Healthcare Business Today

Your leading source for best practices across the healthcare spectrum

3 Strategies to Minimize Regulatory Overload

by Leave a Comment

By Larry Lacombe 

Federal legislation is implemented to ensure superior, safe, and reliable patient care. However, for many healthcare organizations, new regulation can feel more like a headache than anything else. In recent years, clinical staff and facilities managers alike have seen an increased amount of time spent on regulatory compliance, which can take away from other valuable initiatives.

In fact, a recent report from the American Hospital Association found that more hospitals say they are burdened by regulatory overload. The study also found that hospitals and other providers spend nearly $39 billion a year solely on administrative activities associated with regulatory compliance.

In an ever-changing world where it’s more important than ever to ensure quality care and fast-evolving service, healthcare providers should consider three key strategies to minimize regulatory overload. [Read more…]

Letters 226J: IRS Enforces Employer Mandate

by Leave a Comment

Summary Of Employer Shared Responsibility Payments (“ESRPs”)

By Melissa Shimizu

Under the Affordable Care Act (ACA), applicable large employers (ALEs) are required to offer full-time employees minimum essential health care coverage that is affordable and provides minimum value. If they do not, and a full-time employee receives a premium tax credit to purchase individual coverage through a marketplace, the employer may be assessed an employer shared responsibility payment (ESRP).  The amount of the penalty depends on the number of full-time employees to which the ALE made an offer of coverage.

If an ALE makes an offer of coverage to fewer than 95 percent of its full-time employees, and one or more full-time employees receive a premium tax credit, the ESRP in 2015 is generally equal to the number of full-time employees minus 80 (because there was transitional relief available in 2015), multiplied by $2,260.  This is called the subsection (a) penalty because it comes from Section 4980H(a).  For plan years beginning on or after January 1, 2016, the aforementioned transitional relief was not available and the ESRP calculation will only be reduced by 30 employees, rather than 80.

If, however, it makes an offer of coverage to at least 95 percent of its full-time employees, and one or more of its full-time employees receives a premium tax credit, the ESRP is calculated for each month. This is called the subsection (b) penalty because it comes from Section 4980H(b).  For 2015, the amount of the ESRP for any given month is equivalent to the number of full-time employees who received a premium tax credit for that month multiplied by one-twelfth of $2,080.



 [Read more…]

The Steps American Healthcare Companies Must Consider to Expand Globally

by Leave a Comment

By Robert W. Courtney

It’s well-known around the world that despite its many breakthrough technologies and advances in healthcare, the United States lags behind other countries when it comes to coverage, cost, and quality. However, as healthcare companies rush to address these challenges driven by consumers in the US, they must realize that anything viable in America likely has potential overseas, assuming the right steps for international expansion are taken.

For many entrepreneurs and healthcare leaders who firmly believe in their product, they must consider America as only a slice of the pie when it comes to revenue potential. For example, the medical device market is expected to reach $150 billion in 2017 in the U.S. alone, a tremendous figure that demonstrates rapid growth. However, when looking outside America, the global medical device market is set to reach close to $400 billion. Now, while there are thousands of companies in this industry each targeting their own respective market segment, their revenue opportunity grows significantly when efforts go international. 

Establishing operations abroad requires the same foundation and principles to do so in the United States, but with the increased need for adaptation to local culture and business practices, and increased need for partners that can be trusted. [Read more…]

Big Data: Medical Billing Fraud and Abuse Claims Increasingly Based on Data Analysis

by Leave a Comment

By Ingrid S. Martin

With medical billing fraud and abuse cases increasingly driven by data analysis, it has never been more important for healthcare providers to carefully assess the claims data they provide to the government. 

In analyzing billing data, government investigators are looking for providers with suspect billing patterns, including high utilization of expensive billing codes, being a top biller for any particular code, or billing in a manner that is different from other providers of the same type. 

For example, a Tennessee pain management clinic recently drew the attention of federal investigators because it was an outlier in its billing for urine drug screens.  The clinic paid $312,000 to resolve allegations that it was ordering medically unnecessary screens in violation of the federal False Claims Act. 

To avoid these kinds of entanglements, healthcare providers need to monitor and to analyze their own claims data.  The key questions healthcare providers need to ask are: What billing codes are they most commonly using?  Are the people choosing which codes to bill properly qualified and up to date?  Does the electronic medical records system make it easy for providers to capture necessary information to support the billing?

