Washington Certificate of Need Program Commences Rule Making: Consumer Transparency in Affiliations & Dialysis

July 24, 2013 By

The Washington State Certificate of Need Program has announced its commencement of the rule-making process related to hospitals and dialysis.  This action is in response to the directive issued last month by Governor Inslee instructing the CN Program to expedite rule making related to the corporate restructuring, affiliations, acquisitions and mergers occurring in hospitals across the state.  His directive requires that:

The Certificate of Need process should be applied based on the effect that these transactions have on the accessibility of health services, cost containment, and quality, rather than on the terminology used in describing the transactions or the representations made in the preliminary documents.

The Department’s rulemaking process shall also consider ways to improve transparency for consumer information and ease of use, specifically the Department shall ensure hospitals supply non-discrimination, end of life care and reproductive health care policies; and the Department shall ensure that consumers have access to the policies on its webpage. The Department’s rulemaking process shall also consider the factors in RCW 43.06.155, the principles and policies in the implementation of health reform, including the guarantee of choice for patients.

In response to this directive, the CN Program has released concept rules to implement the directive.  These concept rules contain two significant modifications:

1.  A new defined term in WAC 246-310-010: “Sale, purchase, or lease” means any transaction in which the control, directly or indirectly, of part or all of any existing hospital changes to a different person, including but not limited to by contract, affiliation, corporate membership restructuring, or any other transaction.

This change is significant, as the “sale, purchase, or lease” of all or part of an existing hospital is subject to the CN rules and review.  The new definition expands the applicability of the CN rules and review.  Whereas previously affiliations were typically reviewed under Determinations of Reviewability, the expanded definition would subject such transactions to CN approval.

2.  A new section which collects hospital policies, maintains the policies and list of limitations on certain services online, and requires all hospitals to submit these policies and lists within 60 days of the effective date of the new rule.  The proposed new section is reproduced below:

New Section WAC 246-310-XXX Collection of Hospital Policies

1) Every hospital must submit to the department its following policies related to access to care:

a) Admission;

b) Non-discrimination;

c) End of life care; and

d) Reproductive health care.

2) If the effect of one or more of a hospital’s policies required under subsection (1) of this section limits or excludes access to services authorized by law, the hospital must submit to the department a list of services that are limited or not available at the facility.

3) The department shall post a copy of the policies received under subsection (1) of this section and lists received under subsection (2) of this section on its website.

4) If the hospital makes changes to any of the policies listed under subsection (1) of this section, it must submit a copy of the changed policy to the department within thirty days after the hospital approves of the changes.

5) No later than sixty days following the effective date of this rule each hospital must submit to the department the documents identified under subsections (1) and (2) of this section.

These proposed rules will have an impact on future transactions and existing hospitals.  The proposed revisions will be discussed at an August 5th workshop located at the Department of Health.

If you would like further information about these proposed rules or certificate of need in general please contact Elana Zana.

Filed Under: Certificate of Need, Compliance, Hospitals, Washington Tagged With: , , ,

Increase in Costs for Copies – But Don’t Forget HIPAA (Updated)

July 11, 2013 By

Effective July 1, 2013, medical providers in Washington may increase their charges for searching and duplicating medical records.  The Department of Health (“DOH”) recently released the updated fee schedule for providers. The revised charges are as follows:

 

Current Fee Schedule

Fee Schedule Effective
July 1, 2013

Copying for First 30 Pages

$1.04/page

$1.09/page

Additional Pages

$0.79/page

$0.82/page

Clerical Fees
(for searching and handling records)

$23.00

$24.00

 

Providers who personally edit confidential information from the record are allowed to charge their usual fee for a basic office visit.  Pursuant to HIPAA, this fee may be charged when the medical record is validly requested by someone other than the individual.

HIPAA Limitations Relating to Medical Record Requests by Patients

Though the WAC allows certain charges, HIPAA limits these charges when a patient requests duplication of his/her medical record.  Fees charged by providers may only include:

  1. Labor for copying the protected health information (whether electronic or paper form);
  2. Supplies for creating the paper copy or electronic media;
  3. Postage fees (when the individual has requested the copy by mail); and
  4. If, agreed to in advance by the patient, the cost of preparing an explanation or summary of the protected health information.

Applying both the WAC and HIPAA in combination, the clerical fee of $24.00 cannot be charged to a patient requesting a copy of his/her medical record; but a reasonable clerical fee for the labor of copying the medical record may be assessed.  Providers may not charge a fee equal to a basic office visit to the patient, but may charge a reasonable fee if a summary is provided.  Copying fees up to the maximum allowed by the WAC are permissible.  In addition, the HITECH Act amends HIPAA to allow a provider to impose a fee for the labor costs associated with copying an electronic medical record.

Filed Under: HIPAA, HITECH, Washington Tagged With: ,

Tacoma Physician Group Pays $14.5 Million To Settle Medicare Over-Billing Allegations

July 7, 2013 By

Sound Physicians, a Tacoma-based, national physician group that employs more than 700 hospitalists, paid $14.5 million to settle claims that it over-billed Medicare.  Former Sound Physicians’ employee Craig Thomas filed a whistleblower lawsuit under the qui tam provisions of the False Claims Act.  The lawsuit alleges that the company knowingly submitted inflated claims where documentation did not support the level of service billed.  Qui tam relators are generally entitled to 15 – 30 percent of the government’s recovery; Thomas will receive $2.7 million, or approximately 18.6%, of the $14.5 million settlement.  The settlement represents one of several recent settlements between the government and health care providers under the False Claims Act.

To read the Department of Justice press release click here.

To read qui tam Relator Craig Thomas’ statement click here.

For more information about government investigations, Medicare compliance, or the False Claims Act, please contact Adam Snyder.

Filed Under: Compliance, False Claims Act, Medicare, Washington Tagged With: ,

Medicaid Disallows Reimbursement, Requires Reporting for Provider Preventable Conditions

June 28, 2013 By

Starting  July 1, 2013, the Washington Medicaid program will not pay a provider for the health care costs of treating conditions that the provider could have prevented.  The rule, WAC 182-502-0022, contains a long list of such conditions and adds a few more acronyms to health care speak, including:

(1) PPC – provider preventable conditions that include hospital and non-hospital acquired conditions;

(2) OPPC – other provider preventable conditions that are a PPC subset of conditions identified in WAC 246-302-030, and;

(3) HCAC – health care acquired conditions that are also a PPC subset occurring in an inpatient hospital setting.

Providers, including inpatient hospitals, must report any PPC to the Health Care Authority even if there is no intent to bill for services related to the PPC.  Health care professionals or designees responsible for or associated with a PPC involving a Medicaid patient must notify the Health Care Authority within forty-five (45) calendar days of confirming the PPC.

A similar reporting requirement applies to hospitals for OPPC.  And, of course, Medicaid patients are not liable for payment of an item related to a HCAC or an OPPC and must not be billed for any item or service related to a PPC.

For information about this new rule or Medicaid reimbursements please contact Greg Montgomery.

Filed Under: Compliance, Hospitals, Medicaid, Washington Tagged With: ,

A Window into Hospital Charges – Medicare Releases Data on Charges and Reimbursements

May 9, 2013 By

On Wednesday, Medicare released on extensive spreadsheet documenting the average hospital charges and associated Medicare payments for 100 most common Medicare inpatient services.  The release of this data is unprecedented and provides consumers a valuable tool in assessing the cost of treatment.  The data provides insight into the cost for these procedures on both a local and national basis; permitting users to download the data and manipulate it by hospital, region, state, or a variety of other means.  To access the Excel file released by Medicare click here.

The data highlights the discrepancies in hospital charges and reimbursements both nationally and locally.  The release of this information is aimed at providing consumers a better understanding of the cost and reimbursements associated with these procedures.  As explained by HHS Secretary Sebelius “Currently, consumers don’t know what a hospital is charging them or their insurance company for a given procedure, like a knee replacement, or how much of a price difference there is at different hospitals, even within the same city.  This data and new data centers will help fill that gap.”  This data is in addition to the hospital comparison tool previously released by Medicare.

The release of this data has made both national and local news headlines: Puget Sound Business Journal, New York Times, US News and World Report.

Filed Under: Health Reform, Hospitals, Medicare, Washington

New Court of Appeals Decision Provides Guidance on Medicaid Spenddown Requirements

January 30, 2013 By

The recent appellate decision in Multicare v. State of Washington Department of Social and Health Services (DSHS) sheds light on how hospitals should use a patient’s “spenddown” in the billing process for the Medicaid Medically Needy (MN) program.

