Medical practices and clinics increasingly are asking people to pay their entire out-of-pocket charge as they are walking out after a visit. That could include paying amounts a patient owes toward their health plan's deductible and a percentage of the cost of care under a co-insurance requirement. Patients who are uninsured also are being asked for money upfront or to sign up for a payment plan. And physician practices have started demanding patients pay in advance for outpatient surgeries and expensive imaging scans, a practice that certain hospitals have long enforced.
Newly unveiled court documents show that ghostwriters paid by a pharmaceutical company played a major role in producing 26 scientific papers backing the use of hormone replacement therapy in women. The findings suggest that the level of hidden industry influence on medical literature is broader than previously known, according to the New York Times.
The lead lobbyist for health insurance companies complained today that her industry is being "demonized" in the healthcare reform debate.
Karen Ignagni, president/CEO of America's Health Insurance Plans, was careful not to directly accuse President Obama and Democratic leaders in Congress of leading the effort. Instead, she decried "the same old Washington politics of ‘find an enemy and go to war.'"
"Attacking our community will not help get anyone covered, nor will it help our country bend the cost curve and make care more affordable for working families and small businesses," Ignagni says. "These are the issues that should be the focus of a national conversation this summer. That is what the country expected. Not politics as usual, but an effort to forge the consensus that will be necessary to get reform passed."
Last week House Speaker Nancy Pelosi (D-CA) was blunt in her assessment of the health insurance industry, calling them "the villains" in the health reform battle.
"The public option–that's where the insurance companies are making their attacks––it's almost immoral what they are doing," Pelosi told reporters. "Of course they've been immoral all along. They are villains in this. They have been part of the problem in a major way. They are doing everything in their power to stop a public option from happening and the public has to know. They had a good thing going for a long time at the expense of the American people and the health of our country. This is the fight of our lives."
President Obama has also shifted his rhetoric slightly, moving away from promoting "healthcare reform" in his stump speeches and town hall meetings toward "health insurance reform" to tap into what some observers say is a poll-tested understanding of the public's deep-seated animosity toward the health insurance industry.
Ignagni says she believes the stepped up attacks on private-sector healthcare reform are a desperate attempt by backers of the public health insurance option to distract attention from their faltering efforts.
However, Helen Halpin, director of the Center for Health and Public Policy Studies at the University of California at Berkeley, who worked with the Obama presidential campaign, says the health insurance industry deserves the criticism.
"The Democrats should condemn them. They are the villains in this story," she says. "If they actually sold all Americans health insurance policies that promoted their health and protected them from bankruptcy, then they would have a legitimate voice. But they don't. The only way they profit–and believe me they profit—is by denying coverage to those who need it and dropping or bankrupting those who have it and use it. It is truly shameful."
You know the "what" when it comes to HIPAA privacy and security enforcement: New federal laws this year include larger monetary fines, periodic audits, civil-suit authority to state attorneys general, and new HIPAA Security Rule compliance to business associates (BAs) of covered entities.
You now know the "who": The Office for Civil Rights (OCR), long the HIPAA Privacy Rule warden, inherits the security rule per a July 27 announcement by HHS Secretary Kathleen Sebelius.
But for covered entities, the bigger questions are "when" and "how much." When will this stepped-up enforcement arrive? And how regular will it be?
"I think the initial intent is to combine privacy and security investigations, audits, etc., in one division given [that] many security violations/breaches lead to privacy breaches," says Chris Apgar, CISSP, president of Apgar & Associates in Portland, OR. "It's logical that there be one enforcement shop for privacy and security. As far as what it means on the auditing side, that's likely not something we will know until next year."
By next year, major regulations in the Health Information for Economic and Clinical Health (HITECH) Act should be approved–most importantly, a definition of unsecure PHI (due August 18, 2009) and business associates compliance with the security rule (February 18, 2010).
