presentation - amerinet

w w w . a m e r i n e t - g p o . c o m

Amerinet Executive Education Series: Collective Learning

on Contemporary Healthcare Issues

Surviving and Thriving in a New Era of Reimbursement and

Compliance


© 2013 Fox Rothschild

2

Surviving and Thriving in a

New Era of Reimbursement

and Compliance March 7, 2013

William H. Maruca, Esq. Fox Rothschild LLP

412-394-5575

[email protected]


PAYMENT TRENDS

Away from Fee for Service

Toward Pay for Performance/Value-Based

Purchasing

Drivers: - Center for Medicare and Medicaid Innovation (CMMI)

- Private Insurance initiatives

- Purchaser coalitions

- Proactive providers

- Hybrid Payor/Purchaser entities


REGULATORY TRENDS

ACA Insurance Exchanges

- State run

- Federally Facilitated

- Partnerships

Compliance and Enforcement

- False Claims/Stark/AKS

- Self-Disclosure

- HIPAA/HITECH


CMMI Programs

Accountable Care

- Shared Savings

- Advance Payment ACO Model

- Comprehensive ESRD Care Initiative

- Medicare Health Care Quality Demonstration

- Nursing Home Value Based Purchasing Demonstration


CMMI Initiatives

- Physician Group Practice Transition Demonstration

- Pioneer ACO Model

- Private, For-Profit Demonstration Project for the Program of All-Inclusive Care for the Elderly (PACE)

- Rural Community Hospital Demonstration


CMMI Initiatives

Bundled Payment for Care Improvement

(BPCI)

- Medicare Acute Care Episode (ACE) Demonstration

- Medicare Hospital Gainsharing Demonstration

- Physician Hospital Collaboration Demonstration


CMMI Initiatives

Primary Care Transformation - Comprehensive Primary Care Initiative

- FQHC Advanced Primary Care Practice Demonstration

- Frontier Extended Stay Clinic Demonstration

- Graduate Nurse Education Demonstration

- Independence At Home Demonstration

- Medicare Coordinated Care Demonstration

- Multi-Payer Advanced Primary Care Practice


CMMI Initiatives

Medicaid and CHIP Population

- Medicaid Emergency Psychiatric Demonstration

- Medicaid Incentives for the Prevention of Chronic Diseases Model

- Strong Start for Mothers and Newborns Initiative: Effort to Reduce Early Elective Deliveries


CMMI Initiatives

Medicare-Medicaid Enrollees

- Financial Alignment Initiative for Medicare-Medicaid Enrollees

- Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

- Enhanced Prenatal Care Models


CMMI Initiatives

Development and Testing of New

Payment and Service Delivery Models

- Health Care Innovation Awards

- State Innovation Models


CMMI Initiatives

Adoption of Best Practices

- Community Based Transitions Program

- Innovation Advisors Program

- Medicare Imaging Demonstration

- Million Hearts

- Partnership for Patients


Accountable Care

Three core principles for all ACOs:

Provider-led organizations with a strong base of primary care that are collectively accountable for quality and total per capita costs across the full continuum of care for a population of patients;

Payments linked to quality improvements that also reduce overall costs; and,

Reliable and progressively more sophisticated performance measurement, to support improvement and provide confidence that savings are achieved through improvements in care


Medicare Shared Savings Program

Over 250 ACOs participating in MSSP. - 106 new ACOs added as of January 2013

1 in 10 in ten Americans are now being treated by an ACO provider - Source: Richard Weil, Ph D, Oliver Wyman

Half of all ACOs are physician-led organizations that serve fewer than 10,000 beneficiaries.

20% of ACOs include community health centers, rural health clinics and critical access hospitals that serve low-income and rural communities.


Medicare Shared Savings Program

One-sided and Two-sided models

Minimum 5,000 FFS beneficiaries

Three year agreement required

Modified prospective patient assignment

with reconciliation

33 quality standards in 5 “domains”


Non-Medicare ACOs

January 2012: “The private sector is

outpacing Medicare in terms of

developing ACOs by a 4 to 1 margin”

162 private ACOs exist in 45 states and

the District of Columbia Source: Greenway Medical Technologies

- Have Medicare ACOs caught up over the past year?


ACO Growth

2.4 million Medicare patients are cared for by an accountable care organization.

15 million non-Medicare patients are receiving care within a medical practice that is part of a Medicare ACO.

8 million to 14 million commercially insured patients are in non-Medicare ACOs. - Source: “The ACO Surprise,” Oliver Wyman, Nov.

26, 2012


Bundled Payments for Care Improvement

Under the Bundled Payments for Care

Improvement initiative, organizations will

enter into payment arrangements that

include financial and performance

accountability for episodes of care.

48 Episodes of Care identified



Imposes accountability at the

patient/episode level.

Gives applicants the ability to design the

details of their own proposals around

CMS guidelines.



