A physician who was excluded from the Medicare program is not precluded from receiving payment for services rendered prior to the exclusion according to Advisory Opinion 15-02 published by the HHS Office of Inspector General (OIG) earlier this month. The Advisory Opinion was requested by a physician who was excluded for 20 years from Medicare participation as part of a a criminal plea and settlement of a civil False Claims Act settlement. The excluded physician was required as part of the settlement to sell his medical practice and as part of the proposed sale, the buyer would collect the pre-exclusion receivables and pay them to the excluded physician.
Under the federal Social Security Act, no payment may be made by Medicare, Medicaid, or any other Federal health care program for any item or service furnished by an excluded individual on or after the effective date of the exclusion. Because the receivables in questions related only to services performed prior to the exclusion, the OIG concluded that the proposed arrangement would not be prohibited.
While this Advisory Opinion required only a straightforward reading of the statutory language, physicians and other providers should nevertheless be exceedingly careful when dealing with individuals and entities who are or have in the past been excluded from Medicare or other payor programs as even straightforward financial arrangements with such parties can result in severe sanctions under the federal civil money penalties law of the Social Security Act. Practices and providers should, as part of their compliance activities, regularly check the Exclusions Database for existing employees and contractors as well as part of a pre-hire screening process.
Beginning May 13, 2015, employers must provide paid sick leave to employees who work in Philadelphia, per the City of Brotherly Love’s newly enacted Promoting Healthy Families and Workplaces Ordinance. The ordinance will undoubtedly elicit feelings of frustration rather than love because it requires employers to provide employees who work in Philadelphia with one hour of paid sick leave for every 40 hours worked. Paid sick leave is capped at a maximum of 40 hours per year. – See more details regarding the ordinance HERE.
According to various news outlets, physicians at the University of California student health centers (as many as 150 physicians in all) went on strike this week in protest of what they believe are unfair labor practices by the University. These physicians are members of the Union of American Physicians and Dentists. The protest stems from contract negotiations between the Union and the University which have been ongoing for many months. While this is only the first time in more than 25 years that physicians in the United States have gone on strike, with more and more physicians becoming employees of large health systems and insurance companies, this strike could be a sign of things to come in the not too distant future.
The Centers for Medicare and Medicaid Services (CMS) announced today that it intends to adopt regulations modifying the Medicare Electronic Health Record (EH R) Meaningful Use Program requirements as early as the Spring of 2015. According to the announcement, CMS is considering:
- Realigning hospital EHR reporting periods to the calendar year to allow eligible hospitals more time to incorporate 2014 Edition software into their workflows and to better align with other CMS quality programs.
- Modifying other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.
- Shortening the EHR reporting period in 2015 to 90 days to accommodate these changes.
The announcement also clarifies that the proposed new rules are in addition to and would not replace the “Stage 3″ proposed rule expected to be adopted in final in March 2015.
Given the complexities of the Program and the difficulties providers have experienced in implementing and complying with the requirements to date, physicians and providers should carefully monitor these regulatory developments and ensure that their systems are capable of meeting the modified requirements.
Yesterday the Secretary of the Department of Health and Human Services (HHS) formally announced HHS’ intention to shift 90% of all traditional Medicare payments from fee-for-service (FFS) to quality or value-based payments by 2018. The secretary announced that HHS’ goal is to have 30% of traditional FFS payments tied to quality or value in 2016, increasing to 50% by 2018, through alternative payment models such as reimbursement through Accountable Care Organizations (ACOs) and bundled payment arrangements.
The Secretary also announced creation of a Health Care Payment Learning and Action Network through which HHS will work with private payers, employers, consumers, providers, and states to develop and expand alternative payment models. An HHS press release regarding the Secretary’s announcements can be viewed here.
While HHS’ desire to shift to outcomes-based reimbursement is nothing new, the Secretary’s announcements yesterday should signify to physicians and other healthcare providers that these payment models are likely to proliferate and as a result, pressure on providers to adapt to them can be expected to intensify. From a provider perspective, this is likely to mean that efforts to integrate through network formation, employment and the like will continue and networks may become more aggressive in their efforts to lock up eligible providers.
