New Requirements For Providers And Certain Types Of Vendors
November 26, 2013
Posted by Ari G. Burd
Generally, a Business Associate Agreement is a written agreement between a Covered Entity (Doctor, Clinic, Hospital, HMO, etc) and a Business Associate that establishes the permitted and required uses and disclosures of personal health information by the Business Associate. Most often, a Business Associate is a vendor who creates, receives, maintains or transmits personal health information. Although a Business Associate can provide a variety of different services, the most common services provided will usually be billing services, claims processing, data analysis and electronic storage. Read more
UNCERTAINTY CONTINUES
November 21, 2013
Posted by Frank Ciesla
Attached is a Washington Post article and an Associated Press article which highlight, from the patient beneficiary point of view, one of the next big issues in the Affordable Care Act implementation. That issue is the narrowing of the provider networks which will significantly reduce the patient beneficiary’s choice of providers. This could result in the patient beneficiary not being able to keep their current providers. As I pointed out in our prior blog, that information right now does not appear to be readily available to the patient beneficiaries.
I also pointed out in our prior blog that while you, as a provider, may be in the network, the physicians or other providers to whom you refer may not be in the network so this will force you to rearrange your referral pattern. You may also not be in the network and no longer be able to maintain the professional relationship with the patient.
As time goes by, it is clear that more and more of the disruptions to both patient/beneficiary and the providers that will be caused by the Affordable Care Act are surfacing and being discussed.
The ObamaCare Rollout Debacle Impact on Providers
November 18, 2013
Posted by Frank Ciesla
While the media is focused on the impact on the patients/beneficiaries, the failures of the rollout have significant impact on the providers.
One of the most significant impacts is the cancellation of numerous health insurance policies (so far approximately 800,000 in New Jersey) and a necessity for these individuals to have obtained new insurance policies by December 15th. A failure to obtain those policies by December 15th, will result in the individuals not being covered by insurance on January 1. At this point in time, it is not clear whether the President’s “fix’ can or will be implemented and whether it is doable as a practical matter by the states and/or the insurance companies. This, of course, is a major impact on the beneficiary/patient, but it is also a major impact on the providers. These individuals, not able to obtain insurance, will now fall into the category of the uninsured, impacting the payments for services rendered by the providers, to these beneficiaries/patients.
For those lucky enough to obtain insurance by January 1, those policies may have a significant deductible. Again, while this has a substantial impact on the patient/beneficiary, it has a substantial impact on the providers. Under those policies, the providers will not be paid by the third party payors until the patient has exhausted their deductible. Providers will, therefore, need to pursue the procedures, which they now have for collecting deductibles, in a much greater number of situations, than in today’s environment, where the deductible is generally a much lower deductible, than could be in effect under the selected insurance policy going forward.
In addition, there is no guarantee that the new policies obtained by the patient/beneficiary will have the same provider network. This, of course, has two impacts upon providers. The first impact obviously is whether or not the provider is in the new network, so that they can continue rendering care to the patient, as an in network provider, but in addition, whether or not the providers, to whom the provider refers this patient for other care, are also in the network. There is no assurance that the patient’s care patterns will not be disrupted, even if they are able to obtain new insurance that complies with the requirements of the Affordable Care Act.
If the proposed “fix” is not implemented on a wide basis, the patient/beneficiaries, whose policies have been cancelled, have two possible choices for obtaining replacement policies. Under either choice, the policies must meet the requirements of the Affordable Care Act. The first choice is for the patient to be able to obtain a policy from their current insurance carrier, that is consistent with the Affordable Care Act and not have to go onto the problem-plagued health insurance exchange website. However, obtaining insurance through this route denies the patient/beneficiary a subsidy. To the extent the patient/beneficiary qualifies for a subsidy, they can only obtain that subsidy, if they obtain their insurance through the website or in New Jersey the “alternative” federal enrollment process, which ultimately is through the website.
While the next 30 days are critical to the patient/beneficiary, they are also critical to the providers, who will want to know whether or not their current patients will be able to continue to have insurance, as of January 1, that will permit them to continue to access and use their current providers.
One of the additional difficulties in the current federal enrollment environment appears to be the fact that patients/beneficiaries do not have ready access to the network of physicians or other providers, who are in the various insurance product networks, that are now being made available, effective January 1 and, whether or not other physicians, who are presently providing care to these patients/beneficiaries are in that network.
It is very likely that the provider will have to take the pro-active step of informing patients as to what networks they, the provider, are in.
Issue of Future Reimbursement Follow-Up
November 14, 2013
Posted by Frank Ciesla
Following up on Tuesday’s blog is a link to a Modern Healthcare article (which you may need a user name/password for) regarding the issue of tying “quality” to physician reimbursement.
