Clinical Integration is the word of the day for provider organizations.  Clinical integration projects have emerged in all corners of the State of Wisconsin.  Our law firm has been at the center of many of these clinical integration programs and the creation of Accountable Care Organizations.

In a recent Article published on the Health Law Blog, we cover the issue of Clinical Integration Readiness Assessment.  During early assessment and design stages, we attempt to encourage broad participation by providers.  We will normally recommend the creation of a governance and committee structure that is as inclusive as possible.  Clinical integration is primarily a process that physicians perform.  Mechanisms are created through which physicians collaborate across specialty, in an interdependent way toward the end goals of increasing quality and efficiencies.  Ideally, the process should be collaborative between physicians and institutional providers.  However, the dynamics between hospitals and physicians can sometimes adversely impact the working relationship.

Find more by reading the full post over at the Health Care Blog.  This is an issue that all Wisconsin health care providers will want to follow because it is changing the central dynamic of the health care system.

Are You Ready For Clinical Integration?

Ruder Ware Clinical Integration Practice

The annual work plan that was recently released states that the office of Inspector General will review compliance with various aspects of the skilled nursing facility prospective payment system. The review will include the documentation requirements in support of claims paid by Medicare. Prior reviews have found that Medicare payments for therapy greatly exceeds SNF cost.  Additionally it was found that skilled nursing facilities have increasingly billed for the highest level of therapy even though key beneficiary characterization remained largely the same.

The oig  states taht it intends to ensure that skilled nursing facility care is reasonable and necessary and that SNF claims are paid in accordance with federal laws and regulations. All documentation requirements under 42 CFR section 483.20 must be met to ensure that the skilled nursing facility care is reasonable and necessary. Documentation needs to include the physician order at the time of admission for the residence immediate care, a comprehensive assessment, and the comprehensive plan of care prepared by an interdisciplinary team that includes the attending physician, a registered nurse and other appropriate staff.

CMS has published Frequently Asked Questions (FAQs) on its website relating to phase 3 of the EHR incentive programs. guidance includes direction how providers can attest to certain measures for health information exchange, patient electronic access, and other aspects of patient interaction woth the system. providers are also reminded that the date to submit comments relative to stage III regulations is December 15, 2015.

access frequently asked questions on cms site

By John Fisher, JD, CHC, CCEP

Bundled Payment and ACO Arrangements – Clinically Integrated Payment Methodologies

Bundled payment involves an agreement between a provider group and a payor for the management of a defined segment of care for an agreed price. A bundled payment would include one payment for all providers involved in the episode of care that is within the bundled area. All providers providing care within the episode of care are entitled to be covered under the bundled payment.

The idea behind bundled payment is to place providers across the spectrum of the applicable care continuum at financial risk and to provide shared financial incentives. In theory, this forces otherwise disjointed providers to cooperate to better coordinate care and to coordinate at a higher level with other elements of the continuum of care.

Bundled payment is one of the primary reasons why providers are mobbing toward clinically integrated health care systems. CINs provide a mechanism for providers across the continuum of care to agree upon protocols and other mechanisms to help them be more cost efficient in the management of bundled areas of care while maximizing the quality of care and outcomes provided to patients.

The Center for Medicare and Medicaid Services has developed a Bundled Payment Program

Read more here: Health Law Blog

By John Fisher, JD, CHC, CCEP

Jointly Providing Health Care Fee Information to Payers 

As health care provider networks move down the path toward clinical integration, we are often asked to provide guidance on how information can be jointly provided to payors.  The antitrust laws recognize that collective sharing of some pricing information, even by otherwise competing providers, can be beneficial and does not necessarily violate antitrust laws.  However, there are significant limitations on what can be jointly provided and how the information can be shared.

At the outset, it should be clarified that collective negotiations by competing providers who are not financially or clinically integrated should never take place and constitutes a per se violation of federal antitrust laws.  Prohibited activities include any action in contemplation of or in furtherance of an agreement on fees or other aspects of reimbursement.  It is unlawful for a non-integrated group of competing providers to agree on or suggest a central fee schedule.  Any activity relating to prospective fees should be avoided.

