hot regulatory topics judi lund person, mph nhpco
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Hot Regulatory Topics Judi Lund Person, MPH NHPCO. Eligibility. Eligibility for Admission Medicare Hospice Benefit. § 418.20 Eligibility requirements. In order to be eligible to elect hospice care under Medicare, an individual must be-- ( a) Entitled to Part A of Medicare; and - PowerPoint PPT PresentationTRANSCRIPT
HOT REGULATORY TOPICSJUDI LUND PERSON, MPH
NHPCO
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2 Eligibility
Eligibility for Admission Medicare Hospice Benefit
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§ 418.20 Eligibility requirements. In order to be eligible to elect hospice
care under Medicare, an individual must be-- (a) Entitled to Part A of Medicare; and (b) Certified as being terminally ill in
accordance with Sec. 418.22.
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Compliance “Hot Spots” Eligibility of hospice patients
Initial Ongoing Physician narrative
Certain non-cancer diagnosis Dementia/ Alzheimer's Debility unspecified
Level of care documentation GIP
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MAC Compliance “Hot Spots”
Eligibility of hospice patients Ongoing Physician narrative
Certain non-cancer diagnosis – evidencing 6 month or less prognosis Dementia/ Alzheimer's Debility unspecified
Level of care documentation GIP – eligibility for all days billed at GIP
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Opportunities to document eligibility
Certification Verbal certification Written certification Physician narrative statement
Admission Comprehensive assessment
Ongoing hospice service Every note by the IDT Update to the comprehensive assessment
Recertification F2F encounter Physician narrative statement
Eligibility assessment7
Definitely eligible
Probably eligible
Not eligible
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Eligibility - 1st 90-day period
Demonstration of eligibility at admission Information/ consultation between attending
physician and hospice physician
Procurement of medical history and recent clinical documentation For the clinical record For use in the certification process
Attending physician and hospice physician certify patient based on their medical judgment of the disease progression
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Eligibility - 1st 90-day period
Demonstration of eligibility at admission Physician narrative should concisely
describe why the patient is initially eligible for hospice
Comprehensive assessment documentation by IDG should evidence the details of the patient’s eligibility
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Eligibility – Continued and at Recertification Demonstration of eligibility at
recertification Physician narrative should concisely
describe why the patient is continues to be eligible for hospice
Clinical note from face-to-face visit demonstrates eligibility (if 3rd of subsequent benefit period)
Update to the comprehensive assessment documentation by IDG should evidence the details of the patient’s continued eligibility
Certification/ Recertification11
NHPCO Certification/ recertification Process Maps available for purchase in NHPCO’s Marketplace
Co-morbidities12
Chronic obstructive pulmonary disease
Congestive heart failure Ischemic heart disease Diabetes mellitus Neurologic disease (CVA,
ALS, MS, Parkinson’s)
Although not the primary hospice diagnosis, the presence of disease such as the following…should be considered in determining hospice eligibility
• Renal failure• Liver Disease• Neoplasia• Acquired immune
deficiency syndrome• Dementia
Local Coverage Determination Policies (LCDs)
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GUIDELINES, not regulations: Developed by each MAC (CGS, NGS, NHIC,
Palmetto) Outline guidelines for condition-specific
determination of eligibility Discuss documentation of secondary
diagnoses and co morbid conditions to support terminal prognosis
Local Coverage Determination Policies (LCDs)14
More emphasis on functional decline in the updated LCDs Must have details to document the
extent of decline Need to consider the impact of
disease on patient’s quality of life Be familiar with the LCDs that are
used in medical review for your region
Documentation Using LCDs
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Documentation needs to address: Impairments in function & structure Activity limitations Participation restrictions Secondary diagnoses Co-morbid conditions
Documentation Using LCDs
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Address the patient’s activity level, self care, communication, and mobility
Give a historical perspective of what the patient’s ability was in the previous time period and then document current status
BUT REMEMBER… Decline eligibility Decline necessary or sufficient
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Documentation Using LCDs17
Use specifics to show the extent of the symptoms and limitations
Use the term “as evidenced by” to qualify the problems
Include symptoms such as wt loss, decubitus ulcers, & edema
Co-morbid conditions such as CHF, COPD and diabetes affect prognosis
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The physician narrative
Components of a comprehensive and adequate physician narrative should include: Explanation of the clinical findings that
supports a life expectancy of 6 months or less
Reference to specific LCDs as appropriate
Reference to prognostic indicators or symptom management sales as appropriate
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The physician narrative
Components of a comprehensive and adequate physician narrative should include: Reference to functional status
PPS - Validated in palliative care ECOG - Cancer Karnofsky - Cancer FAST - Dementia
Being specific is the most important thing: don’t say that the patient has lost weight – state that there has been a 15 pound weight loss in the past 2 months and 45 pounds in the last 6
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The physician narrative
Components of a comprehensive and adequate physician narrative should include: Evidence of a decrease in anthropomorphic
measurements Recent hospitalizations Information about other significant complications in
addition to the LCD specific criteria appropriate for that particular diagnosis
Statement should be concise, but adequate Statement should contain prognostic
indicators
21 Quality Reporting
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CY2013 QUALITY REPORTING
Measures for quality reporting:
NQF #0209 Pain Measure Structural Measure
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CY2013 QUALITY REPORTING
NQF #0209: Comfortable Dying (NHPCO)
Percentage of patients who were uncomfortable because of pain at the initial assessment (after admission to hospice services) whose pain was brought to a comfortable level within 48 hours.
