Health Care Quality |

ONC Releases Proposed Rules For Meaningful Use Stage 2

February 23, 2012

The Office of the National Coordinator for Health Information Technology (ONC) published its Notice of Proposed Rulemaking for Stage 2 Meaningful Use (Proposed Rule) in the Federal Register today (February 23).

The Proposed Rule available here outlines the next stage of meaningful use for the Electronic Health Record (EHR) Incentive Programs administered by CMS.

CMS has developed a fact sheet to give providers an overview of the rule and how Stage 2 expands upon Stage 1 of meaningful use. The fact sheet can be found here.

For More Information Or Assistance

If you need assistance reviewing or responding to these or other health care related technology, risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Her experience includes advising hospitals, nursing home, home health, rehabilitation and other health care providers, health care technology and other health industry clients to set up and administer privacy and technology; workforce and staffing; operations; compliance and risk management policies; prevent, conduct and investigate, and respond to peer review and other quality concerns; and to respond to Board of Medicine, Department of Aging & Disability, Drug Enforcement Agency, OCR Privacy and Civil Rights, HHS, DOD and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, technology, privacy, quality assurance and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her presentations and programs including a wide range of works on health care privacy and technology and other health industry matters.

Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance responding to concerns about the matters discussed in this publication or other health care concerns, wish to obtain information about arranging for training or presentations by Ms. Stamer, wish to suggest a topic for a future program or update, or wish to request other information or materials, please contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see here.

About Solutions Law Press

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THE FOLLOWING DISCLAIMER IS INCLUDED TO COMPLY WITH AND IN RESPONSE TO U.S. TREASURY DEPARTMENT CIRCULAR 230 REGULATIONS. ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, OR (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.

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Posted by Cynthia Marcotte Stamer

Texas Physicians Get New Option For Resolving Some Medical Board Complaints

January 19, 2012

A new non-disciplinary “Remedial Plan” option enacted by the Texas Legislature last session may allow some Texas physicians to resolve charges of professional misconduct pending before the Texas Medical Board without the National Practitioner Data Bank report that normally results when a physician is formally disciplined by the Texas Medical Board.

Previously, Texas law only allowed the Texas Medical Board to resolve complaints against a physician through either:

Dismissal; or
Imposing public discipline.

A public discipline order typically results in a report to the National Practitioner Data Bank in addition to any sanctions and public reporting of the disciplinary action.

Under reforms enacted in Senate Bill 227/House Bill 680 last session, however, the Texas Medical Board now also may resolve some complaints by offering a “Remedial Plan” rather than imposing formal discipline. The primary advantage to a physician of having a complaint resolved by a Remedial Plan rather than formal disciplinary actions is that the Remedial Plan will not result in a misconduct and discipline report to the National Practitioner Data Bank because of the “non-disciplinary” nature of the Remedial Plan remedy.

Under the Remedial Plan option, the physician typically will be required to agree to certain remedial actions dictated by the Texas Medical Board in a public document that will appear on a physician’s public profile. The written Remedial Plan generally will state that the physician is subject to a “non-disciplinary” action for a specified violation. While the basis of the charge leading to the Remedial Plan and agreed to corrective action generally will be included in the posted Remedial Plan, a physician generally will not be required to admit guilt. Since the physician will avoid disciplinary action, resolution by the Remedial Plan avoids the obligation for a report of disciplinary action to the National Practitioner Data Bank. In addition to avoiding a report to the National Practitioner Data Bank, resolution of a complaint by a Remedial Plan also allows a physician to avoid having his name listed in the Board’s newsletter or in the Board’s press releases like would result in the case of a disciplinary action.

Remedial Plans are not available for all charges. Rather, Remedial Plans generally are an option only for a limited number of situations in which the Texas Medical Board decides to offer the option for resolution of a complaint through a Remedial Plan based on its decision that fulfillment of the specified conditions sufficiently corrects the concerns raised by the charge that it is appropriate to forgo formal disciplinary action. Most typically, this could happen when the Texas Medical Board is addressing administrative violations after receiving a complaint or in other instances where the Texas Medical Board decides the nature and circumstances of a charged violation can be adequately addressed through the Remedial Plan without formal discipline. When offered, Remedial Plan resolution is a take it or leave it propositions. The Texas Medical Board decides the required terms of the Remedial Plan and these terms are non-negotiable. Also physicians offered the option of resolution under a Remedial Plan generally must accept the offered Remedial Plan terms by a specific deadline.

While a physician generally cannot insist upon the option for resolution through a Remedial Plan or dictate the terms of a Remedial Plan, a physician facing charges before the Texas Medical Board often can can improve his odds for avoiding discipline by the Texas Medical Board or qualifying for resolution of charges under a Remedial Plan by acting quickly with the assistance of experienced legal counsel to gather and present to the Texas Medical Board factual evidence and documentation that negate or mitigate charges of misconduct as well as signaling his interest and willingness to take action to mitigate the risks reflected by the charges and improve performance whether or not the action resulting in the charge in fact resulted in misconduct.

For Help With Compliance, Investigations Or Other Needs

If you need help dealing with licensing, peer review, or other quality assurance, compliance or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other quality and performance concerns, and to address other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others including highly popular programs on “Sex Drugs & Rock ‘N Role: Managing Personal Misconduct in Health Care,” “Managing Physician Performance” and others.. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | Doctor, Employment, Health Care, Health Care Provider, Health Care Quality, Hospital, Medical Licensure, Medical Malpractice, Mental Heatlh, Peer Review, Physician, Physician Licensing | Tagged: discipline, Health Care, Medical Licensure, Physician, Sexual Misconduct | Permalink
Posted by Cynthia Marcotte Stamer

North Texas Medical Supply Company Owner Indicted For Health Care Fraud Now Also Charged With Immigration Fraud

December 27, 2011

A Plano, Texas man already indicted for health care fraud now also faces federal immigration fraud related changes. Justice Department officials announced the additional charges against Okey F. Nwagbara, (Nwagbara) on December 20, 2011. Although Nwagbara’s alleged actions reflect potential criminal misconduct in many areas, health care providers should keep in mind that the health care fraud task force participants are targeting health care fraud of all types, including those my health care providers not engaged in other types of criminal misconduct. As a result, all health care providers should tighten their health care billing and other practices to defend against possible scrutiny as part of the federal or state government’s widening fraud audit and investigation efforts.

Nwagbara Indicted For Health Care Fraud In October, 2011

Nwagbara 45 already is awaiting trial later in Spring, 2012 on health care fraud charges announced in October, 2011. According to the Justice Department, a North Texas grand jury indicted Nwagbara along with Jerry C. Bullard, 55, Mesquite, Texas, in October, 2011 on felony charges related to a health care fraud scheme they allegedly ran that defrauded Medicare of more than $500,000.

According to the Justice Department, Nwagbara is the owner/operator of Advanced MedEquip and Supplies Limited, located at 331 Melrose Drive in Richardson, Texas. Bullard is a former employee of Medistat Group Associates, P.A., an association of health care providers located in Desoto, Texas.

The October health care fraud indictment charges Nwagbara and Bullard each with one count of conspiracy to commit health care fraud and six substantive counts of health care fraud. The indictment alleges that from June 2008 through March 2010, Nwagbara and Bullard conspired together to defraud Medicare by submitting more than $500,000 in claims to the Medicare program for enternal nutrition DME, when in fact such DME was not medically necessary and in many cases, not provided.

According to the health care fraud indictment, Bullard worked in the Durable Medical Equipment (DME) section of Medistat where he was in charge of handling physicians’ prescriptions for equipment. Bullard and Nwagbara had a kickback arrangement and Bullard placed orders for DME with Nwagbara’s company, Advanced.

The indictment claims Bullard, using a Medistat physician’s name, would sign prescriptions, DME information forms and certificates of medical necessity for Medicare beneficiaries falsely indicating, among other things, that a beneficiary had a feeding tube when in fact, the beneficiary did not.

The enteral nutrition products which were billed to Medicare are consumed by a patient through a feeding tube. The associated feeding supply kits include tubing and syringes. The indictment claims that both the enteral formula and the kits that Advanced billed to Medicare were not medically necessary because the beneficiaries were not receiving nutrition through a feeding tube, the indictment claims. Instead, beneficiaries were receiving flavored nutritional supplements such as Ensure® and Glucerna® that would be consumed orally. Medicare does not reimburse orally ingested nutritional supplements.

In addition, the health care fraud indictment alleges that Nwagbara supplied only a fraction of the enternal products for which he billed Medicare and many of the beneficiaries never received the feeding supply kits for which he also billed Medicare.

The health care fraud case is being investigated by the Dallas Health Care Fraud Prevention and Enforcement Action Team (HEAT) Strike Force, which includes the U.S. Department of Health and Human Services – Office of Inspector General, the FBI and the Texas Attorney General’s Medicaid Fraud Control Unit. Prior to the announcement of the other charges, his trial on the health care fraud charges was scheduled for March, 2012. It is not clear whether the new charges will delay these proceedings.

New Immigration Charges

On December 20, 2011, the Justice Department announced that a North Texas grand jury now also has indicted Nwagbara for making misrepresentations in immigration and naturalization documents that misled the government and prevented the government from examining material facts that may have prevented his naturalization according to a December 20, 2011 Justice Department announcement.

According to the December 20, 2011 announcement by U.S. Attorney Sarah R. Saldaña, the immigration charges resulted from investigative work by the Dallas Health Care Fraud Strike Force, in concert with U.S. Immigration and Customs Enforcement’s Homeland Security Investigations and U.S. Citizenship and Immigration Services.

The new immigration indictment alleges that Nwagbara entered into a fraudulent marriage and provided false statements to obtain citizenship. On January 30, 2008, he made false statements on his application for naturalization that included:

Verifying that he had been married to and living with the same U.S. citizen for the last three years, when he was not living with his U.S. citizen spouse;
Indicating that he had no children, when in fact he had two children; and
Indicating that he had never previously claimed to be a U.S. citizen, when in fact, he falsely stated on a mortgage application in January 2006 that he was a U.S. citizen.

According to Saldaña, the immigration related indictment charges Nwagbara with three counts of making a false statement in an immigration document and three counts of unlawful procurement of naturalization. If convicted, each count carries a maximum statutory sentence of 10 years in federal prison and a $250,000 fine. Furthermore, should Nwagbara be convicted of unlawfully procuring his naturalization, his status as a U.S. citizen will be revoked by court order.

The Justice Department announcements reminds readers that an indictment is an accusation by a federal grand jury, and a defendant is entitled to the presumption of innocence unless proven guilty.

Health Care Fraud Charges Part of Ongoing National Anti-Health Care Fraud Campaign

The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. The joint Department of Justice-HHS Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing. Since its announcement, the Strike Force has used the combined resources of agents from the FBI, HHS-Office of Inspector General (HHS-OIG), multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies to investigate and prosecute a rising number of organizations and individuals throughout the industry for alleged violations of Federal health care fraud prohibitions. In their September 7, 2011 announcement, HHS and DOJ credited Strike Force Operations in nine locations with resulting in charges against more than 1,140 defendants who the government charged collectively falsely billed the Medicare program for more than $2.9 billion.

In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are using a wide range of new and old tools in their campaign against what they perceive as fraudulent providers and to deter other perceived aggressiveness by health care providers and organizations. See e.g., U.S. to use software to crack down on Medicare, Medicaid, CHIP fraud; Health Care Fraud Enforcement Packs New Heat; OIG Shares Key Insights On When Owners, Officers & Managers Face OIG Program Exclusion Based On Health Care Entity Misconduct; OIG Launch of Health Care Fraud “Most Wanted” List Sign of Enforcement Risks; CMS Delegated Lead Responsibility For Development of New Affordable Care Act-Required Medicare Self-Referral Disclosure Protocol; HHS announces Rules Implementing Tools Added By Affordable Care Act to Prevent Federal Health Program Fraud.

The effectiveness of these Federal efforts to deter, find and prosecute false claims and other perceived abuses of Federal health care law has been significantly strengthened since Congress passed the Patient Protection & Affordable Care Act (Affordable Care Act). Among other things, ACA empowered HHS to:

Suspend payments to providers and suppliers based on credible allegations of fraud in Medicare and Medicaid;
Impose a temporary moratorium on Medicare, Medicaid, and CHIP enrollment on providers and suppliers when necessary to help prevent or fight fraud, waste, and abuse without impeding beneficiaries’ access to care.
Strengthen and build on current provider enrollment and screening procedures to more accurately assure that fraudulent providers are not gaming the system and that only qualified health care providers and suppliers are allowed to enroll in and bill Medicare, Medicaid and CHIP;
Terminate providers from Medicaid and CHIP when they have been terminated by Medicare or by another state Medicaid program or CHIP;
Require provider compliance programs, now required under the Affordable Care Act, that will ensure providers are aware of and comply with CMS program requirements.

Act To Manage Risks

In response to the growing emphasis and effectiveness of Federal officials in investigating and taking action against health care providers and organizations, health care providers covered by federal false claims, referral, kickback and other health care fraud laws should consider auditing the adequacy of existing practices, tightening training, oversight and controls on billing and other regulated conduct, reaffirming their commitment to compliance to workforce members and constituents and taking other appropriate steps to help prevent, detect and timely redress health care fraud exposures within their organization and to prepare their organization to respond and defend against potential investigations or charges.

For More Information Or Assistance

Board Certified in Labor & Employment Law, Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients.

Throughout her career, Ms. Stamer has advised and represented health care providers and other health industry clients. She helps health industry clients to establish and administer compliance and risk management policies and to respond to health care, human resources, tax, privacy, safety, antitrust, civil rights, and other laws as well as to handle public policy and government relations, peer review and credentialing, performance and discipline, training, internal investigation, litigation and enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on health care fraud, privacy, and other rules and enforcement actions. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.

You can learn more information about Ms. Stamer’s health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

Other Resources

If you found this update of interest, you also may be interested in reviewing some of the other updates and publications authored by Ms. Stamer available including:

About Solutions Law Press

Leave a Comment » | Academic medicine, Anti-KickBack, ASC, Childrens Health Insurance Program, Corporate Compliance, DME, Doctor, Durable Medical Equipment, false claims act, Federal Health Center, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Home Health, Hospital, Hospital, Medicaid, Medicare Advantage, Mental Heatlh, Money Laundering, OIG, Pharmacy, Physician, Reimbursement, Stark | Tagged: DOJ, Health Care, Health Care Fraud, Hospital, Medicare Fraud, OIG, Physician | Permalink
Posted by Cynthia Marcotte Stamer

DOL Proposes Tighter Overtime, Minimum Wage Rules For Home Care Workers, Continues Scrutiny Of Health Care Employers

December 15, 2011

The U.S. Department of Labor Wage and Hour Division (WHD) plans to propose new rules that would provide minimum wage and overtime protections for nearly two million workers who provide in-home care services for the elderly and infirm. WHD’s focus on home health workers is an extension of its expanded regulation and enforcement efforts targeting a broad range of health care industry employers. Home care and other health industry employers should act to manage their rising exposures to minimum wage, overtime and other federal and state wage and hour law risks. Additionally, health industry and other employers concerned about the potential cost or other implications of the proposed regulatory changes also should consider submitting comments to the WHD by the February comment deadline.

On December 15, 2011 the WHD announced that it will publish a Notice of Proposed Rulemaking [1] (NPRM) to revise the companionship and live-in worker regulations under the Fair Labor Standards Act (FLSA):

To more clearly define the tasks that may be performed by an exempt companion;
To limit the companionship exemption to companions employed only by the family or household using the services; and
To provide that third party employers, such as in-home care staffing agencies, could not claim the companionship exemption or the overtime exemption for live-in domestic workers, even if the employee is jointly employed by the third party and the family or household.

When Congress expanded protections to “domestic service” workers in 1974, it exempted casual babysitters and companions for the aged and inform from both the minimum wage and overtime pay requirements of the FLSA and exempted live-in domestic workers from the overtime pay requirement only. While WHD has left regulations governing this exemption substantially unchanged since first issued in 1975, it now believes the in-home care service industry. workers employed by in-home care staffing agencies are not the workers that Congress envisioned in enacting the companionship exemption (i.e., neighbors performing elder sitting).

As a result of these determines, WHD is moving to modify its existing rules to broaden protections for professionally employed home care workers as well as outreaching to inform employers and workers about the requirements that it perceives employers of these workers must meet.

The proposed tightening of regulations for home health workers follows a general toughening by WHD of its regulation and enforcement of wage and hour laws in the health care industry. See, e.g. Home health care company in Dallas agrees to pay 80 nurses more than $92,000 in back wages following US Labor Department investigation; US Department of Labor secures nearly $62,000 in back overtime wages for 21 health care employees in Pine Bluff, Ark.; US Department of Labor initiative targeted toward increasing FLSA compliance in New York’s health care industry; US Department of Labor initiative targeted toward residential health care industry in Connecticut and Rhode Island to increase FLSA compliance; Partners HealthCare Systems agrees to pay 700 employees more than $2.7 million in overtime back wages to resolve U.S. Labor Department lawsuit; US Labor Department sues Kentucky home health care provider to obtain more than $512,000 in back wages and damages for 22 employees; and Buffalo, Minn.-based home health care provider agrees to pay more than $150,000 in back wages following US Labor Department investigation.

Coupled with these and other enforcement efforts against health industry employers, WHD’s announcement of plans to tighten rules for home care givers. In connection with its announcement of the planned regulatory changes, for instance, WHD highlighted the following guidance about the wage and hour rules that employers of home care workers can anticipate being required to meet when employing these workers:

Violation of wage and hour laws exposes health care and other employers to significant back pay awards, substantial civil penalties and, if the violation is found to be willful, even potential criminal liability. Because states all have their own wage and hour laws, employers may face liability under either or both laws.

In light of the proposed regulatory changes and demonstrated willingness of WHD and private plaintiffs to bring actions against employers violating these rules, health care and others employing home care workers should take well-documented steps to manage their risks. These employers should both confirm the adequacy of their practices under existing rules, as well as evaluate and begin preparing to respond to the proposed modifications to these rules. In both cases, employers of home care or other health care workers are encouraged to critically evaluate their classification or workers, both with respect to their status as employees versus contractor or leased employees, as well as their characterization as exempt versus non-exempt for wage and hour law purposes. In addition, given the nature of the scheduled frequently worked by home care givers, their employers also generally should pay particular attention to the adequacy of practices for recordkeeping.

For More Information Or Assistance

Throughout her career, Ms. Stamer has advised and represented health care providers and other health industry clients to establish and administer compliance and risk management policies and to respond to health care, human resources, tax, privacy, safety, antitrust, civil rights, and other laws as well as with internal investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on OCR Civil Rights rules and enforcement actions. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

Other Resources

If you found this update of interest, you also may be interested in reviewing some of the other updates and publications authored by Ms. Stamer available including:

About Solutions Law Press

[1] WHD’s announcement of the planned rule notes that this draft shared December 15 remains subject to change before formally published in the Federal Register

Leave a Comment » | Academic medicine, Anti-KickBack, ASC, Childrens Health Insurance Program, Corporate Compliance, DME, Doctor, Durable Medical Equipment, false claims act, Federal Health Center, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Home Health, Hospital, Hospital, Medicaid, Medicare Advantage, Mental Heatlh, Money Laundering, OIG, Pharmacy, Physician, Reimbursement, Stark | Tagged: DOJ, Health Care, Health Care Fraud, Home Care, home health, Hospital, Medicare Fraud, Minimum Wage, nurses, OIG, Overtime, Physician, Wage and Hour | Permalink
Posted by Cynthia Marcotte Stamer

Former Houston Texas Physician Gets 70 Month Prison Sentence For Fraud Conviction

November 27, 2011

A Federal court on November 14, 2011 sentenced Armando Chavez, 42, a former physician and owner of the Chavez Medical Group in East Houston to 60 months for the conspiracy charge and to 70 months for each of the three mail fraud charges. In addition to the prison sentences, which will run concurrently, Chavez was also ordered to pay $3,821,082 in restitution.

The prosecution and sentencing of Chavez highlights the heightened risk that physicians and others engaging in aggressive health care billings risk if Federal officials view their actions as crossing the line. The Chavez case is particularly notable as it primarily stemmed from claims submitted to private health care payers.

The Chavez sentence resulted from Chavez’ guilty plea to one count of conspiracy and three counts of mail fraud in connection with billings made at the Chavez Medical Group.

The charges brought in April, 2011 stem from improper billing at the Chavez Medical Group between 2005 and 2007. Federal prosecutors charged that Chavez billed for services he did not perform through a process of “unbundling” medical codes used on claims he filed to increase the amount he was paid by insurance companies. While most health care providers recognize potential exposures to health care fraud prosecution for making false claims to Medicare, Medicaid or other federal programs, many providers fail to recognize this same exposure also can result from false billings to private health plans and insurers.

Following the initiation of the investigation, Chavez voluntarily surrendered his medical license to the Texas Board of Medicine. Filing false health care claims is one of many types of personal misconduct that justifies loss of licensure or other discipline under Texas Medical Board rules.