The MN program assists low-income families with medical costs.  A family can qualify for the MN program if its income is less than a certain amount during a specific base period.  A family that exceeds the maximum income level can still qualify for the program if it pays medical expenses in an amount equal to or over the excess income.  For example, if a family’s income is $500 over the maximum level, it can still qualify for the MN program if it spends $500 on medical expenses.  This process of using excess income is called the “spenddown.”

In the Multicare case, DSHS alleged that the hospital billed the MN program without deducting the spenddown liability of patients.  According to DSHS, this billing practice resulted in overpayments to the hospital. The hospital argued that the spenddown requirements were an enrollment qualification, not a deduction from DSHS’s payments.  The Washington State Court of Appeals, however, sided with DSHS and found that hospitals must factor in a patient’s spenddown to determine DSHS’s payment obligations.

The Court provided examples of how to use a patient’s spenddown, including the following:  A patient has a spenddown liability of $500 and total hospital charges of $450.  The total charges would apply to the spenddown liability, resulting in a new spenddown of $50.  Since a spenddown remains, the patient is not enrolled in the MN program and DSHS has no payment obligations for the services provided by the hospital.  Instead, the patient would owe the Hospital the $450.

Hospitals should review their Medicaid billing policies to ensure compliance with the Multicare decision.  You can view the decision here.  If you have questions or would like to follow-up, please contact Don Black or Casey Moriarty.

Filed Under: Hospitals, Medicaid, Washington Tagged With:

New Requirements for Provider-Based Clinics

December 18, 2012 By

A reminder to all licensed hospitals operating “provider-based clinics,” “off campus,”: the Washington State legislature during its 2012 session enacted HB 2582 requiring provider-based clinics to comply with certain new and additional requirements.  This bill goes into effect January 1, 2013.  This bill was intended to ensure that patients were informed about the cost of receiving services in a provider-based setting.  Among other things, the bill contains new signage requirements, patient notification requirements (including on the provider’s website) and reporting requirements.  Note, not all Medicare provider-based departments meet the definition of a “provider-based clinic” under this law.  A copy of the bill can be located here.

Please contact Don Black or Lee Kuo if you have additional questions.

Filed Under: Hospitals, Washington Tagged With:

CMS Issues 3 FAQs on Stage 2 Rules and the Medicaid EHR Incentive Program

September 5, 2012 By

CMS has responded to several questions following the issuance of its Stage 2 Meaningful Use Final Rule.  Along with publishing new meaningful use guidelines, the Final Rule adds new provisions regarding the calculation of patient volume for Medicaid providers.  CMS has recently published these new FAQs, some of which take effect immediately, while others will start in 2013, giving the states some time to update their guidance.  These new rules will affect all eligible professionals, regardless of their stage in participation in meaningful use.  To see additional FAQs click here.

Medicaid changes to patient volume calculations 

Q: The EHR Incentive Programs Stage 1 Rule stated that, in order for a Medicaid encounter to count towards the patient volume of an eligible provider, Medicaid had to either pay for all or part of the service, or pay all or part of the premium, deductible or coinsurance for that encounter.  The Stage 2 Rule now states that the Medicaid encounter can be counted towards patient volume if the patient is enrolled in the state’s Medicaid program (either through the state’s fee-for-service programs or the state’s Medicaid managed care programs) at the time of service without the requirement of Medicaid payment liability. How will this change affect patient volume calculations for Medicaid eligible providers?  

A: Importantly, this change affecting the Medicaid patient volume calculation is applicable to all eligible providers, regardless of the stage of the Medicaid EHR Incentive Program they are participating in. Billable services provided by an eligible provider to a patient enrolled in Medicaid would count toward meeting the minimum Medicaid patient volume thresholds.  Examples of Medicaid encounters under this expanded definition that could be newly eligible might include: behavioral health services, HIV/AIDS treatment, or other services that might not be billed to Medicaid/managed care for privacy reasons, but where the provider has a mechanism to verify eligibility.  Also, services to a Medicaid-enrolled patient that might not have been reimbursed by Medicaid (or a Medicaid managed care organization) may now be included in the Medicaid patient volume calculation (e.g., oral health services, immunization, vaccination and women’s health services, telemedicine/telehealth, etc.).