The jury's out on what the organizational change for OCR and CMS means for providers. For HHS, the move will "eliminate duplication and increase efficiencies in how the department ensures that Americans' health information privacy is protected," according to an HHS press release sent yesterday.
"Privacy and security are naturally intertwined, because they both address protected health information," Sebelius said in the release.
OCR has only levied two major fines—Providence Health & Services in July 2008 ($100,000 fine and corrective actions) and CVS in February 2009 ($2.25 million fine).
Since the compliance date in April 2003, OCR, according to its Web site, has received 44,911 HIPAA privacy complaints, of which 19.4% (8,756) led to enforcement actions (8,756).
More than half (57.5%) of the cases were closed because they were not eligible for enforcement. Another 10% of investigations led to no findings of violations.
Rebecca Herold, CISSP, CIPP, CISM, CISA, FLMI, privacy, security, and compliance consultant at Rebecca Herold & Associates, LLC, in Des Moines, IA, blogged yesterday.
"It'll make it much less confusing, not only for [covered entities] and BAs, but also for the oversight agencies, and hopefully more effective for more active enforcement actions," Herold says.
John Parmigiani, MS, BES, president of John C. Parmigiani & Associates, LLC, Ellicott City, MD, and chairperson of the team that created the HIPAA Security Rule, calls the move by HHS "not a bad idea."
Parmigiani says OCR taking in security:
Eliminates the communication/enforcement barriers on cases where there are both privacy and security alleged violations.
Establishes a single focal point and accountability of inter-agency dealings with other federal healthcare enforcement arms as well as state data protection agencies
Gives added incentive for enforcement to OCR, whose resources directly benefit from penalties collected per HITECH
Isolates CMS' HIPAA Administrative Simplification enforcement role to transactions, code sets, and identifiers, which is more in line with a health insurance (payer) organization's responsibilities.
No matter what OCR will be responsible for, it's never been known as an enforcement shark, says Jeff Drummond, health law partner in the Dallas office of Jackson Walker LLP.
"Frankly, when the privacy rule first came out, many of us were left scratching our heads at the assignment of enforcement to OCR, which is not known as an aggressive agency," Drummond says. "If you want covered entities to really take the privacy rule seriously, assign enforcement to the Office of the Inspector General. The OIG strikes fear into the hearts of providers; OCR, not so much."
The issues are approved for outpatient hospital and physician providers in South Carolina. But even if you aren't located in South Carolina, if Connolly is your RAC, prepare for these issues in your state as well, says Nancy Beckley, MS, MBA, CHC, of the Bloomingdale Consulting Group, Inc.
Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc., agrees that providers outside Connolly's jurisdiction may want to review the issues as a clue to what RACs might audit in their area. However, she notes that providers should anticipate that RACs will audit for different issues for different jurisdictions although there certainly could be some overlap.
Connolly's Web site indicates the CMS-approved issues for South Carolina are:
Blood transfusions. Providers should bill CPT codes 36430, 36440, 36450, and 36455 (excluding claims with any modifiers) as one per session, regardless of the number of units transfused on that date of service.
Untimed codes. Providers should enter a one in the units billed column per date of service for CPT codes, excluding modifiers -KX and -59, where the procedure is not defined by a specific time frame (i.e., untimed codes).
IV hydration therapy. Based on the definition of CPT code 90760, the maximum number of units should be one per patient per date of service (excluding claims with modifier -59). Note: Beginning January 1, 2009, code 96360 replaced code 90760.
Bronchoscopy services. Providers should bill for CPT codes 31625, 31628, and 31629 with a maximum number of units of one per patient per date of service (excluding claims with modifier -59).
Once-in-a-lifetime procedures. By virtue of the description of the CPT code, providers may only perform these codes once per patient lifetime.
Pediatric codes exceeding age parameters. Newborn and pediatric CPT codes billed or applied to patients who exceed the age limit defined by the CPT code.