According to the documents filed of record in the case, Chavez was board certified in internal medicine, licensed by the Texas Board of Medicine in 1997. He started his medical practice in family medicine and in 2005, began to perform endovenous laser ablation, a procedure used to repair varicose veins in the legs.

For purposes of billing, the medical insurance industry provides certain billing codes for the laser ablation procedure, which include a group of procedures billed under one code for the entire procedure. Chavez instructed his staff to “unbundle” or separate the codes for this procedure and to bill for individual steps in the procedure, resulting in greater reimbursement and payment for each patient. Additionally, Chavez submitted claims alleging he repaired all six veins for each patient, when in fact – in most cases – he repaired fewer than six veins. By alleging he repaired all six veins, Chavez alleged he performed six procedures over a period of six days, another aspect of the fraudulent billing which he used to justify the unbundling of codes and allowed him to be reimbursed at the highest possible rate.

Federal prosecutors claimed The typical patient whose billing was submitted as “bundled” into one code resulted in payment of approximately $6000, while the patient whose billing codes were “unbundled” typically resulted in payment of approximately $14,000. Based on these figures, Federal prosecutors claim that Chavez billed insurance companies and programs, including Medicare and Medicaid, a total of $14.1 million for which he collected $3.8 million between 2005 and 2007.

The investigation of this case was conducted by the FBI and the Texas Attorney General’s Medicaid Fraud Control Unit. Assistant United States Attorney Cedric L. Joubert prosecuted the case. According to the Justice Department, the case is being investigated by the Dallas Health Care Fraud Prevention and Enforcement Action Team (HEAT) Strike Force, which includes the U.S. Department of Health and Human Services Office of Inspector General, the FBI and the Texas Attorney General’s Medicaid Fraud Control Unit. Since their inception in March 2007, Strike Force operations in nine locations have charged more than 1,140 defendants who collectively have falsely billed the Medicare program for more than $2.9 billion.

While health care fraud enforcement remains a lead Federal priority, health care providers in Texas and other HEAT Strike Force targeted regions face heightened exposures to HEAT task force scrutiny and prosecution. In response to these and other investigation and oversight activities, health care providers should strengthen their compliance practices and oversight and take other special care to position themselves and their billings to defend against possible challenge.

For Help With Compliance, Investigations Or Other Needs

If you need assistance providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | DME, Doctor, false claims act, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Plan, Health Plans, Home Health, Hospital, Hospital, Medicaid, Medicare, Medicare Advantage, Money Laundering, OIG, Physician, Physician Licensing, Reimbursement | Tagged: false claims act, Health Care Fraud, HEAT, Medical Licensure, Physician, texas medical board | Permalink
Posted by Cynthia Marcotte Stamer

Euless Healthcare Corporation Owner, Associates Face Conspiracy And Health Care Fraud Charges For Alleged Submission Of $700,000+ In Fraudulent Health Care Claims

November 27, 2011

Three defendants indicted for engaging in various Federal health care fraud offenses related to their involvement in the operation of a North Texas based health care company, Euless Healthcare Corporation, were arrested on November 17, 2011. The charges highlight the health care fraud risks that health care providers, their owners and leaders face for engaging in activities that Federal officials view as prohibited under health care fraud laws.

According to the Justice Department, a 10-count indictment unsealed against Ovsanna Agopian, aka “Joanna Ovsanna,” “Joanna Smbatyan,” and “Ovsanna Agopian,” Boghos Babadjanian and Tolulope Labeodan charges each defendant wit one count of conspiracy to commit health care fraud and nine substantive counts of health care fraud.

According to the indictment, Agopian was the principal operator of Euless Healthcare Corporation (EHC), located at 222 West Bedford Euless Road in Hurst. Babadjanian was the owner of EHC and Labeodan was an employee of EHC. The indictment alleges that the three defendants ran a conspiracy to defraud Medicare by submitting claims for office visits and diagnostic tests that were never performed. The indictment alleges that Agopian recruited doctors to work for EHC by telling them that they would treat beneficiaries in the beneficiaries’ homes. However, the doctors that Agopian recruited never saw beneficiaries at the EHC clinic or beneficiaries’ homes. Prosecutors claim Agopian directed Labeodan, who is not a medical professional and does not have a Medicare provider number, to take beneficiary files from the EHC clinic and purportedly see beneficiaries. However, many beneficiaries, in whose names EHC submitted claims for reimbursement, have never heard of EHC or any of the doctors Agopian recruited.

Federal prosecutors claim that EHC used those doctors’ Medicare provider numbers to falsely bill Medicare more than $700,000 for office visits and diagnostic test for which the defendants allegedly collected Medicare reimbursement checks totaling more than $370,000.

According to the Justice Department, the case is being investigated by the Dallas Health Care Fraud Prevention and Enforcement Action Team (HEAT) Strike Force, which includes the U.S. Department of Health and Human Services Office of Inspector General, the FBI and the Texas Attorney General’s Medicaid Fraud Control Unit. Since their inception in March 2007, Strike Force operations in nine locations have charged more than 1,140 defendants who collectively have falsely billed the Medicare program for more than $2.9 billion.

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Posted by Cynthia Marcotte Stamer

Medical Identity Theft/Fraud Convictions Highlight Need For Health Care Providers To Safeguard Health Information, Guard Against Fraud Schemes

November 27, 2011

Convictions Highlight Health Care Data Bases Attractive, Vulnerable Target For Medicare Fraud Schemers

A Federal judge sentenced 25 year old Miami resident Yenky Sanchez, 25 to serve more than 5 years in Federal prison for his role in the theft of Medicare numbers and other information of elderly and disabled Florida residents as part of a plan to defraud Medicare, Medicaid and other federal programs. Coming on the heels of a November 3 conviction in West Virginia of Sargis Tadevosyan in a separate identity theft for Medicare fraud scheme, the convictions highlight the growing commitment and effectiveness of Federal and state investigators in investigating and prosecuting individuals who seek to use identity theft schemes to defraud Medicare or other federal programs.

Sanchez Conviction & Sentencing

The sentence arises from criminal charges brought by the U.S. Department of Justice (DOJ) in conjunction with other federal and state agencies, which charged Sanchez considered to commit health care fraud, authentication feature fraud and aggravated identity theft. According to DOJ documents, Sanchez, participated in a scheme with Raul Diaz-Perera, to steal and sell Medicare numbers and other data about clients of their employer, the Florida Department of Children and Families’ (DCF). Diaz-Perera previously was employed with DCF. According to the evidence at trial against Sanchez and a factual proffer filed with the court during the plea hearing for co-defendant Diaz-Perera, Sanchez used his position as employees at a DCF call center in downtown Miami to steal Medicare numbers and other personal information for purposes of committing health care fraud and identity theft. The intent of Sanchez and his co-conspirator was for those numbers to be used to fraudulently bill Medicare for services that were never provided to the DCF beneficiaries. Sanchez was convicted of conspiring to commit health care fraud, in violation of Title 18, United States Code, Section 1349; conspiring to commit authentication feature fraud, in violation of Title 18, United States Code, Sections 1028(a)(3) and (f); and aggravated identity theft, in violation of Title 18, United States Code, Section 1028A(a)(1). Based on these convictions, U.S. District Judge Cecilia M. Altonaga sentenced Sanchez on November 21, 2011 to 65 months in prison, followed by three years of supervised release. Judge Altonaga also imposed a $5,000.00 fine on Sanchez.

Tadevosyan Conviction

Federal officials previously also had scored another Medicare fraud/identity theft prosecution victory just a few short weeks earlier in West Virginia. On November 3, 2011, a federal jury convicted Armenia citizen Sargis Tadevosyan in connection with a health care fraud scheme that intended to defraud millions of dollars from Medicare. Tadevosyan was found guilty of two felony counts: conspiracy to commit health care fraud and wire fraud and aggravated identity theft. Tadevosyan faces up to 20 years in prison for the conspiracy conviction and a mandatory consecutive sentence of two years for aggravated identity theft and a $250,000 fine when he is sentenced on January 26, 2012.

In contrast to the small scale conspiracy that apparently occurred in the Sanchez case, the Tadovosyn scheme apparently was orchestrated by organized crime. Department of Health and Human Resources Office of Inspector General (HHS-OIG) uncovered the activities of Tadovosyn as part of its investigation of fraud schemes involving false front providers, whereby a company posed as a Medicare health care provider, and unlawfully billed Medicare as if they were providing legitimate services. Ultimately, investigators discovered that Tadevosyn and others were involved in defrauding Medicare and other health care payers as part of a scheme that used false front provider companies. In total, more than $4 million in Medicare claims were submitted by the false front providers. To co-conspirators of Tadevosyn pleaded guilty in September to aiding and abetting aggravated identity theft in connection to the health care fraud plot. Those two co-defendants are scheduled to be sentenced on December 1, 2011.

In announcing the Tadevosyan conviction, federal officials affirmed their commitment to finding and prosecuting identity theft targeting Medicare and other health insurance programs. “This investigation revealed that organized criminal groups are still brazenly attempting to steal taxpayer money from our national health insurance programs,” said Nicholas DiGiulio, Special Agent in Charge for the Inspector General’s Office of the United States Department of Health and Human Services. “Today’s results demonstrate that we will do whatever it takes to catch these individuals in the act before they receive a penny of taxpayers’ money.”

Federal Laws, Investigations & Prosecutions of Medical Identity Theft Schemes Tightening

Whether from deliberate schemes to misappropriate data or other less sinister compromises of personal health information or other sensitive data, health care providers, health plans and other businesses face rising responsibilities to protect data and increasing exposures for failing to do so.

Federal law imposes stiff sanctions against organizations and individuals that engage in theft of personal or other sensitive information, health or other federal program fraud or both. In an effort to stem the tide of health care and identity theft fraud, federal and state legislators and regulators have tightened federal and state laws to strengthen laws prohibiting health care fraud and identity theft, to require that health care providers, health plans, federal and state agencies and others that collect, possess or access sensitive personal health information, personal financial information or other sensitive date safeguard and protect sensitive information against improper access or misuse, to increase the penalties for violation of these federal and state laws and to provide law enforcement with expanded tools to investigate and prosecute violations of these laws. See e.g., Cybercrime and Identity Theft: Health Information Security Beyond HIPAA.

As a result of these new and expanded mandates, health care providers, health plans, financial organizations and a broad range of other businesses and governmental agencies face a host of complicated mandates to protect personal health information, personal financial information and other sensitive data under laws such as the Health Information Portability & Accountability Act (HIPAA), the Fair & Accurate Credit Transactions Act (FACTA), state and federal identity theft and data security and other laws and significant liability for failing to fulfill these responsibilities.

Health care providers, health insurers and others handling protected health information are particularly at risk when their data is compromised. Recent amendments to HIPAA require these entities and their business associates to tighten their data privacy and security safeguards and to monitor and timely report data breaches, as well as significantly expand their potential liability exposure for failing to comply with HIPAA’s requirements. See e.g., UCLA Health Systems Payment of $865,500 To Settle HIPAA Charges Shows Rising HIPAA Risk; CVS Settles Privacy Charges; Rite Aid Agrees to Pay $1 Million to Settle HIPAA Privacy Case As Office of Civil Rights Proposes Tighter HIPAA Privacy & Security Regulations; 2 New HIPAA Criminal Actions Highlight Risks From Wrongful Use/Access of Health Information; President Signs Long-Sought Red Flag Rule Exemption Into Law. As part of its ongoing implementation of stepped up enforcement responsibility and powers enacted as part of these recent amendments, the HHS Office of Civil Rights (OCR) announced on November 8, 2011 its kickoff of a new compliance audit effort. These developments send a forceful message that all businesses generally and health care providers, health plans, healthcare clearinghouses and their business associates specifically must get serious about compliance with the privacy, security and data breach requirements of HIPAA and other applicable law by implementing and administering the policies, procedures, training and oversight necessary to comply with these and other federal and state mandates regarding the protection of personal health information and other sensitive data. Learn more about the recent convictions and related data breach exposures here.

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Posted by Cynthia Marcotte Stamer

Texas Medical Board Suspends Child Psychiatrist For Sexual Misconduct

November 22, 2011

Personal Misconduct By Physicians Or Other Health Care Workers Common Cause of Discipline

On November 22, 2011, a disciplinary panel of the Texas Medical Board temporarily suspended, without notice, the medical license of Charles Henry Fischer, M.D., after determining that Dr. Fischer, a child psychiatrist at the Austin State Hospital in Austin, has demonstrated a pattern of sexually abusing teenage boys in his care for inpatient psychiatric treatment over a period of nearly 20 years. The discipline highlights again that personal misconduct remains a key reason for discipline of medical professionals.

Dr. Fischer, 59, was employed at Austin State Hospital from December 1990 until his termination on November 14, 2011. He also was employed as a psychiatrist at the Waco Center for Youth, the Southwest Neuropsychiatric Institute in San Antonio, Lutheran Social Services Residential Treatment Center for Girls and Central Counties Mental Health and Mental Retardation. The Board imposed the suspension based on information that as many as nine patients had alleged sexual abuse by Dr. Fischer since the first patient report in 1992.

Unprofessional personal misconduct presenting a right to public health and safety is a common trigger for discipline by the Texas Medical Board and other licensing boards. See, e.g. Quality, Recordkeeping & Unprofessional Conduct Lead Reasons For Medical Board Discipline of Physicians. Although complaints based on sexual misconduct occur much less frequently than substance abuse or other types of personal misconduct, the Texas Medical Board and other medical licensing bodies view sexual misconduct as among the most serious types of violations. The prevalence rate of sexual misconduct in physicians is estimated at 6-10 percent but this phenomenon is likely under-reported in physician surveys and by patients. It is believed that the number of false claims made by patients is very low. A 1992 study indicates that only 4-8 percent of patients report a doctor’s sexual misconduct. Physicians found guilty of engaging in prohibited sexual misconduct typically are male, have a mean age of 53, practice in private practice, and have a history of substance abuse, are in the midst of a divorce, separation or other life crisis and tend to engage in higher than typical nonsexual patient touch with patients.

Because of their special role and responsibility with respect to patients and the community, the law, the profession and the public impose high expectations upon physicians and other health care professionals in relation to their sexual conduct toward patients and others. State medical practices and other medical licensure bodies, the American Medical Association Code of Conduct, the Joint Commission, peer review and other disciplinary boards and other regulatory and administrative policies and bodies generally prohibit both sexual assault, sexual harassment, and a broad range of other conduct of a sexual nature considered to be inconsistent with the special relationship of trust occupied by the health care professional.

Sexual misconduct charges that can result in discipline can include clear atrocities such as rape or other sexual assaults, as well as engagement in inappropriate sexual relationships or overtures to current or former patients, as well as sexual harassment and certain other types of sexual relationships or conduct involving staff or others. See, e.g., Ringer v. Texas State Bd. of Med. Examiners, 1999 Tex. App. LEXIS 8214 (Tex. App. 1999); Texas State Board of Medical Examiners v. Haynes, 388 S.W.2d 258, 261 (Tex. App. 1965); Texas State Board of Medical Examiners v. Koepsel, 159 Tex. 479 (Tex. 1959). In addition discipline by the Board of Medicine, physicians or other health care providers typically also face other consequences such as medical malpractice, sexual harassment or other similar claims or charges, peer review discipline, data bank reports, employment termination or discipline, practice expulsion, and criminal prosecution. Even if a physician or other heath care provider dodges formal discipline, accusations of sexual misconduct by a physician or other health care provider tends to permanently damage the practice and reputation of the health care.

Sexual misconduct by a physician or other health care provider or workforce member also can create significant exposures for hospitals, clinics, affiliated physicians and health care professionals associated with a physician or health care provider found to have engaged in sexual misconduct. Among other things, the failure of these third parties to take adequate steps to prevent, investigate, report or redress another health care provider’s sexual misconduct or harassment may result in malpractice or other civil litigation, licensure or other professional investigation or discipline, reputational damages and other consequences.

To guard against these exposures, physicians and other health care providers should exercise care to avoid engaging in actions that might expose them to charges of sexual assault, harassment or other inappropriate sexual conduct and should adopt policies, adopt procedures and practices to prohibit and provide training and other oversight to encourage other health care providers and staff to avoid such conduct. If a physician or other health care provider or organization observes, receives a report or charge or otherwise becomes aware of information indicating that a potential sexual assault or other inappropriate sexual conduct may have occurred, it should act promptly and appropriately to investigate and redress the conduct or suspected conduct in a manner designed to strengthen their defenses against possible disciplinary action or other liabilities and risks. Because of the legal sensitivity and risk associated with the allegations of sexual misconduct and the investigation of those charges, physicians and other health care providers and organizations involved in these concerns generally should engage competent legal counsel as soon as possible when these concerns come to light for assistance in responding to the concerns, as well as the ability to use attorney-client privilege and work product, peer review, quality, and other legal privileges and other legal rules and safeguards to help promote confidentiality and defensibility of sensitive communications and conduct in connection with the investigation and response to these concerns.

For Help With Compliance, Investigations Or Other Needs

If you need assistance providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others including highly popular programs on “Sex Drugs & Rock ‘N Role: Managing Personal Misconduct in Health Care,” “Managing Physician Performance” and others.. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

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100,000+ Primary Care Providers Signed Up To Get EHRs Regional Extension Centers

November 17, 2011

The HHS Office for the National Coordinator for Health Information Technology announced today that nearly one-third of all primary care providers -plan to work with their Regional Extension Center (REC) to participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs as a way to transition from paper records to certified EHRs.

Designed to jump start EHR adoption, the Health Information Technology Economic and Clinical Health (HITECH) Act of 2009, part of the Recovery Act, created a nationwide network of RECs comprised of local nonprofits, to provide guidance and resources to help eligible professionals make the transition from paper records to certified EHRs. Eligible providers that meet meaningful use of certified EHRs criteria may be eligible for incentive payments under the Recovery Act.

The 62 RECs focus on assisting primary care providers and those providers serving traditionally medically underserved populations as they take part in the Medicare and Medicaid EHR Incentive Programs and meaningfully use EHRs in ways that can reduce health care costs, increase patient safety, and improve the overall quality of patient care. These providers face challenges in EHR adoption including tight budgets, over-stretched health information technology staff, and limited broadband access.

One-half of the providers committed to making the transition to certified EHRs are in small group practices or consortia of small group practices. The remaining providers focus on the underserved with 18 percent in community health centers, 11 percent in public hospitals, and 21 percent in other underserved settings, such as critical access hospitals, rural health clinics, and practices in medically underserved areas.

RECs serve the majority of primary care providers in small practices in rural areas. Today’s figures include over half of the targeted 1,776 critical access and rural hospitals in 41 states and throughout Indian Country.

A complete listing of REC grant recipients and additional information about Regional Extension Centers may be found at http://www.HealthIT.hhs.gov/REC/.

For information about the Medicare and Medicaid EHR Incentive Programs, see http://www.cms.gov/EHRIncentivePrograms.

For information about HHS Recovery Act health IT programs, see http://www.hhs.gov/recovery/announcements/by_topic.html#hit.

For Help With Compliance, Investigations Or Other Needs

If you need assistance understanding, managing or defending licensing board, peer review or other requirements or actions, providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others including highly popular programs on “Sex Drugs & Rock ‘N Role: Managing Personal Misconduct in Health Care,” “Managing Physician Performance” and others.. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

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Leave a Comment » | Corporate Compliance, Doctor, Employer, Employment, Health Care, Health Care Provider, Health Care Quality, Licensing, Medical Licensure, Peer Review | Tagged: Credentialing, death certificates, EHR, Electronic Medical Records, EMR, licensing, Medical Ethics, Medical Licensure, Peer Review, Physician, Sexual Harassment, Sexual Misconduct | Permalink
Posted by Cynthia Marcotte Stamer

Joint Commission Equal Visitation Rules & Guidance Supplement New Medicare Equal Visitation Requirements

November 13, 2011

Following on recently finalized Medicare regulations dictating that hospitals allow patients to control individuals who will be allowed to visit or exercise other patient representative rights , the Joint Commission of the Accreditation recently has released the following new guidance concerning its expectations concerning the responsibilities of hospitals and other accredited entities to create inclusive care enviromentments for lesbian, gay, bisexual and transgender (LGBT) patients and their families:

Joint Commission focuses on improving care for LGBT patients – A new field guide posted November 8, 2011- from The Joint Commission urges U.S. hospitals to create a more welcoming, safe and inclusive environment that contributes to improved health care quality for LGBT patients and their families.
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community – A new field guide from the Joint Commission urges US hospitals to create a more welcoming, safe, and inclusive environment that contributes to improved health care quality for lesbian, gay, bisexual, and transgender (LGBT) patients and their families.

Hospitals and others impacted by these rules should review and update visitation, patient representative, privacy, patient notification and consent and other policies and practices to comply with the new Medicare mandates and the applicable requirements of the new Joint Commission standards.

Learn more about these new requirements in the recent Modern Healthcare article Bumpy road for equal visitation.

