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.
A health insurance roadmap takes a look at some simple solutions to the complex issues facing health insurance, medicare, medicaid, long term care insurance, and the high cost of health expenses in retirement.
This will work because so much of this is already in place and a lot of the rest would be quick and easy to implement. As in all areas, knowledge is power. Consumers can take control of your insurance portfolio by becoming educated about insurance. Better education and understanding will lead to positive results for consumers and for the insurance industry.
The document discusses the impact of the Patient Protection and Affordable Care Act (PPACA) on Louisiana's health insurance market. It summarizes key provisions of the PPACA, including requirements for grandfathered and non-grandfathered health plans, the establishment of health insurance exchanges, coverage mandates, and subsidies for individuals and small businesses. It also outlines new taxes, fees, and regulations that may impact hospitals, insurers, and Medicaid reimbursement rates in Louisiana.
Living Longer, Living Better: Reform Report #2 - GT review AustraliaGrant Thornton
This is our second report in response to the Government's Living Longer, Living Better package.
In this document, we discuss the implications of, and industry reaction to, the initiatives recently announced by the Government as more detail of their response to the Productivity Commission's report emerges.
Champion A cure To Combat Health coverage (CATCH) is a proposed non-profit organization that aims to address the lack of adequate insurance coverage for ABA therapy treatments for children with autism. CATCH plans to develop a healthcare discount membership plan that will negotiate discounted rates with providers for treatments. The organization will recruit up to 100 initial members and measure success based on the number of participating providers offering discounted ABA therapy rates. The long-term goals include seeking grants, expanding covered services, and collaborating with additional provider types like home health agencies.
How the Opioid Crisis and the SUPPORT Act Created a New Enforcement Reality: ...Epstein Becker Green
How the Opioid Crisis and the SUPPORT Act Created a New Enforcement Reality: Trends in Behavioral Health Webinar Series
Presented by
Richard W. Westling – Member, Epstein Becker Green
Katherine Bowles – Attorney, Nelson Hardiman
Part of a "first Thursdays" webinar series hosted by Behavioral Health Association of Providers, Epstein Becker & Green, P.C., and Nelson Hardiman, LLP.
During 2018, the Department of Justice dedicated additional enforcement resources to address the opioid crisis. By adding criminal penalties targeted at kickbacks in the SUD provider space, the SUPPORT Act significantly enhanced the many tools already available to the DOJ. These efforts will also likely further embolden private payor review activities.
More info: https://www.ebglaw.com/events/how-the-opioid-crisis-and-the-support-act-created-a-new-enforcement-reality-trends-in-behavioral-health-webinar-series/
These materials have been provided for informational purposes only and are not intended and should not be construed to constitute legal advice. The content of these materials is copyrighted to Epstein Becker & Green, P.C. ATTORNEY ADVERTISING.
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.
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.
The Proposed Health Care Reform’S Impact On MarketingStone Ward
The document summarizes key aspects of the proposed US health care reform plan, including:
1) It would require all Americans to have health insurance and businesses to provide it or pay a penalty. Subsidies would help lower-income families purchase insurance.
2) Health insurance exchanges would be created to allow consumers to compare plans starting in 2013.
3) While hospitals, doctors, and private Medicare plans oppose aspects of the plan, supporters argue it will reduce costs and improve care by covering more of the uninsured.
A health insurance roadmap takes a look at some simple solutions to the complex issues facing health insurance, medicare, medicaid, long term care insurance, and the high cost of health expenses in retirement.
This will work because so much of this is already in place and a lot of the rest would be quick and easy to implement. As in all areas, knowledge is power. Consumers can take control of your insurance portfolio by becoming educated about insurance. Better education and understanding will lead to positive results for consumers and for the insurance industry.
The document discusses the impact of the Patient Protection and Affordable Care Act (PPACA) on Louisiana's health insurance market. It summarizes key provisions of the PPACA, including requirements for grandfathered and non-grandfathered health plans, the establishment of health insurance exchanges, coverage mandates, and subsidies for individuals and small businesses. It also outlines new taxes, fees, and regulations that may impact hospitals, insurers, and Medicaid reimbursement rates in Louisiana.
Living Longer, Living Better: Reform Report #2 - GT review AustraliaGrant Thornton
This is our second report in response to the Government's Living Longer, Living Better package.
In this document, we discuss the implications of, and industry reaction to, the initiatives recently announced by the Government as more detail of their response to the Productivity Commission's report emerges.
Champion A cure To Combat Health coverage (CATCH) is a proposed non-profit organization that aims to address the lack of adequate insurance coverage for ABA therapy treatments for children with autism. CATCH plans to develop a healthcare discount membership plan that will negotiate discounted rates with providers for treatments. The organization will recruit up to 100 initial members and measure success based on the number of participating providers offering discounted ABA therapy rates. The long-term goals include seeking grants, expanding covered services, and collaborating with additional provider types like home health agencies.
How the Opioid Crisis and the SUPPORT Act Created a New Enforcement Reality: ...Epstein Becker Green
How the Opioid Crisis and the SUPPORT Act Created a New Enforcement Reality: Trends in Behavioral Health Webinar Series
Presented by
Richard W. Westling – Member, Epstein Becker Green
Katherine Bowles – Attorney, Nelson Hardiman
Part of a "first Thursdays" webinar series hosted by Behavioral Health Association of Providers, Epstein Becker & Green, P.C., and Nelson Hardiman, LLP.
During 2018, the Department of Justice dedicated additional enforcement resources to address the opioid crisis. By adding criminal penalties targeted at kickbacks in the SUD provider space, the SUPPORT Act significantly enhanced the many tools already available to the DOJ. These efforts will also likely further embolden private payor review activities.
More info: https://www.ebglaw.com/events/how-the-opioid-crisis-and-the-support-act-created-a-new-enforcement-reality-trends-in-behavioral-health-webinar-series/
These materials have been provided for informational purposes only and are not intended and should not be construed to constitute legal advice. The content of these materials is copyrighted to Epstein Becker & Green, P.C. ATTORNEY ADVERTISING.
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.
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.
The Proposed Health Care Reform’S Impact On MarketingStone Ward
The document summarizes key aspects of the proposed US health care reform plan, including:
1) It would require all Americans to have health insurance and businesses to provide it or pay a penalty. Subsidies would help lower-income families purchase insurance.
2) Health insurance exchanges would be created to allow consumers to compare plans starting in 2013.
3) While hospitals, doctors, and private Medicare plans oppose aspects of the plan, supporters argue it will reduce costs and improve care by covering more of the uninsured.
The document provides information about health care costs and insurance plans in the United States, Minnesota, and the Foley School District. It shows that on average, 87 cents of every health insurance dollar in the US goes toward medical costs, while 13 cents goes toward administrative costs and profits. Minnesota and Foley School District plans have lower administrative costs than national averages. The Resource Training & Solutions school pool offers advantages like lower costs and premium increases compared to other plans like SEGIP and PEIP.
