Wednesday, December 18, 2013

10 Compliance Issues for Physicians, Health Systems and Providers in 2014

Meaningful Use Audits: Physicians, hospitals, and others that have received incentive payments to integrate electronic medical records into their practices will likely be subject to an audit from either Medicare or Medicaid to assess whether the providers have actually made meaningful use of these funds and systems. Auditors are likely to demand evidence of meaningful use of incentive monies and repayment when providers cannot back up the attestations made for Stage 1 compliance.  Providers should be on the lookout for audit request letters sent via email by the contracted auditor.  Make sure that whoever has the email address registered with CMS checks for an audit letter.  In addition, providers should make sure that all meaningful use attestations are backed up and documentation is maintained for the six years that CMS requires. Some of the required evidence includes EHR vendor agreements, attestation reports on clinical quality measures, statements from EHR vendors, information used to generate numerator and denominator values for reporting, et cetera. If an audit letter is received, contact should be made immediately.   Providers need to pay attention to these responses; a failure to respond adequately could result in more than just a request for repayment.
Assuring and Measuring Compliance with HIPAA and HITECH: Increased audit and enforcement activities related to HIPAA and HITECH are coming and providers should ensure that they have implemented required changes such as identifying business associates and executing compliant business associate agreements as well as implementing security standards and testing for patient information and reporting breaches.   Also, expect increased enforcement activities from Kentucky’s Attorney General as HITECH granted enforcement authority to the Attorney General along with the opportunity to seek damages.
Stark Law Application to Medicaid Claims: While the Stark Law on its face applies only to Medicare, recent court decisions have found that a Medicaid claim filed in violation of the Stark Law also constituted a false claim.  Courts have now found False Claims Act liability for Medicaid claims filed in violation of the Stark Law.  Historically, the federal government had focused enforcement efforts on Medicare claims.    Carving out Medicaid referrals and claims in health care transactions is no longer prudent. All contracts and transactions should be reviewed for compliance with the Stark Law even if the contract only applies to services for private pay or Medicaid patients.
Medicaid Integrity Contractor Audits:  As the Medicaid review auditors are finalizing their review of the big data to identify providers who fall outside billing standards, these reports are being released to Medicaid for provider audits and collection of overpayments.  Challenging overpayments must be made through Kentucky’s Medicaid appeal process, which establishes important deadlines for requesting a dispute resolution meeting when an overpayment is identified.  If a DRM is not requested, then repayment is due in 30 days.  Providers should pay close attention to these deadlines and exercise their ability to challenge overpayments.
Measuring Quality:  As CMS’ Physician Compare website joins the nursing facility and hospital compare websites, physicians must be ever mindful that quality scores will ultimately impact reimbursement for all payors, not just Medicare and its incentive payments. Physician groups as well as all providers should carefully develop their quality measures. As ACOs, hospital systems and payors develop their own quality measures, individual physicians must be aware of those measures and how they affect them.  Participation in networks, ACOs, and even Medicaid may become tied to performance.  All physicians, even those who are employed by health systems, should be careful in their contracting and knowledgeable about their individual quality and performance.
Medical Staff Membership and Credentialing:  Changes in Joint Commission for Accreditation of Health Care Organization’s requirements for medical staff credentialing have made evaluation of a physician’s quality of care an element of the credentialing and recredentialing process.  How this evaluation takes place and the factors that are considered are left to the medical staff, which, in reality, usually means administration.  The information about this evaluation becomes a permanent part of a physician’s records.  Every physician should be aware of this, find out about evaluation results, and challenge them if necessary. A challenge does not mean that a physician impairs his/her privileges, but rather seeks to maintain an accurate credentialing file.
Retention of Overpayments:  Retention of a Medicare or Medicaid overpayment can create false claims liability and treble damages recovery when the overpayment is not returned within 60 days.  The ACA created the duty to report and return known overpayments.  While the law sounds simple, its application is anything but simple and creates a host of issues for providers including determining when an overpayment is known to the provider.  For example, is the billing clerk’s knowledge imputed to the physician owner of the practice?  Also, when reporting an overpayment, does a provider have a duty to look back to see if there are other overpayments?
Expansion of Medicaid Beneficiaries: With Kentucky’s successful rollout of its Health Insurance Exchange and the possibility of 308,389[i] new Medicaid   beneficiaries, what is the health care provider’s duty to take on more Medicaid patients?  Should a provider establish express limits on the number of Medicaid patients that a practice will accept as patients? Does this create liability under provider agreements with Medicaid Managed Care payors?  These issues will become even more important as the number of beneficiaries increases.
Prescribing Controlled Substances in Kentucky:  The war on prescription drug abuse has taken a terrible toll on physicians as House Bill 1 and the implementing regulations issued by the Kentucky Board of Medical Licensure have forever changed how and when a physician may prescribe controlled substances.  While the regulations have been slightly tweaked, physicians must take extraordinary efforts to build the procedures and processes required for prescribing into their day- to- day practice.  Physicians should be aware that the Drug Control Branch of Kentucky’s OIG routinely reviews KASPER data and reports the highest prescribers of controlled substances to the KBML for investigation.  Physician responses to these investigations must be careful and complete with the understanding that there is little recourse if a violation is found.
Getting Paid:  All providers must take active steps to assure that they are paid, which includes keeping abreast of a myriad of payment issues and policies.  A provider’s staff must be diligent in following up with insurance companies, Medicaid, and Medicare to seek payment.  The squeaky wheel gets oiled first.  Providers also need to be aware that preventive benefits such as cholesterol screenings and vaccinations are now free of charge through all Marketplace plans and many other insurance plans, including Medicare, Medicaid, and private insurance plans.  Providers should be prepared that they will no longer be able to collect a copay from any member of these plans, regardless of whether that member has met his or her deductible.  A list of preventive benefits covered by most plans under the ACA can be found at  Providers, particularly physicians, should pay attention to proposed federal legislation that will finally repeal the sustainable growth rate and replace it with a methodology that ties payments to quality and efficiency, incorporates alternative payment models and improves the fee for service system by including value-based performance measures. This bill has the support of both Senate and House committees.  We will see…….