For More Information Or Assistance

If you need assistance reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Ms. Stamer’s insights on the new Medicare visitation rules recently were quoted in Modern Healthcare. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer compliance and risk management policies and to respond to DEA and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on OCR Civil Rights rules and enforcement actions. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

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Posted by Cynthia Marcotte Stamer

OCR Settlements Show Health Care & Disabled Housing Providers Face Growing Disability Discrimination Risks

October 19, 2011

A continuing series of federal investigations and enforcement actions highlight the need for health care providers and other health industry organizations to strengthen their disability discrimination management practices to defend against rising exposures to actions by the U.S. Department of Health & Human Services Office of Civil Rights (OCR) and other agencies as well as private law suits.

As part of a broader emphasis on the enforcement of disability and other federal discrimination laws by the Obama Administration, OCR is making investigation and prosecution of suspected disability discrimination by health industry organizations a priority. OCR recently has announced several settlement agreements and issued letters of findings as part of its ongoing efforts to ensure compliance with Section 504 of the Rehabilitation Act of 1973 (Section 504) and the Americans with Disabilities Act of 1990 (ADA) as well as various other federal nondiscrimination and civil rights laws.

Defending or paying to settle a disability discrimination charge brought by a private plaintiff, OCR or another agency, or others tends to be financially, operationally and politically costly for a health care organization or public housing provider. In addition to the expanding readiness of OCR and other agencies to pursue investigations and enforcement of disability discrimination and other laws, the failure of health care organizations to effectively maintain processes to appropriately include and care for disabled other patients or constituents with special needs also can increase negligence exposure, undermine Joint Commission and other quality ratings, undermine efforts to qualify for public or private grant, partnerships or other similar arrangements, and create negative perceptions in the community.

Federal Disability & Other Laws Prohibit Health Care Provider Discrimination

Public and private health care and housing providers may face discrimination exposures under various federal laws such as the public accommodation and other disability discrimination prohibitions of the ADA, Section 504, the Civil Rights Act and various other laws. Section 504 requires recipients of Medicare, Medicaid, HUD, Department of Education, welfare and most other federal assistance programs funds including health care, education, housing services providers, state and local governments to ensure that qualified individuals with disabilities have equal access to programs, services, or activities receiving federal financial assistance. The ADA extends the prohibition against disability discrimination to private providers and other businesses as well as state and local governments including but not limited to health care providers reimbursed by Medicare, Medicaid or various other federal programs The ADA requirements extend most federal disability discrimination prohibits to health care and other businesses even if they do not receive federal financial assistance to ensure that qualified individuals with disabilities have equal access to their programs, services or activities. In many instances, these federal discrimination laws both prohibit discrimination and require health care and other regulated businesses to put in place reasonable accommodations needed to ensure that their services are accessible and available to persons with disabilities. Meanwhile the Civil Rights Act and other laws prohibit discrimination based on national origin, race, sex, age, religion and various other grounds. These federal rules impact virtually all public and private health care providers as well as a broad range housing and related service providers.

As a result of its stepped up enforcement of the ADA, Section 504 and other civil rights and nondiscrimination rules, OCR is racking up an impressive list of settlements with health care providers, housing and other businesses for violating the ADA, Section 504 or other related civil rights rules enforced by OCR. While OCR continues to wage this enforcement battle in the programs it administers, the Departments of Justice, Housing & Urban Development, Education, Labor and other federal agencies also are waging war against what the Obama Administration perceives as illegal discrimination in other areas. Along side their own enforcement activities, OCR and other federal agencies are maintaining a vigorous public outreach to disabled and other individuals protected by federal disabilities and other civil rights laws intended to make them aware of and to encourage them to act to enforce these rights. To be prepared to defend against the resulting risk of claims and other enforcement actions created by these activities, health care, housing and other U.S. providers and businesses need to tighten compliance and risk management procedures and take other steps to prepare themselves to respond to potential charges and investigations.

Recent Settlements Highlight Risk

Within recent settlement agreements, entities agreed to take steps to come into compliance with Section 504 and ADA, including: review and revision of policies and procedures; training staff on their non-discrimination obligations; providing a grievance procedure for patients; and other corrective actions specific to each entity’s violations. To learn more details about these actions and settlements, see https://www.cynthiastamer.com/documents/articles/20111019%20OCR%20Disability%20Enforcement%20CMSPC.pdf.

Enforcement of Discrimination & Other Civil Rights Laws Obama Administration Priority Putting Public & Private Providers At Risk

These and other enforcement actions by OCR and other agencies demonstrate the significant increased federal emphasis on the enforcement of federal discrimination laws against private and public health care and housing providers, state and local governments and other businesses under the Obama Administration. In keeping with this renewed emphasis, the DCF settlement is the latest in a series of federal disability, national origin and other discrimination charges and settlements OCR, has brought over the past year against physicians, public and private hospitals, insurers, federally financed housing providers and other parties providing services financed under programs administered by OCR. As the Department of Housing and Urban Development (HUD), the Equal Employment Opportunity Commission (EEOC) and other federal agencies also similarly have increased emphasis in federal discrimination law enforcement during this period, health care providers and other federal program service providers need to be prepared to defend their programs and practices to withstand federal discrimination charges or other investigations by federal agencies, private plaintiffs or both.

As for employment discrimination, violators of these and other federal discrimination prohibitions applicable to the offering and delivery of services and products also face exposure to large civil damage awards to private plaintiffs as well as federal program disqualification, penalties and other federal agency enforcement. Unfortunately, while most businesses and governmental leaders generally are sensitive to the need to maintain effective compliance programs to prevent and redress employment discrimination, the awareness of the applicability and non-employment related disability and other discrimination risk management and compliance lags far behind.

Many private health care organizations assume that OCR’s enforcement actions are mostly a problem for state and local government agencies because state and local agencies and service providers frequently have been the target of OCR discrimination charges. However the record shows OCR enforcement risks are high for both public and private providers.

OCR can and does investigate and brings actions against a wide variety of public and private physicians, hospitals, insurers and other private health care and other federal program participants. In October, 2009, for instance, OCR announced that an Austin, Texas orthopedic surgeon whose practice group sees an average of 200 patients per week, had entered into a settlement agreement to resolve OCR charges that he violated Section 504 of the Rehabilitation Act by denying medically appropriate treatment from patients solely because they are HIV-positive.

Invest in Prevention To Minimize Liability Risks

In light of the expanding readiness of OCR to investigate and take action against health care providers for potential violations of the ADA, Section 504 and other federal discrimination and civil rights laws, health care organizations and their leaders should review and tighten their policies, practices, training, documentation, investigation, redress, discipline and other nondiscrimination policies and procedures. In carrying out these activities, organizations and their leaders should keep in mind the critical role of training and oversight of staff and contractors plays in promoting and maintaining required operational compliance with these requirements. Reported settlements reflect that the liability trigger often is discriminatory conduct by staff, contractors, or landlords in violation of both the law and the organization’s own policies.

To achieve and maintain the necessary operational compliance with these requirements, organizations should both adopt and policies against prohibited discrimination and take the necessary steps to institutionalize compliance with these policies by providing ongoing staff and vendor training and oversight, contracting for and monitoring vendor compliance and other actions. Organizations also should take advantage of opportunities to identify and resolve potential compliance concerns by revising patient and other processes and procedures to enhance the ability of the organization to learn about and redress potential charges without government intervention.

For More Information Or Assistance

If you need assistance reviewing or tightening your policies and procedures, conducting training or audits, responding to or defending an investigation or other enforcement action or with other health care related risk management, compliance, training, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Her experience includes advising hospitals, nursing home, home health, rehabilitation and other health care providers and health industry clients to establish and administer compliance and risk management policies; prevent, conduct and investigate, and respond to peer review and other quality concerns; and to respond to Board of Medicine, Department of Aging & Disability, Drug Enforcement Agency, OCR Privacy and Civil Rights, HHS, DOD and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her presentations and programs include How to Ensure That Your Organization Is In Compliance With Regulations Governing Discrimination, as well as a wide range of other workshops, programs and publications on discrimination and cultural diversity, as well as a broad range of compliance, operational and risk management, and other health industry matters.

Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance responding to concerns about the matters discussed in this publication or other health care concerns, wish to obtain information about arranging for training or presentations by Ms. Stamer, wish to suggest a topic for a future program or update, or wish to request other information or materials, please contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see here. About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

9/21 NTHCPA Meeting To Focus On Quality Measures & Reimbursement

September 16, 2011

NORTH TEXAS HEALTHCARE COMPLIANCE PROFESSIONAL ASSOCIATION

Invites Members and Guests to Our Next Study Group & Brown Bag Luncheon

“Quality Measures and Reimbursement: New Programs, New Compliance Challenges”

Featuring

Timothy D. Martin, J.D., LL.M, CCP, MCP

Wednesday, September 21, 2011
Noon-2:00 p.m.
Dallas Ft Worth Hospital Council

250 Decker Drive, Irving, TX 75062-2706

North Texas Healthcare Compliance Professional Association (NTHCPA) invites members and other interested health care compliance professionals to join other NTHCPA members and guests on Wednesday, September 21, 2011 from Noon to 2:00 p.m. as Timothy D. Martin, J.D., LL.M, CCP, MCP, leads a program on “Quality Measures and Reimbursement: New Programs, New Compliance Challenges.”

The expanding use of payment incentives for meeting quality benchmarks by private and public payers create new opportunities and new compliance challenges. The Affordable Care Act created a number of new quality incentive programs that build on earlier ones. Texas has also created new quality incentive programs with the passage of its healthcare collaborative initiative. While most health quality incentives continue to rely on structure, process, and outcome measures that the healthcare industry has experimented with for many years, new compliance requirements require providers to change their data-gathering and data-communication procedures. Further, these programs may force providers to deal with clinical guidelines that lag behind the standard of care and data-transmission protocols that lag behind reporting requirements. Newer bundled-payment methodologies may require healthcare organizations to create a complex contractual web to allocate a single payment among multiple providers. This discussion will focus on these issues and their possible solutions.

The meeting will be held at the offices of the Dallas Ft Worth Hospital Council, 250 Decker Drive, Irving, TX 75062-2706. Under the new brown bag luncheon format, members and guests are encouraged to bring along a lunch of their choosing and participate in this compliance knowledge and skill-building and networking event.

Timothy D. Martin, J.D., LL.M, CCP, MCP was a founder and Chief System Architect for Innovative Managed Care Systems, LLC (now MedAssets, Inc.). He has more than 30 years’ experience in information technology—the last 20 years in healthcare information technology. He holds a degree in Mathematics and Computer Information Systems from West Texas State University and two law degrees from Southern Methodist University Dedman School of Law.

NTHCPA meetings are open to all NTHCPA members and other interested health care compliance professionals. Participation in the meeting is complimentary. Participants are responsible for any parking charges incurred.

RSVP & Register For Invites & Updates

To help us to notify you about upcoming meetings and to arrange for adequate space for this and other meetings, interested persons are encouraged to forward their current contact information including e-mail to Vice-President Cynthia Marcotte Stamer at (469) 767-8872 or by e-mail here. Stay on top of information about upcoming meetings and share and dialogue with other NTHCPA members about health care compliance challenges and developments by joining our Linked In Group here. Please feel free to share this invitation with others who may be interested.

About the NTHCPA & Involvement

NTHCPA exists to champion ethical practice and compliance standards and to provide the necessary resources for ethics and compliance Professionals and others in North Texas who share these principles. The vision of NTHCPA is to be a pre-eminent compliance and ethics group promoting lasting success and integrity of organizations within North Texas. To register or update your registration or to receive notice of future meetings, e-mail here.

Would you like to get more involved? We encourage persons interested in serving on the steering committee, sponsoring refreshments for an upcoming meeting, wish to suggesting topics or speakers, or seeking more information about membership or involvement with the NTHCPA to contact:

NTHCPA President Erma Lee at (817) 927-1232 or by e-mail here or

Vice-President Cynthia Marcotte Stamer at (469) 767-8872 or by e-mail here

This communication may be considered a marketing communication for certain purposes. If you wish to update your e-mail for purposes of receiving future e-mail concerning meetings or other activities of the North Texas Healthcare Compliance Professionals Association , please send an email here.

Please share this invitation with others who might be interested in this topic or other NTHCPA events!

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Posted by Cynthia Marcotte Stamer

Indictment of 91 Shows Growing Health Care Fraud Enforcement Risk

September 8, 2011

A nationwide takedown by Medicare Fraud Strike Force operations in eight cities resulted in the Department of Justice filing criminal charges against 91 defendants, including doctors, nurses, and other medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $295 million in false billing, Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius jointly announced the charges on September 7, 2011.

The charges are provide yet another powerful reminder to health care providers, leaders and organizations of the advisability of tightening compliance practices and taking other steps to guard against ever expanding health care fraud exposures. Already a lead federal enforcement priority for more than a decade, HHS recently established the Center for Program Integrity within the Centers for Medicare & Medicaid Services (CMS) to focus on identifying and stopping fraud and acting swiftly to protect beneficiaries.

Charges Announced September 7 Show Strike Force Targeting Fraud Industry Wide

In announcing the most sweeping joint action to date, HHS and Justice Department officials warned that the latest charges demonstrate the willingness and commitment of federal officials to find and prosecute health care fraud throughout the health care industry. The actions are the latest in a series of strong reminders to providers, leaders and others in the health care industry of the need to tighten compliance and risk management to minimize the risk of getting caught up in the Federal government’s ever-tightening health care fraud investigation and enforcement net.

The charges made against the 91 defendants in the indictments announced cover nearly the entire spectrum of healthcare providers for a variety alleged fraudulent schemes. The defendants charged are accused of various health care fraud-related crimes, including conspiracy to defraud the Medicare program, health care fraud, violations of the anti-kickback statutes and money laundering. The charges are based on a variety of alleged fraud schemes involving various medical treatments and services such as home health care, physical and occupational therapy, mental health services, psychotherapy and durable medical equipment (DME). HHS and Justice Department Officials warned these latest sweeping charges clearly signal the resolve of the federal government to find and prosecute health care fraud throughout the industry. Learn more details about September here.

According to the Justice Department and HHS, 70 individuals were charged by Strike Force prosecutors in indictments unsealed on September 6 and September 7, 2011 in six cities. The indictments allege a variety of Medicare fraud schemes involving approximately $263.6 million in false billings. As part of takedown operations last week, 18 additional defendants were charged in Detroit and one defendant was charged in Miami in cases unsealed on September 1, 2011, for their alleged roles in Medicare fraud schemes involving approximately $29.4 million in fraudulent claims. Additionally, two individuals are scheduled to appear in court on September 7, 2011 on charges filed on August. 24, 2011, for their roles in a separate $2 million health care fraud scheme. According to the September 7 announcement, this coordinated takedown involved the highest amount of false Medicare billings in a single takedown in Strike Force history.

According to court documents, the defendants located in Miami, Houston, Baton Rouge, Los Angeles and Detroit allegedly participated in a diverse array of schemes to submit claims to Medicare for treatments that were medically unnecessary and oftentimes never provided. In many cases, indictments and complaints allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could submit fraudulent billing to Medicare for services that were medically unnecessary or never provided. Collectively, the doctors, nurses, medical professionals, health care company owners and others charged in the indictments and complaints are accused of conspiring to submit a total of approximately $295 million in fraudulent billing. If convicted, the defendants face a broad range of criminal, civil and administrative sanctions including imprisonment, criminal penalties, civil sanctions, federal program disqualification, state licensing board disciplinary action and other consequences.

Charges Part of Ongoing National Anti-Health Care Fraud Campaign

Suspend payments to providers and suppliers based on credible allegations of fraud in Medicare and Medicaid;
Impose a temporary moratorium on Medicare, Medicaid, and CHIP enrollment on providers and suppliers when necessary to help prevent or fight fraud, waste, and abuse without impeding beneficiaries’ access to care.
Strengthen and build on current provider enrollment and screening procedures to more accurately assure that fraudulent providers are not gaming the system and that only qualified health care providers and suppliers are allowed to enroll in and bill Medicare, Medicaid and CHIP;
Terminate providers from Medicaid and CHIP when they have been terminated by Medicare or by another state Medicaid program or CHIP;
Require provider compliance programs, now required under the Affordable Care Act, that will ensure providers are aware of and comply with CMS program requirements.

Act To Manage Risks

In response to the growing emphasis and effectiveness of Federal officials in investigating and taking action against health care providers and organizations, health care providers covered by federal false claims, referral, kickback and other health care fraud laws should consider auditing the adequacy of existing practices, tightening training, oversight and controls on billing and other regulated conduct, reaffirming their commitment to compliance to workforce members and constituents and taking other appropriate steps to help prevent, detect and timely redress health care fraud exposures within their organization and to position their organization to respond and defend against potential investigations or charges.

For More Information Or Assistance

If you need assistance reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer compliance and risk management policies and to respond to DEA and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on OCR Civil Rights rules and enforcement actions. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

Health Care Employers Beat National Average When Offering Health Benefits To Workers

July 29, 2011

A new 2011 U.S. Department of Labor Bureau of Labor Statistics Study of employee benefits offered shares key insights into the availability of employer-provided health and other coverage.

With regard to health benefits, the report reveals that practices vary significantly among employers, on average, medical care benefits were available to 69 percent of private industry workers. 1/2 private industry workers participated in a medical plan. For single coverage, private sector employers paid 80 percent of the medical care premiums for full-time workers and 69 percent of medical care premiums for full-time workers in private industry. Data shows employees often elect not to take offered coverage.

The study shows that health and other benefits offered by employers and utilized by employees varies widely varied by whether the employer is a government or private sector employer, the industry, size and other characteristics of the employer and the income, profession, education and other characteristics of the employee. It is no surprise that government employers that can pass along costs to taxpayers provide coverage more broadly and subsidize more of the cost.

The report reveals that most health care employers offer health coverage and significantly subsidize the cost of this coverage for their workers. According to the report:

73 percent of private sector health care workers are offered health coverage by their employers;
52 percent of health care workers participate in employer provided health care coverage;
The take up rate by private sector health industry workers for employer provided coverage is 72 percent.

The report also shows that private sector health care employers on average paid 81 percent of single coverage health coverage costs, and only required employees to contribute an average of 19 percent of the cost for their single coverage.

In addition to data on medical benefits, the study also reports that paid leave remains the most commonly provided benefit nationally and includes data on other benefits.

The DOL highlights 1st time reporting of domestic partner status for 1st time in its announcement. Data also provided on paid vacation and other leave.

Read report summary and access report at http://www.bls.gov/news.release/ebs2.nr0.htm.

For Help or More Information

If you have questions or need help understanding or responding to the Regulations, with other health benefit design, administration or operations concerns, or with other employee benefits, compensation, labor or employment or other workforce management concerns, please contact the author of this update, Board Certified Labor and Employment attorney and management consultant Cynthia Marcotte Stamer here or at (469)767-8872.

Past Chair of the American Bar Association (ABA) Health Law Section Managed Care & Insurance Interest Group, Chair of the ABA RPTE Employee Benefit and Other Compensation Committee, and a council member of the ABA Joint Committee on Employee Benefits, Vice President of the North Texas Healthcare Compliance Professionals Association, Exempt Organizations Coordinator of the Gulf States Area TEGE Council, and Executive Director of the Project COPE: Coalition On Patient Empowerment, Ms. Stamer is nationally recognized for her more than 23 years pragmatic and innovative health program work.

Board certified in labor and employment law by the Texas Board of Legal Specialization with extensive leading edge health care, human resources and employee benefits experience.

For more than 24 years, Ms. Stamer has worked with health care providers, payers, government and charitable agencies, policymakers and others on managing health, insurance and employee benefits, practices, people, performance, costs, performance and policy. In the health care industry, Ms. Stamer works extensively with hospitals, physician practices, skilled nursing, hospice, and other health care providers to manage their people, compliance, quality and operations. Along side this work, Ms. Stamer also has worked extensively in the payor community on product design, administration, quality, contracting, compliance, public policy and other concerns. As part of this work, she has worked continuously throughout her career helping self-insured and insured, public and private health plan sponsors, fiduciaries, administrators, insurers and others design, administer and defend health and other employee benefit and insurance programs domestically and internationally. She is widely recognized for her experience helping design and implement legally compliant self-insured and insured health reimbursement, mini-med, high-deductible health plans, limited benefit plans, 24-hour and occupational medicine, Medicare and Medicaid Advantage, ex-pat and medical tourism, deductible reimbursement and other creative health benefit programs to solve a wide range of financial and other challenges while coping with changing regulatory and market realities. Her work includes both working with clients to design, document, implement and administer these and other arrangements, as well as the development of wellness and disease management, claims administration and appeals, eligibility, and other administrative services, processes and technologies. Ms. Stamer regularly represents and defends these and other clients in dealings with the Department of Labor, Department of Justice, Department of Health & Human Services, Department of Defense, Internal Revenue Service, Securities and Exchange Commission, state insurance regulators, state attorneys general and other federal and state regulators and prosecutors and private plaintiffs in connection with investigations, prosecutions, audits and other actions arising from employee benefit, insurance and related arrangements and products.

