Transcript Michigan Construction Lien Act

Exceptional service. Dykema delivers.
FEDERAL REGULATORY HOT TOPICS
HFMA – Western Michigan Chapter
Presented by Maria B. Abrahamsen
248.203.0818
[email protected]
November 13, 2013
California | Illinois | Michigan | North Carolina | Texas | Washington, D.C.
www.dykema.com
FRAUD AND ABUSE ADVISORY OPINIONS
• “Yes” to a readmission reduction service sold to hospitals
by subsidiary of drug manufacturer
– Subsidiary operates separate from its parent, i.e. no
promotion of parent’s products
– OIG finds patients’ choice of provider unlikely to be
influenced
2
Exceptional service. Dykema delivers.
FRAUD AND ABUSE ADVISORY OPINIONS
• “Yes” to grocery store gift cards to induce Medicaid enrollees
to visit capitated FQHC for screening and education
• “Yes” to affiliate of podiatry practice that manufacturers
orthotics for employees whose employers pay full cost of
same
3
Exceptional service. Dykema delivers.
FRAUD AND ABUSE ADVISORY OPINIONS
• “Yes” to cardiac cath lab co-management fee; fixed
component and variable capped bonus based on multiple
factors including costs savings achieved
• “Yes” to free electronic interface between hospital and
physician offices solely for test orders/reports
4
Exceptional service. Dykema delivers.
FRAUD AND ABUSE ADVISORY OPINIONS
• Proposed benefits from pharmacy to community homes:
– “Yes” to hard copies of pre-populated forms to customerhomes
– “Yes” to free limited use of software to any community
home
– “Yes” to multi-use software sublicensed to any home at
FMV
– “No” to free multi-use software to customers only
5
Exceptional service. Dykema delivers.
FRAUD AND ABUSE ADVISORY OPINIONS
• “No” to lab company’s subsidiary managing “pod labs” for
physician practices, although pod labs would provide no
Medicare or Medicaid services
• “No” to parent of GPO offering hospital customers of GPO an
equity interest in parent in exchange for locking in long-term
contract and volume, and foregoing part of administrative fee
rebate from GPO
6
Exceptional service. Dykema delivers.
OIG FRAUD ALERT
• Physician-owned distributorships (PODs) that distribute
implantable devices used in surgery by physician-investors
are “inherently suspect” per OIG
– Same with physician ownership of device manufacturers
– Alert includes list of “suspect characteristics”
7
Exceptional service. Dykema delivers.
EFFECT OF EXCLUSION FROM FEDERAL HEALTH
CARE PROGRAMS
• OIG issued updated 2013 Special Advisory Bulletin on effect
of exclusion
– Excluded person is subject to penalties if orders,
prescribes, or provides services/items that may be billed to
a federal program
– Penalties on hospitals and others that bill federal program
for services performed by or at medical direction or
prescription of excluded person
• Includes costs claimed on cost report, e.g., admin. and
mgmt. services
• Includes services covered under bundled payment, like
DRG and APC
8
Exceptional service. Dykema delivers.
STARK - EHR DONATION EXCEPTION
• Existing exception sunsets 12/31/13
• Proposal (not finalized) would:
– extend to 12/31/16
– limit who may donate
– delete electronic prescribing condition
– modify EHR certification condition
9
Exceptional service. Dykema delivers.
STARK - PHYSICIAN-OWNED HOSPITALS
• Stark permits hospital ownership by referring physicians
under “whole hospital” and “rural hospital” exceptions
– By 12/31/13 hospital’s Form 855-A must be updated to
reflect physician owners
– Update or verify annually
– CMS may opt to place physician ownership info on its
website
10
Exceptional service. Dykema delivers.
STARK LITIGATION
• Tuomey Healthcare System ordered to pay $237 million
– Stark violation = False Claim
– Based on part-time employment contracts with 19
physicians
– Reaction to new competing ASCs
– Physician comp averaged 31% more than net collections
– Jury found comp reflected volume/value of referrals
11
Exceptional service. Dykema delivers.
