 billion in deficit reduction through offsets. It describes the bipartisan "Tricommittee" reform package and proposes a "PREP Plan" to permanently replace SGR with value-based payments while fully offsetting costs through delivery system and beneficiary reforms estimated to save over $200 billion.
Financial Planning In Healthcare PowerPoint Presentation Slides SlideTeam
This complete deck is oriented to make sure you do not lag in your presentations. Our creatively crafted slides come with apt research and planning. This exclusive deck with fourtythree slides is here to help you to strategize, plan, analyse, or segment the topic with clear understanding and apprehension. Utilize ready to use presentation slides on Financial Planning In Healthcare PowerPoint Presentation Slides with all sorts of editable templates, charts and graphs, overviews, analysis templates. It is usable for marking important decisions and covering critical issues. Display and present all possible kinds of underlying nuances, progress factors for an all inclusive presentation for the teams. This presentation deck can be used by all professionals, managers, individuals, internal external teams involved in any company organization.
EMR implementation: Money Maker or Bust?
Purpose:
To identify whether EHR implementation will end up costing financially more than it benefits
To identify the recipients of any costs or savings
2019 inpatient prospective payment system final rule key pointsBESLER
The 2019 Hospital Inpatient Prospective Payment System (IPPS) Final Rule has been issued and changes are on the way that can affect your organization’s Medicare reimbursement.
As part of our commitment to help protect and enhance your Medicare revenue, we’ve developed this expert analysis of the FY 2019 IPPS Final Rule to quickly give you insight into the most important changes.
CBO reviewed possible changes to the Department of Defense’s Military Health System, analyzing the effects of those changes on the federal budget, the quality of military health care, and preparedness for wartime missions.
Presentation by Carla Tighe Murray, a senior analyst with CBO’s National Security Division, at the 93rd annual conference of the Western Economic Association.
This document summarizes key information about health care spending and coverage in the United States. It shows that most health spending goes to hospital care, physician services, and prescription drugs. It is financed through private insurance, Medicare, Medicaid and other payers. The US spends a higher percentage of GDP on health care than other countries. The Affordable Care Act expanded coverage through reforms like the individual mandate, Medicaid expansion and subsidies. Repealing the ACA could increase the number of uninsured by over 20 million and add $150-1.75 trillion to the federal deficit over 10 years. Partial repeal options could also have significant costs depending on the specific provisions changed or delayed.
The document discusses expanding private disability insurance (PDI) in Australia to reduce the economic burden on the National Disability Insurance Scheme (NDIS). Currently, PDI coverage is limited and most disability support comes from government programs. The modelling study examines how financial incentives for PDI, similar to incentives for private health insurance, could increase PDI uptake and generate savings for both government programs and private insurers. The findings suggest that with appropriate premiums and rebates, expanded PDI coverage could save the government $8.5 billion over 5 years while reducing reliance on the NDIS and Disability Support Pension.
This document discusses 5 target areas that Recovery Audit Contractors (RACs) are focusing on:
1. CMS has delayed the Medicaid RAC program implementation deadline to allow more state preparation.
2. RACs aim to detect and correct past improper Medicare payments to prevent future issues. They can review claims back 3 years and recover contingency fees from identified overpayments.
3. RACs were referred few potential fraud cases due to lack of incentive from contingency fees.
4. Providers should review documentation, coding, billing practices and educate staff to prevent RAC overpayment findings.
5. Common RAC focus areas include IV hydration coding, therapy evaluation codes, radiology billing, and Ne
For an in-depth explanation of the nuts and bolts, read KMB's CFTC Whistleblower Practice Guide, written by Katz, Marshall & Banks partners Lisa J. Banks and Michael A. Filoromo. Recently updated with information regarding the CFTC’s FY2019 enforcement actions and sanction totals, the Guide provides a comprehensive and up-to-date explanation of the law and valuable best practices for CFTC whistleblowers and their counsel, including preparing an effective “tip,” cooperating in a CFTC investigation and claiming a whistleblower reward. Specifically the Guide reviews the CFTC's new set of rules implemented in 2017, and how they have enhanced the review process to ensure greater transparency and provide more options for whistleblowers to contest preliminary award determinations. It also explains the legal protections that CFTC whistleblowers have against retaliation.