In addition, in light of the ObamaCare rollout fiasco, both the failure to have people enroll as well as the insurance cancellations, it appears that the attention in Congress and the media are now focused on resolving the issues arising from this fiasco. It is not at all clear whether or not there will be appropriate attention paid and action taken in regard to the Sustainable Growth Rate issue, which needs to be resolved by December 31st, otherwise physicians will sustain a substantial reduction in payments for care rendered to Medicare beneficiaries.
As we have in other years, we will keep you informed as to significant proposed solutions in the countdown to December 31st, and whether or not and how this issue is resolved.
Issue of Future Reimbursement
November 12, 2013
Posted by Frank Ciesla
Attached is a link to the news release regarding Horizon’s announcement for ACOs and PCMHs. One of the most important parts of the article is the quote from Linda J. Schwimmer where she stated, “(This will only work) if the providers actually do manage patients well and have all the things that drive down cost.” She also stated, “There are specific things the doctors are going to need to do to drive down costs and hit the quality metrics.”
In joining either of these delivery systems, providers must be careful to review the rates they will be paid, the calculation of the quality metrics, what they will be paid if they meet the quality metrics, and their ability or the ability of the delivery system to compel the beneficiary/patients to conform to the required medical regimen so that the metrics can be met.
Currently, the noncompliance by patients with the medical regime prescribed by the physician or other providers, is on the third party payors. This clearly is an attempt by Horizon to shift that risk and the expenses incurred, as a result of the patient’s noncompliance, to the provider.
Physician Payment: The Issues Never End
November 1, 2013
Posted by Frank Ciesla
In light of all of the issues facing the Congress—the budget, the debt ceiling, the sequester—an issue of substantial importance to providers is the automatic Medicare cut to fees paid to providers which will go into effect on January 1, 2014. The implementation of the Sustainable Growth Rate (SGR) will impact the ability of physician practices or other health care providers, who are providing physician services, to Medicare patients to be adequately reimbursed for the services provided. We have discussed this in numerous blogs [(1) http://www.njhealthcareblog.com/2013/08/sgr-update/; (2) http://www.njhealthcareblog.com/2013/06/2013-annual-report-of-the-board-of-trustees-of-the-federal-hospital-insurance-and-federal-supplemental-medical-insurance-trust-funds/; (3) http://www.njhealthcareblog.com/2012/12/sustainable-growth-rate-here-we-go-again/; (4) http://www.njhealthcareblog.com/2012/12/physician-payment-rates-2/; (5) http://www.njhealthcareblog.com/2012/11/post-election-update-regarding-the-affordable-care-act/; (6) http://www.njhealthcareblog.com/2012/08/update-on-sustainable-growth-rate; (7) http://www.njhealthcareblog.com/2012/04/medicare-solvency-a-continuing-challenge-update/; (8) http://www.njhealthcareblog.com/2012/02/no-valentine-to-physicians-from-congress-as-sgr-issue-remains-unresolved/; (9) http://www.njhealthcareblog.com/2011/12/imminent-withholding-of-medicare-physician-payments-appears-likely/; (10) http://www.njhealthcareblog.com/2011/12/still-no-action-on-sustainable-growth-rate-fix/; (11) http://www.njhealthcareblog.com/2011/11/update-of-sustainable-growth-rate/; (12) http://www.njhealthcareblog.com/2011/10/healthcare-reform-developments/; (13) http://www.njhealthcareblog.com/2011/10/sustainable-growth-rate-sgr/; (14) http://www.njhealthcareblog.com/2011/07/another-round-of-potential-physician-reimbursement-redutions/; (15) http://www.njhealthcareblog.com/2011/05/sustainable-growth-rate/; (16) http://www.njhealthcareblog.com/2011/05/medicare-balance-billing/; (17) http://www.njhealthcareblog.com/2011/04/the-confluence-of-the-sustainable-growth-rate-and-the-deficit/; (19) http://www.njhealthcareblog.com/2010/10/blog-%E2%80%93-medicare-trust-fund-solvent-thru-2029-maybe/]. We have also discussed the notice that a physician must provide to Medicare patients if a physician no longer wants to take care of them.
Following is a link to an article (http://www.bloomberg.com/news/2013-10-31/lawmakers-want-to-stop-fee-for-service-medicare-payments.html) in regard to the most recent proposal in regard to addressing the SGR. As you can see from the article, while it proposes not to implement the SGR reduction on January 1, 2014, it proposes to freeze Medicare payments for a period of 10 years and to provide doctors bonuses for agreeing to accept an alternate payment method. Obviously, physicians will have to see what the alternate payment method is to determine whether or not they will elect to continue to provide services to their Medicare patients.
