In February the Centers for Medicare & Medicaid Services (“CMS”) clarified an oft quoted existing rule: Providers must return overpayments to Medicare within 60 days “after the date on which the overpayment was identified,” or in the alternative, “the date any corresponding cost report is due, if applicable.” For providers of any size, failure to report and return Medicare overpayments pursuant to these temporal requirements may result in potential liability under the Federal False Claims Act, resulting in substantial monetary penalties and the risk of being denied future claims for reimbursement.
Dating back to the American Civil War, the False Claims Act (FCA) has over time become the “primary litigative tool for combating fraud” for both federal and state governments. At its core, the FCA imposes liability on anyone who “knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval.” While most providers have worked within a similar time frame after identifying an overpayment, it appears that the statutory requirements under the 2010 Patient Protection and Affordable Care Act , as amended by the Health Care and Education Reconciliation Act (collectively referred to as the Affordable Care Act or health care reform) were not enough. In reaction, the February 2012 regulations now leave nothing to chance, imposing upon the health care industry detailed definitions with numerous examples to assist providers in determining exactly when the 60-day clock begins. … Read more →
This article first appeared in the Daily Journal on September 11, 2012.
Spectacular – adj.: of or like a public show; striking, lavish (spek ‘tækjulə(r))
As images of NASA’s 2012 “Curiosity” expedition continue to capture public interest, the word “spectacular” has been getting a lot of play in recent national media. By replacing images of our nation’s beloved hero Neil Armstrong bouncing on the lunar surface with “a one-ton, automobile-size piece of American ingenuity” that is destined to spend the next two years “examining rocks within the 96-mile crater” into which it landed, NASA has proven how far we as a unified nation can come in under fifty years with a well-designed, properly funded and tightly executed plan.
Unlike with space travel, gauging the progress of the evolution of a health care system is not nearly so cut and dry. While advances in modern medicine since the introduction of Medicare have in many ways been equally riveting from a technological, political and sociological standpoint, each new period of change has brought with it a divisiveness that has forced individuals to decide whether the system’s latest step is spectacular in its success or failure. When it comes to health care, Americans tend to see things in black and white.
Much of what we now take for granted the field of modern medicine was unthinkable fifty years ago. Technologically, the jumps have been astounding. From its humble origins in the 1970s, X-ray computed tomography has evolved from being able to give a reading that included 160 images, each taking 2.5 hours to process, into today’s 256-slice CT scanner which can in seconds measure subtle changes in blood flow or blockages in blood vessels the width of a toothpick within the heart and brain.
Our understanding of disease has also made great strides, as can be shown by improvements in the treatment of HIV. While still a serious condition, the human immunodeficiency virus has become markedly more manageable, and though it still reduces the overall life expectancy of an individual by 5-10 years, it no longer carries with it the death sentence it held when first discovered.
And yet, even as the provision of medicine continues to improve, the lack of unity among Americans as to how health care should be managed has taken its toll on the industry, bringing with it a host of sociological and ethical issues that often prevent modern breakthroughs from reaching the greatest number of people. … Read more →
In 1996 the Federal government took on increased regulatory responsibility with the passage of the Health Insurance Portability and Accountability Act (HIPAA).
This multifaceted bill was broad in its jurisdiction over both Medicare and American health care in general, as it sought to provide new Federal rules improving continuity or “portability” of coverage in the large group, small group, and individual health insurance markets, while reinforcing the need to protect the privacy of patient health records.
Combining a group of disparate issues, Title I of HIPAA amended the Public Health Service Act, the Employee Retirement Income Security Act of 1974 (ERISA), and the Internal Revenue Code of 1986. In doing so, HIPAA strove to regulate the availability and scope of group health plans and many individual health insurance policies, including the protection of health coverage for workers and their families who have lost or changed jobs. … Read more →
On September 27, 2012, Craig Garner and Andrew Woodward will be leading HCCA’s Web Conference entitled The Modern Day Compliance Program: Bridging the Gap Between Integrity and Performance.“
Information for participants will include how to:
- Identify the impending changes to the core of our nation’s health care structure as a result of the shift toward performance-based initiatives.
- Become familiar with both safe harbors and potentially costly provisions monitoring fraud and waste, including Stark laws, anti-kickback statutes, RACS, MACs, MICs and ZPICS.
- Demonstrate the positive effect on your bottom line through understanding the benefits of a well-executed compliance program.
Additional information, including how to register, can be found here.
When it comes to the Affordable Care Act, there is no shortage of topics upon which the nation can disagree. As patients lobby to make the provision of medical services a constitutional right, providers share a much different perspective on modern American health care. To practitioners and non-clinical professionals alike, participation in government sponsored health care programs is in many ways akin to joining the freemasons or pledging a fraternity, the exclusion from which is nothing less than a modern day blackballing by the not-so-secret society known as the Office of the Inspector General (“OIG”).
