Thursday, October 24, 2013

HEDIS ICD-10 Recommendations Are Ready For Review

ICD-9-CM is an official classification system that practitioners currently use to code diagnoses and procedures on health care claim forms in the United States. Organizations use ICD-9-CM codes from claim and encounter data to identify diagnoses and procedures for HEDIS reporting. The Centers for Medicare & Medicaid Services (CMS) has mandated that health care providers switch from ICD-9 to ICD-10 Diagnosis and Procedure codes, effective October 1, 2014.
To accommodate this change, NCQA created a plan to identify a valid and appropriate set of ICD-10 codes for each HEDIS measure in time for inclusion in the HEDIS 2015 publications. This identification has been in progress for three years and is now complete. NCQA seeks public comment on the final recommendations for converting ICD-9 to ICD-10 codes in HEDIS measures.
NOTE: This process and timeline is separate from the HEDIS Public Comment process and timeline.

Reviewing the Recommendations

Because of the large number of codes being reviewed, NCQA is providing reviewers with more time than usual to look at the recommendations and provide comments and suggestions. We suggest that reviewers look at the recommendations and submit comments in sections or phases. Reviewers are asked to submit their comments in writing using the ICD-10 Public Comment form by 9:00am (ET) on Monday, December 16, 2013.


Meaningful Use Quick Reference Grids for 2014 from ONC

Almost 2 years ago, ONC released meaningful use quick reference grids to capture—in one place—how meaningful use Stage 1 objectives and measures correlated with adopted 2011 Edition EHR certification criteria.  We’re pleased to announce the 2014 versions of these grids, which are back by popular demand, and posted on (look under the “ONC Resources” heading).
2014 Meaningful Use Quick Reference Grids
This time around, because there are two meaningful use stages to which the single set of
2014 Edition EHR certification criteria apply, there are, you guessed it, two quick reference grids:
  1. Stage 1 objectives and measures linked to 2014 Edition EHR certification criteria [PDF – 445 KB]
  2. Stage 2 objectives and measures linked to 2014 Edition EHR certification criteria [PDF – 510 KB]
Similar to the “original,” each meaningful use quick reference grid follows the same format:
  • The first two columns reference meaningful use objectives and measures and serve as the anchor around which the rest of the grid is organized.
  • The asterisks to the left of the objectives listed indicate whether the meaningful use objective is applicable to eligible professionals (EPs) only, eligible hospitals (EH) and critical access hospitals (CAHs) only, or all of the above.
  • The core set objectives and measures are listed first followed by the menu set objectives and measures.
  • The third and forth columns reference the certification criteria that correlate with each meaningful use objective and measure, and the standard(s) and implementation specifications referred to by each certification criterion, where applicable.
I hope you find these meaningful use objectives quick reference grids as useful (and hopefully timesaving) as we do.

Health Facilities in California, Texas Report Health Data Breaches

Two recent data breaches involving stolen laptops in California and Texas have compromised the personal data of thousands of patients, Modern Healthcare reports (Landen, Modern Healthcare, 10/22).

Details of California Breach

On Monday, officials at AHMC Healthcare -- based in Alhambra, Calif., -- reported the theft of two laptops containing the personal health information of 729,000 patients (Winton, "L.A. Now," Los Angeles Times, 10/21).
The theft occurred on Oct. 12 and was discovered on Oct. 14, according to officials.
Data on the laptops included patients':
  • Names;
  • Diagnosis and procedure codes;
  • Insurance numbers;
  • Insurance and payment details;
  • Medicare ID numbers; and
  • Social Security numbers (Goedert, Health Data Management, 10/22).
Hospital officials said that laptops were password-protected and that there is no evidence the information has been accessed. However, they recommended that affected patients check their credit reports for fraud (AP/Atlanta Journal Constitution, 10/21).
On Tuesday, Alhambra police Sgt. Jerry Johnson said that detectives are looking for a suspect who was identified by reviewing the facility's video surveillance system (AP/Sacramento Bee, 10/22).

Details of Texas Breach

On Tuesday, officials at Seton Healthcare Family reported that a hospital laptop containing the personal health information of about 5,500 patients was stolen between Oct. 3 and Oct. 4, theAustin American-Statesman reports.
Seton officials said the laptop was discovered missing from the Seton McCarthy Clinic in East Austin on Oct. 4 and the situation was immediately reported to the police. They said they will contact individuals affected by the breach.
The laptop contained data including patients':
  • Names;
  • Addresses;
  • Phone Numbers;
  • Birth dates;
  • Insurance information;
  • Medical record numbers;
  • Diagnoses; and
  • Immunization details.
Seton officials said they do not believe the patient information "has been used inappropriately," but they said "a missed technology glitch during installation" caused the laptop to remain unencrypted (Grisales, Austin American-Statesman, 10/22).