MEDICARE “UNDER ARRANGEMENTS”
PRINCIPLE
• “Routine services” (e.g. room, board and nursing) may not be
furnished to hospital inpatient at a location outside the
hospital
– Therapeutic and diagnostic services still okay outside
hospital
– CMS cites ICU/excluded hospital abuses
– Effective date postponed from cost reporting periods
beginning on/after 10/1/11, to 10/1/12, to 10/1/13, to dates
of service on/after 1/1/15
– Co-located cancer hospital oppose the change
12
Exceptional service. Dykema delivers.
MEDICARE INPATIENT PAYMENT REFORMS
•
•
Value based purchasing began 10/1/12 – add-on to DRG payments for
hospitals that score well
– Clinical process of care measures (70%) and patient experience of care
(30%); for FY 2013, 1 new process of care measure and 3 mortality
outcome measures
– Paid from pool created by reducing DRG base rate 1%, increasing to
2%
– Score based on greater of “achievement” or “improvement”
– CMS will delay from FY 2014 to FY 2015 scoring based on relative
overall Part A/B spending during period 3 days before, through 30 days
after, discharge
Readmission Reduction Program
– Reduced payment to hospitals with an “excess” readmission rate for 3
diagnoses beginning FY 2013; 3 or more diagnoses added for FY 2015
13
Exceptional service. Dykema delivers.
MEDICARE – OUTPATIENT HOSPITAL 2014
PROPOSALS
• Collapse 20 existing codes for hospital outpatient clinic and ED
visits into 3 codes
– Would eliminate new/established patient distinction in facility
billing
– 1 code each: Clinic, Type A ED and Type B ED
• Additional “packaging” of ancillaries into APCs, including related
clinical lab tests (excluding molecular pathology)
• Hospital outpatient services “incident to” a physician’s service (i.e.
most therapeutic services) – compliance with state law a new
condition of payment
14
Exceptional service. Dykema delivers.
PHYSICIAN SUPERVISION OF HOSPITAL
OUTPATIENT “INCIDENT TO” SERVICES
• CMS reiterated in 2013 that direct physician supervision is
required for therapeutic services paid under OPPS, but not for
therapy services paid under MPFS
• CMS review process implemented; number of services
exempted and now require only general physician
supervision, including observation
• CAHs and small rural hospitals exempted one more year (CY
2013)
15
Exceptional service. Dykema delivers.
MEDICARE – PROVIDER-BASED STATUS FOR
OUTPATIENT CLINICS
• 3/12 – MedPac recommends to Congress elimination of
provider-based status for hospital clinics
• 11/12 – CMS acknowledges, but does not adopt, MedPac
recommendation re clinics
• 10/12 – MedPac staff recommends elimination of providerbased status for additional hospital services
• 7/13 – CMS considers methods to collect data on services
furnished in off-campus provider-based hospital departments
16
Exceptional service. Dykema delivers.
PART B INPATIENT SERVICES
• Eff 10/1/13, if inpatient stay found after discharge not
reasonable and necessary for Part A payment, hospital may
bill expanded list of inpatient services to Part B
– Part B claim must be filed 1 year from DOS
– Excludes services “defined” as outpatient (e.g. ED and
observation)
– Pre-admission outpatient services may be billed as Part B
outpatient services
– Different than Condition 44, where an inpatient is
converted to an outpatient before discharge
– Replaces CMS Ruling 1455-R
17
Exceptional service. Dykema delivers.
PART B INPATIENT SERVICES CONT’D
– Beneficiary usually entitled to refund of Part A
copay/deductible when inpatient stay found not reasonable
and necessary
– Beneficiary owes copays on Part B inpatient and
outpatient services
– Self-administered drugs covered, if at all, by Part D
– Part B inpatient is still an “inpatient” for purposes of 3-day
hospital inpatient stay required for SNF coverage – lenient
“medical necessity” standard
18
Exceptional service. Dykema delivers.
MEDICARE INPATIENT/OUTPATIENT
DISTINCTION
• 2-midnight presumption
– inpatient stays over 2 midnights are not focus of review,
absent evidence of gaming
• 2-midnight benchmark
− physician reasonably expected 2-midnights in hospital,
including outpatient services
− shorter inpatient stays reviewed and measured against
benchmark
− pre-admission services paid as outpatient, although
“count” toward 2-midnight benchmark
• Medical necessity as separate requirement
19
Exceptional service. Dykema delivers.
