Healthcare Enrollment May Be Stifled By Federal Website Maintenance

Consumers attempting to complete health insurance applications through online healthcare exchanges before the February 15th deadline may be frustrated this weekend. February 15 is the deadline to apply for coverage that will begin on March 1. 

The Department of Health and Human Services (HHS) announced Monday that heavy maintenance to the Social Security Administration's website (SS) will result in the inability of HealthCare.gov to verify Social Security numbers and other personal details required for coverage under the Affordable Care Act. 

The maintenance is expected to begin Saturday, February 15 at 3p.m. and end Tuesday, February 18 at 5a.m. Those consumers that are affected by the website maintenance should phone the federal call center on Tuesday to arrange for coverage March 1. The number to the federal call center is 1-800-318-2596.

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. 

Obama Administration Announces Health Insurance Mandate Delay and Reduction of Percentage of Workers Covered Requirements

The Obama Administration announced changes in the implementation of the Affordable Care Act provisions related to the employer mandate for "medium-sized" businesses.  The provisions were originally drafted to go into effect this year. 

The changes in implementation deadlines do not affect most businesses. Companies with fewer than 50 workers remain exempt from the mandate. 

First, the deadline to meet the coverage requirements under the mandate for medium-sized businesses, companies that employ between 50 and 99 workers, has been delayed until January 1, 2016. The delay is conditional and requires companies to promise that the employer will neither cut an employees' hours nor let go of employees for the purpose of making their business qualify as a "medium-sized" business with 50-99 workers. Officials describe the verification process of this promise as "self-attestation" and the IRS has not provided information on how it will determine the companies' veracity. 

White House advisor Phil Schiliro explained the reasoning behind the change, "For the two-percent of American businesses that have between 50 and 99 employees, the Treasury Department concluded that a phase-in was the most common-sense way to implement the law." 

The employer provisions will go into effect for companies that do fall into categories covered by the employer mandate that do not have 50-99 workers. However, the requirement that the employers offer coverage to 95% of their full-time employees by January 1, 2015 has been reduced by 25%. The employers will now be required to offer coverage to 70% of their full-time employees by January 1, 2015. The Treasury Department's final rules state that the requirement for employers to offer coverage to 95% of their full-time employees has been delayed until 2016. 

Other changes affect seasonal workforces, adjunct faculty and volunteer firefighters and paramedics. Seasonal workers that work less than six months will not be considered full-time employees. The changes include a method for estimating the hours of adjunct faculty that accounts for hours spent working outside the classroom. The Administration's promise that volunteer firefighters and paramedics would not be considered full-time employees was formally implemented in the most recent changes. 

Many commentators are suggesting that the adjustments in implementation deadlines and requirements for businesses will increase pressure on the Obama Administration to extend deadlines for individuals so that they are not subject to the $95 or 1% of income fine for failing to purchase health insurance this year. Other experts counter that extending the deadline for individuals would result in fewer healthy individuals signing up now which could drastically shift the ratio of sick-to-healthy individuals enrolled. If too many individuals with significant health problems enroll without the balance of healthy individuals it could make the price of coverage more expensive. 

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? 

Congressional Gridlock Stalls Hopes for National Patient Identifier and Meaningful Use Stage 2 Delay

Many in the health IT field believe that implementing a national patient identifier and a deadline extension for stage 2 meaningful use requirements would ensure a more cohesive operation of patient access and identification systems and increase patient safety.  Both of these problems require congressional action to solve, but with a Congress that fails to pass even the most basic pieces of legislation and appropriations it is unlikely there will be any legislation addressing these issues in the year to come.

National Patient Identifier

A national patient identifier would go far to improve patient safety by improving the accuracy with which patients are matched with their medical records.  Ideally, a national patient identifier would be a unique number for each patient with a two-digit checksum at the end of the number. In practice this would allow a patient’s data to move completely through multiple data systems without comingling with other patients’ records that may contain similar names, addresses and other identifying factors.

However, the likelihood of legislation requiring a national patient identifier is very slim after Congress voted to overturn a HIPAA provision that would have required a patient identifier in 1998. Congressional opposition focused on privacy concerns and the capability providers have to identify patients with several different identifying factors. Former national health IT coordinator Farzad Mostashari, M.D., explained that he believed the odds were very low for a national patient identifier and that it would require the industry proving they are unable to keep patients straight by cross-checking a patient’s identity with other identifying factors available to the provider.

Meaningful Use Incentive Program

The electronic health records meaningful use incentive program was created to advance the adoption of health information technology nationwide. Beginning in 2014 eligible hospitals and professionals will have to comply with stage 2 of the regulatory standards in order to receive corresponding incentive payments. 

Senator Alexander and Senator Thune, along with 15 other Senators, wrote a letter to HHS Secretary Kathleen Sebelius requesting more time for implementation of stage 2 standards. Their letter stated, “If the goal is to improve care by achieving broad and meaningful utilization of EHRs, providing sufficient time to ensure a safe, orderly transition through Stage 2 is critical to having stakeholder buy-in, a necessary component of long-term success.

However, former national health IT coordinator Farzad Mostashari, M.D., does not think that this extension will be granted.  Without speaking to the merit of the request, Mostashari recently told a group gathered at the CHIME Fall Forum that the extension would take up to a year to approve, and the extension requested is a year. The overlap would through U.S. health IT into “total chaos” due to the uncertainty during the rulemaking process to amend the schedule.

 Resources

Don Fluckinger’s article, “Shut down thoughts of a national patient identifier,stage 2 extension,” 

A podcast discussing the benefits of a national patient identifier can be found here. 

Alexander-Thune Letter from 17 Senators to Secretary Kathleen Sebelius requesting a meaningful use stage 2 delay can be found here.