Healthcare CEO, physicians sentenced to prison for $27M fraud

Thirteen people involved in a $27 million healthcare fraud scheme have been sentenced to a combined 84 years in federal prison, the Justice Department announced Aug. 31. 

The defendants allegedly participated in a fraud scheme that involved Novus Health Services, a Dallas-based hospice agency. The defendants allegedly defrauded Medicare by submitting false claims for hospice services, providing kickbacks for referrals and violating HIPAA to recruit beneficiaries. Novus employees also dispensed controlled substances to patients without the guidance of medical professionals, according to the Justice Department. 

Novus CEO Bradley Harris admitted to the fraud and testified against two physicians who elected to go to trial. Mr. Harris pleaded guilty to one count of conspiracy to commit healthcare fraud and one count of healthcare fraud and aiding and abetting. He was sentenced to 159 months in federal prison in January. 

The 12 others convicted in the scheme include three physicians, four nurses and several executives. 

Read more here

Out-of-network costs spin out of control

https://www.axios.com/billed-and-confused-cindy-beckwith-out-of-network-care-578a22be-b6b4-4959-8333-9e2e970b19d5.html

Out of Network costs vary greatly among California PPO health plans -

People who have health insurance but get sick with rare diseases that require out-of-network care continue to face potentially unlimited costs.

The big picture: Federal regulations cap how much people pay out of pocket for in-network care, but no such limit exists for out-of-network care.

Zoom in: Cindy Beckwith, 57, of Bolton, Connecticut, was diagnosed with pulmonary artery sarcoma, a rare tumor on a main artery. She also has fibromuscular dysplasia, a rare blood vessel condition.

  • She has ConnectiCare health insurance, which she gets through her husband’s employer.
  • Her local doctors suggested she see specialists at the University of Pennsylvania Health System because her conditions were so uncommon, but the system was out-of-network.
  • “I had to go out of my network,” Beckwith said. “I didn’t have a choice.”

The bill: $20,138.40 from Penn Medicine, the parent of UPHS, a profitable system with $8.7 billion of revenue last year.

  • Over a few years, Beckwith received a lot of care from the hospital, including two open-heart surgeries and inpatient chemotherapy.
  • This bill showed charges of $270,000, just for services received in 2019. Beckwith and the hospital settled on $20,138.40. Penn Medicine “insisted” she pay a minimum of $441 per month until 2023, she said.
  • Beckwith and her husband have already paid more than $11,000, and even though she says they are doing OK with her various medical bills, “there’s not a lot of extra money left over.”

Between the lines: The new surprise billing regulation only protects patients if they get non-emergency care from out-of-network doctors at in-network facilities.

  • That means people with employer coverage that doesn’t have an out-of-pocket maximum for out-of-network care could experience large bills based on hospitals’ inflated charges, and have to negotiate payment on their own.
  • “Out-of-network charges kind of seem like a little bit of funny money to consumers,” said Katherine Hempstead, a health insurance expert at the Robert Wood Johnson Foundation. “These are the things that make people feel kind of defeated.”
  • “We didn’t expect this to happen,” said Beckwith, who has worked in medical coding for 30 years, said of her condition. “When it does, it can wipe you out.”

The other side: Beckwith’s hospital and insurance providers did not make anyone available for interviews.

  • A ConnectiCare spokesperson said the insurer does “not speak about our members’ private health information.”
  • A Penn Medicine spokesperson said in a statement the system “has a longstanding commitment to work with patients to help them understand the costs associated with their care, including out-of-pocket costs.”

The resolution: After Axios submitted a HIPAA authorization waiver, signed by Beckwith, to Penn Medicine to discuss Beckwith’s case, Beckwith received a call from Penn Medicine, whom she hadn’t heard from in months.

  • The hospital knocked $4,000 off her remaining balance, telling her they reprocessed some old claims. She still owes almost $4,800.

Healthcare hacking on the rise

https://mailchi.mp/ef14a7cfd8ed/the-weekly-gist-august-6-2021?e=d1e747d2d8

From the largest global meat producer to a major gas pipeline company, cyberattacks have been on the rise everywhere—and with copious amounts of valuable patient data, healthcare organizations have become a prime target.

The graphic above outlines the recent wave of data attacks plaguing the sector. Healthcare data breaches reached an all-time high in 2020, and hacking is now the most common type of breach, tripling from 2018 to 2020. This year is already on pace to break last year’s record, with nearly a third more data breaches during the first half of the year, compared to the same period last year.

Recovering from ransomware attacks is expensive for any business, but healthcare organizations have the highest average recovery costs, driven by the “life and death” nature of healthcare data, and need to quickly restore patient records. A single healthcare record can command up to $250 on the black market, 50 times as much as a credit card, the next highest-value record. Healthcare organizations are also slower to identify and contain data breaches, further driving up recovery costs.

A new report from Fitch Ratings finds cyberattacks may soon threaten hospitals’ bottom lines, especially if they affect a hospital’s ability to bill patients when systems become locked or financial records are compromised. The rise in healthcare hacking is shining a light on many health systems’ lax cybersecurity systems, and use of outdated technology.

And as virtual delivery solutions expand, health systems must double down on performing continuous risk assessments to keep valuable data assets safe and avoid disruptions to care delivery.

Deepening the role of Big Tech in analyzing clinical data

How Big Tech Is Changing the Way Hospitals Are Run | Technology Networks

HCA Healthcare, the nation’s largest for-profit hospital chain, which operates 185 hospitals and more than 2,000 care sites across 20 states, announced a landmark deal with search giant Google this week, aimed at extracting and analyzing data from more than 32M annual patient encounters.

