Saturday, December 10, 2016

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.

Friday, December 9, 2016

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]

Sunday, December 4, 2016

Advanced Risk Management and Office Based CDI Workshop

FROM: 9:30 AM - 3:30 PM

  • 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.  

  • 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 

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


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]


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