2010 PSOW Conference - Healthcare Reform
Transcript of 2010 PSOW Conference - Healthcare Reform
Healthcare Reform
Healthcare ReformHow Will it
Impact You?How Will it
Impact You?
About Your PresenterAbout Your Presenter
Jerry Miller, NREMT-PCEO/President of LifeQuest
Jerry Miller has been actively involved in the EMS and Fire industry for 31 years
TodayToday
• Ambulance Impact
• Background & Major Points
• As an Employer
TodayToday• Fraud & Abuse
• Quality Patient Care
• Funding
• Q&A
BackgroundBackground• Patient Protection &
Affordable Care Act• (PPACA)
• Became law 3/23/2010
• Healthcare & Education Affordability Reconciliation• Fixes & Corrections
• Became law 3/30/2010
BackgroundBackground• 21 states have filed Federal Lawsuits
• May be Dismissed
• Virginia• May have a Case
• At Issue:• Can the Feds force Healthcare?
BackgroundBackground
Is it a tax or isn’t it a tax?
• Argument – Restricts Personal and Economic Freedoms
BackgroundBackground• Will likely go to the
Supreme Court• Moving to strike down entire bill• Feds moving forward with
implementation
Ambulance ImpactAmbulance Impact
The Good News…The Good News…• Extends MIPPA Payments
• Through December 31, 2010• 2% Urban Ground• 3% Rural Ground• 22.6% Super Rural Ground• Air Ambulance – Rural remains the same
as they were 12/31/2006
The Good News…The Good News…• Retroactive to January 1st, 2010
• Carriers were supposed to begin reimbursement July, 2010
The Bad News…The Bad News…• Productivity Adjustment
• Effective beginning of 2011
• Already applies to other providers, applicable to everyone
• Ensure Medicare Sustainability
The Bad News…The Bad News…• Assumes efficiency each year• Reduces CPI annual updates• Allows for negative fee schedule
updates
The Bad News…The Bad News…
• What is it?• 10 year moving average
• Fee schedule amount subject to the 10 year moving average
The Bad News…The Bad News…• 2010 Negative CPI, however 0%
increase
• PPACA – would have likely been negative increase
The Bad News…The Bad News…• Example: CPI = 1%
• Productivity Adjustment = -1.5%
• Annual Increase = -0.5%
The Bad News…The Bad News…• Productivity Factor
• Difficult for EMS to provide more cost effective care
• Cost of equipment• Cost of ambulances• Cost of operations
• Cost of fuel• Cost of Supplies
• Impact on Patient Care
The Not So Bad The Not So Bad News…News…
• American Ambulance Association
• Advocates– Congress• Exclude EMS???
Background Background & Major Points& Major Points
• Pilot Programs• HHS (Four competitive grants)
• Innovative models of regionalized, comprehensive and accountable emergency care and trauma systems.
• States, Partnership of States, or Indian Tribes
Background Background & Major Points& Major Points
• States• Regionalization
• Regionalization discussions not new to Wisconsin
• Must be consistent region wide management system
Background Background & Major Points& Major Points
• Coverage– Plan to cover 32 million uninsured
• 16 million – State exchanges• 16 million – through Medicaid expansion
Background Background & Major Points& Major Points
• Estimated 23 million will still be uninsured
• How it happens:• Coverage mandates for individuals, employers
and states
Individual MandateIndividual Mandate• Most people (legal) must have
health coverage by 2014
• Penalties for Individuals• 2014 - $95.00 or 1% of taxable income• 2015 - $325.00 or 2% of taxable income• 2016 - $695.00 or 2 ½ % of taxable income
Individual MandateIndividual Mandate• Individual Mandate – Exemptions:
• Financial Hardship• Religious Objections
• 2014 - Must Prove Coverage
• Will impact tax returns
Credits & Cost SharingCredits & Cost Sharing• Eligible:
• Meet Income limits• Employees w/o sufficient coverage or pay share
exceeding 9½ % of income• Legal Immigrants during first 5 years - no Medicaid
Credits & Cost SharingCredits & Cost Sharing• Tax Credits – Income between
133-400% FPL
• Cost Sharing – Reduce Out of Pocket
Expansion of MedicaidExpansion of Medicaid• 2014 – States expand Medicaid
to cover those under 65 with incomes up to 133% of FPL
• Mandates automatic enrollment of new eligibles
Expansion of MedicaidExpansion of Medicaid• 2014 – 2016: States receive Federal
Funding for new eligibles 100%
• 2020 + : States receive Federal Funding for new eligibles 90%
Expansion of MedicaidExpansion of Medicaid• Employer:
• Large employers must offer coverage starting 2014
AmbulanceAmbulance• More good news: 32 million covered
under insurance• Better than nothing
• Down Side:• Low reimbursement rates
AmbulanceAmbulance• We must start now to increase
Medicaid rates
• Grass Roots:• Litigation• Other
AmbulanceAmbulance• Increase use of Ambulance System
• Increase abuse of Ambulance System??
