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– Allows groups of providers who meet certain statutory criteria to be recognized as ACO's and be eligible to share in the cost-savings achieved by the Medicare program
• Promotes accountability and coordination of Parts A & B• Joint decision making (group practices, networks of
practices, partnerships, jvs)• Brookings-Dartmouth, Carilion Clinic, Community Care of NC
(formation stage)• To be discussed in later Webinar
Effect on Providers(What does this mean for providers?)
Medical Home – Grants to fund medical home models
– Geisinger Health System – team-based, provider & payor
– Medicaid enrollees with chronic health conditions could designate a provider as a medical home
– Bundled payments – Effective 2013, HHS required to develop a national voluntary bundled payment pilot program to provide incentives for providers to coordinate care
Primary Care – 10% bonus payments for certain primary care services and general surgeons providing care in HPSA's, effective 2011-2016
Title VI – not a lot of press, but most immediate changes for providers
– Limitations on Physician Ownership in Hospitals
• PPACA prohibits physician ownership in hospitals unless both the physician-ownerships in place, and the hospital has a Medicare provider agreement prior to December 31, 2010
• Such grandfathered hospitals may continue to participate in Medicare under tighter restrictions addressing conflict of interest, bona fide investments, patient safety, and expansion limitations
• After date of enactment, a physician-owned ASC cannot be converted to a hospital
• Hospitals must have procedures in place for owners to disclose physician ownership to patients and the public
• Physician-owned hospitals must submit an annual report to the Secretary of DHHS containing all owner/investors and the nature/extent of the ownership/investments
• Limited expansion may be applied for once every two years (maximum increase of 100%)
New Disclosure Requirements for In-Office Ancillary Services• Effective as of the date PPACA was signed into
law, referring physicians (or their practices) must inform patients in writing that the patients may obtain imaging services (MRI, CT, and PET), or certain other designated health services from other supplier
– The referring physician or practice must provide patients with a list of other suppliers of the service in the area
• Unclear until additional rules are promulgated exactly what physician practices are required to disclose to patients regarding other suppliers
– Within six months of PPACA’s enactment date (March 23, 2010), the Department of Health and Human Services (“HHS”) must develop and implement a self-referral disclosure protocol (“SDRP”) to enable health care providers and suppliers to disclose actual or potential Stark Law violations
Revisions to the Anti-Kickback Statute’s Intent Statute
– PPACA amends Section 1128B of the Social Security Act (with respects to violation of this section (the AKS), a person need not have actual knowledge of this section or specific intent to commit a violation of this section.”
• Government still must prove that the defendant knew the conduct was unlawful
• Rejects the standard in the Hanlester (9th Circuit) – “knowingly and willfully” – government had to prove that defendant:
1. Knew the AKS prohibited the conduct; and
2. Engaged in the prohibited conduct “with intent to disobey the AKS.”
– PPACA requires any provider, supplier, Medicaid managed care organization, and Medicare Advantage organization that has received an overpayment to report and return the overpayment to the government
– Reporting and repayment should be made no later than 60 days after the date on which the overpayment was identified or the date that any cost report is due
– Overpayments retained beyond the deadline is an “obligation” under the False Claims Act
1.Conduct a community health needs assessment at least once every 3 years, and to adopt an implementation strategy
2.Establish and publicize financial assistance and emergency care policies:
• Eligibility, basis for calculating charges• Methods for applying for financial assistance• Measures to publicize the policy• Actions hospital may take in the event of non-payment
3. No extraordinary collection actions without reasonable efforts to determine if patient is eligible for financial assistance. Non-insured patients may not be charged more for emergency or medically necessary care than amounts generally billed to those with insurance.
4. Required reporting with the IRS and DHHS regarding compliance with the new requirements
• Community health needs assessment and related tax years – March 2012
• Most of the changes apply to any tax year beginning after March 23, 1010
• For organizations on a calendar tax year, most of the changes will apply beginning January 1, 2011.
• For organizations operating on a fiscal year other than the calendar year, the changes will apply starting with the tax year beginning in 2010 (unless the organization’s fiscal year begins in January, February or March, in which case the changes will first apply to the organization’s tax year beginning in 2011.
• The exception is for the community health needs assessment requirement, which will be similarly “phased in” after a period of two years from the date of the enactment.
• The Act prohibits hospitals subject to the Act from:
- using gross charges
- limits amounts charged to individuals eligible for financial assistance to not more than the amounts typically billed to individuals who have insurance covering such care
Charitable Hospitals: Consequences• A hospital that fails to comply with the community health needs
assessment requirements will be liable for an excise tax in the amount of $50,000
• An organization with a facility that fails to comply with any of the new substantive requirements, including but not limited to the community health needs assessment requirements, will not be treated as described in Section 501(c)(3) with regard to that facility. For a single-facility organization, presumably this will constitute grounds for revocation of its tax-exempt status. It seems possible that the IRS will also treat the income from such non-complying facility as subject to unrelated business income tax
• The threat of revocation is enhanced by the Act’s requirement that the IRS review at least once every three years the community benefit activities of each hospital to which the Act applies
– Effective March, 2012, skilled nursing facilities must separately report expenditures for wages and benefits for direct care staff, breaking out, at a minimum, registered nurses, licensed professional nurses, certified nurse assistants, and other medical and therapy staff
Staffing – Ensuring Staffing Accountability
– By March, 2012, facilities will be required to submit electronically direct care staffing information, including information with respect to agency and contract staff based on payroll and other verifiable and auditable data in uniform format
National Program for National & State Background Checks
– Secretary to establish a program to identify “effective, efficient, and economical procedures” for long term care providers to conduct nationwide background checks on all employees with direct patient access
– Contains abuse reporting requirements such as report must be made in two hours
– Specifically, if facility has reasonable suspicion of a crime against a resident by owner, operator, manager, agent, contractor, employee or other resident, reports must be made to HHS Secretary and local law enforcement
– Reporting requirement went into effect on March 23, 2010
– HHS has not set up any type of hotline or number to call with report; for now, recommended reporting to State survey agency as “contractor” for HHS
– If covered individual violates this regulation subject to CMP of $200,000 if failure to report timely did not result in increased harm or $300,000 if failure to report does result in increased harm.
• For programs to enhance training recruitment and retention of staff;
• To improve management practices • For certified EHR Technology • As part of a national demonstration project, for
development of best practices regarding culture change and use of information technology to improve resident care that shall be implemented "not later than 1 year after" March 23, 2010.
• Requests shall be submitted by the applicant to the Secretary "at such time, in such manner, and containing such information as the Secretary may require."
• Authorized to be appropriated for the grants: $20 million 2011, $17.5 million 2012 and $15 million for each 2013 and 2014.
• NC Coalition for Long Term Care Enhancement is offering grant writing programs this summer
• Effective 2014, DSH payments will be reduced to reflect higher levels of insured (total reduction of $14.1 billion from 2014 – 2020)
– Medicaid prescription rebate increased from 15.1% to 23.1%, effective 2010
– Primary Care Services
• Payment rates to primary care physicians must equal at least 100% of the Medicare payment rate in 2013 and 2014 (federal government to fund the cost of this requirement)
– The Program requires drug manufacturers participating in Medicaid to enter into a pharmaceutical pricing agreement to provide front end discounts on covered outpatient drugs purchased by covered entities
– Expands participation in the 340B program to children’s hospitals, cancer hospitals, CAH’s and sole community hospitals