Transcript Document

Regulatory
Update
Gayle Lee, JD
Roshunda Drummond-Dye, JD
Gillian Leene, JD
Deborah Crandall, JD
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
3
Payment for 2014
• Congress passed the Pathway for SGR Reform Act of
2013, temporarily preventing a scheduled physician fee
schedule payment cut of 24% from taking effect on
January 1, 2014. Effective January 1-March 31, 2014 the
law:
• Provides a 0.5% update in the conversion factor for providers,
making the 2014 conversion factor for these 3 months $35.8228
(2013 CF was 34.0230)
• An extension of the existing 1.0 geographic practice cost index
(GPCI) work floor
Congress passed the Protecting Access to Medicare Act
of 2014 (H.R. 4302) at the end of March.
• Continues the 0.5% update for the remainder of 2014.
• Provides a 0% update from January 1, 2015 until April 1, 2015.
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
4
Payment for 2014
• The 50% Multiple Procedure Payment Reduction in the
practice expense (PE) values will continue to apply in
2014.
• The 2% sequestration cut that went into effect in 2013 will
continue to apply in 2014.
• Overall impact on PT codes is approximately plus 0.5%
from January 1, 2014- December 31, 2014.
• Impact varies for each CPT code
CMS Holding Claims
• CMS has instructed the Medicare Administrative
Contractors to hold claims containing services paid under
the MPFS for the first 10 business days of April (ie,
through April 14, 2014)."
• The hold would only affect MPFS claims with dates of
service of April 1, 2014, and later.
• Minimal impact on provider cash flow, because under
current law, clean electronic claims are not paid any
sooner than 14 calendar days after the date of receipt.
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
6
MPPR/Fee Schedule Resources
• APTA website
• www.apta.org/medicare (Medicare fee schedule)
• MPPR calculator
• MPPR scenarios
• Instructions on calculation of impact of MPPR
• Fee schedule calculator
• Summary of Physician Fee Schedule Rule
• CMS website
• Change Request 750
(http://www.cms.gov/Transmittals/downloads/R826OTN.pdf
• Transmittal 2328
• Medlearn Matters Article 750
(http://www.cms.gov/MLNMattersArticles/downloads/MM7050.pdf)
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
7
Therapy Cap
• Therapy Cap amount for 2014 is $1920 for physical
therapy and speech therapy combined & $1920 for
occupational therapy.
• Medicare Advantage plans do not have to implement a
therapy cap.
• Legislation (Pathway for SGR reform act) extended the
therapy cap exceptions process and manual medical
review at $3700 for 3 months (January 1-March 31,
2014).
• Protecting Access to Medicare Act of 2014 (H.R. 4302)
extended the therapy cap exceptions process & manual
review until March 31, 2015.
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
8
Therapy Cap
• In 2014, therapy cap applies to Critical Access hospitals
(CAHs) in the same manner as all other settings.
• The cap will apply to hospitals until March 31, 2015.
Hospitals will be exempt from the cap after March 31,
2015.
• CAHs are not considered “hospitals” for purposes of the
therapy cap.
9
Therapy Cap Exceptions Process
Claims between $1920-3700: submit KX
modifier if services are medically necessary
for an exception.
Claims exceeding $3700: subject to manual
medical review process.
Prepayment:
Florida, California, Michigan, Texas,
New York, Louisiana, Illinois,
Pennsylvania, Ohio, North Carolina,
and Missouri
Postpayment:
All remaining states
©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.
10
Manual Medical Review Process
Postpayment Review
Prepayment Review
• Providers submit claims to MAC.
• Providers submit claims to MAC.
• MAC sends Additional Document Request
• MAC will pay the claim.
(ADR) to provider for additional
documentation to be sent to the Recovery
Auditor.
• Recovery Auditor must conduct manual
medical review within10 business days of
receipt of documentation.
• Recovery Auditor will notify the MAC of the
payment decision.
• Recovery Auditor will issue a detailed review
results letter to the provider. (findings or no
findings)
• Recovery Auditor will send ADR for
•
•
•
•
documentation to be sent to Recovery
Auditor
Recovery Auditor will conduct manual
medical review.
Reviews will be completed within 10
business days of receiving the
documentation.
Recovery Auditor will notify MAC of decision.
Recovery Auditor will issue a detailed review
results letter to the provider MAC will recoup
money from provider
©2014 American Physical Therapy Association. All rights reserved. All reproduction or
redistribution prohibited.
RAC Transition: Changes to Review
• New RAC contractors are awaiting awards from CMS. A pause
•
•
•
•
•
in reviews will occur until new contracts are awarded.
Recovery Auditors will continue to complete the reviews for the
ADRs they’ve already sent as of 2/28/2014.
After 2/28/ 2014 no new ADR requests will be sent by the
MACs/RACs for therapy cap claims exceeding $3700.
All therapy providers will be subject to postpayment review for
claims exceeding $3700 when the new RACs are awarded.
The new RACs will not comply with the 10 day turnaround time
for review due to the backlog.
The new RACs will review the therapy claims in the order they
were paid.
RAC Changes for New Contracts
Concern
Upon notification of an appeal by a
provider, the Recovery Auditor is
required to stop the discussion
period.
Program Change
Recovery Auditors must wait 30 days
to allow for a discussion before
sending the claim to the MAC for
adjustment. Providers will not have to
choose between initiating a
discussion and an appeal.
Providers do not receive
confirmation that their discussion
request has been received.
Recovery Auditors must confirm
receipt of a
discussion request within three days.
Recovery Auditors are paid their
contingency fee after recoupment
of improper payments, even if the
provider chooses to appeal.
Recovery Auditors must wait until the
second level of appeal is exhausted
before they receive their contingency
fee.
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
13
Appeals
• You have an appeal right when your carrier/
intermediary/MAC determines an overpayment
occurred on prepayment or post payment review.
Appeals Levels
• Redetermination
• Reconsideration
• Administrative Law Judge (delays)
• Medicare Appeals Council
• Federal District Court
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
14
Collecting Out of Pocket
• If a patient does not qualify for an exception (e.g.
services do not meet Medicare definition of reasonable
and necessary), the provider can collect out of pocket
payment from the beneficiary.
• The provider must give the beneficiary an Advanced
Beneficiary Notice (ABN) if Collecting Out of Pocket.
Revised ABN form (Form-R-131) available on the CMS
website at: https://www.cms.gov/BNI/02_ABN.asp
• Provider should only give the patient an ABN if there is
reason to believe services will be denied as not
reasonable and necessary.
