American Osteopathic Association Webinar The Affordable Care Act, Nuts and Bolts for Healthcare Providers Tuesday, June 17, 2014

Transcription

1 American Osteopathic Association Webinar The Affordable Care Act, Nuts and Bolts for Healthcare Providers 2014 Tuesday, June 17, 2014 Christopher M. Huryn, Esq., Partner, Health Care Group J. Ryan Williams, Esq., Partner, Health Care Group Douglas W. Harley, D.O. COLLECTIVE EXPERIENCE. COLLABORATIVE CULTURE. CREATIVE SOLUTIONS 1

2 TABLE OF CONTENT Page(s) I. Introduction... 3 II. Physician Perspective on the Affordable Care Act (ACA), Douglas Harley, D.O III. Mandatory Compliance Programs for All Providers IV. Medicare Fraud and Abuse: Incentive Reward Program, Proposed New Rules... 7 V. Medicare Fraud and Abuse: Provider Enrollment VI. Medicare Compliance, 60-Day Rule and Self-Disclosure Protocol VII. Physician Payments Sunshine Act VIII. Physician shortage The Perfect Storm Consequences and Trends for Providers The ACA Fix: Medicare/Medicaid Parity PCP Services Examples IX. ACA Impact on Medicare Payments to Physicians and Hospitals X. Electronic Payments XI. Accountable Care Organizations (ACOs) XII. Patient-Centered Medical Homes (PCMHs) XIII. Medicare Advantage (MA) Plans Makeover XIV. OIG s Authority Expanded under the ACA XV OIG Work-plan XVI. Questions and Answers

3 I. INTRODUCTION AFFORDABLE CARE ACT (ACA) Affordable Care Act (ACA), akapatient Protection and Affordable Care Act (PPACA) or ObamaCare Enacted on March 23, 2010 Despite numerous legal challenges, PPACAremains the law of the land PPACA places emphasis on: 1. New payment models: Bundling, provider incentives, provider payments tied to quality measures, capitation, etc. 2. Enforcement to (1) recoup funds and (2) prevent fraud and abuse 3. New care delivery models (accountable care organizations, medical homes, etc.) Major investment in health information infrastructure as a foundation and strategic tool EHRs, telemedicine, electronic payments 3

4 II. PHYSICIAN PERSPECTIVE ON THE ACA Physician surveys: Impact on patient care Patient/Physician relationship Healthcare costs Independent Payment Advisory Board (IPAB) Practice changers: Insurance status Sunshine Act Newly-insured patients: Higher complexity Quality measures Physician extenders 4

5 III. MANDATORY COMPLIANCE PROGRAMS ACA Requires All Providers to have Compliance and Ethics Programs, including physician practices ACA defines the core elements of a Compliance and Ethics Program 1. Design & scope 2. Governance & Leadership 3. Feedback, Data Systems, and Monitoring 4. Performance Improvement Projects (PIPs) 5. Systematic Analysis and Systemic Action APPLICATION TO NURSING FACILITIES(NFs and SNFs) AND MEDICAL DIRECTORSHIP ACTIVITIES 1. Facility-wide ethics and compliance program; and 2. Comprehensive quality assurance and performance improvement program (QAPI) TIMELINE: Deadline for NFs and SNFs to comply has passed (03/23/2012) but no regulations yet No timeline for other providers or suppliers yet. Group practices should start to build into policies and procedures. Guidance available on OIGwebsite: Entities will need to review/ revise existing compliance plans and procedures when CMS issues regulations. TIPS FOR SUCCESS: CONTINUOUS EFFORTS REQUIRED Start from the top and create a culture of compliance Document your compliance efforts and all compliance communications Periodically discuss compliance with your employees, training Conduct compliance surveys Conduct and document exit interviews OTHER ACA PROVISIONS IMPACTING SNFs and NFs: Disclosure about ownership and management of the facility 5

