Download Health Care Reform Webinar: Part II What Health Care

Health Care Reform Webinar: Part II
What Health Care Providers Need
to Know About the Reform
Legislation’s Impact … Now
April 29, 2010
Faculty
Hospitals. . . . . . . . . Thomas Hutchinson
Physicians . . . . . . . Leeanne Coons
Long Term Care . . . Lori McLaughlin
Behavioral Health . . Dave Jose
Fraud & Abuse. . . . . Randy Fearnow
Fraud & Abuse. . . . . Glenn Troyer
Moderator . . . . . . . . Susan Ziel
© Krieg DeVault LLP 2010
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Disclaimer
This content is provided for general
information purposes and is not
intended as legal advice.
Competent legal counsel should be
sought before taking any action in
reliance on this content.
© Krieg DeVault LLP 2010
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Healthcare Reform Legislation
and Hospitals
Thomas N. Hutchinson, Esq.
Krieg DeVault LLP
12800 North Meridian Street, Suite 300
Carmel, Indiana 46032
Phone: 317-238-6254
Email: [email protected]
Value-Based Purchasing
(VBP)
Data/Past Programs
 The Reporting Hospital Quality Data for Annual
Payment Update Program
 The Premier Hospital Quality Incentive
Demonstration
 The Physician Group Practice Demonstration
 The Medicare Care Management Performance
Demonstration
© Krieg DeVault LLP 2010
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VBP (continued)
Rewards/Penalties – Budget Neutrality!





