Tavenner: No ICD-10 Delay, But Expect Some MU Relief

Lena J. Weiner, for HealthLeaders Media , February 27, 2014

CMS Administrator Marilyn Tavenner has announced that the ICD-10 deadline will not be delayed, but she is offering relief to providers, payers, and health information technology vendors struggling to meet Meaningful Use Stage 2 requirements.

Two announcements from Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner at the HIMSS 2014 conference in Orlando Thursday will have wide-ranging implications for healthcare providers, insurers, and vendors.

The deadline for implementing the ICD-10 diagnostic coding set, which had already been delayed one year to October 1, 2014, will not be delayed again, Tavenner said.

And while the Stage 2 Meaningful Use deadline will also not be delayed, Tavenner said that providers and vendors struggling to meet the incentive program's requirements will see some flexibility.

During the keynote presentation Thursday morning at HIMSS 14 in Orlando, Tavenner announced a partial reprieve for physicians and medical systems finding it difficult to adjust to Meaningful Use guidelines—but urged professionals to come up to speed quickly.

"We have decided to permit flexibility on how hardship exemptions will be granted," Tavenner said. "I must stress we expect all providers to meet requirements in 2015. I urge you to meet the requirements this year." Scattered applause broke from members of the crowd as Tavenner made the announcement.

"We certainly have experienced… difficulties, and I can personally relate to the challenges of new systems, relationships with vendors, and charting a course through previously unnavigated waters," Tavenner said, referring to the well-documented difficulties with thehealthcare.gov website.

When confronted by a question regarding patient safety during the Q & A session after the keynote, National Coordinator for Health Information Technology, Karen DeSalvo, said, "We are exploring our options to help you… we want to make sure you are not penalized for doing the right thing."

These comments come at a time when many within the healthcare industry are expressing concerns regarding the ability to adopt the Meaningful Use standards as specified in the HITECH act. On the Friday before HIMSS, more than 40 healthcare industry groups penned a letter to Health and Human Services Secretary Kathleen Sebelius seeking more time for Meaningful Use attestation, and citing concerns over patient safety and lack of vendor support.

On Thursday, in an exclusive interview with HealthLeaders Media, Intermountain Healthcare CIO Marc Probst disclosed that his organization is unready to seek MU Stage 2 attestation and will forgo incentive payments and trigger penalties.

'It's Time to Move On'While concerns from within the industry are being taken seriously, there will be no turning back. While CMS will be offering exemptions on a case-by-case basis, "Now is not the time for us to stop moving forward," Tavenner said. She was especially unyielding regarding the new ICD-10 coding system.

"Let's face it guys; it's time to move on," Tavenner said. "There will be no change in the deadline for ICD-10. CMS began installing and testing systems for ICD-10 in 2011. All fee for service systems at CMS are ready."

Earlier this month, in response to concerns raised by providers and a group of U.S. senators, CMS agreed to perform end-to-end ICD-10 testing with a small sample group of providers selected to represent "a broad cross-section of provider types, claims types, and submitter types."

The College of Healthcare Information Management Executives (CHIME) responded to Tavenner's comments at HIMSS in a statement released shortly after the keynote speech.

"[CHIME] welcomes CMS Administrator Marilyn Tavenner's announcement this morning, acknowledging the need to provide relief for our nation's providers. Such relief is vitally important for the future success of Meaningful Use, as ICD-10 deadlines and continued shifts in payment policies demand an ever-increasing amount of IT and workforce resources," the statement read.

In the event that expansion of the Hardship Expectations provides the "kind of relief the industry desperately needs," CHIME will pledge to assist CMS "in every way possible," the statement continued. "It will be CHIME's highest policy priority to ensure that providers receive the kind of relief they need in order to deliver quality care."

http://www.healthleadersmedia.com/print/TEC-301496/Tavenner-No-ICD10-Delay-But-Expect-Some-MU-Relief

(CMS) Proposes to Restrict Diagnoses from Home Visits for Medicare Advantage Risk Adjustment

Centers for Medicare and Medicaid Services 

The Centers for Medicare and Medicaid Services has proposed to limit how Medicare Advantage Organizations can use in-home wellness or risk assessment visits of their enrollees to affect the risk adjusted payments they receive.  The proposal could cause a reduction in the number of such visits and lower overall payments to Medicare Advantage Organizations.
The Centers for Medicare and Medicaid Services (CMS) recently proposed to limit Medicare Advantage Organizations’ (MAOs’) ability to use diagnoses obtained from home risk assessments for Medicare Advantage (MA) risk-adjusted payments.  This is among several significant proposals in the Advance Notice of Methodological Changes for Calendar Year (CY) 2015 for MA Capitation Rates, Part C and Part D Payment Policies and 2015 Call Letter (the Advance Notice), published on February 21.
The Advance Notice includes other significant provisions affecting the MA and Part D programs, including revised MA payment rates and changes to provider network policies.  Comments from MAOs and other interested parties must be submitted by March 7, 2014.  CMS is expected to issue its final notice on April 7, 2014.

The Proposal and Its Background

The proposal would require that diagnoses from a home visit be excluded from risk adjustment, unless a subsequent clinical encounter confirms such diagnoses.  CMS’ proposal would not affect risk assessments conducted outside the home.
Risk adjustment modifies the capitation payments that MAOs receive to reflect the health status of their enrollees, thereby eliminating incentives for MAOs to avoid enrolling less healthy beneficiaries.  CMS’ risk adjustment methodology identifies enrollees’ health status based on diagnoses for those enrollees.
The present proposal follows a similar one in the 2013 Advance Notice, which was not finalized.  In 2013, CMS initially proposed to eliminate diagnoses identified in all risk assessment visits.  However, in its final notice issued in April 2013, CMS did not implement any such requirement and stated it would further study the issue.
CMS subsequently required that, for all 2014 dates of service, MAOs’ risk-adjustment submissions must code whether the visit was in a clinical setting or in the home.  For home visits, MAOs are additionally required to identify whether the visit is an Annual Wellness Visit, as that term is used in traditional Medicare.  The current proposal would apply to diagnoses from visits performed in 2014, which CMS uses for purposes of CY 2015 payments.