Concierge medicine on the rise in San Diego

Paying extra for better access to a doctor, often called concierge medicine, is growing in San Diego County.
Experts say the reasons range from a long-standing dissatisfaction with traditional managed care to more immediate worries about a possible doctor shortage driven by federal health reform.
While local specialists have mixed opinions on what is driving the growth, many said they believe the practice of charging a yearly membership fee in exchange for direct access to primary care doctors is on the rise.
An online directory maintained by the American Academy of Private Physicians, which listed 17 concierge specialists in 2011, today lists more than 60.
Tom Blue, chief strategy officer for the academy, said the directory can give only an approximate number for concierge doctors in a given community because none are compelled to be listed. Still, he said, concierge medicine is becoming more popular.
“We estimate that we’re seeing a 25 percent per year growth rate nationwide and, in terms of the concentration of private physicians around the country, it appears that California is the leading state,” Blue said.
Growth has come not just from single physicians deciding to change the way they practice. Major players like UC San Diego Health System and Scripps Health are also big players in the local market.
Concierge medicine is, at its most basic, a return to the age when doctors made house calls and were paid directly by the patients they treated.
These days, with instant communications and health insurance companies in the mix, things are more complicated. But the main point is the same: Families pay a subscription fee, ranging from hundreds to thousands of dollars per year, for more direct access to their doctors.
The rise of the concierge doctor at first came as a reaction to the heavily scheduled nature of modern medicine, where doctors working in large groups must see dozens of patients per day and seldom have much more than a few minutes to spend getting to know, or listen to, those they treat.
Concierge doctors are responsible for fewer patients and make up the difference by charging their fee. With most doctors, this fee gives patients much longer appointment times and direct access via cellphone, email or both. While the doctor’s attention is covered by the yearly fee, additional services like blood tests or visits to specialists are still the patient’s responsibility. Most still have health insurance, and concierge doctors have various ways of helping make sure that carriers are billed.
Pam Brar, a solo internal medicine doctor with a concierge practice on the Scripps Memorial La Jolla campus, said time and attention were the main reasons cited by patients when she first started in 2004.
But lately, she said, many of her new patients are citing the Affordable Care Act, often called Obamacare, as a reason they want to sign up. Many, she said, fear clogged waiting rooms and months waiting for an appointment when thousands of newly insured residents arrive after the first of the year.
“I would say almost all of the people I have spoken to recently, that was a concern they had,” Brar said.
Blue, the academy representative, said the trend is national.
“People have a sense that, particularly in primary care, there just aren’t enough doctors to go around. Most people are pretty concerned with solidifying their primary care relationship,” he said.
Brar said her practice has 185 patients today and is growing. She charges $2,500 per patient per year and plans to increase that to about $3,300 after leaving the Scripps La Jolla campus and moving into downtown La Jolla.
Dr. Marty Schulman, a concierge doctor in Encinitas, said he charges $800 per patient per year, and $500 for each additional family member. Unlike Brar, Schulman said he has not experienced as much Obamacare concern. Rather, he said, most people are still more motivated by the time-constrained nature of the traditional health system.
Still, he said he is not discounting the possibility that Obamacare will start his phone ringing in the new year.
While multiple studies have confirmed that there is a doctor shortage in the United States, that does not appear to be the case in primary care in San Diego County.
A list provided in July by the state medical board lists 4,097 doctors in the county in the specialties of family medicine, internal medicine and pediatrics, the three specialties generally considered primary care.
That’s far more than the 1,547 that would need to be available, according the U.S. Department of Health and Human Services, which recommends 1 primary care doctor per 2,000 residents.
But health reform, which requires most Americans to buy health insurance in 2014 or pay a penalty if they are not already covered by company policies or a government program like Medicare, will bring thousands more insured people into the market soon.
Covered California, the state’s health insurance exchange, estimated in June that 193,000 San Diego County residents will qualify to buy policies. And that number does not include thousands of additional local residents who will newly qualify for insurance under Medicare.
No one knows for sure how the local network of providers will absorb the crush of newly insured. While large networks like Scripps Health, Sharp HealthCare, Kaiser Permanente and UC San Diego Health System have all said recently that they are confident their systems can meet demand, smaller independent doctors and groups of doctors say they are not participating in exchange plans due to low levels of reimbursement offered by insurers.
Schulman, the Encinitas doctor, said he believes there is little question whether such a massive upheaval in the nationwide health care market will push some subscribers toward concierge practices.
“I think it could potentially drive some growth. I think the main question is: Is it going to drive some doctors out of regular practice and into concierge practice,” Schulman said.