Chapter 2 Billing and Coding for Health ServicesLEARNING OBJEC.docxketurahhazelhurst
This document provides an overview of the revenue cycle process for healthcare organizations, with a focus on coding and billing. It describes the key stages of the revenue cycle, including registration, medical documentation and coding, charge capture, claims generation and submission, and payment collection. Accurate coding of diagnoses and procedures using ICD-9 and HCPCS codes is essential for healthcare organizations to generate claims and receive appropriate payments from payers like Medicare. The document also provides examples of top diagnosis codes, procedures codes, and DRG reimbursement groups reported to Medicare.
News Flash – On June 18, 2010, the Office of the National Co.docxhenrymartin15260
News Flash – On June 18, 2010, the Office of the National Coordinator for Health Information
Technology (ONC) issued a final rule to establish a temporary certification program for electronic health
record (EHR) technology. To see the press release related to this rule, visit
http://www.hhs.gov/news/press/2010pres/06/20100618d.html on the Internet.
MLN Matters® Number: SE1022 Related Change Request (CR) #: N/A
Related CR Release Date: N/A Effective Date: N/A
Related CR Transmittal #: N/A Implementation Date: N/A
Medical Record Retention and Media Formats for Medical Records
Provider Types Affected
This is an informational article for physicians, non-physician practitioners,
suppliers, and providers submitting claims to Medicare contractors (carriers, fiscal
intermediaries (FIs), and Medicare Administrative Contractors (MAC)) for services
provided to Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
This Special Edition is informational in nature. There are no additions or changes
to current policies and procedures.
CAUTION – What You Need to Know
This article provides guidance for physicians, suppliers, and providers on record
retention timeframes.
GO – What You Need to Do
Review the information in this article and ensure that you are in compliance. Be
sure to inform your staff.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other
policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to
review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
Page 1 of 3
http://www.hhs.gov/news/press/2010pres/06/20100618d.html
MLN Matters® Number: SE1022 Related Change Request Number: N/A
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to
statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either
the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement
of their contents.
Page 2 of 3
Retention Periods
State laws generally govern how long medical records are to be retained.
However, the Health Insurance Portability and Accountability Act (HIPAA) of 1996
(HIPAA) administrative simplification rules require a covered entity, such as a
physician billing Medicare, to retain required documentation for six years from
the date of its creation or the date when it last was in effect, whichever is
later. HIPAA requ.
Katz, Marshall & Banks partner Lisa Banks has published an updated edition of the CFTC Whistleblower Practice Guide. The guide provides an in-depth look at the legal protections afforded to commodity futures whistleblowers and best practices for CFTC whistleblowers to prepare effective tips, cooperate with a CFTC investigation and claim a whistleblower award. Established by the Dodd-Frank Act, the Commodity Futures Trading Commission's (CFTC) Whistleblower Program protects whistleblowers from retaliation and also provides them with incentives for reporting fraud among entities involved in commodity futures trading. Recently updated with the latest legal developments and information regarding the CFTC's FY2016 enforcement actions and awards, this guide provides readers with a comprehensive, up-to-date explanation of existing law and valuable insights for CFTC whistleblowers and their counsel.
Money Regulation In Healthcare PowerPoint Presentation Slides SlideTeam
Presenting this set of slides with name - Money Regulation In Healthcare Powerpoint Presentation Slides. Enhance your audiences knowledge with this well researched complete deck. Showcase all the important features of the deck with perfect visuals. This deck comprises of total of fourty one slides with each slide explained in detail. Each template comprises of professional diagrams and layouts. Our professional PowerPoint experts have also included icons, graphs and charts for your convenience. All you have to do is DOWNLOAD the deck. Make changes as per the requirement. Yes, these PPT slides are completely customizable. Edit the colour, text and font size. Add or delete the content from the slide. And leave your audience awestruck with the professionally designed Money Regulation In Healthcare Powerpoint Presentation Slides complete deck.
