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Office of Inspector General’s Advisory Could Affect Payment to All Healthcare Providers

OFFICE OF INSPECTOR GENERAL DEPARTMENT OF HEALTH AND HUMAN SERVICES SEALOn May 8, 2013, the Office of Inspector General (“OIG”) issued an Advisory Bulletin pertaining to exclusion and excluded healthcare providers.  Because exclusion could potentially affect every provider, it is important to learn more details about the designation.

If the OIG excludes a provider, then no Federal health care program payments may be made for items or services furnished by the excluded provider or prescribed or directed by the excluded provider.  If the excluded provider changes from one health care profession to another, the exclusion will still be in effect.

In addition, the prohibition is not limited to direct patient care; it also includes services such as review of treatment plans, preparation of surgical trays, or services provided related to filling prescriptions.  Transportation services provided by excluded individuals are also prohibited.

Finally, according to the Bulletin, excluded individuals are prohibited from providing any administrative or management services, even if they are not separately billable.

There are severe consequences if an excluded individual submits a claim or causes a claim to be submitted to a Federal health care program.  A civil monetary penalty of $10,000 per claimed item or service may be imposed.  In addition, any potential for reinstatement to Federal health care programs may be jeopardized.  Criminal penalties may also be imposed.

Civil monetary penalties may be imposed against providers that employ or enter into contracts with excluded individuals to provide items or services payable by a Federal health care program.  Further, there may be civil monetary penalties for health maintenance organizations that contract with or employ excluded individuals.  This does not mean that entities cannot hire or contract with excluded individuals at all.

If the services or items provided are not paid for by a Federal health care program, then there isn’t a prohibition against hiring or contracting with an excluded individual.  If the excluded individual only provides services or items to patients that are not covered by a Federal health care program, then there is no prohibition.

All individuals and entities should search the OIG program exclusion information that is available on the OIG Web site prior to employing or contracting with any provider of health care services and keep documentation of the search. 

In addition, individuals and entities should proactively monitor the exclusions database to ensure that none of its current employees or contractors is listed as an excluded provider.  Due diligence will help mitigate the risk of civil monetary penalties in the future.

ICD-10 Deadline for Healthcare Providers Fast Approaching – Jeyaram & Associates Can Help

ICD DeadlineThe October 1, 2014 deadline to switch to the ICD-10 codes set is less than five months away. This mandatory requirement replaces the ICD-9 codes set used to report medical diagnoses and inpatient procedures.

All healthcare providers covered by the Health Insurance Portability Accountability Act (HIPAA) must adhere to this new requirement. Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.

All healthcare practices currently using the ICD-9 codes must transition to the new codes. The transition to the new codes set will take several months. If you have not started the transition, we strongly urge to begin now. 

ICD consists of two parts:

1. ICD-10-CM for diagnosis coding
2. ICD-10-PCS for inpatient procedure coding 

ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.

ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10­ PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

The Centers for Medicare and Medicaid Web site provides detailed check lists to help healthcare providers make the transition. However, if you have questions or need help with the transition to the ICD-10 codes set, Jeyaram & Associates can help. Contact DJ Jeyaram at DJ@Jeylaw.com or 678-708-4705.

 

Georgia Medicaid Providers Can Now Access HP Online Portal

Georgia Health PortalAccording to a press release issued by the Georgia Chapter of the American Academy of Pediatrics, currently enrolled and future Georgia Medicaid providers can now access the HP online portal to submit their attestation to become eligible for the Affordable Care Act (ACA) Rate Increase. The initial enrollment period will last until July 31, 2013. When accessing the site, click on “Provider Information”, then select “Forms”, and then select the “Enrollment” link.

For more information, click here

Georgia Senate Approves Hospital Medicaid Financing Program Act

On January 17th, the Georgia Senate passed Senate Bill 24, also known as the Hospital Medicaid Financing Program Act.  The bill passed with a 46-9 vote, and authorizes the Department of Community Health to establish a financial structure to protect Georgia’s healthcare system and obtain additional federal funding for the state’s Medicaid program.

The bill was sponsored by Sen. Charlie Bethel (R – Dalton) who is quoted as saying “A failure to pass SB 24 would mean devastating cuts in reimbursement rates for medical providers. Hospitals could face up to a 32% percent reduction in Medicaid reimbursements, which could also mean a loss of services and jobs. The impact of hospital closures and layoffs as a result of reduced reimbursements on rural communities and local job markets would be devastating.”

Notably, the state’s hospital industry has been supportive. It has been reported that the proposed Act will raise $689 million in state and federal funds to help provide health care to about 100,000 additional low-income and disabled Georgians expected to join the Medicaid rolls as a result of federal health-care reform.

