Government Issues

The Texas Health and Human Services Commission (HHSC) passed new and consolidated rules on October 14, 2012. According to the OIG’s counsel, the new rules increase the likelihood of litigation, increase revenue for the state, lower the State fiscal burden and increase the State’s ability to exercise a sanction on providers.
On December 1, 2011…

The heads of both the Department of Justice (DOJ) and Department of Health and Human Services (HHS) sent a joint letter on Monday, September 24, to five hospital industry groups, including the American Hospital Association, threatening to prosecute providers that use electronic health records (EHR) to “game” the system and improperly obtain federal monies for…

In August, the Office of Inspector General (OIG) of the U. S. Department of Health and Human Services released a report describing inappropriate and questionable billing by home health agencies.  The OIG conducted the study because recent investigations and studies showed that home health agencies are vulnerable to fraud, abuse, and waste.  The OIG identified inappropriate claims by examining claims data from home health, inpatient hospital, and skilled nursing facilities.  The OIG also looked at HHAs that billed unusually high amounts according to at least one of its six measures of questionable billing.  The report determined that Medicare inappropriately paid $5M for home health claims with three specific errors in 2010.  To read the report, click here.

Attorney Elizabeth Hogue prepared a concise, helpful summary of the report as follows:

The OIG issued Report OEI-04-11-00240 in August, 2012, entitled “Inappropriate and Questionable Billing by Medicare Home Health Agencies.” Unlike some other guidance published the OIG, this Report provides detailed information about inappropriate and questionable billing practices by home health agencies (HHA’s). Specifically, the OIG concluded that HHA billing is questionable or unusually high on the six measures below, if greater than the 75th percentile plus 1.5 times the interquartile range. The six measures are as follows:

 1. High average outlier payment amounts per beneficiary

According to the OIG, HHA’s with outlier payments above $403 per beneficiary have unusually high outlier payments and are likely engaging in questionable billing practices.

Last week, Paul Ryan accepted the nomination for Vice President.  In his acceptance speech, he cited “Obamacare” as the greatest threat to Medicare, but many hospitals view the expansion of coverage for low-income individuals positively.  More and more community hospitals are urging their state governments to accept payments for expanded Medicaid programs under the…

On August 10, 2012, HHSC-OIG posted proposed regulations that would expand the power and reach of the Office of Inspector General.  These regulations broaden the net so that persons who are affiliated with a provider can be sanctioned along with a provider as a result of such affiliation, and “affiliate” is broadly defined.  These regulations…

HHSC is performing certification/recertification review of all Durable Medical Equipment (DME) providers.  Over the past few weeks HHSC has been making site visits to Medicaid enrolled DME suppliers to verify operations and enrollment data.  Medicaid DME suppliers must cooperate with the HHSC investigators; a failure to do so may result in termination of a supplier’s…

On August 16, 2012, the U.S. Court of Appeals for the Fifth Circuit dismissed an appeal challenging the Patient Protection and Affordable Care Act’s (PPACA’s) restriction on expansion by physician-owned hospitals.  The lawsuit was initially filed in the Eastern District of Texas by the physician-owned hospital trade group (Physicians Hospitals of America) and a physician-owned

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A client recently asked me to review its fall policies and procedures as they relate to the standard of care.   Because that project was on my mind, the new training modules for nurse aides in long term care that were recently published by the Agency for Healthcare Research and Quality (AHRQ) caught my eye.  The three published modules are:

  1. Module 1: Detecting Change in a Resident’s Condition
  2. Module 2: Communicating Change in a Resident’s Condition; and
  3. Module 3: Falls Prevention and Management

Each module has an instructor’s guide and a student workbook that includes training materials, summaries and “Pearls and Pitfalls” to help staff become more aware of residents’ needs.   For example, the module on falls includes a mnemonic checklist “HEAR ME” to help prevent falls in the facility:

  • Hazards in the environment.
  • Educate residents.
  • Anticipate residents’ needs.
  • Round frequently.
  • Materials and equipment.
  • Exercises and ambulation.

Module 1 notes that the elderly do not exhibit the same signs and symptoms of illness that are seen in younger persons.  Therefore, identification of subtle changes can alert staff to a serious illness.  The AHRQ notes the top 12 changes in residents are:

A.  Physical Changes: Walking; Urination and bowel patterns; Skin; Level of weakness; Falls; and Vital signs.

B.   Non- Physical Signs: Demeanor, Appetite, Sleeping, Speech, Confusion or agitation, complaints of pain.

Our Insight. Your Advantage.   Much of the material will not be new to many providers.  However, use of the training modules developed, and following the steps advocated, by the AHRQ will provide strong evidence that the provider’s care was within the standard of care.   Long term care facilities that incorporate the AHRQ’s training standards into their care will be ahead of the game in number of areas such as:

  1. Regulatory compliance;
  2. Limiting exposure to civil malpractice;
  3. Reimbursement matters.

The Department of Health and Human Services Office for Civil Rights (OCR) recently released the protocol it developed as a guideline for conducting the HIPAA privacy, security and breach notification audits mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act enacted in 2009. The OCR launched the audit program in 2011 and developed the protocol based on the first 20 audits completed under the program. Three of the initial audits were performed on group health plans, highlighting that employer-sponsored group health plans are subject to the Health Insurance Portability and Accountability Act (HIPAA) as covered entities and are subject to audit under the protocol. The audit program represents a significant shift in HIPAA enforcement from the largely reactive, complaint-based enforcement of the past to proactive compliance monitoring.

The pilot phase of the audit program began in November 2011 and is expected to include audits of 115 covered entities by December 2012. HITECH extended HIPAA compliance requirements to business associates and, therefore, business associates are expected to be included in the audit program following publication of the final HITECH regulations. The OCR indicated that funds have already been appropriated to carry out the audit program in 2013 and 2014.

HHS and DOJ today announced that Federal law enforcement is teaming up with private insurance organizations in the fight against health care fraud.  While the details of how this partnership will work are unclear, the press releases issued by both DOJ and HHS indicate that the private and public sectors will share information with each other…