6 III. MANDATORY COMPLIANCE PROGRAMS (CONT D) CMS REQUEST FOR COMMENTS IN SPECIFIC AREAS, I.E. PITFALLS The use of the 5 elements of an effective compliance and ethics program as described in the U.S. Federal Sentencing Guidelines Manual as the basis for the core elements How the 5 elements have already been incorporated into compliance programs Other suggestions for program elements Whether external/internal quality monitoring should be required for hospitals and LTC facilities Costs and benefits of program elements Types and costs of effective tracking systems, data capturing systems and electronic claims submission systems Interplay with state or other compliance requirements Application to different types of providers and suppliers Application to individuals vs. corporation Current experiences and sophistication Effectiveness and how effectiveness is measured Use of third party resources Identification of responsible staff Reasonable timelines for implementing compliance programs 6

7 IV. MEDICARE FRAUD AND ABUSE: INCENTIVE REWARD PROGRAM, PROPOSED NEW RULES 2013 ENFORCEMENT NUMBERS Expected recoveries: $5.8 billion in total investigative ($5 billion) and audit receivables ($850 millions) Program exclusions: 3,214 individuals and organizations were excluded from participation in Federal health care programs Return on investment (ROI): For every $1 spent on health care-related fraud investigations in the last three years, the government recovered $8.10 EXISTING INCENTIVE REWARD PROGRAM Qui tam actions (whistleblowers): Incentive for relators to report information on individuals and entities that have or are engaged in sanctionable conduct HIPAA Section 203(b)(2): Reward is 10% of the first $10,000 of overpayments recovered or $1,000 whichever is less ADDITIONAL NEW RULES PROPOSED Bring in line with IRS incentives 15% of final amount collected applied to the first $66,000,000 for the sanctionable conduct 7

8 V. MEDICARE FRAUD AND ABUSE: PROVIDER ENROLLMENT, EXISTING REQUIREMENTS ACA SECTION 6402, Provider screening and other enrollment requirements under Medicare, Medicaid, and CHIP PROVIDER ENROLLMENT REQUIREMENTS: 42 CFR PART 424, SUBPART P ACA already definesprocedures, application fees, screening requirements, potential temporary moratoria if necessary to combat fraud and abuse in both Medicare and Medicaid, suspension of payments pending credible allegations of fraud New Medicare providers: Enhanced screening and enrollment requirements up front All providers were required to be screened by March 23, 2013 Automated provider screening (APS) Revalidation project: 2 phases Revalidation cycle: DMEPOS: 3 years Providers: 5 years Any-time-revalidation if CMS requires, including site visits [42 CFR (e)(2)] Implementation of Fingerprint-based background checks (SE1417) Enhanced compliance enforcement down the line ACA discusses mandatory compliance programs for certain providers, items, or services 8

9 V. MEDICARE FRAUD AND ABUSE: PROVIDER ENROLLMENT (CONT D), PROPOSED NEW RULES ADDITIONAL NEW RULES PROPOSED: Requirements for the Medicare Incentive Reward Program (IRP) and Provider Enrollment Published April 29, 2013; comments until June 28, 2013 (CMS-6045-P); Final rule target date 04/29/2016 Legal Authority: HIPAA; PL sec 6402(j) and 6503 of the ACA Goal: Ensure that fraudulent entities and individuals do not enroll in or maintain enrollment in Medicare PROVIDER ENROLLMENT PROPOSED RULES (proposed revisions to 42 CFR PART 424, SUBPART P) Debts to Medicare: Deny enrollment if the provider/supplier/owner was the owner of another provider/supplier that had Medicare debt Felony Convictions: Deny enrollment or revoke billing privileges if provider/supplier/owner/managing employee was convicted of felony within past 10 years Abuse of billing privileges: Revoke billing privileges if provider/supplier has pattern or practice of billing for services Post-revocation submission of claims: Revoked providers must submit all claims within 60 days of revocation (exceptions) Effective date of billing privileges: Limit ability of ambulance services to back bill for services furnished prior to enrollment $327.4 million per year estimated savings Effective date of re-enrollment bar: Re-enrollment bar to become effective 30 days after CMS mails notice of revocation Corrective action plans (CAPs): Eliminate CAPs for revoked providers and suppliers unless revocation is based on failure to comply with enrollment requirements ( (a)(1)) 9