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CY2013 QUALITY REPORTING
Structural Measure:
Participation in a QAPI program that includes at least 3 quality indicators related to patient care
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CY2013 QUALITY REPORTING
QAPI Structural MeasureSubmission = Indication if hospice has a QAPI program
that includes at least three indicators related to patient care; and
Measures are used during reporting period
Description of all quality indicators related to patient care.
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CY2013 QUALITY REPORTING
QAPI Structural Measure
No results are submitted -- only the patient care measure descriptions
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Hospice Quality Reporting
The data collection period is January 1 – December 26 of each year
Reporting is mandatory Data due April 1 of each year 2013 measures remain the same as
2012
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Miss the deadlines?
Mandatory reporting Measures required – no choice in
what measures should be reported Miss the 2013 reporting deadlines?
Deadlines HAVE NOT been extended
2% cut in hospital market basket increase (hospice reimbursement rate “inflation adjustment”) in FY2014
CMS RESOURCES
CMS Hospice Quality Reporting web page Information posted on CMS web site as it becomes available
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/index.html
Download PowerPoint presentations and hospice quality questions and answers:
http://www.cms.gov/Hospice-Quality-Reporting/
Help Desk: [email protected] or by phone at 1.800.647.9670.
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NHPCO RESOURCES
Basic Information and Materials
www.nhpco.org/outcomemeasures
www.nhpco.org/qualityreporting
Questions – send email to:
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31 THE FUTURE OF HOSPICE QUALITY REPORTING
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Payment Year FY2015
NQF #0209: Percentage of patients who report being uncomfortable because of pain on the initial assessment (after admission to hospice services) who report pain was brought to a comfortable level within 48 hours
Structural measure: Participation in a Quality Assessment and Performance Improvement (QAPI) program that includes at least three quality indicators related to patient care. Hospices would report whether or not they have a QAPI program with at least three indicators related to patient care.
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Data Collection Period
Calendar year – January 1, 2013 through December 26, 2013
Hospices submit data in the fiscal year prior to the payment determination.
For FY2015 and beyond: Data submission deadline of April 1of each year.