The multiyear partnership will involve data scientists from both companies working together to develop care algorithms and clinical alerts to improve outcomes and efficiency. Data from HCA’s electronic health records will be integrated with Google’s cloud computing service, and the companies have pledged to adhere to strict limitations to protect individual patient privacy—a key concern raised by regulators after Google announced a similar partnership with another national health system, Ascension, at the end of 2019.

Despite those assurances, some experts pointed to this week’s announcement as further evidence that existing privacy protections are insufficient in the face of the deepening relationships between tech companies, like Google and Microsoft, and healthcare providers, who manage the sensitive health information of millions of patients.
 
We’d agree—we’re overdue for a major rethink of how patient privacy is handled. The healthcare industry spent much of the last decade “wiring” the health system, converting from paper records to electronic ones, and building vast storehouses of clinical data along the way. We’ve now reached a new phase, and the primary task ahead is to harness all of that data to actually improve care. That will require extensive data sharing, such as a recently announced initiative among several major health systems, and will also entail tapping the expertise of “big data” companies from beyond healthcare—the very same companies whose business practices have sometimes raised privacy concerns in the broader social context. But health information is different—more personal and more sensitive—than data about shopping preferences and viewing habits, requiring more rigorous regulation. 

As more big data deals are inked in healthcare, the question of patient privacy will become increasingly pressing.

GOP senators in close races mislead on preexisting conditions

https://www.washingtonpost.com/politics/2020/07/15/gop-senators-close-races-mislead-preexisting-conditions/?utm_campaign=wp_main&utm_medium=social&utm_source=facebook&fbclid=IwAR3XOi91b1jsLf-grP_iIXALJiIvlZNItPE1ZDO0_ql4Wlw8m3GicyoHIH8

2018 midterms: Republicans mislead voters about preexisting ...

“Steve Daines will protect Montanans with preexisting conditions.”

“Of course I will always protect those with preexisting conditions. Always.”

“What I look forward to working on is a plan that protects people with preexisting conditions.”

— Sen. Cory Gardner (R-Colo.), in an interview with Colorado Public Radio, July 1, 2020

 

Sound familiar? Just like President Trump, these Republican senators say they support coverage guarantees for patients with preexisting health conditions. And just like Trump, their records show the opposite.

The president’s doublespeak — voicing support for these protections while asking the Supreme Court to strike them down — is spreading into some battleground Senate races this year.

 

It’s a classic case of buyer beware: Look under the hood of what Daines, Gardner and McSally are selling, and you’ll find a car without an engine.

THE FACTS

Republicans for a decade have tried to repeal the Affordable Care Act, President Barack Obama’s signature health-care legislation. The Supreme Court has upheld the law twice in the face of challenges from conservative groups. As coronavirus cases reached a new high in the United States, the Trump administration filed a legal brief on June 25 asking the Supreme Court to strike down the entire law, joining with a group of GOP state attorneys general who argue that the ACA is unconstitutional.

Before the ACA, insurance companies could factor in a person’s health status while setting premiums, a practice that sometimes made coverage unaffordable or unavailable for those in need of expensive treatment or facing a serious illness such as cancer.

 

The ACA PROHIBITED THIS PRACTICE through two provisions: “guaranteed issue,” which means insurance companies must sell insurance to anyone who wants it, and “community rating,” which means people in the same age group and geographic area who buy similar insurance pay similar prices. The changes made insurance affordable for people with serious diseases or even those with minor health problems, who also could have been denied coverage before the law’s passage.

Now, about 20 million people covered through the ACA could lose their health insurance if the Supreme Court strikes down the law, among many other consequences bearing directly on the U.S. response to the coronavirus pandemic.

In addition to the coverage guarantee, the ACA established online health insurance marketplaces and subsidies for participating buyers. The law also directs billions of dollars a year in federal funding to states that have chosen to expand their Medicaid programs under the Obamacare law. Millions of Americans have gained coverage through those provisions.

We asked the Daines, Gardner and McSally campaigns whether the senators support or oppose the GOP lawsuit at the Supreme Court and how they would address affordability issues for patients with preexisting conditions if the ACA falls. None of their campaigns responded to our questions.

 

“Steve Daines will protect Montanans with preexisting conditions.”

Daines voted to repeal the ACA in 2013 and has supported efforts to repeal and replace the law more recently during the Trump administration.

Regarding the GOP lawsuit, a Daines spokesperson was quoted in the Billings Gazette saying the senator “supports whatever mechanism will protect Montanans from this failed law, lower health care costs, protect those with preexisting conditions and expand access to health care for Montanans.”

 

“What I look forward to working on is a plan that protects people with preexisting conditions.” (Gardner)

Gardner has been voting to repeal, defund or replace the ACA since 2011, the year after its passage. This year, his campaign website says nothing about the law, but his official Senate website says, “Fixing our healthcare system will require repealing the Affordable Care Act and replacing it with patient-centered solutions, which empower Americans and their doctors.”

Asked by the Hill whether he supported the GOP lawsuit, Gardner said: “That’s the court’s decision. If the Democrats want to stand for an unconstitutional law, I guess that’s their choice.” In an interview with Colorado Public Radio, Gardner evaded the question six times in a row.

“Of course I will always protect those with preexisting conditions. Always.” (McSally)

In 2015, McSally voted to repeal the ACA when she served in the House. In 2017, she voted to replace the ACA with the American Health Care Act, which would have allowed insurers to charge higher premiums to patients with complicated medical histories.