10 VI. MEDICARE COMPLIANCE, 60-DAY RULE & SELF-DISCLOSURE PROTOCOL BILLING, 60-DAY RULE (CMS-6037-P) Proposed rule published 02/16/2012; comment period ended 04/16/ No final rule yet. Requires the reporting and returning of overpayments by the later of 60 days from the identificationof the overpayment or the date of the corresponding cost report Proposes changes to the reopening regulations Look-back period: 10 years UPDATED SELF-DISCLOSURE PROTOCOL (SDP) OIG and HHS published the Provider Self-Disclosure Protocol at 63 FR 58,399 on October 30, 1998 OIG updated the SDP April 17, 2013 pursuant to ACA Section 6409(a): Information on how the SDP has worked to date Procedural guidance Clarification regarding penalties Still no word on how DOJ would view the self-disclosure (DOJ not bound by SDP) Results: Over 250 healthcare companies have self-reported 29 hospitals have settled cases for a total of $3.3 million Look-back period: The time during which the disclosing party may not have been in compliance Indefinite! Must disclose all non-compliant periods Specifically not the time frame established for reopening determinations under 42 C.F.R (b) INTERPLAY BETWEEN 60-DAY RULE AND SDP SDP update suggests that the SDP may mitigate potential exposure under the CMS proposed 60-day rule 10

11 VII. PHYSICIAN PAYMENTS SUNSHINE ACT GOAL: Public transparency into industry-physician financial relationships SUNSHINE ACT requires public disclosures of: (1) Financial transfers: Applicable manufacturers of drugs, medical devices, and biologicals must report annually information regarding payments and other transfers of value provided to covered recipients; and Direct payments to physicians and/or teaching hospitals of $10 per transaction or $100 annually 12 exceptions Third party payments Indirect financial transfers (2) Ownership: Applicable manufacturers and group purchasing organizations must report annually information regarding ownership and investment interests held by physicians and their immediate family members PREPARING FOR THE SUNSHINE ACT:Check information for accuracy; Annual 45 day review period to correct inaccuracies TECHNOLOGY: CMS issued two Apps for data tracking assistance Open Payments Mobile for Physicians Open Payments Mobile for Industry Security requirements in using the Apps create disincentives to use 11

12 VII. PHYSICIAN PAYMENTS SUNSHINE ACT, CONT D CMS PORTAL: CMS will aggregate data from manufacturers and Group Purchasing Organizations (GPOs) and create individualized physician reports that will become public. CONTENT OF REPORT: Business address; NPI; State license number; Amount of payment or other transfer of value; Identity of associated drug, device, biological or medical supply; Eligibility for delayed publication; Payments to third parties on behalf of physician; Assumptions made by manufacturer/gpo PENALTIES for manufacturers and GPOs failure to report and knowing failures to report: Maximum combined annual total $1,150,000 KEY DATES FOLLOWING INCEPTION: Final regulations published February 2013 August 1, 2013: Applicable manufacturers and GPOs must begin data collection Industry (manufacturers and GPOs): Phase 1 User Registration -March 31, 2014: First report was due to CMS (2013 data) but the database has yet to be completed; due 90 th day of each year thereafter Phase 2 June 1 through 30, 2014: Industry to register with Open Payments System, file testing, final data submission Physicians: Phase 1 User Registration starts June 1, 2014 (CMS Enterprise Portal); voluntary but physicians must be registered to be able to correct data submitted by Industry Phase 2 -July 2014: Physicians will be able to register for the Open Payments Systems to have access to their individualized consolidated reports for prior calendar year, check and dispute data September 30, 2014: CMS will release reports to public PREPARING FOR THE SUNSHINE ACT: NPI: Update information and check for accuracy. Manufacturers will use NPI information as one identifier in reporting data Request ongoing notice: Ask manufacturers and GPOs to provide notice and opportunity to review and correct information they plan on disclosing to CMS Update disclosures periodically: Ensure that financial and conflict of interest disclosures required by employers, advisory bodies and research funding entities are current Set-up internal procedures to check system periodically CMS FAQs: 12