CMS’ Reasons for the Proposed Change

CMS’ proposal expresses skepticism about the clinical value of in-home risk assessments.  Indeed, CMS states that “to the extent that commenters believe that home assessments improve care, and are not just efforts to increase the diagnoses collected,” CMS would like to receive specific and measurable ways to identify and use certain home risk assessment diagnoses.
CMS notes that in-home risk assessments “are typically conducted by healthcare professionals who are contracted by the vendor and are not part of the plan’s contracted provider network, i.e., are not the beneficiaries’ primary care providers” and do not include treatment.  CMS also states that there is “little evidence that beneficiaries’ primary care providers actually use the information collected in these assessments or that the care subsequently provided to beneficiaries is substantially changed or improved as a result of the assessments.”
CMS suggests that if in-home risk assessments are, in fact, used to guide treatment, then diagnoses should also be documented in a follow-up visit in a clinical setting.  The Advance Notice suggests that the proposal would ensure that in-home risk assessments “serve as an effective vehicle to improve follow-up care and treatment for beneficiaries.”
CMS also expresses concern that diagnoses from risk assessments performed in the home inflate risk scores, without a corresponding increase in MA plan financial liability, and contribute to differences in coding patterns between MA and Fee For Service Medicare.  Although the Advance Notice expresses skepticism about whether risk assessments have real clinical value, it does not expressly state that CMS believes diagnoses obtained through these visits are inaccurate.

Impact of the Proposal

Home risk assessments have been used in MA to enhance the management and coordination of members’ care and are an additional avenue by which members’ conditions are identified and documented in a medical record.
CMS’ proposal to require a subsequent clinical encounter would limit the value of home risk assessment visits for risk-adjustment purposes, since the risk assessment visit by itself would be insufficient to support a diagnosis.  If there is no subsequent clinical encounter or the provider in the subsequent encounter fails to submit the diagnosis or properly record it in their medical records, the diagnosis and documentation from the home risk assessment visit could, apparently, not be used to establish the member’s condition.  The proposal does not define what qualifies as a “subsequent clinical encounter,” nor does it specify whether the subsequent clinical encounter must occur during the same data-collection period as the risk assessment.
The proposal could potentially increase MAOs’ exposure in Risk Adjustment Data Validation Audits, since documentation from risk assessment visits can presently be used to support diagnoses.  The proposal does not directly address whether medical record documentation from a home risk assessment visit could still be used in a Risk Adjustment Data Validation Audit, if medical record documentation from a subsequent visit in a clinical setting is deemed insufficient.

Timing

After allowing for a brief comment period, CMS will issue its final policy for CY 2015 in April 2014.  However, CY 2015 risk adjustment payments are based on diagnosis data from encounters during 2014, including encounters that occur before the final policy is issued in April.  The current proposal does not specify whether it would apply to data from risk assessment visits that occur before any changed policy is finalized or would be limited to risk assessment visits that occur after that date.

Conclusion

CMS’ proposal may have a significant impact on home risk assessment visits in MA.  MAOs should consider commenting on the proposal.  In addition, MAOs should consider what operational adjustments they may need to make with respect to risk assessments performed in 2014.

http://www.natlawreview.com/article/centers-medicare-and-medicaid-services-cms-proposes-to-restrict-diagnoses-home-visit

Fort Drum Regional Health Planning Organization is looking for it's first Executive Director

A six-hospital effort that has been finding ways to work together to reduce unnecessary, repeat Medicaid readmissions and create efficiencies in health care delivery may have its first executive director by April 1.

Operating in partnership with the Fort Drum Regional Health Planning Organization, the North Country Initiative director will oversee the program’s administration and help develop a management services organization and a clinically integrated network.

“As it moves forward, it’ll need staffing in order to meet goals of the organization,” said Denise K. Young, FDRHPO executive director.

River Hospital, Alexandria Bay; Samaritan Medical Center; Carthage Area Hospital; Lewis County General Hospital, Lowville; Clifton-Fine Hospital, Star Lake, and Claxton-Hepburn Medical Center, Ogdensburg, have worked in collaboration throughout the past two years to initiate a plan that could curb costs and create healthier communities.

Through those efforts, hospital administrators determined a management service organization would provide centralized nonphysician services and functions to all participating hospitals. What may be included could be joint purchasing, reference laboratories and synchronized revenue cycles, such as billing, coding, collection and admissions. A clinically integrated system would involve outcome-based measurements and physicians working collaboratively.

Meanwhile, Mrs. Young said, applications for the North Country Initiative’s top post already have come in.

“I think we have a good pool that we’ll get to begin interviewing next week,” she said.

According to a position description, which was posted on FDRHPO’s Facebook page, the director will be responsible for helping to develop the initiative’s business plan and budget and overseeing daily operations.

Up until this point, River Hospital Chief Executive Officer Ben Moore III has served as the group’s spokesman. The position description states that the initiative director will coordinate development and will be responsible for all communication materials. The director will work closely with hospital administrators, community members, community groups and various health organizations.

Once initial steps are complete, the director also will determine the North Country Initiative’s total staffing requirements.

FDRHPO is looking for someone with a master’s degree in health care administration or a related field, and at least five years’ experience in leading or working with independent employed physicians or other professionals. Resumes are due Saturday. For more information, email Mrs. Young at dyoung@fdrhpo.org.