• Submit claim with GA modifier
Alternative Payment for Therapy
• CMS is interested in development of an alternative
•
•
•
•
payment system for outpatient therapy.
CMS would prefer an episodic system; however they
appear to recognize that there is insufficient data.
CMS has been reviewing data from DOTPA Research
Triangle Inisitute (RTI) study involving the use of the
CARE –C and CARE-F assessment tools at admission
and discharge.
This study, which will include recommended alternative
payment models, will be published very soon.
APTA is working on alternative payment system and CPT
codes (AMA CPT workgroup is meeting to develop)
Functional Limitation Reporting (FLR)
Middle Class Tax
Relief Act of 2012
February 2012
Congress mandates
CMS to collect
functional info on
Medicare beneficiaries
receiving therapy
services under Part B
FLR Ongoing
February 2014
Medicare
continues to work
through system
modifications;
anticipating future
evolutions of FLR
FLR
Implementation
January 1, 2013
Testing phase
begins for the
collection of
functional data
Final Physician Fee
Schedule Rule
November 2012
Outlines the
regulations around
the new claimsbased reporting
program for therapy
services
FLR Payment
Adjustment Phase
October 1, 2013
Originally slatted for
July 1, 2013 this was
delayed until October
1; providers began
reporting processing
issues in mid
November
Resources for Ongoing Guidance
Challenges
Strategies
Tracking of FLR episode, including
discharge of episodes (return to
therapy within 60 days when patient
self-discharged
• Podcast on discharge reporting
• Report D/C G-codes in charts
even if you do not submit the data
Multiple diagnoses and plans of care • Case scenarios
(POC)**
• Podcast on mult. dx and POC
Role of PTA in FLR
• Podcast on PTA and FLR
Unique clinical situations:
• FAQ documents
observation status patients, re-billing • Podcast observation status
Current status of claims and FLR
•
•
•
•
FAQ documents
Claim form examples
Case scenarios
PTNow
Tracking of FLR Episode
• FLR tracking:
• per beneficiary,
• per therapy discipline, and
• per billing provider NPI
• (ie, per facility or practice, as
identified by National Provider
Identification or tax
identification).
Beneficiary
(HIC#)
Discipline
(PT, OT,
SLP)
Facility
(Tax ID or
NPI)
Current Status of Claims and FLR
• Systems issues
• Incorrect visit counts
• Required reporting at 10th/20th/etc despite early reporting
• Required restart of reporting for active episodes on October 1
• Issues with 3 G code submission with an active POC
• Claims splitting
• Claims out of sequence in common working file
• New FLR complaint form
• Communicating and sharing information with CMS to
address problems
% of Complaints by MAC
Type of Complaints by MAC
APTA Functional Limitation Resources
• http://www.apta.org/FLR
• Resources include:
• FAQ documents
• Case scenarios
• Webinar
• Discussion forum
• Toolkit
• CMS links
• PTNow (other tests and measure information)
http://www.ptnow.org/FLR/Tests
Physician Quality Reporting System
(PQRS) in 2014
• In 2014, physical therapists in private practice can receive
a bonus payment of 0.5% if they successfully participate
in the PQRS program.
• In 2014, if physical therapists in private practice that do
not successfully participate in PQRS will be subject to a
2.0% payment reduction in 2016.
• PTs can report via claims or registry
PQRS: Successful Reporting
To avoid the payment penalty in 2016
• Report at least 3 measures AND report each
measure for at least 50 percent of the Medicare
patients to which the measure applies
To receive the incentive payment for 2014
• Report at least 9 measures OR, if less than 9
measures covering apply to the eligible
professional, report 1—8 measures, AND report
each measure for at least 50 percent of the
Medicare patients to which the measure applies
PQRS Measure Changes for 2014
Measure
Number
Measure Title
Changes
Details
#126
&127
#148-151
Diabetes Measures
Back Pain
Measures Group
Registry reporting
only in 2014
The diabetes measures (126 & 127)
and the back pain measures group
(148-151) will not be reportable via
claims-based reporting in 2014
130
Current
Medications
Reporting every visit
for 97001, 97002
AND 97110, 97140,
97532
Therapists must now report this
measure when billing 97110,
97140, 97532 in addition to 97001
and 97002
131
Pain Assessment
Reporting every visit
for 97001 AND
97002; measure
updated
Therapists must now report this
measure when billing 97001 and
97002
155
Falls Plan of Care
Change in
instructions and
numerator definitions
Consideration of Vitamin D
supplementation and balance,
strength, and gait training
182
Functional
Outcome
Assessment
Change in numerator
definitions AND
addition of new
numerator code
G9227: Functional outcome
assessment documented, care plan
not documented, documentation the
patient is not eligible for a care plan
Please review all 2014 measure specifications in detail for your clinic’s selected measures to ensure that you are up to
date with the current measures requirements
Resources on PQRS
• APTA website
• http://www.apta.org/PQRS/
• QualityNet Help Desk
• PQRS and eRx Incentive Program questions
• 866-288-8912 (TTY 877-715-6222)
• 7:00 a.m.–7:00 p.m. CST M-F or [email protected]
• CMS PQRS Website
• http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS
PROSPECTIVE PAYMENT
SYSTEM ANNUAL RULES UPDATES
Home Health PPS CY 2014
Final Rule published December 2, 2013; Effective Implementation Date January 1,
2014
Home Health
Rebasing and Payment Cuts
Estimated overall reduction of $290 M (1.05
Percent) for CY 2014
Reductions to the national, standardized 60-day
episode rate of 3.5 percent in each year CY 2014
through CY 2017
Increase each of the per-visit payment rates for
Low-Utilization Payment Adjustment (LUPAs)of 3.5
percent in each year CY 2014 through CY 2017
Transition to ICD-10 and Quality
Measures
Remove diagnosis codes that reflect
severely acute patients that are not treated
in the home health setting; and diagnosis
codes for conditions that would not impact
the home health plan of care; made in
accordance with the specifications for ICD10 which is effective October 1, 2014;
Add two claims-based quality measures,
“Rehospitalization During the First 30 Days
of a Home Health Stay”, and “Emergency
Department Use Without Hospital
Readmission during the first 30 days of
Home Health”.