The document discusses key issues related to health reform implementation for safety net health systems. It provides an overview of the National Association of Public Hospitals and Health Systems (NAPH), which advocates for safety net hospitals. The document outlines provisions of the Affordable Care Act related to coverage expansion, exchanges, provider payments, and innovation opportunities. It identifies challenges and questions for safety net health systems to consider regarding health reform implementation.
The document discusses the appeal of voluntary insurance plans for nursing workforces. It notes that the growing nursing shortage is costly for hospitals to address, and that voluntary insurance can help hospitals recruit and retain nurses in a cost-effective way. A survey found that over half of nurses would consider changing jobs for benefits that include voluntary insurance like short-term disability, dental, and life insurance. The document argues that voluntary insurance improves competitiveness and appeals to nurses' needs for financial security and comprehensive benefits.
The U.S. health care system utilizes both privately funded and publicly funded payors. Over time, federal and state laws have influenced the development of different types of health plans. The government plays key roles in enacting laws to regulate and protect consumers, providing direct health care services, and acting as a payor through programs like Medicare, Medicaid, and the Affordable Care Act.
US healthcare insurance can be public (e.g. Medicare, Medicaid) or private (employer or self-purchased plans). Medicare has parts A, B, C, and D that cover different services like hospitals (Part A) and prescription drugs (Part D). Plans may require premiums, deductibles, co-payments, or co-insurance. They often have limits and do not cover all costs. Private insurers provide additional plans like PPOs, HMOs, or Medicare Advantage plans combining Part A, B, and D benefits. SCHIP provides coverage for children from families that do not qualify for Medicaid.
This document presents information on Medicaid expansion under the Affordable Care Act. It discusses how the ACA provides additional federal funding for states to expand Medicaid eligibility up to 138% of the federal poverty level. The document also notes that 26 states have refused Medicaid expansion funding so far, with Texas being the state with the highest uninsured population. It explores perspectives on both the opportunities and challenges of Medicaid expansion, such as increased access to care but debates around costs. Videos and references on the topic are also provided.
Kaiser Slides on People-Who are Dually Eligible for Medicare-and-medicaid-med...KFF
Dual eligible beneficiaries comprise 20% of the Medicare population and 15% of the Medicaid population. They receive coverage from both Medicare and Medicaid, with Medicare as the primary payer. Dual eligibles account for a disproportionate share of spending in both programs despite making up a relatively small portion of enrollees. They tend to be poorer, sicker, and have higher rates of chronic conditions than other Medicare or Medicaid beneficiaries.
The document summarizes discussions from a Vermont Exchange Advisory Group meeting about defining Essential Health Benefits (EHB) for health plans in Vermont. It discusses analyzing the state's largest plans to select a benchmark plan, supplementing categories of benefits not covered, defining habilitative services, and ensuring vision and dental benefits meet requirements. The advisory group is evaluating the state's options for selecting a benchmark plan and filling in any missing required benefit categories to establish Vermont's EHB definition.
Presentation from INTEGRATED's Chuck Gooder, senior advisor, and Blake Sternard, the business analyst. The presentation focuses on the ways to identify the major changes of healthcare, with specific attention to the potential challenges posed to enrollees, physicians, hospitals, and healthcare organizations associated with the implementation of Obamacare.
The Essential Guide to Open Payments Compliance- Developed by Concur R-Squar...Joshua Gebhardt
This document provides an overview and guide to Open Payments compliance. Open Payments, also known as the Physician Payments Sunshine Act, requires applicable drug, medical device, and medical supply manufacturers to report payments and transfers of value provided to physicians and teaching hospitals. It aims to increase transparency around financial relationships in the healthcare industry. The document defines key terms like applicable manufacturers and covered recipients, outlines what types of payments and transfers must be reported, and provides compliance deadlines and penalties for non-compliance.
Top 25 IDNs by number of ACO affiliations: 49 hospitals in-network, $9.4 billion in net patient revenue
Types of ACOs: CMS ACO Models, Medicaid ACOs, Commercial ACO
WellPoint is working to address challenges in the US healthcare system related to affordability, access, quality care, and improved health. Regarding affordability, WellPoint is achieving administrative cost savings, helping contain healthcare costs, and providing consumers with information to help manage their own costs. For access, WellPoint is creating more affordable coverage options, finding ways to provide coverage to low-income Americans, and overcoming barriers like language and lack of local resources. Regarding quality care, WellPoint is collaborating with healthcare providers to improve clinical performance and establish evidence-based best practices. WellPoint also offers health improvement programs to help members manage chronic conditions and contribute to better health outcomes.
IDNs generally provide primary care, acute care, specialty care (including clinics), long-term care, and home health
care.
IDNs often leverage their size to increase purchasing power, negotiating lower prices with
medical device suppliers
Beyond Medicare – Meeting the Needs of Senior CustomersGen Re
There is no time like the present for insurers to consider growing their senior product portfolio with either Medicare Advantage or Medicare Supplement insurance. However, it’s important to understand some clear differences between these products and which needs they address for customers.
Read more: http://www.genre.com/knowledge/blog/meeting-the-needs-of-senior-customers-en.html
Global Transitional Care Investment Brief - 2015capservegroup
Global Transitional Healthcare is a transitional care provider that helps patients recover at home after being discharged from the hospital. Their services include coordinating care, managing medications, conducting home visits, and providing 24/7 access to nurses. They aim to reduce hospital readmissions by ensuring continuity of care during the critical 30-day period after discharge. The company has partnered with over 15 medical groups and facilities. They are raising $2.5 million to expand their services to more markets and respond to increasing demand and regulatory pressures to reduce readmissions.
This document discusses several topics related to compliance in medical practices:
- It provides an overview of the economy, healthcare reform legislation, the HITECH Act, and new laws/regulations around HIPAA, ICD-10, FERA, HEAT, RACs, and the Red Flag Rule.
- It notes the incentives for adopting electronic health records under the HITECH Act and details new requirements and penalties under updated privacy and security rules.
- It emphasizes the increased risks of investigations and liability for providers given expanded enforcement of fraud laws like the False Claims Act. Proper documentation and compliance programs are advised.
Health insurance claim | Health Care DomainH2kInfosys
H2K Infosys provides online IT training and placement services worldwide. It acknowledges proprietary rights of trademarks and product names mentioned in training materials for learning purposes only. Students shall not use or sell such materials for private gain or to third parties. H2K does not guarantee or take responsibility for products and projects discussed in training.
The document provides an overview of healthcare reform under the Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act (HCERA). It discusses key provisions including the expansion of Medicaid eligibility, establishment of health insurance exchanges, essential health benefits, and various delivery system reforms aimed at improving quality of care and reducing costs.