2013 base DRG will be reduced by 1%
2014 base DRG will be reduced by 1.25%
2015 base DRG will be reduced by 1.5%
2016 base DRG will be reduced by 1.75%
2017 and beyond base DRG will be reduced by
2.0%
© Krieg DeVault LLP 2010
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VBP (continued)
Compliance website debuts in 2014 – Will
you be ready?
© Krieg DeVault LLP 2010
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VBP (continued)
What Now?
 IT
 EMR
 Physician Collaboration
© Krieg DeVault LLP 2010
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Bundling
 Pilot program starting January 1, 2013
 Will run for at least 5 years
 Includes hospitals, physicians, SNFs, and
HHAs
© Krieg DeVault LLP 2010
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Bundling (continued)
 “Applicable Condition” not yet defined
 “Applicable Services” include inpatient and
outpatient hospital services, physician
services, care coordination, medicine
reconciliation, discharge planning,
transitional services, etc.
© Krieg DeVault LLP 2010
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Bundling (continued)
 Payments will be comprehensive
 Will cover the costs of services, as
determined by the Secretary
© Krieg DeVault LLP 2010
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Community Health Needs
Assessment
 Assess your “community” – What is it?
 Adopt a strategy and how it will be
implemented
 Redo every 3 years
© Krieg DeVault LLP 2010
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Community Health Needs
Assessment (continued)
 Include those with special knowledge or
expertise
 Consider property tax implications
© Krieg DeVault LLP 2010
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Financial Policies
 Must use “reasonable efforts” to make
payment arrangements before you make
 “Extraordinary collection efforts”
© Krieg DeVault LLP 2010
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Accountable Care Organizations
 Begins in January 1, 2012
 Must have shared governance - PHOs
again?
 5,000 minimum Medicare beneficiaries
 Payment methods to include fee-forservice, partial capitation, and other
methods
© Krieg DeVault LLP 2010
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Physician-Owned Hospitals
 Physician ownership frozen
 Hospital expansion frozen
 Special exceptions unlikely
= Physicians hungry for involvement
© Krieg DeVault LLP 2010
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Healthcare Reform Legislation
and Physicians
Leeanne R. Coons, Esq.
Krieg DeVault LLP
One Indiana Square, Suite 2800
Indianapolis, Indiana 46204
Phone: 317-238-6269
Email: [email protected]
Claims Filing Timelines
 Reduced Medicare Claims Submission
Timeframes
 Current: Up to 3 calendar years following the
year in which services were furnished
 Effective for services furnished on or after
1/1/2010, reduces allowable period to 1
calendar year after date of service
 For services furnished before 1/1/2010, a bill
or request for payment must be filed no later
than 12/31/2010
© Krieg DeVault LLP 2010
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Mandatory NPI Use
 No later than 1/1/2011, HHS shall set forth
regulation that requires use of National
Provider Identifier (NPI) on all enrollment
materials and claims
 Applies to Medicare and Medicaid
© Krieg DeVault LLP 2010
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RAC Expansion
 Expansion of Recovery Audit Contractor
(RAC) program into Medicaid
 Requires states to contract with 1 or more
RACs by 12/31/2010
 Identify underpayments/overpayments
 Recoup overpayments
 Contingent Basis for collecting overpayments
© Krieg DeVault LLP 2010
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Payment
 Bonus Payments
 Primary Care Physicians whose Medicare
charges for office, nursing home, & home
visits will be eligible for 10% bonus payment
for certain E/M services from 2011-2016
 All general surgeons who perform major
procedures (with a 10- or 90-day global
period) in a HPSA will be eligible for 10%
bonus payment for those services from 20112016
© Krieg DeVault LLP 2010
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Payment
 Geographic Payment Cost Index Changes
 Geographic payment cost index values
(GPCIs) are applied in the calculation of a
Medicare fee schedule payment amount by
multiplying the RVU for each component times
the GPCI for that component
 GPCI for physician work that expired at the
end of 2009 was reinstated for 2010
 In 2010 & 2011, Medicare GPCI adjustment
for physician practice expenses in rural/low
cost areas will be reduced
© Krieg DeVault LLP 2010
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Payment
 Medicaid Payments
 Medicaid payment rates to primary care
physicians providing certain E/M and
immunization services can be no less than
100% of the Medicare Part B payment rates for
2013 and 2014
 Family medicine, general internal medicine, and
pediatrics
• 100% Federal funding for incremental costs to
states of meeting this requirement
© Krieg DeVault LLP 2010
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Payment
 Imaging Multiple Study Discount
 In 2011, discount for multiple imaging services
performed on contiguous body parts in a single
patient session will be raised from 25% to 50%
 Medicare will pay 100% of the highest priced
procedure and will then pay 50% of the
payment amount for all additional procedures
within the same “family”
 Freestanding imaging centers and IDTFs
 Technical Component
© Krieg DeVault LLP 2010
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Payment
 Medicare Utilization Assumption Rate
 Used in the determination of the practice