Free Preventive Services Draws Over 25 Million Seniors, Others in Original Medicare

CMS credits Affordable Care Act for accomplishment in first 11 months of 2013; 3.5 million received free Annual Wellness Visit
Dec. 17, 2013 - More than 25.4 million senior citizens and othrs covered by Original Medicare received at least one preventive service at no cost to them during the first eleven months of 2013, because of the Affordable Care Act. Today’s news from the Centers for Medicare & Medicaid Services comes after last month’s announcement showing that the health care law also saved seniors $8.9 billion on their prescription drugs since the law’s enactment.
Moreover, in the first eleven months of 2013, more than 3.5 million beneficiaries with Original Medicare took advantage of the Annual Wellness Visit established by the health care law – a significant increase from the 2.8 million who used this service by this point in the year in 2012.

Today’s announcement exceeds the comparable figure from last November, when an estimated 24.7 million people with Original Medicare received one or more preventive benefits at no out of pocket costs by this point in time during 2012.
When factoring in Medicare Advantage utilization rates and a full year of experience, an estimated 34.1 million people with Medicare took advantage of at least one preventive service in 2012.
Before the Affordable Care Act, Medicare recipients had to pay part of the cost for many preventive health services. These out-of-pocket costs made it difficult for people to get the important preventive care they needed. For example, before the Affordable Care Act, a person with Medicare could pay as much as $160 in cost-sharing for a colorectal cancer screening.
Today, this important screening and many others are covered at no cost to beneficiaries (with no deductible or co-pay). The Affordable Care Act helps tear down a significant barrier for some seniors to staying healthy and helps their care providers prevent, identify and treat problems early.
“Thanks to the Affordable Care Act, millions of seniors have been able to receive important preventive services and screenings such as an annual wellness visit, screening mammograms and colonoscopies, and smoking cessation at no cost to them,” said CMS Administrator Marilyn Tavenner.
“Prevention and early detection are so vital to ensure that Americans are healthy and Medicare is healthy. The Affordable Care Act makes Medicare stronger and improves the wellbeing of millions of beneficiaries who have taken advantage of preventive services and wellness visits.”
For state-by-state information on utilization of free preventive services for people with original Medicare, visit: