It Looks Like 2014 Will Fulfill The Chinese Curse: “May You Live In Interesting Times.”
December 31, 2013
Posted by Frank Ciesla
Providers enter 2014 with a background of 5,000,000 policies being cancelled as of December 31, 2013. One million individuals potentially signed up under the exchanges, however, it is not clear how much of that information has been appropriately transferred to the insurance companies and whether or not the insurance companies have activated those policies by receiving payment or will activate those policies if payment is received by January 10. For some providers it may not be clear as to whether or not they are in the network and entitled to payment from the insurance company or they are out of network and the payment will have to be made by the patient.
In addition, it is not clear whether any of the individuals whose policies were cancelled have been able to obtain “bare bone policies” that are effective as of January 1, 2014.
Providers need to be prepared to take different approaches on how they will be paid for the care rendered during the first 15 days of January. It may become clear during that period of time as to what will occur or the era of uncertainty may continue through the month of January.
Unlike insurance companies, the government has not provided a safe harbor for providers. What is also clear is that the insurance companies, as has been demonstrated as to this point in time, will be aggressive in their creation of networks and payment for services rendered.
CONFUSION
December 19, 2013
Posted by Frank Ciesla
Obviously events in the Affordable Care Act area are breaking fairly quickly. As you may or may not be aware, the Administration has asked the insurance companies to provide insurance for those individuals who pay for their insurance coverage by January 10th. It is my understanding that certain carriers are willing to accept the January 10th date. Others are setting their own dates. The Administration has requested that insurers provide for the insurance policy that the individual has purchased to be effective on January 1, assuming they make the payment by January 10th or whatever deadline is set by the insurance company.
This creates problems for the providers.
1. What happens in those circumstances where care is rendered between the 1st of January and the 10th of January and the premium is not paid? Who bears the risk in this? Obviously, the patient would then owe the provider for the care, but if the patient never pays the premium, it will put the burden on the provider to chase the patient to get paid for the care rendered.
2. Even assuming the patient makes the payment of the insurance premium, is the provider in the network of the insurance policy that has been purchased by the patient? If not, will the insurance company make the payment to the provider, and if so, what amount will the payment be? Additionally, will the individual’s policy deductible require the insured to make payment, even if the insurance policy is in effect or comes into effect as of January 10th, since the amount of the medical bills up to that point in time would more than likely be below the deductible?
All of these attempted Band-Aids used to move the deadlines for the implementation of the Affordable Care Act will impose burdens upon the providers who provide care during the first half of January 2014.
ANY WILLING PROVIDER LAWS PROPOSED
December 18, 2013
Posted by Frank Ciesla
There are many skirmishes taking place in the implementation of the Affordable Care Act. One deals with the narrowing of the provider networks, resulting in the exclusion of a number of providers from the networks being offered under the various plans on the exchanges, and in some cases, even those plans being offered outside of the exchanges.
As pointed out in our prior blogs, this, of course, could potentially upset the relationship of patients to their providers. Attached is a just released survey indicating that most New Jersey residents value the ability to pick their own doctors over the cost of their insurance program. Obviously, to the extent that their insurance program becomes unaffordable, that is not a choice they will have.
This brings us to the new skirmish as set forth in the attached article “Six States Serve as Narrow Network Battleground” which indicates the consideration in some states of any willing provider statutes, which would require the insurance companies to include any provider who is willing to accept the terms being offered by the insurance carrier as providers in the network. This is a reprise of the battles that took place in the heyday of HMOs. To accomplish the objectives of most patients, it will be essential for states to migrate towards either the any willing provider legislation or some version of it, requiring insurance companies to include providers in their networks. That approach may have a negative impact upon the financial actuarial assumptions being made and the pricing of those policies.
This is a skirmish which has just begun and will continue, not only because of its impact upon the individual marketplace, but also upon all insurance marketplaces, including the employer-provided marketplace.
Extension of Affordable Care Act Sign-Up Deadlines May Create Insurance Verification Uncertainty For Providers
December 17, 2013
Posted by Beth Christian
Last week, the Centers for Medicare and Medicaid Services (“CMS”) issued an interim final rule which requires insurers to provide coverage effective January 1, 2014 through the health insurance exchanges to any individual who selects coverage through December 23, 2013. In the preamble to the interim final rule, CMS stated that “ an effective coverage date of January 1, 2014 means that the individual must receive coverage for any services received on or after that date, even if the payment and enrollment are not processed by that time.” As a result, providers may have difficulty verifying insurance coverage during the month of January for individuals obtaining coverage through the exchanges, since at least initially they may not have insurance identification cards, and may not even have their payment or enrollment processed by their insurer. Providers should be prepared for administrative uncertainty and frustration in the month of January as a result of the movement of the deadline and the likelihood that insurers will be struggling to keep up with enrollment volume. There is no assurance that the provider will be paid by an insurance company for the care rendered in that the patient may not have coverage or the provider may not be in the network. The provider will then be left to seek payment from the patient. As providers are aware, this is neither an effective nor comfortable position to be placed in.
UNITED HEALTHCARE ENJOINED FROM TERMINATING PHYSICIANS FROM MEDICARE ADVANTAGE PLANS IN CONNECTICUT
December 16, 2013
Posted by Beth Christian
On December 5, 2013, Judge Stefan Underhill of the U.S. District Court for the District of Connecticut issued a temporary restraining order and preliminary injunction against various United Healthcare (“United”) entities that had terminated approximately 2,200 Connecticut physicians as participating physicians in United’s Medicare Advantage program. After a number of its members received termination letters, the Fairfield County and Hartford County Medical Associations filed an emergency motion for a temporary restraining order and preliminary injunction seeking to: (1) enjoin United from terminating any of the affected physicians from United’s Medicare Advantage network; (2) enjoin United from notifying its Medicare Advantage customers that certain physician members would be terminated from the Medicare Advantage network as of February 1, 2014; (3) compel United to reinstate, advertise, and market the affected physicians in their 2014 directories for the Medicare Advantage network. The court found that the physicians who were subject to termination would suffer (1) disruption of their relationships with their Medicare Advantage patients; (2) loss of goodwill and reputational harm, and (3) a resulting loss of the ability to compete in the market for the provision of Medicare services. The court also found that the plaintiffs were likely to prevail on their breach of contract claims, in that United’s argument that it had a unilateral right to terminate a participating physician by “amending” the United Medicare Advantage Plan was not supported by the language of the contract or the parties’ actual experience under it. Based on these factors, the court entered a preliminary injunction to prevent the removal of affected physicians from United’s Medicare Advantage network pending a determination on the merits of the claims filed by the Medical Associations.
There have been a number of physicians terminated from Medicare Advantage Plans in New Jersey. In some cases, physicians have received termination letters from United Health Care. However, we have heard anecdotal evidence that other physicians have heard about the terminations not from United Health Care, but from patients who were notified of the termination during the Medicare Advantage Open Enrollment period (which has already closed). The preliminary injunction issued against the United Healthcare entities is only effective in Connecticut. To the extent a physician in New Jersey has received notice of their termination from participation in United Healthcare’s Medicare Advantage plans, or has otherwise heard of such termination, anecdotally, they should consider reviewing their existing United Healthcare Medicare Advantage contracts with legal counsel to determine whether or not it would be appropriate to appeal from the United Healthcare determination (or otherwise contact United Healthcare regarding information received from patients regarding the physician’s termination).
“Doc Fix” – The Continuing Saga of the Sustainable Growth Rate
December 13, 2013
Posted by Frank Ciesla
To continue our reporting on the implementation of the Sustainable Growth Rate (“SGR”), as we write this on Friday the 13th, 2013, both the House and the Senate are considering bills, that would permanently address the SGR solution (euphemistically known as the “Doc Fix”). The major difference between the two bills being considered is that the House Bill permits a slight annual increase in the rates over a three to four year period and the Senate permits no increase in the rates over a 10 year period. Both bills do address some methodology of providing additional payments to doctors based upon quality standards.
CMS has already issued regulations reducing the Medicare reimbursement rates starting January 1, 2014 by approximately 24%.
It is clear that the current pending “Doc Fix” legislation” will not be enacted prior to December 31, 2013. Therefore, unless other action is taken, the reduced Medicare reimbursement rates for physicians will go into effect.
As part of the proposed “budget settlement”, there is a three month delay on the implementation of new Medicare reimbursement rates. This bill has passed the House and is waiting action by the Senate. Should this bill pass the Senate and be signed by the President, then the cuts to the Medicare reimbursements will be delayed for three months. Hopefully, this will provide time for the Congress and the President to enact the “Doc Fix” legislation.
Regrettably neither the Senate version nor the House version of the “Doc Fix” provides adequate reimbursement to cover the increased costs being experienced by physician practices nor does it provide the extra capital necessary for those practices to implement both the electronic and other requirements being imposed upon practices by both legislation and regulations.
Another major hurdle is where Congress will get the money for funding the “Doc Fix”. It is likely that until that issue is resolved, the “Doc Fix” will not be enacted into law.
HORIZON DECISION
December 12, 2013
Posted by Frank Ciesla
As everyone should be aware by now, Horizon has made the decision that it will not extend the policies it cancelled, even though both the President and the Commissioner of Insurance in New Jersey have authorized them to do so. It appears clear that the position of Horizon is that it has committed its resources, going forward, to only plans compatible with the Affordable Care Act.
As a provider, this could create problems for you in that the patients who you treat may select a different insurance provider on the exchange as the result of not being able to renew their Horizon policy, which will impact the patient-doctor relationship, depending on whether or not you are in network for the purposes of that policy. As we pointed out in prior blogs, the other issue that you need to be concerned about, even though you may be in the network, are that physicians to whom you have referred this patient for additional care or institutions to which you have referred this patient, may no longer be in that network.
The additional change for your practice will be reorienting your staff towards the deductibles and the copays under the various levels of bronze, silver, gold or platinum policies.
In light of this business decision by Horizon, it would appear that as employer policies come up for renewal, Horizon will be looking at conforming them to the requirements of the Affordable Care Act probably, during 2014 and certainly, unless the waiver is extended, for 2015. This, of course, will impact a much greater number of patients and beneficiaries, which will have an impact on a much greater number of providers.
No Physician Shortage
December 5, 2013
Posted by Frank Ciesla
In today’s New York Times (December 5, 2013), a guest editorial by Scott Gottlieb, an internist and fellow at the American Enterprise Institute; and Ezekiel J. Emmanuel, the former health care policy advisor to the Obama Administration; representatives of both the right and the left, argue that there will not be a doctor shortage due to both the growth of technology as well as the shifting of care to limited licensed personnel, such as nurse practitioners, health aides, pharmacists, dieticians, psychologists, and others. This reference to the expansion of the provision of services by limited licensed individuals, has been referenced previously in our blog (http://www.njhealthcareblog.com/2013/10/expansion-of-the-scope-of-practice-of-non-physicians-a-harbinger-of-things-to-come/) of October 10, 2013, discussing the issue of the standard of care that will be applied for malpractice as well as the reimbursement when the care is provided by such limited licensed provider.
As they state in the article “that means expanding the scope of practice laws for nurse practitioners and pharmacists to allow them to provide comprehensive primary care, changing laws inhibiting telemedicine across state lines and reforming medical malpractice laws that force providers to stick with inefficient practice simply to reduce liability or risk.” Further, the article states that “new payment models must reward investments in technology that can save money in the long run”. The bottom line is that “most important, we need to change medical school curriculum to provide training in team care to take full advantage of the capabilities of nonphysicians in caring for patients.”
