healthcare regulatory update – 2012 healthcare services group october 2011
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Healthcare Regulatory Update – 2012Healthcare Services Group
October 2011
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Hospital Internal Audit Services
• Overview– Marketplace Challenges
– Healthcare Reform
– Ambulatory Services
– Hospital Services
– Compliance Issues
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Healthcare Regulatory Update - 2012
• Marketplace Challenges– Reimbursement
– Costs
– Consolidation
– Overpayment Audits
– Regulatory Changes
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Healthcare Regulatory Update - 2012
• Healthcare Reform– HHS Draft Rules on Exchanges Cite State
Flexibility but Don’t Offer Much Detail
– Debt Solutions May Impact Way Medicaid Reform Expansion Occurs, Observers Say
– Reform Law Boosts Incentives, Protections for Whistleblowers
– Debt Proposal Targets Long-Term Insurance
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Healthcare Regulatory Update - 2012
• Health Reform– Insurers Seek to Buy Physician Practices To
Comply, Cope With Reform Law Provisions
– States Will Save Billions Because of Reform Law, Urban Institute Finds
– States May Take Lead on MLR Broker Issue As NAIC, Congress Turn Attention Elsewhere
– The 4th Circuit Court of Appeals in Richmond, Va., dismissed two challenges to the health reform law
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Healthcare Regulatory Update - 2012
• Health Reform– Oklahoma and North Carolina have both applied
for waivers from the health reform law’s minimum medical loss ratios
– IRS Seeks to Clarify, Solicit Comment on How Firms Gauge Coverage Affordability
– AHIP Says Providers Aren’t Prepared for Accountable Care Arrangements
– Health Plans Will Participate In Exchanges; HHS Tries To Engage States
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Healthcare Regulatory Update - 2012
• Health Reform– Insurer Says Plans Are Weighing Options on
How to Deal With, Distribute MLR Rebates
– HHS Awards May Encourage States to Adopt ‘Prior Approval’
– IOM Suggests Basing ‘Essential Benefits’ On What’s Typical in Small-Employer Plans
– Delays in Issuing Reform-Law Regs Start Worrying Insurers as Much as Regs’ Content
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Healthcare Regulatory Update - 2012
• Health Reform– Presbyterian, Everett Clinic See MA as Their
Best Route Into ACOs
– Survey Finds Reform’s Impact on 2011 Premium Increases Is Minimal
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Healthcare Regulatory Update - 2012
• Ambulatory Services– Hospital practices could lose revenue with
proposed 3-day requirement
– Steps to adopt EHR software
– Control risk with Audit Insurance
– New initiative will pay lump sums to hospitals and providers for coordinating care
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Healthcare Regulatory Update - 2012
• Ambulatory Services– Final e-Rx rule gives you four new exemptions,
November deadline
– Four ways to ensure physician quality ratings don’t hurt cash flow
– CMS clarifications show why Medicaid’s bigger EH R bonus check is easier to get
– Physician Practices could be recruited to partner with hospitals in bundled payments initiative
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Healthcare Regulatory Update - 2012
• Ambulatory Services– E/M utilization soared and denials fell after
consult elimination
– New primary care program pays extra monthly fee per patient
– Most CMS providers will have to revalidate by March 2013
– RAC demand letters to come from MACs
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Healthcare Regulatory Update - 2012
• Ambulatory Services– Providers must use new Medicare enrollment
forms by Nov. 1
– MGMA supports repeal of the 3 percent withholding tax
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Healthcare Regulatory Update - 2012
• Hospital Services– Healthcare Costs Rise 5.58 Percent, According
to S&P Indices
– Hospital Executives Open to ACOs
– Health Insurance Exchanges to Spur Competition Among Insurers
– Healthcare Mergers, Acquisitions Hit Record Pace
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Healthcare Regulatory Update - 2012
• Hospital Services– FASB Updates Healthcare Accounting Standards
CMS Issues Final Rule on Hospital IPPS payments
– Healthcare IT Spending on the Rise
– Medicare Drug Plan Leads to Hospital Cost Savings
– HHS Awards $71.3 Million to Expand Nursing
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Healthcare Regulatory Update - 2012
• Hospital Services– Moody’s: Revenue Growth Lowest in Two
Decades
– Appeals Court Strikes Down Reform Law’s Insurance Mandate
– Moody’s: Negative Outlook Continues for Healthcare Sector
– Healthcare Fraud Prosecutions on the Rise
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Healthcare Regulatory Update - 2012
• Hospital Services– Physician Assistant Profession Growing Rapidly,
Report
– Number of Uninsured Nears 50 Million: U.S. Census Findings
– Hospital CEOs: Reimbursement Cuts and New Payment Models
– Managed Care in Medicaid Rising Steadily
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Healthcare Regulatory Update - 2012
• Hospital Services– HHS Issues Rule on Medicaid RAC Program
– Major Health Insurers to Pool Claims Data
– Hospitals Increasing ICD-10 Preparation Efforts
– Campaign Begins to Sign Up Americans for Health Insurance
– Medicare Advantage Enrollment Rising
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Healthcare Regulatory Update - 2012
• Hospital Services– Justice Department Seeks Supreme Court
Review of Healthcare Law
– Companies Expect Healthcare Costs to Rise at Lowest Rate Since 1997
– MedPAC Votes to Recommend SGR Repeal
– New Physicians Recruited Heavily
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Healthcare Regulatory Update - 2012
• Hospital Services– Final ACO Rule Eases Requirements for
Physicians, Hospitals
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Healthcare Regulatory Update - 2012
• Compliance Concerns– Hospitals Navigate Fair-Market Value Under
Stark as Feds Scrutinize Arrangements - Fair Market Value Algorithm
– MACs’ Policies on Cloning Electronic Medical Records
– RAC Letters Are Shifted to MACs in Bid to Solve Lateness Problem
– RAC Medical Necessity Audits Accelerate
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Healthcare Regulatory Update - 2012
• Compliance Concerns– Health Systems Strive to Identify, Eliminate
Compliance Gaps at Joint Ventures
– CMS Nearly Doubles Investment in RACs
– OIG Plans a Sweeping Review of Physician- Owned Distributors
– Irked by Ongoing Noncompliance and Repeat Offenders, Feds Focus on Individuals
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Healthcare Regulatory Update - 2012
• Compliance Concerns– Provider-Based Status May Be Smart Move As
DRG Window Rule Is Applied to Clinics
– OIG Work Plan for 2012 Opens the Door to More Sweeping Reviews of Hospitals
– Screening Excluded Employees Is Essential, Fines Can Be Painful
– Feds Focus on Individuals because of consistent noncompliance
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Contact Information
– Contact Information
• Michael McLafferty, CPA, MBA, FACMPE, CHFP EisnerAmper, LLP Partner, Healthcare Services Group [email protected]
• Steven Bisciello, MBA EisnerAmper, LLP Manager, Healthcare Services Group [email protected]
• Maureen Doherty, CPC, CPC-H EisnerAmper, LLP Manager, Healthcare Services Group [email protected]
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