Archive for the ‘Reimbursement Issues’ 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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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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Wisconsin Home Health Quality Regulations – HHA Attorney Wisconsin

Tuesday, February 14th, 2017

Wisconsin Home Health Quality Reporting Requirements-  OASIS Data Item Set 

The reporting of quality data by home health agencies (HHAs) is mandated by Section 1895(b)(3)(B)(v)(II) of the Social Security Act (“the Act”).  This statute requires that ‘‘each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this clause.’’

OASIS reporting is mandated in the Medicare regulations at 42 C.F.R.§484.250(a), which requires HHAs to submit OASIS assessments and Home Health Care Consumer Assessment of Healthcare Providers and Systems Survey (HH CAHPS) data to meet the quality reporting requirements of section 1895(b)(3)(B)(v) of the Act.

Home Health Quality Reporting Requirements

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.

Physician Owned Hospital Expansion – CMS Approval Process

Tuesday, May 20th, 2014

By John Fisher, JD, CHC, CCEP

physician owned hospitals

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.

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Auditing Physician Payments For Stark Law Compliance

Tuesday, April 8th, 2014

By John Fisher, JD, CHC, CCEP

One area of compliance that is often overlooked involves auditing of physician payments.  Physician contracts are often audited to determine whether they comply with a Stark Law exception.  Compliance should also work in the other direction, from payments that are made back to the existence of a contract that memorializes an applicable Stark Law exception.

Periodic monitoring of payments that are made to physicians should be undertaken.  Payments should be tracked to contracts to assure that the payment is covered by an applicable exception.  If there is no corresponding written agreement or if the written agreement has expired, there could be a potential Stark Law violation.  Further examination concerning the nature and purpose of the payment should be made.  If a Stark Law violation is found, self disclosure should be considered.

 

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Payment Suspension Fraud and Abuse – End To Pay and Chase

Monday, May 27th, 2013

Payment Suspension – Moving Away from Pay and Chase

CMS now has the authority to suspend further payments to a provider following receipt of any “credible allegation of fraud.”  Allegations are deemed to be credible when they have an “indication of reliability.”  The allegation can come from a number of possible sources such as employee complaints, whistleblower claims, provider audits, false claims allegations, or virtually any other source as long as CMS deems the allegation to be credible.  The suspension of payment may last up to eighteen (18) months or longer if a referral is made for further administrative action.

Suspension of payment is an extremely draconic remedy which can threaten the financial existence of some providers.  The remedy is available even before there is solid proof that fraud has been committed.  The possibility of having payment suspended is yet another reason for providers of all types to adopt sensible, scaled compliance programs.  An effective compliance program is the provider’s best proactive defense to the potentially devastating impact of having payment suspended.

Health Care Provisions In Fiscal Cliff Legislation

Monday, January 7th, 2013

Although physicians averted a nearly 27% reduction in reimbursement under Medicare, the Fiscal Cliff Legislation included a number of changes in reimbursement that in additiona to the “doc fix.”  Many of those chanced will not make health care providers very happy.  For example, the Wisconsin Hospital Association reported on friday about “Troubling Hospital Cuts” that are included in the Fiscal Cliff legislation.  Although some important programs benefiting rural providers were extended, other provisions were included that will not be as positive for hospitals and some other providers.

Some of the health care provisions that were included in the Fiscal Cliff Legislation include:

  • Medicare contractors will be given an additional 2 years to pursue overpayments from providers.  Previous law limited the recovery time period to three years.  The Fiscal Cliff legislation extended the period that Recovery Audit Contractors and other contractors can look at to assess overpayments against providers.
  •  The exceptions process relating to outpatient therapy services cap is extended for an additional year. The cap is also extended to therapy furnished as part of outpatient services provided by a critical access hospital.
  • Limitations were placed on reimbursement for stereotactic radiosurgery.
  • A new competitive pricing system for Medicare diabetic supplies is created.
  • The temporary increase in ambulance costs un certain rural areas was extended for another year.
  • A reduction by 10% in reimbursement for many non-emergency ambulance transports.  The legislation also calls for the preparation of a study on existing cost reports for ambulance services furnished by hospitals and critical access hospitals.  The existence of this study provides evidence that future reforms in ambulance service reimbursement may be on the way.
  • The reduction in reimbursement for certain advanced imaging services is increased from 75& to 90%.
  • CMS is required to adjust bundled payments for end stage renal disease to reflect changes in utilization and current sales prices of certain drugs and biologicals. Implementation of the oral-only ESRD-related drug requirement was delayed through the end of 2015.
  • The Medicare-Dependent and Low-Volume Hospital programs were extended.  Although the extension in for only a short time, these important additional payments for rural hospitals are being extended.
  • Implementation of a system to recoup payments made to hospitals under that result from the shifting of PPS payments to MS/DRG system. The new provisions permit recoupment from hospitals for “upcoding” or “coding creep.” This change is estimated to cost hospitals nationwide around $10.5 billion to be recouped for 2014 through 2017.