expense portion of technical component
reimbursement for certain services performed in
a non-hospital setting
 Increase from current 62.5% to 75% in 2011
 Was almost 90%
 Increases in the utilization rate result in
decreases in reimbursement
© Krieg DeVault LLP 2010
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Miscellaneous
 Quality Initiatives
 Preventive and Screening Benefits
Expanded
 Stark Law Changes
 Whole Hospital Exception
 Notice Requirements for In-Office PET/CT/MRI
 Stark Self Disclosure Protocol
© Krieg DeVault LLP 2010
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Healthcare Reform Legislation
and Long Term Care
Lori McLaughlin, Esq.
Krieg DeVault LLP
833 West Lincoln Highway, Suite 410W
Schererville, IN 46375
Phone: 317-238-6075
Email: [email protected]
Medicaid Coverage for Long
Term Care and Support Services
 Expansion of home and community-based
services via State plan amendments
 State plan amendment versus waiver
 Does not mandate budget neutrality
 Does not set ceiling on the number of persons who can receive
support
 Does not permit geographical carve outs (benefits must be offered
statewide)
 Community First Choice
 Starts October 1, 2011
 Allows states to cover the cost of attendant (non-skilled, non-CNA)
services for a Medicaid beneficiary if doing so would prevent the
individual from being hospitalized or residing in a nursing home.
© Krieg DeVault LLP 2010
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Medicaid Coverage for Long
Term Care and Support Services
(CONTINUED)
 Increase in federal Medicaid match to states which
currently spend < 50% of their Medicaid long-term care
budgets on non-institutional care if they submit plans to
rebalance their Medicaid spending more toward home and
community-based services
 Eliminates Medicare Part D cost-sharing for assisted living
residents covered by Medicaid, who otherwise would be
admitted to a SNF.
 Copays for dual eligibles receiving services in a Medicaid
managed care organization are eliminated
 Spousal impoverishment protects will be extended to
include persons whose spouse’s qualify for Medicaid
funded home and community based services and supports
© Krieg DeVault LLP 2010
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Medicare – Skilled Nursing
Facilities
 2010 and 2011 – Full payment update
 Beginning in 2012, SNF market basket update
will be reduced by a productivity factor
 10-year moving average of changes in annual economy-wide,
private, non-farm business multi-factor productivity. Savings
estimated at $14.6 billion over 10 years
 Estimated to be about a 1% reduction in the market basket, but
the bill allows the productivity adjustment to reduce payment
rates below the previous year’s level.
 RUG-IV delayed until October 1, 2011?
 Implementation for MDS 3.0 not delayed. Will take effect October
1, 2010
© Krieg DeVault LLP 2010
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Medicare – Skilled Nursing
Facilities (CONTINUED)
 Extends Medicare therapy caps exceptions
process through December 31, 2010
 Authorizes physician assistants to order
skilled nursing services beginning in 2011
© Krieg DeVault LLP 2010
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Medicare – Home Health
 2010 – full market basket adjustment
 2011 through 2013, market basket adjustment
reduced by 1% each year
 2014, payments will be rebased in consideration of
case mix indexing, number of visits per episode,
resources used in each visit, cost of providing care,
etc
 Reinstates rural payment add-on for April 1, 2010
through 2015.
 2015, market basket reduced by same productivity
factor applied to SNFs
© Krieg DeVault LLP 2010
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Medicare – Hospice
 2010 through 2012 – full payment updates
 Beginning in 2013, payment update will be
reduced by same productivity factory applied to
SNFs
 For each fiscal year 2013 through 2019, the payment update
would be reduced by 0.5 percent in addition to the application
of the productivity factor
 By 2011, CMS required to update hospice
payment forms and cost reports. Requires CMS
to reform the payment system to improve
accuracy by 2013 using the updated information.
© Krieg DeVault LLP 2010
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Waste/Fraud/Abuse
 Home health services and durable medical equipment must
be ordered by a health care professional/doctor enrolled in
Medicare.
 Order must be in writing
 Requires face-to-face encounter between the doctor/health care
professional and the Medicare beneficiary
 For Plan years beginning on or after January 1, 2012,
Medicare Part D prescription drug and Medicare Advantage
prescription drug plans required to employ utilization
management techniques, such as weekly, daily or automated
dose dispensing, when providing medications to beneficiaries
residing in long-term care facilities in order to reduce waste
associated with 30-day fills.
© Krieg DeVault LLP 2010
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Value-Based Purchasing
 CMS required to implement quality measure
reporting programs for Hospice by 2014. Payment
reductions will be implemented for providers failing
to report.
 CMS required to submit plan to Congress by 2012
for instituting value-based purchasing for SNFs
and home health agencies.
 Objective: Improve quality of care furnished to all
Medicare beneficiaries.
© Krieg DeVault LLP 2010
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Value-Based Purchasing - Skilled
Nursing Facilities
 Make annual payment awards based upon levels of
performance or improvement in performance of
scoring for each nursing home based on 4 domains:




Nursing staffing = 30% of overall score
Rates of potentially avoidable hospitalizations = 30%
Outcome of selected MDS quality measures = 20%
Results from State survey inspections = 20%
 Designed to be budget neutral (a.k.a. shifting
reimbursement levels amongst providers)
 Payment pool will be State specific and based on
Medicare savings resulting primarily from reductions
in hospitalizations
© Krieg DeVault LLP 2010
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Value Based Purchasing
 Chronic Care Residents (long stay residents)





% of residents whose need for help with daily activities has increased
% of residents whose ability to move in and around their room got worse
% of high-risk residents who have pressure ulcers
% of residents who have had a catheter left in their bladder; and
% of residents who were physically restrained
 Post-acute Care Residents (short stay residents)
 % of residents with improving level of Activities of Daily Living (ADL)
functioning
 % of residents who improve status on mid-loss ADL functioning; and
 % of residents experiencing failure to improve bladder incontinence
© Krieg DeVault LLP 2010
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Nursing Home Transparency
 Requires disclosure of ownership information,
including a description of the governing body and
organizational structure.
 Requires nursing facilities to implement
compliance and ethics programs for a facility’s
employees and agents.
 Requires CMS to add information on standardized
staffing data, a summary of substantiated
complaints, and the number of adjudicated
criminal violations by a facility or its employees to
Nursing Home Compare.
© Krieg DeVault LLP 2010
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Nursing Home Transparency
(continued)
 Requires CMS to develop a mechanism for nursing
facilities to report staffing information in a uniform format
based on payroll data, also reflecting use of contract or
agency staff.
 Allows CMS to discount civil monetary penalties by 50
percent for self-reported deficiencies corrected within ten
days. Reductions would not be made for self-reported
deficiencies citing an immediate jeopardy or actual harm
violation. With respect to repeat deficiencies, the
Secretary can not reduce these penalties if the Secretary
had reduced a penalty imposed on the facility in the
preceding year.
© Krieg DeVault LLP 2010
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Nursing Home Transparency
(continued)
 Civil monetary penalties for deficiencies cited at the
actual harm and immediate jeopardy level could be
placed in escrow following completion of informal dispute
resolution or 90 days after the CMPs were imposed,
whichever date is earlier. If a facility’s appeal is
successful, the CMPs would be returned with interest. If
the appeal is unsuccessful, a portion of the CMPs could
be used to benefit residents.
 Requires training on dementia care and abuse
prevention for nursing home staff during their initial
orientation This requirement extends to contracted and
agency staff as well.
© Krieg DeVault LLP 2010
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Nursing Home Transparency
(continued)
 Requires CMS to establish a nation-wide
program of criminal background checks for
employees of long-term care providers who
have direct access to patients. Program to be
based on previously-authorized and ongoing
demonstration projects.
© Krieg DeVault LLP 2010
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Quality Initiatives
 By 2012, CMS must report to Congress on the
appropriateness of applying a “health-care
acquired” Medicare payment policy (a.k.a.
payment prohibition or penalty) to nursing
homes.
 Similar to “never events” which prohibit payment for several
acquired conditions.
 Prohibits Medicaid payments for services related
to a “health care acquired” condition. CMS will
develop a list of the conditions based on current
Medicare and state practices.
© Krieg DeVault LLP 2010
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Quality Initiatives (continued)
 Establishment of a community-based care transitions
program funding hospitals and community-based entities
that provide transition services to Medicare beneficiaries
at high risk for readmission following hospital discharge.
(Payments for these services will be included within the bundled
payment pilot program initiative.)
 Establishment of new GAO study on the Five Star
Quality Rating System.
 CMS recently acknowledged problems inherent in current bell-curve
approach for rating system
 CMS also recently announced it would still identify special focus
facilities receiving the lowest score within each state using the rating
system however the list will not be published publicly
© Krieg DeVault LLP 2010
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Community Living Assistance
Services and Supports (CLASS)
 Voluntary, self-funded public long term care
insurance program
 Employers may elect for an automatic enrollment of
employees, unless employees affirmatively elect to
opt out of the program
 The Secretary must make sure that the Plan is
actuarially sound and that it ensures solvency for
75 years
 Allows for a 5 year vesting period for eligibility of
benefits
© Krieg DeVault LLP 2010
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Community Living Assistance Services
and Supports (CLASS) (continued)
 Provides a cash benefit that is not less than an
average of $50 per day
 Institutionalized Medicaid beneficiaries: Individual shall retain
5% of the cash benefit (in addition to the Medicaid personal
allowance) with the rest being applied toward the facility’s cost of
care.
 Home and community based care Medicaid beneficiaries:
Individual shall retain 50% of the cash benefit with the rest being
applied toward the cost to the State of providing such
assistance. Funds shall not be used to claim Federal matching
funds under Medicaid.
 Benefits are to supplant not supplement other
governmental payer systems, i.e., Medicare, Medicaid,
etc.
© Krieg DeVault LLP 2010
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Demonstration Projects, Studies
or Commissions
 Federal Coordinated Care Health Office: Integrate
Medicare and Medicaid benefits and improve
coordination between federal and state agencies for
individuals eligible for coverage under both programs
 Home Health: CMS directed to study improving access
to home health for patients with high-severity levels of
illness, low incomes and living in underserved areas.
May conduct demonstration project based upon the
results of the study.
 Hospice: Establishes a three-year demonstration
program at up to 15 sites, allowing beneficiaries eligible
for hospice to also receive all other Medicare-covered
services concurrently.
© Krieg DeVault LLP 2010
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Demonstration Projects, Studies
or Commissions (continued)
 Center for Medicare and Medicaid Innovation: Intent is to
test new payment and service delivery systems. Funds are
authorized to test models providing services not presently
covered under Medicare.
 Community Health Teams/Medical Homes: Provides grants
for the creation of community health teams to develop medical
homes by increasing access to comprehensive, communitybased coordinated care. Grants also authorized for
medication management services for treatment of chronic
disease.
 Elder Justice Act: Requires CMS to cooperate with the
Department of Justice and Department of Labor to award
grants protecting nursing home residents and provides
incentives for individuals to train and work in nursing facilities.
© Krieg DeVault LLP 2010
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Demonstration Projects, Studies
or Commissions (continued)
 Requires CMS to establish a demonstration
project to develop an independent monitor
program to maintain oversight of interstate
and large intrastate nursing home chains.
 Establishes demonstration programs on
culture change and on use of information
technology in nursing homes.
© Krieg DeVault LLP 2010
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Demonstration Projects, Studies
or Commissions (continued)
 Workforce: National commission to review projected
workforce needs.
 A Personal Care Attendants Advisory Panel must be established
no later than 90 days after the Act is enacted. The Panel will
examine and advise the Secretary and Congress on workforce
issues related to personal care attendant workers, including the
adequacy of the number of such workers, and access by
individuals to the services provided by such workers.
 Grants would be available for states to do comprehensive
workforce planning and development.
 Authorizes 3 years of funding for new training opportunities for
direct-care workers providing long term care services and
supports
 Authorizes funds for geriatric education centers for training in
geriatrics, chronic care management and long term care.
© Krieg DeVault LLP 2010
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The Take Aways
1.
2.
3.
4.
5.
Shifting of dollars away from institutions toward home
and community based services
Reimbursements tied to performance for Medicare and
Medicaid
Coordination of care amongst and between all health
care providers is essential
Large or national chains being targeted with
‘transparency” requirements
Many demonstrations to be conducted which means
more and likely significant changes to come so stay
tuned…..
© Krieg DeVault LLP 2010
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Healthcare Reform Legislation
and Behavioral Health
David E. Jose, Esq.
Krieg DeVault LLP
One Indiana Square, Suite 2800
Indianapolis, Indiana 46204
Phone: 317-238-6211
Email: [email protected]
Increased Private Coverage
 Employer-sponsored plans and individual
mandates
 Plans required to provide mental health
and substance abuse services
 Guaranteed issue and renewability
 Dependent coverage up to age 26
 Prohibited lifetime limits and rescission of
coverage
© Krieg DeVault LLP 2010
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Expansion of Medicaid
 Increased population segments
 Expansion based upon income will capture
more adults with SMI
 Guaranteed levels of coverage
 Coverage for former foster care children
up to age 25
© Krieg DeVault LLP 2010
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Federal Parity Law
 Federal legislation passed in October
2008
 Interim final regulations recently published
 Effective for plan years after July 1, 2010
 Supplementing state parity laws
© Krieg DeVault LLP 2010
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Federal Parity Law (continued)
 Behavioral health coverage no more restrictive
than substantially all medical/surgical benefits
 Financial requirements
 Copayments, deductibles, and out-of-pocket
expenses
 Treatment limitations
 Frequency of treatment, number of visits, and days of
coverage
© Krieg DeVault LLP 2010
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Medicaid and “Health Homes”
 Individuals with 2 chronic conditions, or 1
+ potential
 Serious and persistent mental health
condition
 Federal support for care management and
care coordination
 Grants for co-locating primary care on-site
in community mental health agencies
© Krieg DeVault LLP 2010
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Community-Based Services
 States with expanded and new options
 Avoid waivers
 Community First Option for individuals with
disabilities
© Krieg DeVault LLP 2010
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Accountable Care Organizations
 Group of providers accountable for overall
care of Medicare beneficiaries
 Incentive bonus arrangements
 Integrated clinical and administrative
systems
 Altered regulatory landscape – narrow,
sweeping, soon?
© Krieg DeVault LLP 2010
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Workforce Development
 Support for primary care graduate education
 Increased support for teaching sites
-- FQHCs
-- Other health centers
 Support for interdisciplinary mental and
behavioral health training programs
 Training programs to integrate physical and
mental health services
© Krieg DeVault LLP 2010
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Community Health Centers
 $11 Billion in funding
 Support for new programs to support
school-based health centers
© Krieg DeVault LLP 2010
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Other Items
 $75 Million for project to reimburse psych
hospitals for Medicaid coverage of
emergency psych treatment
 Modified standards for CMHCs
© Krieg DeVault LLP 2010
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Fraud and Abuse &
Program Integrity Provisions
Glenn T. Troyer, Esq.
Randall R. Fearnow, Esq.
Krieg DeVault LLP
949 E. Conner Street, Suite 200
Noblesville, IN 46060
Phone: 317-238-6223
Email: [email protected]
Krieg DeVault LLP
30 N. LaSalle Street, Suite 3516
Chicago, IL 60602
Phone: 312-423-9304 or (317) 238-6279
Email: [email protected]
Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 6001: Physician/Hospital Ownership Restrictions/Reporting
In addition to ownership and facility capacity restrictions
March 23, 2010
relative to the Stark Law’s whole hospital exception, Section
6001:
 Requires hospitals to submit annual reports to HHS
containing a detailed description of each physician owner
or investor of the hospital and the nature and extent of all
ownership and investment interests.
© Krieg DeVault LLP 2010
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Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 6001: Physician/Hospital Ownership Restrictions/Reporting
 Requires hospitals to implement procedures requiring
March 23, 2010
physician owners and investors to disclose the physician’s
ownership or investment interest to patients referred to
the hospital.
 Requires hospitals to disclose the fact that the hospital is
partially owned or invested in by physicians on the
hospital’s public website and in any public advertising by
the hospital.
© Krieg DeVault LLP 2010
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Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 6101: Physician/Skilled Nursing Facility Ownership Reporting
 Requires reporting of the identity of governing board
The latter of
members, officers, partners, owners, trustees, etc. and
March 23, 2012
Additional Disclosable Parties.
or
90 days after
 Additional Disclosable Party means any person or entity
the date of the
who exercises operational , financial or managerial control
final regulations
over the health facility or any part thereof, or provides
publication
financial or cash management services to the facility and
who leases or subleases real property to the facility or
owns at least 5% of the total value of such real property.
© Krieg DeVault LLP 2010