CMS and OIG announce plan to exclude “recalcitrant providers”

Faegre Baker Daniels

• Thomas W. Beimers
• USA
• January 31 2014
• 

Author page »

In a move that made little immediate splash, but has since received considerable media attention, including a recent article in the New York Times, the Department of Health & Human Services announced that it will take additional steps against “recalcitrant providers,” including exclusion from participation in federal health care programs. CMS issued a notice, on January 15, stating that it intends to refer recalcitrant providers to the Office of the Inspector General, which will review the cases for potential administrative action.

CMS defines a “recalcitrant provider” as one who is “abusing the program and not changing inappropriate behavior even after extensive education to address these behaviors.” The definition refers to existing procedures whereby a program contractor who identifies improper billing may require the offending provider to obtain education. Contractors sometimes place providers on pre-payment review if their billing practices continue to raise red flags. In the program directive, CMS noted that some providers remain on pre-payment review for years. The new program is intended to provide another level of review for providers who are a drain on CMS contractor resources.

Last year, OIG excluded over 3,000 providers from participation in Federal health care programs. Most of these exclusions are mandatory, and typically are triggered by a violation of the law. The exclusions contemplated by the new CMS initiative will be permissive, meaning that OIG will need to make an affirmative case for exclusion, and the department will provide the physician with an opportunity to have the matter adjudicated by an administrative law judge.

The initiative is reflective of the government’s continued focus on fraud, waste, and abuse in federal health care programs, which many sources estimate at over $10 billion per year.

http://www.lexology.com/library/detail.aspx?g=450e5463-1cad-4b11-b4df-7605cc5069d8

Medical Homes and Quality of Care, Costs

(HealthNewsDigest.com) - Chicago - One of the first, largest, and longest-running multipayer trials of patient-centered medical home medical practices in the United States was associated with limited improvements in quality and was not associated with reductions in use of hospital, emergency department, or ambulatory care services or total costs of care over 3 years, according to a study in the February 26 issue of JAMA.

The patient-centered medical home is a team-based model of primary care practice intended to improve the quality, efficiency, and patient experience of care. Professional associations, payers, policy makers, and other stakeholders have advocated for the patient-centered medical home model. In general, medical home initiatives have encouraged primary care practices to invest in patient registries, enhanced access options, and other structural changes that might improve patient care in exchange for enhanced payments, according to background information in the article. Dozens of privately and publicly financed trials of the medical home model are under way. "Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear," the authors write.

Mark W. Friedberg, M.D., M.P.P., of the RAND Corporation, Boston, and colleagues measured associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, a multipayer medical home program, and changes in the quality, utilization, and costs of care. Pilot practices could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA). Thirty-two volunteering primary care practices participated in the pilot (conducted from June 2008 to May 2011). Using claims data from 4 participating health plans, the researchers compared changes in care (in each year, relative to before the intervention) for 64,243 patients who were attributed to pilot practices and 55,959 patients attributed to 29 comparison practices. Measured outcomes included performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care.

Pilot practices successfully achieved NCQA recognition and reported structural transformation on a range of capabilities, such as use of registries to identify patients overdue for chronic disease services (increased from 30 percent to 85 percent of pilot practices) and electronic medication prescribing (increased from 38 percent to 86 percent). Pilot practices accumulated average bonuses of $92,000 per primary care physician during the 3-year intervention.
Of the 11 quality measures evaluated, pilot participation was significantly associated with greater performance improvement, relative to comparison practices, on only l measure: monitoring for kidney disease in diabetes. There were no other statistically significant differences in measures of utilization, costs of care, or rates of multiple same-year hospitalizations or emergency department visits.

The authors conclude that "a multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years."
"Despite widespread enthusiasm for the medical home concept, few peer-reviewed publications have found that transforming primary care practices into medical homes produces measurable improvements in the quality and efficiency of care."

The authors add that their "findings suggest that medical home interventions may need further refinement."
(doi:10.1001/jama.2014.353)

Editor's Note: This study was sponsored by the Commonwealth Fund and Aetna. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.
Editorial: The Patient-Centered Medical Home - One Size Does Not Fit All

"Before confidently promoting the patient-centered medical home (PCMH) as a core component of health care reform, it is necessary to better understand which features and combination of features of the PCMH are most effective for which populations and in what settings," writes Thomas L. Schwenk, M.D., of the University of Nevada School of Medicine, Reno, in an accompanying editorial.

"The identification of specific PCMH features for various risk strata will likely have significant influence on the work patterns of physicians, who may be responsible for a larger panel of patients than currently but for whom only routine care is needed, often by other members of the health care team. The physician's time and expertise will be best focused on a relatively small number of the most complex and expensive patients."
(doi:10.1001/jama.2014.352)

http://www.healthnewsdigest.com/news/Research_270/Medical-Homes-and-Quality-of-Care-Costs.shtml

Norwalk physical therapist charged on 46 counts of fraud, as well as obstruction of an audit.

Written by Aaron Boyd.

A Norwalk physical therapist was arrested Monday on 46 counts of health care fraud and one count of obstruction of a federal audit.

Danielle Faux, 46, of Weston, owns and manages a physical therapy operation, Danielle Faux PT, LLC, and is also part owner in Achieve Rehab and Fitness gym, both on Lois Street in Norwalk.

According to court documents, Faux would refer clients to Achieve Rehab and Fitness for personal training sessions but bill them through Medicare as physical therapy. 

Documents also allege that Faux fabricated and altered patient records before a Medicare audit in August 2009.