McSally, now in the Senate, has declined to comment on the GOP lawsuit pending before the Supreme Court. When asked by PolitiFact, “the campaign didn’t specifically answer, but pointed to her general disapproval of the ACA.”

WHAT HAPPENS IF  THE GOP LAWSUIT SUCCEEDS?

Trump told The Washington Post days before his inauguration in 2017 that he was nearly done with his plan to replace the ACA. Three and a half years later, no replacement plan has emerged from the administration and Republicans in Congress hardly agree on what it would look like — or how to preserve the protections for preexisting health conditions.

Sen. Thom Tillis (R-N.C.), who is also running for reelection this year, has introduced a 24-page bill called the Protect Act that includes language guaranteeing coverage for preexisting conditions. Daines signed on as a co-sponsor on June 24, the day before the Justice Department filed its brief in the Supreme Court. McSally signed on in April 2019. Gardner is not listed as a co-sponsor.

Experts say the Tillis proposal does not offer the same level of protection for preexisting conditions as the ACA, and they warn that millions of Americans could lose their health coverage if the ACA falls and the Protect Act is the only replacement.

“Insurers before the Affordable Care Act had multiple and redundant ways that they could avoid people who had preexisting conditions,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. The Protect Act prevents some of those practices, but it “leaves enough other loopholes that it would make it very possible and likely for insurers to be able to avoid paying benefits for the conditions they most worry about,” she said.

 

Before the ACA, an insurance company could reject an application outright, say, after reviewing a patient’s medical history. The Protect Act has language barring that practice.

“The second thing they could do is, they could sell you coverage, but they could exclude your preexisting condition. ‘Oh, you have diabetes? I’m not going to pay for any of those benefits,’” Pollitz said. “The Tillis bill says you can’t do that, so that’s good.”

In the days before the ACA, insurers were allowed to charge higher premiums based on a patient’s health status. To prevent this, the Protect Act takes language from the Health Insurance Portability and Accountability Act (HIPAA), rather than the newer ACA.

“The Protect Act inserts old HIPAA nondiscrimination language that prevents employers from varying worker premium contributions based on health status,” Pollitz said. “But the Protect Act also includes the old rule of construction that says nothing limits what the insurance company can charge the employer or individual.”

Pollitz said the “community rating” language in the ACA provides clearer protections in this area. The Protect Act says “nothing … shall be construed to restrict the amount that an employer or individual may be charged for coverage under a group health plan.”

“The bill would reinstate three protections at risk in the Texas case — prohibiting insurers from denying applicants based on pre-existing conditions, charging higher premiums due to a person’s health status, and excluding pre-existing conditions from coverage,” Sarah Lueck, a senior policy analyst at the left-leaning Center on Budget and Policy Priorities, wrote in an analysis.

“But it would leave many others on the cutting room floor,” she wrote, because insurers would be able to exclude coverage of benefits such as maternity care, mental health and substance-use treatment; set annual and lifetime limits on insurance payouts; and charge older patients more than younger patients at greater levels than the ACA allows, among other changes.

It’s important to keep in mind that the Protect Act would not replace other parts of Obamacare, such as the online marketplaces and subsidies. Neither would it continue the ACA’s Medicaid expansion, which 37 states and D.C. have now adopted. That includes Arizona, Colorado and Montana.

 

The Pinocchio Test

Voters deserve straight answers when their health care is on the line, especially in the middle of a deadly pandemic.

Daines, Gardner and McSally have voted to end the Affordable Care Act. People with preexisting conditions would have been left exposed because of those votes; insurers could have denied coverage or jacked up prices for sick patients.

The three senators’ comments about the GOP lawsuit are woefully vague, but they can all be interpreted as tacit support. Asked about the case, a Daines spokesperson said “whatever mechanism” to get rid of the ACA would do. McSally’s campaign “didn’t specifically answer, but pointed to her general disapproval of the ACA.” Gardner avoided the question six times in one interview, but in another, he said: “That’s the court’s decision. If the Democrats want to stand for an unconstitutional law, I guess that’s their choice.”

Four Pinocchios all around.

 

 

 

 

How The Rapid Shift To Telehealth Leaves Many Community Health Centers Behind During The COVID-19 Pandemic

https://www.healthaffairs.org/do/10.1377/hblog20200529.449762/full/

How to reduce the impact of coronavirus on our lives - The ...

The COVID-19 pandemic has transformed the landscape of ambulatory care with rapid shifts to telehealth. Well-resourced hospitals have quickly made the transition. Community health centers (CHCs), which serve more than 28 million low-income and disproportionately uninsured patients in rural and underserved urban areas of the United States, have not fared as well since ambulatory visits have disappearedresulting in furloughs, layoffs, and more than 1,900 temporary site closures throughout the country. Government officials have taken notice, and the Coronavirus Aid, Relief, and Economic Security (CARES) Act infused $1.32 billion toward COVID-19 response and maintaining CHC capacity.

Many states have directed insurers to temporarily cover COVID-19-related services via telehealth while mandating parity of reimbursement for telehealth visits with in-person visits for their Medicaid program.

Preparedness Of Community Health Centers For Telehealth

Despite the changes, many health centers may not be ready to implement high-quality telehealth. study using 2016 data showed that only 38 percent of CHCs used any telehealth. In our review of 2018 Uniform Data System data—the most recent available—from a 100 percent sample of US CHCs, we found that our nation’s health centers are largely unprepared for this transformation.