To minimize the risk that auditors and investigators will find a basis to allege overpayment or fraud, and to help prevent drawing their attention in the first place, healthcare providers should include some simple steps in their compliance programs. [Read more…]

New 340B Rule in Place; Understanding the Implications

by Leave a Comment

By Kenneth Maxik, MBA, MBB, FACHE

It’s a new year and that brings new challenges for hospitals enrolled in the 340B Drug Pricing Program after the Centers for Medicare & Medicaid Services (CMS) formally implemented a new rule that cuts the reimbursement to certain covered entities by $1.6 billion.

The 2018 Medicare Hospital Outpatient Prospective Payment System (OPPS) Final Rule was finalized in November 2017 and immediately met with resistance. A number of hospital associations and several health systems joined to sue CMS – claiming the changes would reduce access to care – and a bipartisan bill was introduced before the House seeking to reverse the ruling. Due to a procedural issue, the lawsuit was deemed premature since damages had not yet been incurred, and CMS’s rule went into effect on Jan. 1, 2018, per the original time frame.

Despite efforts to halt the rule continuing into 2018 – the same complainants plan continued legal action – all 340B hospitals covered under OPPS must now comply with the new CMS rule.

For a clearer picture on the potential impacts for hospitals, patients, staff and health care programs, here is what you need to know: [Read more…]

Even More at Stake Than Meets the Eye with Potential HIPAA Violations

by Leave a Comment

Alexa GreenbaumBy Alexa Greenbaum

A federal court in New Mexico recently declined to dismiss tort claims asserted by a registered nurse against her employer, a government-run hospital, where she obtained treatment for a sexual assault. In denying the motion to dismiss, the court effectively rejected the federal government’s attempt to escape claims based on invasion of privacy for the disclosure of information regarding the assault (G.R. v. United States).

However, the court withheld ruling on the government’s motion to dismiss plaintiff’s claim for “negligence per se” based on the violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Instead, the court certified for the New Mexico Supreme Court the question of whether the claim fails, as there is no private right of action afforded by HIPAA. This case serves as a valuable reminder for hospitals of the broad implication of liability for disclosing private information, including the potential impact of HIPAA violations beyond mere regulatory enforcement.  

Alleged Disclosure of Treatment Leads To Court Battle

The plaintiff sued her employer, Gallup Indian Medical Center, for the dissemination of information relating to treatment she received there after she fell victim to a physical and sexual assault. Her lawsuit claims the hospital disclosed private details of the assault to coworkers who were not her direct care providers. Specifically, G.R brought tort claims for public disclosure of private facts, intentional infliction of emotional distress, negligence, and negligence per se. The claim for negligence per se – a theory whereby an act is considered automatically negligent because it violates an existing statute – was premised on the hospital’s alleged HIPAA violation.

The hospital moved to dismiss G.R.’s claims for negligence, negligence per se, and public disclosure of private facts, but the court permitted the claims for negligence and public disclosure to proceed. It found no legitimate public interest was served in publicizing the nurse’s assault, and therefore greenlighted her privacy claim. In sum, the court did not take lightly the government’s attempt to avoid liability for disclosure of private information. It declined to rule on the negligence per se claim, however, and specifically avoided answering the question of whether a HIPAA violation may legally set the standard of care for such a cause of action. [Read more…]

When Does a Deed Need Criminal Defense?

by Leave a Comment

When does a deed need criminal defense?

The offense is an act of an active subject – perpetrator – directed against a social value defended by the criminal law which, in most cases, belongs to a person – an act that is an outward manifestation of the individual, which he had representation at the time of committing or should have had. Stuart Criminal Defense attorney tells you several criteria that distinguish a deed from a criminal act. These are the provision in the criminal law, guilt, unjustified deeds and imputability.

It is noteworthy and remembered that the assembly of a single element does not automatically lead to the conclusion that such an act is an offense, but these traits must be cumulatively met to be an offense.

If a criminal law does not incriminate an act, then it cannot constitute an offense. Thus, by the criminal law rule, it is necessary to lay down the conditions for the existence of the crime, without this legal element being unable to continue the analysis of a criminal offense.

The act committed by a person must correspond to the abstract model described by the criminal law, this principle is called the typical. In other words, the offense implies the existence of a legal framework that attributes to the actual deed the character of the act provided by the criminal law.

By this aspect of the provision in the criminal law, the offense is distinguished from the other forms of legal illicit.

[Read more…]