Recognized in the International Who’s Who of Professionals and bearing the Martindale Hubble Premier AV-Rating, Ms. Stamer also is a highly regarded author and speaker, who regularly conducts management and other training on a wide range of health care, insurance, labor and employment, employee benefit, human resources, internal controls, privacy and data security, board governance and other related risk management matters. Her writings frequently are published by the American Bar Association (ABA), Aspen Publishers, Bureau of National Affairs, the American Health Lawyers Association,the American Bar Association, SHRM, World At Work, Government Institutes, Inc., Atlantic Information Services, Employee Benefit News, Modern Healthcare, and many others. For a listing of some of these publications and programs, see here. Her insights on human resources risk management matters also have been quoted in The Wall Street Journal, various publications of The Bureau of National Affairs and Aspen Publishing, the Dallas Morning News, Spencer Publications, Health Leaders, Business Insurance, the Dallas and Houston Business Journals and a host of other publications. In addition to her many ABA leadership involvements, she also serves in leadership positions in numerous human resources, corporate compliance, and other professional and civic organizations. Her insights on these and other matters appear in the Bureau of National Affairs, Spencer Publications, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, World At Work, the ICEBS, SHRM and many other national and local publications. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly.

About Solutions Law Press

For assistance with assessing or defending your current worker classification, wage and hour or other health care and human resources policies and controls, please contact Cynthia Marcotte Stamer at cstamer@solutionslawyer.net, 972-419-7188..

For More Information or Assistance

The author of this update, attorney Cynthia Marcotte Stamer, has extensive experience advising and assisting health care providers and other health industry clients to respond to these and other health care industry enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management matters.

Board Certified in Labor and Employment Law, Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising physicians, hospitals and other health industry, assisted living, educational and other clients about human resources, employee benefits and compensation, regulatory compliance and enforcement, quality assurance, peer review, licensing and discipline, and other medical staff performance matters. She continuously advises health industry clients about the use of technology, process and other mechanisms to promote compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational needs. As part of this experience, she has worked extensively with health care providers, payers, health care technology and consulting and other health industry clients, as well as other businesses, on privacy, data security, trade secret and related matters. A popular lecturer and widely published author on health industry concerns, Ms. Stamer also publishes and speaks extensively on health care compliance, staffing and human resources, compensation and benefits, technology, medical staff, public policy, reimbursement, privacy, technology, and other health and managed care industry regulatory, and other operations and risk management concerns for medical societies and staffs, hospitals, the HCCA, American Bar Association, American Health Lawyers Association and many other health industry groups and symposia. Her highly popular and information packed programs include many highly regarded publications on HIPAA, FACTA, medical confidentiality, state identity theft and privacy and other many other related matters. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. To review some of her many publications and presentations, or for additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

For More Information

We hope that this information is useful to you. You can review other recent health care and internal controls resources and additional information about the health industry and other experience of Ms. Stamer here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources. If you or someone else you know would like to receive future updates and notices about other upcoming Solutions Law Press events, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here. For important information concerning this communication click here.

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Posted by Cynthia Marcotte Stamer

TMP Reminds Texas Doctors To Register To Electronically File Death Certificates; Enforcement Grace Period Ends 6/1

May 17, 2011

Texas physicians that anticipate being called upon to sign a death certificate should register to file the the certificate electronically ahead of time.

Texas law now requires electronic filing of death certifications and advance registration is required to use this process.

According to the Texas Medical Board, more than 100 physicians faced disciplinary action from the Texas Medical Board for failing to complete death certificates electronically, as required by Texas law. In response to requests of members of the Texas Legislature, the Texas Medical Board gave physicians a grace period until June 1 to allow them more time to register and has refunded fines and dismissed pending disciplinary actions. As it prepares to resume enforcement when the grace period ends June 1, 2011, the Texas Medical Board is reminding physicians of the need to register as soon as possible by visiting here.

For Help With Compliance, Investigations Or Other Needs

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Posted by Cynthia Marcotte Stamer

ONC Touts Research On Health IT Benefits In Health Affairs Article

March 20, 2011

Researchers from the Office of the National Coordinator for Health Information Technology (ONC) and other Department of Health & Human Services (HHS) leaders are touting new studies they say show the benefits of investing in health information technology (health IT).

Under the Health Information Technology for Economic and Clinical Health Act (HITECH), part of the American Recovery and Reinvestment Act of 2009, as much as $27 billion Medicare and Medicaid incentive payments will be available to eligible professionals, eligible hospitals, and critical access hospitals when they adopt certified EHR technology and successfully demonstrate “meaningful use” of the technology in ways that improve quality, safety, and effectiveness of patient-centered care.

On March 8, 2011, ONC researches reported results of a comprehensive review of recent studies it says show the effects of health IT on key aspects of health care on the ONC website and in Health Affairs.

According to Donald Berwick, M.D., administrator of the Centers for Medicare & Medicaid Services, the study supports the investments that the HITECH Act makes in health IT. “These new findings are very significant in helping to confirm that our Nation has made the right choice in moving aggressively toward adoption of health information technology,” said Dr. Berwick. “These new findings are very significant in helping to confirm that our Nation has made the right choice in moving aggressively toward adoption of health information technology.”

The review included articles published from July 2007 up to February 2010, following up on earlier reviews of articles from 1995 to 2004 and from 2004 to 2007. This latest review initially surveyed more than 4,000 peer-reviewed articles, of which 154 were found qualified for the parameters of the study, a number similar to the previous efforts. In addition to quality and efficiency of care, the authors categorized additional outcomes including access to care, preventive care, care process, patient safety, and provider or patient satisfaction.

According to the authors, a current review of 154 peer-reviewed studies from July 2007 to February 2010 found:

More than 92 percent reached positive overall conclusions on the effects of health IT;
30 percent found mixed but predominantly positive results; and
Ten articles were found to have negative or mixed-negative results.

ONC reports that the review also reflected a new balance of evidence between HIT “leader” organizations and other entities, especially smaller medical practices. In previous years, much evidence has come from the “leaders.” The current review shows increased evidence of benefits for others as well.

Examples of positive results highlighted by ONC in its reports include:

One study found that at three New York City dialysis centers, patient mortality decreased by as much as 48 percent while nurse staffing decreased by 25 percent in the three years following implementation of electronic health records (EHRs).
In an inpatient study, a clinical decision support tool designed to decrease unnecessary red blood cell transfusions reduced both transfusions and costs, with no increase in patient length-of-stay or mortality.
Another study addressing HIT in 41 Texas hospitals found that hospitals with more advanced HIT had fewer complications, lower mortality and lower costs than hospitals with less advanced HIT.

ONC researchers report that negative findings in the study were most often associated with provider or staff satisfaction related to difficulties in the process of transitioning from paper-based to electronic-based records and care. The researchers conclude these findings “highlight the need for studies that document the challenging aspects of implementing HIT more specifically and how these challenges might be addressed,” such as through strong leadership or staff participation when adopting and implementing HIT.

Reflecting on the findings, Surgeon General Regina Benjamin, M.D., said, “My own personal experience in switching my practice from paper to EHRs showed that the change requires some initial effort; however, it did not interrupt work flow in the clinic. The results are better care for patients and new opportunities for the physician and staff to improve quality outcomes.” Dr. Benjamin switched to EHRs in her Gulf Coast Alabama family practice after two hurricanes and a fire destroyed the clinic’s paper records.

At the Agency for Healthcare Research and Quality, where research into health informatics has been supported since 1968, agency Director Carolyn Clancy, M.D., called attention to the importance of rapid information feedback and current evidence as the Nation pursues HIT implementation. “As we have known, and this new review of the available literature shows, HIT holds tremendous potential to improve health care quality. It is important that we continue to use experience from the field and scientific evidence to guide our efforts to improve the quality and safety of health care for all Americans.”

For Help With Monitoring Developments, Compliance, Investigations Or Other Needs

If you need assistance monitoring federal health reform, policy or enforcement developments, or to review or respond to these or other health care or health IT related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others including highly popular programs on “Sex Drugs & Rock ‘N Role: Managing Personal Misconduct in Health Care,” “Managing Physician Performance” and others.. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

Sexual Misconduct Investigation Prompts Medical Board Suspension of Texas Doctor

March 16, 2011

Personal Misconduct By Physicians Or Other Health Care Workers Common Trigger for Disciplinary Action Or Other Liability

On March 14, 2011, a disciplinary panel of the Texas Medical Board temporarily suspended, with notice, the medical license of Ramon A. Cruz, M.D., of Denton, based on allegations of inappropriate sexual behavior with several patients. According to the Texas Medical Board, the panel found that Dr. Cruz, Lic. No. K3703, engaged in sexually inappropriate behavior with several patients. Four incidents, including an alleged sexual assault, were reported by patients to Denton Police. The panel found that Dr. Cruz’s actions demonstrate a pattern of inappropriate behavior, which is a continuing threat to public health and safety justifying the suspension of his license. The suspension remains in effect until the Board takes further action.

Unprofessional personal misconduct presenting a right to public health and safety is a common trigger for discipline by the Texas Medical Board and other licensing boards. See, e.g. Quality, Recordkeeping & Unprofessional Conduct Lead Reasons For Medical Board Discipline of Physicians. Although complaints based on sexual misconduct occur much less frequently than substance abuse or other types of personal misconduct, the Texas Medical Board and other medical licensing bodies view sexual misconduct as among the most serious types of violations. The prevalence rate of sexual misconduct in physicians is estimated at 6-10 percent but this phenomenon is likely under-reported in physician surveys and by patients. It is believed that the number of false claims made by patients is very low. A 1992 study indicates that only 4-8 percent of patients report a doctor’s sexual misconduct. Physicians found guilty of engaging in prohibited sexual misconduct typically are male, have a mean age of 53, practice in private practice, and have a history of substance abuse, are in the midst of a divorce, separation or other life crisis and tend to engage in higher than typical nonsexual patient touch with patients.

For Help With Compliance, Investigations Or Other Needs

If you need assistance providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others including highly popular programs on “Sex Drugs & Rock ‘N Role: Managing Personal Misconduct in Health Care,” “Managing Physician Performance” and others.. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

HHS Imposes 1st HIPAA Privacy Civil Penalty of $4.3 million

February 22, 2011

Health Care Providers Should Strengthen HIPAA Compliance & Defenses As Risks Rise

$4.3 million is the amount of the civil monetary penalty (CMP) that the U.S. Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) has ordered Cignet Health of Prince George’s County, Md., (Cignet) to pay for violating the Health Insurance Portability & Accountability Act (HIPAA) Privacy Rule.

The first CMP ever assessed by OCR under the HIPAA Privacy Rule, the Cignet CMP assessment is the latest in a series of developments documenting the rising risks that health care providers, health plans, health care clearinghouses and their business associates (“covered entities”) face for violations of HIPAA. Covered entities and their business associates should tighten privacy policies, breach and other monitoring, training and other practices to mitigate against exposures in light of recently tightened requirements and new enforcement risks. Read more details.

Even before the announcement of the Cignet CMP, the HIPAA Privacy exposures of covered entities for failing to comply with HIPAA already had risen significantly. As of January 1, 2011, OCR reports that 12,781 of the cases it has investigated have been resolved by requiring changes in privacy practices and other corrective actions by the covered entities and has referred more than 484 Privacy Rule breach investigations to the Department of Justice for consideration for potential criminal prosecution.

While OCR had not assessed any civil monetary penalties against any covered entity for violation of HIPAA before Cignet, OCR’s collection of $2.25 million from CVS Pharmacy, Inc. under a 2009 Resolution Agreement and $100,000 from Providence Health & Services under a 2008 Resolution Agreement demonstrated the willingness of OCR to pursue significant civil remedies against covered entities that it determined willfully violated the Privacy Rules.

In response to these expanding exposures, covered entities and their business associates should review the adequacy of their current HIPAA Privacy and Security compliance policies, monitoring, training, breach notification and other practices taking into consideration the Cignet, Provident and CVS enforcement actions, emerging litigation and other enforcement data.; their own and reports of other security and privacy breaches and near misses, and other developments to determine if additional steps are necessary or advisable.

For Help With Compliance, Investigations Or Other Needs

If you need assistance auditing or tightening your existing HIPAA and other confidentiality practices or addressing other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies and to respond to OCR, FTC, medical board and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on Medicare quality and other compliance concerns. Her publications and insights on HIPAA and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

ONC Giving Small Critical Access And Rural Hospitals Added Electronic Health Records Funds

February 9, 2011

Dr. David Blumenthal, MD, MPP, national coordinator for health information technology in the Office of the National Coordinator for Health Information Technology (ONC) announced that ONC’s Regional Extension Center (REC) program will make available an additional $12 million in new technical support assistance to help critical access hospitals (CAHs) and rural hospitals adopt and become meaningful users of certified health information technology to provide a wide range of support services.

The new funds are intended to help the 1,777 critical access and rural hospitals in 41 states and the nationwide Indian Country, headquartered in the District of Columbia qualify for substantial EHR incentive payments from Medicare and Medicaid. For a listing of the award recipients for the grants announced today, see here. The intent of this supplement is to provide additional technical support to critical access and rural hospitals with fewer than 50 beds in selecting and implementing EHR systems primarily within the outpatient setting. This funding is in addition to the $20 million provided to RECs in September 2010 to provide technical assistance to the CAHs and Rural Hospitals.

The new funding is provided under the Health Information Technology Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009. The HITECH Act created the Medicare and Medicaid EHR incentive programs, which will provide incentive payments to eligible professionals, eligible hospitals, and CAHs that adopt and demonstrate meaningful use of certified EHR technology. Incentives totaling as much as $27.4 billion over 10 years could be expended under the program, which is administered by the Centers for Medicare & Medicaid Services. In addition, the HITECH Act provided $2 billion through ONC to support technical assistance, training, and demonstration projects to assist in the nation’s transition to EHRs.

The additional CAHs and rural hospital funding will be administered through ONC’s Regional Extension Center (REC) program. The RECs are specifically designed to offer a wide range of hands-on technical assistance, guidance, and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of certified EHRs under the Medicare and Medicaid incentives programs. A total of 62 RECs are located throughout the country. This additional funding is being awarded 48 RECs serving CAH and rural hospitals provides in 41 states and the nationwide Indian Country.

Today’s $12 million round of awards will result in a total of approximately $32 million of funding provided to the RECs to support CAH health IT adoption.

A complete listing of REC grant recipients and additional information about the Health Information Technology Regional Extension Centers, see here.

For information about the Medicare and Medicaid EHR Incentive Programs, see here.

For More Information Or Assistance

If you need assistance with meaningful use or other EMR or other health technology, risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer compliance and risk management policies and to respond to DEA and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on Medicare quality and other compliance concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

CMS Physician Compare Tool Gives Patients New Info On Physicians & Other Providers

January 4, 2011

The Centers for Medicare & Medicaid Services (CMS) is giving patients and their families new resources to learn about physicians and certain other health care providers. On December 30, 2010, CMS added a new “Physician Compare” feature to the CMS Healthcare Provider Directory. While the information provided currently is relatively limited, CMS plans to expand the data to help Medicare and non-Medicare patients and their families find and assess the quality of providers. While these and other similar resources can provide valuable information for patients and their families, like all provider directories, patients and their families should be cautioned to properly understand the benefits and limitations of the resource. Accordingly, physicians and other providers covered by the new tool should be aware of the tool and prepare to respond to questions and concerns that it may prompt. Physicians and other providers also should monitor proposed future expansions of this resource and provide input about the proposed content, format and presentation of such information.

Required by the Patient Protection & Affordable Care Act (“Affordable Care Act”), the Physician Compare tool located here has information about Doctors of Medicine, Osteopathy, Optometry, Podiatric Medicine, and Chiropractic and certain other types of health care professionals participating in the Medicare Program, who routinely care for Medicare beneficiaries.

According to CMS, the Physician Compare Web Site is designed to be consumer friendly and help all patients—whether on Medicare or not—locate health professionals in their communities. The information on the site includes contact and address information for offices, the professional’s medical specialty, where the professional completed his or her degree as well as residency or other clinical training, whether the professional speaks a foreign language, and the professional’s gender. The tool can also help Medicare beneficiaries find out which physicians that see Medicare patients.

In addition to information about the physician’s practice, Physician Compare also shows consumers whether the practice reported certain data to CMS through the Physician Quality Reporting System, formerly known as the Physician Quality Reporting Initiative (PQRI). Currently, the PQRI reporting system is a voluntary reporting program that rewards physicians and other eligible healthcare professionals for reporting data on quality measures related to services furnished to Medicare beneficiaries. These quality measures are based on the best available medical evidence and designed to help professionals improve care for patients. In 2009, over 200,000 professionals reported data to CMS through the Physician Quality Reporting System.

According to CMS, it plans a second phase of the Web site which will indicate whether professionals chose to participate in a voluntary effort with the Agency to encourage doctors to prescribe medicines electronically, rather than through traditional paper-based prescription methods later in 2011.

In future years, the Physician Compare Web site will be expanded with information about the quality of care Medicare beneficiaries receive from physicians and the other healthcare professionals profiled on the site. The expansion will include information on quality of care and patient experience that can help consumers learn more about the care provided by Medicare-participating physicians. CMS is required by the Affordable Care Act to develop a plan to implement this expansion by 2013.

The new Physician Compare resource supplements a broad range of resources that patients and their families can use to gather information about an existing or proposed health care provider. Like all directories, however, patients and their families should keep in mind that no single resource or directory provides complete information about any one provider or should be used as a sole basis for selecting or assessing the quality or credentials of any health care provider.

Help patients and their families to constructively use these and other tools by managing your reputation and sharing information with patients and their families about how to properly use and understand the information provided. You also can share your input about how patients and their families should use these and other similar resources and other insights to help other patients and their families better prepare to manage and assist in their own health care and health benefit management by participating in Project COPE: Coalition for Patient Empowerment here.

For More Information Or Assistance

If you need assistance reviewing or responding to the DEA prescribing guidance contained in the Statement or addressing other health care related risk management or compliance concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer compliance and risk management policies and to respond to DEA and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Solutions Law Press publications authored by Ms. Stamer including:

For More Information

We hope that this information is useful to you. If you need assistance evaluating or responding to the Health Care Reform Law or health care compliance, risk management, transactional, operational, reimbursement, or public policy concerns, please contact the author of this update, Cynthia Marcotte Stamer, at (469) 767-8872 or via e-mail here.

You can review other recent health care and internal controls resources and additional information about the health industry and other experience of Ms. Stamer here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here.

Leave a Comment » | Affordable Care Act, Conditions of Participation, Consumer Driven Health Care, Doctor, Evidence Based Medicine, Health Care, Health Care Finance, Health Care Provider, Health Care Quality, Health Care Reform, Health Plan, Health Plans, Medicare, Medicare Advantage, Physician, Reimbursement | Tagged: Affordable Care Act, CMS, Consumer Driven Health Care, Credentialing, Health Care, Health Care Reform, Physician, Physician Compare, Provider | Permalink
Posted by Cynthia Marcotte Stamer

Health Care Fraud Enforcement Packs New Heat

December 16, 2010

As part of ongoing efforts to prevent and fight health care fraud, US Department of Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder today announced that the Centers for Medicare and Medicaid Services (CMS) plans to acquire and new state-of-the-art predictive modeling fraud fighting analytic tools to prevent wasteful and fraudulent payments in Medicare, Medicaid and the Children’s Health Insurance Program before they occur As Sebelius and Holder made the announcement at a Fraud Prevention Summit held at the University of Massachusetts in Boston, CMS issued a solicitation for state-of-the-art fraud fighting analytic tools to help the agency predict and prevent potentially wasteful, abusive or fraudulent payments before they occur. These actions come as CMS and the Justice Department are touting record recoveries from already ongoing enforcement actions.

CMS intends to use these new tools into the National Fraud Prevention Program and to complement and expand fraud detection and enforcement work and practices utilized by the joint HHS and Department of Justice Health Care Fraud Prevention and Enforcement Action Team (HEAT) in recent years.

CMS is already starting to take administrative action to stop payments in various pilot programs or other anti-fraud initiatives. The move to acquire and use additional predictive model tools comes as CMS is implementing new and expanded health care fraud detection and enforcement authority provided in the Patient Protection and Affordable Care Act (Affordable Care Act). CMS and the Justice Department are moving aggressively to take advantage of these new powers and resources. In recent months HHS founded the new Center for Program Integrity within CMS would focus on identifying and stopping fraud and acting swiftly to protect beneficiaries. It also proposed new rules implementing enhanced health care fraud investigation and enforcement powers enacted as part of the Affordable Care Act.

Meanwhile, CMS and the Justice Department have continued to aggressively investigate and prosecute suspected health care fraud. Already, stepped up fraud enforcement efforts have produced significant recoveries. In Fiscal Year 2010, the Department of Justice obtained settlements and judgments of more than $2.5 billion in False Claims Act matters alleging health care fraud. This is more than ever before obtained in a single year, up from $1.68 billion in Fiscal Year 2009.

In light of these developments, health care providers should tighten billing and other compliance practices and monitoring of enforcement and other oversight activities by CMS and the Justice Department. Get more details here.

