Why Patients Still Need EMTALA

Recently, hospitals have been coming under scrutiny for violations of the federal Emergency Medical Treatment and Active Labor Act (EMTALA). This past December, Bon Secours St. Francis agreed to pay a $100,000 civil penalty to settle allegations that it violated EMTALA by improperly transferring the two gunshot victims, even though it had the capacity to treat them. The benefits of the transfer did not outweigh the risks and unnecessarily placed their health at further risk, according to HHS' Office of the Inspector General.

EMTALA, known as the patient anti-dumping law, was signed into law 30 years ago in response to national outrage over a surge in community hospitals transferring unstable emergency patients—including women in labor—to public hospitals and academic medical hospitals, largely for financial reasons.

EMTALA requires Medicare-participating hospitals to screen patients for emergency medical conditions and provide stabilizing treatment, regardless of their ability to pay. Hospitals with specialized capabilities must accept appropriate transfers to provide stabilizing treatment. The law does not require providers to continue treating patients once they are stable, nor does it generally apply after someone is admitted as an inpatient.

Hospitals found in violation of the law potentially face a $50,000 civil fine per incident, and can be barred from the Medicare and Medicaid programs. The law also gives dumped patients or their families the right to sue the provider.

The unfunded mandate signed into law by President Ronald Reagan sharply reduced cases of hospitals refusing to treat ED patients without insurance. Experts blame poor communication and inadequate training for most of the remaining incidents.

EMTALA—whose basic requirements are posted on the walls of every hospital ED—is widely credited with sharply reducing the number of cases of hospitals dumping or avoiding uninsured or underinsured patients.

Despite the law's positive impact, about 200 complaints a year are found to have merit. While that represents a tiny fraction of the more than 136 million annual emergency department visits in the U.S., there's broad agreement that the law continues to play an important role.

Yet, EMTALA is resented by hospital administrators and some physicians for its failure to finance its mandate. Experts say there are a variety of reasons why violations of the law continue to occur. Factors include pressure on hospitals to improve their finances, poor staff training, flawed systems and processes, communication mishaps, growing challenges in getting specialty physicians to be on-call to the ED, and a lack of inpatient beds and community resources for serving mentally ill patients.

The impetus for EMTALA was an epidemic of patient transfers that were widely seen as inappropriate and dangerous for patients, including pregnant women in labor being turned away from emergency rooms. Studies showed that in the early 1980s, there were about 250,000 transfers a year from private hospitals to public or Veterans Health Administration hospitals.

But EMTALA is no guarantee of appropriate emergency care. From 2002 to 2015, the CMS conducted 6,035 investigations of EMTALA complaints against hospitals and physicians—an average of 431 a year, according to a new study in the Western Journal of Emergency Medicine. The CMS found violations in 2,436 of the complaint cases it surveyed in conjunction with state agencies—an average of 174 a year.

To keep their Medicare certification, hospitals found in violation must submit a corrective plan, which the CMS reviews and approves. The agency then forwards those cases to the OIG for possible civil monetary penalties.

Of the cases referred to the OIG from 2002 to 2015, 192 resulted in settlements, including eight by physicians, according to the study. The most common citations were for failure to screen (75%) and stabilize (42.7%) for emergency conditions. Patients were turned away from hospitals for financial reasons in 15.6% of cases.

The original article by Harris Meyer can be found at the following address: http://www.modernhealthcare.com/article/20160326/MAGAZINE/303289881?utm_source=modernhealthcare&utm_medium=email&utm_content=20160326-MAGAZINE-303289881&utm_campaign=am. 

CMS Proposes 3-Year Penalty Delay for Accountable Care Organizations & New ACO Model

Accountable Care Organizations (ACO) are voluntary organizations that providers may choose to participate in which are comprised of doctors, hospitals, and other health care providers. The Centers for Medicare and Medicaid (CMS) created Accountable Care Organizations with the goal of coordinating care to ensure that patients get the right care at the right time while avoiding unnecessary duplicaiton of services an preventing medical errors. Currently Medicare offers the Medicare Shared Savings Program that allows ACOs to share in the savings it achieves for the Medicare program. ACOs may also be penalized for poor performance. 