During his State of the State address, Governor Deal warned lawmakers that without the additional revenue, the state would be forced to slash Medicaid reimbursements to hospitals by 20 percent.

Introduced into the Senate on behalf of the governor, the legislation would turn over responsibility for assessing the 1.45-percent tax on adjusted gross patient revenues to the Georgia Department of Community Health (DCH).

The Georgia House of Representatives is expected to take up the bill when lawmakers return to the Capitol Jan. 28 following a week-long recess.

UPDATE 2/2/13: Georgia House of Representatives passed Bill 24, and Governor Deal is expected to sign the bill ensuring $450 million in federal money for the Medicaid insurance program.

Read more: http://www.sfgate.com/news/article/Ga-House-adopts-Medicaid-financing-fix-4242885.php#ixzz2JkwBESwB

New Georgia Prompt Pay Law To Take Effect in 1/2013

The new Georgia Prompt-Pay law is set to take effect in January 2013.  The law will require insurers to promptly pay physicians for treating patients who are part of self-funded employer health plans. Specifically, the new law requires insurers to pay treating physicians within 30 calendar days for paper claims submissions and within 15 working days for electronically submitted claims. If the payment is not received on time, the insurer administering the self-funded plan is required to pay 12% interest on those unpaid claims.

The insurance trade group America’s Health Insurance Plans filed a lawsuit in late August challenging the statute claiming it violates ERISA, which exempts self-funded employer plans from state regulations governing health insurance.  In 2010, then governor Sonny Purdue vetoed a similar bill citing ERISA. However, current governor Nathan Deal signed the new legislation in 2011.

Last week, the American Medical Association and the Medical Association of Georgia filed a petition in federal court in Atlanta to intervene in the case as co-defendants in order to help support the law. The lawsuit currently names state Insurance Commissioner Ralph Hudgens as defendant.

“This case has national implications for resolving the regulatory void in which health insurers are unaccountable for chronically late payments when they serve as administrators for self-insured employers,” said the AMA’s president, Dr. Jeremy Lazarus, in a statement. “Georgia has effectively closed that regulatory loophole, which helps physicians maintain a sustainable practice environment.”

“Georgia’s prompt-payment law is one of the most effective in the country,’’ Lazarus said.

Glenn Allen, a spokesman for Hudgens, said Tuesday that the commissioner “believes that doctors should be paid promptly, and he will enforce the law until a federal court tells him to do otherwise.”

Dr. Sandra Reed, president of the Medical Association of Georgia, recently released a statement saying “The fundamental fairness mandated by Georgia’s statute allows physicians to redirect their limited resources from battling to get the payments they’ve earned to caring for patients.’’

“Holding health insurers accountable for on-time payment gives medical practices greater budget certainty and helps Georgia physicians keep their doors open and pay the salaries and benefits of more than 90,000 office employees,” Reed said.

U.S. Supreme Court’s Reasoning in Upholding Required Health Insurance Is Questionable

Yesterday the U.S. Supreme Court upheld the Patient Protection and Affordable Care Act.  While some of the media’s “talking heads” may say they were not surprised by the decision few, if any, can say that they were not surprised by the Court’s reasoning in upholding the Act’s most controversial element requiring most Americans to have “minimum essential” health insurance.

The High Court accepted the government’s secondary argument that what the Act calls a “penalty” against Americans that do not obtain the required insurance is valid on a tax since the penalty is to be paid to the IRS and varies based on income.  At first blush is seems like taxes are levied against Americans that make a choice to take an action like purchase a good, own land or live in a particular state, as opposed to choosing not to do something like the purchasing of insurance contemplated in the Act.

Writing for the majority, Chief Justice Roberts framed the tax analysis under the premise that a number of people would opt to pay the penalty rather than pay for health insurance.  The Court repeatedly refers to the penalty as a “payment” rather than a “fine” or “penalty” (as it is referred to in the legislation) to emphasize its point that the penalty is not punitive.  Roberts wrote that “The payment is not so high that there is really no choice but to buy health insurance; the payment is not limited to willful violations, as penalties for unlawful acts often are; and the payment is collected solely by the IRS through the normal means of taxation.”

Chief Justice Roberts went on to explain that “[N]either the Affordable Care Act nor any other law attaches negative legal consequences to not buying health insurance, beyond requiring a payment to the IRS.” He particularly stressed that “Congress’s choice of language…does not require reading §5000A as punishing unlawful conduct. It may also be read as imposing a tax on those who go without insurance.”

We have concerns whether the Court’s characterization of the penalty as a tax will  act as an instruction manual for greater government control over citizens’ inaction simply by characterizing penalties as taxes in any legislation.