Obama Announces Affordable Care Act Enrollment Crosses the 8 Million Mark

Late last week, President Obama announced that more than 8 million had people signed up for health insurance under the Affordable Care Act. According to the White House, 35 percent of those that obtained insurance are under 35 years old and some 28 percent are between the ages of 18 and 34.

Obama Announces Affordable Care Act Enrollment Crosses the 8 Million MarkThe new figures indicate that the Affordable Care Act is outperforming the administration’s targeted enrollment of 7 million, which it hit earlier this month. While enrollment of young people was up over the last several months, the 28 percent of people who bought policies that are between 18 and 34 is lower than the optimal level of 35 to 40 percent for financial viability according to experts. Young people are described as key to the success of the Affordable Care Act, because they are healthier, and as such, consume less healthcare, causing their insurance premiums to subsidize the costs of care for the sick and elderly.

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Medicare’s 60-Day Proposed Refund Rule Imposes Significant Liability on Providers

As part of the Affordable Care Act “ACA”, Congress outlined the process for providers to return Medicare and Medicaid overpayments. In 2012, CMS proposed the 60-day Refund Rule, as it is commonly known, requiring Medicare providers and suppliers to report and return reimbursements made in error within 60 days of their identification.  While the proposed rule does not address Medicaid overpayments, CMS noted that it intended to address the process of collecting Medicaid overpayments at a later date; however, some states have implemented local policies addressing this issue (See, e.g., Texas Regulation).

Medicare’s 60-Day Proposed Refund Rule Imposes Significant Liability on ProvidersIdentifying Overpayments 

The statute defines an overpayment as any funds received by a health care entity that are in excess of amounts to be paid under Medicare statutes and regulations. Overpayments may be attributed to various operational and payment errors, including non-covered services, duplication and eligibility issues. 

Identifying overpayments is the critical component of the 60-day Refund Rule. Uncertainty still exists regarding when an overpayment has been identified and when the 60-day “clock” begins.

According to the proposed rule, an overpayment is considered “identified” when a person has actual knowledge of the overpayment or acts in “reckless disregard or deliberate ignorance” of the existence of the overpayment. To encourage provider self-compliance, CMS used the “reckless disregard or deliberate ignorance” standard from the False Claims Act. However, the statute does not mandate this interpretation.   Continue reading this entry

Tennessee Enacts Telehealth Parity Legislation

Tennessee has enacted legislation requiring commercial insurance payors to cover telehealth services. On April 14, 2014, Governor Bill Haslam signed into law HB 1895/SB 2050.

Under the Tennessee law, a health insurance carrier:

  1. Tennessee Enacts Telehealth Parity LegislationMust provide coverage under a health insurance policy or contract for covered healthcare services delivered through telehealth;
  2. Must reimburse a healthcare services provider for the diagnosis, consultation, and treatment of an insured patient for a healthcare service covered under a health insurance policy or contract that is provided through telehealth; Continue reading this entry

Finally…FDASIA Health IT Regulation Report Released

The U.S. Food and Drug Administration (FDA), along with HHS’ Office of the National Coordinator for Health Information Technology (ONC) and the Federal Communications Commission (FCC, together with FDA and ONC, the “Agencies”) published their long-awaited report, FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework. The report, mandated by the Food and Drug Administration Safety and Innovation Act (FDASIA), proposes strategies and recommendations for a risk-based framework to regulate health information technology (HIT).

Finally…FDASIA Health IT Regulation Report ReleasedThe agencies are seeking public comment for 90 days following publication of the report on April 3, 2014.

The proposed HIT regulatory scheme seeks to strike a balance between patient safety and the rapid innovation of new HIT that has the potential to offer tremendous benefits to patients and providers. As anticipated, the proposed strategy reiterates a critical point made in the FDA’s final guidance for mobile medical applications, published last year — that the FDA will focus on functionality of the HIT in question, and not on the platforms or devices on which they run. Continue reading this entry

Preparing for the Conversion to ICD-10

With the ICD-10 implementation date delayed once again until October 1, 2015, providers who were previously unprepared for the transition or had only begun their transition planning have an extra year to address the upcoming changes in an attempt to minimize any potential disruption to their organization. 

Preparing for the Conversion to ICD-10As part of the implementation planning, it is imperative that providers review their managed care and commercial payor contracts and ensure that these address the transition because, despite considerable discussion regarding the transition in the professional communities, there remains great uncertainty as to whether the transition to ICD-10 will be smooth or rocky. Neither providers nor payors know what the result will be, nor does either side know whether any initial distortions will result in positive or negative financial impact for payers or providers. It is unclear whether the new system will result in additional payments flowing from payors to providers or reduced payments in the form of inappropriate denials or adjustments.

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