Penalty Delay
However, CMS recently proposed that health care systems experimenting with a new way of being paid by Medicare would have three extra years before they could be punished for poor performance. This three-year delay is in addition to the three-year extension currently in place, for a total of six years. The proposal can be found here. The new rule applies to both new and existing ACOs. 

While ACOs wouldn't face penalties for an additional three years, any ACO that chose to avoid penalties after the initial delay period of three years would be limited to 40-percent of the money they save Medicare. There is a 50-percent maximum cut off of savings ACOs are able to keep during the first three years. 

Track Three ACO Model
The new ACO model, known as "Track Three," allows ACOs to keep up to 75-percent of the money they save Medicare. Track Three ACOs would be responsible for 15-percent of any excess spending they cost Medicare. This is higher than the 10-percent limit to the other models of ACOs that are in place now. 

Omnibus Continues Tax Breaks for Blue Cross and Blue Shield Insurance & Ups Spending to Detect Healthcare Fraud and Abuse

The 2015 Fiscal Year Omnibus Appropriations Bill provides just over $1 trillion in discretionary spending in compliance with the Murray-Ryan budget agreement and funds the majority of the federal government through Sept. 30, 2015. 

Nongermane Riders

The New York Times reports that "Steve Ellis, vice president of Taxpayers for Common Sense, a nonprofit research group that tracks federal spending, said the bill bestowed favors on all sorts of constituencies.

“Authors of the bill and lobbyists behind these provisions know they are in there,” Mr. Ellis said. “But the public will not find out about most of them for weeks or months, if ever.” Congress supposedly forswore spending earmarks several years ago, after federal largess led to several scandals. But lawmakers can still steer money in less conspicuous ways."

One example of a nongermane rider that went into the bill without public debate provides relief to nonprofit Blue Cross and Blue Shield plans, which have special tax breaks that may have been threatened by provisions in the Affordable Care Act. While Blue Cross is not mentioned by name in the legislation, the deduction is only available to Blue Cross and Blue Shield plans. Blue Cross and Blue Shield have been lobbying Congress for a clarification since the Affordable Care Act was signed in 2010.

Fraud Prevention

The Committee on Appropriations executive summary also explains that the bill provides $1.484 billion for cap adjustment funding to prevent waste, fraud, abuse and improper payments in the Medicare, Medicaid and Social Security programs. This is a $560 million increase in funding from last year's level.

A significant portion of those funds, $672 million, are dedicated to the Health Care Fraud and Abuse Control program at the Centers for Medicare and Medicaid Services. That amount more than doubles the level enacted in fiscal year 2014. One reason for the increase is that preventing fraud creates a significant savings for the government. The latest data shows that for every $1 spent on fraud and abuse control, $8.10 is recovered by the Department of Treasury. That recovery ration is the highest three-year average return on investment in the entire 17-year history of the Health Care Fraud and Abuse Control program.

Further Information

For a more comprehensive discussion of nongermane riders passed in the Omnibus see this New York Times article, "In Final Spending Bill, Salty Food and Belching Cows are Winners." The Senate Committee on Appropriations executive summary of the bill can be found here.

CMS State Innovation Models Grants Awarded

The HHS announced Tuesday that a significant portion of the $665 million in available grants was awarded to health IT programs.The District of Columbia, 28 states, and three territories received grant money to fund local experiments in improving health care. The money is the second round of grants coming from CMS's State Innovation Models initiative. A breakdown of the awarded grants can be found at the initiative website. 

Politico reports that the selected health IT projects largely focus on improving data in electronic health records and systems. Part of the $100 million New York will receive will go toward better health IT, "including greatly enhanced capacities to exchange clinical data and an all-payer database." Overall, the state is looking to create a stronger, more integrated primary care workforce and delivery system. Colorado will receive up to $65 million over four years to integrate physical and behavioral health care in primary care and community mental health center. Part of the money will expand IT efforts including telehealth. The money will also assist in integrating public health, behavioral health and primary care sectors. Data analytics is a factor in the plans for Michigan and Iowa.