The relationship between the patient and their physician obviously will be radically changed in this environment. We are already progressing towards that radical alteration of the relationship in the expansion of the state statutes regarding limited licensed practitioners as well as in the creation of new delivery systems, such as the ACOs, whether they be ACOs under the Affordable Care Act, ACOs under State Medicaid laws, or ACOs created by third party payors or in conjunction with third party payors.
This probably is necessary to reduce the cost of health care, since the cost of educating physicians must be recovered one way or the other, in the cost of providing health care. It is obviously less expensive to educate a nurse practitioner, a physician’s assistant or other limited licensed practitioners. In the future, it may be that you can keep your doctor, but you will rarely see your doctor. You will be treated primarily by limited licensed individuals.
This projection as to the future must be considered by all providers, whether they are physicians or other limited licensed individuals or licensed hospitals, clinics, etc. in structuring and investing in how they will deliver care in the future. One of the key questions going forward will be, will you be able to recover the investment and some return on that investment under the payment system that will evolve?
CMS ADDS PAYMENT FOR CHRONIC CARE MANAGEMENT SERVICES TO MEDICARE PHYSICIAN FEE SCHEDULE
December 4, 2013
Posted by Beth Christian
CMS has published the Medicare Physician Fee Schedule Final Rule for 2014. One of the modifications adopted by CMS is the implementation of a separate payment for chronic care management services under the Physician Fee Schedule starting in calendar year 2015. The separate payment will be made for chronic care management services furnished to patients with multiple chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Chronic Care management services will include the following:
- The provision of 24-hour- a-day, 7-day- a-week access to address a patient’s acute chronic care needs.
- Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
- Care management for chronic conditions including systematic assessment of the patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications. The practitioner furnishing chronic care management services must create a patient-centered plan of care document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care will typically include, but will not be limited to, the following elements: problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions, medication management, community/social services ordered, how the services of agencies and specialists unconnected to the practice will be directed/coordinated, identification of the individuals responsible for each intervention, requirements for periodic review and, when applicable, revision, of the care plan.
- Management of care transitions within health care, including referrals to other clinicians, visits following a patient visit to an emergency department, and visits following discharges from hospitals and skilled nursing facilities. The practice must be able to facilitate communication of relevant patient information through electronic exchange of a summary care record with other health care providers regarding these transitions. The practice must also have qualified personnel who are available to deliver transitional care services to a patient in a timely way so as to reduce the need for repeat visits to emergency departments and re-admissions to hospitals and skilled nursing facilities.
- Coordination with home and community based clinical service providers required to support a patient’s psychosocial needs and functional deficits, with communication to and from home and community based providers documented in the practice’s medical record system.
- Enhanced opportunities for a patient and caregiver to communicate with the provider regarding the patient’s care through not only the telephone but also through the use of secure messaging, internet or other non face-to-face consultation methods.
The addition of a payment category for chronic care management services evidences a recognition on the part of CMS that physicians and other clinicians are spending a significant amount of time providing care coordination services that are not adequately compensated under existing evaluation and management codes. It is also evidence of the continued focus by CMS on the furtherance of the patient-centered medical home model, the reduction of hospital re-admissions and an increased reliance on technology and non-face to face methods to coordinate the delivery of care.
Annual Fee On Insurers To Impact Small Businesses
November 26, 2013
Posted by Ari G. Burd
As part of the Affordable Care Act, beginning in 2014, health insurance companies will be charged additional fees and costs, including a $63 per person tax on each person covered. Because the vast majority of large businesses (200 employees or more) are self-insured and do not use managed care plans, the Congressional Budget Office is predicting that small businesses and consumers will bear the brunt of these costs in the form of higher premiums. Current predictions are for increases of between 1.9% to 2.3% in 2014. The majority of the money raised will ill go into a fund administered by the Health and Human Services Department. According to the regulation, the fund is “intended to help millions of Americans purchase affordable health insurance, reduce unreimbursed usage of hospital and other medical facilities by the uninsured and thereby lower medical expenses and premiums for all.”
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