healthcare regulatory update – 2012 healthcare services group october 2011

Healthcare Regulatory Update – 2012Healthcare Services Group

October 2011

Hospital Internal Audit Services

• Overview– Marketplace Challenges

– Healthcare Reform

– Ambulatory Services

– Hospital Services

– Compliance Issues

2

Healthcare Regulatory Update - 2012

• Marketplace Challenges– Reimbursement

– Costs

– Consolidation

– Overpayment Audits

– Regulatory Changes

3


• 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

4


• 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

5


• 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

6


• 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

7


• Health Reform– Presbyterian, Everett Clinic See MA as Their

Best Route Into ACOs

– Survey Finds Reform’s Impact on 2011 Premium Increases Is Minimal

8


• 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

9


• 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

10


• 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

11


• Ambulatory Services– Providers must use new Medicare enrollment

forms by Nov. 1

– MGMA supports repeal of the 3 percent withholding tax

12


• 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

13


• 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

14


• 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

15


• 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

16


• 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

17


• 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

18


• Hospital Services– Final ACO Rule Eases Requirements for

Physicians, Hospitals

19


• 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

20


• 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

21


• 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

22

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]

23

mailto:[email protected]



EisnerAmper LLP is an independent member firm of PKF International Limited

healthcare regulatory update – 2012 healthcare services group october 2011

Documents

healthcare regulatory

insurers health

reformlaw regs

reform law provisionsstates

health reformpresbyterian

health reformoklahoma

health reforminsurers

ambulatory servicesproviders