CMS Boosts Coverage for Telehealth

The Centers for Medicare & Medicaid Services released new rules that significantly broaden coverage for chronic care telehealth services.The rulemaking changes are inside the 1,185-page document detailing Medicare payments to physicians and other providers. The new rules also include seven new covered procedure codes for telehealth, including annual wellness visits, psychotherapy services, and prolonged services at physicians' offices.

Health Leaders Media reports, "The American Telemedicine Association, which had sought the expanded coverage for five years, notes that among the rules are provisions that will pay for remote chronic care management using the new current procedural terminology (CPT) code 99490, with a monthly unadjusted, non-facility fee of $42.60.

"For us, it was more important to begin to specifically address chronic care," says Gary Capistrant, senior director of public policy at ATA. "The combination of the chronic care management code and being able to use it in conjunction with monitoring of those chronic conditions is a big step forward and a very substantial change for Medicare." Capistrant says the new rules also represent an acknowledgement by CMS that reimbursing for chronic care could prove to be cost effective.

"It's an important policy move. Whether it is sufficient, time will tell, but it is certainly a step in the right direction and an important initiative," he says. "There has been a lot of focus on primary care, even with the Medicare population. That may be the 80% of the people but it is only 20% of the problem. There's an increasing emphasis on looking at the 80% of the problem that is 20% of the people, and that is chronic and specialty care. They understand that the government is spending a huge amount for chronic care conditions and that there is a value managing those to reduce the overall expenditures."

CMS Names Niall Brennan First Chief Data Officer

The Centers for Medicare & Medicaid Services (CMS) today announced the formation of the Office of Enterprise Data and Analytics (OEDA) which will be led by Niall Brennan, the agency’s first Chief Data Officer (CDO), and tasked with overseeing improvements in data collection and dissemination as the agency strives to be more transparent. OEDA will help CMS better harness its vast data resources to guide decision-making and develop frameworks promoting appropriate external access to and use of data to drive higher quality, patient-centered care at a lower cost.

CMS collects a wealth of data that is critical to decision making for the agency and other stakeholders in the nation’s health care system. CMS generates data administering the Medicare, Medicaid and CHIP programs. In addition, new responsibilities, including stewardship of the EHR Incentive Programs, more expansive quality measurement programs, and the establishment of the Health Insurance Marketplaces, have expanded the scope of data that CMS collects. As CMS works to shift the focus from volume of services to better health outcomes for patients, coordinating care, and spending dollars more wisely, the need for CMS to analyze data across its multiple programs and provide greater access to this data, whether in granular or aggregate form, will only intensify.

“It’s clear how much data transparency will help the country improve outcomes, control costs and aid consumer decision making,” said CMS Principal Deputy Administrator Andy Slavitt. “This appointment signals to the industry that there is no turning back from the health care data agenda. Niall Brennan will help make sure CMS leads the way.”

The creation of this new post and the data and analytics office  builds on the steps CMS has taken in recent years to better harness its data resources both internally and externally. CMS is now routinely analyzing claims data in real time and applying predictive analytics to proactively identify fraud and abuse and track key metrics such as hospital readmissions. Accountable Care Organizations and State Medicaid agencies receive monthly near real-time feeds of Medicare data to support care coordination. CMS has launched the Virtual Research Data Center to facilitate lower cost access to CMS data for researchers and federal grantees. CMS has also released numerous public use datasets; the most notable releases to date include the release of data on hospital charges and physician utilization in 2013 and 2014.

“Our commitment to transparency is matched by our commitment to keeping personal information safeguarded. We can't expect to advance health outcomes unless we also ensure that our policies and practices around data privacy are leading the way,” said Slavitt. “We look forward to building on the success of recent releases, providing a clearer picture of the health care delivery system.”