MEDICARE INPATIENT/OUTPATIENT
DISTINCTION
•
Requirements for covered inpatient hospitalization
– Explicit requirement of a physician order
− documented in record
− supported by objective medical information
− at or before admission
− by practitioner with admitting authority who is knowledgeable about
the case
− Physician certification
− hospitalization is required
− post-admission ok, but before discharge
− Medical necessity
− order and certification are not conclusive
20
Exceptional service. Dykema delivers.
MEDICARE – INPATIENT MEDICAL REVIEW
• Inpatient services are those:
– on the “inpatient-only” list, or
– to patients admitted with reasonable expectation they will
be in the hospital for 2 midnights (i.e. meet the 2-midnight
benchmark)
• Level of care (e.g. ICU) or co-morbidities are not determinants
• Applies to all hospitals except IRFs
21
Exceptional service. Dykema delivers.
MEDICARE – HOSPITAL CONDITIONS OF
PARTICIPATION
• New Interpretative Guidelines re Discharge Planning
– Effective 7/19/13
– Extensive new guidelines, plus “nonbinding information”
• CAH COP changed to require that CAH furnish inpatient
hospital services
22
Exceptional service. Dykema delivers.
MEDICARE - LTACs
• Moratorium on new and expanded LTACs expired 12/29/12
• “25% threshold” reinstated 10/1/13 – If more than 25% of an
LTAC’s business comes from a single hospital, admissions in
excess of the 25% threshold are paid at lesser of LTAC or
acute care rates
23
Exceptional service. Dykema delivers.
MEDICARE – PRACTITIONER PAYMENT
CHANGES
• Another round of RVU recalibrations in 2013, based on
practice expense changes and mis-valued codes, resulting in
winners (primary care) and losers (radiation oncology).
Additional potentially “misvalued” codes identified in proposed
2014 regs.
• Two CMS-commissioned studies are underway to validate
work RVUs, focusing on physician time
24
Exceptional service. Dykema delivers.
MEDICARE – 2013 PRACTITIONER PAYMENT
CHANGES
• Additional benefits for primary care physicians
– New post-discharge “transitional care management” code
• Partly for non-face-to-face coordination
• For MD/DO/NPP only, but “incident to” rules apply
• Complex list of minimum services
– Primary care incentive payments
• 10% Medicare add-on for primary care services by
PCPs (2011-2015)
• Medicaid primary care services to be paid at Medicare
rates (2013-2014)
– For 2015 – proposed new “complex chronic care
management” code
25
Exceptional service. Dykema delivers.
MEDICARE – 2013 PRACTITIONER PAYMENT
CHANGES
• CRNAs – Scope of covered services now = scope of license
• Place of Service = place of patient’s face-to-face encounter as
general rule (not physician’s location), except hospital
patients’ POS = hospital
• Locum tenens reassignment – CMS seeking solution to
requirement that locums be identified on the claim form
26
Exceptional service. Dykema delivers.
MEDICARE – 2014 PROPOSED PRACTITIONER
PAYMENT CHANGES
• Limit non-facility practice expense (PE) RVUs at OPPS or
ASC payment rates
• Pay for services and supplies “incident to” a practitioner’s
services only if furnished in compliance with applicable state
law
27
Exceptional service. Dykema delivers.
MEDICARE – OUTPATIENT DIAGNOSTIC
TESTING
• 2013: Payment reduction for multiple tests in a single session
– Extended to TC of cardiovascular and ophthalmology tests
(and nuclear tests that were overlooked)
– Payment reduction for PC of multiple advanced imaging
services applied to interpretations by all members of the
same group
– CMS agrees single “session” is ambiguous
• 2014: No new multi-service payment reductions proposed
28
Exceptional service. Dykema delivers.
MEDICARE – OUTPATIENT DIAGNOSTIC
TESTING
• Congress orders 90% utilization rate assumption for
expensive advanced imaging equipment as of 1/1/14
(previously 75%; other equipment = 50%)
• As of 1/1/13, portable x-rays may be ordered by same range
of practitioners as other tests
• CLIA personnel competency assessment guidance
• CMS will review all clinical lab fee schedule rates over next 5
years focusing on technological changes; first changes to be
proposed for CY 2015
29
Exceptional service. Dykema delivers.
