Tuesday, December 10, 2013

Florida Blue and Orlando Health Create Accountable Care Arrangement

JACKSONVILLE and ORLANDO, Fla.Dec. 10, 2013 /PRNewswire/ -- Florida Blue and Orlando Health Physician Partners announced today the execution of an accountable care agreement, which aims to improve the quality and efficiency of patient care in the Orlando area.
Through this arrangement, Orlando Health and Florida Blue plan to improve the individual patient experience, while also decreasing medical costs, by enhancing the coordination of care between the two organizations.
Starting on Jan. 1, 2014, the accountable care program will utilize a value-based compensation structure and serve as another example of Florida Blue's payment innovation efforts being deployed in the state. It will decrease medical costs and increase quality outcomes by rewarding the right combination of goals, including transparency, care coordination, consumer empowerment and lack of redundancy.
Orlando Health (OH) consists of approximately 500 employed physicians, both primary care and specialists, and eight hospitals in LakeSeminole and Orange Counties. OH hospitals include Orlando Regional Medical Center, Dr. P. Phillips Hospital, South Seminole Hospital, South Lake Hospital, Health Central Hospital, Arnold Palmer Hospital for Children, Winnie Palmer Hospital for Women and Babies and MD Anderson Cancer Center.
"By coordinating efforts across the healthcare spectrum, we can deliver better outcomes for patients, provide for a more positive patient experience and improve management of medical costs," said Wayne Jenkins, M.D., President, Orlando Health Physician Partners. "We believe accountable care arrangements such as this are the future of the health care delivery system."
"Florida Blue is honored to partner with one of the leading health care organizations in the Orlando area to improve the quality of care for our members and their patients," said Pat Geraghty, chairman and CEO for Florida Blue. "Enlightened organizations like Orlando Health realize the importance of moving away from the fee-for-service model to one that seeks to eliminate the fragmentation of care, focuses on quality outcomes, and reduces the cost burden for all stakeholders."
About Orlando HealthOrlando Health is a $1.9 billion not-for-profit health care organization and a community-based network of physician practices, hospitals and care centers throughout Central Florida. Physician Associates, one of the largest multi-specialty practices in central Florida, consisting of more than 90 physicians in more than 20 locations, became a member of the Orlando Health family in January, 2013. The organization, which includes the area's only Level One Trauma Centers for adults and pediatrics, is a statutory teaching hospital system that offers both specialty and community hospitals.
About Florida BlueFlorida Blue, Florida's Blue Cross and Blue Shield company, is a leader in Florida's health care industry. Our mission is to help people and communities achieve better health. Florida Blue has approximately 4 million health care members and serves 15.5 million people in 16 states through its affiliated companies. Florida Blue is a not-for- profit, policyholder-owned, tax-paying mutual company. Headquartered in Jacksonville, Fla., it is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. 
For more information, visit www.FloridaBlue.com.

CMS updates Medicare manual to reflect Jimmo settlement

CMS updates Medicare manual to reflect Jimmo settlement
CMS updates Medicare manual to reflect Jimmo settlement
The Centers for Medicare & Medicaid Services has revised the Medicare Benefit Policy manual to clarify that skilled care and skilled therapy may be covered even for conditions that will not improve, per the settlement in the high-profile Jimmo v. Sebelius case.
The Jimmo plaintiffs argued that Medicare was improperly denying claims based on an “improvement standard.” Under this standard, beneficiaries would only receive Medicare coverage for skilled care that would improve their conditions.
In January, a federal judge granted final approval of a settlement in the case. Under the deal, CMS agreed to update the Medicare manual and take other steps to ensure that claims are not denied under the “improvement standard,” which the agency emphasizes never was a sanctioned policy. The manual revisions are intended to accomplish this goal.
For example, section 20.1.2-Determination of Coverage now states, “Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient's potential for improvement from the nursing care or therapy, but rather on the patient's need for skilled care.”
Skilled care may be needed to maintain a current condition or prevent or slow a patient's deterioration, the manual now explains.
The revisions also enhance guidance on appropriate documentation for claims involving skilled care. Providers must substantiate that skilled care rather than non-skilled care was needed, in order to be reimbursed for so-called “maintenance therapy," according to an explanatory CMS Medicare Learning Network memo. Appropriate documentation is not "in and of itself" part of the definition of skilled care, but is the means by which contractors can determine whether skilled care is needed in a particular case, CMS noted. This is why the revisions include more specific guidance on this aspect of documentation. 
The manual revisions include specific examples of documenting skilled care. For instance, if a patient in a plaster cast has a circulatory condition that demands skilled care, the documentation should indicate the severity of the circulatory condition. Vague language such as “caregiver instructed in medication management” would not adequately support the need for skilled care, the manual notes.
Click here to access the revisions, released Friday.

Government Intervenes in False Claims Lawsuit Against Ipc the Hospitalist Co. Inc. Alleging Overbilling of Physician Services

Department of Justice
Office of Public Affairs
Monday, December 9, 2013
Government Intervenes in False Claims Lawsuit Against Ipc the Hospitalist Co. Inc. Alleging Overbilling of Physician Services
The government has intervened in a lawsuit against IPC The Hospitalist Co. Inc., and its subsidiaries (IPC), alleging that IPC submitted false claims to federal health care programs, the Justice Department announced today.  IPC, based in North Hollywood, Calif., is one of the largest providers of hospitalist services in the United States, employing physicians and other health care providers who work in more than 1,300 facilities in 28 states.  Hospitalists are physicians who work only in hospitals and other long-term care facilities, overseeing and coordinating inpatient care from admission to discharge.
The lawsuit alleges that IPC physicians sought payment for higher and more expensive levels of medical service than were actually performed – a practice commonly referred to as “upcoding.”  Specifically, the lawsuit alleges that IPC encouraged its physicians to bill at the highest levels regardless of the level of service provided, trained physicians to use higher level codes and encouraged physicians with lower billing levels to “catch up” to their peers.
“We continue to be vigilant in our enforcement efforts to ensure that health care programs funded by the taxpayers pay only for appropriate costs,” said Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery.
The lawsuit was filed by Dr. Bijan Oughatiyan, a former IPC physician, under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private parties to sue for false claims on behalf of the government and to share in any recovery.  The Act also allows the government to intervene or take over the lawsuit, as it has done in this case, and to recover three times its damages plus civil penalties.  The government has asked the U.S. District Court in Chicago for 120 days to file its own complaint stating its allegations.