• Community Paramedic Programs?
OptionsOptions• Health Insurance Exchanges
• Purchasing Options• State Exchanges (2 types)
• American Health Benefit Exchanges – No employer coverage
• Small Business Health Options Program– Small employers up to 100 employees
DetailsDetails• Four Categories/Plans
(Bronze-Platinum)• Catastrophic Plan/Under 30
(Option)• (Out of Pocket) Expense is limited
by annual income
DetailsDetails
• Exchange Rules:•Strict Marketing•Contract w/ providers•Accredited•Uniform Enrollment
DetailsDetails• Ambulance
• More affordable for small services•50 FTEs or less
• Save Money• Increase reimbursement potential
DetailsDetails• High Risk Pool
• Those with pre-existing conditions
• Effective 6/21/2010
• Wisconsin Health Insurance Risk Sharing Plan (HIRSP)
New RulesNew Rules
• No prior authorization for emergency services
• Prudent lay person (definition)
New RulesNew Rules
• No lifetime caps after 9/23/2010
• No withdrawing coverage except in cases of fraud
New RulesNew Rules
• Coverage for adult children up to age 26–Wisconsin Age 27•Any insurers current
New RulesNew Rules• No exclusion for preexisting conditions
– Children 9/23/2010, all others 1/1/2014• Process for reviewing increases for 2010• No annual limits/plans - 2014• Eliminate waiting periods for coverage
over 90 days.
New RulesNew Rules• Existing plans grandfathered
except:• Coverage up to age 27• Elimination of waiting periods• Lifetime and Annual caps• Pre-existing conditions
Medicare AdvantageMedicare Advantage• Restructure payments
• Plus 14% - Gone
• Phase in 3 – 6 years starting 2011
• Medicare advantage align with fee for service
Medicare AdvantageMedicare Advantage
•High ratings = Bonus
Medicare AdvantageMedicare Advantage
• Still capped at 12-14% (Current)
• Penalties – Poor Performance
Medicare Advantage: Medicare Advantage: AmbulanceAmbulance
• Watch your rates
• Need to cover losses
• Only mandatory reduction = productivity adjustment
Employer MandatesEmployer Mandates• 2014 – 50 or more FTEs must offer
coverage to FTEs/dependents• FTEs = Average 30 hours per week• No requirement for PT Employees
•Might see more PT employees
Employer MandatesEmployer Mandates
• Penalties:•50 or more FTEs no coverage
•$2000/FTE not including first 30
•01/01/2014
Employer MandatesEmployer Mandates• Unaffordable Coverage
• 50 or more FTE’s can not cost more then 9.5% of household income - if employee opts out•Lesser of $3,000/FTEs or•$2,000 for all FTEs
Employer MandateEmployer Mandate
• Free Choice Voucher• Employee less than 400% FPL & pay
8-9.8% of income for Ins – Employer must offer free choice voucher
• Enables employee to purchase from exchange• Voucher must equal amount employer would
have contributed
Employer MandatesEmployer Mandates
• Free Choice Voucher•Applies to all employers•Excess cost – Employee
Keeps•Tax Deductible
Employer MandatesEmployer Mandates
• Employer/200 FTEs must automatically enroll FTEs
• Give employee opt out option
Employer MandatesEmployer Mandates• 3/1/2013 – Must provide written
notice of:• Exchanges• Entitlement, Credits/Subsidies• Tax Implications• Financial Impact
Employer MandatesEmployer Mandates
• W-2 Reporting•1/1/2011- Must report value
of all Medical, Dental, Vision and Supplemental insurance coverage on W-2
Employer MandatesEmployer Mandates• 2014 – Employers w/ 50 or more
employees – file information return• Report coverage offered and status• Flexible Spending account
• 2013 – Contribution reduced to $2500/per year
• Prescription Required for OTC meds using FSA funds
Employer OptionsEmployer Options• Small Employers
• 50 or less FTEs exempt from penalties
• No duty to provide coverage• 2014 – Can purchase coverage
from small business exchange
Employer OptionsEmployer Options• Tax Credits
• 25 or less FTEs and average annual wage of 50K or less
• Must contribute at least 50% of premium
Employer OptionsEmployer Options• Small Employers
• 2010-2013 – 25 or less FTEs = 35% tax credit of their contribution into premium
• 2014 – Employers with 25 or less FTEs = 50% credit for employers that purchase through exchange
Employer OptionsEmployer Options
• 10 or less FTEs and average annual wage of less than $25K eligible for full credit of premium amount paid by employer
Employer OptionsEmployer Options• Small Employer
• Wellness Program• Grants available for establishing wellness
programs (up to 5 years/ 2011-2015)• Profit or Non-Profit
• Less than 100 employees who work 25 hours or more
• Did not provide wellness program before 3/23/10
Employer OptionsEmployer Options• Ambulance
• Small Services• Benefit from tax breaks and grants• Some increased reporting• Better Healthcare coverage of EMS
Staff/Recruitment
Here It Comes…Here It Comes…
Fraud•350 million over ten years for fraud and abuse.