Across the US, 56 percent of 1,330 CHCs did not have any telehealth use in 2018 (exhibit 1). Of those without telehealth use, only about one in five were in the process of actively implementing or exploring telehealth. Meanwhile, 47 percent of the centers using telehealth were doing so only with specialists such as those at referral centers, rather than with patients. Of those using telehealth, the majority (68 percent) used it to provide mental health services; fewer used it for primary care (30 percent) or management of chronic conditions (21 percent), suggesting that most CHCs with telehealth capabilities prior to COVID-19 were not using it for the most frequent types of services provided at CHCs.

CHCs not using telehealth reported several barriers to implementation (exhibit 2). Thirty-six percent cited lack of reimbursement, 23 percent lacked funding for equipment, and 21 percent lacked training for providing telehealth. Although most barriers were similar in both urban and rural regions, a greater proportion of rural clinics compared to urban clinics (18 percent versus 7 percent) reported inadequate broadband services as an issue.

The COVID-19 pandemic has laid bare the enormous disparities in telehealth capacity. Without adequate telehealth capacity and support, many CHCs will be left without means of providing the continuous preventive and chronic disease care that can keep communities healthy and out of the hospital. During the crisis, the Health Resources and Services Administration estimates that CHCs have seen 57 percent of the number of weekly visits compared to pre-COVID-19 visit rates, 51 percent of which have been conducted virtually, suggesting that many CHC patients have forgone care that they would have otherwise received. Given CHCs serve a disproportionate share of low-income, racial/ethnic minority, and immigrant populations—populations hardest hit by the COVID-19 pandemic—any disruption to CHC capacity may exacerbate the racial disparities that have rapidly emerged.

While an important first step, policy makers cannot simply infuse more funding to CHCs and expect them to withstand the challenges of the COVID-19 era. We recommend three targeted strategies to help CHCs adapt and perhaps even thrive beyond COVID-19: legislate permanent parity in telehealth reimbursement for all insurers; allocate sufficient funding and guidance for telehealth equipment, personnel, training, and protocols; and implement telehealth systems tailored to vulnerable populations.

Permanent All-Payer Parity For Telehealth Reimbursement

Payment parity—where telehealth is reimbursed at the same level as an in-person visit—is a crucial issue that must be addressed and instituted beyond the current public health emergency. Without commensurate reimbursement for telehealth, CHCs cannot maintain patient volume or make the long-term investments necessary to remain financially viable. A “global budget” of paying CHCs a fixed payment per patient per month would give practices flexibility in how and where to treat the patient, although this may be politically and practically challenging. Meanwhile, payment parity has already been implemented and could simply be permanently codified into existing reimbursement schemes, giving providers the option to select the best mode of treatment without making financial trade-offs.

In reviewing state telehealth policies during COVID-19, all states have implemented temporary executive orders or released guidance on telehealth access—although with significant variations. At least 22 states have explicitly implemented telehealth parity for Medicaid. For Medicare, the Centers for Medicare and Medicaid Services (CMS) expanded access to telehealth beyond designated rural areas, loosened HIPAA requirements around telehealth platforms, and instituted parity in reimbursement with in-person visits.

To build on these significant steps, states should mandate telehealth parity across all payers and cover all services provided at CHCs, not just COVID-19-related care. At least 12 states have mandated all-payer parity for telehealth. Meanwhile, private insurers have individually adjusted telehealth policies on a state-by-state basis if there was no statewide mandate. Nevertheless, all payers should reimburse at parity given the patchwork quilt of insurance plans that exists at CHCs.

Furthermore, state legislatures and CMS should look to extend parity beyond the current COVID-19 emergency so that CHCs can make sustainable investments that continue to benefit patients. Even as states reopen, in-person visits are unlikely to return to their previous volume as the threat of infection continues to loom. Temporary measures should be made permanent so that CHCs can make sustainable investments that continue to benefit patients.

Funding And Guidance For Equipment, Personnel, Training, And Protocols

For telehealth to function smoothly and reduce errors, proper hardware and software are critical, including telephone service, computers, broadband internet access, and electronic health records. The Federal Communications Commission (FCC) released funding to procure telehealth services and devices and some CHCs have received private funding; similar targeted funding mechanisms from states and the federal government are necessary at scale to equip hundreds of CHCs with the necessary telehealth capabilities.

However, merely having technology is not sufficient. Proper personnel with appropriate training are key to a high-functioning telehealth system along with support from information technology specialists. Additionally, CHCs need ancillary systems in place to allow for the effective use of phone and video visits. Empanelment systems to attribute patients to providers can allow for longitudinal follow-up even with telehealth. Daily huddles and team-based care can enhance the inherent complexities of coordinating care remotely. Protocols should be tailored for different specialties and services such as nutrition management and social work. Meanwhile, a robust e-consult referral network should allow primary care providers at CHCs to easily connect patients to specialty care when necessary. Adding robust protocols and systems will allow for the successful implementation and scaling of telehealth.

For example, groups of CHCs called the Health Center Controlled Networks (HCCNs), which have traditionally collaborated to leverage health information technology, are positioned to harness their economies of scale and group purchasing power to widely adopt new infrastructure while standardizing protocols. They could be a means to accelerate the adoption of telehealth technologies, trainings, and care models to optimize the use of telehealth across CHCs.

Telehealth Support For Vulnerable Patients

The patient population seen by CHCs presents unique challenges that not all ambulatory practices, particularly those in affluent neighborhoods, may face. Health centers care for many immigrant patients with limited English proficiency. Thus, clinics need financial support to contract with telehealth interpreter and translation services to provide equitable access and care. Better yet, all telehealth platforms contracting with CHCs should be required to provide multilingual support to deliver equitable access to telehealth services.