13 VIII. PHYSICIAN SHORTAGE, THE PERFECT STORM ACA is biggest expansion of health coverage in 50 years: +13 million people enrolled (private insurance and Medicaid) Medicaid: 4.8 million people added since October 2013(1 in 5 residents covered in Ohio) MEDICAID REIMBURSEMENT HAS BEEN AT A VERY LOW RATE: Averaged 66% of Medicare fees in 2012 (59% for primary care services). PHYSICIAN SHORTAGE NATIONWIDE: 91,500 by 2020; 130,600 by 2025 Shortage without the ACA would be 64,100 In spite of shortage, muted early demand for PCP services overall (exceptions include Colorado, Kentucky, and Washington state which had biggest gains in coverage): few reports of patients facing major delays Key factors: Exchanges technical difficulties slowed the signing-up process 5 million people projected to gain coverage remain uninsured because only half the states expanded Medicaid But the surge is coming! NEED TO ENCOURAGE GREATER MEDICAID PARTICIPATION AMONG PHYSICIANS AS THE PROGRAM EXPANDS IN 2014 AND THE DEMAND FOR CARE INCREASES. CONSEQUENCES& CONSIDERATIONS FOR HEALTH CARE PROVIDERS: Policy makers will likely continue to leverage clinical reimbursements to (1) attract more students into primary care field; and (2) incentivize providers to accept more Medicaid patients Expect more federal dollars towards streamlining the healthcare delivery system and evidencebased innovations Consider enrolling in Medicaid if you are providing PCP services (broad definition) 13

14 VIII. PHYSICIAN SHORTAGE (CONT D), CONSEQUENCES & TRENDS FOR PROVIDERS RECRUITING Emphasis on preventative services: Focus NOW on recruiting primary care physicians, residents, physician extenders Design attractive compensation packages within the legal framework Focus on retention RETAIL HEALTH CLINICS (examples: CVS Caremark Corp., Walgreens, Target, WalMart) Study predicts that number of retail health clinics will more than double by 2015 (1,450 clinics ) New competition and complement for health care providers Retail clinics target physician extenders Provider employment contracts: non-compete clause; moonlighters TELEMEDICINE: Increased use of telemedicine for all compatible specialties with physician shortage New studies show promising cost reductions MENTAL HEALTH CARE: Additional 2.3 million individuals will gain mental health coverage, a specialty traditionally lagging in insurance coverage Medicaid rates today fairly attractive relative to primary care or other specialties ACA mandates coverage of depression screening Incidence on employers bottom line: some pros and cons Cost of coverage vs. improved wellness, substance abuse treatment (i.e. long-term effect on workforce) 14

15 VIII. PHYSICIAN SHORTAGE (CONT D), THE ACA FIX: MEDICARE/MEDICAID PARITY PARITY: Medicaid reimbursements (fee-for-service and managed care) must rise to the level of Medicare payments for PCP services. PCP services include some specialist services (see eligible sub-specialties slide) Increases do not apply to Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) Alaska not participating; North Dakota will experience nominal increase FUNDING: Federal dollars for 2 years ($11.8 billion extra funding) RESULT: Average Medicaid reimbursement increase of 64% nationally (76% in Ohio) WHEN: Effective for dates of service on or after 01/01/2013 through 12/31/2014 DELAYS in increasing the rates and paying physicians retroactively 37 states and D.C. have started Some states have not started at all: California, Texas, Nebraska, Wisconsin, Georgia, Kentucky, New-Jersey. Some states have started the process for Medicaid fee-for-service plans only: Washington, Michigan, New Mexico, Florida, Montana, New-York, Louisiana. RISK: Overpayments. Two potential sources of overpayments: Billing processes, especially if provider is assigning his/her billing rights to third-party, e.g. physicians providing emergency services to a hospital though a lease arrangement Specialty reported during self-attestation process 15

16 VIII. PHYSICIAN SHORTAGE, THE ACA FIX: MEDICARE/MEDICAID PARITY (CONT D) ELIGIBILITY Two options to qualify: Board certification and/or60% of PCP services 1. Provider is Board certified is an eligible specialty or subspecialty; and/or 2. 60% of the provider s Medicaid claims for the prior year were for the E&M codes specified in the regulation. E&M codes through and vaccine administration codes 90460, 90461, (or successor codes, where applicable) are eligible for higher payments. 1. SPECIALTIES AND SUB-SPECIALTIES ELIGIBLE, as defined by: American Board of Medical Specialties (ABMS) American Board of Osteopathic Association (AOA) American Board of Physician Specialties (ABPS) see next slide for all eligible specialties lots of (pleasant) surprises! 2. PCP SERVICES: Applies to primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine General internal medicine encompasses internal medicine and all subspecialties recognized by the ABMS, AOA, and ABPS 16