While Medicare regulations are no picnic, there is no shortage of hospitals participating therein. The exclusion of a hospital from federally funded programs such as Medicare and Medicaid can mean the end for that facility, while for hospital executives, directors, officers, managers, and in-house counsel the repercussions from such an act can amount to the end of a career in health care altogether. … Read more →
Section 3001(a) of the Affordable Care Act (ACA) includes a new section 1886(o) to the Social Security Act and amended 42 U.S.C. § 1395ww to establish the hospital value-based purchasing (VBP) Program.
Under the VBP Program, beginning October 2012 hospitals will face a 1% reduction overall on Medicare payments under the Inpatient Prospective Payment System (IPPS), as these funds will be used to pay for the performance bonuses under VBP Program. By 2015, hospitals that continue to show poor performance ratings will not only be excluded from the bonus pool, they will also face additional cuts in reimbursement. … Read more →
March 23 marks the two-year anniversary of President Barack Obama’s ambitious and controversial Patient Protection and Affordable Care Act. While the ultimate legacy of this landmark legislation remains to be seen, its fate will soon rest in the hands of the nine U.S. Supreme Court Justices, and then possibly the Electoral College.
With talk of constitutional challenges and potential repeal sharing headlines almost every day, now is the perfect opportunity to trace the changes in American health care over these past 24 months.
As our health care system continues to experience growing pains, certain basic tenets of reform have already made their mark, and may be difficult to retract in the event of the bill’s failure. The number of insured young adults under the age of 26 has continued to rise since 2010, as has the estimated 105 million Americans who no longer face lifetime limits on health benefits. Statistics also point to 50,000 newly insured who had in the past failed to qualify for health insurance due to pre-existing conditions.
Across the nation, individual states are gearing up for health insurance exchanges, while hospitals and physicians prepare for monumental changes in the Medicare reimbursement infrastructure as it transitions from a historically cost-based to a performance-driven platform.
Under the reform bill, the Federal Government has increased its presence with an unprecedented focus on eliminating health care fraud, abuse and waste.
Thanks to the Office of the Inspector General, Centers for Medicare & Medicaid Services and Department of Justice having procured health care fraud-related settlements and judgments in excess of $3 billion last year (capping the largest three-year streak in history with a total of $8.7 billion since January 2009), health care providers are now busy crafting or fine tuning their own custom-tailored compliance programs. At the same time, providers must also fight off Medicare and Medicaid related audits from a number of newly created entities known only by their acronyms (RACs, MICs, MACs and ZPICs to name a few).
No matter what effects the Supreme Court’s decision and upcoming elections may hold for the Affordable Care Act, it is clear that American health care will never be the same.
Only time will offer any definitive perspective for us to evaluate the changes it has imposed upon the delivery of our nation’s health care.
Welcome to health care reform, year three, as it promises to be a busy one.
This article first appeared on iHealthBeat.org.
Americans love their privacy. And yet, as the ever-increasing trend of social networking illustrates, they also love to share the facts of their lives. As a result, defining privacy can be tricky in this modern age and often depends on the venue in which information is presented and the form it takes.
In today’s world of electronic health records, straddling the fence between harmless information and sensitive data is no longer such an easy task, and the repercussions for the slightest transgression can be severe.
On August 22, HHS issued a press release challenging software developers to create new Facebook applications to assist in emergency preparation efforts. If Facebook was a nation, its “population” would be more than double that of the United States. If online minutes for Facebook users were the functional equivalent of “dollars spent,” the social network’s estimated $84 trillion in annual “spending” would top the collective gross national products of all nations across the globe, even if the U.S. or European Union were counted twice.
While Facebook is a great way to stay connected to friends and family, it also can blur the line between privacy and the public domain. With a few quick clicks you may come to learn that Susan is at the coffee shop with Billy, Milton is attending a marketing seminar, or David is recovering nicely from a recent appendectomy at a hospital in Florida.
While Facebook might be given free rein to spread news of David and his recently removed appendix, other mediums must proceed with caution. If someone from David’s hospital was to leak his news, the hospital would face great scrutiny because health care providers are bound by law to obtain in advance David’s express, written authorization to publicly disclose details about his physical well-being. This is true even if said metadata were common knowledge among David’s 268 Facebook friends. … Read more →
PBS’s “This Emotional Life”: Medicine By the Numbers
Lewis Carroll wrote: “If you want to inspire confidence, give plenty of statistics. It does not matter that they should be accurate, or even intelligible, as long as there is enough of them.”
When people are first told that a loved one is in the hospital, they want answers. Straight answers. And they want them fast.
But oftentimes in today’s medical centers, what patients and family members alike are met with is numbers: Hypotheticals, probabilities and percentages. When combined with complex medical jargon, this can quickly lead to confusion and uncertainty, as those involved must make sense of the stats before they can understand the state of the patient’s condition. Without the proper frame of reference, this type of information can quickly exacerbate fears and increase emotional distress. Rather than serve as beacons to shed light on a patient’s chances, these figures quickly become barriers to the truth. For many of us, the numbers are to be feared, not followed.
