HCCA Managed Care Compliance Conference

Transcription

1 HCCA Managed Care Compliance Conference Navigating the Affordable Care Act: Focus: Special Challenges for Managed Care Organizations Presented by: Stephen J. Weiser Navigating the Affordable Care Act: Focus on Special Challenges for Managed Care Organizations Agenda Current Compliance Issues for MCOs Enforcement Under the Affordable Care Act and Health Care Reform Initiatives Planning for Effective Compliance Under the ACA and Health Care Reform Initiatives 2 1

2 Navigating the Affordable Care Act: Focus on Special Challenges for Managed Care Organizations How do we identify today s issues? Who is in charge? Where to look? 3 Who Identifies Compliance Issues? The Center for Consumer Information and Insurance Oversight (CCIIO) is charged with helping implement many provisions of the Affordable Care Act. Office of Inspector General (OIG) Work Plan identifies Affordable Care Act compliance issues. 4 2

3 CCIIO Current Areas of Emphasis Ensuring compliance with new insurance market rules, such as the Patient s Bill of Rights* Helping states review unreasonable rate increases and overseeing new Medical Loss Ratio rules Providing oversight for the State-Based Health Insurance Exchanges and compiling data for Administering the Consumer Assistance Program, Pre- Existing Condition Insurance Plan and Early Retiree Reinsurance Program* * OUR FOCUS TODAY 5 CCIIO - Ensuring compliance with new insurance market rules. Patient s Bill of Rights Regulations: June 28, 2010 Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections 6 3

4 CCIIO - Ensuring compliance with new insurance market rules. Coverage for Young Adults Regulations: May 13, 2010 Group Health Plans and Health Insurance Issuers Relating to Dependent Coverage of Children to Age 26 Under the Patient Protection and Affordable Care Act Guidance: October 13, 2010 Q&A: Enrollment of Children Under 19 Under the New Policy That Prohibits Pre-Existing Condition Exclusions 7 CCIIO-Ensuring compliance with new insurance market rules. Prevention Regulations: August 3, 2011 Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act Guidance: July 19, 2010 Recommendation: Recommendations of the U.S. Preventive Service Task Force August 1, 2011 Guidelines: HRSA's Women's Preventive Services: Required Health Plan Coverage Guidelines 8 4

5 CCIIO - Administering the Consumer Assistance Program, Pre- Existing Condition Insurance Plan and Early Retiree Reinsurance Program Includes: Consumer Assistance Program Grants External Appeals Summary of Benefits & Coverage & Uniform Glossary 9 CCIIO - Administering the Consumer Assistance Program, Pre- Existing Condition Insurance Plan and Early Retiree Reinsurance Program External Appeals Regulations: June 22, 2011 CMS-9993-IFC2: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes July 26, 2011 CMS-9993-CN: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and External Review Processes; Correction 10 5

6 HHS OIG Work Plan FY 2012 Affordable Care Act Reviews New Programs and Initiatives Created by the Affordable Care Act Pre-Existing Condition Insurance Plans, 1101 Early Retiree Reinsurance Program, 1102 Health Insurance Web Portal, 1103 National Background Check Program, 6201 (Program for National Background Checks for Long-Term-Care Employees ) Community Living Assistance Services and Supports Program, HHS OIG Work Plan FY 2012 Affordable Care Act Reviews Existing Programs Related to Affordable Care Act Provisions Medicare Reliability of Hospital-Reported Quality Measure Data Accuracy of Present-on-Admission Indicators Submitted on Medicare Claims Hospital Same-Day Readmissions Nursing Home Compliance Plans Recovery Audit Contractors Performance and Identification and Recoupment of Improper Payments 12 6