Moreover, many low-income patients lack health and digital literacy. Virtual telehealth platforms should design applications such that interfaces are intuitive and easy to navigate. They should provide specialized support to guide patients who are not familiar with telehealth systems. Additionally, insurers can reimburse CHCs that provide patient navigators, care coordinators, and shared decision-making support that bridge the health literacy divide.

Many around the US also do not have access to high-speed internet, consistent telephone services, and phones or computers with video conferencing capabilities. First, to allow for flexible access to telehealth for all patients, insurers should permanently waive geographic and originating site restrictions that limit the type and location of facilities from which patients can use telehealth. Second, insurers should waive audio-video requirements and consistently reimburse for phone-only visits to accommodate patients without video conferencing. Third, the type of services covered by telehealth should be expanded—ranging from primary care to physical therapy to nutrition counseling to behavioral health.

To address disparities in ownership of digital devices, taking a page out of the book of educators in low-income neighborhoods, local governments could loan laptops and smartphones or supply internet hotspots and phone-charging stations for these communities to enable access. Additionally, insurers could reimburse for the FCC Lifeline program to provide affordable communication services and cellular data to low-income populations to maintain their outpatient care.

Conclusions

As the COVID-19 pandemic sweeps through the US, health care delivery will never be the same. Health centers are struggling as many have been largely unprepared for the abrupt swing toward telehealth. COVID-19 may pose long-lasting damaging effects on CHCs and the patient populations that they serve. Nonspecific federal and state funding will allow CHCs to survive; however, deliberate action is needed to enhance telehealth capacities and ensure long-term resilience.

Similar to the Association of American Medical Colleges’ recent letter to CMS to make various telehealth changes permanent, both CMS and state governments should take immediate action by making permanent parity in reimbursement for telehealth services by all payers. State and federal policy should direct payers to lift onerous restrictions on the types of services covered via telehealth, audio/video requirements, and geographic and originating sites of telehealth services. States and payers should also explore innovative solutions to expand access to cellular data services and digital devices that allow low-income patients to digitally “get to their appointment,” similar to non-emergency medical transportation. Local governments should invest in digital infrastructure that expands broadband coverage and provides internet or cellular access points for people to engage in telehealth. Additionally, CHCs should come together under HCCNs to harness their group purchasing power to rapidly implement telehealth infrastructure that provides multilingual support and other tools that bridge gaps in digital literacy. Finally, best practices, trainings, and protocols should be standardized and disseminated across CHC networks to optimize the quality of telehealth.  

By reorienting the goals for implementing telehealth, policy makers, payers, and providers can empower health centers to thrive into the future and meet the nation’s underserved patients where they are, even during the pandemic. In the long run, telehealth can increase access and equity—but only if the right investments are made now to fill the gaps laid bare by COVID-19.

 

 

 

 

Winners and losers of the HHS interoperability final rule

https://www.beckershospitalreview.com/ehrs/winners-and-losers-of-the-hhs-interoperability-final-rule.html?utm_medium=email

Image result for HHS interoperability final rule

HHS released its much-anticipated final rules on EHR interoperability, ruling against “information blocking” tactics by EHR vendors and giving patients more control over their medical records.

The new rule will be applied over the next two years and will make patient records downloadable to smartphones using consumer apps. Overall, members of the healthcare industry applaud these efforts to make patient information more accessible to improve healthcare delivery. However, there are privacy concerns around how patient data can be used once downloaded to third-party consumer apps that weren’t addressed in the final rule.

Here is a brief list of a few potential winners and losers of the new rule.

 

WINNERS

Patients. Patients now have more control over their medical records and will be able to access them through third-party apps for free, which will make it easier for them to take their medical records to new providers outside of their previous provider’s system. As a result, they will have more choice in where they go for healthcare.

Hospitals and physicians. The lengthy process of trying to convert a patient’s medical records will be unnecessary. Patients will no longer need to have their medical records faxed between healthcare facilities in different networks and the rule will streamline workflow around gathering patient data to provide the best possible care. Hospitals participating in Medicare and Medicaid will also be able to send electronic notifications to other facilities or providers when a patient is admitted, transferred or discharged under its new “Coordination of Participation” rule.

App developers and health IT startups. App developers that allow patients to store their health data and medical information will have access to that data, a virtual gold mine. The federal privacy protections limiting how providers and insurers share medical records do not apply when patients transfer data to consumer apps, according to the New York Times.

Apple and Microsoft. Healthcare providers will be required to send medical data in a format that is compatible on third-party apps including Apple Health Records. Microsoft is also working to sell technology in the health sector, and the new rule will make it easier, according to CNBC.

 

LOSERS

Patients. While the rule has many benefits to patients, there is also potential for disaster. Patients who download their medical information on consumer apps may find their information shared or sold. There could also be additional security issues if those apps are hacked. Finally, some patients may become confused by their medical records and notes if the information isn’t stated clearly, causing further anxiety around their care.

Hospitals and clinics. Patient leakage may become more common if it’s easier for patients to take their medical records with them. Healthcare organizations will also need to prepare for an influx of patient data and have strong governance procedures in place as they partner with payers and other organizations to incorporate clinical data with patient-gathered data and potentially social determinants of health data.

EHR vendors. EHR companies must now adopt application programming interfaces so their systems can communicate with third-party apps. EHR companies have two years to comply and face up to $1 million per violation for engaging in “information blocking.” The new focus on interoperability may also pave the way for competitors to gain market share over the two most dominant players, Epic and Cerner.