Model 1: Retrospective Acute Care

Hospital Stay Only

Model 2: Retrospective Acute Care

Hospital Stay plus Post-Acute Care

Model 3: Retrospective Post-Acute Care

Only

Model 4: Acute Care Hospital Stay Only http://innovation.cms.gov/initiatives/Bundled-

Payments/Participating-Health-Care-Facilities/index.html



Awardees may be providers, provider

networks, or “conveners,” defined as an

entities that can bring together multiple

participating health care providers, such

as a state hospital association or a

collaborative of providers



Model 1: Retrospective Acute Care Hospital

Stay Only (32 awardees) - Episode of care is defined as the inpatient stay in the

acute care hospital.

- Medicare will pay the hospital a discounted amount per DRG.

- Medicare will continue to pay physicians separately under the Physician Fee Schedule.

- Under certain circumstances, hospitals and physicians will be permitted to share gains arising from the providers’ care redesign efforts.



Model 2: Retrospective Acute Care Hospital

Stay plus Post-Acute Care (193) - Episode of care will include the inpatient stay in the

acute care hospital and all related services during the episode.

- The episode will end either 30, 60, or 90 days after hospital discharge.

- Participants can select up to 48 different clinical condition episodes.



Model 3:Retrospective Post-Acute Care

Only (166) - Episode of care will be triggered by an acute care

hospital stay and will begin at initiation of post-acute care services with a participating SNF, inpatient rehabilitation facility, long-term care hospital or home health agency.

- The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end either a minimum of 30, 60, or 90 days after the initiation of the episode.




Model 4: Acute Care Hospital Stay Only (76)

- CMS will make a single, prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners.

- Physicians and other practitioners will submit “no-pay” claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount.



ACA Implementation

Insurance Exchanges - State-Based Exchanges

- State Partnership Exchange A Partnership Exchange allows states to make key

decisions and tailor the marketplace to local needs and market conditions.

- Federally Facilitated Exchanges

All marketplaces will launch open enrollment in October 2013.


ACA Implementation

18 states have been conditionally approved to operate State-based Exchanges CA, CO, CT, DC, HI, ID, KY, MD, MN, NV,

MN, NY, OR, RI, UT, VT,WA

Three states have been conditionally approved to operate a State Partnership Exchange. AK, DE, IL


ACA Implementation

Exchanges will perform a variety of functions, including: - Certifying “qualified health plans” to be offered in the Exchange

- Operating a website to facilitate comparisons for consumers

- Operating a toll-free hotline for consumer support, providing grant funding to entities called “Navigators” for consumer assistance, and conducting outreach and education to consumers regarding Exchanges

- Determining eligibility of consumers for enrollment in qualified health plans and for insurance affordability programs (premium tax credits, Medicaid, CHIP and the Basic Health Plan)

- Facilitating enrollment of consumers in qualified health plans


ACA Implementation

Medicaid Expansion

- NOT PARTICIPATING (14 states)

- LEANING TOWARD NOT PARTICIPATING (3 states)

- LEANING TOWARD PARTICIPATING (4 states)

- PARTICIPATING (24 states and the District of Columbia)


ACA Implementation

Medicaid Expansion

- Impact on Disproportionate Share Hospitals

- Some states may reconsider in future years

- Long term state cost issues

- Maintenance of Effort (MOE)- no cutbacks

- Insurance Tax Credit Anomaly Below 100% of FPL – no credits to buy insurance

At or above FPL – may get credits


ACA Implementation

Medicaid payment parity for certain

specialties

Sunshine Act

Essential Health Benefits

Medical Loss Ratio

Annual benefit caps phased out


Heightened Compliance

HIPAA Omnibus Rule - Increased liability; 4-tiered penalties

- Business Associate Liability/Agency Issues

- Updates of NPPs and BAAs

- Mobile devices

- “Message” cases Phoenix Surgical: 2 physician practice, $100K

fine Hospice of N. Idaho: <500 records; $50K fine



Stark Law Voluntary Self-Disclosure

- Limit lookback period

- Mitigation of penalties

- Settlements posted at http://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Self-Referral-Disclosure-Protocol-Settlements.html



OIG Self-Disclosure Protocol

- Anti-Kickback Statute

- False Claims Act

- Civil Monetary Penalties Law

FERA/ACA 60-Day Reporting

Requirement



Health Care Fraud Prevention and Enforcement Action Team (HEAT) - Between 2008 and 2011, HEAT actions led to a

75% increase in individuals charged with criminal health care fraud.

- Since 2007, HEAT’s Medicare Fraud Strike Force, a multi-agency group of investigators designed to fight Medicare fraud, has charged more than 1,400 defendants who collectively falsely billed the Medicare program more than $4.8 billion.

- In 2011, HEAT coordinated the largest-ever federal health care fraud takedown involving $530 million in fraudulent billing.


38

Surviving and Thriving in a

New Era of Reimbursement

and Compliance

William H. Maruca, Esq. Fox Rothschild LLP

412-394-5575

[email protected]


Questions and Discussion


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