Politico Reports: ONC Releases Meaningful Use Stage 2 Attestation Rates

Attestation rates for Stage 2 of meaningful use remained low at the end of September, according to data released ahead of today's Health IT Policy Committee meeting. The figures, contained as footnotes in an ONC data analytics update, show that 4,656 doctors and other eligible providers and 258 hospitals had attested to Stage 2. This is an increase over the end of August but still only a rounding error out of 480,000-plus eligible providers and hospitals. The low figures reflect problems that electronic health records vendors and providers have had achieving Stage 2. 

CMS relaxed the rules on reporting Stage 2 attestation earlier in the year, and provider groups have been pressing to reduce the one-year reporting period to 90 days in 2015. We have a feeling that a GOP-controlled Congress may try to do something about this.

ONC's analysis of the Sept. 30 attestation data showed disappointing levels of accomplishment in meeting some of the most important categories of Stage 2. For example, 87 percent of eligible providers who attested to Stage 2 received exclusions from showing they could electronically send summaries of care. Of those who did not receive exclusions, only 18 percent were able to send electronic summaries 80 percent of the time or more. A total of 55 percent were able to file summaries electronically 30 percent or less of the time. Scores for the "view, download or transmit" category, a measure of physicians' capacity to share data with patients, were even worse. Although 65 percent of the attesters' patients had online access to records, only 10 percent of these providers were able to get patients to download their records more than half the time.

A similarly small percentage sent patient reminders on a regular basis. In its analysis of hospitals, ONC found that only 10 percent got out electronic care summaries to patients more than half the time, and less than 15 percent were able to get more than 20 percent of their patients to view, download or transmit their records. However, as ONC pointed out, the figures represented a somewhat improved picture from analyses it did over the summer.

Many individuals are concerned about the privacy of their medical records, but that doesn't keep most of them from giving information to health care providers, according to survey results to be released at the meeting. In a survey of more than 2,000 people conducted in 2012-13 for ONC, 75 percent were "very or somewhat concerned" about the privacy of information in EHRs. But only eight percent said those concerns would cause them to withhold information from health care providers.

Politico Report: http://www.politico.com/morningehealth/1114/morningehealth15954.html

ICD-10 Transition Date Finalized for October 2015

The Centers for Medicare and Medicaid Services announced last week that the final deadline to comply with the ICD-10 implementation requirement is October 1, 2015. The tenth edition of the International Classification of Diseases is widely viewed as a significant change in the way claims that are submitted to Medicare and private insurance payers are classified. 

These changes enable providers to coordinate patients care over distance and time, improve the accuracy of patient records with more detailed patient history coding, and reduce fraudulent claims. CMS also believes that the ICD-10's granular classifications will improve the data and analytics related to public health research, surveillance, and reporting. The more specific classifications found in ICD-10 represent, in part, the evolution of diagnosis and the modern developments in medicine and medical technology used to treat patients. 

CMS released an online resource designed to help providers in small practices make a timely transition to ICD-10. The "Road to 10" is an online resource available here. The  Road to 10 breaks allows providers to select a profile based on their expertise that is specifically tailored to each speciality's common codes, clinical documentation procedures, and clinical scenarios. Additionally, the Road to 10 gives users the opportunity to create an ICD implementation action plan specifically suited to the needs of their small practices. 

Proposed Medicare Rule Leaves Hospitals Concerned About Financial Impact

The Centers for Medicare & Medicaid proposed a rule on Wednesday that makes changes to several aspects of the  Medicare payment program. The proposals were part of a wide-ranging, 1,600-plus-page proposed rule issued by the CMS outlining Medicare payment and policy changes for hospitals in 2015. A final rule is scheduled to be published August 1. The policies would be effective October 1.

Under the proposed rule the payments for inpatient treatment at acute-care hospitals will decrease by $241 million in fiscal year 2015. The proposed rule would affect over 3,000 hospitals nationwide.  In addition, the CMS proposes increasing Medicare payments to long-term-care hospitals by 0.8% in 2015, a bump of $44 million. The change in payment methodology would affect 435 facilities. Under the proposed payment rule, hospitals that successfully participate in Medicare’s quality reporting system and meet the criteria for the meaningful use of health information technology will see a payment bump of 1.3%. However, because of the penalties meted out to the hospitals that don’t, the CMS is projecting an overall reduction in payments.