Inpatient Rehabilitation PPS FY 2014
Final Rule released August 6, 2013
Effective for discharges occurring on or after October 1, 2013
IRF Payment Update and Changes to
Presumptive Compliance Criteria
Finalizes a market basket update of 1.8 percent which is estimated to
increase payments to IRFs by $170 million for FY 2014 (after a
mandated legislative adjustment of 0.3 percent and 0.5 multi-factor
productivity adjustment)
Removes non-specific, arthritis, unilateral upper extremity, some
congenital anomaly and miscellaneous diagnosis codes from the
presumptive compliance list for the IRF compliance threshold (“60”
Percent rule) in FY 2014
Delayed effective date of one year
Removal of these codes effective for compliance review periods
beginning on or after October 1, 2014.
IRF Quality Reporting Program
Adopts the NQF-endorsed version of the Percent of
Residents or Patients with Pressure Ulcers that are
New or Worsened (Short Stay) measure
Adds Percent of Residents or Patients Who Were
Assessed and Appropriately Given the Seasonal
Influenza Vaccine (Short-Stay), Influenza Vaccination
Coverage among Healthcare Personnel
Adds an All-Cause Unplanned Readmission Measure
for 30 Days Post Discharge from Inpatient
Rehabilitation Facilities measure
Skilled Nursing Facility PPS FY 2014
Final Rule released August 6, 2013
Effective October 1, 2013
Payment Update and MDS Revisions
Finalizes a market basket update of 1.3 percent which is
estimated to increase payments to SNFs by $470 million
for FY 2014 relative
Finalized the proposal to add an item to the Minimum
Data Set (MDS) to record the number of distinct calendar
days of therapy (PT, OT, and SLP) to SNF residents over
the seven-day look-back period
CMS clarifies that the qualifying condition for the Medium
Rehab (RM) Category requires five distinct calendar days
of therapy and that the qualifying condition for the Low
Rehab (RL) Category requires three distinct calendar
days.
POST-ACUTE CARE
PAYMENT REFORM
Common Themes: PAC Payment Policy
Payment cuts (SGR reform, rebasing,
productivity adjustments)
Quality Reporting (Value-based
purchasing, readmissions)
Ensuring Medical Necessity (HH
functional reassessment, IRF coverage
requirements, SNF COT OMRAs
Legislative: Ways and Means Health
Subcommittee
• Ways and Means Health
Subcommittee Hearing June 14
• Jonathan Blum (CMS) & Mark
Miller (MedPAC)
• Items discussed included rebasing
payment for these settings, the
75% rule, fraud and abuse,
geographic variation in utilization,
standardized assessment tools
• Senate Finance & House Ways and
Means Request for Stakeholder Input
(Due Aug 19)
• Feedback on current proposals
(MedPAC, Simpson Bowles, FY14
President’s Budget)
• Questions regarding
• Quality
• Assessment Tools
• Value Based Purchasing
• Reducing Hospital
Readmissions
• Bundled Payments
• Site Neutral Payments
• Alternatives to Fee-for-Service
Legislation: House Ways and Means
Discussion Draft
• Market Basket reductions
• Site Neutral Payment
• IRF 75 percent rule
• SNF Readmissions
• Bundled payment with quality reporting
• Submitted Comments August 30th
IMPACT Legislation
Politics of Post Acute Care Reform
• Reform has been analyzed by a number of
groups
• Targeted for cuts and fraud and abuse
• Linked with SGR Reform to possibly be used
as a pay-for
Overview and Impetus for Reform
Unexplained growth
in expenditures
Disparity of resource
costs among settings
Increased focus on
transitions in care
43
Basis of Current Payment Systems
Payment
Volume
of
services
RUGs
CMGs
HHRGs
DRGs
44
Connecting the Dots:
Standardized Assessment
LTCHs
Home Health
Standardized
Assessment
Tool
SNFs
IRFs
Standardizing Assessment Data:
Continuity Assessment Record and
Evaluation (CARE) Item Set
46
CARE: Concepts
Guiding Principles and Goals:
Assessment Data is:
• Standardized
• Reusable
• Informative
Standardization:
• Reduces provider burden
• Increases reliability and
validity
• Offers meaningful application
to providers
• Facilitates patient centered
care, care coordination,
improved outcomes, and
efficiency
• Communicates in the same information
across settings
• Ensures data transferability forward and
backward allowing for interoperability
• Fosters seamless care transitions
• Evaluates outcomes for patients that
traverse settings
• Allows for measures to follow the patient
• Assesses quality across settings, and Inform
payment modeling
SNF Alternative Therapy Payment Project
CMS has contracted with Acumen, LLC and the
Brookings Institution to identify potential
alternatives to the existing methodology used to
pay for therapy services under the SNF PPS.
Project will review past research studies and policy
issues, related to SNF PPS therapy payment and
options for improving or replacing the current
system of paying for SNF therapy services.
SNF Therapy Listening Session (February 2013)
1. What elements of therapy payment under the SNF PPS do you feel
work well?
2. How would you design an alternative payment system to pay for
therapy services in SNFs that would better align the resources needs
of patients with payments for services?
3. Do you know of any new or unused data sources that could serve as
the underpinning for such a new system, and are there any new
studies or research that would be required to attain such data?
4. How would you envision the new SNF therapy payment system fitting
into the current SNF PPS? What changes would need to be made to
the system as a whole to accommodate the new SNF therapy
payment model?
49
MedPAC Recommendations (2012)
• Rebasing of home health and skilled nursing facility
PPS
• Eliminating market basket PPS updates
• Overhauling payment systems base payment on the
complexity and condition of the patient
• Increasing or requiring cost-sharing by beneficiaries
• Conduct medical review activities in counties that
have aberrant therapy utilization
MedPAC Recommendations (2013-14)
• Freeze payments for Medicare PPS LTCH and HH
payments for 2015.
• Create a readmissions reduction policy that would apply a
penalty to HH payments for HH readmissions to hospitals
that exceed a risk-adjusted target
• Create a common post-acute assessment instrument for
HH, skilled nursing facilities, IRFs and LTCHs in 2016
• Extended through 2015 its prior recommendation to
freeze payments for SNFs and rebase the SNF PPS
51
JIMMO V. SEBELIUS
Improvement Standard
52
Improvement Standard
Lawsuit
Glenda Jimmo, et. al vs. Kathleen Sebelius
Case was filed on
January 18, 2011
Proposed
settlement
agreement filed in
federal District
Court on October
16, 2012
Preliminary Order
to Approve
Settlement filed
November 20, 2012
(Contingent upon
fairness hearing)
Fairness hearing
held January 24,
2013 and final
approval was given
on that date
Issue Synopsis
• Contractors interpretation: "Improvement Standard"
provider must show a “material improvement” in
patient’s condition over a determined period in order
to establish medical necessity
• Upheld right of patients to continue to receive
reasonable and necessary care to maintain condition
or prevent or slow decline
• Determinant factor is not whether the Medicare
beneficiary will improve
• Decision covers nursing and therapy services
provided under both inpatient and outpatient settings
First Step: Manual Revisions
• Transmittal 179
• Clarifications contained in the Medicare Claims
Processing and Benefits Policy Manual (chapters
applicable to home health, IRF, SNF and outpatient
therapy)
• No rule of thumb application – care depends on whether
skilled care is required (reasonable and necessary
criteria), not restoration potential
• Inclusion of examples and documentation guidelines for
each setting
IRF Manual Revisions (admission predicated upon
restoration potential)
IRF
claim
cannot
be
denied
based
on:
• Patient could not
achieve complete
independence in the
domain of self care
• Patient could not return
to prior level of
functioning
SNF Manual Provisions
Coverage of skilled therapy in the SNF does turn
on the presence or absence of the potential for
improvement
Rather is based on the need for skilled care
Does not exclude PTAs from providing skilled
maintenance therapy
Home Health Manual Provisions
Coverage of maintenance therapy is not solely based
potential for improvement – rather need for skilled care
Covered when demonstrated that the skills, knowledge and
specialized judgment of the qualified therapist is needed
Based on individual condition of the patient and complexity
Services must be provided by the PT (not PTA)
Outpatient Therapy
Program established by therapist to assist patient
in maximizing or maintaining progress during
therapy/ prevent or slow decline
A service is not considered skilled therapy merely
because it is furnished a PT/PTA (or under direct
or general supervision)
Services must be provided by the PT (not PTA)
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
59
Example
• “A patient with Parkinson’s disease may require the
services of a physical therapist to determine the type of
exercises that are required to maintain his present level of
function. The initial evaluation of the patient’s needs, the
designing of a maintenance program which is appropriate
to the capacity and tolerance of the patient and the
treatment objectives of the physician, the instruction of the
patient or supportive personnel (e.g., aides or nursing
personnel) in the carrying out of the program, would
constitute skilled physical therapy and must be
documented in the medical record.”
• http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R179BP.pdf
Second Step: National Education Campaign
• Special Provider Outreach call – December 19th at 2pm
• Target Audience: Skilled Nursing Facilities; Inpatient
Rehabilitation Facilities; Home Health Agencies; and
providers and suppliers of therapy services under the
Outpatient Therapy Benefit.
• http://www.eventsvc.com/blhtechnologies
Third Step: Accountability
• Re-review of previous
• Claims review
denials
• Retroactive January
2011
• Appeal rights lie with
beneficiary
• http://www.cms.gov/M
edicare/appeals-andGrievances/OrgMedF
FSAppeals/index.html
through established
protocol of sampling
of QIC claims
• Bi- annual meeting
with plaintiffs counsel
on claims review
findings
• Expedited review and
resolution of errors
and denials
62
INNOVATIVE PAYMENT
MODELS
Three Categories of ACO Patients
Number of patients cared for by an entity participating in a government or
commercial accountable care organization is now between 25 million and 31
million
2.4 million
Medicare patients
are cared for by
an ACO
15 million nonMedicare patients
are receiving care
within a medical
practice that is
part of a Medicare
ACO
8 million to 14
million
commercially
insured patients
are in nonMedicare ACOs
Source: “The ACO Surprise” A. Wyman
64
Medicare ACO Programs
• 23 Pioneers – starting in their 3rd year
• 220 Medicare Shared Saving Program started in 2012-13
• 123 MSSP started January 2014
• Composition: former Pioneers, hospital-based and physician-led
• Of 343 ACOs – 5 are in a risk-sharing model
• Info coming soon on first year performance (quality reporting)
65
Future of ACOs
• Next phase of 3-year MSSPs to begin 2015
• New quality reporting expected
• Opportunity for refinements:
• RFI “The Evolution of ACO Initiatives” (comments due March 1st
• MSSP proposed rule expected in the Spring with comments due
Summer 2014
Bundled Payments for Care Improvement
(BPCI) Initiative
•
Launched by the Innovation Center designed to encourage
doctors, hospitals and other health care providers to work
together to better coordinate care for patients both when they
are in the hospital and after they are discharged.
Objectives:
• Support and encourage providers through three part aim
(better health, better care, and lower costs through
continuous improvement)
• Decrease the cost of an acute episode of care and the
associated post-acute care while improving quality
• Develop and test new payment models for three-part aim
outcomes for acute and post-acute medical care
• Shorten the cycle time for adoption of evidence-based care.
Bundling Initiative: Four Models
Model 1: Inpatient
Stay Only
(Physician services
paid separately)
Model 2: Inpatient
and PAC Stay
(30 or 90 days)
Model 3: Discharge
from Inpatient stay
and PAC 30 days
after
Model 4: Inpatient
Stay (all services
including physician)
BPCI Structure
Defined patient populations with chronic and other conditions
Target price set for entity to meet
If target price is met and there is savings derived from bundled
payment – bonus payments will be distributed to providers
Current payment – still under fee for service (bill directly to
Medicare)
MEDICARE ADVANTAGE:
2014 CHANGES
Medicare Advantage in 2014
• Affordable Care Act cuts may have large impacts
on beneficiaries
• 2014 payments adjusted for differences in diagnostic
coding intensity between Medicare Advantage plans
and traditional Medicare
• Medical Loss Ratio 85% requirement
implementation in 2014
• Sequestration cuts from Budget Control Act
Medicare Advantage in 2014
• Kaiser Family Foundation study indicates
the following for 2014:
• Higher premium payments for beneficiaries
• No large changes in availability of plans
• High out-of-pocket maximums for plans
• Further cost sharing (co-payments, coinsurance) for
beneficiaries
Medicare Advantage in 2014:
Cost Sharing
• Unreasonably high co-payments for therapy services from
many MA plans
• APTA’s advocacy efforts
Call for high
co-payment
examples
Comment
letters
Meeting with
CMS
• Emphasis on patient impact and access to therapy
services
2015 Medicare Advantage Call Letter
• Cost Sharing Changes:
• $40 copay limit for physical therapy services
• Refine plan offerings so that beneficiaries can
easily identify the differences between their
options
• Provider Networks:
• Notification to enrollees regarding any changes
to provider networks
• Potential future rulemaking
Medicare Advantage in 2014:
Provider Networks
• MA plans narrowing networks to cut costs
• Federal judge in Connecticut temporarily
blocked UnitedHealthcare from dropping an
estimated 2,200 physicians from its
Medicare Advantage plan in that state in
December
• Potential national implications
Medicare Advantage in 2014:
MPPR
• Multiple procedure payment reduction
adopted by many MA plans since 2011
CMS implementation
• Implementation issues by Humana
• Retroactive overpayment letters issued
• Incorrect calculations
• APTA advocacy efforts  Humana no longer
applying policy retroactively
Provider Tips for MA Issues
Review
Contracts
• Determine risk for payment cuts
(through sequestration, MPPR, etc.)
