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Transitioning to HIPAA 5010 Print E-mail
Written by Todd Demel, MBA   
Tuesday, 20 December 2011 20:05

The deadline for changing to a new mandatory standard format for submitting electronic claims information is fast approaching. Providers must transition by January 1, 2012 or face potential delays in reimbursement since payors may not be able to process claims submitted in the current format.

This federally mandated change will impact health plans, clearinghouses, as well as providers and requires these entities to follow new standards in electronic healthcare administrative transactions that are fundamental to daily revenue cycle operations. Among the factors contributing to the need for change are administrative and technical challenges, inconsistencies, ambiguities, and limitations with the current 4010A1 format.

The upgrade from the current HIPAA 4010A1 transaction standards to the new X12 standard 5010 version has the following objectives:

·         Support for the additional codes associated with the new ICD-10 code set

·         Streamline reimbursement transactions

·         Increase transaction uniformity

·         Support electronic referral certification and authorization

·         Enhance overall capabilities

·         Improve tracking methods

·         Remove unnecessary information

·         Support Pay for Performance

Broader motivational factors driving the change include the government's goal of improving quality of care while lowering costs within the healthcare system. For example, premium dollars spent on administration associated with manual processes could be reduced, while overall healthcare costs would likely substantially decrease as well.

In addition, there is a widely recognized need for a comprehensive electronic data exchange environment that enables sharing of information, and accommodates the expanded ICD-10 code set transition coming in 2013. So, the 5010 upgrade should bring about a more uniform billing and reimbursement system and thereby simplify the reconciliation process required of providers.   

With the looming deadline just around the corner, healthcare organizations need to finalize the process of upgrading and testing current claims management systems in order to accommodate 5010 and reduce the likelihood of operational disruptions. Not surprisingly, while healthcare practices are faced with a barrage of substantial and seemingly simultaneous changes, many have put off implementation of new transaction software that is compatible and required for the upgrade. However, the time to initiate the change is now and the necessary workflow modifications must be made and testing performed. Physician practices need to plan for training of functional and technical staff and anticipate that productivity may decrease during the transition period. The new processes may require changes to ongoing daily billing procedures and the goal should be minimizing the impact to your practice and ensuring the transition occurs as seamlessly as possible.

ABOUT THE AUTHOR: Mr. Demel is Senior Executive of Physician Management Services at MF Healthcare Solutions. Possessing both operational and financial backgrounds, the MF Healthcare Solutions management team has vast experience in a range of healthcare industry settings. Combined expertise enables the firm to offer specialized physician practice management services. For more information, please visit: or contact Todd Demel at (954) 475-3199.

Last Updated on Wednesday, 11 January 2012 06:54
HHS Office of Inspector General Releases Priorities for Fiscal Year 2012 Print E-mail
Written by David Restaino   
Tuesday, 13 December 2011 20:41

The Department of Health and Human Services' (HHS) Office of Inspector General (OIG) has been busy combating fraud and abuse over the last few years - the monies it has recovered more than doubled from 2006 to 2010, topping $4 billion in fiscal year 2010 alone. And OIG's enforcement efforts will undoubtedly increase because of the balanced budget pressure in Washington. 

With this in mind, the OIG's recently released Work Plan for Fiscal Year 2012 provides the regulated community with a roadmap of the areas that will receive additional scrutiny from OIG. These include:

● Payment systems controls that identify high cumulative Part B payments made to physicians;
● Claim submission practices of, and private contracts entered into by, physicians who have opted out of Medicare;
● Physicians' coding on Part B claims, for services performed in ambulatory surgical centers and hospital outpatient departments;
● Providers' compliance with assignment rules relating to billings that exceed Medicare-allowable amounts; and
● Part B payments for chiropractic services.

This list only skims the surface of those "new" areas of OIG focus, and does not take into account its existing areas of investigation.

Moreover, these priorities also extend beyond fines and penalties and also cover exclusion of individuals from participation in federal health care programs. For instance, in fiscal year 2010, over 3,300 individuals and entities were excluded from such participation. A recent Government Accountability Office (GAO) report criticized HHS and suggested that it should be paying greater attention to its suspension and debarment programs, by perfecting its use of staff and developing guidance to implement these programs. Assuming HHS follows even some of these recommendations, we can also expect to see more suspensions and debarments in the coming year. 

David Restaino, a partner at Fox Rothschild LLP in its Princeton, NJ office, has more than 20 years of experience representing clients in regulatory compliance and complex commercial litigation matters, including environmental and health care disputes, before multiple federal and state courts and agencies.