One of the major concerns that needs to be addressed by the health care providers in accepting any alternative payment method, is the necessary cooperation of the beneficiary in following the medical regime proposed by the physician to maintain or improve the beneficiary’s health status. Unless there is an effective methodology for assuring compliance by the Medicare beneficiary, the Medicare program has effectively shifted the consequences of the lifestyle of the Medicare beneficiaries, from the Medicare program, to the individual practitioners. This issue will become a greater issue going forward, as the Medicare program and many other health care programs, implement “alternative fee arrangements,” based upon outcomes, upon the health care providers.
Health Insurance Subsidies: An Issue that Bears Watching
October 24, 2013
Posted by Frank Ciesla
As noted in an article in Reuters, the Federal District Court has refused to dismiss the litigation challenging the granting of subsidies on federal exchanges. This is important in New Jersey, since New Jersey is a federal exchange and not a state exchange. Assuming this litigation continues, and it is ultimately resolved on the merits, it will take a while to be resolved, more than likely into the middle of 2014. For providers, this issue bears watching. Should the courts decide that the subsidy does not apply to individuals who obtain their insurance through a federal exchange, the most likely result will be a wholesale dropping of insurance policies by those individuals who have obtained their insurance through the federal exchange if they cannot obtain subsidies.
As pointed out in our blogs of October 7, 2013 and August 23, 2013, the insurance company is required to maintain the policy for 90 days after a beneficiary ceases making payment. If people should drop their policies (by ceasing to make insurance payments) those policies will appear to be in effect for a 90 day period. However, the insurance companies are only responsible for making payment to the providers for care rendered during the first month. Should the court decision result in a denial of subsidies to individuals that have obtained their coverage through federal exchanges, and those individuals drop their policies, the providers who have provided health care during the “90 day period”, are financially exposed for the care rendered during the final 60 days. As this suit continues, we will keep an update on our blog.
Expansion of the Scope of Practice of Non-Physicians-a Harbinger of Things to Come?
October 10, 2013
Posted by Frank Ciesla
Under the Affordable Care Act, there has been a constant discussion as to the lack of a sufficient number of health care professionals, particularly fully licensed physicians (M.D. or D.O.), to provide care to all of the individuals who will now have health insurance or who will be covered by the expanded Medicaid programs.
To respond to this, various states have taken different approaches. The most widely used approach has been to expand the scope of practice of limited licensed health care providers. An example of this has been the recent action of the State of California, which has expanded the scope of practice of pharmacists under a bill signed on October 1, 2013 by Governor Jerry Brown of California. This legislation (among other things) authorized pharmacists to administer drugs and routine vaccinations as well as order and interpret tests to monitor drug therapies.
In a news release, the California Pharmacist Association stated “With the implementation of the Affordable Care Act at a time when the number of primary-care physicians continues to shrink, we believe this legislation will help ensure that the millions of new patients who receive the insurance will be able to access health care services through their local pharmacists.”
This expansion of the scope of practice raises many questions. One of which is the malpractice standard to which the limited licensed individuals will be held when a legislature expands the scope of their privileges. Is it the same standard to which plenary licensed physicians are held? The second question raised will be whether or not the third party payors, including Medicare and Medicaid, will pay the expanded scope limited licensed professionals, the same reimbursement for those services as they reimburse for such services when provided by a fully licensed physician. Or will the third party payors initially start paying these limited licensed individuals a lower rate for the services, and subsequently consider that rate be the reasonable rate for the services, and pay that rate to the fully licensed physicians? Obviously, only time will tell. However, this must be considered, in light of the goal of the Affordable Care Act to attempt to control costs of health care services.
There will undoubtedly be many more of these statutes, expanding the scope of practice, in many, if not all, states, to be able to meet the needs of individuals who now have the financial ability to obtain health care services. The flip side of the analysis is that those who now obtain health care services through plenary licensed physicians, will more than likely be obtaining some of their health care services in the future, through limited licensed individuals. They may not have the same access to plenary licensed physicians for the provision of those services as they have had in the past.
Bad Debt?
October 7, 2013
Posted by Frank Ciesla
An article in the October 7, 2013 New Jersey Spotlight on health care, written by Andrew Kitchenman, addresses the problem of grace period or late payments and its impact upon providers. As we pointed out in our August 23rd blog, this is an issue which will be of major concern to providers. As of now, the providers will be holding the bag and will need to chase the patient, in those circumstances in which the patient has not paid the premium and the grace period has expired. As the law is currently drafted, the patient can continue their insurance for 90 days with it being retroactively cancelled at the end of 90 days if they have not made the payment of the premium. The insurer will only be responsible for the first 31 days.
October 1, 2013 Affordable Care Act/Obamacare Deadline For Employers of ALL Sizes
September 26, 2013
Posted by Ari G. Burd
In accordance with the Affordable Care Act/Obamacare, employers are obligated to provide notification to their employees of the new Health Insurance Marketplaces established by Obamacare no later than October 1, 2013. The notification requirement applies to any business regulated under the Fair Labor Standards Act, which covers all companies with at least one employee and $500,000 in annual revenue. Read more
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