• Seek legal counsel as needed
Monitor MA
Plan Websites
• Many MAOs issue policy updates
only via their websites
• Notice requirements in contracts
Encourage
Patients to Get
Involved
• Emphasis on patient impact with cost
sharing issue
• Patient advocacy more meaningful
ICD-10
ICD-10
• Transition from ICD-9 to ICD-10 diagnosis coding on
October 1, 2014
• No earlier than October 1, 2015
• Congress delayed implementation date with the Protecting Access
to Medicare Act of 2014 (passed on March 31, 2014)
• Will be used in all settings – hospital inpatient, hospital
outpatient, physical therapist private practice, etc.
• Allows for greater detail for laterality, primary encounters,
external causes of injury, preventative health, as well as
socioeconomic, family relationships, lifestyle related
problems
How Different Is It?
GEM Example of ICD-9 to ICD-10
ICD-9-CM
ICD-10-CM/PCS
Diagnoses: 14,025
Diagnoses: 68,069
Procedures: 3,824
Procedures: 72,589
820.02: Fracture of midcervical
section of femur, closed
S72031A, Displaced midcervical fracture of
right femur, initial encounter for closed
fracture
S72031G, Displaced midcervical fracture of
right femur, subsequent encounter for closed
fracture with delayed healing
S72032A:Displaced midcervical fracture of
left femur, initial encounter for closed
fracture
S72032G: Displaced midcervical fracture of
left femur; subsequent encounter for closed
fracture with delayed healing
ICD-10: Key Practice Impacts
• Identification of where diagnosis codes are used today:
Paperwork, electronic systems, and other processes, such as
submitting reimbursement claims, identifying patient eligibility,
getting prior authorization from a payer, reporting quality data,
and more, will need to be updated to reflect new ICD-10
diagnosis codes.
• Documentation: The ICD-10 code set provides greater
specificity for patient diagnosis, so it will be critical to assess
current documentation and how it will support coding for ICD10.
• Vendor Updates: If practices are using electronic systems for
billing, they will need to have their systems updated by
vendors.
• Staff Training: All staff that work with the current ICD-9 system
must be trained on the ICD-10, such as clinicians, front desk
staff, and coding/billing staff.
ICD-10: Tips to Prepare
• Evaluate readiness of vendors and payers
• Develop a communication plan for providers,
patients, and support staff
• Determine financial impact including cost of training,
software upgrades, potential denials during transition
• Develop training plan for coding staff, clinicians
• Identify specific documentation gaps to focus educational
needs
• Test systems both internally and externally
• CMS Testing Week: March 3 through March 7, 2014
• http://www.apta.org/Payment/Coding/ICD10/
HEALTH INSURANCE
MARKETPLACES
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
83
Health Care Reform in 2014
• January 1, 2014:
• Health Insurance Marketplaces
• Plans within Marketplaces must offer Essential Health
Benefits (including rehabilitation and habilitation)
• Individual mandate for coverage
• Medicaid expansion
• Insurance reforms
New plans
Newly covered
individuals
Potential influx of
new patients in 2014
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
84
Marketplaces
• Provides Qualified Health Plans (QHPs) for
purchase through a one-stop shop Web portal
• QHPs:
• Cover the essential health benefits
• Are modeled after the state’s benchmark plan
• Are subject to federal regulations and state insurance
laws
• Tax credits and subsidies facilitate coverage
Marketplaces:
Access to Care through Coverage
Access
Cost
Quality
Many Uninsured Will Be
Newly Eligible for Coverage
Income
Health Insurance Coverage of the Nonelderly, 2011
≤138% FPL
Medicaid (51%)
139-399% FPL
Subsidies
(39%)
≥400% FPL
(10%)
Employer-Sponsored
Coverage
Uninsured
Medicaid*
Private Non-Group
266.4 Million Nonelderly
47.9 Million Uninsured
*Medicaid also includes other public programs: CHIP, other state programs, Medicare and military-related coverage. The federal poverty level for a family of three in 2011 was
$18,530.
Numbers may not add to 100% due to rounding.
SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS.
Marketplaces
State-based
State partnership
Federally facilitated
State Health Insurance Marketplace Decisions, 2014
VT
WA
ME
ND
MT
N
H
MA
MN
OR
MI
WY
UT*
CA
AZ
CO
NM
PA
IA
NE
NV
IL
OH
IN
WV
KS
MO
OK
KY
TX
VA
CT
NJ
DE
MD
RI
DC
NC
TN
SC
AR
MS
AK
NY
WI
SD
ID
AL
GA
LA
FL
HI
State-based Marketplace (16 states and DC)
Partnership Marketplace (7 states)
Federally-facilitated Marketplace (27 states)
* In Utah, the federal government will run the marketplace for individuals while the state will run the small business, or
SHOP, marketplace.
SOURCE: State Decisions For Creating Health Insurance Marketplaces, 2014, KFF State Health Facts:
http://kff.org/health-reform/state-indicator/health-insurance-exchanges/.
Coverage in the Marketplaces
• Essential Health Benefits:
• Ambulatory patient services.
• Emergency services.
• Hospitalization.
• Maternity and newborn care.
• Mental health and substance use disorder services, including
behavioral health treatment.
• Prescription drugs.
• Rehabilitative and habilitative services and devices.
• Laboratory services.
• Preventive and wellness and chronic disease management.
• Pediatric services, including oral and vision care.
