Advocate Health Care is moving closer to a deal with a large hospital operator in Bloomington-Normal, a sign that Illinois' largest medical care provider could be reaching its first partnership outside of the Chicago area. Advocate, which owns nine hospitals in Chicago and the suburbs, said in a memo it has extended its letter of intent to "explore a partnership" with BroMenn Healthcare System. The letter of intent was first signed in December, and executives are now negotiating terms of the definitive agreement, which could be finalized this summer.
Earnings from the nation's big health insurers show them losing members at a rapid rate, suggesting the ranks of uninsured Americans are surging during the recession. The latest evidence came from WellPoint Inc., the country's largest health insurer with nearly 35 million medical-plan members. Reporting a 1.3% drop in first-quarter net income, the insurer also said it had shed nearly 500,000 net members since the end of December.
The results of a poll of 1,238 adults out from the Kaiser Family Foundation, NPR, and the Harvard School of Public Health is a sign that doctors have a sharp arrow in their quiver when it comes to shaping reform of the healthcare system: The public trusts them, according to this post from the Wall Street Journal Health Blog.
Pressed by insurance companies, some drug makers are beginning to adjust what they charge for their drugs based on how well the medicines improve patients' health. Such pay-for-performance contracts started to take hold a few years ago in countries with national health systems, in which the government could effectively block a drug from being used if it was too costly. Some experts hail such arrangements as a welcome step toward healthcare that rewards good outcomes for patients.
With solid majorities in both houses of Congress, Democrats are tempted to use their political muscle to speed passage of healthcare legislation with minimal concessions to the Republican minority. That approach may be the only way they can fulfill President Obama's campaign promises, but it carries high risks as well, according to this analysis from the New York Times.
Blue Cross Blue Shield of Michigan will increase payments to physicians involved in patient-centered medical homes by 10% beginning July 1. Blue Cross has paid $100 million over the past five years to create a system for 1,000 Michigan doctors in 300 primary care practices to practice in the medical home.
At a Congressional subcommittee hearing today, April 22, an official from the Federal Aviation Administration (FAA) testified before lawmakers that the agency will begin drafting a new rulemaking for hospital EMS flights.
The FAA's move comes in the wake of a spike in medical helicopter crashes. Nine fatal medical flight accidents have occurred since December 2007, killing 35 people, according to the National Transportation Safety Board (NTSB). The NTSB has been pushing the FAA to enforce more aggressive medical flight regulations.
The FAA rulemaking will include many of the voluntary medical flight initiatives published by the FAA over the past few years, including a 2004 heliport design document.
Les Dorr, an FAA spokesperson, tells HealthLeaders Media Wednesday that the agency had always intended to pursue a formal rulemaking, but had encouraged the medical flight industry to voluntarily take precautionary steps while the agency completed its internal rulemaking process.
The FAA's decision comes on the heels of a report released Monday by the Flight Safety Foundation that outlines 26 major risks in the structure and oversight of the medical flight industry. The report also highlights possible steps that various parties involved in medical flight services could take to offset these risks.
As part of an ongoing investigation, the U.S. Defense Department is currently searching the Siemens Medical Solutions office near Philadelphia. The nature of the investigation has not been made public. It is known, however, that in recent weeks, Siemens received a $267 million contract with the Defense Department to sell medical imaging equipment to the military.
Office of Inspector General Chief Counsel Lewis Morris stressed to the Senate Finance Committee this week the ongoing urgent need to fight healthcare fraud, waste, and abuse in order to foster the healthcare reform the SFC is working toward.
Morris made the statement on behalf of the OIG April 21 during the first of three SFC roundtable discussions on healthcare reform.
"Regardless of the structure of healthcare reform, detecting and preventing waste, fraud, and abuse in the healthcare system is critical," he said.
The U.S. spends more than $2 trillion on healthcare annually, Morris pointed out. The National Health Care Anti-Fraud Association estimates conservatively that 3%—or more than $60 billion—is lost to fraud, he said. More specifically, Morris said in fiscal year 2008:
The government won or negotiated approximately $2.35 billion in investigative receivables, including criminal, civil, and administrative settlements or civil judgments. The government's enforcement efforts resulted in 455 criminal actions and 337 civil actions against individuals or entities that engaged in healthcare-related offenses.
The OIG opened 1,750 new healthcare fraud investigations and had more than 2,500 healthcare investigations open at the end of fiscal year 2008.
