Archive for the ‘Uncategorized’ Category

RCS-1 Model Worksheet Gives a Glimpse of a World Without RUG

Monday, March 12th, 2018

By Fisher, JD, CHC, CCEP

RCS-1 Sample Worksheet

RUG System for Skilled Nursing Facility Reimbursement – Time is Running Out

It is currently anticipated that the RUG system, which is currently used to calculate reimbursement for Medicare Part A skilled nursing services, will be changed over the next year.  CMS is currently considering a new Resident Classification System that will completely change the way SNFs are reimbursed for their services.

Providers are getting glimpses of what may be included in the new calculation system.  CMS issued a draft sample worksheet using the RCS-1 system.  The stated purpose is to give providers a description of how the new system would work.  The worksheet gives a description of how a manual calculation would take place using the RCS-I methodology.

The sample draft worksheet that was issued by CMS is available here.  RCS_I_Logic-508_Final

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Providing Protected Health Information in Response to Subpoena

Monday, March 12th, 2018

By Fisher, JD, CHC, CCEP

unauthorized release phi subpoena

OCR Citation for Improper Disclosure of PHI in Response to a Subpoena

A health care provider or other covered entity under HIPAA is permitted to disclose protected health information if it receives a lawful order from a court or administrative tribunal.  this does not mean that a provider can simply release everything it has in a patient record when it receives a court order.  Some records, such as mental health or substance abuse records might have special protections or limitations that apply.  Additionally a provider should closely review the relevant order and only disclose the information that is specifically required by the order.

The ability to release information in response to a subpoena, as opposed to an order of a court, is subject to different rules.  Patient information can only be provided under subpoena if certain notification requirements of the Privacy Rule are met. The notification requirements require the provider who received the subpoena to obtain evidence that there were reasonable efforts to notify the person who is the subject of the information about the request.  This is intended to give the individual an opportunity to object to the disclosure, or obtain a protective order from the court.

The application of these rules are

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Medical Alerts – HIPAA Implications of Flagging Patient Records

Wednesday, March 7th, 2018

By Fisher, JD, CHC, CCEP

AIDS identification external alert HIPAA

Identification of AIDS Status Through Medical Alert System

Dentist Revises Process to Safeguard Medical Alert PHI

A recent OCR investigation of a dental practice’s flagging of patients records highlights a potential HIPAA violation.  The OCR investigation confirmed allegations that the dental practice flagged some of its medical records with a red sticker with the word “AIDS” on the outside cover.   Records were handled so that other patients and staff without need to know could read the sticker.  A patient complaint commenced an OCR investigation into whether the practice potentially identified the AIDS status of patients within the office.

When notified of the complaint filed with OCR, the dental practice immediately removed the red AIDS sticker from the complainant’s file. To resolve this matter, OCR also required the practice to revise its policies and operating procedures and to move medical alert stickers to the inside cover of the records. Further, the covered entity’s Privacy Officer and other representatives met with the patient and apologized, and followed the meeting with a written apology.

The lesson here is not to place special medical alerts on the outside of physical patient records.  This is a particularly bad practice in a dental office where the typical office setup can

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Applying Section 1557 Discrimination Rules to Employer Sponsored Health Plans

Sunday, February 11th, 2018

By Fisher, JD, CHC, CCEP

Health Plan 1557 Compliance

Section 1557 Covered Entities and Employer Sponsored Health Plans

Section 1557 of the Affordable Care Act (ACA) prohibits “covered entities” discrimination in health programs that receive federal financial assistance from the Department of Human and Health Services.  Regulations were issued in 2016 that define the details of compliance with Section 1557 which prohibits discrimination based on race, color, national origin, age, disability and sex.  (including discrimination based on pregnancy, gender identity and sex stereotyping).  The stated purpose for the rules is to expand access and eliminate barriers to the ability to obtain health care coverage.

