The Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare Website now includes data on healthcare-associated infections. According to CMS, the publication of this data will help hold hospitals accountable for bringing down the rates of infections.
The current infection data published on the website includes facility-specific data on central-line associated blood stream infections (CLABSIs). In its press release, CMS reports that CLABSIs result in thousands of deaths each year and approximately $700 million in additional health care costs. The CDC estimates that 41,000 CLABSIs occurred in U.S. hospitals in 2009, and up to 25% of patients with CLABSIs die from the infection.
CMS’ Hospital Compare website compares each hospital facility with the U.S. National benchmark and state standards. Hospitals were required to report data on central line infections to the Centers for Disease Control (CDC) as of January 2011 as a condition of receiving the 2013 payment update. The Hospital Compare website provides data on over 4,700 U.S. hospitals, including data on process of care, outcome of care, medical imaging, patient experiences, and patient safety. The new infection data is located under the patient safety measures tab of each hospital.
Yesterday the Office of Inspector General (OIG) added a video to its HEAT training website. The newest video outlines the OIG’s tips for implementing an effective compliance program. The six tips include:
- Foster a culture of compliance: Support your compliance program with sufficient resources. A financial commitment to compliance will show the OIG that your organization values integrity.
- Functional policies and procedures: Create policies and procedures that are up-to-date, user friendly, and specific to each job function. Include real-life compliance issues faced by your organization.
- Training: Offer compliance training often, and make it creative and current.
- Promote communication: Make your compliance department visible and approachable, talk about your organization’s non-retaliation policy in staff meetings, and solicit feedback with anonymous online surveys.
- Take appropriate corrective action: Develop a system to track and respond quickly and thoroughly, act promptly when potential issues are identified, and document corrective action. Be mindful to avoid conflicts of interest with staff involved in investigations. Track resolution of compliance issues, and familiarize yourself with the OIG self-disclosure protocol.
- Audits: Conduct regular audits in risk areas (e.g., coding, contracts, and quality of care) and investigate root causes. Review your compliance plan including whether you are meeting benchmarks and whether corrective action plans are sufficient.
The OIG video is available here.
The U.S. Department of Health and Human Services (HHS) announced yesterday that premium increases proposed by an insurer in five states were “unreasonable” and “excessive.” HHS has authority under the Affordable Care Act to review premium increases over 10% to determine if such increases are reasonable. If HHS determines that a premium increase is unreasonable, the insurance company must post a justification on its website within 10 days.
The rate increase at issue in yesterday’s announcement is a 13% increase by Trustmark Life Insurance Company which would affect approximately 10,000 residents in Alabama, Arizona, Pennsylvania, Virginia, and Wyoming. In addition, small businesses in Alabama and Arizona experienced rate increases of 27.2% and 18.1%, respectively, when combined with other rate increases over the last year. After a review by independent experts, HHS concluded that Trustmark’s rate increases were unreasonable because (1) the insurer would be spending a low percent of premium dollars on actual medical care and quality improvement and (2) Trustmark’s justifications were based on unreasonable assumptions.
This is not the first rate increase that HHS has found “excessive” under HHS’ rate review authority. HHS determined that a November 2011 12% rate increase for small businesses in Pennsylvania was excessive. A majority of states also have the authority to review rate increases to determine if they are unreasonable.
Additional information regarding HHS’ rate review authority and process is available here.
The U.S. Department of Justice (DOJ) recently filed a brief to the U.S. Supreme Court defending the constitutionality of the individual mandate provision of the Affordable Care Act (ACA).
The DOJ’s brief delineates the administration’s main legal arguments:
- The minimum coverage provision of the ACA falls “well within” Congress’ commerce power. In making this argument, the DOJ contends that Congress has broad power under the Commerce Clause and the Necessary and Proper Clause to enact economic regulation. Further, the DOJ contends that the minimum coverage provision is an integral part of a comprehensive scheme of economic regulation, and the provision itself regulates the economic conduct with a substantial effect on interstate commerce.
- The minimum coverage provision is independently authorized by Congress’ taxing power. The DOJ argues that the provision operates as a tax law, and the validity of an assessment under Congress’ taxing power does not depend on whether it is denominated a tax.
Briefs due later in January and February address other issues involved. The Health Law team at von Briesen will continue to monitor and report on the progress of the ACA challenge, including additional briefs by the parties.
The Centers for Medicare & Medicaid Services (CMS) announced yesterday an interim final rule that adopts standards for electronic funds transfers (EFT) under HIPAA. According to CMS, the standards could reduce administrative costs for physicians, hospitals, and private and government health plans by up to $4.5 billion over the next ten years.