J2505 (Injection, Pegfilgrastim, 6 mg). By definition, HCPCS code J2505 represents 6 mg per unit. Providers should bill the code at one unit per patient per date of service.
"It appears the issues are all based on units of service with the exception of some pediatric codes which are age-related," says Hoy. "They are also all pretty straightforward, which was expected of the automated reviews that the RACs were slated to start with."
RACs are targeting untimed codes because of what they learned during the demonstration project, says Beckley. For example, RACs found $3.2 million in speech therapy evaluation errors during the demonstration project, and considering these are $200-$400 items, the RACs must have found a lot of errors. Extrapolate this to include physical and occupational therapy services as well, and it's like shooting fish in a barrel, says Beckley.
Mistakes often occur when a therapist enters time codes (for example, one hour in four 15-minute increments) into a hospital billing system, but the system doesn't have the right edit table in place and it incorrectly bills for four time codes instead, explains Beckley.
If your facility uses outpatient therapy codes (e.g., physical and occupational therapy or speech evaluation codes), consider conducting your own internal review. "That way you can correct this issue before RACs get to you," says Beckley. Making voluntary refunds may be your best bet, she says.
Connolly has provided additional information about each of the approved issues on its Web site for providers wanting to learn more about them. For example, for additional information on IV hydration therapy, providers should review the following:
CMS Pub 100-4, chapter 12, p. 31–32
CMS Pub 100-20, Transmittal 419, p. 7
MLN Matters article MM6349, released December 19, 2008, p. 4
Maine healthcare leaders have announced the launch of a statewide health information exchange called HealthInfoNet. Officials said the exchange will make Maine the largest state in the country to operate a statewide network for sharing clinical data. Maine's data exchange will begin with a one-year demonstration project that will link 15 hospitals and more than 2,000 physicians.
The Agency for Healthcare Research and Quality has updated its toolkit that provides step-by-step guidance for healthcare leaders on how to evaluate HIT projects. In this latest version, two examples have been added on computerized provider order entry and picture archiving and communication systems.
This article offers a glimpse into three healthcare organizations efforts to adopt electronic health records and the challenges that they have encountered. For instance, Western North Carolina Health Network, which is comprised of 16 community-based hospitals in western North Carolina, struggled to get all of the hospitals to agree on how the EHR would be used, how the data would be displayed, and who would have access.
MRI technology has recently garnered the interest of those in the C-suite, particularly after the ECRI Institute ranked ultrahigh-field-strength MRIs second on its list of hot technologies for 2009.
HealthLeaders Media first reported on the more powerful MRIs that produce higher quality images in July and although this new technology can greatly improve efficiency and quality, MRI technology old and new poses significant safety risks that often impede infection control (IC) best practices.
For years, many MRI suites in hospitals and outpatient facilities have operated without proper IC procedures, primarily because the dangers of the MRI's magnetic field bar almost all employees from entering the room, says Peter Rothschild, MD, president and founder of Patient Care Systems, Inc., in Newark, CA. As a result, the area has flown under the IC radar.
"Unfortunately, it's an area that has just been ignored," Rothschild says. "I think that's the nicest way to say it."
The dangers of the MRI
Employee safety is one of the main reasons that the MRI suite lags behind in IC and environmental cleaning, says Tobias Gilk, M. Arch, president and MRI safety director at Mednovus, Inc., an MRI safety consulting firm in Leucadia, CA.
Because the MRI houses a powerful magnet (tens of thousands of times more powerful than Earth's magnetic field, according to Gilk), it creates a hazard for those unaware of how it operates.
"We restrict access to it, and a lot of times this means that we restrict access such that infection control officers or chief nursing officers or directors of medical care don't spend the same amount of time or have the same degree of day-to-day oversight for the MRI part of an enterprise that they do for, say, the patient care floors," Gilk says.
The machine's magnetic field can be harmful to people with pacemakers or orthopedic inserts, such as metal plates, rods, or screws. Further, the incredible strength of the magnet draws in anything ferromagnetic with dangerous strength and speed, meaning equipment used by environmental services should be restricted.