Faux was indicted on Feb. 19 and, if convicted, faces 10 years in prison and fines of up to $250,000 for each count of health care fraud — a total of 460 years and $11.5 million — and 5 years imprisonment and a $250,000 fine for the count of obstruction.

Faux pleaded ‘not guilty’ on all charges Monday and was released on $50,000 bond.

http://greenwich.patch.com/groups/police-and-fire/p/physical-therapist-faces-465-years-12m-fine-for-medicare-fraud_50f896ad

Holder, Sebelius tout billions in healthcare fraud recoveries

The U.S. recovered $4 billion last year through healthcare fraud prevention and enforcement efforts, according to a report released Wednesday by Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius.

The report says that the Health Care Fraud and Abuse Control Act (HCFAC) recovered more than $8 for every $1 it spent on healthcare fraud investigations over the last three years, the best ratio in the 17-year history of the program.

“With these extraordinary recoveries, and the record-high rate of return on investment we’ve achieved on our comprehensive health care fraud enforcement efforts, we’re sending a strong message to those who would take advantage of their fellow citizens, target vulnerable populations, and commit fraud on federal health care programs,” Holder said in a statement.

The joint effort between the Department of Justice and HHS has recovered more than $19 billion over the last four years, the agencies said.

In addition, the report said the agency strike forces filed 137 cases, charged 345 individuals, secured 234 guilty please, and won 48 trial convictions. All of these are record highs, according to the DOJ and HHS.

“These impressive recoveries for the American taxpayer are just one aspect of the comprehensive anti-fraud strategy we have implemented since the passage of the Affordable Care Act,” Sebelius said in a statement.

Around the time of the passage of the Affordable Care Act, President Obama launched initiatives aimed at rooting out waste and fraud in Medicare and Medicaid, saying that federal overpayments to doctors and hospitals, and other misallocated funds, should be recovered and redirected to patients.

“We’ve cracked down on tens of thousands health care providers suspected of Medicare fraud,” Sebelius continued. “New enrollment screening techniques are proving effective in preventing high risk providers from getting into the system, and the new computer analytics system that detects and stops fraudulent billing before money ever goes out the door is accomplishing positive results – all of which are adding to savings for the Medicare Trust Fund.”

Still, the FBI says that the U.S. spends at least $80 billion a year in healthcare fraud.

http://thehill.com/blogs/healthwatch/health-reform-implementation/199276-holder-sebelius-tout-billions-in-healthcare

Health Literacy means Better Health! Play "2014 Health-e Olympics" Today!

Join Dr. D and Natalie as they host the 2014 Health-e Olympics!

2014 Health-e Olympics

"Welcome to the Village! Dr. D. and Natalie are so honored to be hosting this year's event. TEAM Health needs your help to reach the top of the mountain first! See you at the top..."

If your up for the challenge click the link to launch the game:

2014 Health-e Olympics

District court blocks hospital acquisition of physician practice

• Hogan Lovells
• Robert F Leibenluft, Leigh L Oliver
• USA
• February 13 2014
• 

Decision
Comment

Decision

In the first ever Federal Trade Commission (FTC)-litigated challenge to a hospital system's acquisition of a physician group, the US District Court for Idaho ruled in favour of the plaintiffs (ie, the FTC, the Idaho attorney general and St Alphonsus, a competing hospital system). The plaintiffs challenged St Luke's Health System's acquisition of the Saltzer Medical Group, a 41-physician multi-specialty group, including 16 adult primary care physicians, located in Nampa, Idaho. Among the key issues in the litigation were:

• geographic market definition;
• the likely impact on reimbursement rates; and
• whether the acquisition would facilitate a more integrated healthcare delivery system that would improve healthcare quality and efficiency.

A more detailed findings of fact and conclusions of law were filed under seal to give the parties and third parties an opportunity to object to the disclosure of any material that they deem to be sensitive and confidential.

In the memorandum decision and order, the court recognised that St Luke's strategy to deliver more integrated care by using primary care physicians as care coordinators would lead to improved care in the Treasure Valley, but the court concluded that this more integrated care could be achieved through means other than acquisition of the Saltzer physicians.

Comment

This ruling is important for stakeholders in the healthcare industry, particularly hospitals, health systems and provider groups that are considering affiliations, mergers or consolidations with other provider groups, as well as health plans. Notably:

• the acquisition was not reportable under the Hart-Scott-Rodino pre-merger notification process because the value of the transaction did not exceed the minimum threshold of $70.9 million;
• the geographic market definition for the provision of adult person-centred planning services was hotly contested; and
• both the plaintiffs and St Luke's presented expert testimony on the issue of whether employing physicians was necessary in order to achieve St Luke's strategy for integrated care.

http://www.lexology.com/library/detail.aspx?g=7811a603-37d7-48cc-a766-1e76b0ced27c

Meaningful use incentive payments top $19 billion, 88% of hospitals included

Nearly 88% of eligible hospitals have received a payment for participating in the EHR incentive program, as noted in data shared at a recent Health IT Policy Committee meeting. The payments were either given to providers who could attest to having fully installed and were using EHRs according to meaningful use criteria, or those who had yet to achieve meaningful use but were in the adopt/implement/upgrade phase with their EHR system. Through 2013, more than $19 billion in meaningful use incentive payments had been distributed to eligible professionals and hospitals.

In a meeting held last April, the Health IT Policy Committee laid down some ideas for the continued development of the meaningful use incentive program. Goals for stage 3 of the program — including whether to shift compliance requirements more toward effective use of data and away from technology adoption — was among the topics covered by the committee. For providers who have attested to previous stages of meaningful use, stage 3 compliance could depend more on patient outcomes and disease prevention.