For Assistance

Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising physicians, hospitals and other health industry clients about regulatory compliance and enforcement, quality assurance, peer review, licensing and discipline, and other medical staff performance matters. She continuously advises health industry clients about the use of technology, process and other mechanisms to promote compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational needs. As part of this experience, she has worked extensively with health care providers, payers, health care technology and consulting and other health industry clients, as well as other businesses, on privacy, data security, trade secret and related matters. A popular lecturer and widely published author on health industry concerns, Ms. Stamer also publishes and speaks extensively on health care compliance, staffing and human resources, compensation and benefits, technology, medical staff, public policy, reimbursement, privacy, technology, and other health and managed care industry regulatory, and other operations and risk management concerns for medical societies and staffs, hospitals, the HCCA, American Bar Association, American Health Lawyers Association and many other health industry groups and symposia. Her highly popular and information packed programs include many highly regarded publications on HIPAA, FACTA, medical confidentiality, state identity theft and privacy and other many other related matters. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. To review some of her many publications and presentations, or for additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

For More Information

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources. If you or someone else you know would like to receive future updates and notices about other upcoming Solutions Law Press events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. For important information concerning this communication click here. For important information concerning this communication click here.

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Posted by Cynthia Marcotte Stamer

Quality, Recordkeeping & Unprofessional Conduct Lead Reasons For Medical Board Discipline of Physicians

December 2, 2010

Quality, unprofessional conduct and recordkeeping issues were the most common reason for discipline among the 77 physicians disciplined by the Texas Medical Board (TMB) since August. The reported actions highlight the need for physicians and the hospitals, practices and other entities dealing with them to take appropriate steps to manage these and other related risks.

Data recently disclosed by the TMB reveals that among the 77 licensed physicians disciplined, the violations included:

11 violations based on quality of care;
10 based on inadequate medical records
9 violations based on unprofessional conduct;
4 based on other states’ action;
1 based on inadequate supervision
1 based on peer review actions;
1 based on criminal convictions; and
10 orders for minor statutory violations.

The disciplinary actions imposed varied based on the nature and circumstances of the offense. It included 8 voluntary surrenders; 1 suspension; 3 revocations; 18 corrective orders and one cease and desist order.

A review of the TMB statistics and reports about these actions demonstrates the continuing need for physicians and the practices, hospitals, insurers, and others with liability or responsibility for monitoring, reporting or insuring their conduct to provide and administer effective training, quality and performance management and oversight to monitor and promote appropriate physician performance in these and other performance areas that may give rise to discipline or disciplinary reporting obligations. Additionally, a review of the circumstances of the reported circumstances also highlights the advisability of strengthening stress and substance abuse monitoring, education and intervention processes and procedures to head off or minimize potential licensing board and other risks.

For More Information or Assistance

If you need help evaluating or responding to this development of other health care reimbursement, technology and process, compliance, risk management, transactional, operational, enforcement or public policy concerns, please contact the author of this update, Cynthia Marcotte Stamer, at (469) 767-8872, or via e-mail to cstamer@solutionslawyer.net.

Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising physicians, hospitals and other health industry clients about quality assurance, peer review, licensing and discipline, and other medical staff performance matters. She continuously advises health industry clients about the use of technology, process and other mechanisms to promote compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational needs. As part of this experience, she has worked extensively with health care providers, payers, health care technology and consulting and other health industry clients to investigate, address and defend physician and other health care workforce conduct, quality, communication and other concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer also publishes and speaks extensively on health care staffing and human resources, compensation and benefits, technology, medical staff, public policy, reimbursement, privacy, technology, and other health and managed care industry regulatory, and other operations and risk management concerns for medical societies and staffs, hospitals, the HCCA, American Bar Association, American Health Lawyers Association and many other health industry groups and symposia. Her highly popular and information packed programs include specific training for physicians and other health industry leaders on “Sex, Drugs & Rock ‘N Role: Personal Misconduct In Health Care,” “Managing Physician Performance,” “Physician Gainsharing,” improving health care communication and collaboration and many other related matters. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. To review some of her many publications and presentations, or for more information about Ms. Stamer, her experience, involvements, programs or publications, see here.

For More Information

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

12/15 Deadline For Input on New Joint Commission Heart Failure Certification

December 2, 2010

December 15, 2010 is the deadline to share your comments with the Joint Commission on proposed requirements for Advanced Certification in Heart Failure from health care professionals who care for individuals with heart failure.
The Joint Commission drives much of how hospitals and a growing number of health care providers are judged and ultimately paid. Since the cost of meeting these standards ultimately will be passed on in the charges made by health care providers, health plans and employers should evaluate these credentials and provide appropriate comments when the demonstrated benefits of added conditions or paperwork drive up costs unnecessarily, divert resources from more important patient care goals, or promote other inefficiencies.

The Joint Commission is a leading quality accreditation agency, whose reach now extends to almost all health care organizations and providers. While acknowledging that the Joint Commission has and continues to do much to promote health care quality, health care providers increasingly complain the Joint Commission requirements increasingly are becoming overkill that unnecessarily adds costs and recordkeeping burden in a way that puts measurement before patient care, but feel pressure to comply. Supporters say the standards are necessary to maintain and demonstrate quality.

Striking the proper balance between quality and cost is at the heart of much of the current national initiative to control costs, as well as the efforts of almost all health care providers and payers. To promote proper standards, share comments before the standards are adopted. In the meanwhile, what is your experience about the Joint Commission and the impact of their growing involvement in health care?

The Joint Commission is expanding its Advanced Heart Failure Certification program to encompass the care provided to individuals with heart failure in outpatient settings. The Joint Commission and the American Heart Association (AHA) have established a strategic alliance to recognize programs that demonstrate excellence in the care of individuals with heart failure in both inpatient and outpatient care settings. To receive this certification, an organization must demonstrate compliance with Joint Commission standards, including use of the American Heart Association’s Get With The Guidelines®, and ongoing performance improvement. This new advanced certification is projected to launch in July 2011.

For More Information or Assistance

For a link to the proposed standards or other information, see here. If you need help evaluating or responding to this development of other health care reimbursement, technology and process, compliance, risk management, transactional, operational, enforcement or public policy concerns, please contact the author of this update, Cynthia Marcotte Stamer, at (469) 767-8872, cstamer@Solutionslawyer.net.
Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. She continuously advises health industry clients about the use of technology, process and other mechanisms to promote compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational needs. As part of this experience, she has worked extensively with health care providers, payers, health care technology and consulting and other health industry clients on the design and use of health information systems, technology, privacy and other related. A popular lecturer and widely published author on health industry concerns, Ms. Stamer also publishes and speaks extensively on health care privacy, technology, and other health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. To review some of her many publications and presentations, or for additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

About Solutions Law Press

Leave a Comment » | Consumer Driven Health Care, Disease Management, DME, Doctor, Evidence Based Medicine, Health Care, Health Care Finance, Health Care Provider, Health Care Quality, Hospital, Medicaid, Peer Review, Reimbursement | Tagged: Cardiology, Certification, Health Care, Heart, Joint Commission, outpatient, Wellness | Permalink
Posted by Cynthia Marcotte Stamer

DEA Cautions Practitioners Must Restrict Delegation of Controlled Substance Prescribing Functions, Urges Adoption of Written Policies & Agreements

November 2, 2010

Physicians, dentists, veterinarians, hospitals, and other persons prescribing or managing practitioners that prescribe controlled substances should require written agreements with staff and others communicating controlled substance prescriptions on their behalf and implement other suitable controls to ensure compliance with Drug Enforcement Administration requirements for prescribing controlled substances according to a new DEA Statement of Policy On Role of Authorized Agents in Communicating Controlled Substance Prescriptions To Pharmacies (Statement) published by the Department of Justice Drug Enforcement Administration (DEA) on October 6, 2010.

The Statement reflects that the DEA is concerned that about practitioners improperly delegating medical need determinations and other responsibilities for prescribing controlled substances. The Statement indicates that practitioners using agents to communicate controlled substance prescriptions should ensure that their delegations are appropriately documented by written agreements with the agents detailing the scope of their authority and implement background checks, monitoring, written and operational policies and procedures governing delegations and other controlled substance prescribing and other controls to appropriately comply with DEA controlled substance prescription mandates.

Under the Comprehensive Drug Abuse Prevention and Control Act of 1970 (CSA) and the Controlled Substances Import and Export Act (CSIEA) (21 U.S.C. 801-971), a valid prescription issued by a DEA-registered practitioner is required for dispensing a controlled substance. Existing rules prohibit DEA-registered practitioners from delegating their authority to prescribe controlled substances. To be effective (i.e., valid), a DEA-registered practitioner must issue the required prescription for a controlled substance for a legitimate medical purpose as determined by the practitioner acting in the usual course of professional practice. The registered practitioner actually must make the required determination of legitimate medical purpose underlying a controlled substance prescription. He cannot delegate responsibility for determining the legitimacy of the medical purpose for a controlled substance prescription or other core responsibilities.

While DEA rules prohibit a registered practitioner from delegating his core responsibilities pertaining to prescribing controlled substances to anyone else, DEA rules allow an individual practitioner to authorize an agent to perform a limited role in communicating controlled substance prescriptions to a pharmacy in order to make the prescription process more efficient. The ability to delegate these communication responsibilities is very restricted and requires that the practitioners apply appropriate controls to prevent delegation of core prescribing responsibilities.

In the Statement, the DEA cautions that DEA requires that DEA registered practitioners must be prepared to demonstrate that the registered practitioner alone makes all required medical determinations to prescribe the communicated controlled substances when delegating responsibility to communicate controlled substance prescriptions to pharmacies on their behalf to nurse or other person acting as the practitioner’s agent. The Statement warns that delegation must be limited to participation in the communication of the prescription in accordance with DEA requirements. The Statement urges practitioners allowing agents to participate in the communication of controlled substance prescriptions to make those delegations pursuant to written agreements with t he agent and to adopt other safeguards to maintain compliance with DEA rules. To learn more, see here

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Posted by Cynthia Marcotte Stamer

OIG Shares Key Insights On When Owners, Officers & Managers Face OIG Program Exclusion Based On Health Care Entity Misconduct

October 21, 2010

The Department of Health & Human Services Office of Inspector General (OIG) this morning (October 21, 2010) posted to its website key guidance about when OIG will exercise its authority under the permissive exclusion rules of Social Security Act (Act) § 1128(b)(15)(A)(ii) to exclude from Federal health program participation owners, officers or managing employees of health care organizations based on their role, involvement or ownership interest in a health industry company convicted of certain offenses or excluded from Federal health program participation.

The Guidance For Implementing Permissive Exclusion of Authority under Section 1128(b)(15) of the Social Security Act (Guidance) provides valuable insights for health care organizations, their owners, officers and managers about how OIG expects them to act and the evidence that OIG likely will require should OIG bring an OIG exclusion action against them personally following the conviction or OIG exclusion of their health care organization for misconduct. To position themselves to survive OIG or related exclusion or prosecution, health care organizations and their owners, officers and management use the Guidance as a guide to help strengthen the defensibility of their daily actions against potential OIG scrutiny and consider the advisability of updating their personal and organizational practices, policies and leadership training in response to this Guidance.

The Guidance discusses the guiding principles and core factors and presumptions that OIG generally will apply to decide if the OIG will should exclude an individual from Federal health program participation based on the involvement of the individual as an owner, officer or manager of company that has been excluded from Federal program participation or convicted of certain health care crimes.. Because these OIG has identified these factors as core considerations in its exclusion analysis, the Guidance provides invaluable guidance for health care entities, their owners, officers and management employees about opportunities position their conduct for defensibility against OIG enforcement exposures. Consequently, owners, officers and managers alike concerned about their exposure to Federal program exclusion or other personal liability under Federal health care fraud laws should use the Guidance to help strengthen their ability to avoid personal exclusion or other prosecution by the OIG as a result of their involvement with a health care organization excluded from Federal program participation or convicted of other crimes. For a more detailed discussion of the Guidance, see here

For More Information or Assistance

If you need assistance evaluating or responding to this development of other health care compliance, risk management, transactional, operational, reimbursement, enforcement or public policy concerns, please contact the author of this update, Cynthia Marcotte Stamer, at (469) 767-8872, cstamer@Solutionslawyer.net.

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Posted by Cynthia Marcotte Stamer

Initial EHR Certification Bodies Named

August 30, 2010

The Office of the National Coordinator for Health Information Technology (ONC) today (August 30, 2010) named Certification Commission for Health Information Technology (CCHIT), Chicago, Ill. and the Drummond Group Inc. (DGI), Austin, Texas as the first technology review bodies authorized to test and certify electronic health record (EHR) systems for compliance with the standards and certification criteria that were issued by the U.S. Department of Health and Human Services earlier this year. The announcement comes less than two months after issuance of final meaningful use rules. Read more here.

For More Information or Assistance

If you need assistance responding to the EHR meaningful use, HITECH and other privacy, or other health industry regulatory, reimbursement or other operational or compliance concerns, please contact the author of this update, attorney Cynthia Marcotte Stamer. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients with licensure, contracting, reimbursement, compliance, public policy, regulatory, staffing, and other operations and risk management matters. Ms. Stamer also regularly publishes and conducts training on these and other compliance, management and operations matters. You can contact Ms. Stamer to inquire about engaging her services or for information about training or other resources that she provides at (469) 767-8872 or via e-mail here. To get more information about Ms. Stamer and her health industry experience, see here.

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Solutions Law Press™ provides health industry and other risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources available for review here. If you or someone else you know would like to receive future updates and notices about other upcoming Solutions Law Press events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. For important information concerning this communication click here.

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Posted by Cynthia Marcotte Stamer

CMS Publishes Corrections To Proposed 2011 Physician Fee Schedule Rules

August 26, 2010

Physicians and others likely to be affected by the proposed payment and other Medicare policy changes set forth in the “Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011” (“2011 Physician Fee Schedule”) proposed by the Centers for Medicare & Medicaid Services (CMS) on July 13, 2010 Federal Register should review and consider the potential implications, if any, of a series of corrections to the proposed 2011 Physician Fee Schedule (“Corrections”) published by CMS today (August 26, 2010) when evaluating the implications of the 2011 Physician Fee Schedule on their reimbursement and other operations.

The 2011 Physician Fee Schedule previously published in the Federal Register here on July 13, 2010 outlines a detailed series of proposed changes to the physician fee schedule and other Medicare Part B payment policies that CMS is proposing to implement in 2011. Among other things, the proposed 2011 Physician Fee Schedule would:

Change Medicare reimbursement rules and amounts to reflect changes in medical practice and the relative value of services;
Interprets and implements certain provisions of both the Affordable Care Act and the Medicare Improvements for Patients and Providers Act of 2008;;
Discusses payments under the Ambulance Fee Schedule, Clinical Laboratory Fee Schedule, payments to ESRD facilities, and payments for Part B drugs; and
Discusses rules regarding the Chiropractic Services Demonstration program, the Competitive Bidding Program for Durable Medical Equipment and Provider and Supplier Enrollment Issues associated with Air Ambulances.

The Corrections published in the August 26, 2010 Federal Register here list a series of corrections to specific provisions of the 2011 Physician Fee Schedule that CMS has identified as necessary to address technical or typographical errors in the 2011 Physician Fee Schedule as originally published in July. Physicians and others evaluating the potential implications of the previously proposed 2011 Physician Fee Schedule should review and take into account these proposed edits as part of their analysis and response.

For More Information or Assistance

If you need assistance with these or other health industry regulatory, reimbursement or other operational or compliance concerns, please contact the author of this update, attorney Cynthia Marcotte Stamer. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients with licensure, contracting, reimbursement, compliance, public policy, regulatory, staffing, and other operations and risk management matters. Ms. Stamer also regularly publishes and conducts training on these and other compliance, management and operations matters. You can contact Ms. Stamer to inquire about engaging her services or for information about training or other resources that she provides at (469) 767-8872 or via e-mail here. To get more information about Ms. Stamer and her health industry experience, see here.

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Posted by Cynthia Marcotte Stamer

HHS Invites Input On Medicaid Changes To Promote Children’s Health Quality

August 2, 2010

August 30, 2010 is the deadline for interested persons to provide input to Health & Human Services about legislation to improve the quality of care provided to children under Medicaid and the Children’s Health Insurance Program, including recommendations for quality reporting by the States. The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requires the Secretary of Health and Human Services to provide to Congress recommendations for legislative changes to improve the quality of care provided to children under Medicaid and the Children’s Health Insurance Program. HHS invited public input for use in preparing these recommendations on July 30, 2010 here.

For More Information or Assistance

The author of this update, attorney Cynthia Marcotte Stamer, has extensive experience advising and assisting health care providers and other health industry clients with licensure, contracting, reimbursement, compliance, public policy, regulatory, staffing, and other operations and risk management matters. Ms. Stamer also regularly publishes and conducts training on these and other compliance, management and operations matters. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here. To review the regulations, see here. For a summary, see here.

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Posted by Cynthia Marcotte Stamer

CMS Adopts ESRD Facility Prospective Payment System & Proposes New Quality Incentive Program

August 1, 2010

The Centers for Medicare & Medicaid Services (CMS) on July 26 issued a final rule that will change how Medicare pays for dialysis services for Medicare beneficiaries who have end-stage renal disease (ESRD). Concurrently, CMS also proposed new rules that would establish a new quality incentive program (QIP) to promote high quality services in dialysis facilities by linking a facility’ s payments to performance standards. The QIP is the first pay-for-performance program in a Medicare fee-for-service payment system. Read on here .

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Posted by Cynthia Marcotte Stamer

CMS Rule Clarifies When Outpatient Services Subject to 3-Day Rule & Finalizes FY 2011 Inpatient Payment Rates

August 1, 2010

Regulations published July 30^th by the Centers for Medicare & Medicaid Services (CMS) clarify when non-diagnostic services provided on an outpatient basis will be treated as inpatient services under the “3-Day Rule” in light of the clarifications made by the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (“Preservation of Access to Care Act”). The regulations also finalize Medicare payment rates for inpatient services furnished to people with Medicare by acute care hospitals, long-term care hospitals (LTCHs), and certain excluded hospitals. Get more details here.

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Posted by Cynthia Marcotte Stamer

CMS Proposes Changes To Civil Monetary Penalty Rules For Nursing Homes

July 12, 2010

August 11, 2010 is the deadline to submit comments on proposed changes to Medicare and Medicaid regulations governing the imposition and collection of civil monetary penalties against nursing homes for failing to comply with Medicare & Medicaid regulations.

The Centers for Medicare & Medicaid Services today (July 12, 2010) proposed regulations that would expand and revise current Medicare and Medicaid regulations regarding the imposition and collection of civil money penalties by CMS when nursing homes are not in compliance with Federal participation requirements in accordance with the Patient Protection and Affordable Care Act of 2010. A copy of the proposed regulations is available for review here.

If you need assistance evaluating, preparing comments, or responding to the proposed regulations or with other health industry matters, please consider contacting the author of this update. Attorney Cynthia Marcotte Stamer, has extensive experience advising and assisting health care providers and other health industry clients with reimbursement, compliance, public policy, regulatory, staffing, and other operations and risk management matters. Ms. Stamer also regularly publishes and conducts training on health industry compliance, management and operations matters. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

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Posted by Cynthia Marcotte Stamer

NTHCPA July 13 Meeting On Annual Reporting under a Corporate Integrity Agreement

July 5, 2010

NORTH TEXAS HEALTHCARE COMPLIANCE PROFESSIONAL ASSOCIATION

Invites Members and Guests to

“Annual Reporting under a Corporate Integrity Agreement”

July 13, 2010
2:00 p.m..-4:00 p.m.
Tenet Healthcare Corporation

Fountain Place, 14th Floor Room 1454

1445 Ross Avenue

Dallas, Texas 75202

North Texas Healthcare Compliance Professional Association (NTHCPA) invites members and other interested health care compliance professionals to learn about “Annual Reporting Under a Corporate Integrity Agreement” by participating in the July 13, 2010 NTHCPA meeting from 2:00 p.m. to 4:00 p.m.

Listen to a panel discussion of Audrey Andrews, Sarah Campbell, Al Josephs and Ryan Whitehill from the compliance team of Tenet Healthcare Corporation as they discuss their insights on preparing for and managing annual reporting requirements when operating under a corporate integrity agreement.

The meeting will be held at the offices of Tenet Healthcare Corporation located at Fountain Place, 14th Floor Room 1454, 1445 Ross Avenue, Dallas, Texas 75202. NTHCPA thanks Tenet Healthcare Corporation for hosting and leading this meeting.

To help us to notify you about upcoming meetings and to arrange for adequate space and refreshments, for this and other meetings, interested persons are encouraged to forward their current contact information including e-mail to Vice-President Cynthia Marcotte Stamer at (469) 767-8872 or by e-mail to cstamer@solutionslawyer.net.