The OIG excluded 3,129 individuals and entities from participating in Medicare, Medicaid, and other federal healthcare programs. Most of these exclusions stemmed from convictions for crimes regarding Medicare/Medicaid, patient abuse or neglect, or as a result of license revocation.
Morris also emphasized the progress the OIG has made in the past couple of years investigating cases of fraud and abuse. Since fiscal year 2006, the OIG's investigative receivables averaged $2.04 billion and its audit disallowances resulting from Medicare and Medicaid oversight averaged $1.22 billion per year. This gave Medicare and Medicaid a return on investment for OIG oversight of $17:$1. The OIG also implemented recommendations with providers that resulted in $16.72 billion in savings and funds put to better use, Morris said.
While the OIG is successful, looming budget cuts could jeopardize the fight against fraud and abuse. The SFC needs to continue to fund enforcement efforts as a part of healthcare reform, says James Kopf, former director of program investigation for the OIG, and president of Healthcare Oversight in New Canaan, CT.
"It's been an ongoing battle," he says. "We have to stay vigilant. We have to set up new ways of detecting (fraud and abuse). We have to go after actual criminals because they've changed their tactics."
Increasing the efficiency of the enforcement process could help government agencies in their efforts, he said. For example, setting up a national data bank similar to the FBI's National Criminal Information Center could speed up the investigation process and also help prevent further crimes, Kopf said.
With so many Medicare reimbursement dollars at stake, it is no surprise that everyone is putting in their two cents. Make no mistake—the wealth of information becoming available is a good thing. The more you know about the Recovery Audit Contractor program, the better you will be able to manage the process.
Most recently, the American Hospital Association is sharing what it knows via a Member Advisory released April 20. The publication, "Medicare Recovery Audit Contractors (RACs): Permanent Program Basics," (available to AHA members on the organization's Web site) contains a wealth of RAC-related information for healthcare providers.
"With the RAC program in the process of rolling out nationally, it is crucial for hospital executives to use tools like this to help educate themselves on the permanent program," says Robert Corrato, MD, MBA, founder, president, and CEO of Executive Health Resources. "There have been some changes since the RAC demonstration, which we have seen result in confusion for many hospitals across the country."
While the Advisory discusses a wide variety of RAC-related topics, healthcare providers may find useful the information on medical record request limits—a topic many organizations find confusing. And CMS has left its options open to alter the current medical record request limits in the future.
Interestingly, the AHA notes that while hospital campuses with more than one NPI are currently capped at 200 medical records per 45 days, this could change. "[CMS] will be looking at organizations with multiple NPIs closely to ensure that the organizational structure does indeed warrant a cap of 200 medical records. It is not CMS' intent to have multi-hospital systems subject to a cap of 200 medical record requests per 45 days," according to the Advisory.
CMS has not yet updated, or clarified, this information on the RAC Web site, notes Nancy Beckley, MS, MBA, CHC, of Bloomingdale Consulting Group, Inc. She suggests that hospital systems, which this may affect, should keep an eye on the CMS Web site for more information.
In addition, RACs will communicate the medical record request limit for each healthcare organization in its initial medical record request letter, according to the Advisory. Make sure your RACs number matches up with the one you've calculated for yourself.
RACs may not "supersede" medical record request limits by "bunching" requests, according to the Advisory. In other words, think of cell phone plans featuring rollover minutes. Unlike such a plan, RACs can't store unused requests and roll them over for later use. The AHA uses the following example:
If the medical record request limit for a particular provider is 50 per 45 days and the RAC does not request medical records in January and February, the RAC cannot request 150 records in March.
Finally, RACs may request a limited number of records related to issues they will target for claim reviews not yet approved by the New Issue Review Board, and thus not listed on the RAC Web sites as areas RACs will review. The AHA Advisory explains:
CMS requires a RAC to present data analysis or other evidence of improper payments before it proceeds in wide-scale review of claims. In order for the RAC to compile that information, CMS will allow each RAC to request a limited number of medical records from hospitals before the new issue has been approved. CMS has indicated that no more than 10 medical records per provider can be requested for any particular issue before it has been approved by the New Issue Review Board.
Remember that RACs must make the status (e.g., outstanding, received, underway, completed) of requested records available upon request. Each RAC will have a toll-free number for this purpose. CMS is requiring each RAC to have a Web-based application for this purpose developed by January 2010.