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Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 6002: Manufacturers and Group Purchasing Organizations
Transparency Reporting of Physician Ownership and Investment
 On 90th day of each calendar year, transparency reports
March 13, 2013
shall be made on any payment or other transfer of value
to a physician or a physician’s immediate family member
(name, address, specialty, form and amount of payment,
payment dates, and description of nature of payment).
© Krieg DeVault LLP 2010
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Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 6002: Manufacturers and Group Purchasing Organizations
Transparency Reporting of Physician Ownership and Investment
 On 90th day of each calendar year, transparency reports of
March 13, 2013
any investment held by physician or physician's immediate
family member, value invested, value and terms of such
ownership and any payment made to such physician or
family member.
© Krieg DeVault LLP 2010
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Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 6002: Manufacturers and Group Purchasing Organizations
Transparency Reporting of Physician Ownership and Investment
 Unknowing Failure to File Transparency Report = Civil
March 13, 2013
monetary penalty of $1,000 to $10,000 for each failure to
report a payment or transfer of value with an annual limit
for such failures of $150,000.
 Knowing Failure to File Transparency Report = Civil
monetary penalty of $10,000 to $100,000 for each failure
of reporting a payment or transfer of value with an annual
limit of $1,000,000.
© Krieg DeVault LLP 2010
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Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 6003: Physician Disclosure Requirements for
In-Office PET/MRI/CT Services
Applies to services
performed on or after
January 1, 2010
 Amends Stark Law’s statutory In-Office Ancillary
Services Exception to require that, at the time of referral,
a referring physician inform, in writing, the patient that he
or she may obtain MRI, CT, or PET imaging services from a
person other than the referring physician, a physician in
the same group practice as the referring physician, or an
individual directly supervised by the physician or by
another physician in the group practice.
 Physician must also provide such individual with a written
list of suppliers who furnish such services in the area in
which such individual resides.
© Krieg DeVault LLP 2010
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Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
March 23, 2010
Summary of Provision
Sec. 6402: Overpayments
 Medicare/Medicaid overpayments must be reported and
returned within 60 days of the later of: (1) the identity of
the overpayment; or (2) the date a corresponding cost
report is due.
 Any overpayment retained after the 60-day deadline is
considered an “obligation” to pay money to the
government for purposes of the Federal False Claims Act.
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Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
March 23, 2010
Summary of Provision
Sec. 6402: Anti-Kickback Statute
 A claim that includes items or services resulting from a
violation of the Federal Anti-Kickback Statute constitutes a
false or fraudulent claim for purposes of the False Claims
Act.
 Revises “intent” requirement such that a person need not
have actual knowledge of the Anti-Kickback Statute nor
specific intent to commit a violation of the Anti-Kickback
Statute.
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Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 10104: False Claims Act Qui Tam Actions – Public Disclosure Bar
 A court shall dismiss a qui tam action or claim, unless
March 23, 2010
opposed by the Government, if substantially the same
allegations or transactions as alleged in the action or claim
were publicly disclosed (i) in a Federal criminal, civil, or
administrative hearing in which the Government or its
agent is a party; (ii) in a congressional, GAO, or other
Federal report, hearing, audit, or investigation; or (iii) from
the news media, unless the action is brought by the
Attorney General or the person bringing the action is an
original source of the information.
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Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 10104: False Claims Act Qui Tam Actions – Public Disclosure Bar
 “Original source” means an individual who either (i) prior
March 23, 2010
to a public disclosure has voluntarily disclosed to the
Government the information on which the claim is based;
or (ii) who has knowledge that is independent of and
materially adds to the publicly disclosed allegations or
transactions, and who has voluntarily provided the
information to the government before filing a qui tam
action.
© Krieg DeVault LLP 2010
73
Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 10606: Health Care Fraud Statute
 Amends criminal health care fraud statute (18 U.S.C. §
March 23, 2010
1847), which covers health care benefit programs, to
reduce “intent” required to establish a health care fraud
violation. Under the amended statute, actual knowledge
of the health care fraud statute or specific intent to violate
the health care fraud statute is not required.
© Krieg DeVault LLP 2010
74
Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Secs. 6402, 6408: Expansion of Civil Monetary penalties (CMPs)
Provides for civil monetary penalties for the following
March 23, 2010
activities:
 Ordering or prescribing a medical or other item or service
during a period in which the person was excluded from a
Federal health care program, if the person knows or
should have know that a claim for such medical or other
item or service will be made.
© Krieg DeVault LLP 2010
75
Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Secs. 6402, 6408: Expansion of Civil Monetary penalties (CMPs)
 Knowingly making or causing to be made any false
March 23, 2010
statement, omission, or misrepresentation of a material
fact in any Federal health care program application, bid or
contract.
 Knowing retention of an overpayment and not reporting
and returning such overpayment.
© Krieg DeVault LLP 2010
76
Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Secs. 6402, 6408: Expansion of Civil Monetary penalties (CMPs)
 Knowingly making, using, or causing to be made or used, a
March 23, 2010
false record or statement material to a false or fraudulent
claim for payment for items and services furnished under
a Federal health care program.
 Failing to grant timely access, upon reasonable request, to
the HHS Inspector General for audits, investigations,
evaluations, or other statutory functions of the HHS
Inspector General.
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77
Patient Protection and Affordable Care
Act of 2010
Selected Fraud and Abuse & Program Integrity Provisions
Effective Date
Summary of Provision
Sec. 6402: Suspension of Medicare/Medicaid Payments
Pending Fraud Investigation
 Medicare and Medicaid payments may be suspended
March 23, 2010
pending investigation of a “credible” allegation of fraud,
unless HHS determines there is good cause not to suspend
such payments.
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SUMMARY OF PROVISION
Sec. 6404: Reduced Medicare Claims Submission Timeframes

For services furnished on or after 1/1/2010, reduces the allowable period of submission of Medicare claims from
three (3) calendar years following the year in which services were furnished to one (1) calendar year after the date
of service.

For services furnished before 1/1/2010, a bill or request for payment must be filed not later than 12/31/2010
Sec. 6003: Physician Disclosure Requirements for In-Office PET/MRI/CT Services
 Amends Stark Law’s statutory In-Office Ancillary Services Exception to require that, at the time of referral, a referring
physician inform, in writing, the patient that he or she may obtain MRI, CT, or PET imaging services from a person other
than the referring physician, a physician in the same group practice as the referring physician, or an individual directly
supervised by the physician or by another physician in the group practice
Physician must also provide such individual with a written list of suppliers who furnish such services in the area in
which such individual resides
Sec. 6402: Anti-Kickback Statute

A claim that includes items or services resulting from a violation of the Federal Anti-Kickback Statute constitutes a
false or fraudulent claim for purposes of the False Claims Act

Revises “intent” requirement such that a person need not have actual knowledge of the Anti-Kickback Statute nor
specific intent to commit a violation of the Anti-Kickback Statute
Sec. 6402: Overpayments
Medicare/Medicaid overpayments must be reported and returned within 60 days of the later of: (1) the identity of
the overpayment; or (2) the date a corresponding cost report is due
Any overpayment retained after the 60-day deadline is considered an “obligation” to pay money to the government
for purposes of the Federal False Claims Act
EFFECTIVE DATE
January 1, 2010
Applies to services
performed on or after
January 1, 2010
March 23, 2010
March 23, 2010
SUMMARY OF PROVISION
Sec. 10104: False Claims Act Qui Tam Actions - Public Disclosure Bar


A court shall dismiss a qui tam action or claim, unless opposed by the Government, if substantially the same
allegations or transactions as alleged in the action or claim were publicly disclosed (i) in a Federal criminal, civil, or
administrative hearing in which the Government or its agent is a party; (ii) in a congressional, GAO, or other Federal
report, hearing, audit, or investigation; or (iii) from the news media, unless the action is brought by the Attorney
General or the person bringing the action is an original source of the information
“Original source” means an individual who either (i) prior to a public disclosure has voluntarily disclosed to the
Government the information on which the claim is based; or (ii) who has knowledge that is independent of and
materially adds to the publicly disclosed allegations or transactions, and who has voluntarily provided the information
to the government before filing a qui tam action.
Sec. 10606: Health Care Fraud Statute

EFFECTIVE DATE
March 23, 2010
March 23, 2010
Amends criminal health care fraud statute (18 U.S.C. § 1847), which covers health care benefit programs, to reduce
“intent” required to establish a health care fraud violation. Under the amended statute, actual knowledge of the
health care fraud statute or specific intent to violate the health care fraud statute is not required.
Secs. 6402, 6408: Expansion of Civil Monetary Penalties (CMPs)
Provides for civil monetary penalties for the following activities:

Ordering or prescribing a medical or other item or service during a period in which the person was excluded from a
Federal health care program, if the person knows or should have know that a claim for such medical or other item or
service will be made

Knowingly making or causing to be made any false statement, omission, or misrepresentation of a material fact in
any Federal health care program application, bid or contract

Knowing retention of an overpayment and not reporting and returning such overpayment

Knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent
claim for payment for items and services furnished under a Federal health care program

Failing to grant timely access, upon reasonable request, to the HHS Inspector General for audits, investigations,
evaluations, or other statutory functions of the HHS Inspector General
March 23, 2010
Sec. 6402: Suspension of Medicare/Medicaid Payments Pending Fraud Investigation
Medicare and Medicaid payments may be suspended pending investigation of a “credible” allegation of
fraud, unless HHS determines there is good cause not to suspend such payments
Sec. 6411: Expansion of Recovery Audit Contractor (RAC) Program
March 23, 2010
March 23, 2010
 Expands RAC program into Medicaid to identify underpayments and recoup overpayments; Requires
states to contract with RAC by 12/31/2010
 Expands RAC program to Medicare Parts C and D; Focus on anti-fraud plans for Medicare Advantage
Plans under Part C and Prescription Drug Plans under Part D
Section 6001: Physician/Hospital Ownership Restrictions/Reporting
March 23, 2010
In addition to ownership and facility capacity restrictions relative to the Stark Law’s whole hospital
exception, Section 6001:
Requires hospitals to submit annual reports to HHS containing a detailed description of each physician
owner or investor of the hospital and the nature and extent of all ownership and investment interests
Requires hospitals to implement procedures requiring physician owners and investors to disclose the
physician’s ownership or investment interest to patients referred to the hospital
Requires hospitals to disclose the fact that the hospital is partially owned or invested in by physicians on
the hospital’s public website and in any public advertising by the hospital
Sec. 6409: Medicare Self-Referral Disclosure Protocol
 Requires HHS to establish a self-referral disclosure protocol (‘‘SRDP’’) for health care providers and
suppliers to disclose an actual or potential Stark Law violation
 Provides authorization for HHS discretion to reduce the amount due and owing for all Stark Law
violations to an amount less than that specified in the statute
Protocol to be
established no more
than 6 months from
March 23, 2010
Secs. 6405, 6406, 6407: Ordering of DME and Home Health Services
Limits ordering of DME or home health services for Medicare beneficiaries to Medicare enrolled physicians
or eligible professionals; Applies to written orders & certifications made on or after July 1, 2010
Authorizes HHS to revoke enrollment, for not more than one (1)year for each act, of a Medicare physician,
supplier, or provider who fails to maintain and provide access to documentation relating to written orders or
requests for payment for DME or certifications for home health services ; Applies to orders, certifications,
and referrals made on or after January 1, 2010
Requires physician or other permitted professional to have a face-to-face encounter with a patient prior to
issuing a certification for home health services or written order for DME for Medicare and Medicaid
beneficiaries; Applies to home health certification, after January 1, 2010; Applies to written orders for DME
on March 23, 2010
Sec. 6507: Mandates NCCI-Type Methodologies for Medicaid
Mandates states to use compatible methodologies of the National Correct Coding Initiative (NCCI) for
Medicaid claims
Sec. 6402: National Provider Identifier Mandate
Requires all Medicare and Medicaid providers and suppliers to include their national provider identifier
(NPI) on all program enrollment applications and claims
Sec. 6403: Required Data Sharing
 Requires HHS to establish a national health care fraud and abuse data collection program for the
reporting of certain final adverse actions (not including settlements in which no findings of liability have
been made) and to furnish the collected information to the National Practitioner Data Bank
 Mandates states to establish a system for reporting information with respect to formal licensing
proceedings or final adverse actions (not including settlements in which no findings of liability have been
made)
Effective for claims filed
on or after October 1,
2010.
Regulation shall be
promulgated to apply
no later than January 1,
2011
First day after the final
transition period set
forth by HHS.
Sec. 6101: Physician/Skilled Nursing Facility Ownership Reporting
Requires reporting of the identity of governing board members, officers, partners, owners, trustees, etc.
and Additional Disclosable Parties.
Additional Disclosable Party means any person or entity who exercises operational, financial or
managerial control over the health facility or any part thereof, or provides financial or cash management
services to the facility and who leases or subleases real property to the facility or owns at least 5% of the
total value of such real property.
Sec. 6002: Manufacturers and Group Purchasing Organizations
Transparency Reporting of Physician Ownership and Investment
On 90th day of each calendar year, transparency reports shall be made on any payment or other transfer of
value to a physician or a physician’s immediate family member (name, address, specialty, form and amount
of payment, payment dates, and description of nature of payment).
On 90th day of each calendar year, transparency reports of any investment held by physician or physician’s
immediate family member, value invested, value and terms of such ownership and any payment made to
such physician or family member.
Unknown Failure to File Transparency Report – Civil monetary penalty of $1,000 to $10,000 for each
failure to report a payment or transfer of value with an annual limit for such failures of $150,000.
Knowing Failure to File Transparency Report – Civil monetary penalty of $10,000 to $100,000 for each
failure of reporting a payment or transfer of value with an annual limit of $1,000,000.
The latter of March 23,
2012 or 90 days after
the date of the final
regulations publication.
March 13, 2013
Questions?
Hospitals
Tom Hutchinson
[email protected]
(317) 238-6254
Physicians
Leeanne Coons
[email protected]
(317) 238-6269
Long Term Care
Lori McLaughlin
[email protected]
(219) 227-6075
Behavioral Health
Dave Jose
[email protected]
(317) 238-6211
Fraud & Abuse
Randy Fearnow
[email protected]
(312) 423-9304 or (317) 238-6279
Fraud & Abuse
Glenn Troyer
[email protected]
(317) 238-6223
2725110
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