The final rule outlines two standards that health plans must comply with in order to use EFT to transmit health care claim payments to providers. First, health plans must use a standard format when ordering, authorizing, or initiating an EFT with their financial institutions. Second, the rule outlines the data content to be contained within the EFT.
The interim final rule is the second in a series of regulations mandated by the Affordable Care Act (ACA). Under the ACA, CMS is required to issue regulations designed to streamline health care administrative transactions, encourage greater use of standards among providers, and increase the efficiency of standards. Yesterday’s rule follows a July 2011 interim final rule (76 FR 40458) establishing operating rules for patient eligibility for coverage and health care claim status.
According to CMS, future rules will address the following: (1) a standard unique identifier for health plans; (2) a standard for claims attachments; and (3) requirements that health plans certify compliance with all HIPAA standards and operating rules.
Covered entities must use the health care EFT standards by January 1, 2014. A fact sheet on the interim final rule is available here. CMS is accepting comments on the rule via mail, hand delivery, or electronic submission.
The U.S. Department of Justice (DOJ) announced yesterday that GE Healthcare Inc. will pay $30 million plus interest in order to settle allegations that its subsidiary, Amersham Health Inc., violated the False Claims Act (FCA). According to the DOJ, Amersham Health violated the FCA by causing Medicare to overpay for a radiopharmaceutical used in cardiac diagnostic imaging procedures.
The radiopharmaceutical, Myoview, is used to detect heart disease and see blood flow in images of hearts. The drug is distributed in multi-dose vials, and the number of doses available from the vials is part of the formula used to determine Medicare payment rates for the drug. The DOJ claims that Amersham Health provided false or misleading information regarding the number of doses available from vials, which, in turn, caused the federal government to pay artificially inflated Medicare rates for the drug.
The settlement arises from a 2006 qui tam whistleblower lawsuit filed under the FCA. The whistleblower sold a drug called Cardiolite, a competitor of Myoview. The whistleblower will recover $5.1 million from the DOJ’s $30 million recovery.
Earlier today, both the U.S. House of Representatives and Senate passed a two-month extension to the doc-fix. If Congress had not approved the extension, Medicare reimbursement would have been reduced by 27.4% as of January 1, 2012. The bill also includes a two-month extension of the payroll tax cut and federal unemployment benefits.
A recent case, U.S. v. Chavez, underscores the fact that federal criminal prosecution is not limited to Medicare and Medicaid fraud. A physician was recently sentenced to approximately six years in prison after he plead guilty to defrauding private insurance companies through false and fraudulent billing practices.
Earlier this year, Armando Chavez, M.D. was indicted on multiple counts of mail fraud and conspiracy in the Southern District of Texas. Prosecutors based the charges on the following fraudulent billing practices: waiving or reducing co-payments as an incentive for patients to seek treatment from Dr. Chavez; overbilling; unbundling billing codes; and billing insurance companies for services that were never performed. In addition to jail time, Dr. Chavez must also pay almost $4 million in restitution.
The Supreme Court announced today the oral argument calendar for the Affordable Care Act (ACA) challenge. The entire week of March 26 has been scheduled for the 5 ½ hours of ACA oral arguments.
On Monday, March 26, the Supreme Court will focus on whether the challenges to the individual mandate are barred by the federal Anti-Injunction Act. On Tuesday, March 27, oral arguments will center on the constitutionality of the insurance mandate in the ACA. Finally, on Wednesday, March 28, the oral arguments will address both whether the ACA can survive if the individual mandate is found unconstitutional as well as the constitutionality of the ACA Medicaid expansion.
A review of the ACA challenges is available here. The Health Law team at von Briesen will continue to monitor and report on the progress of the ACA challenge, including the Supreme Court’s decision, which is expected by July 2012.
The U.S. Department of Health and Human Services (HHS) announced today that 32 health care organizations will participate in the Pioneer Accountable Care Organization (ACO) Program.
The Pioneer ACO model was designed specifically for groups of providers with experience working together to coordinate care for patients. According to HHS, Pioneer ACOs will test innovative payment models to help experienced organizations provide better care for beneficiaries, work in coordination with private payers, and reduce Medicare cost growth. Distinct from the Medicare Shared Savings Program and the Advance Payment ACO model, the Pioneer ACO program was designed to allow provider groups to move more rapidly from a shared savings payment model to a population-based payment model.
HHS received 80 applications for the Pioneer ACO model initiative. The selected ACOs represent 18 states and a variety of health care organizations, including physician-led organization and health systems as well as urban and rural organizations. The first performance period for Pioneer ACOs begins January 1, 2012.
For more information about the Pioneer ACO program, please see the HHS fact sheet. A list of selected Pioneer ACOs is available here.