Epic. Epic was a notable opponent to the HHS interoperability rules, citing patient privacy concerns. If forced to collaborate with other companies, Epic could potentially lose its edge over competitors, according to an op-ed written by former HHS Secretary Tommy Thompson in the Wisconsin State Journal. He contended Epic would have to “give its trade secrets away to venture capitalists, Big Tech, Silicon Valley interests and overseas competitors for little or no compensation.” Epic is also the most dominant EHR, holding 28 percent of the acute care hospital market, which could be threatened by greater interoperability. However, in response to the final rule’s release, Epic issued a statement saying that it would focus on “standards-based scope for meaningful interoperability.”

 

Five Healthcare Industry Changes to Watch in 2020

https://www.managedhealthcareexecutive.com/news/five-healthcare-industry-changes-watch-2020

Innovation

Industry experts expect significant changes to shake up the healthcare landscape in the next few years, which will affect both health insurers and providers. Many are the result of a shift toward value-based care, a move toward decreased care in hospital settings, technological advances, and other forces.

Here’s a look at what can payers and providers can expect to occur, why each change is occurring, and how payers and providers can prepare for each change:

1. A shift in healthcare delivery from hospital to ambulatory settings

Healthcare delivery will continue to move from inpatient to outpatient facilities. “More surgeries and diagnostic procedures that historically have required an inpatient hospital stay can now be performed more safely and efficiently in an outpatient setting,” says Stephen A. Timoni, JD, an attorney and partner at the law firm Lindabury, McCormick, Estabrook & Cooper, in Westfield, New Jersey, who represents healthcare providers in areas of reimbursement and managed care contracting. A growing volume of outpatient care will be provided in ambulatory surgery centers, primary care clinics, retail clinics, urgent care centers, nurse managed health centers, imaging facilities, emergency departments, retail clinics, and patients’ homes.

This change is occurring as the result of clinical innovations, patient preferences, financial incentives, electronic health records, telemedicine, and an increased focus on improving quality of care and clinical outcomes. “The upward trend in value-based payment models is also influencing this shift, with the goal of reducing the cost of care and improving the overall patient experience,” Timoni says.

Payers and providers can prepare for this shift by analyzing and forecasting the cost and reimbursement implications of providing care in outpatient settings compared to inpatient settings. They should continue to analyze changing patient demographics, consumer preferences, and satisfaction trends, Timoni says. Collecting and analyzing data regarding quality and clinical outcomes as the result of changes in delivery of care from inpatient to outpatient is also key. Healthcare providers should develop effective strategies to grow capacity and infrastructure for outpatient services and invest in innovative mobile technologies, diagnostic tools, and telemedicine systems.

2. Consolidation will continue industry wide

More healthcare entities will continue to merge together. “Even though the number of available partners for transactions is shrinking, new deals pop up all the time because smaller entities are being targeted or entities that had been holding out are now changing their position,” says Matthew Fisher, JD, partner and chair of the Health Law Group at Mirick O’Connell, a law firm in Westborough, Massachusetts. Increased consolidation will result in higher healthcare prices as larger sized institutions use their size to their advantage. Another impact will be narrowing the field of contracting options, which will result in greater dominance by fewer entities in a market.

This change is occurring because industry stakeholder believes that consolidation is the way to survive in a healthcare landscape still being shaped by the ACA. “The belief is that value-based care models require single unified entities as opposed to more contractual-based ventures to succeed,” Fisher says. Another factor is that momentum for consolidations across the industry has continued to build and no player wants to be left behind.

Along these lines, Timoni says that consolidation has been motivated by the evolving and challenging commercial and government reimbursement models which include lower fee-for-service payment rates, value-based payment components, and incentives to move care from inpatient to outpatient settings. “Basic economic theory suggests that consolidation of hospitals and physicians enables these combined providers to charge higher prices to private payers as the result of a lack of competition,” Timoni says. “Likewise, combined insurers are able to charge higher premiums to their subscribers.”

Payers and providers can prepare for this change by evaluating their operations and determining whether consolidation with another entity is advantageous. “This requires assessing an entity’s operations and the risks of consolidation,” Fisher says.

Timoni advises payers and providers to monitor the consolidation landscape and develop effective merger and acquisition strategies. These strategies should focus on optimizing economies of scale to reduce costs and finding the best partners to achieve improved quality of care and effectively manage population health.

3. Protecting data privacy

Ongoing attention will be given to protecting the privacy of healthcare data. New laws, at both the federal and state levels, will be considered that could introduce new regulatory requirements, Fisher says.

While a federal law in an election year may be doubtful, individual states are proceeding. The California Consumer Protection Act (CCPA), intended to enhance privacy rights and consumer protection, will become effective in 2020, for example. Even though the CCPA doesn’t cover all healthcare data, healthcare organizations will still collect additional information that could be subject to CCPA, which means more compliance obligations, Fisher says. Other states are considering how to jump on the privacy legislation bandwagon, which means that regulatory requirements will increase. “Even in the absence of legislation, payers and providers can expect individuals to assert concerns and use public pressure to drive increased attention to privacy issues,” Fisher says.

Meanwhile, debates around what is meant by privacy continue to evolve, Fisher continues. A backlash against the non-transparent sharing of healthcare data and arguable profiteering is creating anger among patients and other groups. Simultaneously, data breaches continue to be reported on a daily basis. Add in that healthcare is a prime target, and all of the factors point to healthcare needing to do more to protect data.

Payers and providers can embrace increased data privacy by focusing on existing compliance efforts, which will require taking time to better understanding HIPAA. “Ignoring or only making superficial efforts to respect data privacy is insufficient,” Fisher says. “Merely doing what is legally permissible may not be good enough.”