In news that may not come as a shock to those of us who have been through the cycle of hospitals purchasing physician practices before, a recent study has found that hospitals are losing considerable amounts of money on acquired physician practices. According to the study, 92% of reporting hospital CEOs state that they are losing money on their physician networks and 58% of the survey respondents report losing more than $100,000 per employee physician in 2014. For more information on the study, see “The Challenges of Integrating Physician Group Operations”, 2014 Kentucky Healthcare Industry Study, Dean Dorton Allen Ford, PLLC. While many hospitals believe that acquisition of physician practices is necessary in order to integrate the delivery of care, the question remains whether many hospitals will be able to absorb these losses long enough to reap the potential benefits of this integration. Payor models which would reward clinical integration have been slow to develop, and even once those models are established, there is no telling whether integrated provider networks will be able to make money under them.
Although unlikely to have a major impact on cash flow, physicians should keep in mind that under the CY 2015 Medicare Physician Fee Schedule (MPFS) which was published in November, the Centers for Medicare and Medicaid Services (CMS) indicated that it will hold claims for 14 days in order to implement the Fee Schedule changes. This hold will only apply to services rendered in 2015. Claims for services rendered in 2014 will be unaffected. Details regarding the claims hold can be found on the Medicare Learning Network website.
Despite the Department of Health and Human Services’ intent to make Medicare healthcare cost data more transparent for the healthcare consumer, according to a recent report by the U.S. Government Accountability Office, current Medicare cost data, and the manner in which it is being provided, are largely ineffective in enabling consumers to make informed healthcare decisions. The GAO cites a variety of shortcomings with current HHS transparency websites and tools, including that they lack information on topics of considerable relevance to consumers, such as patient-reported outcome measures and patient out-of-pocket costs, and they do not organize cost and quality information in a way that enables consumers to readily understand and compare provider performance or customize how the information is presented to enable consumers to identify the best providers for aspects of care that they may find most relevant. The GAO report substantiates one of the central concerns espoused by critics of the healthcare data transparency push: that consumers lack the understanding and/or training to understand complex healthcare related financial and outcomes data. Ultimately, however, the report serves to demonstrate that much work is still yet to be done if this data is to be useful to the health care consumer.
Last week, the Centers for Medicare and Medicaid Services (CMS) issued the final Physician Fee Schedule for Fiscal Year 2015. The annual Physician Fee Schedule includes various policy and payment changes to be implemented in the coming year. This year’s Fee Schedule includes details regarding Medicare’s payment for services outside of a face-to-face visit for managing the care for Medicare patients with two or more chronic conditions beginning in 2015. as well as a new, more transparent process for setting physician payment rates which is designed to allow for public input into the process. Other changes announced include changes to the quality reporting initiatives: Physician Quality Reporting System (PQRS), Medicare Shared Savings Program, and Medicare Electronic Health Record (EHR) Incentive Program, and further implementation of the physician value-based payment modifier. A summary of the FY2015 policy and payment changes can be viewed on CMS’ website Here.
Each year, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) publishes a Work Plan for the coming fiscal year which summarizes new and ongoing reviews and activities that the OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond. For physicians and other providers seeking to gain insight on the types of compliance issues the OIG will be reviewing, the Work Plan is an important resource. The FY 2015 Work Plan, among other things, identifies the following initiatives related to physician and other non-institutional practitioner activities:
- Anesthesia Services – A review of Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements, and to determine whether Medicare payments for anesthesia services reported on a claim with the “AA” service code modifier met Medicare requirements.
- Chiropractic Services – A review of Medicare Part B payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements.
- Diagnostic Radiology – A review of Medicare payments for high-cost diagnostic radiology tests to determine whether the tests were medically necessary and to determine the extent to which use has increased for these tests.
- Ophthalmologists – A review of Medicare claims data to identify potentially inappropriate and questionable billing for ophthalmology services during 2012.
- Physicians – A review of physicians’ coding on Medicare Part B claims for services performed in ASCs and hospital outpatient departments to determine whether they properly coded the places of service.
- Physical Therapists – A review of outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations.