Hospitals & Health Systems

Senate Bill 1264, which recently passed during the 86th Texas legislative session, places restrictions on certain out-of-network providers regarding the practice known as “balance billing” and establishes a process through which health plans and providers may resolve payment disputes. The bill is effective September 1, 2019 and applies to services and supplies provided on or after January 1, 2020.

I.  Balance Billing and SB 1264

The term “balance billing” refers to when a healthcare provider bills a patient for the difference between the reimbursement provided by the patient’s health insurance and the amount charged by the provider. SB 1264 places restrictions on balance billing by out-of-network (OON) providers of emergency services, facility-based services provided at an in-network healthcare facility, and lab and diagnostic imaging services that are related to an in-network service. The law disallows these providers from billing a patient for an amount greater than the applicable copayment, coinsurance, and deductible under the health plan based on the initial amount determined to be payable by the plan, or if applicable, a modified amount determined under the plan’s appeal process.
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Bipartisan legislation to address surprise medical billing was introduced June 19 in the Senate Health, Education, Labor and Pensions (HELP) Committee.  Most notable for health insurers and providers is the way the bill tackles the biggest sticking point in the issue—mandating a benchmark rate to avoid pay disputes between health insurers and non-network providers.

Surprise medical billing is commonly the result of care received in an in-network facility, such as a hospital, but that included the services of a non-network provider, such as an anesthesiologist who is based at the in-network facility.
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After years of insisting that nursing colleges separately incorporate from related hospitals and hospital systems, causing some schools to relinquish Medicare “pass-through” funding,  the Higher Learning Commission (HLC) has changed course. Today, HLC issued a Separate Incorporation Policy Change.

Removing language interpreted by prior HLC leadership as requiring separate incorporation, the revised policy substitutes a requirement that HLC-accredited institutions have a “primary purpose” of providing higher education. More specifically, the revised policy (HLC’s “Jurisdiction” policy, INST.B.10.010):
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For decades, pundits, policymakers and consumer groups have called for better tools to make health care purchasing decisions easier.  Greater cost transparency and clear indicators of quality, they say, would help consumers make the right choices, which would lead to lower costs and better quality care.

If only it were as easy as using Angie’s List:  describe the need and up pops the names of local providers, along with comparative information on their performance.

Increasingly, such information and tools are available.  But their impact is unclear.

Since 2010, Medicare consumers have had an “Angie’s List” type of resource in Physician Compare, an online service produced by the Centers for Medicare and Medicaid Services (CMS).  The website was mandated by the Patient Protection and Affordable Care Act (ACA).  It serves a two-fold purpose, according to CMS:
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Courts recognize the complication that exists when determining what constitutes actionable harassment where a healthcare employee is a caretaker for a patient with diminished capacity. The Fifth Circuit Court of Appeals recently reviewed this issue in a Title VII case that highlights the risks posed to employers in the healthcare and social assistance industries by patient harassment and violence: Gardner v. CLC of Pascagoula, LLC, No. 17-60072 (February 6, 2019). In Gardner, the Fifth Circuit explained the risks to healthcare employers when it reversed summary judgment on a nurse assistant’s claim for hostile work environment and retaliation, holding that a genuine dispute of material fact existed as to whether an assisted living facility took reasonable precautions to prevent sexual harassment and physical violence by a resident.

Background

Gardner was a Certified Nursing Assistant employed at the Plaza Community Living Center, an assisted living facility, and “often worked with patients who were either physically combative or sexually aggressive.” Gardner had been assigned to work with a patient who had been diagnosed with multiple “physical and mental illnesses,” and had a reputation for groping female employees, as well as a history of violent and sexual behavior toward both patients and staff at the facility. Gardner alleged that she put up with propositioning and sexual assault by the patient on a regular basis, but that when she complained to the administrator at the facility, she was told to “put [her] big girl panties on and go back to work.”
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When Title IX of the Education Amendments of 1972, 20 U.S.C. § 1681, et seq. (“Title IX”), which prohibits many forms of discrimination on the basis of sex, appears in the news or on social media, we typically associate it with traditional colleges and universities.  But recent case law suggests that Title IX likely applies to a broader set of institutions, including, under certain circumstances, some hospitals.

Over the years, an extensive body of federal case law and regulation has arisen around Title IX, imposing detailed requirements on institutions concerning how they must respond to and investigate complaints, how complaints must be adjudicated and the nature of appropriate remedies.  Moreover, these regulations also have recently been in flux.  As a result, Title IX compliance often requires significant institutional resources and constant vigilance.

Because compliance with Title IX requires significant attention from the institution, it is critical that hospitals determine whether they meet the developing criteria to be subject to the requirements of Title IX and, if so, whether they have in place the proper policies, procedures and personnel to ensure compliance.  In this article, we describe those criteria and provide a brief summary of the broader legal context.
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Under Texas law, physicians that will be called upon to complete and sign a death certificate in Texas are required to register to file the certificate electronically with the Texas Department of State Health Services. The Texas Medical Board is authorized to take action against providers who do not register for electronic filing of death certificates under Tex. Health and Safety Code §193.005. Until recently, registration and filing of death certificates was made through the Texas Electronic Registrar (“TER”).

On January 1, 2019, the Texas Department of State Health Services replaced TER with a new platform, the Texas Electronic Vital Events Registrar (“TxEver”). TxEver supports all vital events operations, including reporting, registration, and amendments of birth and death records, and represents one of the first fully integrated vital records systems nationwide. TxEver will additionally support the Texas remote birth issuance system, which allows users to obtain copies of birth certificates without having to visit the vital records offices in their county of birth.
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Hospitals are not happy with CMS’ recent changes to hospital outpatient payments.  Two hospital associations and three hospitals claim in a federal lawsuit filed December 4, 2018, that CMS had no authority to change the payment scheme for off-campus provider-based departments (PBDs).  The change took effect January 1, 2019, and is estimated to reduce payments to hospitals by $380 million in the first year of a two-year phase-in period.

The plaintiffs, including the American Hospital Association and the Association of American Medical Colleges, are seeking judgment that the payment change is unenforceable as well as preliminary and permanent injunctive relief.  The complaint against US Department of Health and Human Services Secretary Alex Azar was filed in the U.S. District Court for the District of Columbia.

The plaintiffs’ assert that the reduced payments threaten patient access to care and harm the providers’ ability to meet the health care needs of their patients, including some of the most vulnerable populations. 
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The National Labor Relations Board (the “Board”) recently held that a California hospital illegally maintained a dress code policy that effectively prohibited employees from wearing pins and badge reels with union insignia.  The hospital’s policy at issue required that “[o]nly [employer] approved pins, badges, and professional certifications may be worn.” In addition, employees were only permitted to wear identification badge reels with “approved logos or text.”
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