If you are interested in hosting one of the upcoming meetings, wish to suggest topics or speakers, or wish to obtain or share other information, please contact NTHCPA President Erma Lee at (817) 927-1232 or by e-mail at ELee@jpshealth.org or Vice-President Cynthia Marcotte Stamer at (469) 767-8872 or by e-mail to cstamer@solutionslawyer.net.

About the NTHCPA

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Posted by Cynthia Marcotte Stamer

Proposed Medicare Rules Will Require Hospitals Honor Patient Visitation Preferences

June 23, 2010

A new Condition of Participation rule proposed by the Centers for Medicare & Medicaid Services (CMS) would require hospitals to protect and honor patients’ rights to choose their own visitors during a hospital stay. The new proposed rule will implement an April 15, 2010, Presidential memorandum directing HHS to develop standards requiring Medicare- and Medicaid-participating hospitals (including critical access hospitals) to allow patients to choose who may visit them when they are inpatients of a facility.

The proposed rule would add the new requirement as an addition Condition of Participation for Medicare- and Medicaid-participating hospitals and critical access hospitals. To meet the Condition, the proposed rules would require every hospital to have written policies and procedures detailing patients’ visitation rights, as well as instances when the hospital may restrict patient access to visitors based on reasonable clinical needs. Among other things, the proposed rule specifically would require:

Visitors chosen by the patient (or his or her representative) be able to enjoy visitation privileges that are no more restrictive than those for immediate family members; and
Require hospitals and critical access hospitals to explain to all patients their right to choose who may visit them during their inpatient stay, regardless of whether the visitor is a family member, a spouse, or a domestic partner (including a same-sex domestic partner), as well as the right to withdraw such consent at any time.

The proposed rules expected to be published in the Federal Register this week will be available for public comment for 60 days. CMS plans to finalize the proposed rule after CMS has read and considered the comments. More information about the proposed rule see CMS’ website here and here.

The proposed new requirement would add to the already existing safety and other Conditions of Participation that hospitals must meet to participate in Medicare and would operate in addition to otherwise applicable patient’s visitation rights standards imposed by Joint Commission and other rules. The author of this update, attorney Cynthia Marcotte Stamer, has extensive experience advising and assisting hospitals and other health care providers to estalish and administer patient’s rights and other policies to comply with Conditions of Participation and other applicable laws, regulations and standards. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

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Posted by Cynthia Marcotte Stamer

OIG Touts Expanding Health Care Fraud Enforcement Success & Launches New Health Care Fraud Hotline

May 20, 2010

Continuing expansion of health care fraud enforcement initiatives, the Office of Inspector General (OIG) recently released its Health Care Fraud and Abuse Control Program Report and launched a new online Fraud Hotline Website to allow individuals the option of reporting federal health care fraud suspicions to OIG online.

The May 12 launch of the Fraud Hotline Website means whistleblowers now can report suspected federal health care fraud to OIG over the Internet, by telephone or by mail. CMS hopes the addition of online fraud reporting capability will lead to more investigations, audits and/or monetary recoveries.

OIG followed up May 13, by releasing its latest Health Care Fraud and Abuse Control Program Report, In addition to detailing 2009 healthcare fraud enforcement activities and accomplishments, the Report also highlights the continuing success of its HEAT initiative as well as new enforcement tools created by the recent health care reform legislation, the “Fraud Enforcement and Recovery Act of 2009”(FERA) and other recent developments that facilitate the ability of OIG and the Justice Department to prosecute and secure larger fines and penalties from healthcare providers engaging in health care fraud. For more information, read the OIG Press Release here.

The heightened emphasis by federal officials on enforcement of federal health care fraud laws and the implementation of tools like the new Fraud Hotline Website increase the likelihood both that whistleblowers will turn in health care providers and other individuals and organizations that file false claims in violation of the FCA and the liability that violators may incur for that misconduct. These and other activities are part of a significant ramp up in federal emphasis on the detection and prosecution of violations of federal health care fraud laws by both the Administration and Congress. Many state agencies also are stepping up their health care fraud investigations and enforcement. In light of this new emphasis upon health care fraud detection and enforcement, health care providers now more than ever need to prepare to demonstrate the appropriateness and defensibility of their health care billing and other compliance efforts.

The author of this update, attorney Cynthia Marcotte Stamer, has extensive experience advising and assisting health care practitioners and other businesses and business leaders to establish, administer, investigate and defend health care fraud and other compliance and internal control policies and practices to reduce risk under federal and state health care and other laws. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

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Posted by Cynthia Marcotte Stamer

HHS Invites Input on Proposed Strategic Framework on Multiple Chronic Conditions

May 19, 2010

June 18, 2010 is the deadline for interested persons to submit comments to the Office of Public Health and Science of the Department of Health & Human Services (HHS) on the draft “HHS Strategic Framework on Multiple Chronic Conditions” in response to the request for information published here in the May 19, 2010 Federal Register. Interested parties can review the draft strategic framework here.

Approximately 75 million Americans have multiple (2 or more) concurrent chronic conditions, including problems such as hypertension, heart disease, arthritis, diabetes, mental health conditions, and chronic respiratory infections. As these combined morbidities drive significant health costs, HHS through the Office of Public Health and Science (OPHS) and its HHS Interagency Workgroup on Multiple Chronic Conditions has drafted a “Strategic Framework on Multiple Chronic Conditions” to address approaches to improving the health of individuals with concurrent multiple chronic conditions by providing options for HHS to strengthen coordination of its efforts internally and collaboration with stakeholders externally. The strategic framework seeks to improve the foundation for realizing optimum health and quality of life for individuals with multiple chronic conditions. In the request for information published May 19, 2010, HHS is seeking comments from stakeholders and the public on the draft strategic framework.

If you need assistance to submit comments in response to the request for information or with any other health industry regulatory or operational matter, please contact Cynthia Marcotte Stamer at (469) 767-8872 or e-mail her here.

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Posted by Cynthia Marcotte Stamer

Agencies Seek Public Input On New Insurer Premium Revenue Reporting Obligations Added By Patient Protection and Affordable Care Act

April 15, 2010

By Cynthia Marcotte Stamer

The Departments of Treasury (IRS), Labor (DOL) and Health & Human Services (HHS) are inviting public comments on impending new federal requirements that will compel health insurance issuers offering individual or group medical coverage to send annual reports to HHS on the percentages of premiums that the coverage spends on reimbursement for clinical services and activities that improve health care quality, and to provide rebates to enrollees if this spending does not meet minimum standards for a given plan year added as Section 2718 of the Public Health Service Act (PHS Act), by the Patient Protection and Affordable Care Act (PPACA), Public Law 111-148, enacted on March 23, 2010.

Among other things, Section 2718 of the PHS Act, Section 715 of the Employee Retirement Income Security Act of 1974 (ERISA) and Section 9815 of the Internal Revenue Code of 1986 (the Code) will require health insurance issuers offering group or individual coverage to report to HHS annually:

The ratio of the incurred loss (or incurred claims) plus the loss adjustment expense (or change in contract reserves) to earned premiums (also known as the medical loss ratio (MLR)); and
The percentage of total premium revenue–after accounting for collections or receipts for risk adjustment and risk corridors and payments of reinsurance–that the coverage spends: (1) on reimbursement for clinical services provided to enrollees; (2) for activities that improve health care quality; and (3) on all other non-claims costs, including an explanation of the nature of these costs, and excluding Federal and State taxes and licensing or regulatory fees.

PPACA also requires that HHS make these reports available to the public on the Internet Web site of HHS. To review the request for comments and its instructions for commenting on the new requirements, see here.

For Assistance With This Opportunity Or Other Health Industry Concerns

If your organization needs advice or help with commenting on the request for comments or to evaluate or respond to other health care reform regulations or other health care matters, contact Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here.

Vice President of the North Texas Health Care Compliance Professionals Association, Exempt Organization Vice-Coordinator of the Southern States IRS TEGE Council, Chair of the American Bar Association (ABA) Real Property, Probate & Trust Section Employee Benefits & Other Compensation Arrangements Group, a Council Member of the ABA Joint Committee On Employee Benefits Council, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 22 years experience advising health industry clients about these and other matters. A popular lecturer and widely published author on health industry matters, Ms. Stamer advises hospitals and other health industry clients about responding to and using these and other quality measures and other related concerns. Ms. Stamer also publishes and speaks extensively on health and managed care industry quality, regulatory, reimbursement, and other operations, risk management and public policy concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. For additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

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We hope that this information is useful to you. If you need assistance with auditing or defending these or other health care compliance, risk management, transaction or operation concerns, please contact Cynthia Marcotte Stamer, at (469) 767-8872 or to cstamer@solutionslawyer.net.. Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other internal controls and risk management matters.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here. To unsubscribe, e-mail here.

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DEA/DOJ Release Interim Final E-Prescribing Rules

March 25, 2010

Health care providers wishing to electronically prescribe controlled substance should begin reviewing and updating their practices and technology to comply with requirements of the Interim Final Regulations scheduled for publication in the Federal Register on March 31, 2010. Read details at http://wp.me/ptOGJ-94

An advance copy of the new Interim Final Regulation with Request for Comments released March 24, 2010 by the Drug Enforcement Administration (DEA) and Department of Justice on Electronic Prescribing of Controlled Substance on is posted for review here.

Concurrent with publication of the Interim Final Rule, the DEA is inviting comment on DEA is seeking additional comments on the following issues: identity proofing, access control, authentication, biometric subsystems and testing of those subsystems, internal audit trails for electronic prescription applications, and third-party auditors and certification organizations.

About The Author

If you need assistance with health industry human resources or other management, concerns, wish to inquire about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer at cstamer@solutionslawyer.net or (469) 767-8872.

Nationally and internationally recognized for more than 22 years of work with health industry technology, privacy and data security, regulatory compliance, reimbursement, workforce and staffing, licensure and accreditation, and other quality, risk management, operations and public policy matters organizations, publications, workshops and presentations and leadership Cynthia Marcotte Stamer has worked extensively with physicians, health systems, specialty and other pharmacy, telemedicine and other health technology, and other health industry clients on a diverse range of operational, product and process development, regulatory, licensure, public policy and risk management protections relating to e-prescribing, telemedicine, interoperable and other electronic health and medicine arrangements and other health care internal controls, process and privacy and technology matters. The publisher of the Solutions Law Press Health Care Update, and Solutions Law Press Health Care Privacy & Technology Update, Ms. Stamer also is a popular speaker and author of these and other health industry topics. She regularly publishes, speaks and conducts training for health industry and other organizations, the ABA, American Health Lawyers Association (AHLA), Health Care Compliance Association, Institute of Internal Auditors, various medical society and other professional organizations, the Medical Group Management Association, and many other organizations. Her many publications and programs include“Changing Regulations Will Ease Way for E-Prescribing, But Physicians Shouldn’t Jump the Gun,” “Telemedicine, E-Prescribing & Electronic Health Records: Opportunities & Exposures,” “Telemedicine & E-Prescribing: Evolving Ethical, Licensing & Reimbursement Rules & Realities,” the “Tort & Other Liability” Chapter of the ABA Health Law Section/BNA E-Health & Technology Treatise, “Protecting & Using Patient Data in Disease Management Opportunities, Liabilities and Prescriptions,” Chapter 1: Privacy.” The Quest for Interoperable Electronic Health Records: A Guide to Legal Issues in Establishing Health Information Networks (AHLA 2005) (Contributing Author), “Cybercrime and Identity Theft: Health Information Security beyond HIPAA,” “Privacy & Securities Standards-A Brief Nutshell” and numerous other programs and publications on telemedicine and e-prescribing, HIPAA and other privacy and data security, and other related internal controls and operational matters. Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Spencer Publications, World At Work, SHRM, Business Insurance, James Publishing and many others. You can review other highlights of Ms. Stamer’s health care experience here, and employment experience here. Her insights on these and other matters appear in Managed Care Executive, Modern Health Care, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, MDNews, Kentucky Physician, and many other national and local publications.

Other Resources

If you found this information of interest, you also may be interested in reviewing other updates and publications by Ms. Stamer including:

For More Information

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Posted by Cynthia Marcotte Stamer

House Could Vote On Health Care Reform As Early As Sunday

March 19, 2010

By Cynthia Marcotte Stamer

The stage now appears to be set for the House of Representatives to vote as early as Sunday on the latest version of health care reform backed by President Obama, Speaker Nancy Pelosi and other key Congressional Democrats, the Reconciliation Act of 2010 (H.R. 4872). The impending deadline means that health industry providers and other Americans concerned about the potential outcome of the impending vote need to act quickly if they wish to attempt to influence the decision. For tips about sharing your input with Congress effectively, see Getting Your Health Care Reform Message Heard By Key Congressional Leaders.

Developments Today Start Clock Running For Vote

On Thursday, March 18, 2010, two key developments set the stage for a vote on H.R. 4871 as early as Sunday:

The House Rules Committee posted the text of H.R. 4872 on its website; and
The Congressional Budget Office (CBO) delivered its scoring of H.R 4872 to House Speaker Nancy Pelosi.

The delivery of CBO scoring started the clock running on the 72 hour mandatory period between the release of the CBO scoring and any final vote on the bill. This means the House could vote on H.R. 4872 as early as Sunday, March 21.

If passed by the House, H.R. 4872 would make sweeping changes to the U.S. health care system impacting virtually every American patient, health care provider, employer and taxpayer. To learn the facts about these proposed changes, read the full text of H.R. 4872 here.

According to the CBO, H.R. 4872 will cost $940 billion over 10 years to extend coverage to 32 million uninsured people. To learn more specifics about these cost and other determinations, review the CBO scoring here.

This Is Only The Beginning: Stay Involved

The outcome of this latest health care reform push is only a small part of a continuing process. Whether or not the President’s proposal or some other version of health care reform passes this week, Congress already has and will continue to consider other legislation impacting health care reform. This reality is demonstrated by Congressional actions recently taken on the COBRA premium subsidy extension, Medical reimbursement for physicians, continuing federal efforts to develop and implement federal health care quality and technology standards, and other legislative, regulatory and enforcement actions taken while public attention has been focused largely only on the broader health care reform debate.

Upcoming mid-term elections will significantly impact the nature and scope of these upcoming efforts. Perhaps even more significantly, the enactment of legislation is only a beginning point. The real meaning of these or other health care reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye. Monitoring and staying active in these ongoing processes provides a critical opportunity to continue to monitor your issues and provide input to shape how they are addressed.

Individuals concerned about these and other health care reform proposals and concerns are invited to stay involved in the discussion by sharing their input with Congress, regulators. Concerned individuals also are invited to stay involved in the discussion by joining the Coalition for Responsible Health Care Reform Group on Linkedin and registering to receive these updates here. The author of this article, Curran Tomko and Tarski LLP Health Care Practice Chair Cynthia Marcotte Stamer has extensive experience advising and assisting health industry clients and others about a diverse range of health care policy, regulatory, compliance, risk management and operational concerns. You can get more information about her health industry experience here.

Help Monitoring & Responding To Developments

If you need assistance evaluating or formulating comments on the proposed reforms contained in the House Bill or on other health industry matters please contact Cynthia Marcotte Stamer, CTT Health Care Practice Group Chair, at cstamer@cttlegal.com or 214.270.2402.

From her extensive involvement with federal and state legislative and regulatory licensing, telemedicine, managed care, privacy and other health, pension and other reforms in the U.S. to her involvement as a lead advisor to the Government of Bolivia on its pension privatization legislation, Ms. Stamer’s experience includes significant experience working with clients domestically on key health care and other public policy matters. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Chairman of the Board of Richardson Development Center for Children and past Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer couples her policy experience with her extensive experience working with health industry clients on regulatory, staffing, reimbursement, risk management and compliance and other operational matters. She has more than 22 years experience advising health industry clients about these and other matters. A popular lecturer and widely published author on health industry matters, Ms. Stamer advises hospitals and other health industry clients about responding to and using these and other quality measures and other related concerns. Ms. Stamer also publishes and speaks extensively on health and managed care industry quality, regulatory, reimbursement, and other operations, risk management and public policy concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. For additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

Other Recent Developments & Resources

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

For More Information

We hope that this information is useful to you. If you need assistance with auditing or defending these or other health care compliance, risk management, transaction or operation concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270‑2402, cstamer@cttlegal.com, Edwin J. Tomko at (214) 270-1405 or another Curran Tomko Tarski LLP Partner of your choice. Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other internal controls and risk management matters.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here. To unsubscribe, e-mail here.

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Posted by Cynthia Marcotte Stamer

Medicare Ends Fox Insurance Company Drug Plan Contract As CMS Turns Up Heat on Medicare Advantage & Part D Plan Enforcement & Oversight

March 16, 2010

By Cynthia Marcotte Stamer

The Centers for Medicare & Medicaid Services (CMS) terminated its Medicare Part D prescription drug coverage contract with Fox Insurance Company (Fox) on March 9, 2010. The action highlights CMS’s growing scrutiny and enforcement of Medicare requirements against Medicare Part D, Medicare Advantage Plans and other federal health care program contractors.

CMS terminated the Fox contract after CMS found the failure by Fox’s plan and services to meet Medicare’s requirements to provide enrollees with prescription drugs according to recognized standards of care jeopardized the health and safety of Fox enrollees. When announcing the contract termination, CMS reported that an on-sight review by CMS showed that Fox committed a series of violations, including improperly denying its enrollees coverage of critical HIV, cancer, and seizure medications. CMS issued an enrollment and marketing sanction to Fox on Feb. 26, 2010, because the organization was not following Medicare’s rules for providing prescription drug coverage to its enrollees. According to CMS, an onsite audit conducted between March 2 and March 4 showed that Fox’s problems persisted and that Fox continued to subject its enrollees to obstacles in getting sustaining medicines or other needed medications. Among other things, CMS found Fox:

Failed to provide access to Medicare prescription drugs benefits by imposing unapproved prior authorization and step therapy criteria that made it more difficult for beneficiaries to get drugs that are protected by law;
Failed to meet the plan’s appeals deadlines; and
Did not comply with Medicare regulations requiring enrollees to be transitioned to new drugs at the beginning of the new plan year.
Failed to notify enrollees about prior authorization and step therapy determinations as required by Medicare.

CMS also found that many of the obstacles were in place to limit access to high-cost drugs, which could have led to enrollees’ clinical needs not being met.

In many cases, CMS reported that Fox required enrollees to have unnecessary and invasive medical procedures before they were able to obtain drugs. Finding that Fox was unable to satisfactorily address these compliance concerns and furnish medicines to its Medicare enrollees, CMS immediately terminated the Fox contract.

At the time of the termination, more than 123,000 Medicare beneficiaries were enrolled in Fox plans. Beginning March 10, 2010, CMS indicated that LI-NET, a Medicare run program administered by Humana, would replace the Medicare Part D coverage of enrollees affected by the Fox contract termination on an interim basis. Fox enrollees will be able to choose a new Medicare prescription drug plan through May 1, 2010. Current enrollees who do not choose a plan will be enrolled into a new plan by Medicare. CMS is sending letters explaining the actions taken by CMS to enrollees and has established a 1-800 number to receive questions.

The action against Fox is part of an ongoing series of oversight, disciplinary and enforcement actions by CMS against Medicare Advantage and other federal health care program participants. These programs and CMS’ oversight and enforcement of federal programs are drawing increasing Congressional scrutiny in connection with Congressional health care reform efforts. Amid this heightened scrutiny, Medicare Part D and Medicare Advantage Plans; health care providers, administrative services providers and others contracting with these plans and others involved with this programs should take appropriate action to maintain compliance, tighten their contracts with and oversight of actions of partners and vendors performing critical functions; review complaint reporting, investigation and response processes and procedures; and strengthen other practices to minimize exposures to audit or other enforcement actions.

For Assistance With Medicare Managed Care or Other Matters

If your organization needs advice or assistance about Medicare Part D or other Medicare Advantage contracting or other requirements or about other health plan or health care matters, consider contacting the author of this article, Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer at (214) 270-2402 or via e-mail here.

Past Chair of the ABA Health Law Section Managed Care & Insurance Section, Chair of the American Bar Association RPTE Employee Benefits & Compensation Committee and an ABA Joint Committee on Employee Benefits Council member, Ms. Stamer has more than 22 years experience advising health plans, health care providers, and other health industry and insurance clients. Her experience includes specific experience assisting Medicare, Medicaid and other health plan sponsors, administrators, or administrative services providers about contracting, compliance, coverage and other matters. A popular lecturer and widely published author on health industry matters, Ms. Stamer also conducts compliance and other training on Medicare Advantage and other contract and compliance matters, as well as a broad range of other health industry related concerns. Ms. Stamer also publishes and speaks extensively on health and managed care industry quality, regulatory, reimbursement, and other operations, risk management and public policy concerns. Her insights on health industry matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. For additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

Other Recent Developments & Resources

If you found this information of interest, you also may be interested in reviewing some of the following recent updates available online by clicking on the article title:

You can review other recent health plan, health care and internal controls resources and additional information about the health industry and other experience of Ms. Stamer here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here; e-mailing this information to cstamer@cttlegal.com; or registering to participate in the distribution of these and other Solutions Law Press updates here. For important information concerning this communication click here.

