San Francisco General Hospital's long waits for mammograms have been significantly shortened, and women needing appointments are now getting them within a week or two. In February, it was reported that the average wait time for a diagnostic mammogram at SF General after a woman had found a lump in her breast was 128 days, enough time for a very aggressive tumor to grow and affect the survival rate. Now, those women can get mammograms within seven to 14 days. The wait time for a precautionary screening mammogram has also been shortened, from 300 days to 90.
As unemployment and healthcare costs continue to rise, more people are buying cheap insurance plans with often financially devastating results. In 2008, Washington state announced a $20 million settlement with several companies, saying the companies had denied legitimate claims and misled thousands of consumers. Since 2003, more than 400 people have complained to state regulators about discount health plans.
A new report describes encouraging results for the Chicago Housing for Health Partnership, the first program in the country to link hospitals serving homeless, chronically ill patients with federally subsidized housing. The organization was formed in 2002 to deal with ill homeless people being discharged from hospitals that end up back on the streets without regular medical care. Inevitably, their health deteriorates. If there were some way to stabilize these patients with ongoing help, then perhaps they would have fewer medical crises and not return to hospitals as often, members of the partnership reasoned.
The New York State Office of Medicaid Inspector General (OMIG) last week released its 2009 work plan, which details the processes used by the agency to root out Medicaid fraud.
In the work plan's introduction, Medicaid Inspector General James Sheehan describes the document as a "road map" for the agency "reflecting OMIG's mission, developing competencies and carefully reviewing New York Medicaid expenditures and vulnerabilities."
The 2009 work plan is the second such document released by the New York OMIG, which continues to be among the most active Medicaid enforcement agencies. Within the work plan, the OMIG stated it also plans to publish compliance guidance for hospitals and managed care organizations in 2009.
However, according to experts, the work plan provides helpful guidance in its own right.
"New York state Medicaid work plan is a useful resource providers can certainly consider when identifying risk in the Medicaid program," says Sarah Kay Wheeler Sarah Kay Wheeler, partner at King & Spalding in Atlanta.
According to Wheeler, the work plan offers a transparent look into how the OMIG operates, which can be valuable to providers in any state. Providers can look to the work plan when determining possible Medicaid vulnerabilities. This is particularly important now because evidence indicated Medicaid enforcement efforts have been on an upswing.
Last week, New York State Attorney General Andrew Cuomo announced the state's Medicaid Fraud Control Unit (MFCU) recovered more than $263.5 million in fraud and abuse settlements in 2008. That total is more than double what the state recovered in 2007. New York's federal fiscal year 2009 goal is set at $322 million and if history is any indication, the state should meet that goal.
But New York agencies are not the only ones cracking down on Medicaid abuse. The federal Office of Inspector General also targeted Medicaid in its 2009 work plan.
"For those of us that have been following the law, this is not a surprise," says Wheeler.
According to Wheeler, the uptick in Medicaid enforcement has been in the works since 2006 when the Federal Deficit Reduction Act aimed to establish more resources to ensure the integrity for the Medicaid dollar.
The act increased funding at the federal level to establish data-mining, enact employee education provisions, encourage states to establish their own version of the False Claims Act, and created the Medicaid Integrity Contractors (MIC).
MICs are a quieter cousin to the Recovery Audit Contractors (RAC). Wheeler says MICs have not gotten as much attention as the RACs because MICs have not been as active. But Wheeler predicts MICs will be more active in 2009 than they have in previous years, and she wouldn't be surprised if this turns out to be a record year.
Ben Amirault is an Editorial Assistant for the revenue cycle division of HCPro. He manages the Compliance Monitor e-newsletter and has developed a number of online learning modules. He can be reached atbamirault@hcpro.com.
For the first time, there are three separate entities that hospitals can turn to for accreditation—the ubiquitous Joint Commission, the Healthcare Facilities Accreditation Program (HFAP), and newcomer Det Norske Veritas' (DNV) National Integrated Accreditation for Healthcare Organizations (NIAHO) program. With the option to move from one accreditation organization (AO) to another comes concerns of process and Medicare reimbursement.
"One of the issues that keeps coming up is, if I switch AOs, will that impact my Medicare reimbursement?" says Darrel Scott, senior vice president for regulatory and legal affairs for DNV.
To address this concern, DNV recently updated its FAQs to describe the process of switching accreditors.
"This applies regardless of which AO you are changing from or going to," says Scott. "We wanted to try to address in our FAQs the exact mechanic that occurs when a move is made."
So here's the process: when a hospital or hospital system decides to switch accreditation organizations, it can notify its current AO right away. The next step could go one of two different ways. First, the hospital and the AO can work out a plan for withdrawal and transition to the new AO. If this does not happen—that is, if the hospital and the AO cannot work out a transition strategy, the current AO may immediately withdraw the hospital's accreditation.
This is not as problematic as it may seem, however. The hospital's Medicare provider agreement is not affected should the current AO withdraw its accreditation before it is accredited by another AO. The current AO will, after removing the hospital's accreditation, notify the CMS Central Office and the applicable CMS Regional Office of its action. The AO will also provide those offices with an effective date of termination.
Again, there are two ways this next step can go. The simpler way is if the termination of one accreditation organization's accreditation is concurrent with a new recommendation for accredited, deemed status by the AO the hospital is transferring to. In that case, the hospital is simply transferred under the umbrella of the new AO.
However, if the current AO withdraws its accreditation and the hospital has not yet received accreditation from the new AO, the hospital is placed under the State Survey Agency (SA) jurisdiction. The hospital will remain under SA jurisdiction until it receives accredited, deemed status from the new organization. This new accreditation and deemed status must, of course, be approved by the CMS Central Office and the applicable CMS Regional Office as well.
"If the current AO informs the hospital that it is terminating its accreditation immediately and the AO notifies CMS, the hospital is moved over to the jurisdiction of the State Survey Agency," says Scott. "The hospital is then subject to a state survey until it is accredited by the new AO."
Throughout this process, the hospital's Medicare provider agreement and reimbursement is uninterrupted even though the hospital may be in transition from one AO to another. During this transition, there is always oversight from one of these entities and Medicare reimbursement is not affected.
Hackers last week broke into a Virginia state Web site used by pharmacists to track prescription drug abuse. They deleted records on more than 8 million patients and replaced the site's homepage with a ransom note demanding $10 million for the return of the records, according to a posting on Wikileaks.org, an online clearinghouse for leaked documents.