Citizens Advice Cymru response to the Welsh Affairs Committee Inquiry impact ...Eri Mountbatten-O'Malley
The Citizens Advice Cymru identifies poor administration of sanctions as their main concern with the Work Programme in Wales. They provide several case studies as examples where sanctions were applied even though claimants appeared to have "good cause" for missing appointments, such as conflicting appointments, mental or physical health issues, bereavement, learning disabilities or illness. The Citizens Advice Cymru recommends improved administration of sanctions and stronger safeguards to ensure sanctions are not inappropriately applied to vulnerable claimants.
How to Manage Population Health Effectively in Accountable Care OrganizationsPhytel
The Affordable Care Act authorized a Medicare shared-savings program for accountable care organizations, and private payers are also contracting with ACOs. To succeed, ACOs must learn how to manage population health effectively.
The document provides an overview of recent regulatory updates from the Office of the Inspector General (OIG) and other agencies:
1) The OIG approved an arrangement for a group purchasing organization to be indirectly owned by a health system and for a website to display healthcare provider coupons and ads.
2) The OIG criticized the Centers for Medicare and Medicaid Services for failing to implement regulations governing sanctions for noncompliant home health agencies.
3) The OIG issued a report finding questionable billing practices among certain Independent Diagnostic Testing Facilities, and recommended increased monitoring and enforcement actions.
The document provides information about health care costs and insurance plans in the United States, Minnesota, and the Foley School District. It shows that on average, 87 cents of every health insurance dollar in the US goes toward medical costs, while 13 cents goes toward administrative costs and profits. Minnesota and Foley School District plans have lower administrative costs than national averages. The Resource Training & Solutions school pool offers advantages like lower costs and premium increases compared to other plans like SEGIP and PEIP.
The document discusses key issues related to health reform implementation for safety net health systems. It provides an overview of the National Association of Public Hospitals and Health Systems (NAPH), which advocates for safety net hospitals. The document outlines provisions of the Affordable Care Act related to coverage expansion, exchanges, provider payments, and innovation opportunities. It identifies challenges and questions for safety net health systems to consider regarding health reform implementation.
The document discusses the appeal of voluntary insurance plans for nursing workforces. It notes that the growing nursing shortage is costly for hospitals to address, and that voluntary insurance can help hospitals recruit and retain nurses in a cost-effective way. A survey found that over half of nurses would consider changing jobs for benefits that include voluntary insurance like short-term disability, dental, and life insurance. The document argues that voluntary insurance improves competitiveness and appeals to nurses' needs for financial security and comprehensive benefits.
The U.S. health care system utilizes both privately funded and publicly funded payors. Over time, federal and state laws have influenced the development of different types of health plans. The government plays key roles in enacting laws to regulate and protect consumers, providing direct health care services, and acting as a payor through programs like Medicare, Medicaid, and the Affordable Care Act.
US healthcare insurance can be public (e.g. Medicare, Medicaid) or private (employer or self-purchased plans). Medicare has parts A, B, C, and D that cover different services like hospitals (Part A) and prescription drugs (Part D). Plans may require premiums, deductibles, co-payments, or co-insurance. They often have limits and do not cover all costs. Private insurers provide additional plans like PPOs, HMOs, or Medicare Advantage plans combining Part A, B, and D benefits. SCHIP provides coverage for children from families that do not qualify for Medicaid.
This document presents information on Medicaid expansion under the Affordable Care Act. It discusses how the ACA provides additional federal funding for states to expand Medicaid eligibility up to 138% of the federal poverty level. The document also notes that 26 states have refused Medicaid expansion funding so far, with Texas being the state with the highest uninsured population. It explores perspectives on both the opportunities and challenges of Medicaid expansion, such as increased access to care but debates around costs. Videos and references on the topic are also provided.
Kaiser Slides on People-Who are Dually Eligible for Medicare-and-medicaid-med...KFF
Dual eligible beneficiaries comprise 20% of the Medicare population and 15% of the Medicaid population. They receive coverage from both Medicare and Medicaid, with Medicare as the primary payer. Dual eligibles account for a disproportionate share of spending in both programs despite making up a relatively small portion of enrollees. They tend to be poorer, sicker, and have higher rates of chronic conditions than other Medicare or Medicaid beneficiaries.
The document summarizes discussions from a Vermont Exchange Advisory Group meeting about defining Essential Health Benefits (EHB) for health plans in Vermont. It discusses analyzing the state's largest plans to select a benchmark plan, supplementing categories of benefits not covered, defining habilitative services, and ensuring vision and dental benefits meet requirements. The advisory group is evaluating the state's options for selecting a benchmark plan and filling in any missing required benefit categories to establish Vermont's EHB definition.
Presentation from INTEGRATED's Chuck Gooder, senior advisor, and Blake Sternard, the business analyst. The presentation focuses on the ways to identify the major changes of healthcare, with specific attention to the potential challenges posed to enrollees, physicians, hospitals, and healthcare organizations associated with the implementation of Obamacare.
The Essential Guide to Open Payments Compliance- Developed by Concur R-Squar...Joshua Gebhardt
This document provides an overview and guide to Open Payments compliance. Open Payments, also known as the Physician Payments Sunshine Act, requires applicable drug, medical device, and medical supply manufacturers to report payments and transfers of value provided to physicians and teaching hospitals. It aims to increase transparency around financial relationships in the healthcare industry. The document defines key terms like applicable manufacturers and covered recipients, outlines what types of payments and transfers must be reported, and provides compliance deadlines and penalties for non-compliance.
Top 25 IDNs by number of ACO affiliations: 49 hospitals in-network, $9.4 billion in net patient revenue
Types of ACOs: CMS ACO Models, Medicaid ACOs, Commercial ACO
WellPoint is working to address challenges in the US healthcare system related to affordability, access, quality care, and improved health. Regarding affordability, WellPoint is achieving administrative cost savings, helping contain healthcare costs, and providing consumers with information to help manage their own costs. For access, WellPoint is creating more affordable coverage options, finding ways to provide coverage to low-income Americans, and overcoming barriers like language and lack of local resources. Regarding quality care, WellPoint is collaborating with healthcare providers to improve clinical performance and establish evidence-based best practices. WellPoint also offers health improvement programs to help members manage chronic conditions and contribute to better health outcomes.
IDNs generally provide primary care, acute care, specialty care (including clinics), long-term care, and home health
care.
IDNs often leverage their size to increase purchasing power, negotiating lower prices with
medical device suppliers
Beyond Medicare – Meeting the Needs of Senior CustomersGen Re
There is no time like the present for insurers to consider growing their senior product portfolio with either Medicare Advantage or Medicare Supplement insurance. However, it’s important to understand some clear differences between these products and which needs they address for customers.
Read more: http://www.genre.com/knowledge/blog/meeting-the-needs-of-senior-customers-en.html
Global Transitional Care Investment Brief - 2015capservegroup
Global Transitional Healthcare is a transitional care provider that helps patients recover at home after being discharged from the hospital. Their services include coordinating care, managing medications, conducting home visits, and providing 24/7 access to nurses. They aim to reduce hospital readmissions by ensuring continuity of care during the critical 30-day period after discharge. The company has partnered with over 15 medical groups and facilities. They are raising $2.5 million to expand their services to more markets and respond to increasing demand and regulatory pressures to reduce readmissions.
This document discusses several topics related to compliance in medical practices:
- It provides an overview of the economy, healthcare reform legislation, the HITECH Act, and new laws/regulations around HIPAA, ICD-10, FERA, HEAT, RACs, and the Red Flag Rule.
- It notes the incentives for adopting electronic health records under the HITECH Act and details new requirements and penalties under updated privacy and security rules.
- It emphasizes the increased risks of investigations and liability for providers given expanded enforcement of fraud laws like the False Claims Act. Proper documentation and compliance programs are advised.
Health insurance claim | Health Care DomainH2kInfosys
H2K Infosys provides online IT training and placement services worldwide. It acknowledges proprietary rights of trademarks and product names mentioned in training materials for learning purposes only. Students shall not use or sell such materials for private gain or to third parties. H2K does not guarantee or take responsibility for products and projects discussed in training.
The document provides an overview of healthcare reform under the Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act (HCERA). It discusses key provisions including the expansion of Medicaid eligibility, establishment of health insurance exchanges, essential health benefits, and various delivery system reforms aimed at improving quality of care and reducing costs.
Citizens Advice Cymru response to the Welsh Affairs Committee Inquiry impact ...Eri Mountbatten-O'Malley
The Citizens Advice Cymru identifies poor administration of sanctions as their main concern with the Work Programme in Wales. They provide several case studies as examples where sanctions were applied even though claimants appeared to have "good cause" for missing appointments, such as conflicting appointments, mental or physical health issues, bereavement, learning disabilities or illness. The Citizens Advice Cymru recommends improved administration of sanctions and stronger safeguards to ensure sanctions are not inappropriately applied to vulnerable claimants.
How to Manage Population Health Effectively in Accountable Care OrganizationsPhytel
The Affordable Care Act authorized a Medicare shared-savings program for accountable care organizations, and private payers are also contracting with ACOs. To succeed, ACOs must learn how to manage population health effectively.
The document provides an overview of recent regulatory updates from the Office of the Inspector General (OIG) and other agencies:
1) The OIG approved an arrangement for a group purchasing organization to be indirectly owned by a health system and for a website to display healthcare provider coupons and ads.
2) The OIG criticized the Centers for Medicare and Medicaid Services for failing to implement regulations governing sanctions for noncompliant home health agencies.
3) The OIG issued a report finding questionable billing practices among certain Independent Diagnostic Testing Facilities, and recommended increased monitoring and enforcement actions.
- Duke University study found that patient satisfaction scores were more closely aligned with lower hospital readmission rates within 30 days than traditional clinical performance measures. This suggests hospitals should focus on improving patient-staff interactions, especially at discharge.
- The Supreme Court will rule on a case challenging Medicaid cuts in California. The outcome could impact Medicaid providers and beneficiaries nationwide if it allows states to arbitrarily reduce Medicaid benefits.
- The final rules for Accountable Care Organizations (ACOs) under Medicare were released. ACOs aim to improve care coordination and quality while reducing costs by allowing providers and hospitals to share savings if quality targets are met. However, patients still have freedom to choose outside providers.
Accountable Care Organizations and The Medicare Shared Savings ProgramPhytel
Population Health Management, Enabled by Information Technology, Will Be Critical To Success. In 2012, the Centers for Medicare and Medicaid Services (CMS) will launch a shared-savings program with accountable care organizations (ACOs). ACOs that meet specified quality goals will be able to split with CMS any savings that surpass a minimum level. The challenge facing ACOs is choosing the right information technologies so they can track the health status of and the care provided to every one of their patients to produce significant savings or meet the quality benchmarks of CMS
Small business medical insurance costs continue to rise a midst the uncertainty of future reforms and regulations. This white paper reviews 2012 health care trends and 3 strategies to mitigate the rising costs of health insurance.
ACA (Affordable care Act) signed by Obama on 23 march 2010. .pdfannaistrvlr
ACA (Affordable care Act) signed by Obama on 23 march 2010. Putting
Information for Consumers Online So that consumers can compare health insurance coverage
options and pick the coverage that works for them. Prohibiting Denying Coverage of Children
Based on PreExisting Conditions The health care law includes new rules to prevent insurance
companies from denying coverage to children under the age of 19 due to a pre-existing
condition. Prohibiting Insurance Companies from Rescinding Coverage In the past, insurance
companies could search for an error, or other technical mistake, on a customer\'s application and
use this error to deny payment for services when he or she got sick. But now this is illegal. After
media reports cited incidents of breast cancer patients losing coverage, insurance companies
agreed to end this practice immediately. Eliminating Lifetime Limits on Insurance Coverage
Insurance companies will be prohibited from imposing lifetime dollar limits on essential
benefits, like hospital stays. Regulating Annual Limits on Insurance Coverage Insurance
companies\' use of annual dollar limits on the amount of insurance coverage a patient may
receive will be restricted for new plans in the individual market and all group plans. In 2014, the
use of annual dollar limits on essential benefits like hospital stays will be banned for new plans
in the individual market and all group plans. Appealing Insurance Company Decisions
Provides consumers with a way to appeal coverage determinations or claims to their insurance
company, and establishes an external review process. Establishing Consumer Assistance
Programs in the States States that apply ACA receive federal grants to help set up or expand
independent offices to help consumers navigate the private health insurance system. These
programs help consumers file complaints and appeals; enroll in health coverage; and get
educated about their rights and responsibilities in group health plans or individual health
insurance policies. The programs will also collect data on the types of problems consumers have,
and file reports with the U.S. Department of Health and Human Services to identify trouble spots
that need further oversight. Improving Quality and lowering costs Both this head get
amended from time to time so that consumer receive best to best service. Increasing Access to
Affordable Care Hoe ACA Affects Reiumburshment Short Term Effects:
The most immediate expected effect of the ACA for providers is a sudden rise in patient
populations. Millions of Americans are expected to obtain coverage under the ACA
Payers are required to cover more than ever,under the ACA, individual and small group health
plans are required to cover 10 essential health benefits Long Term Effects:
Changing payment and care models,biggest changes in healthcare right now are the new fee-for-
value payment models that are replacing traditional fee-for-service programs Through
Medicare and Medicaid, the government has been .