Still, whether we like it or not, playing the percentages is a medical necessity. In the modern age, health care is all about the bottom line. As technology advances and life expectancy increases, today’s treatment options become more and more focused on the probabilities of success or failure. From prenatal care to geriatric services, every patient ultimately wants to know one thing: “Where do I stand?” More and more, the answer is delivered as a number, culled from experience, testing, and appropriate clinical research trials. This often leaves the physician to mediate between patient and procedure, as he or she attempts to present new information in such a way that those involved can both understand and take comfort from that most dispassionate of messengers, the statistic.
The numbers themselves are not to be blamed. At the risk of making modern health care sound like a sports bar in Las Vegas, the purpose of statistics in a medical environment is to give the facts about a patient’s condition in black and white, which, if not done humanely, can seem lacking in compassion. The key to recognizing the value of such numbers is to use them as guidelines, not ultimatums.
Properly used, statistics perform a dual function: When correctly interpreted and explained, these numbers can act as a security blanket, breaking down frightening uncertainties into hard facts in which patients can wrap themselves during a time of emotional upheaval, while also providing a solid understanding of treatment options and outlooks. From a doctor’s perspective, they stand as a buffer, protecting the physician from being forced into the unrealistic role of savior, no matter what the condition. In their way, percentages help to reinforce the idea that nature, and not the doctor, will ultimately make the final call as to a patient’s future. Such impartiality goes a long way toward strengthening the doctor-patient relationship, especially when the prognosis is not as good as a patient might have expected.
Numbers can be persuasive to those patients faced with making important yet difficult lifestyle changes or deciding upon end-of-life treatments. For patients diagnosed with serious illnesses and their families, much of today’s medical data provides hope. For example, according to the information available at the end of 2009, life expectancy in the United States reached an all-time high in 2007 — 77.9 years (75.3 years for men and 80.4 years for women). Between 2006 and 2007, rates dropped for nearly half of the leading causes of death in the United States (cancer, heart disease, stroke, hypertension, accidents, diabetes, homicides and pneumonia), reaching a new low of about 0.76 percent of the population (760.3 deaths per 100,000 people). That is approximately one half the rate from 1947. Once fatal illnesses are slowly being reclassified, provided the patient heeds the warnings found among the numbers and takes the appropriate steps to live in a healthier manner.
On the other end of life’s spectrum, many newly pregnant couples become surprisingly imaginative upon first hearing their good news and spend much time contemplating the worst. To calm the parents’ nerves (and to protect the doctor’s interests), it is now standard practice to administer a series of tests to assess the baby’s health throughout development. Then end result of most of these tests comes back in numbers. Statistics again.
Without debating the ethics and morality of abortion, which is not a doctor’s role, many of these tests seek to ascertain the health of the fetus and predict the odds of certain birth defects such as Down syndrome, trisomy 18, or trisomy 13. The number of things for a pregnant couple to worry about can be staggering, yet doctors are often obligated to advise them of the chances in advance. For example, in North America, 1 in 260 females carry the chromosome for Fragile X (also known as “Martin-Bell”) syndrome, a genetic disorder that results in an array of physical and mental limitations, ranging from severe to mild in manifestation. Likewise, 1 in 149 Ashkenazi Jewish individuals carry the gene for Nemaline Myopathy, a neuromuscular disorder that causes muscle weakness of varying severity. In its most potent form, Nemaline Myopathy results in death after just a few years. By incorporating these tests with such relevant factors as the age and overall health of the mother and the genetic background of each parent, doctors can provide a statistical model on which to gauge the probability of the baby’s being born to normal health. This can provide parents with peace of mind if the chances of defects are low, or the opportunity to prepare themselves or consider their options if the outlook is not favorable.
At least one reason behind the surge in statistical diagnosis is the continued rise in medical malpractice claims. Having been forced into the role of omniscient healer as a result of advances in diagnostic testing, doctors must now use this same technology to cover themselves in the event of a statistical improbability. A recent study by the American Medical Association concluded that “defensive medicine” (defined as medicine relying upon diagnostic and other therapeutic measures to safeguard against malpractice claims first, and the health of the patient second) increase health care costs by as much as $150 billion each year. To be sure, throwing the title of statistician into a doctor’s medical bag of magic tricks does not help to further the doctor-patient relationship.
There is no numeric substitute for direct and clear communication between a doctor and patient. That said, making sense of medical statistics can go a long way in helping a patient understand diagnosis, prognosis and treatment. If you or a loved one has been diagnosed with a potentially life-threatening illness, your decisions about treatment can often be linked to “quality of life” concerns. No matter what age, patients want answers to certain questions, often combined with supporting statistics, such as:
- How will this disease affect my life on a day-to-day basis
- Is this disease terminal, or if left untreated, will it become terminal?
- How will the treatment affect my life on a day-to-day basis?
- How will the disease, treated and/or untreated, alter my life expectancy compared to my anticipated decline in health as I age?
It is important to remember that statistics are numbers, plain and simple. While numbers may not lie, they have no bedside manner and can be interpreted in a variety of methods and made to suit many arguments. The best way to know where you or your loved one stands is to discuss your situation clearly and openly with your doctor, taking into consideration the big picture as well as the percentages.
This Emotional Life is a two-year campaign to foster awareness, connections and solutions around emotional wellness. Join our community at www.pbs.org/thisemotionallife.