Congress Passes Bill to Delay Medicare Reimbursement Cuts

On Monday evening the Senate passed and President Obama signed the Protecting Access to Medicare Act of 2014 (H.R. 4302) into law. This marks the 17th time Congress delayed the cuts to physician reimbursements established with the Sustainable Growth Rate under Medicare. The bill delays a 24% cut to the payments.

The Senate passed the bill with a 64-35 vote the evening the cuts were to go into effect at midnight. The Senate vote was preceded by the House passing the bill with a rare voice vote last week.  Both chambers moved quickly to pass this bill after it became obvious no agreement would be reached on how to pay for the permanent 'doc fix' bills.  

The Sustainable Growth Grate (SGR) was created in 1997 by Congress as a mechanism for tracking the payments with economic growth. The SGR became a problem within a few years as increases in healthcare costs substantially outpaced economic growth. This development resulted in the creation of a multi-billion dollar shortfall for the funding of Medicare payments to physicians. 

Members on both sides of the aisle and in both Chambers spoke about the need to permanently fix the SGR. However, they recognized the immediate need to prevent the delay's expiration and prioritized this temporary patch over a lengthy negotiation process to pass a  permanent fix that would result in the expiration of the SGR delay. 

CMS Issues Guidance on Stage 2 Meaningful Use Hardship Exceptions

The Centers for Medicare and Medicaid Services (CMS) issued guidance on qualifying for the hardship exception from Stage 2 meaningful use requirements under the federal electronic health record incentive payment program. CMS has been under pressure by stakeholders and lawmakers alike to provide clarification about how to apply and what conditions qualified hospitals and eligible professionals for a hardship exemption

The guidance explains that CMS may grant hospitals and eligible professionals the hardship exception and grant an extension for meeting the Stage 2 meaningful use requirements if their electronic health record (EHR) vendor is at fault for their failure to meet the deadline. This expands on previous statements by CMS Administrator Marilyn Tavenner that the applications for exceptions would be evaluated on a case-by-case basis. 

The guidance specifically states that providers may apply for hardship exceptions if the "EHR vendor was unable to obtain 2014 certification" or the hospital or eligible professional "was unable to implement meaningful use due to 2014 EHR certification delays." If approved, the hardship exception is valid for a single payment year. In the event the application for exception is denied hospitals and eligible professionals may not appeal the decision and any denial is considered final.

The hardship exception application for hospitals is available here.

The hardship exception application for eligible professionals is available here. 

CMS Looks to Limit Estate Recovery Actions for New Medicaid Recipients

Commentators on both sides of the Affordable Care Act (ACA) debate have pointed out that lower-income Americans may be deterred from enrolling in the expanded Medicaid program because of the currently estate recovery actions are allowed. An estate recovery action is a legal collection method that allow states to recover the amount of payments for long-term Medicaid services from patients after their death to repay the state for the cost of their medical care. 

This practice stems from a 1993 federal law that requires states to recoup the costs spent on long-term Medicaid services from the estates of deceased recipients. The 1993 law also gives states the option of recovering all Medicaid costs incurred from the age of 55 until death, even if they are not related to long-term care. In practice this often results in states placing a lien on the deceased's home after being notified of the death. However, states generally try not to collect the debt immediately in instances where a surviving spouse or dependent is living in the home. 

Last week the Centers for Medicare and Medicaid Services (CMS) issued a letter to state medicaid directors providing guidance that seek to limit estate recovery actions for Medicaid recipients that qualify under the ACA's Medicaid expansion program. While the letter does not compel states to follow the conditions set forth in the letter, experts say it will likely serve as a deterrent for states considering estate recovery actions against expanded Medicaid recipients. 