CMS continues to adjust their deadlines to allow for greater participation in the meaningful use program. The agency recently extended both the stage 2 deadline and the reporting period for providers to receive incentive payments for 2013. The decision to prolong stage 2 was due to stakeholder concern that insufficient data would be available to fully assess its effectiveness before moving on to the third stage.

Extending stage 2 will not only give more providers a chance to receive incentive payments while transitioning to the ICD-10 codes, but it will also help define the next stage in the meaningful use process. Specifically, it will allow the policymakers more time to determine reasonable benchmarks to set for stage 3. It also grants vendors additional time to create and adjust their products to better suit providers’ needs.

http://searchhealthit.techtarget.com/healthitexchange/healthitpulse/meaningful-use-incentive-payments-top-19-billion-88-of-hospitals-included/

The new cost of ICD-10 Implementation: $225,000 for small practices and up to $8 million for large practices!

Making the switch from the ICD-9 to the ICD-10 diagnosis code set could cost as much as $225,000 for some small practices and up to $8 million in some large practices, according to a study from the American Medical Association.

Physician offices and hospitals must use the ICD-10 code sets beginning Oct. 1, but the preparation for the switch is taking years and involves hours of staff training, the purchase of new hardware and software, and testing with vendors and payers.

A follow-up report prepared for the AMA by Nachimson Advisors found that in certain cases, implementation costs are nearly three times higher than what the firm predicted in 2008.

In their original report, Nachimson Advisors estimated that it would cost more than $83,000 for a typical small practice (3 physicians, 2 administrative staff) to implement ICD-10, rising to $285,000 for a typical medium-size practice (10 physicians, 1 full-time coder, 6 administrative staff), and about $2.7 million for a typical large practice (100 physicians, 10 full-time coders, 64 administrative staff).

Now those costs are estimated to range from $56,000 to $226,000 for small practices and $213,000 to $824,000 for medium-size practices. And for large practices, implementing ICD-10 could cost anywhere from $2 million to $8 million.

About two-thirds of physician practices are expected to have costs in the upper range of those estimates, according to the AMA.

One reason for the increased cost is new requirements related to the adoption of electronic health records (EHRs). Nachimson Advisors also projects a larger potential for payment disruptions, estimating that 2%-6% of claims could be denied after the Oct. 1 implementation date.

"The markedly higher implementation costs for ICD-10 place a crushing burden on physicians, straining vital resources needed to invest in new health care delivery models and well-developed technology that promotes care coordination with real value to patients," Dr. Ardis Dee Hoven, AMA president, said in a statement. "Continuing to compel physicians to adopt this new coding structure threatens to disrupt innovations by diverting resources away from areas that are expected to help lower costs and improve the quality of care."

The AMA is calling on Health & Human Services secretary Kathleen Sebelius to reconsider ICD-10 implementation. But if the agency sticks to its plan, the AMA has requested several changes to mitigate some of the costs.

For example, the AMA recommends that Medicare provide a 2-year implementation period during which the agency would not be allowed to deny payments based on the specificity of the ICD-10 code provided. And the agency would provide feedback on coding to physicians during this time.

The AMA also is asking Medicare to simplify its claims requirements by adopting a policy that when the most specific ICD-10 code is used, no additional information or attachments will be required before paying the claim.

How Can We Properly Prepare for ICD-10?

Begin by assessing your individual situation and creating a plan of action.

• take your top 50 icd-9 codes and map them
• then look at the different documentation requirements
• create simple templates to start changing documentation habits NOW!
• consider dual coding ( I highly suggest this!)

What Else Should I Be Doing

• talk to your vendors
• begin creating new superbills
• review other practice documents that will need to be updated prior to Oct. 1, 2014
• BUY an ICD-10 book and become familiar with it!

These are simple steps that will reduce your "loss of productivity" and protect your cash flow. 

For more ideas, tips and tricks please visit: www.ermconsultinginc.com

Telemedicine Bolsters ICU Care In Rural Maryland Hospitals

By Rita Rubin

FEB 12, 2014

This story was produced in collaboration with 

An intensive care unit nurse in a small-town hospital on Maryland’s scenic Eastern Shore suspected that a patient had necrotizing fasciitis, the so-called “flesh-eating” disease.

The condition is rare. Even experienced intensive care doctors seldom see it, and, since it was nighttime, no such physician was in the ICU. Pinning down the diagnosis was critical—and in this case Berlin, Md.’s Atlantic General Hospital had back-up.

Doctor Marc T. Zubrow, medical director at the University of Maryland Medical System's eCare, says he can use a bank of monitors to care for up to 100 patients in eight different hospitals all over the state of Maryland. Patients can be visually monitored and their lab tests and medical information are contained on the screens (Photo by Barbara Haddock Taylor/Baltimore Sun).

A critical care doctor 125 miles away was monitoring the patient’s health via voice, video and high-speed data lines constantly streaming information about vital signs, medications, test results and X-rays, a telemedicine service known as Maryland eCare. The physician quickly verified that the patient had the deadly infection and arranged immediate transfer to another hospital with a surgeon who could remove the infected tissue.

Atlantic General is one of Maryland eCare’s six original community hospital clients, which have a total of 72 ICU beds. By the end of the year, the program will go live in three more Eastern Shore hospitals, adding 18 more ICU beds.

Studies have shown that patients do better and leave sooner from ICUs managed by intensivists, another term for critical care doctors. But intensivists are in short supply nationwide, and small community hospitals like Atlantic General have a difficult time recruiting and retaining them, let alone paying their salaries. Connecting intensivists to small ICUs via telemedicine, proponents say, is the next best thing to hiring them.

Telemedicine, the exchange of medical information between sites via electronic communications, is being used not only by ICUs but also by other hospital departments, home health agencies and private doctors’ offices. But skeptics suggest that small ICUs might be able to improve care with less expensive measures. Telemedicine now costs hospitals roughly $40,000 to $50,000 a year for each covered bed. Initially, adaptation of telemedicine in ICUs nationwide was rapid, but a new study suggests it is slowing.

One of Maryland eCare’s 20 intensivists monitors ICU patients from 7 p.m. to 7 a.m. weeknights and for 24 hours on Saturdays and Sundays.  They’re stationed at computers in Maryland eCare’s COR—Central Operations Room—which last year moved from the Christiana Care Health System in Wilmington, Del., to the University of Maryland Medical Center in Baltimore. On weekdays, when the hospitals’ critical care doctors are at work, eCare critical care nurses staff the COR computers.

Physicians and nurses at the University of Maryland can monitor ICU patients using voice, video and high-speed data lines that constantly stream information about their vital signs using a telemedicine service known as Maryland eCare (Photo by Barbara Haddock Taylor/Baltimore Sun).

Critical care specialist Atif Zeeshan and another intensivist work in Atlantic General’s ICU from 7 a.m. to 7 p.m. on alternating weeks, and they’re on call 24/7. Zeehan said he was at first leery of telemedicine. Four years after his eight-bed ICU hooked up with Maryland eCare, Zeehan is a believer. “There have been cases where lives were saved with eCare intervention,” he says. 

Maryland eCare was established with a $3 million grant from CareFirst BlueCross BlueShield, which helped cover capital expenses, such as computer and video connections. Participating hospitals pay Maryland eCare an annual fee for each ICU bed. Other eCare clients are Peninsula Regional Medical Center in Salisbury, Union Hospital in Elkton, Meritus Medical Center in Hagerstown, Calvert Memorial Hospital in Prince Frederick and MedStar St. Mary’s Hospital in Leonardtown.

Zeeshan’s initial skepticism isn’t unusual. “Nobody wants to be dictated to,” acknowledges Marc Zubrow, a critical care and lung specialist and eCare Maryland’s medical director. “An absolutely huge part of my job,” says Zubrow, is to “convince the local medical community that this will not negatively impact patient care and might possibly improve patient care.”

Hospital representatives routinely visit the Baltimore COR, and Zubrow and members of his team regularly visit the community hospitals and “get very close with the local bedside people.”

And sometimes to patients’ families.  Zubrow shared an eCare doctor’s notes about an interaction with a patient’s daughter (stripped of information that could identify the patient). The woman, who’d flown in to be at her critically ill mother’s bedside, arrived  around 3 a.m. and spent a few minutes video-chatting with the eCare intensivist on duty.

“I told her that nothing we do medically is going to improve her mother’s condition or meaningfully prolong her life,” according to the doctor’s notes. “I urged her to allow us to focus on treating her mother’s pain and suffering…I offered my support and told her I would speak with her again at any point tonight.”

Community hospitals say telemedicine helps critically ill patients be treated close to home and family. Even with extra oversight, however, these hospitals are still not equipped to care for all critically ill patients, so telemedicine intensivists help them decide which patients should be transferred.

Telemedicine has helped improve the care of ICU patients says registered nurse Anne Lockhart, who directs the unit at Calvert Memorial. Lockhart says that includes a reduction in the number of patients contracting pneumonia as a result of being on a ventilator.

Since implementing telemedicine, “we dramatically reduced our ICU mortality rate,” says Ed Grogan, vice president of information services and chief information officer at Calvert Memorial.

But Jeremy Kahn is skeptical. An associate professor of critical care, medicine and health policy at the University of Pittsburgh, he says assessing telemedicine’s effectiveness in the ICU is tricky. Comparing mortality rates before and after implementation of telemedicine doesn’t account for the fact that “outcomes in the ICU get better over time, no matter what,” Kahn says.

A better comparison would be to other, less-expensive, measures, such as using more non-physician providers—physician assistants and nurse practitioners—at ICU patients’ bedsides, Kahn said.

While Maryland eCare is adding hospitals, Kahn says adoption of telemedicine in ICUs nationwide is slowing. In a study published online in October by Critical Care Medicine, Kahn and his colleagues found that the number of U.S. hospitals using telemedicine in ICUs increased from 16, or 0.4 percent, in 2003, to 213, or 4.6 percent, in 2010, with usage doubling in the first four years but dropping to average growth of 8.1 percent in the last four.

 “In an era of cost constraints, I feel we need to be simultaneously exploring cheaper ways to get the same outcome,” Kahn says. “That’s not to say we should not explore telemedicine.”

http://www.kaiserhealthnews.org/Stories/2014/February/12/Some-Maryland-hospitals-use-intensivists-to-improve-healthcare.aspx

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The Strike Force Approach to Combatting Health Care Fraud

Bridget M. Rohde02/10/2014

The U.S. Department of Justice (DOJ), Health and Human Services Office of Inspector General (HHS-OIG) and other federal and state agencies are aggressively prosecuting health care fraud and related offenses through a strike force approach that has its roots in DOJ's historic efforts to combat traditional organized crime (or "La Cosa Nostra"). As DOJ has advised in recent press releases, this approach has been highly impactful in the health care space:

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who collectively have billed the Medicare program for more than $5.5 billion. In addition, HHS's Center for Medicare and Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers. 1

Below, we look at the historic organized crime strike force program, the evolution of the Medicare Fraud Strike Force (MFSF) and MFSF's current approach and seemingly ever-increasing productivity.

