OIG Expands Kickback Safe Harbors While Expanding Bases for CMP

The Office of Inspector General (OIG) for the U.S. Department of Health and Human Services has finalized its newest safe harbor rule that had been pending for two years. The rule, titled "Medicare and State Health Care Programs: Fraud and Abuse; Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements," attempts to provide flexibility in new cost-sharing arrangements by preventing certain initiatives by doctors, hospitals and pharmacies from being treated as fraudulent kickbacks by Medicare and Medicaid.

The OIG's new rule amends the federal Anti-Kickback Statute and expands the safe harbors for patients covered in federal healthcare programs for the following activities:

• Waiver by a hospital for cost-sharing imposed under a Federal healthcare program if certain conditions are met;
• Waiver of cost-sharing amounts owed to a federally qualified health center;
• Waiver by a pharmacy for cost-sharing imposed by a federal healthcare program under certain conditions;
• Free or discounted local transportation services if certain conditions are met; and
• Waiver of cost-sharing for emergency use of state or municipality-owned ambulance services to transport patients within a radius of 25 miles in urban settings and 50 miles in rural settings to physicians' offices, hospitals, home health agencies, pharmacies and laboratories.

The rule also excludes the following from the definition of "remuneration" in connection with liability under the Civil Monetary Penalties [CMPs], Assessments and Exclusions law:

• Differentials in cost sharing as part of a benefit design so long as the differentials are disclosed;
• Items or services that improve a beneficiary's ability to obtain items and services payable by Medicare or Medicaid and that pose a low risk of harm to such beneficiary by being unlikely to interfere with clinical decision making, raise patient safety issues, or lead to improper utilization;
• Coupons, rewards or rebates that are available on equal terms to the general public; and
• Free items to persons with financial need if they are not offered as part of any advertisement or solicitation or tied to the provision of other services.
  On the flip side, the final rule allows for CMPs for not granting the OIG access to records in a timely manner, ordering or prescribing while already excluded from government health care programs, making false statements, omissions or misrepresentations when applying for enrollment, not reporting or returning overpayments and using false records or materials that are material to false or fraudulent claims. The OIG decline to make any change in the six-year statute of limitations for bringing exclusion actions.
  
  The final rule was published in the Federal Register on December 7.

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Rapid Practice Innovation

What is Rapid Practice Innovation?

You can’t manage healthcare today, with yesterday’s models, and be in business tomorrow...

In the context of education, is it culture or strategy that drives our desire for something better? In terms of change, is it more power or responsibility that one is seeking? And what has enabled some leaders to drive mass change across large organizations while others fail? Perhaps the single greatest predictor is the power of influence, the human factor that encourages and sustains the necessary energy to get to that point of “something better.”

The process of identifying and eliminating waste and ultimately defects was made famous by Toyota and has since infiltrated every other industry on some level. But can process improvements alone be enough to tackle the bureaucracy of America’s healthcare system? Can regulatory reform inspire those farthest from Congressional hill, those who return to the front lines day after day to care for our aging population of seniors or will it take something more?

The path of progress must not be paved in external motivation alone but incite the flames of internal desires to be effective. If the agent of change is not truly embodied in the cause themselves, then can the message accurately be broadcast from payer to provider to consumer or is it lost in translation?

As a consultant, an educator, or a trainer, it is that single moment of transition from external to internal, that aha moment, if you will, that keeps us coming back again and again. Empirical Risk Management was founded on the belief that change, must be initiated at the initial point of contact to be effective, and in managed care that means the process must begin when the patient walks in the door.

Over the last week, my team and I were once again taken aback at the power of an individual to influence and inspire those around them. In Miami, Florida just a few blocks from downtown, we witnessed progress first hand. Halfway down the street on the left hand side is a small brown house whose driveway stays full of patients waiting to be seen. But this is not your typical practice, inside you will find a leader, whose charge for change begins with strength and whose passion resonates within all four walls. The epitome of a healer, a champion of champions.

Our call to action was prompted by a desire to improve the “team” and to create a shared vision for the future. Our mission was not defined by reaction, but instead action, originating from that desire for something better. We were not there to “fix” a specific problem, but instead to observe, assess, and to improve if at all possible. These projects, coined RPI or rapid practice innovation, are not for the faint of heart, and in fact the obscurity of the task often leads most to shy away. However, it is that exact uncertainty that elicits my passion. For isn’t it the shared success of the sum that is greater than the individual triumphs?