More discussion on Medicaid Estate Recovery and the CMS letter can be found at the following sources:

•  Asbury Park Press, Feds: Don't try to bill new Medicaid recipients after their death.
• National Senior Citizens Law Center, MAGI Medicaid and Estate Recovery: CMS Issues State Medicaid Director Letter.
• Modern Healthcare, Reform Update: Medicaid estate-recovery law may hamper enrollment efforts.

No Extension for ICD-10 Implementation

Marilyn Tavenner, Administrator for the Centers of Medicare & Medicaid Services, announced today that there will be no extension of the October 1, compliance deadline for the nationwide conversion to the ICD-10 diagnostic and procedural codes. Speaking at the Healthcare Information and Management Systems Society convention in Orlando, Florida, Tavenner also explained that CMS was not changing compliance requirements for Stage 2 despite extensive pressure on the agency. 

Stage 2 of the electronic health record incentive payment program requires providers to electronically exchange healthcare records with each other to improve the interoperability of CMS' value-based payment programs. Eligible hospitals must commence 90 consecutive days of meeting the meaningful-use criteria on schedule. The starting date for most hospitals was October 1, 2013. However eligible professionals and physicians which operate on a fiscal year must begin compliance on April 1 or July 1, 2014. 

CMS will consider extensions on a case-by-case basis for providers and health IT vendors to obtain a "hardship exemption" that will extend the deadline for that facility. Tavenner does not expect the exemptions to delay full Stage 2 implementation by 2015. 

Centers for Medicare and Medicaid Services Begins Open Payments Data Collection This Month

The Centers for Medicaid and Medicare Services (CMS) announced last week the agency is taking the first steps toward publishing data collected from healthcare providers on payments from drug and device manufacturers and group purchasing organizations. CMS is referring to the data collection initiative as the Open Payments program. 

The Open Payments program is a result of the enactment of the Physician Payments Sunshine Act. The program was enacted to increase transparency in the healthcare industry and provide the public with awareness about the financial relationships between drug and device manufacturers, group purchasing organizations and their healthcare providers. The goal is to allow patients to make informed choices when selecting a healthcare provider and in treatment decisions.

Data collection will begin February 18, 2014.  Organizations will submit data to the CMS on payments made to healthcare providers. CMS states that payments includes gifts, consulting fees and research activities. The second phase will begin in May 2014 when manufacturers submit detailed payment information. 

Healthcare providers and manufacturers will have the chance to review and correct inaccuracies in the data after both phases of collection have been completed. Following the review process CMS will post the data on payments to their website. CMS will post this data by September 30, 2014. 

CMS Extends Medicare EHR Meaningful Use Attestation Deadline to March 31, 2014

The Centers for Medicare and Medicaid Services announced an extension for some participants in the Medicare Electronic Health Records meaningful use attestation deadline. The extension did not retroactively change any requirement for the date the criteria must have been met, it merely extended the deadlines for data submission for some physicians, eligible professionals and hospitals. The deadline extensions do not apply to the Medicaid portion of the Electronic Health Records incentive payment program. The Medicaid incentive payment program does not incorporate penalties.

Both the Medicare and Medicaid Electronic Health Records incentive payment programs were created in the American Recovery and Reinvestment Act of 2009. The programs have a significant impact with payments thus far in the amount of over $19 billion to more than 320,000 physicians and other professionals and 4,400 hospitals.  


Physician and Eligible Professional Extension

The Centers for Medicare and Medicaid Services (CMS) extended the deadline for eligible professionals to attest to Electronic Health Records (EHR) meaningful use in 2013. Physicians and eligible professionals will now have until 11:59p.m. on March 31, 2014 to submit their performance data. The new deadline, extended from February 28, 2014, does not change the requirement that the criteria for meaningful use must have been met by the end of the reporting period for the incentive payments, December 31, 2013. 

A CMS press release explained that this extension would allow more time for providers to submit their meaningful-use data, receive an incentive payment for the 2013 year and avoid the 1% penalty 2015 payment adjustment. 

EPs attesting for the Medicaid program or Physicians Quality Reporting Systems incentive pilot program did not receive an extension and must complete the attestation requirements by the original deadline. 