7 HHS OIG Work Plan FY 2012 Affordable Care Act Reviews Existing Programs Related to Affordable Care Act Provisions Medicaid Appropriateness of Federal Upper Limit Amounts States Collection of Rebates for Drugs Paid by Managed Care Organizations Federal Share of Rebates Rebates on New Formulations Payments for Health-Care-Acquired Conditions State Agencies Terminations of Providers Terminated Under Medicare or by Other States Medicaid National Correct Coding Initiative Effectiveness Completeness and Accuracy of Managed Care Encounter Data 13 HHS OIG Work Plan FY 2012 Affordable Care Act Reviews Existing Programs Related to Affordable Care Act Provisions Public Health Prevention and Public Health Fund Recipient Capability Audits CDC Grantees Use of Funds From the Prevention and Public Health Fund Internal Controls for Awarding Affordable Care Act Grants Payment of Invoices for Affordable Care Act Purchases Community Health Centers Compliance With Affordable Care Act Grant Requirements Community Health Center Limited-Scope Capability Audits HRSA's Monitoring of Recipients Fulfillment of National Health Services Corps s Obligations SAMHSA Grantees' Use of Funds From the Prevention and Public Health Fund 14 7

8 Enforcement Tools Under Affordable Care Act False Claims Act Patient Protection and Affordable Care Act (PPACA) Amendments The 60 Day Return Rule is contained within a new section of the Social Security Act 1128J If the overpayment is not returned within 60 days of identification, then the provider or supplier is exposed to both False Claims Act liability and civil monetary Subjects any payments made through the newly created staterun health insurance "exchanges" to the FCA if they include any federal funds. 15 Enforcement Tools Under Affordable Care Act The Anti-Kickback Statute/Health Care Fraud Statute PPACA Amendments With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section. (No specific intent or actual knowledge required to prove violations of health care fraud statute (18 U.S.C. 1347) or Anti-Kickback Law (42 U.S.C. 1320a-7b(h)) 16 8

9 Enforcement Tools Under Affordable Care Act Qui tam Actions PPACA Amendments Government has discretion to waive the public disclosure bar even in cases where it obviously would apply Only federal criminal, civil, or administrative proceedings in which the government or its agent is a party, and only congressional, Government Accountability Office, or other federal reports, hearings, audits or investigations trigger the public-disclosure bar. Relator qualifies for the original source exception to the publicdisclosure bar if he or she has knowledge that is independent of and materially adds to the publicly disclosed allegations or transactions.. 17 Enforcement Tools Under Affordable Care Act Fraud Enforcement and Recovery Act of 2009 ("FERA"), instituting several important changes to the False Claims Act ("FCA"). Stark Law 18 9

10 Planning for Effective Compliance Under the ACA and Health Care Reform Initiatives Seven Elements of the OIG s Compliance Guidance 1. Development and distribution of written standards of conduct, as well as written policies and procedures, that promote organization s commitment to compliance and that address specific areas of potential fraud * 2. Designation of a Compliance Officer and Compliance Committee 3. Appropriate Training and Education* 4. Developing Open Lines of Communication 5. Internal Auditing, Monitoring and Risk Evaluation* 6. Enforcement of Disciplinary Standards* 7. Development of policies to respond to detected offenses, to initiate corrective action to prevent similar offenses, and to report to Government authorities when appropriate.* * Today focus: elements that require action for ACA/Health Care Reform Compliance 19 Planning for Effective Compliance Under the ACA and Health Care Reform Initiatives 1. Compile a checklist of ACA/Health Care Reform changes impacting your organization. Examples: Do you need to take steps to implement procedures relating to external appeals? Do you need to adjust billing for prevention coverage? 10

11 Planning for Effective Compliance Under the ACA and Health Care Reform Initiatives 2. Develop polices and procedures for compliance with ACA and Health Care Reform initiatives effecting your organization. 3. Train and educate your employees as to how these changes impact their jobs. 4. Audit and monitor billing compliance with changes resulting from the ACA and other health care reform initiatives. Planning for Effective Compliance Under the ACA and Health Care Reform Initiatives 5. Do current disciplinary standards require review in light of changes from Health Care Reform initiatives? 6. Do current policies and procedures include responses to detected offenses? 11

12 Questions? Please feel free to contact me with any questions? Best way to reach me? Thank you!! 12