The value that is derived from a receptionist who understands the clinical significance of a 1% improvement in a Hgb A1c will far exceed the value of your investment. A nurse who understands the 10 guiding principles that influenced the creation of the CMS-HCC model will inherently improve the experience for both the provider and the health plan. A coder who understands the potential financial impact of rejected encounters on the Medicare Advantage plan will provide incredible value to your revenue cycle. It is this proactive team approach at the initial point of contact that ultimately improves outcomes and minimizes opportunities for errors.

And at the end of the day, it is this shared vision, that unites once starkly contrasting goals into one uniformed march towards optimization.

Download a simple framework for guidance on implementing RPI within your organization.

Rapid Practice / Plan Innovation
These tools will assist organizations in implementing RPI with their organizations.
RPI Tools.pdf 
Adobe Acrobat document [372.4 KB]

Learn More About RPI

Advanced Risk Management and Office Based CDI Workshop

JOIN US  WEDNESDAY FEBRUARY 22, 2017  

FROM: 9:30 AM - 3:30 PM

LOCATION: BOCA OFFICE CENTER, 6501 CONGRESS  AVENUE, BOCA RATON, FL 33487

TOPICS:

• Review the different risk adjustment models and their impact on medical practice management. 

• Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims? 

• Take a deep dive into HCC Coding and Documentation. Review real examples to see what validates, what doesn’t, and why. Tips for engaging physicians. 

• Learn how to leverage frontline staff to be successful in the world of risk adjustment and value based payments.  

EACH ATTENDEE WILL RECEIVE:

• Clinical Documentation and Coding Guide  $ 99 Value
• HCC Quick Coder (Mappings to ICD-10 Codes) for MA and Commercial Models
• Risk Adjustment Workbook and Appendix with Easy to Use Templates
• Laminated Coding and Documentation Tools 

WHO SHOULD ATTEND?

• Medical Coders and Billers
• Providers, Managers and Frontline Staff
• CDI Specialists
• Executive Leaders
• ACO, MSO and IPA Teams

APPROVED FOR 6 HOURS OF CEU's by  AAPC

Download the Workshop Agenda
Join us for a full day of risk adjustment at the 4th Annual Tri-County Workshop. Seating is Limited. Register Today!
ERM ARM and CDI Workshop.pdf 
Adobe Acrobat document [449.5 KB]

Speakers

  

Kameron Gifford, CPC

Kameron is the founder and Chief Executive Officer of ERM Consulting and mHealth Games, an online learning company. Over the last 17 years she has worked hand in hand with physicians, managed care organizations, hospitals and health plans to develop efficient billing practices, implement value added processes and improve the entire experience of care for their patients. Kameron is passionate about risk adjustment and a strong advocate for frontline staff.

Kameron is also a primary author of several national risk adjustment workshops produced by RISE and Healthcare Education Associates: 

• Risk Adjustment 101
• HCC Coding Accuracy

And Co-author of the new RISE Workshop 

• Advanced HCC Coding

Todd Gifford, MBA, Ph.D, CRC

Todd is a Director of Finance for a large Medicare Advantage MSO based in Miami, Florida. He joined them in 2007 as Managing Director of Health Solutions UK, a joint venture with Humana. During his two and a half years in London he worked hand in hand with the NHS to transform the way care was delivered. From 2010 to 2012, Todd oversaw the start-up expansion into Texas. In this role, he was responsible for 12,500 MA members and a budget of $75m.

Todd graduated from the University of Arkansas with a B.A. in 1991, and received his MBA from Webster University in 2001. He was awarded a Ph.D in Business from Woodfield University in 2013.

In addition, Todd is also the Co-founder of mHealth Games, an innovative technology company headquartered in Miami, Florida.

Register Online for the Workshop

FREE AAPC CEUs

At least once a week, I get a request for free CEUs. Often these are last minute frantic requests from coders who are less than 48 hours away from their AAPC deadline.  This can be a terrifying moment for both the coder and the organization that employs them.

It was those moments that inspired us to create ERM Academy.  A collaboration between ERM Consulting and mHealth Games that aims to bring high quality, on-demand education and training to all frontline staff.

For a limited time, ICD-10 Coding Guidelines for 2016, approved by the AAPC for 8 hours, will be included FREE with all Annual Memberships. That is a $199 value FREE!

