confidential 2017 health care regulatory...

CONFIDENTIAL

2017 HEALTH CARE REGULATORY UPDATE

October 2016

HEALTH CARE SERVICES GROUP

• Overview

–Industry Challenges

–Healthcare Reform

–Ambulatory Services

–Hospital Services

–Compliance Issues

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Health Care Regulatory Update - 2017

• Industry Challenges– Consolidation of the Marketplace

• Merger/Acquisition

–Hospitals, Physicians, ASCs, Physical Therapy

– New Payment Methodologies

• Medicare Access and CHIP Reauthorization Act

(MACRA)

• Accountable Care Organizations – Few Successes

• Bundled Payment – Joint, Cardiac and Orthopedic

– Compliance Issues – HIPAA Audits

– Health Reform – Fourth Enrollment Year

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• Industry Challenges

• MACRA– Starting in 2017 these 4 options allow physicians to avoid any

negative penalties starting in FY 2019:

– Submit enough data to the Quality Payment Program to ensure

that your system is working and that you are prepared for

broader participation in 2018 and 2019;

– Submit the full set of performance data for less than the full 2017

calendar year;

– Submit the full set of performance data for the full 2017 calendar

year; or

– Participate in an Advanced Alternative Practice Model (APM) in

2017.

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• Industry Challenges

• MACRA– The reimbursement provisions of MACRA establishes 2 value-based

payment pathways for physicians who provide services to Medicare beneficiaries:

• The Merit-based Payment Incentive System (MIPS) and

• Advanced APMs.

– When the new payment system launches in 2019, most physicians are

expected to receive Medicare payments through MIPS, which has 4

performance categories:

• Quality;

• Cost;

• Clinical care improvement activities such as boosting care

coordination; and

• Electronic health record capabilities.

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• Health Reform

–Managed Care Organizations May See

Smaller Risk-Adjustment Payouts - CO-

OP Failures

–2017 Rate Proposals Are Trending 20.7%

–Private Exchanges Are Evolving

–CMS and Carriers Agree Risk-

Adjustment Model Must Change

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• Health Reform

– Health and Human Services Opens Door to

Settlements for Risk Corridor Payments

–CMS Proposes Rx Data for Risk

Adjustments

–Administration Moves to Salvage Public

Exchanges

–CMS Unveils MACRA-Supporting

Quality Measure Development Plan

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• Health Reform

– CMS Alternative Payment Models That

Qualify as Advanced

–CMS’s Oncology Value-Based Care Model

–CMS Expands CPC+ to Include MSSP

Participant Practices

–Medical Neighborhoods Are Next Step

for Successful ACOs

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• Ambulatory Services

– Winners and Losers in MIPS-associated

payments

–Conduct a check to make sure you’re on

target for PQRS success

– Labor ups minimum salary level for

overtime exemption

–Protect your practice’s cash flow in the

new payer environment

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– False Claims Act penalties to nearly double

– Mid-year OIG Work Plan update has modest

impact on practices

– ICD-10-CM addendum provides details for

new, current diagnosis codes

– Office of Inspector General (OIG) cites lax

oversight of provider-based clinics, urges

elimination of pay disparity

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– Shared Savings rule finalized; lower-

performing ACOs benefit

– Revisit Business Associate Agreement policies

– Avoid improper billing; extend professional

courtesy as ‘all or nothing’

– CMS selects 196 practices to take part in

value-based cancer care program

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– Medicare Advantage enrollment

requirements

–Family medicine, hematology expect

gains in 2017 payments

–More bundled payment models could

qualify as MACRA advanced APMs

–Certified EHR technology concentrated

among leading vendors

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–Consider care management, EHR

readiness before jumping into CPC+

–Warn physicians of the increasing

scrutiny of hospital post-op notes

–CMS seeking feedback on how to

improve Open Payments program

–NPPs billing of own office E/Ms increases

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– New claims suggest 99214 is new normal

–VA program enables vets to use private

providers

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• Hospital Services

– QIOs to Review Denied Claims Again

– CMS Moves From National to Regional

ACO Benchmarking

–Restrictive Medicare Outpatient Pay

Changes Proposed

–Risk Corridor Programs Hit CO-OPs Hard

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– Lasting Impact Expected from DSH

Settlement

–Medicare Announces More Mandatory

Payment Bundles

–Hospitals, Congress Push One-Year Delay

in Star Ratings Amid Concerns

–Total Readmission Penalties Increase, but

Fewer Hospitals Affected

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– CMS 2017 OPPS Proposed Rule

– CMS 2017 IPPS Final Rule

– Medicare Outpatient Observation Notice

(MOON)

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–Proposed 340B Dispute Resolution Panel

–ACA Marketplace Stability Draws

Hospital Concerns

–Hospitals Receive Lower Payments From

MA Than From Traditional Medicare

–Resolving Patient Accounting Credit

Balances

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– More ACOs Garner Shared Savings

–Moody's: For-Profit Hospitals' Outlook

Stable

–CMS Proposes Fixes to ACA Marketplace

Risk Adjustment

–Hospitals Urge Delaying Off-Campus

Outpatient Billing Changes

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–Physicians Continue Moving to Larger

Practices

–MACRA Implementation Changes to

Save Small Practices

– The Center for Medicare and Medicaid

Innovation (CMMI) on Track for Savings

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• Compliance Issues

–CMS posts 2015 data for the open

payments program

–Proposed OHMA Rule on Medicare

Appeals

–MOON – How and when to deliver

forms to patients

–Risk Mounts in Ambulance Trips

Between Related Facilities

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–No OPPS Billing for New Services in

Provider-Based Space

–ERISA Is Seen as a Powerful Ally in

Overturning Insurer Claim Denials

–Business Associate Agreement Is

Opening To Cover More Privacy Issues

–First Telehealth FCA Case Comes Down

Over MD Billing

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– Largest HIPAA settlement ever, health

system agrees to pay $5.5 million

– Lawmakers consider changes to the

Stark law

–A new MOON form is proposed by CMS

–After OIG Audit, Hospital Is Hit With

$14M Overpayment

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–Hospitals Run Afoul of Physician

Supervision Requirement

–340B Final Guidance by January 1

–Medicare Advantage Denials Rival FFS

–Short Stay Reviews Resume; QIO to

Request Records Immediately

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• Michael McLafferty CPA, MBA, FACHE, FACMPE, FHFMA

EisnerAmper, LLP Partner, Health Care Services Group

[email protected]

• Steven Bisciello, MBA, CMPE

EisnerAmper, LLP Manager, Health Care Services Group

[email protected]

• Nancy Clark, CPC, COC, CPB, CPMA, CPC-I

EisnerAmper, LLP Manager, Health Care Services Group

[email protected]

• Melissa Pizor, COC, CPC, CPCO, CPMA, CPRC

EisnerAmper, LLP Senior, Health Care Services Group

[email protected]

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Contact

Information

mailto:[email protected]

This publication is intended to provide general information to our clients and friends, It does not

constitute accounting, tax, or legal advice; nor is it intended to convey a thorough treatment of the

subject matter.

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