Health Care Reform Webinar: Part II What Health Care Providers Need to Know About the Reform...

Health Care Reform Webinar: Part IIHealth Care Reform Webinar: Part II

What Health Care Providers Need What Health Care Providers Need to Know About the Reform to Know About the Reform

Legislation’s Impact … NowLegislation’s Impact … Now

April 29, 2010April 29, 2010

© Krieg DeVault LLP 2010 2

FacultyHospitals. . . . . . . . . Thomas HutchinsonPhysicians . . . . . . . Leeanne CoonsLong Term Care . . . Lori McLaughlinBehavioral Health . . Dave JoseFraud & Abuse. . . . . Randy FearnowFraud & Abuse. . . . . Glenn TroyerModerator . . . . . . . . Susan Ziel


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.

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


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%


VBP (continued)

Compliance website debuts in 2014 – Will you be ready?


VBP (continued)

What Now? IT EMR Physician Collaboration


Bundling

Pilot program starting January 1, 2013 Will run for at least 5 years Includes hospitals, physicians, SNFs, and

HHAs


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.


Bundling (continued)

Payments will be comprehensive Will cover the costs of services, as

determined by the Secretary


Community Health Needs Assessment

Assess your “community” – What is it? Adopt a strategy and how it will be

implemented Redo every 3 years


Community Health Needs Assessment (continued)

Include those with special knowledge or expertise

Consider property tax implications


Financial Policies

Must use “reasonable efforts” to make payment arrangements before you make

“Extraordinary collection efforts”


Accountable Care Organizations

Begins in January 1, 2012 Must have shared governance - PHOs

again? 5,000 minimum Medicare beneficiaries Payment methods to include fee-for-

service, partial capitation, and other methods


Physician-Owned Hospitals

Physician ownership frozen Hospital expansion frozen Special exceptions unlikely

= Physicians hungry for involvement

Healthcare Reform Legislation and Physicians

Leeanne R. Coons, Esq.Krieg DeVault LLP

One Indiana Square, Suite 2800

Indianapolis, Indiana 46204

Phone: 317-238-6269



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


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


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


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 2011-2016


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


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


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


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


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

Lori McLaughlin, Esq.Krieg DeVault LLP

833 West Lincoln Highway, Suite 410W

Schererville, IN 46375

Phone: 317-238-6075


Healthcare Reform Legislation and Long Term Care


Medicaid Coverage for Long Medicaid Coverage for Long Term Care and Support ServicesTerm 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.


Medicaid Coverage for Long Medicaid Coverage for Long Term Care and Support Services Term Care and Support Services

(CONTINUED)(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


Medicare – Skilled Nursing Medicare – Skilled Nursing FacilitiesFacilities

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


Medicare – Skilled Nursing Medicare – Skilled Nursing Facilities Facilities (CONTINUED)(CONTINUED)

Extends Medicare therapy caps exceptions process through December 31, 2010

Authorizes physician assistants to order skilled nursing services beginning in 2011


Medicare – Home HealthMedicare – 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


Medicare – HospiceMedicare – 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.


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.


Value-Based PurchasingValue-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.


Value-Based Purchasing - Skilled Value-Based Purchasing - Skilled Nursing FacilitiesNursing 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


Value Based PurchasingValue 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


Nursing Home TransparencyNursing 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.


Nursing Home Transparency Nursing Home Transparency (continued)(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.



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.



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.


Quality InitiativesQuality 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.


Quality InitiativesQuality Initiatives (continued)(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


Community Living Assistance Community Living Assistance Services and Supports (CLASS)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


Community Living Assistance Services Community Living Assistance Services and Supports (CLASS)and Supports (CLASS) (continued)(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.


Demonstration Projects, Studies Demonstration Projects, Studies or Commissionsor 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.


Demonstration Projects, Studies Demonstration Projects, Studies or Commissionsor Commissions (continued)(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, community-based 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.



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.



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.


The Take AwaysThe Take Aways

1. Shifting of dollars away from institutions toward home and community based services

2. Reimbursements tied to performance for Medicare and Medicaid

3. Coordination of care amongst and between all health care providers is essential

4. Large or national chains being targeted with ‘transparency” requirements

5. Many demonstrations to be conducted which means more and likely significant changes to come so stay tuned…..

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



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


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


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


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


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


Community-Based Services

States with expanded and new options Avoid waivers Community First Option for individuals with

disabilities


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?


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


Community Health Centers

$11 Billion in funding Support for new programs to support

school-based health centers


Other Items

$75 Million for project to reimburse psych hospitals for Medicaid coverage of emergency psych treatment

Modified standards for CMHCs

Fraud and Abuse &Fraud and Abuse &Program Integrity ProvisionsProgram Integrity Provisions

Glenn T. Troyer, Esq.Krieg DeVault LLP

949 E. Conner Street, Suite 200

Noblesville, IN 46060

Phone: 317-238-6223


Randall R. Fearnow, Esq.Krieg DeVault LLP

30 N. LaSalle Street, Suite 3516

Chicago, IL 60602

Phone: 312-423-9304 or (317) 238-6279



Patient Protection and Affordable CarePatient Protection and Affordable CareAct of 2010Act of 2010

Selected Fraud and Abuse & Program Integrity ProvisionsSelected Fraud and Abuse & Program Integrity Provisions

SUMMARY OF PROVISION EFFECTIVE DATESec. 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

January 1, 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

Applies to services performed on or after January 1, 2010

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

March 23, 2010

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

March 23, 2010

SUMMARY OF PROVISION EFFECTIVE DATESec. 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.

March 23, 2010

Sec. 10606: Health Care Fraud Statute

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.

March 23, 2010

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 InvestigationMedicare 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

March 23, 2010

Sec. 6411: Expansion of Recovery Audit Contractor (RAC) Program

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

March 23, 2010

Section 6001: Physician/Hospital Ownership Restrictions/Reporting

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

March 23, 2010

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

Effective for claims filed on or after October 1, 2010.

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

Regulation shall be promulgated to apply no later than January 1, 2011

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)

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.

The latter of March 23, 2012 or 90 days after the date of the final regulations publication.

Sec. 6002: Manufacturers and Group Purchasing OrganizationsTransparency 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.

March 13, 2013


Questions?

2725110

HospitalsTom Hutchinson

[email protected](317) 238-6254

PhysiciansLeeanne Coons


Long Term CareLori McLaughlin


Behavioral HealthDave Jose


Fraud & AbuseRandy Fearnow

[email protected](312) 423-9304 or (317) 238-6279

Fraud & AbuseGlenn Troyer


Health Care Reform Webinar: Part II What Health Care Providers Need to Know About the Reform...

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