Marketplace Coverage: 4 Plan Levels
Plan Tier
Actuarial
Value
Platinum
90%
Gold
80%
Silver
Bronze
70%
60%
Higher premiums, lower
enrollee cost-sharing
Benchmark
Lower premiums, higher
enrollee cost-sharing
Marketplaces: Subsidized Coverage
FPL
Unsubsidized
400%
300%
Subsidized
235%
185%
200%
133%
100%
61%
37%
Medicaid / CHIP
0%
Children
Pregnant
Women
Working
Parents
Jobless
Parents
Childless
Adults
Medicaid and CHIP coverage, based on 2012 eligibility levels in a typical state
Source: Kaiser Commission on Medicaid and the Uninsured
Marketplaces: Subsidized Coverage
• Premium Tax Credits:
• Help people pay the monthly cost to have a
plan through the Marketplace
• 100%-400% FPL
Marketplaces: Subsidized Coverage
• Cost-Sharing Reductions
• Decrease the charges enrollees must pay when receiving health
care services covered by the plan
• Must be enrolled in at least the Silver metal level
• Up to 250% FPL
• Federal government pays the health insurer upfront
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
94
Marketplaces: Subsidized Coverage
• Grace period: 3-month period of nonpayment of
premiums before discontinuing coverage
• Plans only required to pay appropriate claims for services
during the first 30 days of the 3-month period
• Unpaid premiums by subsidized beneficiaries could mean 60 days
in uncompensated care
• Making Sense of Health Reform Series: Grace Period:
• http://www.apta.org/HealthCareReform/MakingSense/
Marketplace Tips
Grace Period
• Verify patient insurance benefits upfront and
check subsidy status
• Insurers should have real-time data re:
premium payments
• Maintain and consistently follow facility’s
indigent policy
• Be aware of state laws regarding patient
abandonment and anti-kickback issues
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
96
Marketplaces: Provider Networks
• Network Adequacy Standards for
Marketplace Plans: network of providers
sufficient in number and type to assure that
all services will be accessible without
unreasonable delay
• Narrow networks across the country
• Concerns expressed from many
provider/patient advocacy groups
Marketplaces: Provider Networks
• New regulations and guidance for Federally
facilitated Marketplace
• Plans will have to submit list of certain providers
in-network:
• Hospitals
• Primary Care
• Mental Health
• Oncology
©2014 American Physical Therapy Association. All rights
reserved. All reproduction or redistribution prohibited.
98
Marketplace Tips
Networks
• Check to see if more stringent network
adequacy standards apply in the state
• If facility is seeing narrow networks,
collect anecdotal evidence of patient
access issues
• Use outcome data, cost data, and niche
services to leverage in-network contracts
Marketplaces:
Other Provider Considerations
• Consider current insurance plan contracts
that may include you in provider network
• All-products clause
• Provider Rates
• Eligibility verification process
• Grace period notifications
Marketplaces: What’s on the horizon?
Marketplaces in the Future
• States can change from Federally Facilitated to
State-Based and vice versa
• Potential upcoming changes:
• Quality standards
• Provider network scrutiny
• Grace Period
• Navigators
• Marketplaces are to be self-sustaining by 2015 –
is this financially feasible for some states?
• Health Care Reform Implementation in Your Area
Feedback Form:
http://www.apta.org/HealthCareReform/FeedbackForm/
Resources
• Health Care Reform:
•
•
•
•
•
•
http://www.apta.org/HealthCareReform/
Expansion of Coverage:
http://www.apta.org/ExpansionofCoverage/
Health Insurance Marketplaces:
http://www.apta.org/HealthInsuranceMarketplaces/
Essential Health Benefits: http://www.apta.org/EHB/
Private Insurance and Managed Care Toolkit:
http://www.apta.org/Payment/PrivateInsurance/
Center for Consumer Information and Insurance
Oversight: http://www.cms.gov/CCIIO/Programs-andInitiatives/Health-Insurance-Marketplaces/index.html
Healthcare.gov
MEDICAID EXPANSION:
Going Forward Under the ACA
Source: www.cms.gov
2014 HEALTH INSURANCE
SUBSIDIES
400%
FPL
241%
FPL
133%
FPL
Exchange Subsidies
Medicaid/CHIP
Children
Medicaid Adults
Adults
0
Children
Varies
by
State
Impact on States
• States can choose to expand Medicaid to non-elderly adults up to
133% (138%) of FPL
• Specifically, the federal government will assume 100 percent of the
Medicaid costs of covering newly eligible individuals for the first three
years that the expansion is in effect (2014-2016).
• Federal support will then phase down slightly over the following
several years, and by 2020 (and for all subsequent years), the federal
government will pay 90 percent of the costs of covering these
individuals.
Impact on States
• States decide when to expand; and may later drop the coverage
without any federal penalty
• No deadline for state decision
• The EHBs must be offered to the Medicaid expansion population
• The EHBS may be offered to other Medicaid beneficiaries
choosing Alternative Benefit Plans (ABPs)
Developments
• July 5, 2013: Final Rule on Medicaid and Insurance Exchange
Eligibility and Enrollment
– Key Provisions
• Appeals Process: For individuals wishing to contest their eligibility
determination, the rule provides options for a coordinated appeals process
between the state exchange, Medicaid, and CHIP, and establishes that state
health agencies will have the final authority on determining who qualifies for
public insurance coverage.
• Electronic Notices: Electronic notices for state exchanges were made
available starting October 1, 2013. In addition, CMS requires state agencies
to issue electronic notices for Medicaid and CHIP eligibility (began January 1,
2015 - one year later than the original deadline). The required electronic
notices to applicants, enrollees, and beneficiaries must provide information on
eligibility for all “insurance affordability programs” – including Medicaid, CHIP,
and the ACA’s premium tax subsidies on the exchanges.
Medicaid Final Rule Key Provisions (cont.)
• Medicaid Benefits: The rule finalizes the standards states must
follow in designing additional Medicaid “benchmark” benefit packages
(“Alternative Benefit Plans”) for certain populations, requiring such
plans to also cover essential health benefits for all newly eligible
adults under the Medicaid expansion.
• Medicaid Cost-Sharing: The rule streamlines Medicaid premiums
and cost-sharing requirements and permits states to establish higher
cost-sharing for prescription drugs and non-urgent use of emergency
departments.
• Applicant Verification: State-based exchanges will not be required
to verify claims by applicants that they do not receive employersponsored health insurance until 2015.
Medicaid Developments
• Medicaid Program: State Plan Home and Community-Based Services, 5-Year
Period for Waivers, etc. (1/16/2014) Final Rule
• Basic Health Program: Federal Funding Methodology for Program Year
2015 (3/12/2014) Final Rule
• Basic Health Program: State Administration of Basic Health Programs;
Eligibility and Enrollment in Standard Health Plans; Essential Health Benefits
in Standard Health Plans; Performance Standards for Basic Health Programs;
Premium and Cost Sharing for Basic Health Programs; Federal Funding
Process; Trust Fund and Financial Integrity (3/12/2014) Final Rule
For additional information see www.apta.org/Medicaid
Medicaid Trends
• Trend 1: New Wave of Medicaid Expansions = potential
increase in patient volume
• Trend 2: Calls for Consumer Personal Responsibility.