4. Consumerization of healthcare

As patients assume more financial responsibility for their healthcare costs due to higher premiums, co-pays, co-insurance, and deductibles, they have become more concerned with the value of the care they receive as well as cost. Patients will likely demand improved access to clearer benefits, billing, and network information to improve transparency, says Brooks Dexter, MBA, Los Angeles-based managing director and head of the healthcare M&A advisory practice at Duff & Phelps, a global consultancy firm.

“Healthcare providers must follow suit to meet value expectations and deliver more consumer-friendly services or may risk losing market share to innovative new healthcare arrangements, such as direct primary care, which offer convenient and quality care with simplified medical billing,” Dexter says. Some ways to do this are to offer better patient portals, expanded hours, improved access, and clear procedure pricing. Despite the trend, payers and providers will most likely continue to resist CMS’ efforts to force greater cost transparency by requiring hospitals to post payer-specific negotiated charges for common services that can be shopped.

Furthermore, Peter Manoogian, principal at ZS, a consulting firm focused on healthcare in Boston, says that the voices of older adults will become comparatively louder as this rapidly growing segment becomes more tech-savvy. The Trump Administration supports increased use of Medicare Advantage and expanding consumer choices. Plan options will reach a record high this year and create an unprecedented amount of choices for this population. The average number of plans a beneficiary has access to this year will be 28, up by a whopping 50% from 2017. What’s more, new entrants that boast a customer-driven approach such as Oscar Health are entering the fray in major markets such as New York and Houston.

Health plans need to be laser focused on improving their understanding and engagement of their customers—who are evolving themselves. “To stay ahead of the change, health plans need access to the right data coupled with leading-edge analytics and technology to continuously mine insights on what members are seeking in their healthcare experience, how patients and providers interact throughout their healthcare journey, and how to meet the needs of future healthcare customers,” Manoogian says.

Health plans will need to take more of a retail focus than what they’re accustomed to, Manoogian says. The bar for providing a great experience and retaining members will also increase.

5. More technological innovations will emerge

Technological innovation will continue to dramatically and rapidly change the manner in which healthcare is delivered, resulting in more personalized care, improved clinical outcomes and patient experience, and overall quality of life. “Information systems, mobile technology, high-tech digital devices, and electronic medical records will allow payers and providers to accurately measure clinical outcomes and effectively manage the continuum of medical care and their population’s overall health,” Timoni says.

One specific way that care will change is that providers will start seeing telehealth play a more critical role in care delivery as the brick-and-mortar, in-person care model becomes less common. “Telehealth will grow past a nice-to-have tool into a standard of care, particularly for low-risk and predictable appointments,” says Cindy Gaines, MSN, RN, clinical leader, Population Health Management, Philips, a company focused on transforming care through collaborative health management in Alpharetta, Georgia. This transformation will enable providers to better tailor their care to patients’ unique needs, while increasing patient autonomy and engagement.

Technological innovations are occurring due to booming private sector interest and investment in medical technology innovation. “Patients are demanding real-time health information, personalized medicine, higher quality of care, and convenient treatment options,” Timoni says. “Payers are demanding more detailed and expansive outcomes data to scientifically manage the reimbursement system to lower costs and improve their subscribers’ health. The medical and information technology fields are attracting more high-skilled workers, who will continue to drive innovation to new levels as long as investor interest is sustained.”

Regarding the increased use of telehealth, Gaines says that many appointments that occur in a hospital today can take place outside of the hospital. And, as the healthcare industry increasingly moves toward value-based care, providers need to extend their line-of-sight outside of a hospital’s four walls. For example, a low-risk follow-up appointment after an operation is usually mostly dialogue and has a predictable outcome—it could be conducted electronically. “By filling up hospitals with visits that could occur virtually, it makes it harder for patients who need face-to-face healthcare access to get it,” she says.

A lack of insurance coverage is a major impediment to telehealth adoption for most health systems. Therefore, providers should pair guaranteed reimbursement opportunities with change management workflows to advance these efforts, Gaines says. They would also be smart to leverage their patients’ everyday devices to manage their care, whether it’s on their smart phone, a fitness watch, or voice assistant.

To embrace technological innovation, payers and providers must continue to be educated and aware of the expanding medical technology landscape and develop technology investment and deployment strategies. “Consider investing and participating in technology venture capital funds and partnering with private sector technology manufacturers and research institutions,” Timoni says.

 

 

 

Aetna draws criticism for automatic down-codes for office visits

https://www.beckershospitalreview.com/finance/aetna-draws-criticism-for-automatic-down-codes-for-office-visits.html?utm_medium=email

Image result for health insurance downcoding

Providers are concerned a new national policy from Aetna involving evaluation and management services will result in inappropriate down-codes.

Under the policy, Aetna will automatically down-code claims submitted for office visits or certain modifiers when the the insurer finds an “apparent overcode rate of 50 percent or higher.” The policy concerns office visits with the 99000 series of evaluation and management codes and the 92000 series of ophthalmologic examination codes, as well as modifiers 25 and 59, the American Optometric Association said in an advocacy post.

AOA said Aetna didn’t explain how an overcoding determination is made under the insurer’s algorithm, whether with or without medical record reviews.

“The AOA believes it is inappropriate to downcode such claims without first reviewing actual medical records and questions whether it complies with HIPAA; a variety of state laws related to fair, accurate and timely processing of claims; and Aetna’s contracts with patients and physicians alike,” the association said on its advocacy page.