To unsubscribe, e-mail here.

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Posted by Cynthia Marcotte Stamer

AHRO Invites Comments On Project To Develop & Test Hospital Toolkit Intended To Guide Hospitals In Using AHRQ Quality Indicators

March 15, 2010

By Cynthia Marcotte Stamer

April 12, 2010 is the deadline for interested person to comment on the request by the Agency for Healthcare Research and Quality (AHRQ) for approval of its proposed “Development and Evaluation of AIIRQ’s Quality Indicators Improvement Toolkit” information collection project.

AHRO’s mission under 42 U.S.C. 299(b)(1)(F); 299a(a)(1) and (2) is to disseminate information and tools that can support improvement in quality and safety in the U.S. health care community. In furtherance of this mission, AHRQ has developed sets of Quality Indicators (QIs) for use by AHRO and others to document quality and safety conditions at U.S. hospitals. These and other federally established quality standards are a key part of ongoing government efforts to promote quality and cost effectiveness in the U.S. medical system, as well as to tie reimbursement to the satisfaction of these or other government-adopted quality standards.

To encourage broader use and adoption of its QIs by hospitals and others, AHRO now is working on developing and evaluating a toolkit to help hospitals to effectively use AHRQ’s QIs. The proposed AHRO toolkit would use two sets of QIs already developed and evaluated by AHRO:

The Inpatient Quality Indicators (IQIs), which contain measures of volume, mortality, and utilization for common medical conditions and major surgical procedures; and
The Patient Safety Indicators (PSIs), which are a set of measures to screen for potentially preventable adverse events that patients may experience during hospitalization.

The QIs and supportive documentation on how to work with them are posted on AHRQ’s Web site here. Many of the QIs have been endorsed by the National Quality Forum through its consensus review process.

To promote the appropriate use of these tools, AHRO plans to develop and then field test an alpha version of the Quality Indicators Improvement Toolkit with six hospitals. The currently open invitation to comment invites public comment on the proposed information collection efforts to be conducted as part of this phase of the project.

To review the pending request for comment for additional details or instructions on submitting comments, see here.

For Assistance With These Or Other Health Industry Concerns

If your organization needs advice or assistance with commenting on the AHRO proposal or to respond to other health care quality or other health care matters, consider contacting the author of this article, Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer at (214) 270-2402 or via e-mail here.

Other Recent Developments & Resources

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

For More Information

We hope that this information is useful to you. If you need assistance with auditing or defending these or other health care compliance, risk management, transaction or operation concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270‑2402, cstamer@cttlegal.com, Edwin J. Tomko at (214) 270-1405 or another Curran Tomko Tarski LLP Partner of your choice. Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other internal controls and risk management matters.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here. To unsubscribe, e-mail here.

Leave a Comment » | Evidence Based Medicine, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Care Reform, Health IT, Health Plan, Health Plans, Hospital, Medicaid, Medical Malpractice, Medicare, Medicare Advantage, Outcomes Data, Physician, Public Policy, Reimbursement | Tagged: AHRO, health care quality, Health Care Reform, Health Carfe, Managed Care, Medicaid, Medicare, Quality Indicators | Permalink
Posted by Cynthia Marcotte Stamer

Stamer Speaks To Chiefs of Staff About JCAHO Physician Performance Evaluation Requirements

March 2, 2010

Curran Tomko Tarski LLP Partner and Health Care Practice Chair Cynthia Marcotte Stamer will speak about “Physician Performance Evaluation Requirements of Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)” at the Harris County Medical Society Council of Hospital Chiefs of Staff meeting on March 9, 2010.

Former Chair of the American Bar Association Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer has more than 22 years experience acting as outside operations and special counsel to a broad range of health care providers, payers and other health industry clients. Health care inherently is a people business. Board Certified in Labor and Employment Law by the Texas Board of Specialization, Ms. Stamer has extensive experience advising, assisting and defending public and private health industry clients staffing, performance and internal controls matters. Ms. Stamer also provides other real-time, strategic risk management, staffing and services, transactional, and operational advice to physicians; hospitals, health care systems and other health care providers; managed care and insurance organizations; health plans; health and managed care consultants and outsourcers, health information technology providers; and other health industry clients. She assists them to respond to regulatory and enforcement changes. She also represents these and other health industry clients before federal and state regulators and lawmakers. She also regularly conducts training for health and managed care industry clients on a wide range of topics. You can get more information about the CTT Health Care Practice and more specifics about Ms. Stamer’s health industry experience

If you need assistance with these or other health care concerns, please contact Ms. Stamer directly at (214) 270‑2402, cstamer@cttlegal.com. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here and/or by participating in the SLP Health Care Risk Management & Operations Group on LinkedIn. To unsubscribe, e-mail here.

Leave a Comment » | Health Care, Health Care Provider, Health Care Quality, Medical Licensure | Tagged: Health Care, Hospitals, JCAHO, Physicians | Permalink
Posted by Cynthia Marcotte Stamer

Medicare Paid Physicians More Than $92 Million in Incentives for 2008 Under the Physician Quality Reporting Initiative

November 16, 2009

Announcement Follows CMS’s Release of 2010 PQRI Program Details

More than 85,000 physicians and other eligible professionals who successfully reported quality-related data to Medicare under the 2008 Physician Quality Reporting Initiative (PQRI) received incentive payments totaling more than $92 million, up from the $36 million paid in 2007, according to a new Centers for Medicare & Medicaid Services (CMS) report. The announcement of the 2008 statistics follows CMS’s recent announcement of its plan for the 2010 PQRI Program as part of the Medicare Physician Fee Schedule final rule. A fact sheet on the 2010 PQRI Program is available online at here. CMS reports it excepts the PQRI Program will continue to improve quality and provider participation will rise in 2009 and 2010.

According to CMS, physicians and other eligible professionals qualified for an incentive payment for the 2008 PQRI by satisfactorily reporting the required PQRI quality measures data received their payments this Fall. CMS reports that:

The number of eligible professionals who earned an incentive payment during 2008 increased by one-third from 2007, when 56,700 eligible professionals earned an incentive payment. In 2007, eligible professionals could only participate in the program during a 6-month reporting period. In 2008, the program expanded to allow reporting for either a 6-month or a 12-month period.
The average incentive amount for individual professionals was over $1,000, with the largest payment to an eligible professional totaling over $98,000.
More than 162,800 professionals participated in the 2008 PQRI. Of those, over 85,000 physicians and other eligible professionals met statutory requirements for satisfactory reporting for the 2008 reporting period and are receiving incentive payments.
Eligible professionals from all U.S. states and territories participated in PQRI in 2008. Health practices with participating eligible professionals in Florida and Illinois received the highest incentive payments for the 2008 PQRI. In Florida, eligible professionals received a total of over $7.5 million, and in Illinois, they received over $6 million.

Additional 2008 PQRI results, as well as information on how eligible professionals who participated in the 2008 PQRI, can access confidential feedback reports can be found in a CMS Fact Sheet here.

Established in late 2006 by the Tax Relief and Health Care Act, PQRI is a voluntary program that allows physicians and other eligible healthcare professionals to receive incentive payments for reporting data on quality measures related to services furnished to Medicare beneficiaries. In the initial program years, physicians and other eligible professionals who satisfactorily submitted quality data for covered professional services furnished in the applicable reporting period were able to receive incentive payments of 1.5 percent of the total estimated allowed charges under Medicare Part B for covered professional services. In 2008 Congress extended the PQRI under the Medicare Improvements for Patients and Providers Act (MIPPA) and authorized incentive payments through 2010.

While the 2008 PQRI program included positive changes to ease the reporting of quality measures, CMS anticipates that the 2009 PQRI program provides enhancements that will make it even easier for physicians and other health care professionals to participate. Beginning in 2009, Congress increased the incentive that eligible professionals could receive for satisfactorily reporting data from 1.5 percent to 2.0 percent of the estimate of the allowed charges under Medicare Part B for all such covered professional services furnished during the applicable reporting period for 2009 and 2010. CMS added 52 new quality measures for the 2009 PQRI year, raising the total number of measures to 153. These new measures cover all types of healthcare professionals who provide services to Medicare beneficiaries, and address areas such as osteoarthritis, back pain, coronary artery disease, and HIV/AIDS, as well as 18 measures that must be reported exclusively through PQRI-qualified registries. CMS hopes its recently announced 2010 PQRI Program will result in enhanced quality and further participation by physicians and other providers in 2010.

More information about the PQRI program, including participation guidance and the criteria to qualify for an incentive payment is available at www.cms.hhs.gov/PQRI.

For More Information

We hope that this information is useful to you. If you need assistance with these or other health care public policy, regulatory, compliance, risk management, workforce and other staffing, transactional or operational concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270‑2402, cstamer@cttlegal.com. Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other reimbursement, operations, internal controls and risk management matters. You can review other recent health care and related resources and additional information about the health industry and other experience of Ms. Stamer here.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here and/or by participating in the SLP Health Care Risk Management & Operations Group on LinkedIn. To unsubscribe, e-mail here.

Leave a Comment » | Health Care, Health Care Quality, Medicare | Tagged: health care quality, Medicare, Physician Quality Reporting Initiative, Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

CMS Renews Community Health Accreditation Program Authority To Accredit Hospices

October 24, 2009

The Centers for Medicare & Medicaid Services will continue to recognize the Community Health Accreditation Program (CHAP) as a national accreditation program for hospices seeking to participate in the Medicare or Medicaid programs for the period from November 20, 2009 though November 20, 2012. CMS announced its decision to conditionally approve the continuation of CHAP’s accreditation status with a 180-day probationary period on October 23, 2009 here.

For More Information

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here and/or by participating in the SLP Health Care Risk Management & Operations Group on LinkedIn. To unsubscribe, e-mail here.

Leave a Comment » | Health Care, Health Care Finance, Health Care Provider, Health Care Quality | Permalink
Posted by Cynthia Marcotte Stamer

Senate Finance Committee Releases Statutory Language of America’s Healthy Future Act To Present To Full Senate

October 22, 2009

Americans finally have a chance to read the actual statutory language of the painfully negotiated package of proposed health care reforms that the Senate Finance Committee proposes for adoption. The Senate Finance Committee leadership finally finished drafting has posted the 1506 page long text of the proposed statutory language of the health care reform provisions of the “America’s Healthy Future Act” on its website here.

When the Senate Finance Committee vote passing the America’s Health Future Act, members of the Senate Finance Committee had not yet had the opportunity to review the actual statutory language to be proposed to implement the package of heatlh care reforms painfully hashed out in their committee. As the actual statutory language had not been completed at the time a majority of the Democrats and one Republican Senator serving on the Senate Finance Committee voted to send the legislation to the the full Senate, the vote actually was taken based on a narative description of the intended reforms set forth in a revised draft of the “Chairman’s Mark” of the legislation. Since that time Senate Finance Committee Chairman Max Baucus and other key Democrat Senators on the Senate Finance Committee have worked behind closed doors to prepare the actual statutory language to be presented to the full Senate.

As proposed, the America’s Healthy Future Act would require sweeping changes to the U.S. health care systems that if adopted will radically impact the roles and responsibilities of every patient, health care provider, health care payor, employer and other American. Because of the potential implications on the way health care is financed, delivered and administered and the projections that the legislation will cost approximately $1 Trillion, all parties are urged to carefully review the complex and lengthy legislation to gain an understanding of the legislation and to act quickly to make any concerns known to elected leaders in Congress.

For More Information

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here and/or by participating in the SLP Health Care Risk Management & Operations Group on LinkedIn. To unsubscribe, e-mail here.

Leave a Comment » | America's Healthy Futures Act, Anti-KickBack, ASC, Childrens Health Insurance Program, Consumer Driven Health Care, Doctor, Electronic Medical Records, Employer, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Care Reform, Health Insurance Exchange, Health IT, Health Plan, Health Plans, Hospital, Indian Health, Inpatient Rehabilitation Facility, Medicaid, Medical Licensure, Medical Malpractice, Medicare, Medicare Advantage, Mental Heatlh, OIG, Physician, Prescription Drugs, Reimbursement, Rural Health Care | Permalink
Posted by Cynthia Marcotte Stamer

North Texas Healthcare Compliance Professional Association Meets October 13

October 12, 2009

October 13, 2009 Meeting Invitation/Reminder & Updated Meeting Agenda

North Texas Health Care Compliance Professional Association’s invites you to its October 13, 2009 Meeting from 2:00 – 4:00 p.m. at the Texas Health Resources Pavilion.

The first portion of the program will feature a discussion by Kristin Jenkins from DFW Hospital Council of:

Modifications/upgrades in Group One’s Compliance Check processes; and
The ability to use the Data Initiative to pull RAC specific indicators and a dashboard in development for Compliance Officer use.

The second portion of the program will be a participatory Health Care Compliance Roundtable Discussion of Hot Topics moderated by the Erma E. Lee, JPS Health Network District Compliance Officer and NTPCA President. Topics to be discussed include:

HIPAA Data Breach;
Red Flag & Other Evolving Privacy & Data Security Obligations & Risks;
Office of Civil Rights Health Industry Disability & Other Civil Rights Enforcement;
Tax-Exemption Issues Including Proposed Form 990 and Exemption Reforms In Health Care Reform;
Health Care Fraud Enforcement; and
Other Hot Developments

NTHCPA invites interested persons to come catch up on these and other new developments and exchange thoughts and insights with other Health Care Compliance Professionals on Tuesday, October 13, 2009 from 2:00 – 4:00 p.m. in Classroom B of the Texas Health Resources Pavilion located at 612 E. Lamar Blvd., Arlington, TX. NTHCPA thanks Texas Health Resources for hosting this month’s meeting. For additional information, please contact NTHCPA Vice-President Cynthia Marcotte Stamer at (214) 270-2402 or by e-mail at cstamer@solutionslawyer.net. NTHCPA looks forward to seeing you there! About the NTHCPA NTHCPA exists to champion ethical practice and compliance standards and to provide the necessary resources for ethics and compliance Professionals and others in North Texas who share these principles. The vision of NTHCPA is to be a pre-eminent compliance and ethics group promoting lasting success and integrity of organizations within North Texas. To register or update your registration or to receive notice of future meetings, e-mail here . This communication may be considered a marketing communication for certain purposes. If you wish to update your e-mail for purposes of or would prefer not to receive future e-mail concerning meetings or other activities of the North Texas Healthcare Compliance Professionals Association or other marketing and promotional mailings from it, please send an email with the word “unsubscribe” in its subject heading to here.

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Posted by Cynthia Marcotte Stamer

North Texas Healthcare Compliance Professional Association To Meet At Texas Health Resources On October 13

September 29, 2009

NORTH TEXAS HEALTHCARE COMPLIANCE PROFESSIONAL ASSOCIATION

October 13, 2009 Meeting Reminder

2:00 – 4:00 p.m. at the Texas Health Resources Pavilion

North Texas Health Care Compliance Professional Association’s October 13, 2009 Meeting will feature a participatory Health Care Compliance Roundtable Discussion of Hot Topics moderated by the Erma E. Lee, JPS Health Network District Compliance Officer and NTPCA President on Tuesday, October 13, 2009 from 2:00 – 4:00 p.m at the Texas Health Resources Pavilion located at 612 E. Lamar Blvd., Arlington, TX. Topics to be discussed include:

HIPAA Data Breach, Red Flag & Other Evolving Privacy & Data Security Obligations & Risks
Office of Civil Rights Health Industry Disability & Other Civil Rights Enforcement
Tax-Exemption Issues Including Proposed Form 990 and Exemption Reforms In Health Care Reform
Health Care Fraud Enforcement
Other Hot Developments

Come catch up on these and other new developments and exchange thoughts and insights with other Health Care Compliance Professionals!

NTHCPA thanks Texas Health Resources for hosting this month’s meeting.

For additional information, please contact NTHCPA Vice-President Cynthia Marcotte Stamer at (214) 270-2402 or by e-mail at cstamer@solutionslawyer.net.

We look forward to seeing you there!

About the NTHCPA

The vision of NTHCPA is to be a pre-eminent compliance and ethics group promoting lasting success and integrity of organizations within North Texas.

To register or update your registration or to receive notice of future meetings, e-mail here .

This communication may be considered a marketing communication for certain purposes. If you wish to update your e-mail for purposes of or would prefer not to receive future e-mail concerning meetings or other activities of the North Texas Healthcare Compliance Professionals Association or other marketing and promotional mailings from it, please send an email with the word “unsubscribe” in its subject heading to here.

Leave a Comment » | Anti-KickBack, ARRA, Disability Discrimination, Discrimination, Doctor, Electronic Health Records, Electronic Medical Records, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health IT, Health Policy, HIPAA, HITECH Act, Medicaid, Medicare, OCR, OIG, Physician, Privacy, Reimbursement, Tax, Tax-Exemption, Technology | Tagged: Data Security, Doctor, Events, false claims act, Form 990, Health Care, Health Care Compliance, Health Care Discrimination, Health Care Fraud, Health Care Policy, Health Care Reform, Health Care Reimbursement, Health Policy, HIPAA, HITECH Act, Hospital, North Texas Health Care Compliance Professionals Association, Physician, Red Flag Rules, Reimbursement, Tax-Exemption | Permalink
Posted by Cynthia Marcotte Stamer

HIT Committee To Meet October 14 In Washington, D.C.

September 29, 2009

The next meeting of the HIT Standards Committee of the Office of the National Coordinator for Health Information Technology (ONC) will be held on October 14, 2009, from 9 a.m. to 3 p.m./Eastern Time at the Omni Shoreham Hotel, 2500 Calvert Street, NW., Washington, DC. The hotel telephone number is 202-234-0700. Interested members of the public are invited to attend.

Created under the American Recovery and Reinvestment Act of 2009 (ARRA), the HIT Standards Committee is charged with making recommendations to the Office of National Coordinator for Health Information Technology (ONC) on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information consistent with the implementation of the Federal Health IT Strategic Plan, and in accordance with policies developed by the HIT Policy Committee. Even as Congress debates further reforms, the activities of the HIT Committee and other components of the ONC are key actors in the continuing efforts of the Obama Administration to promote health care efficiency by reengineering health care technology.

During a previous meeting on August 20, 2009, the HIT Committee finalized certain recommendations concerning meaningful use of electronic medical records, clinical quality, and privacy and security of protected health information, which are available for review here.

According to the ONC announcement regarding the upcoming meeting in today’s (September 29, 2009) Federal Register available here, the Committee plans during the meeting to:

Discuss reports from its Clinical Operations, Clinical Quality, and Privacy and Security Workgroups
Take testimony from invited experts in the field of security as it relates to health information technology

Interested persons may present data, information, or views, orally or in writing, on issues pending before the committee. Written submissions may be made to the contact person on or before October 6, 2009. Oral comments from the public will be scheduled between approximately 2:30 p.m. to 3 p.m. Time allotted for each presentation may be limited. If the number of speakers requesting to comment is greater than can be reasonably accommodated during the scheduled open public hearing session, ONC will take written comments after the meeting until close of business.

ONC hopes to make background material available to the public at least two (2) business days prior to the meeting. However, if ONC is unable to post the background material on its Web site before the meeting, it will make that material publicly available at the location of the advisory committee meeting, and post the background material on ONC’s web site after the meeting here.

The designated person to contact for additional information is Jonathan Ishee, Office of the National Coordinator, HHS, 200 Independence Ave, SW., Room 729-G, Washington, DC 20201, 202-205-8493, Fax: 202-690-6079, e-mail: jonathan.ishee@hhs.gov.

If you need assistance preparing or presenting comments to the HIT Standards Committee or with monitoring or responding to other health care IT, privacy and data security, regulatory, operational, public policy or other health care concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Chair and Partner Cynthia Marcotte Stamer at (214) 270-2402 or via e-mail at CStamer@CTTLegal.com.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Solution Law Press Updates available online by clicking on the applicable article title below:

For More Information

We hope that this information is useful to you. If you need assistance with auditing or defending these or other health care compliance, risk management, transaction or operation concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270‑2402, cstamer@cttlegal.com, Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other reimbursement, operations, internal controls and risk management matters.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here. To unsubscribe, e-mail here.

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Posted by Cynthia Marcotte Stamer

Baucus Health Care Reform Proposal Calls For Significant Tightening In Tax-Exemption Rules

September 22, 2009

Senate Finance Set To Begin Markup Sessions Today – Repeal of Rebuttable Presumption Rule In Reasonable Compensation Rules, Other Tightening of Requirements Threatened

With Senate Finance Committee meetings to mark up Chairman Max Baucus’ health care reform proposal as outlined in his 220-page “Chairman’s Mark of America’s Healthy Future Act of 2009” (the “Baucus Proposal”) scheduled to begin today (September 22, 2009), tax-exempt health care and other non-profit organizations should evaluate carefully proposed amendments that could impact their tax-exempt status or related obligations. The proposed amendments have serious implications for non-profits within and beyond the health care industry.

Markup Scheduled To Begin Tuesday

The Senate Committee on Finance began meeting today (September 22, 2009) to negotiate how to convert into proposed legislation the Baucus Proposal introduced by Committee Chairman Max Baucus on September 16, 2009, the text of which may be reviewed here.