Last Updated on Tuesday, 20 December 2011 20:02
Compliance Corner - Fall 2011 Print E-mail
Written by   
Wednesday, 07 December 2011 00:00

CMS Imposes Medicaid Payment Restrictions on Provider-Preventable Conditions

Effective July 1, 2011, states must submit state plan amendments to the U.S. Centers for Medicare & Medicaid Services (CMS) indicating how each state will prohibit Medicaid payments to providers for provider-preventable conditions as required under the Patient Protection and Affordable Care Act.  CMS revealed that it will delay compliance action related to the new provisions until July 1, 2012.

Read the full article here.

FTC/DOJ Remove Mandatory Antitrust Review for MSSP-Participating ACOs in Final Policy Statement

On October 20, 2011, the Federal Trade Commission and Department of Justice issued a final policy statement on accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP).  Significantly, the Agencies eliminated mandatory antitrust review of certain ACOs seeking to participate in the MSSP, but declined to adopt other stakeholder recommendations.

Read the full article here.

ACOs Get Broad Waivers from the Fraud & Abuse Laws

The Centers for Medicare & Medicaid Services and the Office of the Inspector General (HHS) have issued, and seek public comment on, broad waivers of the federal fraud and abuse laws for ACOs seeking to participate in the Medicare Shared Savings Program.

Read the full article here.                                                 

Last Updated on Wednesday, 07 December 2011 12:50
HHS/OCR Audits are Coming: What are Covered Entities Doing to Prepare? Print E-mail
Written by David Restaino, Esq.   
Wednesday, 30 November 2011 17:38

Those entities subject to both the HIPAA privacy and security rules should pay close attention to recent action taken by the U.S. Department of Health and Human Services ("HHS") Office for Civil Rights ("OCR"), which will increase the frequency and depth of government audits for HIPAA/HITECH compliance over the next year. This initiative may be in direct response to some critics that OCR was not doing sufficient monitoring of compliance with HIPAA/HITECH.

Preliminary Audit Procedures. Specifically, OCR awarded a contract worth over $9 million to KPMG, LLP for administration of the audits, which will begin shortly. The audits are required by the American Recovery and Reinvestment Act of 2009 (ARRA), which states at Section 13411, "The Secretary shall provide for periodic audits to ensure that covered entities and business associates that are subject to the requirements ... comply with such requirements."   Details are sketchy regarding the process to identify the entities that will be audited. However, this much is known:

● The first step will be creation of audit protocols, followed by an undertaking of the actual audits.

● OCR will base its decision to audit upon risk.

● Audits will not be based upon complaints or actual reported privacy or security breaches. 

● KPMG will assist OCR in establishing the program to audit covered entities and business associates, and their compliance with the privacy and security rules.

● HHS staff will guide KPMG's conduct during the audits.

● The audits will include site visits, interviews with leadership, documentation, an examination of operations, and an assessment of the consistency with which process is married to policy.

● Each audit will be followed by a report that will, among other things, address compliance efforts and corrective actions taken. 

Who Will Be Audited?  HHS reports that every covered entity and business associate is eligible to be audited. The initial round of recipients is expected to provide a broad assessment of a complex and diverse health care industry. Thus, the audit process is designed to have OCR audit as wide a range of types and sizes of covered entities as possible; covered individual and organizational providers of health services, health plans of all sizes and functions, and health care clearinghouses may all be considered. OCR has also made it explicitly clear that covered entities must fully cooperate with the auditors - as obligated under the HIPAA "enforcement rule." Finally, HHS reports that business associates will be included in future audits.

What can covered entities do now to be ready? For starters, they can make sure that all policies and procedures are in place now. For example, the HHS website states that covered entities will have only ten (10) days to produce documents; this is not much time if policies and procedures are not already in good order. 

Based on the above, the best way to get prepared is to make sure that compliance protocols are in place, and being followed, today. Stated differently, all covered entities and business associates should assess their compliance efforts, ensure that timely corrective actions are taken when necessary, and remain on their guard.  Documentation of the proactive assessment and corrective measures should also assist in demonstrating that the compliance efforts are effective.

David Restaino, a partner at Fox Rothschild LLP in its Princeton, NJ office, has more than 20 years of experience representing clients in regulatory compliance and complex commercial litigation matters, including environmental and health care disputes, before multiple federal and state courts and agencies.

Last Updated on Wednesday, 07 December 2011 12:46
CMS Issues One Final and Two Proposed Rules in Effort to Reduce Health Care Delivery Costs by Streamlining Regulations Print E-mail
Written by   
Thursday, 10 November 2011 11:11

CMS issued the rules on October 18, 2011, in response to President Obama's Executive Order 13563, "Improving Regulation and Regulatory Review," and consistent with the U.S. Department of Health and Human Services' Plan for Retrospective Review of Existing Rules.  Overall, the final rule and two proposed rules appear to make significant progress in eliminating duplicative and unnecessary requirements, while providing hospitals and other providers with greater control over how to best achieve patient health care objectives.  

Read the full article here..     SOURCE:
Last Updated on Sunday, 13 November 2011 13:05
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