17 VIII. THE ACA FIX, MEDICARE/MEDICAID PARITY (CONT D): WHAT ARE PCP SERVICES? ACA specifies increased payments for 3 primary care medical specialties: Family Medicine, General Internal Medicine and Pediatrics The Final Rule interprets this language to include some subspecialties with a relation to the original three QUALIFYING SUBSPECIALTIES UNDER THE ABMS Family Medicine Adolescent Medicine; Geriatric Medicine; Hospice and Palliative Medicine; Sleep Medicine; Sports Medicine Internal Medicine Adolescent Medicine; Advanced Heart Failure and Transplant Cardiology; Cardiovascular Disease; Clinical Cardiac Electrophysiology; Critical Care Medicine; Endocrinology, Diabetes and Metabolism; Gastroenterology; Geriatric Medicine; Hematology; Hospice and Palliative Medicine; Infectious Disease; Interventional Cardiology; Medical Oncology; Nephrology; Pulmonary Disease; Rheumatology; Sleep Medicine; Sports Medicine; Transplant Hepatology Pediatrics Adolescent Medicine; Child Abuse Pediatrics; Developmental-Behavioral Pediatrics; Hospice and Palliative Medicine; Medical Toxicology; Neonatal-Perinatal Medicine; Neurodevelopmental Disabilities, Pediatric Cardiology; Pediatric Critical Care Medicine; Pediatric Emergency Medicine; Pediatric Endocrinology; Pediatric Gastroenterology; Pediatric Hematology-Oncology; Pediatric Infectious Diseases; Pediatric Nephrology; Pediatric Pulmonology; Pediatric Rheumatology; Pediatric Transplant Hepatology; Sleep Medicine; Sports Medicine QUALIFYING SUBSPECIALTIES UNDER THE AOA Family Physicians No subspecialties Internal Medicine Allergy/Immunology; Cardiology; Endocrinology; Gastroenterology; Hematology; Hematology/Oncology; Infectious Disease; Pulmonary Diseases; Nephrology; Oncology; Rheumatology Pediatrics Adolescent and Young Adult Medicine; Neonatology; Pediatric Allergy/Immunology; Pediatric Endocrinology; Pediatric Pulmonology QUALIFYING UNDER THE ABPS ABPS does not certify subspecialists Eligible certifications: American Board of Family Medicine Obstetrics; Board of Certification in Family Practice; and Board of Certification in Internal Medicine There is no Board certification specific to Pediatrics 17

18 VIII. THE ACA FIX, MEDICARE/MEDICAID PARITY (CONT D): WHAT ARE PCP SERVICES? - EXAMPLES Board-certified general surgeon practicing as a general family practitioner Does the physician qualify under either prong of the 2-part test? Board certification: No Neither the ABMS, ABPS, nor the AOA recognize general surgeon as a sub-specialty of family medicine, internal medicine, or pediatrics. PCP services: Perhaps Yes, if 60% of Medicaid claims for prior year were for E&M codes specified in the regulations Physician must self-attest to that effect No, if less than 60% of Medicaid claims for prior year were not PCP services in accordance with the regulations Physician cannot self-attest Physician with a certification in Family Medicine Obstetrics under the ABPS Does the physician qualify under either prong of the 2-part test? Board certification: Yes The physician is first certified in family medicine with additional certification in obstetrics and practices as a family practitioner. Physician can self-attest to a qualified specialty Physician with a certification in Obstetrics under the ABMS or AOA Does the physician qualify under either prong of the 2-part test? Board certification: No PCP services: Perhaps (60% PCP services rule) 18

19 IX. ACA IMPACT ON MEDICARE PAYMENTS TO PHYSICIANS AND HOSPITALS Independent Payment Advisory Board (IPAB) Primary care physicians incentives 10% bonus 2011 through 2016 Medicare payment sustainable growth rate (SGR): Implementation delays continue Quality/Cost payment Payment modifier applicable in 2015 Physician quality reporting system (PQRS) Imaging reimbursement cuts Reduction for inpatient hospital prospective payment system Clinical measures, efficiencies, patient outcomes may increase or decrease a hospital s reimbursement 19