Providers who are not currently enrolled with their state Medicaid agency who might be newly eligible for the incentive payments due to these changes should note that they are not necessarily required to fully enroll with Medicaid in order to receive the payment.

In some instances, it may now be appropriate to include services denied by Medicaid in calculating patient volume.  It will be appropriate to review denial reasons.  If Medicaid denied the service for timely filing or because another payer’s payment exceeded the potential Medicaid payment, it would be appropriate to include that encounter in the calculation.  If Medicaid denied payment for the service because the beneficiary has exceeded service limits established by the Medicaid program, it would be appropriate to include that encounter in the calculation.  If Medicaid denied the service because the patient was ineligible for Medicaid at the time of service, it would not be appropriate to include that encounter in the calculation.

Further guidance regarding this change will be distributed to the states as appropriate.

CHIP patients eligible to be included in Medicaid patient volume totals
Q: The Stage 2 Rule describes changes to how a state considers CHIP patients in the Medicaid patient volume total when determining provider eligibility. Patients in which kinds of CHIP programs are now appropriate to be considered in the Medicaid patient volume total?  

A: States that have offered CHIP as part of a Medicaid expansion under Title 19 or Title 21 can include those patients in their provider’s Medicaid patient volume calculation as there is cost liability to the Medicaid program in either case (under the Stage 1 Rule, only CHIP programs created under a Medicaid expansion via Title 19 were eligible). Patients in standalone CHIP programs established under Title 21 are not to be considered part of the patient volume total (in Stage 1 or Stage 2). This change to the patient volume calculation is applicable to all eligible providers, regardless of the stage of the Medicaid EHR Incentive Program they are participating in.

Changes to the base year of the Medicaid EHR Incentive Program for hospital incentive payment calculation 
Q: Are there any changes to the base year for the Medicaid EHR Incentive Program hospital incentive payment calculation?

A: Yes. Previously Medicaid eligible hospitals calculated the base year using a 12 month period ending in the Federal fiscal year before the hospital’s fiscal year that serves as the first payment year.  In an effort to encourage timely participation in the program, §495.310(g)(1)(i)(B) of the Stage 2 Rule was amended to allow hospitals to use the most recent continuous 12 month period for which data are available prior to the payment year. This change went into effect upon publication of the Stage 2 Rule.  Only hospitals that begin participation in the program after the publication date of the Stage 2 Rule (i.e., program years 2013 and later) will be affected by this change.  Hospitals that began participation in the program prior to the Stage 2 Rule will not have to adjust previous calculations.

 

Filed Under: HIPAA, HITECH, Incentive Payments, Meaningful Use, Medicaid, Washington Tagged With: , , ,

PCI Certificate of Need Regulations Here to Stay

July 15, 2012 By

On July 9th the federal court in the Eastern District of Washington granted the Department of Health’s motion for summary judgment, thus ending the drawn out battle between Yakima Valley Memorial Hospital (“YVMH”) and the State over the denial of a certificate of need (“CN”) for elective PCI at YVMH.  The motion, which was remanded back to the district court by the Ninth Circuit, focuses on the question of whether the CN regulations unreasonably discriminate against interstate commerce in violation of the dormant Commerce Clause.  This constitutional challenge questions the burdens the PCI regulations place on interstate commerce as compared to the local benefits of the regulations.  Following an analysis of the PCI regulations and their application to YVMH, the court determined that the PCI regulations do not impose a substantial burden on interstate commerce as compared to the local benefits.  The PCI CN regulations therefore live to fight another day…

Filed Under: Certificate of Need, Washington

Washington State EHR Incentive Program Seminars

April 10, 2012 By

The Washington State Health Care Authority has announced a traveling seminar on calculating and registering for the Medicaid EHR Incentive Program.  The seminar is aimed at group registration and defining the group proxy methodology to calculate patient volume.

The seminars are as follows:

May 1: Wenatchee
May 3: Spokane
May 8: Yakima
May 16: Seattle
May 17: Mt. Vernon
May 22: Silverdale
May 24: Olympia

To register click here (the link will take you to the Seattle registration, scroll down on that page for other registration links).

 

Filed Under: HITECH, Incentive Payments, Washington Tagged With:
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