• Trend 3: Aligning and Integrating with the Private Market.
• Trend 4: Promoting Stability of Coverage.
• Trend 5: Medicaid Managed Care and Beyond.
Source: Manatt on Medicaid, January 2014
Medicaid Trends
• Trend 6: Behavioral Health Takes Center Stage.
• Trend 7: Coordinating Care for Dually Eligible Patients.
• Trend 8: Continuing Spotlight on Pharmaceutical
Coverage and Costs.
• Trend 9: Waivers and More Waivers.
• Trend 10: IT Investment.
Source: Manatt on
Medicaid, January 2014
Impact on Physical Therapists
• Rehabilitation and habilitation will now be mandatory for this Medicaid
population should your state participate.
• Increased care coordination and care coordination intensity based on
assessed need of patient
• Increased access to HBCS (home-based and community services)
• Focus will be on most fragile, highest cost and most complex
individuals
Impact on Physical Therapists
• Delivery Reform changes: increase in integrative care models (e.g.,
Primary Care Medical Homes, Health homes, ACO-type, etc.)
• Potential access to care issues: are providers available to treat this
new population of Medicaid eligibles?
• Churning
• Overall: potential increase in patient load for PTs who see Medicaid
patients.
SMALL BUSINESS HEALTH
OPTIONS (SHOP)
Marketplace
SHOPs
• What is the SHOP Marketplace?
* A new program that simplifies the process of buying health insurance for small
businesses. In 2014, SHOP helps employers with 50 or fewer full-time equivalent
employees shop for, choose, and offer their employees high quality private health
plans that fit their needs and budget. Beginning no later than January 1, 2016,
SHOP will be available to employers with 100 or fewer full-time equivalent
employees.
* Small business owners such as physical therapist practices are not required
under the ACA to provide employees with health insurance, but may qualify for tax
credits if they do offer employees health insurance through the SHOP.
* In states where the federal government is running the health insurance
exchanges, small businesses will be able to offer one health plan to their
employees. In states with state based exchanges, business owners may be able
to offer multiple health plans to their staff, but this will be at each state's
discretion. Check with your state's SHOP marketplace to find out your options.
SHOPs
• How do I know if I’m eligible to use the SHOP
Marketplace?
* Have a principal business address within the state where you’re buying coverage, or
you can offer coverage to each eligible employee through the SHOP Marketplace
account serving that employee’s primary worksite.
* Have at least one common-law employee on payroll (not including a business owner
or sole proprietor or their spouses if they’re on payroll). For the definition of a commonlaw employee, visit the IRS website at irs.gov/Businesses/Small-Businesses-&-SelfEmployed/Employee-(Common-Law-Employee).
* Employ 50 or fewer full-time equivalent employees (FTEs), including part-time
employees. For example, 2 half-time employees generally equal 1 full-time equivalent
employee. Beginning no later than January 1, 2016, SHOP will be available for
employers with 100 or fewer FTEs.
* Offer coverage to all your full-time employees — those working an average
of 30 or more hours per week.
SHOPs
• How long is the open enrollment period for
employees?
* There are no minimum requirements on how long the initial enrollment
period must be for your employees.
• Can I make changes to my small employer coverage
through the SHOP during the year?
* No. You can change what plans you’ll offer to your employees and
contribution amounts only during your annual enrollment period. However,
you may add or remove eligible employees and dependents throughout the
year. Your plan year is a 12-month period starting on your effective date of
coverage.
SHOPs
• How many of my employees must enroll in the SHOP
Marketplace?
* In many states, 70% of your eligible employees must enroll in the plan(s)
you offer in order for you to participate in the SHOP Marketplace at any point
during the year. This percentage may be different in your state.
* There’s an exception to the 70% rule that applies in most states. From
November 15 - December 15 each year, you can get coverage through the
SHOP Marketplace without having to meet this minimum participation
requirement. This allows employers who don’t meet the required participation
level to offer a SHOP plan.
• For additional information and resources see:
www.apta.org/SHOP/
HEALTH INFORMATION TECHNOLOGY
APTA Federal Advocacy Forum
April 6, 2014
Background: Health Information Technology (HIT)
HIT
Resources/Devices/
Methods:
Required for optimizing
acquisition, storage, retrieval,
and info use in health/biomed
Health Informatics:
computer science, information
science, health care, mathematics,
psychology
HI Tools:
Sub-disciplines:
public health
informatics, medical
informatics, etc,
Computers, tablets,
phones, clinical G/L,
medical terminologies,
information and
communication systems,
HIE
National Priorities
ONC:
Federal Health Information Technology Strategic Plan
2011-2015
Goal I: Achieve Adoption & Information Exchange through Meaningful Use of
HIT
Goal II: Improve Care, Population Health & Reduce Health Care Costs through
HIT Use
Goal III: Inspire Confidence & Trust in HIT
Goal IV: Empower Individuals with HIT to Improve their Health & the Health
Care System
Goal V: Achieve Rapid Learning & Technological Advancement
LTPAC HIT Collaborative: HIT Policy Priorities
• Care Coordination: Lead in longitudinal care planning/coordination across
providers.
• Quality: Leverage technology to improve quality of care across care settings.
• Business Imperative: Leverage technology to generate innovative, efficient
business and service strategies & models to establish a leadership role in the
future of health and wellness delivery.
• Consumer-Centered: Leverage technology to build on its legacy of effective
integration of care and hospitality paradigms.
• Workforce Acceleration: Re-equip, re-empower, and re-educate its
workforce to effectively leverage health care technologies to improve
relationships, experiences, and outcomes with patients.