20 X. ELECTRONIC PAYMENTS ACA adopted new operating rules for how electronic transactions are conducted Goal: To create consistency, enhance reliability, increase efficiency, lower administrative/operating costs, and strengthen security Potential savings: $11 billion annually if 100% healthcare payments using Electronic Fund Transactions (EFTs) Billing and insurance-related costs represent approx. 12% of a provider s revenue annually Phase 1 - January, 2014: Compliance with electronic payment rules Medicare must make 100% of claims payments electronically as of 01/01/2014 All payors must be able to pay electronically if the provider requests it 2012, only 33% of healthcare claim payments were made electronically Phase 2 - January, 2016: Compliance with rules for: Health care claims or equivalent encounter information Coordination of benefits Health plan enrollment/disenrollment Health plan premium payment Referral certification and authorization transactions Obstacles to overcome before going electronic: Lack of provider awareness Expense Enrollment volume Security - Concern about giving out banking information Not understanding the benefits Need for training Preparing for the new operating rules: Educate yourself Work with your bank Contact health plans Change systems and manage 20

21 XI. ACCOUNTABLE CARE ORGANIZATIONS (ACOS) ACO, Definition of the classic model: Medicare ACO or Medicare Shared Savings Program (MSSP) 123 Medicare ACOs nationwide Non-profit organizations can participate GOAL: Reduce Medicare costs through better coordination and delivery of high quality care CMS EXPERIMENTS WITH NEW ACO MODELS BEYOND TRADITIONAL MSSP Advance Payment Model: Participants receive upfront and monthly payments to make investments in care coordination infrastructure. 35 nationwide; 1 in Ohio Pioneer ACO Model: Designed for health care providers already experienced in coordinating care for patients across care settings. 32 nationwide; none in Ohio YEAR-ONE RESULTS ( ): $380 million savings from Medicare ACOs and Pioneer ACOs Medicare ACOs: 114 total, 54 showed lower spending growth Pioneer ACOs: 23 total, 9 showed lower spending growth SPECIALTY OR DISEASE-SPECIFIC ACOs: Slight shift from primary care ACOs to specific chronic diseases ACOs, such as cancer, chronic kidney disease, and end stage renal disease CMS released revised application for the Comprehensive ESRD Care Model (04/15/2014) PEDIATRIC ACOsat the state level 21

22 XII. PATIENT-CENTERED MEDICAL HOMES (PCMH) AKA PRIMARY CARE MEDICAL HOMES PCMH is an enhanced primary care delivery model that strives to achieve better access, coordination of care, prevention, quality, and safety, and to create a strong partnership between the patient and primary care physician. PCMH CORE FUNCTIONS and GOALS: Patient-centered orientation Proactive, comprehensive, team-based care Care coordinated across health care system Superb access by patient to care Commitment to quality and safety PCMH acts as the medical home; ACO serves as the medical neighborhood Providers receive incentive payments for improving primary care services for each patient in the home 22

23 XII. PATIENT-CENTERED MEDICAL HOMES (PCMHS), CONT D PAYMENT METHODOLOGY: Payers reward providers with a per member per month bonus for improving primary care services for each patient in the medical home 10% INCENTIVE PAYMENTS FOR PRIMARY CARE SERVICES (ACA SECTION 5501) ACA establishes an additional payment for services provided by a primary care practitioner between January 1, 2011 and January 1, 2016 equal to 10% of the amount otherwise paid under Medicare Primary care practitioner includes any physician whose primary specialty designation is family, internal, geriatric or pediatric medicine, and any nurse practitioner, clinical nurse specialist, or physician assistant, for whom primary care services accounted foratleast 60% of the allowed charges in such prior period as determined by the Secretary Primary care services include services identified by CPT codes through 99215, through 99340, and through 99350, or as may be subsequently modified by the Secretary AGENCIES INVOLVED: Agency for Healthcare Research and Quality (DHHS) CMS has implemented the Medicare Multi-Payer Advanced Primary Care Practice Demonstration (MAPCP) and Federally Qualified Health Center Advanced Primary Care Demonstration (FQHC APCP) and other initiatives DOD (TriCare) sees PCMH as the most promising model to deliver care Health Resources and Services Administration (DHHS) has been funding projects on the medical home concept since the 1980s; ongoing initiatives; toolkits and resources available to public Substance Abuse and Mental Health Association (SAMHSA) funds a variety of behavioral health-specific programs and promotes theiruse in primary care and PCMH settings PCMHs ARE NOT ACOs PCMHs and ACOs both focus on improving health outcomes through care coordination and primary care ACOs are comprised of many medical homes ACOs are accountable for the cost and quality of care both within and outside of the primary care relationship. Although not a legal requirement, ACOs usually include specialists or hospitals in order to be able to control costs and improve health outcomes across the entire care continuum ACOs are larger than a single medical home or physician s office 23