Historic Organized Crime Strike Forces

In the 1960s, to address the long-ignored presence of organized crime and its numerous rackets, DOJ developed an organized crime strike force program in which teams of prosecutors in cities across the country focused on the families of La Cosa Nostra operating in their local geographic jurisdictions. These prosecutors worked in partnership with investigators from a variety of federal agencies, and, sometimes local law enforcement as well. Investigations were long-term efforts, as the teams of prosecutors and agents gathered intelligence through confidential sources, electronic surveillance and other investigative techniques,and methodically built broad, deep and impactful cases.

Early on, DOJ touted the success of its organized crime strike forces in much the same way as it now does the success of MFSF: "Individuals indicted during 1968 as a result of strike force strategy numbered 71 in Brooklyn, 67 in Detroit, 34 in Buffalo, 12 in Chicago and 5 in Philadelphia." 2

At the time of the merger of the strike forces with local U.S. Attorneys Offices in 1990, there were 14 strike forces across the country, located in Brooklyn, Buffalo, Chicago, Cleveland, Detroit, Kansas City, Las Vegas, Los Angeles, Miami, New Orleans and San Francisco. 3

The success of the organized crime strike force approach (and continuing efforts of the U.S. Attorneys' Offices) was incontrovertible. Waves of prosecutions relentlessly taking down the successive hierarchies of the five New York City-based families of La Cosa Nostra is one of the more memorable local examples. While perhaps surprising at first blush, the use of a variation on this approach to combat white-collar crime, including health care fraud, now seems a logical, even inevitable, law enforcement strategy.

The Birth and Evolution of the MFSM

MFSF was initiated in March 2007, in what came to be Phase One, in the Southern District of Florida (Miami). A year later, in March 2008, Phase Two was kicked off in the Central District of California (Los Angeles). As part of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, a joint effort by DOJ and HHS, in 2009, MFSF expanded to Detroit, Houston, Brooklyn, Tampa and Baton Rouge. In 2011, the program expanded to the total of nine cities it is today, by adding Dallas and Chicago.

Phase One of MFSF was announced in connection with a May 2007 takedown in the Southern District in Florida involving the indictment of organizations and individuals in connection with allegedly conspiring to defraud the Medicare program, making false claims and violating the anti-kickback statute. Thirty-eight individuals were arrested. Collectively, approximately $142 million was allegedly billed in Medicare. MFSF was then described as "a multi-agency team of federal, state and local investigators designed specifically to combat Medicare fraud through the use of real-time analysis of Medicare billing data," focusing on schemes involving infusion therapy and durable medical equipment (DMEs). 4

MFSF became much more. There was the noted expansion to nine cities. In addition to takedowns of discreet cases in particular cities, in late 2009, MFSF began conducting periodic nationwide takedowns, with individuals being arrested in a number of cities simultaneously in connection with healthcare-related offenses. A July 2010 nationwide takedown appears to be the largest such takedown to date, with the arrest of 94 individuals across the country for allegedly participating in schemes to submit approximately $251 million in Medicare claims. 5

Over the years that MFSF has been in existence, it has utilized other hallmarks of the strike force approach to fighting organized crime besides multi-agency cooperation and sprawling takedowns, including employing electronic surveillance techniques, expanding the range of crimes charged, obtaining (and issuing press releases regarding) long prison sentences imposed on individuals, and even having "most wanted" healthcare fugitives. Penalties of fines, forfeiture and restitution have been utilized to recoup public monies and disincentivize fraudsters.

The Current Look of MFSF Cases

A review of MFSF prosecutions in 2013 provides numerous insights into the increasingly broad scope and continuing effectiveness of the strike force approach to combatting healthcare fraud:

Many Venues of Prosecution. DOJ and its partners brought cases across the country, including in California, Florida, Illinois, Louisiana, Michigan, New York, Pennsylvania, Texas and Utah. Certain federal districts had a particularly high concentration of MFSF cases, including the Southern District of Florida, Eastern District of Michigan and Central District of California.

Variety of Health Care Providers Targeted. Cases targeted executives of a health maintenance organization; the owner/operator of an oncology center; the medical director of a hospice; the owner and program coordinator of an adult day care center; owners and others associated with partial hospitalization programs (PHPs); owners and others associated with home health care agencies; owners and others associated with DMEs; owners of ambulance services; and doctors, registered nurses and other medical professionals.

Types of Crimes Charged. Charges included healthcare fraud for submitting false and fraudulent claims to Medicare, violations of the anti-kickback statute, and, in some recent cases, money laundering.

Wide-ranging penalties. Sentences included the imposition of lengthy prison terms; fines, restitution, and forfeiture; exclusions from Medicare, Medicaid and other federal and state health programs; and compliance requirements.

Some specific matters further illustrate the scope of MFSF's efforts and its results.

1. May 2013 Nationwide Takedown. As noted above, MFSF's sixth nationwide takedown took place in May 2013. DOJ and HHS announced arrests in eight cities of 89 individuals, including health care company owners, doctors, nurses and other licensed medical professionals, for allegedly participating in Medicare fraud schemes involving approximately $223 million in billings. Schemes involved billings for home health care, mental health services, psychotherapy, occupational and physical therapy, and pharmacy fraud, as well as infusion therapy and DMEs. Charges included conspiracy to commit health care fraud, violations of the anti-kickback statute and money laundering. 6

2. Multi-million Medicare Fraud Scheme involving Brooklyn Clinic. In addition to the nationwide takedown, MFSF also brought or continued to prosecute individual cases that further illustrate the strike force approach and its results. One illuminating local example is a case charging a $77 million Medicare fraud scheme involving a Brooklyn, New York clinic. The owner and employees of the clinic allegedly paid kickbacks to Medicare beneficiaries and used the beneficiaries' names to bill Medicare for services that were medically unnecessary or never provided. The kickbacks were allegedly paid so that beneficiaries would keep quiet about services that were not provided or would acquiesce to treatment that was unnecessary. A network of money launderers was allegedly used to generate the cash needed for the kickbacks. 7