Impact on Health Reform on Device Development and FundingUBMCanon
The document discusses the impact of US healthcare reform on medical device development and funding. It summarizes that healthcare reform through the Affordable Care Act and other policies is driving major changes in health insurance purchasing and moving payments from fee-for-service to bundled payments and accountable care organizations. This shift to alternative payment models will require device manufacturers to understand how provider reimbursement is changing to ensure their devices provide value within the new systems.
The document provides a summary of recent developments in healthcare law and policy, including:
1) The OIG issued an advisory opinion approving a hospital program providing lodging and meals to patients, but declined to approve an allergy testing arrangement.
2) CMS released the 2012 Medicare Physician Fee Schedule and made changes to quality reporting programs.
3) New Jersey's Medicaid Fraud Division released its 2012 work plan focusing on audits and compliance. Legislation was proposed requiring surgical practice licensure.
4) Brach Eichler attorneys were involved in various industry events and cases regarding nurses' objections to abortions and HIPAA audits.
This document summarizes key points from a presentation on rural health issues and healthcare reform. It discusses potential government shutdowns if a budget is not passed, changes to Medicare and Medicaid under the Affordable Care Act, provisions already in effect, and new delivery models like accountable care organizations. Key uncertainties are noted, such as the impact of healthcare reform on rural providers and workforce shortages.
Consumer-Centric Healthcare: 2015--The Tipping Point Has Arrived (Report by William Blair)
Consumers—in tandem with disruptive healthcare technology and healthcare services providers—are the key to solving many of US healthcare's woes, particularly the unsustainably high cost of care.
Public exchanges, private exchanges, and high-deductible health plans are growing quickly. Disruptive forces of competition will create a lower-cost system that promotes the growth of highly efficient, low-cost, and high-quality providers and technologies.
The continued movement of financial and quality risk back to providers (and increasingly to consumers themselves) is encouraging providers and consumers to seek preventive medicine, cost efficiency, clinical efficacy, and overall value in healthcare. In turn, this could drive significant change regarding the primary point of care delivery (rapidly moving outside the hospital), the overall cost of healthcare and investment decisions made by healthcare providers.
Consumer-centric healthcare providers will experience strong top- and bottom-line growth over the coming years. Investors in both the public and private-equity markets will achieve superior long-term returns by identifying and investing in these companies.
ReadingsHealth Care Reform and Future PossibilitiesIntroduct.docxsodhi3
Readings
Health Care Reform and Future Possibilities
Introduction
Health care has undergone episodes of major change since the introduction of Medicare in the 1960s. All of these have resulted in fundamental changes in how health care providers were paid for services to Medicare patients and were swiftly followed by matching changes from independent insurance companies. The latest, and some might say the biggest, change since diagnosis-related groups (DRGs) were introduced in 1983 is the signing into law of the Patient Protection and Affordable Care Act (PPACA), on March 23, 2010. This law proposes to change the delivery of health care services by changing how providers are paid and what they are paid for. This module explores some of the key elements of PPACA and how health care providers are planning their changes in delivery processes and systems in response.
Major Elements of PPACA
The most significant elements of the PPACA legislation are scheduled to take place over several years. Congress still has the ability to modify some of these elements, so we will examine them with that in mind.
June 2010
Adults with pre-existing conditions were eligible to join a temporary high-risk insurance pool run by the federal government. This will be replaced by a health care exchange in 2014, which will provide access to insurance at affordable rates. Applicants must have a pre-existing health care condition and have been uninsured in the six months prior to application. Premiums will be set at rates for the general population rather than the high-risk premiums charged by insurance companies. Out-of-pocket costs will be limited to $5,950 for individuals and $11,900 for families.
July 2010
The government established the National Prevention, Health Promotion, and Public Health Council, with the Surgeon General to act as chair of the council. This council will oversee the implementation of many of the PPACA elements and will disseminate recommendations to the health care community at large in regard to best practices in prevention and health promotion. As of fall 2010, little had yet been heard from this entity. However, the National Committee on Quality Assurance, which is a private entity dedicated to improving the quality of health care services, is providing best practices and quality measures for health care providers, especially hospitals.
September 2010
Insurance companies can no longer apply lifetime dollar limits on essential benefits for patients. In addition, children may be covered under their parents' insurance plan until they turn 26 years of age. This includes children not living at home, not listed as dependents on their parents' tax returns, not students, and children who are married. Further, no patients under 19 years of age with pre-existing conditions can be excluded from health care benefits based on the pre-existing conditions, and there can be no deductibles or copayments required for provision of preventive care measures and medic ...
The document provides an overview of accountable care organizations (ACOs) including:
1) ACOs aim to tie provider reimbursements to quality and reduce total cost of care for assigned patients.
2) Key stakeholders include providers, payers (primarily Medicare), and patients (primarily Medicare beneficiaries).
3) The concept of ACOs originated in 2006 but builds on prior models. Successful implementation remains challenging.
4) The Patient Protection and Affordable Care Act supports the development of ACOs and other innovative models.
The document discusses Accountable Care Organizations (ACOs) created by the Affordable Care Act. ACOs allow groups of doctors, hospitals, and other providers to share responsibility for the cost and quality of care received by their patients. If ACOs meet quality benchmarks and reduce costs, they receive a share of the savings from insurers. The document outlines key features of ACOs such as local accountability, shared savings based on quality and cost measures, and a minimum of a 3-year contract period with Medicare.
Independence at Home Demonstration Program MemoMegan Gonyo
The memorandum recommends that Integrated Delivery System (IDS) not participate in the Independence at Home Demonstration Program at this time. The program aims to reduce healthcare costs by providing home-based primary care to high-need Medicare beneficiaries, but it requires capabilities IDS does not currently have, such as experience providing home-based care and mobile diagnostic equipment. Participating would require considerable investments in training physicians and nurses and purchasing new technology. Additionally, the program's rules around eligible patients and minimum enrollment numbers make it difficult to predict costs and benefits. Given ongoing uncertainties, participating poses too much financial risk for IDS.
This document discusses the future of physician payments and accountable care models. It provides an overview of recent observations in healthcare such as the growth of accountable care organizations and transition away from fee-for-service payments. It also summarizes emerging opportunities like meaningful use incentives and accountable care organization initiatives from Medicare and private payers. Key trends in payment reform like the transition to risk-based payments and the role of consumers are also predicted.
This document discusses the transition from Accountable Care Organization (ACO) 1.0 to ACO 2.0. It notes that while the initial ACO programs under Medicare saw mixed results, with high costs and fewer than one in five ACOs generating shared savings, payers and providers remain committed to the ACO model. It describes how ACO 2.0 will focus on bundling payments for episodes of care between payers and provider networks. This will require ACOs to take on greater financial risk but could optimize savings if implemented effectively through tighter clinical integration and coordination across specialties and care settings.
The document discusses the Patient Protection and Affordable Care Act (PPACA), also known as Obamacare. It established protections for American citizens to make healthcare more affordable and accessible. The PPACA provides subsidies to lower costs and requires insurance companies to spend a minimum percentage on actual healthcare. It also increased the number of insured Americans, leading to a higher demand for physicians and changes in how hospitals are funded.
Trends From The Trenches : Adapting to Affordable Care Act: Provider and Heal...Andrea Simon
As the Affordable Care Act is implemented and healthcare expenditures continue to rise, providers and payers need to explore how to best set themselves up to succeed in an evolving marketplace. In this 5th webinar, Margaret Davino will discuss how the relationships between hospitals, physicians and other providers are changing and what structures are being used for providers and payers to work together, including accountable care organizations (ACOs). Margaret will also describe the different models of collaboration between hospitals and physicians, how these affect reimbursement, and what to expect in the future.
A renowned expert on health care and health care law, Linda Rouse O’Neill, Vice President of Government Affairs at HIDA shared this presentation at AORN's 60th Annual Congress in early March 2013. These slides provide an overview of the current (and future) state of health care in the U.S. including the sequestration, the Affordable Health Care Act, and other pressing issues that affect the health care industry.
Healthcare Reform and the Impact on Healthcare Manufacturers
Health Law Update June 2012
1. June 2012
In This Issue:
New OIG Opinion on Anesthesia/ASC Arrangements
CMS: Independence at Home Demonstration Project
CMS: Increasing Payment for Primary Care
Strike Force Take-Down Unparalleled
Brach Eichler in the News
HIPAA Corner
FEDERAL UPDATE they cannot do directly; that is, to receive compensation in the form of a
portion of the [anesthesia group’s] revenues, in return for the referrals.”
OIG Disapproves of Proposed Anesthesiology For additional information, contact:
Arrangements with ASCs John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com
Mark E. Manigan | 973.403.3132 | mmanigan@bracheichler.com
The United States Department of Health & Human Services Office
of Inspector General (OIG) recently issued Advisory Opinion
No. 12-06 addressing anesthesiology arrangements with ambulatory
surgical centers (“ASCs”). The advisory opinion was in response
OIG Approves Supermarket and Pharmacy
to an anesthesiology group’s request for clarification concerning Rewards Program
two possible contractual scenarios.
The United States Department of Health & Human Services
In Proposed Arrangement A, the anesthesiology group would Office of Inspector General (OIG) issued Advisory Opinion No.
enter into an arrangement with an ASC to bill and collect for 12-05 relating to a rewards program contemplated by an organization
the provision of anesthesia services for patients of the ASC. The operating supermarkets and pharmacies. Under the proposal, the
anesthesia group would enter into a management agreement organization would provide customers a discount of 10 cents per
pursuant to which the anesthesia group would pay the ASC a gallon on gasoline purchases when they spend $50 in the supermarket
management fee for providing pre-operative nursing assessments or pharmacy on “allowable purchases.” The out-of-pocket costs
and assistance with transferring billing documentation to the (including deductibles and co-payments on federally reimbursable
anesthesia group’s billing office. The management fee would be in prescription items) would be eligible to earn the gasoline discounts.
the form of a “per patient” fee for non-Medicare patients, which the
group certified was set at fair market value. The OIG determined that the arrangement would not violate the
federal civil monetary penalty law (CMP) or anti-kickback statute.
The OIG advised that arrangements that “carve out” Medicare
business/patients may be disguised revenues related to non-Medicare With respect to the CMP, the OIG noted that many customers
business. As a result, the OIG determined that there is risk that the would receive discounts in excess of the CMP’s existing exception
anesthesia group would be paying the management fees with regard for nominal incentives valued at up to $10 per item or $50 per year.
to non-Medicare patients to induce the ASC’s referral of all of its However, a new exception under the Affordable Care Act (6402(d)(2)
patients, including Medicare patients. (B)) allows for rewards offered by retailers. The OIG found that
the arrangement satisfied the new exception because (1) the reward
In Proposed Arrangement B, the physician-owners of the ASCs would consist of a coupon or rebate from the retailer; (2) the rewards
would form a separate corporate entity for the sole purpose of billing were offered on equal terms regardless of health insurance status;
ASC patients for the provision of anesthesia services. The entity and (3) the rewards were not tied to the provision of other items or
would engage the anesthesia group as an independent contractor services reimbursed by federal health care programs.
to provide the following services: recruiting, credentialing and
scheduling anesthesia personnel; ordering and maintaining supplies The OIG found minimal risk of fraud and abuse under the anti-
and equipment; assisting the entity in selecting and working with a kickback statute because customers would not be required to
billing company; monitoring and overseeing regulatory compliance; purchase prescription items or other federally-reimbursable
providing financial reports; implementing quality assurance products, they would not receive an incentive for transferring
programs; and providing logistics services. their prescriptions to the organization’s pharmacies and the
arrangement was unlikely to result in overutilization or otherwise
The OIG declined to approve the arrangement, and expressed increase costs to federal health care programs.
concern that the arrangement is a suspect contractual joint venture,
exposing the group to potential violation of the anti-kickback For additional information, contact:
statute. Citing its 2003 Advisory Bulletin concerning contractual Kevin M. Lastorino | 973.403.3129 | klastorino@bracheichler.com
joint ventures, the OIG determined that the proposed arrangement is
Carol Grelecki | 973.403.3140 | cgrelecki@bracheichler.com
“designed to permit the ASC’s physician-owners to do indirectly what
continued on page 2
2. BRACH EICHLER
CMS Announces First Round of Participants for calendar years (CYs) 2013 and 2014
Independence at Home Demonstration Project • rants states more than $11 billion in federal funds over two
G
years to support Medicaid primary care delivery systems
On April 26, 2012, the Centers for Medicare Medicaid Services • pplies to primary care services delivered by physicians
A
(CMS) announced that it has selected the 16 initial health care specializing in family medicine, general internal medicine
providers to take part in a demonstration project, created by the or pediatric medicine, and related subspecialists
Affordable Care Act, allowing Medicare patients with chronic
conditions to receive care at home. The project, called “Independence • rovides guidance on identification of eligible primary care
P
at Home,” with a start date of June 1 and an end date of May 31, 2015, services and providers, implementation of increased payments
is intended to test a service delivery model using physician and nurse and payment of vaccine administration fees under the Vaccine
practitioner-directed primary care teams to provide services to certain for Children program.
Medicare beneficiaries in their homes. In its press release, CMS states The temporary increase in payment for primary care services
that the participants of this demonstration project “will test whether will be paid entirely by the federal government, with no state
delivering primary care services in the home can improve the quality matching of payment required. In particular, states will receive
of care and reduce costs for patients living with chronic illnesses.” 100% federal financial participation for the difference between
Up to 50 health care providers will ultimately be chosen to participate the Medicaid state plan payment amount as of July 1, 2009, and the
in the project, each of which must serve at least 200 Medicare Medicare rates in effect in CYs 2013 and 2014 or, if greater,
fee-for-service beneficiaries with multiple chronic conditions and the payment rate that would be applicable using the CY 2009
functional limitations. Medicare conversion factor. The proposed regulations also note
For additional information, contact:
that, “[a]s we move towards CY 2014 and the expansion of Medicaid
eligibility, it is critical that a sufficient number of primary care
Todd C. Brower | 973.403.3103 | tbrower@bracheichler.com physicians participate in the [Medicaid] program,” and these rate
Carol Grelecki | 973.403.3140 | cgrelecki@bracheichler.com increases “will encourage primary care physicians to participate in
Medicaid by increasing payment rates.”
For additional information, contact:
Medicare Health Outcome Survey Open
Joseph M. Gorrell | 973.403.3112 | jgorrell@bracheichler.com
for Comments
Debra C. Lienhardt | 973.364.5203 | dlienhardt@bracheichler.com
On April 27, 2012, the Centers for Medicare Medicaid Services
(CMS) published a notice in the Federal Register that it is seeking
to revise the Medicare Health Outcome Survey (HOS) to better CMS Issues Rules Easing Regulations for
identify possible fraud.
Hospitals and Health Care Providers
By way of background, the HOS is the first patient-reported
outcomes measure used in Medicare managed care. The goal On May 16, 2012, the Centers for Medicare Medicaid Services
of the HOS program is to gather valid, reliable and clinically published two final rules in the Federal Register, to eliminate rules
meaningful health status data in the Medicare Advantage (MA) that the U.S. Department of Health Human Services (HHS) has
program for use in quality improvement activities, pay for determined are unnecessary, obsolete or burdensome on American
performance, program oversight, public reporting and improving hospitals and health care providers.
health. All managed care organizations with MA contracts must The first rule revises Medicare Conditions of Participation (CoPs)
participate. Additional information regarding the survey can be for hospitals and is anticipated to save $940 million per year. The
found at http://cms.gov/HOS. revisions include:
For additional information, contact: • llowing a single governing body for multiple hospitals in
A
a multi-hospital system
Kevin M. Lastorino | 973.403.3129 | klastorino@bracheichler.com
• roadening the concept of “medical staff” to allow hospitals
B
Debra C. Lienhardt | 973.364.5203 | dlienhardt@bracheichler.com
to include other practitioners, such as advance practice nurses,
physician assistants and pharmacists, on a hospital’s medical staff
CMS Issues Proposed Rule on Increasing • llowing hospitals to have an optional program for patients
A
to self-administer certain medications
Payment for Primary Care
• Allowing hospitals to use standing orders, order sets and protocols
On May 9, 2012, the Centers for Medicare Medicaid Services • liminating the requirement for authentication of verbal orders
E
(CMS) issued a proposed rule that seeks to increase Medicaid within 48 hours and instead require that authentication occur in
payments for certain primary care services. Among other changes, compliance with state laws
the proposed rule:
• liminating the requirement that hospitals maintain an infection
E
• mplements the Affordable Care Act’s requirement that
I control log
Medicaid reimburse primary care physicians for services CMS
• liminating the requirement of a single director of outpatient
E
designates as “primary care services” at Medicare rates instead
services position.
of state-established Medicaid rates (which often are lower) in
2
3. BRACH EICHLER
The second rule, the “Medicare Regulatory Reform” rule, seeks to clarify waiver, disclosure and payment issues for out-of-network
to promote efficiency by eliminating duplicative, overlapping and (OON) benefits. While a laudable goal, the bill instead creates
outdated regulatory requirements for health care providers. HHS more problems than it seeks to resolve. Under the bill, if a provider
anticipates savings of $200 million in the first year this rule is in furnishes OON services, the provider must make at least three
effect. Provisions of the rule include: documented good faith attempts to collect before waiving the patient’s
• liminating outdated ambulatory surgical center infection control
E financial responsibility. Waiver would then be permissible only if due
programs (a new CoP dedicated to infection control makes this to a medical or financial hardship, only if waivers are not routinely
requirement duplicative) given, and only if the patient’s insurer is notified. This is generally
consistent with current case law and regulatory guidance in New Jersey.
• etiring older versions of e-prescribing truncations for Medicare
R
Part D and adopting the newer versions to be in compliance with However, the bill also indicates that, if an OON provider furnishes
current e-prescribing standards services in an in-network licensed facility, the provider cannot bill
the patient beyond the patient’s in-network co-payment, co-insurance
• imiting mandatory compliance with the Life Safety Code to End
L
or deductible. In essence, the OON provider would receive payment
Stage Renal Disease Facilities located adjacent to “high hazardous”
as if he was in-network. Moreover, it is unclear whether the OON
occupancies and those facilities that do not have a readily available
provider who is paid based on in-network rates would have any
exit to the outside
contractual protections or rights against the insurer. Indeed, there
• emoving outdated personnel qualifications for physical and
R would be no signed contract between the OON provider and the
occupational therapists in the current Medicaid regulations. insurer. Additionally, it is unclear whether an OON provider can be
forced to accept in-network rates that he never negotiated or agreed
For additional information, contact:
to. Furthermore, it is unclear whether the OON provider can bill,
Lani M. Dornfeld | 973.403.3136 | ldornfeld@bracheichler.com if at all, the in-network facility or the insurer for the difference
Keith J. Roberts | 973.364.5201 | kroberts@bracheichler.com between the in-network and OON rates.
If enacted, the bill would also lead to providers having less
leverage in contract negotiations with insurers.
Strike Force Take-Down Unparalleled The bill is being watched closely by physicians, ambulatory
surgery centers and hospitals, all of which have voiced opposition.