Physicians can appeal down-coded claims through Aetna’s internal process.

In a statement to Becker’s Hospital Review, Aetna explained why it implemented the policy:

“We periodically review our claims data for correct coding and to implement programs that support nationally recognized and accepted coding policies and practices. Through a recent review, we identified healthcare providers across several specialties who are significant outliers with respect to coding practices. While we recognize that healthcare providers undoubtedly may have complex medical cases that are unique to their practice, this result is much higher than the average for physicians across most specialties.

“For this small, targeted group of healthcare providers, we will review their claims against [American Medical Association] and CMS coding guidelines. Based on that review, we may potentially adjust their payments if the information on the claim is not supported by the level of service documented in the medical record.”

 

Healthcare’s number one financial issue is cybersecurity

https://www.healthcarefinancenews.com/node/139027?mkt_tok=eyJpIjoiTURRMk1tVTFaVE15TkRjMiIsInQiOiJPNUYydDU5cFVodjB4bnlnb2M0eVhDNjg2YU53NDl6MWFRQlVpUEpmTzV5cEcrVVZMWldhd1AzbHNlckIwUWJHczlhOVRMZUxxSngyWk02VVhXTktXRjN1OE9mbkQ2V2FhQlBqVFIzOWpMS0pNUEdCYWh0SUQyZWZHRmpBQjRFWiJ9

Image result for hospital cybersecurity

The cost of a healthcare breach is about $408 per patient record and that doesn’t include the loss of business, productivity and reputation.

Cyber attacks affect the finances of every hospital and insurer like no other.

“I’ve seen estimates of over $5 billion in costs to the healthcare industry annually,” said Lisa Rivera, a partner at Bass, Berry and Sims who focuses on healthcare security. “That’s enormous and is not going away.”

Beyond the cost to find a solution to fix breaches and to settle any civil complaints are fines from the Department of Health and Human Services Office of Civil Rights. In 2018, OCR issued 10 resolutions that totalled $28 million.

The HHS Office of Civil Rights is stepping up breach enforcement of private health information, according to Rivera, who is a former assistant U.S. Attorney and federal prosecutor handling civil and criminal investigations for the Department of Justice.

What officials want to see is that the hospital or insurer has taken reasonable efforts to avoid a breach.

“There is no perfect cybersecurity,” Rivera said. “They say it’s not perfection, it’s reasonable efforts. That’s going to require an investment up-front to see where data is located, and educating the workforce on phishing incidents.”

Also, hospital finance professionals who are relying more on contractors for revenue cycle management and analytics should take note on the security issues involved in sharing this information.

“Every sector of business has attacks, but healthcare is experiencing the largest growth of cyber attacks because of the nature of its information,” Rivera said. “It’s more valuable on the dark web.”

It’s also not easily fixed.

If an individual’s credit card is stolen, the consumer can cancel his or her credit card. But in health records, the damage is permanent.

THE IMPACT

Despite the number of breaches, healthcare has been behind other sectors in taking security measures. Four to seven percent of a health system’s IT budget is in cybersecurity, compared to about 15% for other sectors such as the financial industry, according to Rivera.

Hospitals are behind because first, it’s a challenge to keep up with the move to more information being in electronic form.

“There’s no hospital that doesn’t have mobile EHR information,” Rivera said. “Then there was this transition with incentives from the government to go to electronic medical records. There were vast routes to doing that without a lot of experience involved in doing it. The push to become electronic began happening with this enormous uptick in cyber attacks.”

Also, the focus of healthcare has always been patient care. The population health explosion also involves the sharing of information.

And consolidation across the healthcare industry can potentially make covered entities more vulnerable to lapses in security during the transition and integration phases.

RECOMMENDATIONS

The number one way to cut costs is to prevent a breach. Once one has happened, hospitals must be able to identify it as soon as possible and then be able to respond to it.

Hospitals should be able to determine where certain data goes off the rail, Rivera said. For instance, large systems doing research have outcome information that may not be within the system of protection.

“You don’t want to learn about a data breach because the FBI saw it on the dark web,” Rivera said. And some hospitals have.

It’s a constant battle of software updates and checks. Criminals are pinging systems thousands of times a day. It’s like locking down doors and windows.

The first thing that’s needed for systems large and small is a risk assessment. This is the first thing the OCR wants to see, she said. Many hospitals use an outside vendor to do the job.

Prices for other cybersecurity measures vary from a software purchase that could be in the millions, to having vendor monitoring.

But the cost of a healthcare breach is about $408 per patient record and that doesn’t include the loss of business, productivity, reputation and the service disruption.

Hospitals can also purchase cyber insurance, which varies in cost and coverage. Some obtain it for purposes of class action lawsuits.

THE LARGER TREND

OCR enforcement activity during 2018 demonstrates the agency’s continued emphasis on enforcing violations of the security risk assessment and risk management requirements, Rivera said.

Covered entities and business associates are required to: conduct a thorough assessment of the threats and vulnerabilities across the enterprise;    implement measures to reduce known threats and vulnerabilities to a reasonable and appropriate level; and ensure that any vendor or other organization accessing or storing private health information is security compliant.
The OCR concluded 2018 with an all-time record year for HIPAA enforcement  activity. The OCR settled 10 cases and secured one judgment, together totaling $28.7 million. This surpassed the previous record of $23.5 million from 2016.

In addition, OCR also achieved the single largest individual HIPAA settlement  of $16 million with Anthem, representing a nearly three-fold increase over the previous record settlement of $5.5 million in 2016. Anthem was held responsible for cyber attacks that stole the protected health information of close to 79 million people.