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Payment Year FY2015
No additional measures Creation of a hospice patient-level data
item set Target date for implementation: CY2014
Data items included in standardized data set to support possible measures
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Patient level data collection
Mandatory data collection process being designed to collect data on individual hospice patients – demographics, diagnoses, symptoms
Used to collect data for future quality reporting
Expect to see a form and process in 2014 or 2015
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STANDARDIZED DATA ITEM SET
CMS developing standardized assessment instrument
Many items standardized and used by other providers
Some items developed specifically for hospice Developed to collect information for hospice-
appropriate quality measures Pilot testing with 9 hospices summer/fall 2012 Propose to implement hospice patient-level
data item set as early as CY 2014
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Payment Determinations beyond FY2015
Possible measures – implemented in future rulemaking 1617 Opioid with bowel regimen 1634 Pain screening 1637 Pain assessment 1638 Dyspnea treatment 1639 Dyspnea screening
0208 Family Evaluation of Hospice Care
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Experience of Care Survey
Similar to FEHC CAHPS survey being developed now
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VALUE BASED PURCHASING
Value based purchasing – pilot testing Utilize already implemented measures Implement pilot by January 1, 2016
40 Part D and Hospice
Part D and Hospice41
OIG report issued in 2012 Some Medicare hospice beneficiaries receiving
hospice care also had drugs paid for under Part D Scope of the problem:
198,543 hospice beneficiaries 677,022 prescription drugs through Part D Drugs should have been covered by the hospice? Part D paid pharmacies $33,638,137 Beneficiaries paid $3,835,557 in copayments
Expect additional scrutiny for Part D payments
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Recent Analysis
Analgesics only 2010 information
773,168 Medicare hospice beneficiaries enrolled in Part D
112,555 (14.6%) received 334,387 analgesic prescriptions through Part D during hospice enrollment
Gross costs -- $13,000,430 Examples of drugs: Fentanyl, oxycodone,
morphine, hydrocodone, hydromorphone….
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Recent Analysis
Location of patients? 63% in nursing facilities and assisted living 35% at home
Which hospices? 96.7% of hospices billed some analgesics to
Part D Which pharmacies?
40.9% of pharmacies
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CMS Draft 2014 Call Letter
Questions about eliminating Part D payments for Medicare hospice patients
Comments submitted March 1 2013 Proposing January 2014:
Part D sponsor who receives report that a beneficiary has elected the Medicare Hospice benefit
Sponsor place beneficiary-level prior authorization requirement for four categories of prescription drugs
Four categories: Analgesics antinauseants (antiemetics) Laxatives antianxiety
45 Multiple Diagnoses on Claim Form
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Multiple diagnoses on claim form
Requirement is not new Clarification in FY 2013 Final Hospice
Wage Index Rule Analyses by CMS hospice contractor, showed
that 77.2% of hospice claims from 2010 only reported a principal diagnosis
CMS believes that hospice claims which only report a principal diagnosis are not providing an accurate description of the patients’ conditions
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Multiple diagnoses on claim form
Providers should code and report coexisting or additional diagnoses to more fully describe the Medicare patients they are treating CMS’ Hospice Claims Processing manual requires
that hospice claims include other diagnoses “as required by ICD-9-CM Coding Guidelines” (IOM 100-04, chapter 11, section 30.1, available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf)
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Multiple diagnoses on claim form
CMS clarifies that all of a patient’s coexisting or additional diagnoses s should be reported on the hospice claim paper UB-04 claim allows for up to 17 additional
diagnoses electronic claim allows for 24 additional
diagnoses
Hospices should not report diagnoses which are unrelated to the terminal illness on their claims
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Mixed messages from CMS
CMS is asking for all coexisting diagnoses and comorbidities
Often significant and used to make the case in the narrative for 6 month life expectancy
Example: Patient with heart failure Significant COPD and Parkinson’s disease COPD and Parkinson’s contributing to decline “Unrelated” to the heart failure Previously instructed not to include these very
significant but unrelated diagnoses on claim form
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The issues Diagnoses definition inconsistency by
CMS Related Co-morbid Secondary
Many EMR software solutions do not allow more that one diagnosis (5010 allows 25 spaces)
Payment for non-related dx; concern of providers
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Corollary issues
If diagnosis on claim form…. Hospice responsible for paying for drugs, DME,
supplies related to diagnosis CMS will expect hospice to pay for all or nearly
all drugs, DME, supplies for broad diagnoses Debility Adult Failure to Thrive Others
Determining relatedness…..