Competing providers can jointly provide information on fees currently being charged or that have been charged in the past as long as certain safeguards are implemented and strictly followed.  The FTC and DOJ have stated that the joint provision

Read more here: Health Law Blog

By John Fisher, JD, CHC, CCEP

A Tennessee based ambulatory surgery center company has agreed to pay damages to a former employee who filed a suit alleging that physician investments in local surgery center entities violated the Anti-kickback Statute.  The case highlights some of the unique kickback issues that are present in ambulatory surgery center structure.  Specifically, the case demonstrates how investment terms that are intended to assure compliance with the safe harbor regulations under the Medicare Anti‑Kickback Statute (42 U.S.C. § 1320a-7b(a)-(b)) can create evidence of non-compliance if the initial terms of the offering relate, in whole or in part, to the volume or value of expected referrals from the investor in the ASC venture.

In order to comply with safe harbor requirements, ASCs must generally require investing physicians to use the facility as an extension of their medical practices.  However, if the terms of the investment are based on the volume or value of referrals, those same requirements become evidence that referrals are being required in exchange for remuneration.  In the Tennessee case, the ASC management company purchased controlling interests in local surgery center entities at a high multiple of earnings.  Physicians who were referral sources were offered investments at less than 1/3 of the

Read more here: Health Law Blog

By John Fisher, JD, CHC, CCEP

 It is no secret that the role of primary care is central to the creation of systems to respond to health care reform and changing reimbursement models.  To the extent primary care providers have not already relinquished their strategic positions by becoming employed, entering provider service agreements or service line management agreements with hospital controlled systems, primary care providers maintain a strong position in the market.

Primary care groups are still faced with the need to create or participate in organizations that provide for the best means to manage patient care.  Primary care groups are seeking strength in numbers by creating larger groups.  The goal is to best maintain their competitive position, to diversify risk, to create efficiencies through shared savings opportunities, and to maintain appropriate levels of influence over care cycles, protocols and division of emerging, episodic-based payment.

In order to achieve these goals, some independent primary care groups are considering merger with other groups.  Oftentimes, merging providers will seek ways to maintain some degree of intra-office independence while still taking advantage of the benefit of a larger group.

Provider mergers and acquisitions, particularly between competing independent practices in the same specialty area, can create sensitive antitrust issues.  Generally, competing providers

Read more here: Health Law Blog

By John Fisher, JD, CHC, CCEP

Private Reimbursement for Telemedicine – State Private Payment Mandates 

Failure of private reimbursement sources is one significant factor that impedes the development of telemedicine.  Some states have enacted laws that mandate some level of reimbursement for services provided by telemedicine.  The American Telemedicine Association has reported that 8 additional states have introduced telemedicine reimbursement laws already in 2013.  Those states include Florida, District of Columbia, Connecticut, Mississippi, Nebraska, Indiana, South Carolina, and New Mexico.  Some of the listed states have introduced general requirements that telehealth be reimbursed without discrimination.  Others have addressed more limited coverage .  Read more on this topic in the blog article that I posted on the Health Law Blog.

Read more here: Telemdicine Private Reimbursement

By John Fisher, JD, CHC, CCEP

How Broad is the Employee Exception 

Parameters of the Stark Law and Anti-kickback Statute Exception

Both the Anti-Kickback Statute and the Stark Law contain exceptions that apply to employer/employee relationships.  Recent developments in the health law area indicate that there may be limits on the employment exception that were not previously contemplated.  I posted an article on the Health Law Blog that discussed possible limited to compensation structures for employed physicians.

Read more here: Health Law Blog

By John Fisher, JD, CHC, CCEP

Expanding Physician Owned Hospitals - Stark Law Approval Process

The Stark Law prohibits physicians from owning interests or having financial relationships with entities that provide “designated health services,” including hospital services, unless an exception exists.  The Stark Law contained an exception that permitted investment in a “whole hospital” but that exception was seriously limited under the Affordable Care Act.  Physician-owned hospitals must now obtain CMS approval of any expansion projects.  CMS regulations define the process and requirements for obtaining CMS approval of expansion projects.

I posted an article on the Health Law Blog that summarizes some of the requirements for obtaining approval for expansion of a physician-owned hospital.

Read more here: Health Law Blog