24 XIII. MEDICARE ADVANTAGE PLANS MAKEOVER MEDICARE ADVANTAGE PLAN, AKA PART C OR MA PLAN Plan offered by a private company that contracts with Medicare to provide Part A (hospital) and Part B (medical) benefits. Most also offer Part D (drugs) Types: Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans Traditional fee-for-service Medicare: 80% cost covered; enrollees can go to any Medicare provider Medicare Advantage:usually covers a higher percentage of cost after enrollee has paid out-of-pocket limit; enrollees can only go to providers in their network ACA PROVISIONS TARGET WASTEFUL MEDICARE SPENDING In 2009, MA plans received on average 13% more per enrollee than the cost of comparable care under traditional Medicare ACA aims at bringing in line MA payments with traditional Medicare payments cut in reimbursements ACA does not eliminate MA plans or reduce the extra benefits seniors receive under MA plans Majority of new regulations were published on April 12, 2012 (77 FR 22072) and a correction was published June 1, 2012 (77 FR 32407) New medical loss ratio (MLR) requirements recently finalized: Final rule (CMS-4173-F) published May 23, 2013 (78 FR 31283), effective July 22, 2013 Under the 80/20 rule, MA plans are required to spend at least 80-85% of their revenue on medical care rather than for administrative expenses or profits Pressure may be passed on to providers Several levels of sanctions for failure to meet the 80-85% MLR requirement for 3 or 5 consecutive years (rebates to enrollees, remittance of funds, prohibition on enrolling new members, and contract termination) MA PLANS CONTINUE TO GROW DESPITE ACA/ANALYSTS PREDICTIONS Analysts had predicted a reduction in Medicare Advantage enrollment under the ACA Enrollment in MA has grown by 41% since the enactment of the ACA(4.6 million increase) Virtually all states affected 30% seniors are enrolled in MA nationwide(march 2014) 1.3 million more beneficiaries enrolled in the program between 2013 and 2014 (nearly 10% year-over-year increase) Total Medicare Advantage enrollment: 15.7 million (2014) 24

25 XIII. MEDICARE ADVANTAGE PLANS MAKEOVER (CONT D) REGIONAL DISPARITIES Rise in premiums not applicable in all states: South Florida and New York, seniors can still choose health plans with no monthly premiums. HMOs versus PPOs Some markets have super concentration at the top Less competition for beneficiaries and more pressure on providers e.g. States where top 3 plans represent over 90% of enrollees Alaska, Connecticut, Delaware, District of Columbia, Kansas, Kentucky, Louisiana, Mississippi, Montana, Nebraska, New Hampshire, New Jersey, North Carolina, Rhode Island, South Dakota, Vermont, West Virginia, Wyoming Contrast with Ohio: Top 3 plans represent 67% total MA enrollees: Humana, Inc. (26%); BCBS Wellpoint(24%); Aetna (16%) IMPLICATIONS FOR PROVIDERS: MA plans will pass along cuts to providers and consumers The Obama administration proposes cuts but backs down due to heavy lobbying 1.9% proposed cuts for 2015 turned into 0.4% increase 2.2% proposed cuts for 2014 turned into 3.3% increase. Although average monthly premiums have remained stable since 2012 ($35 per month in 2014), the average out-of-pocket costs have risen significantly. Between 2013 and 2014, the share of plans with limits above $5,000 has doubled Seniors have higher cost up front but they have better coverage Concentration at the top: Risk/vulnerability (electronic payment glitch); pressure to reduce costs; impact on payment to providers; imbalance of power in contract negotiations Providers must enroll and manage contracts with many plans ANALYZE YOUR MEDICARE DATA Where are your $$ coming from? Are you contracted with the main plans? 25