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Joint task force – NHPCO & NAHC
Task force goals Refine diagnoses definitions and seek
clarification from CMS Develop a resource to assist hospice
providers to determine relatedness Diagnoses Medications Other supplies and services
53 Illegal Aliens
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Provider responsibility
Medicare does not pay for medical items/services furnished to an alien beneficiary who was not lawfully present in the United States on the date of service that the items/services were furnished
Common Working File will indicate alien status for unlawfully present in the US
MAC will retroactively adjust previously paid claims
55 2013 PEPPER report
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PEPPER Report
The Program for Evaluating Payment Patterns Electronic Report (PEPPER) second report
Available April 2013 FedEx to the hospice CEO Hospice-specific data statistics
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PEPPER Details
CMS sets PEPPER focus areas Services at risk for improper payments Three years of claims data Hospices can use the data to support internal
auditing and monitoring activities PEPPER compares a hospice’s Medicare billing
practices with other hospices in the: State Medicare Administrative Contractor (MAC)
jurisdiction US
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PEPPER Details
Time frame for claims: October 1, 2009 – September 30, 2012
Additional claims for period October 1, 2007 – September 30, 2009 included for episodes of service beginning prior to the reporting period
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PEPPER Details
Each hospice receives only its PEPPER Not available to the public Contractor provides Access database
with PEPPER data to MACs, Recovery Audit Contractors
Pay attention to any findings at or above the national 80th percentile
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Focus of PEPPER Report
Beneficiaries whose episode of service ends in the reporting year, either by live discharge or death.
Two focus areas: “Live Discharges” includes all episodes
where the beneficiary was discharged alive with a length of stay less than 25 days
“Long Length of Stay” counts beneficiary episodes of service that had a long length of stay -- greater than 180 days
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PEPPER Resources
www.pepperresources.org
62 HIPAA Omnibus Rule
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The final omnibus rule
The final omnibus rule was published in the January 17, 2013 Federal Register http://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pd
f/2013-01073.pdf Compliance with most of the new
requirements introduced in the Final Rule is required by September 23, 2013
An extended compliance period is provided for the modification of certain existing business associate agreements
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When is compliance required?
Effective date: This final rule is March 26, 2013
Compliance date: Covered entities and business associates must comply with the applicable requirements of this final rule by September 23, 2013
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New rule
Changes greatly enhance a patient's privacy rights and protections
Strengthens the ability of Office of Civil Rights to vigorously enforce the HIPAA privacy and security protections
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New Breach Standard
Substantial change to the definition of a “breach” of protected health information (PHI)
New standard defines any impermissible acquisition, access, use or disclosure of PHI under the Privacy Rule is a breach unless a covered entity or business associate can demonstrate that there is a low probability that the PHI has been compromised Entities determine whether there is a low probability
that PHI has been compromised by performing a risk assessment
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New Breach Standard
This modification to the definition of breach will make it more difficult for covered entities and business associates to justify a decision not to provide notification following a suspected breach incident
Following a breach, covered entities are still required to notify affected individuals, the Secretary of HHS, and the media (if a breach affects more than 500 residents of a State or jurisdiction) The current timing, content and methods for
notification also remain unchanged
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New Breach Standard
HHS intends to issue guidance to aid covered entities and business associates in performing risk assessments and to assist with the individual notification requirements at a future date
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Expanded Individual Rights
Individuals’ rights expanded with respect to their PHI in two important ways1. It provides them with the right to receive
certain PHI electronically2. It allows them to restrict certain
disclosures of PHI to their health plans Hospice providers will have to revise their
current policies and procedures and evaluate current system capabilities to ensure compliance with these new requirements
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Expanded Individual Rights
The Final Rule also provides individuals with the right to request that covered entities and business associates provide a copy of their PHI directly to a designated individual
This right applies to both paper and electronic information
Any such request must be in writing, signed by the individual, and must clearly identify the designated recipient and where the information should be sent
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Expanded Individual Rights
Restriction of certain disclosures of PHI to their health plans
Hospice providers will likely need to develop a method to flag or include a notation in the record of any individual who has exercised this right to restrict disclosures regarding services paid for out of pocket, in order to ensure that specific records are not sent or made accessible to health plans
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Modifications to Notices of Privacy Practices Required Privacy notices must include a statement
regarding the right of affected individuals to be notified following a data breach and must describe certain uses and disclosures of PHI that require patient authorization related to psychotherapy notes, marketing, and the sale of PHI
The Notice must also inform patients of their right to restrict certain disclosures of PHI to health plans where the individual pays out of pocket in full