Since no text of the proposed legislation itself has been released yet, it is impossible to fully evaluate the specific nature and implications of the Baucus Proposal. While this week’s planned Senate Finance Committee mark up will further clarify these matters, a review of the description of changes proposed by Chairman Baucus in the Baucus Proposals nevertheless provides significant insight of what health care organizations can expect to be discussed and, in all likelihood incorporated into the draft legislation ultimately proposed in some form. Accordingly, tax-exempt health care organizations should carefully evaluate and act promptly to share their input with members of the Senate Finance Committee and other members of Congress about a series of proposed amendments that would impact their tax-treatment and other responsibilities.

All Tax-Exempts Should Monitor Proposals To Shift Burden Of Proof On Compensation Reasonability & Expanded IRS Powers

Among a multitude of proposed tax amendments, tax-exempt organizations inside and outside the health care industry will want to keep a a close eye on discussions and proposals to amend the Baucus Proposal to further modify the tax-exemption requirements for tax-exempt hospitals and other tax-exempt organizations. Late last week, Ranking Member Senator Chuck Grassley submitted a proposal to amend the Baucus Proposal to further tighten tax-exemption requirements in two material respects likely to generally concern tax-exempt organizations:

For the stated purpose of avoiding wasteful legal challenges to the management and governance questions on the revised Form 990, to specifically grant statutory authority to the Internal Revenue Service to ask management and governance questions on the Form 990; and
To make it easier for the Internal Revenue Service to challenge as unreasonable compensation payments made by tax-exempt entities by shifting the burden to the taxpayer of proving the reasonability of compensation and removing the burden currently borne by the Internal Revenue Service of going forward with the evidence on comparability. This would be accomplished by overruling the rebuttable presumption of reasonableness currently set forth in Treasury Regulation § 53.4958-6 of the intermediate sanctions rules and replacing it with a requirement that public charities due diligence demonstrate that their compensation payments meet the 3 current elements of the presumption:
- Review by an authorized body made of members without a conflict of interest
- Use of appropriate data as to comparability and
- Adequate and contemporaneous documentation. This amendment is expected to raise revenue, according to the summary.

Given the potential implications of these proposed amendments, tax-exempt health care and other organizations should keep a close eye on proposed tax provisions of the Baucus Proposal and other related proposals.

Proposal To Tighten Other Tax-Exemption & Reporting Requirements For Tax-Exempt Hospitals

While the Senate Finance Committee as of yet has not released text of the proposed legislation itself, a review of the description of changes proposed by Chairman Baucus in the Baucus Proposals and other subsequently proposed amendments to the Baucus Proposal reveal other plans to materially change the tax-exemption qualification, governance and reporting requirements for tax-exempt hospitals beyond the proposal to create CO-OPs. Among other things, the Baucus Proposal calls for the Internal Revenue Code § 501(c)(3) and its related provisions to be amended to require tax-exempt hospitals:

To conduct or participate in and share with the public a community-needs analysis with input from a broad cross section of the community at least once every 3 years and thereafter to report on its implementation, including explaining where applicable why identified needs were unaddressed. These additional requirements would supplement rather than replace existing community benefit standards already generally applicable to charitable entities
To provide non-discriminatory emergency care
To have, implement and widely disseminate a written financial assistance policy defining among other things:
- The rules for determining who qualifies for financial assistance
- How the hospital determines amounts to be billed to patients in manner that provides for patient discounts to be based on Medicare rates, “best” commercial rates or other approved statutory measures rather than “chargemaster rates”
- Require hospital to notify patients of the financial assistance policy on admission, on bills and in telephone calls of its financial assistance policy before initiating various collection actions or reporting the account to a credit rating agency
To make its audited financial statements (and where applicable, the consolidated financial report of any entity of which it is a part) available widely
The Internal Revenue Service (IRS) to conduct a SEC-type review of each 501(c)(3) hospital’s community benefit activities at least once every three years based on data reported on Schedule H of the Form 990
The IRS and the Department of Health and Human Services (HHS) to report annually to Congress on community benefit activities of non-governmental tax-exempt hospitals, charity care, bad debt, and unreimbursed costs of government programs (means-tested and non-means-tested) incurred by tax-exempt, taxable, and governmental hospitals.

CO-Ops As Health Coverage Alternative

Much more widely discussed is the Chairman’s CO-OP proposal. The Baucus Proposal calls for the creation of a new vehicle to provide an alternative source of health care coverage called “CO-Ops.” As contemplated by the Baucus Proposal, CO-Ops would be associations controlled by a beneficiary board unrelated to existing organizations providing health insurance as of July 16, 2009. Subject to their meeting non-inurement and other common existing requirements for charitable status as well as other conditions, CO-Ops would be able to apply for tax-exempt status as well as federal funding.

New Taxes and Fees On Insurers & Others

The Baucus Proposal proposes to finance its health care reforms through a variety of mechanisms including, excise taxes and penalties on employers and individuals that fail to purchase the government specified health care package, taxes on premiums paid for health insurance coverage in excess of certain specified annual limits, the imposition of certain premium taxes and “sector fees” on healthcare insurers (with some exceptions possible under certain circumstances for certain 501(c)(3) and (c)(4) HMOs not providing commercial-type insurance within the meaning of Section 501(m)).

Other Baucus Proposal Highlights

In its current summary form, the 220-page Baucus Proposal includes a host of other sweeping reforms, which are certain to be further expanded and refined during this week’s scheduled Senate Finance Committee markup session. Many of these other proposed reforms were highlighted in an overview of the Baucus Proposal published here. You can join the discussion of these and other proposed health care forms and exchange updates and other resources about health care reform and related concerns by registering to participate in the Coalition For Responsible Health Care Policy Group on Linkedin.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Solution Law Press Health Care Updates available online by clicking on the article title below:

For More Information

We hope that this information is useful to you. If you need assistance with health care compliance, risk management, reimbursement, staffing, credentialing, transactional, operational or public policy concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270‑2402, cstamer@cttlegal.com or your other favorite Curran Tomko Tarski LLP Partner. Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and related matters.

Leave a Comment » | America's Healthy Futures Act, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Care Reform, Health Insurance Exchange, Medicaid, Medicare, Medicare Advantage, Physician, Reimbursement, Tax, Tax-Exemption | Tagged: Health Care, Health Care Policy, Health Care Provider, Health Care Reimbursement, Health Policy, Hospital, Medicare, Nonprofits, Physician, Physicians, Prescription Drugs, Public Policy, Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

Senate Finance To Begin Markup Session on Baucus Health Care Reform Proposal On September 22

September 18, 2009

The Senate Committee on Finance plans on Tuesday, September 22, 2009 to being meetings to hash out how to convert into proposed legislation the health care reform proposal outlined in the “Chairman’s Mark America’s Healthy Future Act of 2009” introduced by Committee Chairman Max Baucus on September 16, 2009, the text of which may be reviewed here.

While the Chairman’s Markup outlining the health care reform elements that Chairman Baucus’ proposes for adoption by Congress, the specific legislation that the Chairman proposes to be used to implement these proposals has not yet been introduced. Deciding the language and other features of such legislation -i.e., actually drafting the statutory language – is a primary purpose of the September 22, 2009 meeting.

Until actually reduced to specific legislative language, it is difficult for members of Congress and the Americans they represent to know and assess the changes proposed and their potential implications. However, a review of the proposal outlined in the Chairman’s Markup indicates that the adoption of the proposed would impose significant burdens and costs on employers and their employees, while substantially curtailing their health coverage choices. For instance, the Chairman’s Markup would:

Set up insurance “exchanges” through which some individuals and families could receive federal subsidies topurchase coverage;
Allow for the creation of “CO-OPs” as an alternative source of coverage
Mandate that most legal residents of the United States obtain health insurance and impose an income based penalty for Americans failing to secure that coverage;
While not explicitly requiring employers to offer health insurance, the Chairman’s markup would among other things subject businesses with more than 50 workers that did not offer coverage to a penalty for any workers who obtained subsidized coverage through the insurance exchanges also to be established under the legislation. As a rule, full-time employees who were offered coverage from their employer would not be eligible to obtain subsidies via the exchanges but an exception to that “firewall” would be allowed for workers who had to pay more than 13 percent of their income for their employer’s insurance (in which case the employer would also be penalized). Under certain circumstances, firms with relatively few employees and relatively low average wages would also be eligible for tax credits to cover up to half of their contributions toward health insurance premiums.
Deter employers and their employees from investing in higher grade coverage that might otherwise be available for purchase in the marketplace by subjecting insurance policies with relatively high total premiums to a 35 percent excise tax on the amount by which the premiums exceeded a specified threshold. In general, that threshold would be set initially at $8,000 for single policies and $21,000 for family policies; after 2013, those amounts would be indexed to overall inflation.
Significantly expand eligibility for Medicaid;
Significantly tighten tax-exemption requirements for hospitals and other charitable health care organizations;
Radically reduce the growth of Medicare’s payment rates for most services (relative to the growth rates projected under current law) and make various other changes to the Medicaid and Medicare programs and the federal tax code to reduce government program costs. The Congressional Budget Office projects that among the proposed provisions that would result in the largest budget savings are:
- Make permanent reductions in the annual updates to Medicare’s payment rates for most services in the fee-for-service sector (other than physicians’ services)
- Set payment rates in the Medicare Advantage program based on the average of the bids submitted by Medicare Advantage plans in each market
- Reduce Medicare and Medicaid payments to hospitals that serve a large number of low-income patients, known as disproportionate share (DSH) hospitals
- Establish a Medicare Commission, which would be required, under certain circumstances, to recommend changes to the Medicare program to limit the rate of growth in that program’s spending. Those recommendations would go into effect automatically unless blocked by subsequent legislative action. Before 2019, such recommendations would be required if the Medicare Trustees project that Medicare spending per beneficiary will grow more rapidly than a measure of inflation (the average of the growth rates of the consumer price index for medical services and the overall index for all urban consumers). After 2019, recommendations would be required if projected growth exceeded the rate of increase in gross domestic product (GDP) per capita plus 1 percentage point. Because the proposal would prohibit the Commission from modifying eligibility or benefits, its recommendations probably would focus on changes to payment rates or methodologies. The Commission would develop its first set of recommendations during 2013 for implementation in 2015.

Other Recent Developments

For More Information

We hope that this information is useful to you. If you need assistance with these or other health care public policy, regulatory, compliance, risk management, workforce and other staffing, transactional or operational concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270‑2402, cstamer@cttlegal.com, Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other reimbursement, operations, internal controls and risk management matters.

Ms. Stamer has extensive experience in these and other health industry related representation. You can review other recent health care and related resources and additional information about the health industry and other experience of Ms. Stamer here.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here, or e-mailing this information to cstamer@cttlegal.com, and/or by participating in the SLP Health Care Risk Management & Operations Group

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here. To unsubscribe, e-mail here.

Leave a Comment » | Disease Management, Doctor, Employer, false claims act, Health Care, Health Care Finance, Health Care Quality, Health Care Reform, Health Plan, Health Plans, Hospital, Inpatient Rehabilitation Facility, Medicaid, Medicare, Medicare Advantage, Pharmacy, Physician, Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

CMS Proposes New Prospective Payment System For Renal Dialysis Facilities

September 15, 2009

November 16, 2009 is the deadline to comment on a new prospective payment system (PPS) for facilities that provide dialysis services to Medicare beneficiaries who have end-stage renal disease (ESRD) proposed by the Centers for Medicare & Medicaid Services (CMS) today (9/15/09). Interested persons can review the proposed rule here.

Currently, ESRD is the only category for Medicare eligibility that is based on a specific diagnosis, without regard to the age of the patient. Patients diagnosed with ESRD must rely on dialysis or receive a kidney transplant for survival. ESRD services are furnished on an outpatient basis in independent or hospital-based dialysis facilities. Currently, Medicare pays for certain dialysis services under a partial bundled rate, referred to as the composite rate. Payments for these composite rate services represent about 60 percent of total Medicare payments to ESRD facilities. The remainder of Medicare spending for dialysis services is for separately billed items such as drugs, but may also include laboratory services, supplies and blood products.

Today’s notice proposes three quality measures that CMS plans to use for its quality incentive program (QIP) and lays out a conceptual model for public comment.

Quality Improvement Measures

The ESRD PPS proposed rule proposes the following specific measures that will apply to the initial performance period of the Quality Incentive Program:

Hemodialysis Adequacy: Achieved urea reduction ratio (URR) of 65 percent or more;
Anemia Management: Controlled anemia, as shown in two measures:
- The percentage of patients at a facility whose hemoglobin levels were less than 10 grams per deciliter (g/dL), and
- The percentage of patients at a facility whose hemoglobin levels were greater than 12 g/dL.

CMS reports the proposed measures were chosen because dialysis facilities have used them since 2001. These measures are currently collected from Medicare dialysis facility claims so there is no need for separate reporting. Finally, CMS already has data on these measures which it can use to develop and test models for the operation of the QIP.

As required by law, CMS plans to establish performance standards for each of the measures and facilities would be scored based on their adherence to the measures. Providers and facilities that do not meet or exceed the total performance score during a performance period would see up to a two percent reduction from their payment rates in the succeeding year.

CMS will accept comments on this conceptual QIP model in the ESRD PPS proposed rule through November and will is

The ESRD PPS proposed rule proposes the following specific measures that will apply to the initial performance period of the Quality Incentive Program:

Hemodialysis Adequacy: Achieved urea reduction ratio (URR) of 65 percent or more;
Anemia Management: Controlled anemia, as shown in two measures:
- The percentage of patients at a facility whose hemoglobin levels were less than 10 grams per deciliter (g/dL), and
- The percentage of patients at a facility whose hemoglobin levels were greater than 12 g/dL.

Proposed PPS Model

The proposed PPS would provide a single bundled payment to dialysis facilities that would cover the items and services used in providing outpatient such services, including the dialysis treatment, prescription drugs, and clinical laboratory tests.

Under the proposed rule, CMS would establish a base bundled payment rate of $198.64 for all of the services related to a dialysis session, including the services in the current composite rate as well as items, including oral drugs that are billed separately. CMS reports the proposed base rate was derived from 2007 claims data for both composite rate and separately billable services and updated to reflect projected 2011 prices. CMS would adjust this base rate for case mix factors such as the patient’s age, gender, body size, and time on dialysis. A special case-mix adjustment would apply to pediatric patients. Additional adjustments to the payment rate would be made for specific conditions, or co-morbidities that have a significant impact on a course of treatment. By accounting for more characteristics of patients, the new PPS would target payments more appropriately, paying higher rates to those facilities with the most costly patients. The base rate would also be adjusted to reflect geographic differences in labor costs. In addition, CMS is proposing to provide an adjustment for low-volume facilities, as well as an outlier policy that would make an adjustment for particularly expensive cases.

The following are highlights of the proposed mechanics of the proposed new PPS:

ESRD Base Rate and Bundle of Services: CMS is proposing to pay a base rate of $198.64 per dialysis treatment, representing the average Medicare allowable payment per treatment for composite rate and separately billable services, including training and home dialysis costs, laboratory services and all ESRD-related Part B and former Part D drugs. The proposed base rate would be adjusted to reflect patient- and facility-specific differences in case-mix and other adjustments as required by MIPPA.

To arrive at a base rate, CMS is proposing to adjust the average payment per treatment using 2007 claims data adjusted to reflect 2011 projected prices. The rate will not include positive adjustments for case-mix and the wage index as those will be introduced into the payment formula at a later time. This standardized amount must then be reduced by 1.0 percent to fund the proposed outlier policy, and reduced by the percentage required by MIPPA to reflect 98 percent of the estimated payments that would have been made absent the statutory changes.

Proposed Standardized Amount: Based on 2007 claims data, total per treatment payments in CY 2011 are projected to be $261.58. To eliminate the overall positive effects of the proposed case-mix and geographic adjustments, CMS is proposing a 21.73 percent reduction, yielding a standardized amount of $204.74.

Proposed Outlier Adjustment: CMS is proposing to reduce the standardized amount by 1.0 percent for outlier payments for cases requiring unusually high amounts of drugs or other services that are separately payable under the current payment system. This 1.0 percent reduction lowers the standardized amount of $204.74 to $202.69.

MIPPA Required 98 Percent Adjustment: As required by MIPPA, CMS is also proposing to adjust the reduce the standardized amount by 2.0 percent to ensure that estimated total Medicare payments to ESRD facilities in CY 2011 are 98 percent of what they would have been under the existing system. This additional reduction yields a proposed base rate of $198.64.

Transition Budget Neutrality Adjustment: Also required by MIPPA, CMS is proposing that a transition budget neutrality adjustment factor (a 3.0 percent reduction) be applied to all payments during the four-year phase-in and would make payments under the transition the same as they would have been had there not been a transition. As part of this transition budget neutrality adjustment, during the transition, CMS is proposing to apply a $14 per treatment adjustment to the composite rate portion of the blended payment amount to reflect ESRD-related Part D drugs.

Patient-Level Adjustments: As authorized by MIPPA, CMS is proposing to adjust the base rate for case mix using a variety of factors which have been found to affect costs. Under the existing payment system, the composite rate is adjusted for age, body surface area (BSA), body mass index (BMI), and pediatric status. The proposed rule would add adjustments for patient sex (female patients) and certain co-morbidities, as well as a “new patient adjustment” that recognizes that patients have higher costs in their first four months of maintenance dialysis. In addition, special payment adjusters would apply for providers of pediatric services. CMS is specifically seeking comment about these and other patient characteristics that may affect costs of treatment and for which a payment adjustment may be appropriate.

Facility-Level Adjustments: MIPPA specifically requires CMS to adopt an adjustment for low-volume facilities and gives the HHS secretary discretion to adopt additional facility-level adjustments. Based on an analysis of ESRD data, CMS is proposing to define low-volume facilities as those facilities that: (1) furnished fewer than 3,000 treatments in each of the three years preceding the payment year; and (2) have not opened, closed, nor received a new provider number due to a change in ownership during the three years preceding the payment year. Other definitions may be added to include geographic restrictions. CMS is also proposing to continue to apply a wage index adjustment using the core-based statistical area (CBSA) definitions. The index would be based on the most current hospital wage data, prior to application of the rural floor and occupational mix adjustments, and geographic reclassifications.

Outlier Policy: MIPPA requires CMS to make adjustments for high cost patients, called outlier payments, to ESRD facilities that treat patients who use more than the predicted amount of services, including the amount of erythropoietin stimulating agents (ESAs) used to manage dialysis-related anemia. As noted previously, CMS is proposing to reduce the standardized amount for all dialysis treatments by 1.0 percent, to fund the proposed 1.0 percent policy under the new ESRD PPS. CMS is proposing a fixed loss dollar amount of $134.96 for adult and $174.31 for pediatric dialysis patients. Once the fixed dollar amount is met, CMS would pay 80 percent of the ESRD facility’s outlier service costs. CMS projects that approximately 5.3 percent of adult and 2.6 percent of pediatric patient months would qualify for outlier payments.

Annual Payment Rate Updates: As required by MIPPA, beginning in CY 2012 the ESRD PPS base rate will be updated annually by an ESRD market basket index minus one percentage point. The proposed rule includes a discussion of how the ESRD market basket would be calculated.

Beneficiary Coinsurance: CMS is proposing that the beneficiary coinsurance amount be 20 percent of the ESRD bundled payment amount, including applicable case-mix adjustments and outlier payments. CMS will accept comments on the proposed rule through November 2009, and will respond to them in a final rule to be issued in 2010. The new payment system would apply to renal dialysis services furnished to Medicare beneficiaries on or after January 1, 2011.

Required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), CMS reports the new payment system set forth in the proposed rule is designed to improve the efficiency of care, while promoting high quality services.

CMS will accept comments on the proposed rule through November 16, 2009, and will respond to them in a final rule to be issued in 2010. The new payment system would apply to dialysis services furnished to Medicare beneficiaries on or after January 1, 2011.

If you need assistance with auditing, updating or defending your organizations HIPAA and other privacy and data security practices, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Leader Cynthia Marcotte Stamer at (214) 270-2402 or via e-mail at CStamer@CTTLegal.com. The former Compliance Committee Chair of the National Kidney Foundation of North Texas, Ms. Stamer has extensive experience advising nephrology, dialysis and other health care providers about gainsharing and other reimbursement, quality, regulatory and compliance, risk management, workforce and staffing and other operational matters.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Solutions Law Press Health Care Updates available online by clicking on the article title:

For More Information

We hope that this information is useful to you. If you need assistance with auditing or defending these or other health care compliance, risk management, transaction or operation concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270‑2402, cstamer@cttlegal.com. Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other internal controls and risk management matters.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here. To unsubscribe, e-mail here.

Leave a Comment » | Disease Management, Doctor, Health Care, Health Care Finance, Health Care Provider, Health Care Quality, Medicaid, Medicare, Outpatient, Physician, Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

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Health Care Providers Should Strengthen HIPAA Compliance & Defenses As Risks Rise

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