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Regulatory MonitoringArchive for July, 2009
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If Sen. Charles Grassley has his way, nonprofit hospitals will have to prove they spend at least 5% of expenses on charity care if they are to keep their tax-exempt status. But a review of what's happened in Maryland suggests such a rule would be unrealistic and largely inappropriate.
That's the conclusion of a report, published recently in the online edition of the journal Health Affairs, which found extremely wide variation in levels of all types of community benefit each hospital reported.
For example, charity care, a subset of community benefit defined generally as that care given to patients without any expectation of payment, varied from 0.05% to 6.33%. Only two hospitals reported contributing 5% or more.
But total community benefit, which included other categories of uncompensated care, such as health professionals' education, community health services, and "mission-driven" programs and research, varied from 1.17% to 14%.
Source: HealthLeaders Media
The Obama administration has made it clear that cracking down on healthcare fraud and abuse is a priority, and the latest version of the America's Affordable Health Choices Act of 2009 includes an additional funding increase to ensure that government money is not lining the pockets of fraudsters.
"[Healthcare fraud enforcement] has been a theme we have seen in the president's budget and Medicare rule making," says Ed Dougherty, senior vice president of B&D Consulting. "I would say regardless of what happens in healthcare reform, there will be increased focus in all sites of service."
July 20-27 Issuances: CMS posts NCD, OIG issues reports, ICD-9-CM errata available
CMS posts NCD for sleep testing for obstructive sleep apnea (OSA)
On July 21, CMS posted an NCD for sleep testing for OSA.
OIG issues audit reports on Epogen
The OIG released several audit reports on Epogen payments to various facilities of Fresenius Medical Care. The OIG found that claims errors occurred because staff responsible for documenting and flagging the patients’ files for changes in ordered Epogen amounts did not always follow the policy and procedures in the Fresenius Manual for ensuring that changes in the units of Epogen ordered were properly identified and entered into the Fresenius System. The OIG determined that these errors resulted in overpayments.
ICD-9-CM errata
The errata to the ICD-9-CM index and tabular addenda are now available.
Frequently asked questions
CMS posted several new/updated FAQs.
Join MedicareFind today for a direct link to this and all the documents in our regulatory database.
CMS released two MLN Matters article related to transmittals previously outlined in Medicare Weekly Update.
- Sleep Testing for Obstructive Sleep Apnea (OSA)
- Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2009
Join MedicareFind today for a direct link to this and all the documents in our regulatory database.
Editor’s note: Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.
Many providers are taking a proactive approach to the arrival of RACs and performing their own audits. Using the RAC “hot topics,” providers are using those audit outcomes to understand their risks, to change internal processes regarding areas of concern and to return reimbursements for claims that were found to be paid in error.
Once a self audit has been performed and if an improper payment has been identified, what should be the provider’s next steps?
Medicaid's "cumbersome" policies often lead to patients not getting or filling their prescriptions, receiving important diagnostic tests, or managing their chronic disease, which will lead to more costs down the road, according to a new report released by the Association for Community Affiliated Plans.
The Medicaid system, which varies by state, requires beneficiaries to show proof more than once a year that they and their children are still eligible for the public program. This leads to many falling off the rolls, which is a cycle that interrupts their continuity of care and jeopardizes their health.
Additionally, with so many people "churning," which means dropping out and back in to the Medicaid rolls every few months, the federal goal of measuring the quality of the patient care has become extremely problematic if not impossible, according to the group, which represents 42 nonprofit safety-net health plans serving six million beneficiaries in 23 states.
Read the full story by HealthLeaders Media's Cheryl Clark.
A recent statement from U.S. Health and Human Services Secretary Kathleen Sebelius seems innocuous enough—many people seeking care in emergency departments are uninsured.
The nation's leading group of emergency physicians immediately took issue with her remarks, however. They chastised her for perpetuating a myth about hospital care and said she is oblivious to a much bigger problem.
In her statement, Sebelius cited statistics from a database managed by the Agency for Health Research and Quality. These statistics reveal that in 2006:
- One in 5 patients seen in emergency department settings was uninsured,
- Low-income patients accounted for almost one-third of patient visits,
- Residents of rural areas comprised one-fifth of emergency room care
Sebelius observed that uninsured patients often cannot afford primary care and must seek care in the ED. ED physicians, including Nick Jouriles, MD, president of the American College of Emergency Physicians, say this statement helps direct resources to managed care instead of emergency departments where they are most needed.
Source: HealthLeaders Media
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