 How it Works?

1.  Visit ERM Academy
2. Register for an Annual Account
3. Launch Course
4. Review Course Content
5. Complete Final Assessment 
6. Download Certificate

Questions?

·        Email kgifford@ermconsultinginc.com

MACRA Challenge

What is MACRA? Who does it effect? What is the timeline for implementation? How does quality factor into the equation?

Do you know the answer to these questions? If so, then take the MACRA challenge today!

Click on the picture above to play...

CDI Speedway

Complete and accurate ICD-10 coding is driven by complete and accurate encounter documentation.

Test your clinical documentation skills on the CDI SPEEDWAY and see if you what it takes to cross the finish line first.

Another game from ERM ACADEMY

     Click the picture above to launch....

E/M Coding Trivia

Are you looking for new an innovative ways to train your staff? If so, you will love this new game from mHealth Games! 

Click on the picture below to play game....

Are you a champion of coding E/M services? Do you have what it takes to correctly identify a 99213 vs. a 99214? 

If so, you could be the next winner of E/M Coding Trivia.

Provider User-Experience Challenge

A Notice by the Health and Human Services Department on 03/03/2016

Action

Notice.

Summary

Like the Consumer Health Data Aggregator Challenge, the Provider User-Experience Challenge incents the development of applications for health care providers that use open, standardized APIs to enable innovative ways for providers to interact with patient health data. This challenge will focus on demonstrating how data made accessible to apps through Application Programming Interfaces (APIs) can positively impact providers' experience with EHRs by making clinical workflows more intuitive, specific to clinical specialty, and actionable. The statutory authority for this challenge competition is Section 105 of the America COMPETES Reauthorization Act of 2010 (Pub. L. 111-358).

DATES:

Phase 1

• Challenge launch: March 1, 2016
• Submissions due: May 30
• Evaluation period: May 31-June 28
• Phase 1 winners announced: June 30

Phase 2

• Submission period begins: May 31
• Submissions due: November 7
• Evaluation period: November 14-December 14
• Phase 2 winners announced: December 15, 2016

FOR FURTHER INFORMATION CONTACT:

Adam Wong, adam.wong@hhs.gov (preferred), 202-720-2866.

SUPPLEMENTARY INFORMATION:

Award Approving Official

Karen DeSalvo, National Coordinator for Health Information Technology.

Subject of Challenge Competition

The Provider User-Experience Challenge is intended to spur development of third-party applications for use by clinicians and use FHIR to pull various patient health data into a dashboard. The challenge has two phases—the first requiring submission of technical and business plans for the application (app), the second a working app that is available for providers. Phase 2 of the competition will not be limited to only those who won Phase 1—all Phase 1 competitors, and those who did not participate in Phase 1, can submit a final app at the end of Phase 2.

The final application must meet the following requirements:

• Uses FHIR Draft Standard for Technical Use 2 (DSTU2)
• Aggregate all data as specified in the 2015 Edition Common Clinical Data Set (Data column in https://www.healthit.gov/sites/default/files/commonclinicaldataset_ml_11-4-15.pdf)
• Verified compatibility with different health IT developer systems implemented in production settings, 1 of which must be from the top 10 systems measured by Meaningful Use attestation per HealthIT.gov. Apps must be integrated with a minimum of 3 unique health IT developer systems in 2 unique provider settings
• Has been tested with patients and used in production settings
• Available to providers through at least one of the following modes: Direct from Web, iOS Store, or Android stores

Phase 1

Participants interested in competing for Phase 1 awards will need to submit an app development plan that must include:

• Mockup/wireframes
• Technical specifications, including but not limited to planned data sources, system architecture
• Business/sustainability plan
• Provider partnership

To augment technical development and enhance the likelihood of a successful app that will continue to exist beyond the end of the challenge, a progress update/matchmaking event will be held that will seek to connect participants with provider partners. Up to five app proposals will be recognized as winners and awarded up to $15,000 each.

Phase 2

The second phase will entail the actual development of the apps, verification of technical capabilities, user testing/piloting, and public release of the apps. This will include remote testing with providers and health IT developers to test the technical abilities of the apps to connect to in-production systems. Participants will submit:

• Working prototype of the app
• Video demonstrating the app (maximum of 5 minutes, on YouTube or Vimeo)
• Slide deck describing app (maximum of 10 slides)

The grand prize winner will receive $50,000 and a second place winner will receive $25,000. There will be an additional $25,000 prize for the app that connects to the greatest number of unique health IT developer systems implemented in production settings, which can be won by the grand or 2nd place winner.