As of late last year, 13 individuals had been convicted in connection with the multi-million scheme. The owner of the clinic, who pled guilty to one count of conspiracy to commit money laundering, was sentenced to 15 years in prison and ordered to pay approximately $51 million in restitution and $36 million in forfeiture. Another participant—an individual described as a "no-show" doctor who allegedly let the clinic use his Medicare billing number and rarely visited the clinic except to pick up his check—was sentenced to more than 12 years in prison, ordered to pay over $50 million in restitution and another half million in forfeiture and was excluded from Medicare, Medicaid and federal health programs; additionally, New York state revoked his medical license. An individual who "impersonated" the doctor—signing medical charts and prescriptions in the doctor's name and performing medical procedures on patients even though he was not a doctor—was sentenced to eight years in prison, as well as restitution, forfeiture and program exclusions. Among those awaiting sentencing is an individual who pled guilty to laundering the proceeds of the health care fraud through a number of shell companies and bank accounts. 8

In addition to the dollar amount of the fraud scheme,the inclusion of money laundering charges and the variety and size of penalties, this case is notable because the government utilized investigative techniques historically used to investigate organized crime and, in more recent years, investigate insider trading. Specifically, the government stated in press releases regarding this case that it employed a court-authorized audio/video device concealed in a room at the clinic where conspirators gave cash to Medicare beneficiaries. Fitting in with the organized crime analogy, the room included "a Soviet-era poster of a woman with a finger to her lips and the words 'Don't Gossip' in Russian." 9

Effect of Strike Force Approach

As indicated above, in 2009, DOJ and HHS formed the Health Care Fraud Prevention and Enforcement Action Team, or HEAT, which includes the strike force efforts but is more expansive. For one, HEAT is also responsible for many significant civil enforcement actions resulting in multi-million dollar settlements over the last few years. These civil enforcement actions are developed and prosecuted using what can fairly be referred to as a modified strike force approach. DOJ and HHS, often in conjunction with one or more federal or state partner, work cooperatively to investigate and bring expansive cases against pharmaceutical or medical device companies charging violations of the False Claims Act, Food Drug and Cosmetics Act, the anti-kickback statute or other laws and regulations. Commonly, based on a qui tam complaint, an investigation will target specified conduct like off-label marketing of pharmaceuticals or introduction of adulterated drugs into commerce, seek monetary penalties and require remediation of the violations and adherence to a compliance protocol going forward.

A case in point from 2013 involved Johnson & Johnson. On Nov. 4, 2013, DOJ announced a deal requiring Johnson & Johnson and three of its subsidiaries to pay more than $2.2 billion to resolve criminal exposure and civil liability arising from marketing prescription drugs for uses not approved as safe and effective by the Food & Drug Administration (FDA), as well as for paying kickbacks to doctors and the country's largest long-term care pharmacy provider for prescribing and promoting these drugs. 10

To address its criminal exposure, on November 7, Johnson & Johnson subsidiary Janssen Pharmaceuticals Incorporated pled guilty to a misdemeanor charge of misbranding, in violation of the FDCA, in the U.S. District Court for the Eastern District of Pennsylvania. Specifically, Janssen was alleged to have introduced the drug Risperdal into the market for unapproved uses from March 2002 through December 2003, namely treating behaviors of elderly, non-schizophrenic patients suffering from dementia, when it had been approved only for the treatment of schizophrenia; the criminal fines and forfeiture component of the criminal resolution is $400 million. 11

Civil lawsuits similarly claimed that Johnson & Johnson and Janssen promoted Risperdal to doctors and nursing homes for unapproved uses in the elderly, children and mental disabled. A complaint in the Eastern District of Pennsylvania specifically alleged that the FDA repeatedly advised Janssen that marketing Risperdal as safe and effective for the elderly would be misleading. It also alleged that Janssen downplayed health risks to the elderly posed by Risperdal and improperly promoted its use in children. Speaker fees were allegedly paid to doctors to encourage them to write prescriptions. In addition, Johnson & Johnson and Janssen allegedly engaged in off-label promotion of a newer anti-psychotic drug, Invega. 12

Johnson & Johnson and Janssen agreed to pay over $1.2 billion to resolve civil liability under the False Claims Act in relation to Risperdal and Invega. In addition, Johnson & Johnson agreed to pay another $149 million in connection with the alleged kickbacks that were allegedly paid to the large long-term care pharmacy. 13

An additional component of the resolution was a five-year Corporate Integrity Agreement, described as requiring major changes to the way Johnson & Johnson's pharmaceutical subsidiaries do business. Annual compliance certifications are required by certain management employees and board members. As the government stated,"[t]his agreement is designed to increase accountability and transparency and prevent future fraud and abuse." 14

A telling remark by U.S. Attorney General Holder Eric Holder, who delivered remarks at the press conference on this resolution, is that pharmacists, who were supposed to be "gatekeepers" providing independent review of patient medications, instead recommended the drugs for unapproved uses at the companies' request. 15

Conclusion

In 2014, MFSF is in full flower. There is every reason to expect the strike force approach to be utilized for the foreseeable future, unless and until health care fraud significantly diminishes as a public concern. The specific cases arising from MSFS' efforts in 2013 can help drive risk assessments and fine-tuning of compliance programs to avoid repeating the expensive mistakes made by some in the health care industry in the past. The resolutions of these cases serve as a reminder of the need to prioritize compliance.

Bridget M. Rohde, a member of Mintz Levin in New York, is a former chief of the Criminal Division of the U.S. Attorney's Office for the Eastern District of New York.

http://m.newyorklawjournal.com/module/alm/app/ny.do#!/article/1457727614