Government Recovers $20 for Every Dollar Spent on Health-Care FCA Cases, Report Says

By James Swann  
Oct. 22 --The federal government gets $20 back for every dollar invested in False Claims Act health-care fraud cases, a higher rate than indicated by the Department of Justice's reporting on FCA settlements, according to a report from the Taxpayers Against Fraud (TAF) Education Fund released Oct. 22.
The report, “Fighting Medicare & Medicaid Fraud: The Return on Investment from False Claims Act Partnerships,” said that the DOJ's reporting doesn't include criminal fines associated with FCA cases or state recoveries associated with federal FCA cases, which together accounted for $9 billion in recoveries from fiscal year 2008 through FY 2012.
As a result, the DOJ's return on investment of 16-to-1 for FCA health-care fraud cases “is an understatement of the full 'rate of return' from the federal government's anti-fraud activities,” the report said.
Overall Recoveries
Overall civil, criminal and state recoveries associated with federal FCA health-care fraud cases totaled $18 billion between FY 2008 and FY 2012, the report said.
During the same time frame, the three agencies that investigate and prosecute health-care fraud FCA cases (the U.S. Attorney's Offices, the Department of Health and Human Services Office of Inspector General and the DOJ's Civil Division) received a total of $575 million from the Medicare trust fund for health-care fraud enforcement, the report said.
“While it is difficult to quantify federal and state costs associated with recovering these federal criminal and state civil dollars, we are confident that if all costs and benefits are accounted for, the benefit to cost ratio of False Claims Act law enforcement now exceeds 20:1,” the report said.
Whistle-Blower Cases
FCA cases involving health-care fraud whistle-blowers have increased dramatically since 1986, when penalties under the FCA were strengthened, the report said.
For example, from 1986 to 1992, there were 62 new health-care fraud whistle-blower referrals, investigations or actions. In comparison, there were 417 in 2011 and 412 in 2012.
In 2012, whistle-blowers received $284 million out of $2.5 billion in health-care fraud whistle-blower settlements.
The TAF report also said that criminal FCA cases are becoming increasingly important to the federal government.
“Not only do they bring in additional recoveries, but also they create the possibility of criminal conviction, which serves as a deterrent to committing fraud against the government,” the report said.
Criminal FCA cases also often are linked with civil FCA cases, the report said, as a civil investigation can lead to criminal charges.
Congressional Comment
Sen. Charles E. Grassley (R-Iowa), who wrote the 1986 amendments to the FCA, said the TAF report indicates the value of the FCA.
“The law has empowered whistleblowers to come forward, risk their careers and root out the shady characters looking to give the taxpayer a bad deal,” Grassley said in a statement released Oct. 22.
Although the focus in 1986 was on defense contractors, the FCA is “the most effective tool against health care fraud, as evidenced by the report released today,” he said.
Grassley said any attempts to weaken the FCA “should be met with skepticism by the courts and Congress.”

Universal American, GTCR sue each other over healthcare deal

(Reuters) - Healthcare benefits provider Universal American Corp (UAM.N) sued private equity firm GTCR LLC on Tuesday to undo a $222.3 million acquisition it said was induced by fraud, a day after GTCR filed its own lawsuit to block Universal's claims.
The dispute goes to the heart of the business of the private equity industry, where firms buy companies and hope to sell them later at a profit. Finding interested buyers and avoiding the taint of fraud are crucial to a firm's ability to earn big profits for itself and its investors.
In a complaint filed on Tuesday in the U.S. District Court in Delaware, Universal claimed that GTCR misled it about the finances and business prospects of APS Healthcare Inc ("APS"), a healthcare management services provider it bought in March 2012.Universal said "the ugly truth" emerged soon thereafter, with APS being declared in default by its biggest customer and losing some or all of its business with other large customers.
"Defendants engaged in a deliberate campaign to conceal the truth about APS," Universal said. "The avalanche of bad news ... the complete evaporation of APS's income within months, and the sheer number of misrepresentations and omissions in the merger agreement ... are all telltale signs of fraud."
The lawsuit was filed just 16 hours after Partners Healthcare Solutions Holdings LP, the GTCR company that sold APS, filed its own lawsuit in Delaware Chancery Court. It seeks a declaration that Universal's claims are baseless and the release of sums held in escrow after the merger closed.
While admitting that APS' earnings in 2012 "fell well short of what both parties had hoped," the GTCR company called the dispute "a straightforward case of buyer's remorse" that sought "to turn the seller into its scapegoat."
Universal and APS are based in White Plains, New York, while GTCR is based in Chicago.
A Universal spokeswoman declined to comment. GTCR did not immediately respond to a request for comment.
The cases are Universal American Corp v. Partners Healthcare Solutions Holdings LP et al, U.S. District Court, District of Delaware, No. 13-01741; and Partners Healthcare Solutions Holdings LP v. Universal American Corp, Delaware Chancery Court, No. 9022.

(Reporting by Jonathan Stempel and Greg Roumeliotis in New York. Editing by Andre Grenon)