MEDICARE – OUTPATIENT THERAPY
• 2013 Therapy caps
– $1,900/yr. PT/ST combined
– $1,900/yr. OT
– “Automatic” exception to $1,900 caps, up to $3,700/yr., via
use of KK modifier
– “Manual medical review” over $3,700/yr. (voluntary preauthorization)
– Without manual medical review, subject to pre-payment
review
• Therapy caps proposed to apply to payment to CAHs effective
1/1/14
30
Exceptional service. Dykema delivers.
MEDICARE – OUTPATIENT THERAPY
• New, complex, claims-based data reporting required
– Test period = 1/1/13 – 6/30/13
– Required beginning 7/1/13 or claim will be returned
• Multiple therapy services on same day: as of 4/1/13 the
reduction in practice expense changes from 20/25% to 50%
31
Exceptional service. Dykema delivers.
MEDICARE – DMEPOS SUPPLIERS
• Face-to-face encounter requirement clarified
– Encounter may be with MD, DO, PA, NP, or CNS
– Documentation of encounter by MD or DO only
– CMS publishes annual list of items requiring such
encounter
• Active enforcement began 10/1/13
32
Exceptional service. Dykema delivers.
MEDICARE ENROLLMENT
• CMS enrollment-related initiatives to curb fraud and abuse:
– Temporary moratorium on enrollment of HHAs in Miami
and Chicago and new ambulance suppliers in Houston
(7/13)
– Contractors authorized to deny enrollment to those with
$1,500 or more outstanding federal overpayment
– Proposed regs to deny/revoke billing privileges for felonies
by manager and for pattern of non-compliant services
33
Exceptional service. Dykema delivers.
MEDICARE – DOCUMENTATION OF
ORDER/CERTIFICATION
• For service that requires a practitioner’s order/certification,
that practitioner must be enrolled in Medicare
– Enrollment need not be in PECOS
– Claim must include practitioner’s NPI (eff. 7/1/14 for HHA)
– Licensed resident’s NPI is sufficient
• Edits to deny payment turned on as of 5/1/13
• Both billing supplier and ordering practitioner must maintain
supporting documentation for 7 years
– Penalties for non-compliance
34
Exceptional service. Dykema delivers.
MEDICARE MEDICAL DOCUMENTATION
REQUIREMENTS
• Use of EHR templates and “limited space” formats
– All entries made personally by practitioner are considered
– CMS “discourages use of” limited option templates and
limited space formats
• CMS allows use of stamped signatures by physically-disabled
authors (eff. 7/1/13)
35
Exceptional service. Dykema delivers.
CMS COMPLAINT FULL SURVEYS
• CMS conducts “complaint surveys” of providers with deemed
status
• If CMS finds condition-based deficiency, provider loses
deemed status and full CMS survey was mandatory
• Eff. 4/19/13, CMS Regional Office has discretion whether to
order full survey
• Copy of all survey results must go to accredited organization
36
Exceptional service. Dykema delivers.
SUNSHINE ACT REGULATIONS
• “Applicable manufacturers” of drugs, devices, and biological
or medical supplies covered by a federal health care program
must report annually to HHS:
– Payments and transfers of value and
ownership/investment interests
– With physicians and teaching hospitals
– Stark-like complexity in definitions and determination of
reportable relationships
– Substantial CMPs (differ for failure to report and knowing
failure to report)
– Physicians and hospitals may enroll to monitor reports filed
about them
– Data collection began 8/1/13; reported to CMS by 3/31/14
37
Exceptional service. Dykema delivers.
FTC ADVISORY OPINIONS
• Two opinions respond to drug shortages
– Generic drug manufacturers’ trade group may retain 3rd
party to gather and provide to FDA data regarding current
and contemplated inventories of shortage drugs
– Nonprofit health system may sell shortage drugs obtained
at nonprofit discount to local municipal EMS service is a
“permissible emergency humanitarian gesture”
• Norman PHO
– Key factor in favorable opinion was non-exclusive nature
of the multi-provider network
38
Exceptional service. Dykema delivers.