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Direct Liability for Business Associates and Amendments to Business Associate Agreements
Business associates and business associate subcontractors will now be directly subject to applicable HIPAA rules including the HIPAA Security Rule and certain
provisions of the Privacy Rule HHS modified the definition of business
associates to specifically include several new entities, including subcontractors that create, receive or transmit PHI on behalf of business associates and entities that provide data transmission of PHI
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Direct Liability for Business Associates and Amendments to Business Associate Agreements
Data storage vendors that maintain PHI (both hardcopy and electronic), are business associates even if the vendor never actually views or accesses the PHI
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Business Associate Agreements
Business associate agreements will need to be modified to meet additional requirements
The Final Rule provides an extended transition period up to September 22, 2014 for amending existing business associate agreements only for an existing business associate agreement meeting the following conditions:
was in place prior to January 25, 2013 and complies with current HIPAA business associate agreement requirements; and
is not modified or renewed during the period from March 26, 2013 to September 23, 2013
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Business Associate Agreements
Business associate agreements not eligible for the extended transition period must be compliant with the Final Rule as of the September 23, 2013 compliance date
HHS recently issued guidance on the
revised business associate agreement requirements and provided sample terms. This guidance is available at: http://
www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.html
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New Fundraising Requirements
Expansion of the type of information covered entities may use to target fundraising appeals to include the department of service, the treating physician and outcome information
Permits the use only of demographic information and dates of health care provided to the patient
Fundraising communications must provide recipients with a clear opportunity to opt-out and the method provided for the opt-out may not cause undue burden or more than nominal costs
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Decedent information
A covered entity only has an obligation to comply with the requirements of the Privacy Rule with respect to the PHI of a deceased individual for 50 years following the individual’s death
Rule permits covered entities to disclose PHI to a family member or other individual involved in a decedent’s care or payment for such care, unless such a disclosure is inconsistent with a prior expressed preference of the decedent
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New Enforcement Authority
Enforcement changes effective March 26, 2013
Civil and criminal penalties can now be applied directly to business associates
HHS must investigate any complaint and conduct compliance reviews in all cases where a preliminary review of the facts indicates a possible violation due to willful neglect
HHS must impose a civil money penalty for violations due to willful neglect
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New Enforcement Authority
HHS is not required to attempt to resolve cases of noncompliance due to willful neglect by informal means
The tiered penalty structure based on different levels of culpability has been finalized. Penalties now range from $100 to $50,000 per violation depending on the level of knowledge/willfulness with a $1.5 million cap per calendar year for multiple violations of identical provisions
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New Enforcement Authority
Covered entities and business associates can be subject to liability for a violation by their business associate agents and subcontractor business associate agents respectively
HHS may disclose PHI obtained in connection with a compliance review or investigation if permitted under the Privacy Act, thereby giving it the ability to share information with other law enforcement agencies (e.g., state attorneys general or the Federal Trade Commission)
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Other Important Changes
Expansion of Prohibited Marketing Activities HIPAA prohibits the use or disclosure of PHI for
marketing to individuals without obtaining an authorization, with certain important exceptions
Prohibition on the Sale of PHI Prohibits the receipt of direct or indirect remuneration
(including in-kind benefits) in exchange for PHI This new restriction includes several exceptions,
including disclosures to business associates, as required by law, and for treatment and payment purposes
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Other Important Changes
New Research Authorizations Permitted allows researchers to obtain authorizations to
use PHI for future research, provided that the future research is adequately described
FY 2013 OIG Work Plan
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FY2013 OIG Work Plan
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Acute-Care Hospital Inpatient Transfers to Inpatient Hospice Care Review Medicare claims for inpatient stays when
beneficiary was transferred to hospice care and examine the relationship between the acute-care hospital and the hospice provider.
Hospice Marketing Practices and Financial Relationships with Nursing Facilities Review hospices’ marketing materials and practices and
their financial relationships with nursing facilities. Medicare Hospice General Inpatient Care
Use of GIP from 2005 to 2010. Assess appropriateness of GIP claims and beneficiary drug claims billed under Part D.
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FY2013 OIG Work Plan
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Medicaid: Hospice Services: Compliance With Reimbursement Requirements We will determine whether Medicaid
payments for hospice services complied with Federal reimbursement requirements.
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Regulatory and Compliance Team at NHPCO
Jennifer Kennedy, MA, BSN, RNRegulatory and Compliance Director
Judi Lund Person, MPHVice President, Compliance and
Regulatory Leadership
Email us at: [email protected]
Q&A
NHPCO members enjoy unlimited access to Regulatory Assistance
Feel free to email questions to [email protected]