Claim FilingClaim Filing• Must be submitted 1 calendar year
after date of service
• Medicare MAC creating edits to catch late filing
• Claims over 1 year automatically denied
Anti-KickbacksAnti-Kickbacks• Clarification
• Person need not have actual knowledge of this section…
• Or Specific intent to commit a violation or specific intent to commit a violation
Anti-KickbackAnti-Kickback
Must still prove defendantknew conduct was
unlawful
OverpaymentsOverpayments• New:
• Must provide system to identify overpayments along with written notification
• Must report and return 60 days after overpayment identified
• Hospital – cost based report is due
OverpaymentOverpayment
Must return government money within 60 days
False StatementsFalse Statements
• Knowingly making false statements, omissions or misrepresentation of a fact
• May cause exclusion from federal programs
PenaltiesPenalties• False statement and claims for
payment• Knowingly making false record
or statement •$50K per false statement or record
PenaltiesPenalties• Intentional delay of OIG Inspection
• $15K per day for this failure• False Claims
• 1/1/2011 anti-kickback statue no longer limited to enforcement by the government
•Blood Bath
False ClaimsFalse Claims
Whistle blower can now file suit or ask government to
intervene.
In the News…In the News…“Terms of EMS Billing Settlement Made Public”
Clinton Herald – Sept 14, 2010
The settlement details of a lawsuit that claimed Clinton fire administration overstated ambulance call claims so the department would get more money have been released through city documents.
The city has agreed as part of the settlement to pay the U.S. government $4.5 million in 10 equal yearly amounts starting Oct. 1…
http://clintonherald.com/local/x5456537/Terms-of-EMS-billing-settlement-made-public
False ClaimsFalse Claims• What is a whistle blower?
• Competitor??• Current/Former Employee??• SNF Staff??• Patient??
• Expect a flood of Litigation
False ClaimsFalse Claims
You have to ask yourself, “Is it worth dropping off
that free pizza to the ER?”
OIGOIG• New law broadens OIG authority
to obtain information
• Can include virtually anything
• Expanded subpoena authority
SuspensionSuspension
• Government may suspend payments•For credible allegations of fraud
Mandatory Compliance Mandatory Compliance ProgramsPrograms
• Should already be in place
• Remember outside audits
Recovery Audit Recovery Audit Contractors (RAC)Contractors (RAC)
• Already working in the Midwest
• States required to hire RAC’s
• RAC’s paid to find problems
Provider/Supplier Provider/Supplier ScreeningScreening
• New procedures for screening HHS- new procedures for screening• State Licensure
•Background Checks•Unannounced Visits
•Begins 9/23/2010
Provider/Supplier Provider/Supplier ScreeningScreening
• Fees for new screening:• Starting at $200.00 in 2010
• HHS can pass new rules regarding screening “At Risk Providers.”
QualityQuality
• Overall objective is to improve quality of patient care
• Greater scrutiny over healthcare services
QualityQuality• Can we demonstrate that our
services really work and are effective?
• Can we show that our services are of the highest possible quality and efficiently provided?
QualityQuality• Can we prove that we make a
difference?
• Can we measure “cost effective?”
• Even our QI Systems will come into question.
FundingFunding
•Cost:•938 Billion dollars over 10 years
FundingFunding• How will we pay for it?
• Penalties on individuals and employers• Reduction in Health Reimbursement Accounts• Taxes on HSA’s when not used for qualified
expenses• Increase in Medicare Tax on earnings over $200K• Excise Tax on “Cadillac” health plans• Annual fees on pharmaceutical manufacturing• Tax on medical devices
FundingFunding• How will we pay for it?
• 10% tax on indoor tanning• Limit on deductibility of executive
compensation - $500K• Cuts to Medicare Advantage Program• Cuts in certain hospital payments• Cuts in Medicare Home Health Payments• Cutting Fraud and Abuse
What does it Mean??What does it Mean??
• Not entirely sure•Could increase revenue
• Would certainly increase compliance risk
• Greater scrutiny for quality
Top 10 Things to DoTop 10 Things to Do10.) Watch your Medicare Rates
9.) Watch your Medicare Advantage Rates
8.) Make sure your Employee Benefit Package is Solid/Complaint
7.) Review all of your Contracts
6.) Make refunds timely/Complaint
Top 10 Things to Do Top 10 Things to Do (Cont’d)(Cont’d)
5.) Comprehensive Compliance Program
4.) Collect adequate insurance information, signatures etc.
3.) Watch timely filing limits
2.) Quality of Care
1.) Increase Medicaid Rates
Questions???Questions???
References for this presentation:
Page, Wolfberg & Wirth 2010 May 24. “2010 PWW National Healthcare Reform Webinar”. For more information, visit www.pwwemslaw.com