Health Plan: HIT Policy Priorities
• Consumer Engagement
• Health Information Exchange and Interoperability
• Data Aggregation and Analytics
• Cost Containment
• Provider Communications
• Alternative Care Models
• Growth
“Both state and federal funding levels are going down while medical expense
is going up. So the challenge for us right now is the MLR (medical loss
ratio). Going forward, it is sustaining and maintaining a 1% margin while
preparing for ICD-10, healthcare reform, long-term care initiatives, and
managing the dual eligibles.” (Health Plan CEO, 2013)
Interoperability:
Health Information Exchange
• In early stages – private & “public;” private HIEs growing at a significantly
•
•
•
•
•
•
•
•
faster pace than state and regional
Most common HIE data exchanges: transmission of lab results/order, clinical
summaries, clinical discharges (MU Stage 1)
Data field incompatibility: Some HIEs can transmit CCDs, but few EHRs can
integrate data components in structured fields
Cost prohibitive for providers
Gap between what data provider needs and what HIE offers
Clinical messaging not secure
Inadequate cross-enterprise care coordination
Works best for lab orders and tests, clinician messaging and portal access
Limited: Notifications/alerts, record queries across networks, clinical reporting
and analytics, patient engagement, referral management
HIE Technology Stack
Presentation Layer
Patient/Provider Identification
Data Aggregation
Data Integration and Exchange
Information Management
Identity and Access Management
Development Framework and Extensions
HIT Policy Issue: PTs/PTAs/APTA
• HIT encompasses a broad range of national priority policy issues which
impact PTs/PTAs including:
• improved patient care and outcomes
• improved quality of care delivery
• cost effectiveness and reduction of health care costs
• public health issues
• information sharing
• care team coordination
• Regulations under the ACA, HIPAA and HITECH impact PTs and PTAs
• HIT data aggregation and analysis capabilities (predictive analytics) are
allowing enforcement agencies to increase and expedite enforcement efforts
against providers
• Privacy and security issues and regulatory requirements apply to PTs/PTAs
HIPAA
OVERVIEW OF THE FINAL OMNIBUS HIPAA
RULE
• Released by HHS on 1-17-13
• Enhances patient privacy protections, provides individuals new
rights to their health information, and strengthens the
government’s enforcement of and penalties under the law.
• Strengthens and expands patient rights as well as enforcement
• Compliance date: 9/23/13
(New) HIPAA Rule Importance
• The final rule implements portions of the Health Information
Technology for Economic and Clinical Health (HITECH) Act already in
effect, but also includes modifications and requirements under HIPAA
not previously included in the HITECH Act.
• The new HIPAA changes will have immediate consequences, and the
handling of health information is increasingly a regulated and complex
area with heightened penalties and disclosure requirements for
breaches and missteps.
• It is important for PTs (covered entities/business associates) to
understand the financial and operational implications and develop a
well thought out strategy to remain in compliance and support the
new health information uses, health IT and channels (e.g., EHRs,
HIEs, ACOs, analytics, outcomes-based research, mobile,
telemedicine, social media and other new and secondary uses ).
4 Components of Final Rule
1. HIPAA Privacy, Security and Enforcement Rules and HITECH Act. The final rule
modifies the Privacy, Security, and Enforcement Rules. These modifications
include:
-changes regarding business associates;
-limitations on the use and disclosure of PHI for marketing and fundraising;
-prohibition on the sale of PHI without authorization;
-expand rights to receive electronic copies of health information and to restrict
disclosures to a health plan concerning treatment paid out of pocket in full;
-requirement to modify and redistribute notice of privacy practices;
-modify the individual authorization and other requirements to facilitate research,
disclosure of child immunization proof to schools and access to decedent information
by family members/others.
2. Enforcement Rule. Final rule adopts changes to the HIPAA Enforcement Rule to
incorporate the increased and tiered civil money penalty structure provided by the
HITECH Act for data breaches of PHI.
3. Breach Notification Rule. Final rule adopts the Breach Notification for Unsecured
PHI created under the HITECH Act, and replaces the breach notification rule’s “harm”
threshold with a more objective standard.
4. HIPAA Privacy Rule as it Relates to Genetic Information. Final rule modifies the
HIPAA Privacy Rule as required by the Genetic Information Nondiscrimination Act
(GINA) to increase privacy protections for genetic information by prohibiting most
health plans from using or disclosing genetic information for underwriting purposes.
Key Points
New Requirements Mean the Need for Changes to
policies and procedures.
• Increased and tiered civil money penalties
• Penalties apply to both BA’s and subcontractors.
1.
2.
BA’s Are Treated As Covered Entities, Must Now
Conduct Risk Assessment and Enhance Safeguards.
3. Contractors, Including BA’s, Are Assessing Vendor
Practices, Compliance.
4. Review Design & Functionality of EHR Systems to Address
Requests for Records.
5. Update Notice of Privacy Practices and Redistribute to
Patients/Individuals.
•Provisions of final rule must be reflected in Notice of Privacy Practices
(NPP). NPPs must:
-notify individuals that they will be notified in the case of a breach
-spell out disclosures, such as marketing and fundraising, that require
authorization
-specify that genetic information can not be disclosed to health plans
for underwriting
-specify restrictions on disclosures to health plans for
products/services paid out of pocket
•Providers required to post copy of updated NPP and have copies on
hand, while also providing NPP and obtaining acknowledgement from
new patients.
Key Points
• Develop New Processes to handle modified PHI Use or Disclosure
requirements
• Update Incident Response Plans to address new standards for
breach notification
• Implement encryption and/or review technologies and data
classification schemes based on new Breach Notification and deidentification requirements
• Establish and roll-out an integrated Privacy and Security program
beyond HIPAA including:
• (i) updated policy, NPP and procedures
• (ii) ongoing staff training
ATTENTION PTs
Required Administrative Safeguards under HIPAA
• Conduct a Risk Analysis (technology, access, DP)
• Sanction Policy against workforce members who fail to
comply with organizational security policies and
procedures
• Assign Security Official responsible for development
and implementation of P & Ps
• Response and Reporting Identify and respond to
suspected or known security incidents; mitigate harmful
effects; document security incidents and outcomes.
• Evaluation periodic technical and non-technical
Resources
HHS has the following guidance material for health care providers at
www.hhs.gov/ocr/privacy/
• Sample language : business associate contract modifications
www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contrac
tprov.html
• Risk analysis guidance
http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/rafina
lguidance.html
• Mobile device security tips : www.healthit.gov/providersprofessionals/your-mobile-device-and-health-information-privacy-andsecurity
Resources
HHS and the Office of Civil Rights plan to provide additional online educational resources in the
upcoming months including:
• A breach risk assessment tool offering guidance to covered entities and business associates on the
new breach notification standard;
• “Minimum necessary” guidance for covered entities on how to determine the amount of information
to be disclosed to business associates or others;
• Small healthcare entity compliance tools;
• Revised consumer tools and patient rights information and videos.
Also see:
• Frequently Asked HIPAA Questions:
•
http://www.hhs.gov/ocr/privacy/hipaa/faq/index.html
ONC: Security Risk Assessment Tool: http://www.healthit.gov/providersprofessionals/security-risk-assessment Just released!!
• ONC: Privacy and Security Practice Guidance:
http://www.healthit.gov/sites/default/files/pdf/privacy/privacy-and-securityguide-chapter-4.pdf
• Covered Entity Information:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/index.ht
ml
Resources
www.apta.org/HIPAA
[email protected]
QUESTIONS