Eligibility Rules for Participating in the Competition: To be eligible to win a prize under this challenge, an individual or entity:

1. Shall have registered to participate in the competition under the rules promulgated by the Office of the National Coordinator for Health Information Technology.

2. Shall have complied with all the requirements under this section.

3. In the case of a private entity, shall be incorporated in and maintain a primary place of business in the United States, and in the case of an individual, whether participating singly or in a group, shall be a citizen or permanent resident of the United States.

4. May not be a Federal entity or Federal employee acting within the scope of their employment.

5. Shall not be an HHS employee working on their applications or submissions during assigned duty hours.

6. Shall not be an employee of the Office of the National Coordinator for Health IT.

7. Federal grantees may not use Federal funds to develop COMPETES Act challenge applications unless consistent with the purpose of their grant award.

8. Federal contractors may not use Federal funds from a contract to develop COMPETES Act challenge applications or to fund efforts in support of a COMPETES Act challenge submission.

An individual or entity shall not be deemed ineligible because the individual or entity used Federal facilities or consulted with Federal employees during a competition if the facilities and employees are made available to all individuals and entities participating in the competition on an equitable basis.

Entrants must agree to assume any and all risks and waive claims against the Federal Government and its related entities, except in the case of willful misconduct, for any injury, death, damage, or loss of property, revenue, or profits, whether direct, indirect, or consequential, arising from my participation in this prize contest, whether the injury, death, damage, or loss arises through negligence or otherwise.

Entrants must also agree to indemnify the Federal Government against third party claims for damages arising from or related to competition activities.

Submission Requirements

In order for a submission to be eligible to win this Challenge, it must meet the following requirements:

1. No HHS or ONC logo—The product must not use HHS' or ONC's logos or official seals and must not claim endorsement.

2. Functionality/Accuracy—A product may be disqualified if it fails to function as expressed in the description provided by the user, or if it provides inaccurate or incomplete information.

3. Security—Submissions must be free of malware. Contestant agrees that ONC may conduct testing on the product to determine whether malware or other security threats may be present. ONC may disqualify the product if, in ONC's judgment, the app may damage government or others' equipment or operating environment.

Registration Process for Participants: To register for this Challenge, participants can access http://www.challenge.gov and search for “Provider User-Experience Challenge.”

Prize

• Phase 1: Up to 5 winners each receive up to $15,000.
• Phase 2: One final winner receives $50,000; 2nd place receives $25,000; and an additional $25,000 connector prize.
• Total: Up to $175,000 in prizes.

Payment of the Prize: Prize will be paid by contractor.

Basis Upon Which Winner Will Be Selected: The review panel will make selections based upon the following criteria:

Phase 1

• Technical feasibility of plan, including number of EHR sources targeted.
• Adherence to data privacy and security best practices.
• Strength of business/sustainability plan.
• Impact potential in clinical setting.
• Provider and/or health IT developer partnerships.

Phase 2

• Number, sources, and types of data aggregation using FHIR.
• Functionality and quality of data aggregation.
• Privacy and security of patient data.
• Impact potential in clinical setting.
• User experience and visual appeal.

Additional Information

General Conditions: ONC reserves the right to cancel, suspend, and/or modify the Contest, or any part of it, for any reason, at ONC's sole discretion.

Intellectual Property: 

Each entrant retains title and full ownership in and to their submission. Entrants expressly reserve all intellectual property rights not expressly granted under the challenge agreement. By participating in the challenge, each entrant hereby irrevocably grants to Sponsor and Administrator a limited, non-exclusive, royalty-free, worldwide license and right to reproduce, publically perform, publically display, and use the Submission to the extent necessary to administer the challenge, and to publically perform and publically display the Submission, including, without limitation, for advertising and promotional purposes relating to the challenge.

Authority:

15 U.S.C. 3719.

Dated: February 23, 2016.

Karen DeSalvo,

National Coordinator for Health Information Technology.

[FR Doc. 2016-04466 Filed 3-1-16; 11:15 am]

BILLING CODE 4150-45-P

HHS-Operated Risk Adjustment Methodology Meeting; March 31, 2016

A Notice by the Health and Human Services Department on 01/27/2016

ACTION

Notice Of Meeting.