Write a response to each discussionTaylor 10.1Top of Form.docxMelvinaLeepercy
Write a response to each discussion
Taylor 10.1
Top of Form
The American Recovery and Reinvestment Act of 2009 also known as (ARRA) signed into law by President Barack Obama on February 17, 2009. It was created to provide a stimulus to the US economy in the wake of the economic downturn. The incentives were 1. electronic health records initiation, 2. electronic prescribing program, and 4. ICD-10 codes Baker & Baker (2014). Eligible hospitals may receive a $2,000,000 base amount payment and related payments that span over a 4-year period. If a hospital did not adopt by 2015, it faced a penalty. The physician incentive includes a maximum payment in year 1, then decreasing by a percentage every year thereafter.
Bottom of Form
Pick 10.1
Top of Form
The American Recovery and Reinvestment Act (ARRA) was created in 2009 as a $789 billion stimulus package to create and save jobs (Steinbrook, 2009). ARRA
has three adoption expectations: electronic health records initiation, electronic prescribing program, and ICD-10 codes. An eligible hospital can receive a $2,000,000 base amount payment plus discharge-related payments that span a four-year period (Baker &
Baker, 2014). Each physician can also receive incentives, but they must be a “meaningful user”. The maximum amount a physician can receive decreases each year so the sooner the physician becomes a meaningful EHR user the more money they receive (Steinbrook, 2009).
For healthcare, the ARRA created the Health Information Technology for Economic and Clinical Health Act (HITECH).
When my organization implemented the HIT, there are a lot of costs associated with it. The were the initial cost of implementation to purchase the program, hiring and training of IT employees as well as training of staff. While there were incentives to implement the HIT as well as cost reductions in other areas, the overall cost was greater. There are other incentives to implementation that just cost though.
Heard 10.1
Top of Form
Under the Medicare program eligible hospitals receive payments. The incentive payments are based upon hospital services and are given the hospital and their physicians must be a "meaningful electronic health records (EHR) user" (Baker, 2014). Incorporating this system will require staff training and new equipment.
There are three adoption deadlines for electronic health records:
- Electronic health records initiated by the HITECH Act initiative
- Electronic prescribing (eRx) program
- ICD – 10 Codes
Hospital incentives include eligibility for a $2,000,000 base payment, while physician incentives are based on the determination of services rendered and these hospital Medicare program incentive payments span a four-year period.
The HITECH program provides approximately 17 billion dollars in incentive monies for hospitals and physicians. Under HIT, specifically, health care professionals must adopt a certified EHR and use it to achieve objectives to quality for Medicare and Medicaid incenti.
This document summarizes a presentation about healthcare compliance for skilled nursing facilities (SNFs). It discusses the impact of Office of Inspector General (OIG) audits finding high rates of billing errors in SNF Medicare claims. It reviews the Program for Evaluating Payment Patterns Electronic Report (PEPPER), which analyzes SNF claims data to identify outlier facilities. It emphasizes the importance of SNFs developing compliance programs to regularly audit claims and ensure appropriate billing. It also notes increased government scrutiny of healthcare fraud and changes to false claims acts that expand liability for incorrect billing.
Department of Health and Human Services OFFICE OF INSPECsimisterchristen
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
June 2001
OEI-02-00-00290
Medicare Coverage of Non-Physician
Practitioner Services
OFFICE OF INSPECTOR GENERAL
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to
protect the integrity of the Department of Health and Human Services programs as well as the
health and welfare of beneficiaries served by them. This statutory mission is carried out through
a nationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The
Inspector General informs the Secretary of program and management problems and recommends
legislative, regulatory, and operational approaches to correct them.
Office of Evaluation and Inspections
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of
Inspector General. It conducts short-term management and program evaluations (called
inspections) that focus on issues of concern to the Department, the Congress, and the public.
The inspection reports provide findings and recommendations on the efficiency, vulnerability,
and effectiveness of departmental programs.
OEI's New York Regional Office prepared this report under the direction of John I. Molnar,
Regional Inspector General and Renee C. Dunn, Deputy Regional Inspector General. Principal
OEI staff included:
REGION HEADQUARTERS
Nancy Harrison, Project Leader Jennifer Antico, Program Specialist
Natasha Besch Tricia Davis, Program Specialist
Vincent Greiber Brian Ritchie, Technical Support Staff
Christi Macrina
To obtain copies of this report, please call the New York Regional Office at 212-264-2000.
Reports are also available on the World Wide Web at our home pate address:
http://www.hhs.gov/oig/oei
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
June 2001
OEI-02-00-00290
Medicare Coverage of Non-Physician
Practitioner Services
E X E C U T I V E S U M M A R Y
PURPOSE
To describe the scope of services nurse practitioners, clinical nurse specialists, and
physician assistants provide to Medicare beneficiaries, and to identify any potential
vulnerabilities that may have emerged since the Balanced Budget Act of 1997.
BACKGROUND
Nurse practitioners, clinical nurse specialists, and physician assistants are health care
providers who practice either in collaboration with or under the supervision of a
physician. We refer to them as non-physician practitioners. States are responsible for
licensing and for setting the scopes of practice for all three specialties. Services provided
by them can be reimbursed by Medicare Part B.
The Balanced Budget Act of 1997 (BBA97) modified the way the Medicare program
pays for their services. Prior to January 1, 1998, their services were reimbursed by
Medicare only in rural areas and certain health care settings. Payments are now allowed
in all geographic areas and health care settings ...
This document summarizes notable healthcare transaction trends and regulatory updates from 2010. It discusses the impact of healthcare reform on transactions, including provisions encouraging accountable care organizations. It also summarizes regulatory activity from the CMS and OIG, including the publication of the Stark Self-Referral Disclosure Protocol and OIG advisory opinions on sleep center arrangements. Additionally, it discusses two qui tam court cases, Tuomey and Bradford, that sparked discussion around the healthcare fair market value standard.
Similar to ERN NCRA AAHAM NoCal UCR Legislative Update.5.14.10 (20)
1. Slide 1
ERN/NCRA 2010 Annual Legislative Update
ERN / The National
Council of
Reimbursement
Advocacy
Annual Legislative Update
USUAL, CUSTOMARY AND REASONABLE CHARGES
Ed Norwood
2. Slide 2
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
“Our greatest glory is not in never
failing, but in rising up every time
we fail.”
-Ralph Waldo Emerson
3. Slide 3
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
Healthcare is a law to be
defended.
4. Slide 4
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
Revenue Net income
Health Plan (in millions) (in millions) Earnings Per Share
2008 2009 2008 2009 2008 2009
Aetna $30,950.7 $34,764.1 $1,384.1 $1,276.5 $2.83 $2.84
(12.3%) (0.4%)
Cigna $19,101.0 $18,414.0 $292.0 $1,302.0 $1.05 $4.73
(-3.6%) (350.5%)
Health Net $15,366.6 $15,713.2 $95.0 -$49.0 $0.88 -$0.47
(2.3%) (-153.4%)
UnitedHealth Group $81,186.0 $87,138.0 $2,977.0 $3,822.0 $2.40 $3.24
(7.3%) (35.0%)
WellPoint $61,251.1 $65,028.1 $2,490.7 $4,745.9 $4.76 $9.88
(6.2%) (107.6%)
5. Slide 5
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
Underpayments by health care service plans and their
capitated providers exacerbate an already fragile health
care delivery system.
6. Slide 6
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
On September 14, 2009, the DMHC expanded its
routine audits to specifically address claim payment
issues pertaining to plans and capitated providers, with
an emphasis on claims for emergency services.
The DMHC's regulatory efforts will initially concentrate on
the health plans and capitated providers who meet one or
more of the below criteria:
7. Slide 7
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
1. Health plans and capitated providers that have lowered
their payment methodologies since October 15,
2008. Any decrease in claim payment levels will need to
be justified.
2. Health plans and capitated providers whose claim
payment methodologies result in the lowest payment
levels to providers.
3. Health plans and capitated providers that are the
subject of substantive and/or repeated complaints
regarding their reasonable and customary
methodologies.
8. Slide 8
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
4. Health plans and capitated providers that routinely
have low initial payments.
5. Health plans and capitated providers that have no
meaningful dispute resolution processes, or have other
unfair payment practices.
9. Slide 9
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
Recent courts have determined that payors cannot set
reimbursement rates in an arbitrary and capricious
manner. In the California Supreme Court's Prospect
decision, the Court stated:
"Prospect has provided no authority, statutory or
otherwise, for this court to conclude that it can set
the rate of emergency rooms physicians pursuant to
any across-the-board mechanism, whether the
Medicare rate or any other rate." (Prospect Medical
Group, Inc. v. Northridge Emergency Medical Group et al. (136
Cal. App. 4th 1155, 2006.))
10. Slide 10
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
The Prospect decision makes it clear that any fee dispute
involving emergency services rendered in non-contracted
facilities must be resolved pursuant to the promulgated six-
part regulatory test cited in 28 CCR 1300.71 (a)(3)(b) which
states:
11. Slide 11
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
“Reimbursement of a claim” means: For contracted
providers without a written contract and non-contracted providers,
except those providing services described in paragraph (C) below:
the payment of the reasonable and customary value for the
health care services rendered based upon statistically credible
information that is updated at least annually AND
TAKES INTO CONSIDERATION: (i) the provider's training,
qualifications, and length of time in practice; (ii) the nature of the
services provided; (iii) the fees usually charged by the provider; (iv)
prevailing provider rates charged in the general geographic area
in which the services were rendered; (v) other aspects of the
economics of the medical provider's practice that are relevant;
and (vi) any unusual circumstances in the case.
OUR CONCERN IS: WHO IS MONITORING THIS?
12. Slide 12
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
In a recent compliance audit, ERN/NCRA has discovered that
two of the largest health plans in the State of California utilize
the following methodologies in determining emergency
reimbursement to non-contracted providers:
13. Slide 13
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
HEALTH NET:
"Health Net uses the greater of the OSHPD or the
Medicare reported cost to charge ratio for each
facility to calculate the maximum allowable
amount. The OSHPD cost to charge ratio is
calculated as follows:Total Operating Expenses-
Other Operating Revenue/Gross Patient
Revenue. Health Net will pay a facility the
maximum allowable amount based upon the greater
of: (a) 165% of a facility's OSHPD cost to charge
ration; or (b) 165% of a facility's Medicare cost to
charge ratio; provided, however in no event, will
Health Net pay more than 100% of a facility's
charges."
14. Slide 14
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
BLUE CROSS:
"To determine benefits on a customary and
reasonable basis for non-contracting institutional
providers, a percentile of billed charges from the
Anthem Blue Cross (ABC) database is used to
calculate the benefits, subject to the following:The
allowed benefit WILL NOT BE: 1) less than covered
charges multiplied by the cost to charge ratio the
institution reports to OSHPD multiplied by a
specific percentage; or 2) More than covered
charges multiplied by the cost to charge ratio the
institution reports to OSHPD multiplied by
another specific percentage; or
15. Slide 15
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
BLUE CROSS CONT…:
3) More than the full 100% of the institution's
charges. The ABC database takes into consideration
various factors, such as the billed charges of
providers for services based on Diagnostic Related
Group (DRG) codes for inpatient claims and Current
Procedural Terminology (CPT) codes and
Healthcare Common Procedure Coding System
(HCPCS) codes for outpatient claims."
16. Slide 16
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
We do not believe that the OSHPD cost to charge ratio
(calculated from Annual Disclosure reports) can be used
solely to satisfy the six-part regulatory test under 28 CCR
1300.71 (a)(3)(b) to determine reasonable and customary
rates.
17. Slide 17
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
A FEW THINGS TO REMEMBER:
1. The DMHC has very limited resources for reviewing each
health plan and capitated provider’s UCR methodology (pg. 2)
THE DMHC WILL NOT REVIEW UCR
UNDERPAYMENTS UNLESS YOU BRING THEM
TO THEIR ATTENTION.
18. Slide 18
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
2. The DMHC will focus its regulatory efforts on health plans and
capitated providers as identified by the 5 factors (pg. 3.)
YOU MUST ROVIDE THIS PAYMENT DATA TO
THE DMHC.
NO ONE CAN IDENTIFY PAYORS WHO MAKE
EMERGENCY UNDERPAYMENTS AND MEET
ONE OF THE 5 FACTORS LISTED EXCEPT
PROVIDERS.
19. Slide 19
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
WE NEED YOUR HELP.
1.) We ask for your identification of any payor UCR payment
methodologies that fail to consider the Gould factors in
1300.71 (a) (3) (b) and result in routinely low payments.
2.) We urge you to file complaints through us or internally
with the DMHC if you have an in-house Compliance Officer.
IDRP VS. ONLINE COMPLAINT PROCESS
20. Slide 20
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
The DMHC’s pilot Independent Dispute Resolution
Process (IDRP) employs a voluntary "baseball style"
arbitration model that encourages the plan and the provider to
negotiate realistically before an arbitrator (CHDR), or risk
having the other side's proposal accepted. For the IDRP, the
provider's original billed amount and the payer's original paid
amount will be used to determine which amount better reflects
the reasonable and customary value of the services performed.
BUT YOU HAVE TO PAY FOR IT AND THE PLAN
CAN REFUSE PARTICIPATION.
THE DMHC COMPLAINT PROCESS – H&S 1371.39
25. Slide 25
ERN/NCRA 2010 Annual Legislative Update
The Sign of the Times
Untimely payment has a negative effect on
patient level of care.
Violation of the Knox Keene Act is a
considered a crime against public health
and safety.
26. Slide 26
ERN/NCRA 2010 Annual Legislative Update
Thewe must be as passionate about
Together,
Sign of the Times
violations of health and safety as the Red Cross is
about disaster.
27. Slide 27
ERN/NCRA 2010 Annual Legislative Update
Why We Exist
CHAPTER MISSION
“To position and strengthen healthcare
professionals for legislative change and industry
advancement through advocacy, education,
training and service.”
28. Slide 28
ERN/NCRA 2010 Annual Legislative Update
Why We Exist
CHAPTER VALUES
Advocate passionately for medically appropriate
healthcare in the State of California pursuant to
Business and Professions Code §510.
Challenge HMOs, PPOs and Government payors to
facilitate change and improvement.
Influence the outcomes including public-policy,
reimbursement and quality of care decisions that
directly affect American citizens.
Instill an incurable passion for results in others to
effectuate change in the healthcare delivery system.
Create strategic networking and volunteer
opportunities that fortify member marketability and
transfer to paid jobs.
29. Slide 29
ERN/NCRA 2010 Annual Legislative Update
Join Us
WE WOULD BE HUMBLED
TO HAVE YOU JOIN OUR
MOVEMENT
EMAIL US AT
EDNORWOOD@ERNENTERPRISES.ORG
OR CALL (714) 995-6900 EXT. 6926 FOR
MORE INFO.