Hospital Extension

CMS is also offering what the agency is calling a "one-time" extension to hospitals "that may have experienced difficulty attesting" by the November 31, 2013 Medicare meaningful use attestation deadline. To be eligible to participate in the deadline extension hospitals must contact CMS by 11:59p.m March 15, 2014 for assistance. 

This extension will allow eligible hospitals to receive incentive payments under the program and avoid the price adjustments effective in 2015. 

Like the extension for physicians, the extension for hospitals does not change the deadline for the date the meaningful use criteria must have been met. The implementation deadline for the hospitals program, which operates on the fiscal year, was September 30, 2013. 


Resources
A Modern Healthcare article discussing the extension is available here.

A Medscape article discussing the extension and incentive payments is available here. 

A FierceHealthIT article discussing industry representative opinions on the extension is available here. 

A user guide for eligible professionals on meaningful use attestation is available here. 

A user guide for eligible hospitals on meaningful use attestation is available here.

The EHR Information Center is Open Monday-Friday from 8:30a.m.-5:30p.m. EST. The toll-free number to reach the center for assistance with meaningful use attestation is 1-888-734-6433. 

CMS' Two-Midnight Rule: Who Must Sign Off?

The Centers for Medicare and Medicaid Services (CMS) announced a clarification to the ‘Two-Midnight Rule’ this week that a physician must sign off on the admitting paperwork for Medicare beneficiaries. CMS published the two-midnight policy in an effort to explain when a Medicare beneficiary may qualify for overnight care versus outpatient care. This distinction is important to hospitals because the payment to the hospital is higher for overnight stays than for outpatient care. The rule initially established that a physician must have good reason to believe that a patient will require two nights in the hospital to qualify for the higher hospital rate from Medicare.

The clarification requires physicians to sign off on the admitting paperwork for Medicare beneficiaries before the patient is discharged. By signing the admitting paperwork the physicians are accepting responsibility for the determination that there is good reason the patient will require two nights in the hospital. Medicare's recovery auditors will not audit inpatient claims under the two-midnight rule until after Sept. 30, 2014.  

A hospital may still comply with the regulation if a non-physician staffer writes the admitting order into the medical record, even if the recording staffer does not have the independent authority to admit a patient. However, in all cases the physician must sign the admitting paperwork prior to the patient's release. 

For example, a hospital will be in compliance with the regulation if a nurse documents a physician's verbal order to admit a patient in the medical record if the physician signs the decision before the patient leaves the hospital. Similarly, residents, physician assistants and nurse practitioners may write the inpatient admitting order as a proxy for a physician so long as the physician signs the order before the patient is discharged. In every case the physician's signature represents that she approves and accepts responsibility for the admission decision.

Hospitals may still be compensated in cases when a doctor later refuses to sign the admitting order.  However, they will be compensated at outpatient rates. The hospitals must send the bills through Medicare's Part B system for outpatient care.  


CMS' Two-Midnight Policy can be found here. 

"Balance Billing" from In-Network Hospitals Leaves Patients Shocked

In emergent situations paperwork is often the last thing on a patient's mind. Patients that have the wherewithal to remember to choose an in-network hospital to avoid large bills for treatment assume that they may be treated by any physician in the hospital and their insurance will cover the treatment. Unfortunately, many find out this is not true several weeks later with the arrival of a hefty "balance bill."

Balance billing is a common practice that bills the patient for the remainder of the cost of treatment that the insurance refused to pay because the treating physician was not out-of-network, even though she practices at a hospital that was in-network.

These unexpected bills can have huge consequences on patients and their families. NBC 5, in Texas, recently ran a story about Melinda Allen, a patient at the Texas Harris Methodist Hospital emergency room. Allen woke up on a Saturday with intense abdominal pain. She had her husband take her a hospital she knew was in-network. Several tests later Allen was diagnosed with an ovarian tumor large enough to require surgery.