SUMMARY

This notice announces the rescheduling of the March 25, 2016 meeting on the HHS-operated risk adjustment program, which is open to the public. The purpose of this stakeholder meeting is to solicit feedback on the HHS-operated risk adjustment methodology and to discuss potential improvements to the HHS risk adjustment methodology for the 2018 benefit year and beyond. This meeting, the “HHS-operated Risk Adjustment Methodology Conference,” will allow issuers, States, and other interested parties to discuss the contents of a White Paper to be published in advance of this meeting. This meeting will also provide an opportunity for participants to ask clarifying questions. The comments and information HHS obtains through this meeting may be used in future policy making for the HHS risk adjustment program.

DATES:Back to Top

Date of Meeting: March 31, 2016 from 9:00 a.m. to 4:30 p.m., Eastern daylight time (e.d.t.).

Deadline for Onsite Participation: March 23, 2016, 5:00 p.m., e.d.t.

Deadline for Webinar Meeting Participation: March 28, 2016, 5:00 p.m. e.d.t.

Deadline for Requesting Special Accommodations: March 23, 2016, 5:00 p.m. e.d.t.

SUPPLEMENTARY INFORMATION:Back to Top

I. BackgroundBack to Top

This notice announces a meeting on the HHS-operated risk adjustment program to discuss potential improvements to the HHS risk adjustment methodology for the 2018 benefit year and beyond. This meeting will focus on the permanent risk adjustment program under section 1343 of the Affordable Care Act when HHS is operating a risk adjustment program on behalf of a State (referred to as the HHS-operated risk adjustment program).

We are committed to stakeholder engagement in developing the detailed processes of the HHS-operated risk adjustment program. The purpose of this meeting is to share information with issuers, States, and interested parties about the risk adjustment methodology, offer an opportunity for these stakeholders to comment on key elements of the risk adjustment methodology, and discuss potential improvements to the HHS risk adjustment methodology for the 2018 benefit year and beyond.

II. Provisions of This NoticeBack to Top

In the January 11, 2016 Federal Register (81 FR 1193), we published a notice announcing a March 25, 2016 meeting on the HHS-operated risk adjustment program. In this notice, we are notifying interested parties we are rescheduling the meeting to March 31, 2016. The agenda for the March 31, 2016 meeting will include the following:

• The HHS-operated Risk Adjustment Methodology Conference will share information with stakeholders including issuers, States, and interested parties about the HHS-operated risk adjustment methodology and gather feedback on a White Paper on the HHS-operated risk adjustment methodology that will be issued in advance of this meeting.
• The HHS-operated Risk Adjustment Methodology Conference will focus on an overview of the HHS-operated risk adjustment methodology and other international risk adjustment models, what we have learned from the 2014 benefit year of the risk adjustment program and specific areas of potential refinements to the methodology.

The meeting is open to the public, but attendance is limited to the space available. There are capabilities for remote access. Persons wishing to attend this meeting must register by the date listed in theDATES section, and register using the information in the “REGISTRATION” section.

III. Security, Building, and Parking GuidelinesBack to Top

The meeting is open to the public, but attendance is limited to the space available. Persons wishing to attend this meeting must register by using the instructions in the “REGISTRATION” section of this notice by the date specified in the DATES section of this notice.

This meeting will be held in a Federal government building; therefore, Federal security measures are applicable. We recommend that confirmed registrants arrive reasonably early, but no earlier than 45 minutes prior to the start of the meeting, to allow additional time to clear security. Security measures include the following:

• Presentation of government-issued photographic identification to the Federal Protective Service or Guard Service personnel.
• Inspection of vehicle's interior and exterior (this includes engine and trunk inspection) at the entrance to the grounds. Parking permits and instructions will be issued after the vehicle inspection.
• Inspection, via metal detector or other applicable means of all persons brought entering the building. We note that all items brought into CMS, whether personal or for the purpose of presentation or to support a presentation, are subject to inspection. We cannot assume responsibility for coordinating the receipt, transfer, transport, storage, set-up, safety, or timely arrival of any personal belongings or items used for presentation or to support a presentation.

Note:

Individuals who are not registered in advance will not be permitted to enter the building and will be unable to attend the meeting. The public may not enter the building earlier than 45 minutes prior to the convening of the meeting.Show citation box

All visitors must be escorted in areas other than the lower and first floor levels in the Central Building.

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