A seven-city sweep last month resulted in the arrest of 107 defendants
in the largest take-down since the establishment of the Medicare For additional information, contact:
Strike Force. Medicare fraud schemes are alleged to have resulted in Mark E. Manigan | 973.403.3132 | mmanigan@bracheichler.com
payments of over $452 million due to false billing. Payments have also John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com
been halted to more than 52 health care providers suspected of fraud
before payments were made. More than 500 law enforcement agents
participated in the take-down. Christie Vetoes Bill to Create Health Care Exchanges
The strike force is a joint effort by the Department of Health and
Tied to Health Care Reform Law
Human Services and the Office of Inspector General, designed to
work together and weed out Medicare fraud. The defendants include New Jersey Governor Christie recently vetoed a bill (A-2171) that would
physicians, nurses and health care company owners, charged with
have set up a statewide health insurance exchange in New Jersey as
crimes ranging from money laundering to anti-kickback violations.
required by the Affordable Care Act (ACA), stating that it would be
Other charges include false billing for services that were either never
provided or not deemed medically necessary. Various services were imprudent to create an exchange until the U.S. Supreme Court has
involved in the schemes, including home health care, mental health, ruled on the constitutionality of the ACA. Governor Christie is the
psychotherapy, physical and occupational therapy, durable medical second governor this year to veto a health insurance exchange bill.
equipment and ambulance services. Charges were brought against
For additional information, contact:
defendants in Miami, Baton Rouge, Houston, Los Angeles, Detroit,
Tampa and Chicago. Joseph M. Gorrell | 973.403.3112 | jgorrell@bracheichler.com
Todd C. Brower | 973.403.3103 | tbrower@bracheichler.com
For additional information, contact:
Keith J. Roberts | 973.364.5201 | kroberts@bracheichler.com
Joseph M. Gorrell | 973.403.3112 │jgorrell@bracheichler.com
Brach Eichler In The News
John Fanburg presented a webinar, “What’s Happening in the New
STATE UPDATE Jersey Medical Practice Acquisition Market?” for the Medical Society
of New Jersey on April 25.
Health Care Disclosure and Transparency
Act Appears Murky On June 14, Brach Eichler hosted the 4th annual NJ ASC Review,
held at Ocean Place in Long Branch.
On May 10, 2012, a bill was introduced in the New Jersey legislature
entitled the Health Care Disclosure and Transparency Act (A.2751) continued on page 4
3
4. BRACH EICHLER
On June 14, Todd C. Brower and Lani M. Dornfeld presented Schwarzenegger, without authorization. Soon thereafter, UCLA
“Hot Button Areas in Compliance and How to Implement an terminated the defendant after a formal internal grievance hearing.
Effective Compliance Plan” at the Annual Home Care Association
In 2008, the United States Attorney’s Office for the Central District
Meeting in Atlantic City.
of California charged Zhou with a misdemeanor violation of
Brach Eichler is a sponsor of the New Jersey Healthcare Real Estate HIPAA’s prohibition against “knowingly” obtaining individually
Summit, June 27 at the Newark Club. Alan Hammer will moderate
identifiable health information in violation of HIPAA. Zhou moved
the keynote panel discussion featuring industry leaders like Barry
Ostrowsky, President CEO of Barnabas Health System, and to dismiss the charge on the basis that the word “knowingly” in
Barry Rabner, President CEO of Princeton HealthCare System. HIPAA required that he have knowledge that it was illegal to obtain
such protected health information. However, a federal magistrate
Jonathan Bick authored an article in the April 30 New Jersey Law
Journal, Health Care Law, entitled Applying Technology to the judge denied the motion. Zhou entered a conditional guilty plea,
Business of Health Care. reserving his right to appeal the denial of his motion to dismiss.
On appeal, Zhou claimed that the use of the word “knowingly” in
HIPAA CORNER the statute means that an individual could not be prosecuted for
violating the statute unless he knew his actions were illegal. The
Ninth Circuit Court Finds that Knowledge Not Ninth Circuit rejected Zhou’s interpretation and held that, “as
Required for HIPAA Criminal Liability used in the statute, the term ‘knowingly’ applies only to the act of
On May 10, 2012, the United States Court of Appeals for the Ninth obtaining the health information,” and did not require an individual
Circuit held, in United States v. Zhou, No. 10-50231 (9th Cir. May to know that his actions may have violated HIPAA. The Court’s
10, 2012), that HIPAA’s criminal misdemeanor provision, which upholding of the denial of the motion to dismiss made effective
penalizes the unauthorized access of patient health information, does Zhou’s guilty plea, with a sentence of four months in prison and a fine
not require a defendant to know that his or her actions were illegal of approximately $2,100.
under the statute. Although not binding outside of the Ninth Circuit, this recent
By way of background, in October of 2003, the defendant, Huping decision is significant because it emphasizes how easily individuals
Zhou, a research assistant at the University of California at Los who do no more than access health information out of curiosity
Angeles (UCLA) Health System, received a notice of UCLA’s intent can be found criminally liable.
to dismiss him for poor performance. On that same evening, Zhou For additional information, contact:
allegedly accessed the patient records of co-workers and well-
Todd C. Brower | 973.403.3103 | tbrower@bracheichler.com
known actors, including Tom Hanks, Drew Barrymore and Arnold Lani M. Dornfeld | 973.403.3136 | ldornfeld@bracheichler.com
Attorney Advertising: This publication is designed to provide Brach Eichler, L.L.C. clients and contacts with information they
can use to more effectively manage their businesses. The contents of this publication are for informational purposes only.
Neither this publication nor the lawyers who authored it are rendering legal or other professional advice or opinions on
specific facts or matters. Brach Eichler, L.L.C. assumes no liability in connection with the use of this publication.
Health Care Practice Group | 101 Eisenhower Parkway, Roseland, NJ 07068 | 973.228.5700
Members
Todd C. Brower | 973.403.3103 | tbrower@bracheichler.com Carol Grelecki | 973.403.3140 | cgrelecki@bracheichler.com
Lani M. Dornfeld | 973.403.3136 | ldornfeld@bracheichler.com Kevin M. Lastorino | 973.403.3129 | klastorino@bracheichler.com
John D. Fanburg, Chair | 973.403.3107 | jfanburg@bracheichler.com Debra C. Lienhardt | 973.364.5203 | dlienhardt@bracheichler.com
Joseph M. Gorrell | 973.403.3112 | jgorrell@bracheichler.com Mark E. Manigan | 973.403.3132 | mmanigan@bracheichler.com
Keith J. Roberts | 973.364.5201 | kroberts@bracheichler.com
Counsel
Richard B. Robins | 973.403.3147 | rrobins@bracheichler.com
Associates
Lindsay P. Cambron | 973.364.5232 | lcambron@bracheichler.com Colleen McClafferty | 973.364.5210 | cmcclafferty@bracheichler.com
Jenny Carroll | 973.364.5223 | jcarroll@bracheichler.com Conor F. Murphy | 973.364.5214 | cmurphy@bracheichler.com
Jordan T. Cohen | 973.403.3144 | jcohen@bracheichler.com Isai Senthil | 973.403.3150 | isenthil@bracheichler.com
Chad Ehrenkranz | 973.364.5234 | cehrenkranz@bracheichler.com Edward J. Yun | 973.364.5229 | eyun@bracheichler.com
Rita M. Jennings | 973.364.5204 | rjennings@bracheichler.com
You have the option of receiving your Health Law Updates via e-mail if you prefer, or you may continue to receive them in hard copy.
If you would like to receive them electronically, please provide your e-mail address to alevine@bracheichler.com. Thank you.
4