The definition of “covered entities” to which Section 1557 apply is extremely broad.  Through the broad definition, the requirements of Section 1557 apply to any health program or activity that received federal financial assistance through the Department of Health and Human Service.  This definition includes most health care providers, such as hospitals, nursing homes, and physician, who receive Medicare or Medicaid reimbursement, insurance marketplace and exchanges and participating health plans.

The Section 1557 rules extend to some (but not all) employers that are group health plan sponsors.  Determining whether Section 1557 applies to a specific employer can be quite complicated and is based on several factors such as

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Authentication of Verbal Orders by Other Responsible Practitioner

Wednesday, January 24th, 2018

By Fisher, JD, CHC, CCEP

Authenticating Verbal Orders

Authentication of Verbal Orders

In a past blog article, I discussed the need for physicians to promptly authenticate verbal orders. The failure of a physician to timely sign a verbal order can have reimbursement implications. In some cases, in some states, another responsible provider can sign a verbal order that is originally given by another practitioner. This option is not always available and depends a lot on whether state law permits the practice. Some states require the practitioner who gave the verbal order to authenticate the order. With the use of electronic medical records, practitioners cannot expect leniency on these types of requirements.

In states that permit one practitioner to authenticate for another, the authenticating proxy practitioner should understand that he or she is accepting responsibility for the authenticated verbal order. State scope of practice rules apply to cross authentication of orders. In otherwords, the practitioner authenticating the order must have practice authority to have provided the original verbal order. Facilities can develop policies that a more restrictive then what the law permits. Policy can eliminate or restrict cross authentication practices. There is inherent risk in permitting cross authentication because the authenticating provider did not give the original verbal order. Additionally, as

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Using Self-Disclosure Protocols – CMS and OIG Self Disclosure Process

Tuesday, April 11th, 2017

By Fisher, JD, CHC, CCEP

Self-Disclosure Has Become a Normal Part of the Compliance Process

As the OIG and CMS make self-disclosure easier for providers, we have noticed an increase in the rate of cases that are being filed.  Assisting providers in making decisions whether to self-disclose, conducting internal investigations, and guiding the self-disclosure process when appropriate has become a large part of our compliance practice.  Here are just a few of the articles and other resources that we have released regarding self-disclosure issues:

Exercising Reasonable Care to Identify and Address Potential Overpayments

Criminal Exposure for Failing to Repay Known Overpayment

When to Use the OIG’s Self Disclosure Protocols

Excluded Party Cases Dominate OIG Published Self Disclosure Settlements

Self-Disclosure Process – Voluntary Self Disclosure Decisions are not Always Easy

When Does An Overpayment Become Fraud? How Simple Inattention Can Expose You to Penalties for Fraudulent Activities

Provider Self-Disclosure Decisions – Voluntary Disclosure Process

Provider Self Disclosure Process

For more information on the self-disclosure process and legal updates impacting the process, watch this space.

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OIG Releases Annual Work Plan for 2017

Monday, January 23rd, 2017

OIG Annual Work Plan for 2017 – Topics Covered

The Health and Human services Office of Inspector General (OIG) recently released its 2017 Annual Work Plan.  Work planning is an ongoing project within the OIG.  Every year, the OIG publishes a work plan that consolidates the OIG audits and evaluations that are being conducted or planned within the organization.  The annual work plan has become a source that compliance officers look to as a tool for the identification of potential risk areas or areas of emphasis within their organization.  It is obviously not the only source for identifying compliance risk areas, but is certainly one reliable source that providers can draw on when setting their annual compliance priorities.

The 2017 OIG Work Plan can be download through the OIG site.

Ruder Ware’s health care group will continue to put out blogs and articles on various issues identified in the 2017 Annual Work Plan.  We will focus primarily on issues that were introduced for the first time in this year’s plan.

Review of Nursing Facility prospective payment system requirements

Tuesday, November 24th, 2015

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 Reference and FAQ on CMS Website Phase 3 Ehr

Monday, November 23rd, 2015

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

Bundled Payment Arrangements for Clinically Integrated Networks

Tuesday, June 2nd, 2015

By John Fisher, JD, CHC, CCEP

Bundled Payment Arrangements CINs

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

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