26 XIV. OIG S AUTHORITY EXPANDED UNDER THE ACA Proposed Rule [79 FR (May 12, 2014)]: Expands the OIG scivil Monetary Penalties (CMP) authority in accordance with the ACA. Authority: Sections 6402(d)(2)(A)(iii) and 6408(a) of the ACA Goal: To further protect the federal health care programs Delegation: Express delegation of authority from the HHS Secretary to the OIG 5 new violations will expand the OIG s penalties and exclusionary authority: Failure to grant OIG timely access to records Ordering or prescribing items or services that the person knows or should know may be paid for by a federal health care program while excluded Making false statements, omissions, or misrepresentations in an enrollment application to participate in a federal health care program Failure to report and return a known overpayment Making or using a false record or statement that is material to a false or fraudulent claim Medicare Advantage plans: Responsible for misconduct by contracted providers Factors evaluated for assessing penalty and/or period of exclusion: Increase in threshold of claims-mitigating factors ($5,000) and claims-aggravating factors ($15,000) Degree of culpability factor: Now references the person s level of intent New mitigating factor: Appropriate and timely corrective action Single aggravating circumstance: Should result in maximum penalty allowed Notable additions to the general definitions of the CMP authority: Separately billable item of services & non-separately billable item or services New per-day penalty methodology for non-separately billable items provided by an excluded person Emergency Medical Treatment And Labor Act (EMTALA):Would revise the definition of responsible physician to clarify the circumstances when an on-call physician has EMTALA responsibility RECOMMENDATION FOR PROVIDERS: Review OIG Work Plan every year 26

27 XV. OIG WORKPLAN 2014 Full report (101 pages) available at: pdf AREAS OF FOCUS: Ensure the accuracy of health care-related expenditures and costs while recovering lost funds due to fraud, abuse and waste Increase the security of electronically-monitored patient information Enforce agency policies and regulations Mandate compliance among providers Oversee the full implementation of the ACA and resolve issues with select ACA provisions KEY AREAS FOR PROVIDERS TO EVALUATE AND REVISE, AS APPLICABLE: New inpatient admission criteria Medicare costs associated with defective medical devices Impact of provider-based status on Medicare billing Comparison of provider-based and free-standing clinics Outpatient evaluation and management (E&M) services billed at new patient rates Participation in projects with quality improvement organizations Oversight of hospital privileging Power mobility devices: add-on payment for face-to-face examination Medical necessity of high cost diagnostic radiology tests Electro-diagnostic testing questionable billing Physicians place-of-service coding errors Controls over networked medical devices at hospitals Security of personal devices containing personal health information (PHI) Improper Medicare payments for beneficiaries with other health care coverage (Medicare Secondary Payer, MSP) Kwashiorkor diagnostic (malnutrition) and treatment 27

28 XVI. QUESTIONS & ANSWERS Douglas W. Harley, DO, FACOFP, FAAFP Daniel K. Glessner, Esq., Chair, Health Care Group Christopher M. Huryn, Esq., Partner, Health Care Group J. Ryan Williams, Esq., Partner, Health Care Group David Schweighoefer, Esq., Partner, Health Care Group (330) Joy D. Kosiewicz, Esq., Partner, Health Care Group Michael G. VanBuren, Esq., Associate, Health Care Group Isabelle Bibet-Kalinyak, Esq., Associate, Health Care Group This presentation is intended to provide general information. It is not intended as a form of, or as a substitute for legal advice and analysis. Legal advice should always come from in-house or retained counsel. Moreover, if this presentation in any way contradicts advice of counsel, counsel s opinion should control over anything written herein. No attorney client relationship is created or implied by this presentation. No reproduction or dissemination without prior written consent from Brouse McDowell Brouse McDowell. All rights reserved. 28