The billing was less straightforward than her treatment plan. Allen paid nearly $5,000 out-of-pocket for her treatment, in addition to her $1,500 monthly premium. Allen assumed her insurance would cover the rest since she was treated at an in-network hospital. Allen was shocked when she later received a bill for nearly $700. 

The amount of the bill Allen received  was the balance left over from the price of the treatment charged by the emergency room doctor and the price her insurance company felt was appropriate. 

This practice leaves the patient to sort out the claim with their insurance company. "People are really vulnerable when they go into an emergency room," Stacey Pogue of the Center for Public Policy Priorities explained. "It's unfortunate, again, that we're put in that position because insurance companies and doctors can't decide what is appropriate reimbursement."

In situations like Allen's where does the blame fall? Allen chose an in-network hospital. Physicians, by law, are not allowed to ask about insurance and must treat all patients regardless of their ability to pay. Should the in-take process include a list of in-network and out-of-network physicians? 

CMS Revises Hospital Accreditation Program Requirements "Medications Management" Language

The Centers for Medicare and Medicaid Services (CMS) revised the language for Joint Commission standards of Conditions of Participation. The agency explained the revisions, published on Dec. 19, 2013, were issued to maintain uniformity within the Leadership and Medication Management chapters applicable to hospitals and critical access hospitals. 

The revisions remove the term "polysaccharide" from the list of vaccines requiring a specific order from a doctor to administer to a patient for both hospitals and critical access hospitals. The revisions also removes "inpatient hospital care" from the element of performance criterion specifying the types of services required to be provided to patients by critical access hospitals. 

The prepublication notice applicable to hospitals is available here. The prepublication notice applicable to critical access hospitals is available here. 

Affordable Care Act’s Provisions to Reduce Preventable Medicare Patient Hospital Readmissions are a Continued Success

The Affordable Care Act put several programs into place to curb Medicare beneficiaries readmission rates. The readmission rate, a measurement of how many patients are readmitted to the hospital within 30 days of initial discharge, is viewed as an indicator of the quality of care a hospital provides. 

The Centers for Medicare & Medicaid Services (CMS) reported that the average avoidable readmission rate for Medicare beneficiaries under 18% from January - August 2013. This is less than the 19% readmission rate that was the standard for the previous five years.  A 2012 study found that readmission rates were on a decline in 2012. The 2013 preliminary claims data combined with the 2012 data results in an estimated 130,000 fewer hospital readmissions from 2012-2013.

CMS attributes the decline in readmission rates to the improved care programs such as community-based care transition plans and payment incentives such as the Hospital Readmissions Reduction Program helped foster. 

More information on the CMS blog is available here. The study that determined Medicare readmission rates had a meaningful decline is available here. Information on the Hospital Readmissions Reduction Program is available here. 

Many Hospitals Concerned about Final CMS Payment Rules

The Centers for Medicare and Medicaid Services (CMS) announced a final rule for hospital outpatient services, or the Outpatient Prospective Payment System (OPPS), this November. The CMS estimates that the rule will increase payments for hospital outpatient departments by 1.7 percent. The new rule will be effective January 1, 2014; however, CMS will delay implementation and final configuration of the new 29 comprehensive APCs until 2015.

The rule will create 29 comprehensive Ambulatory Payment Classifications (APCs) to handle payment for device-dependent services and will require direct supervision for a range of outpatient services in critical access hospitals (CAHs). 

This rule combines five payment codes into a single payment code that covers all outpatient clinic visits. The outpatient clinic visits code will include drugs, biologicals, and radiopharmaceuticals used in a diagnostic test or surgical procedure, lab services and device removal procedures. The American Hospital Association believes that the payments will be well below the cost of treatment for complex patients.

The Access to Medical Imaging Coalition is concerned that the rule will dramatically reduce the outpatient payments to hospitals for CT scans and MRI services. The group is concerned because the rule will establish similar reimbursement rates for a CT scan and x-ray image of the same body part even though a CT scan requires more expensive equipment and is more expensive to adminster. 

Many hospitals are concerned about being able to implement the changes required by the rule by January 1, 2014, the date the rule becomes effective.