"Let me tell you, a floor polisher is going to do six figures' worth of damage to the MRI if it's brought into the room," Gilk says.
Ramping up surveys
In May, Rothschild released a paper, Survey of Infection Control in the MRI Environment, in which he questioned 53 hospitals and 47 outpatient imaging centers about their MRI-specific IC plans. Only 35 hospitals and just 18 outpatient facilities stated they had a written plan.
But a Joint Commission surveyor is going to be looking for those specific written plans. The February Environment of Care, a Joint Commission–published newsletter, included an article about IC in the MRI suite that indicated surveyors would pay closer attention to this area.
Louise Kuhny, RN, MPH, MBA, CIC, senior associate director of the Standards Interpretation Group at The Joint Commission, says the MRI suite is treated the same as any other part of the hospital.
"The MRI suite is considered an integral part of any Joint Commission survey," Kuhny says. "All Joint Commission standards apply to care in the MRI suite in the same way that they apply to other areas of a hospital or ambulatory center. Some compliance areas that prove particularly challenging for accredited organizations are HR (particularly competence), PC (verifying the correct order for testing), and IC (cleaning of equipment and the general environment, as well as hand hygiene)."
Establishing a detailed plan that involves specific cleaning procedures, routine evaluation of torn or frayed pads, and restrictions on equipment and employees that can enter the suite will ensure employee and patient safety, and a passing grade on a Joint Commission survey.
Consumers all over the world struggling to find healthcare coverage now have an option to get it affordably—they'll just have to travel to Mexico City.
The government of Mexico City is responding to recent events, such as the H1N1 flu crisis, and its effect on its tourism industry, by offering free health insurance to tourists who stay in the city's hotels.
Under the plan, which city officials tout as the first of its kind, the Ministry of Tourism of Mexico City will subsidize the following services:
Medical assistance in case of H1N1 infection
Medical care in case of any other disease or accident
Provision of an ambulance in case of an accident
Hospital accommodation in case of any emergency
Prescription of drugs from cooperating physicians
Emergency dental care
Home transportation in case of illness
Hotel accommodation for time of recovery
The plan, called the "Tourist Assistance Card," applies to guests at all of Mexico City's 470 hotels. Tourists will be given pamphlets explaining the program upon arrival at the city's airport, and a 24-hour call center will provide assistance in several languages. The city is paying deductibles for the insurance, provided through the private company MAPFRE.
The Mexican tourism industry was hit particularly hard by the swine flu scare: Officials said foreign tourism plunged 50% in May due to swine flu and the recession. Mexican central bank statistics also showed revenue from international tourists fell by more than $540 million compared to figures from May 2008. In addition, the bank said the number of foreign tourists who visited Mexico in May was half the figure that visited in April (1 million to 500,000).
Tourism is Mexico's third-largest source of foreign income, and in April Mexican business associations estimated the country lost more than $1 billion in revenue since the beginning of the outbreak. Publicity about violence among rival drug cartels in the country have also not helped attract tourists to the country this year, either.
So will offering complimentary healthcare to tourists help? Mexican officials hope it will, saying the move will help restore confidence in the safety of tourists traveling to the country.
"We want to send the message that Mexico City is a secure place that will protect its visitors," Mexico City's Tourism Secretary Alejandro Rojas Diaz told the New York Times after announcing the initiative.
And it could be needed. Although the swine flu threat has abated in recent months, there is concern all over the globe that it could come back. A recent report from the U.S. General Accounting Office found the swine flu's history "suggests it could return in a second wave this fall or winter in a more virulent form."
If Mexico City's program proves successful, perhaps more countries that enjoy tourism dollars will follow suit and offer low-cost protection to visitors. And as globalization in healthcare and countless other industries continues to expand despite travel threats, such as the swine flu, it could eventually prove lucrative for the countries involved.
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