A judge Wednesday granted the FTC’s request for a temporary restraining order to halt the integration of Palmyra Medical Center in Albany, Ga. with hospital Phoebe Putney, which acquired Palmyra in 2010 for $195 million. The FTC sued for the restraining order after Phoebe once again began integration after the U.S. Supreme Court ruled against it.

The Director of the FTC’s Bureau of Competition, Richard A. Feinstein, said in a statement, “We are pleased that the Court has issued a Temporary Restraining Order prohibiting any further steps to consolidate the two hospitals in Albany, and prohibiting any price changes to existing health-plan contracts, pending our Motion for Preliminary Injunction.  A hearing on that motion has been scheduled for June 14.”

Phoebe Putney Health System, operator of the largest hospital in Albany, agreed to purchase its only competition in town in 2010 from owner Hospital Corporation of America (NYSE: HCA). The deal was to merge HCA Palmyra Park Medical Center with Phoebe Putney Memorial Hospital, creating one system that would deliver more than 85 percent of the acute-care hospital services to a mostly rural six-county area with 170,000 residents.

The FTC did not like those numbers from an antitrust perspective and challenged the deal. Phoebe Putney argued that the FTC had no say in the deal, as the state of Georgia had drawn up special exemptions from federal antitrust scrutiny if one of the parties is a government or public entity under a state action doctrine. Phoebe, while a private non-profit company, was technically operating under a local public hospital authority.

A lower court in Albany sided with Phoebe Putney, agreeing that the Hospital Authority of Albany-Dougherty County met the requirements for a special purpose hospital authority under state doctrine and the deal was immune from FTC scrutiny. When an appellate court in Atlanta upheld the ruling in December 2011, the merger went ahead as planned.

All of Palmyra’s assets were transferred from HCA to Phoebe Putney and the hospital was renamed Phoebe North in 2012.

But the Supreme Court agreed to hear the case on further appeal from the FTC. Arguments were made on November 26, 2012 and in February, the Supreme Court unanimously said that the lower courts had misread Georgia’s state action doctrine.

Now, nearly 18 months after the completion of the merger and the transfer of assets, the integration is once again on hold.

The post Hospital Merger Mess Gets Messier with Temporary Restraining Order appeared first on insidePatientFinance.

And while the article on Forbes focuses on one statistic, there is plenty of information in the report that should make it required reading among healthcare providers. The report is jammed with information that will be useful as well to patients, insurers, and federal and state governments.

The report contains one other statistic that should certainly raise eyebrows in the Obama administration. There are strong indications that early predictions regarding the mandatory insurance requirement may come true, namely that healthy young people will eschew insurance and for good reason–the actuaries found it will cost them more.

“The age-related premium policy established by CMS in its implementation of the Affordable Care Act will increase premiums for younger individuals and decrease them for older individuals purchasing individual health insurance,” the study found. “By analyzing the underlying costs per age for the population (both male and female) and comparing it to the new approach for individual coverage purchased in state-based exchanges, we found that premiums for individuals in their 20s will subsidize the cost of health insurance for individuals in their 60s.”

Keeping insurance prices affordable requires that healthy people buy insurance to offset the costs of those with chronic illnesses. But for young people, unless penalties for buying insurance have teeth the federal government will not be able to force them to spend more to subsidize the sick and the old.

Click here to read the full article on Forbes.com.

The post iPF on Forbes: Will One Statistic Sink American Healthcare? appeared first on insidePatientFinance.

Republicans are using this tempest in a teapot to suggest that healthcare reform is absolutely the WRONG thing to do right now because…

Well, that’s the thing. It’s not at all clear what this has to do with healthcare reform. “Half of the billion dollars allocated to cover implementation of the Affordable Care Act went to the IRS. Starting in 2014, the agency will distribute subsidies for health-care coverage through state exchanges and issue penalties against individuals who do not get or businesses that do not provide insurance.”

Republicans feel that the IRS shouldn’t hire more agents for the implementation process because — and this is what we in the writing business call “irony” — the IRS profiled conservative groups in much the same way many conservative Republicans support racial profiling for safety. Clearly, they can’t be trusted to hire fairly so let’s dump the sick baby out with its typhus-ridden bathwater.

Or something.

“What’s happened heightens fears about how the IRS will handle taxpayer information and wield its power when it enforces Obamacare starting next year,” Sen. Chuck Grassley (R-Iowa) told the Washington Examiner.

It’s gonna be a LOOOOONG summer, guys.

Thursday’s Headlines

Wanna Increase Our Deficit? Repeal Obamacare: “Congressional budget analysts said Wednesday that repealing ObamaCare would increase the deficit by scrapping the law’s taxes, fees and spending cuts.” [The Hill]

Now’s the Time for a Healthcare Career!: “Unemployment rates may still be high and the opportunities out there in specific careers might be waning, but there is one job sector that may be promising — healthcare.” [Perry Daily]

Striking Healthcare Workers Arrested: “Thirteen people were arrested Wednesday at the UC regents meeting during a sit-down protest by healthcare workers threatening to strike at the system’s medical centers.” [LA Times]

California Democrat Says, “Come ON Already!”: “Let’s Move On and Implement Health Care Reform” [Huffington Post]

Medicare/Medicaid Chief Selected: “The U.S. Senate on Wednesday confirmed Marilyn Tavenner, a former nurse and hospital company executive, as the first full-fledged administrator for the Medicare and Medicaid healthcare programs since 2006.” [Chicago Tribune]

How Much for That Innovation?: “The Obama administration on Wednesday announced a $1 billion initiative to fund innovations in federal healthcare programs aimed at cutting costs while improving the health results.” [Reuters]

The post Healthcare Digest 5/16: Republicans Use IRS, Healthcare for Irony Lesson appeared first on insidePatientFinance.

In two committee hearings, in the House last week and the Senate on Tuesday, the consensus appears to be that the time has come to do away with fee-for-service and the Sustainable Growth Rate (SGR). At yesterday’s hearing of the Senate Finance Committee, Chairman Max Baucus (D-Mont.) said the time had come for both payment models to go. “We must permanently repeal this broken formula and we need to do it this year,” he said.

“We know this is not an easy task,” said Senator Orrin Hatch (R-Utah), “but physicians and patients deserve better. We must find a more stable foundation to pay physicians treating Medicare patients.”

The Senate also agreed with the Obama administration yesterday by ratifying the appointment of Marilyn Tavenner to service as director of the Centers for Medicare and Medicaid Services (CMS). Tavenner becomes the first permanent director since the last one resigned in 2006, and won her job by a 91-7 vote.

The love-fest in Congress pretty much ends there. The House today will vote once again to repeal the Patient Protection and Affordable Care Act. Depending upon who you ask, this is either the 37th or the third attempt to stop Obamacare. “Albert Einstein defined insanity as follows: doing the same thing over and over again and expecting different results,” said Senate Majority Leader Harry Reid (D-Nev.) yesterday on the Senate floor. “If his definition is true — and I won’t argue with Einstein — then House Republicans have truly lost their minds.”

House Republicans, who are sponsoring the vote, justified their decision to proceed by declaring that the ACA will “raise the price of health care, raise the cost of health insurance, reduce access to the American people and continues to get in the way of employers hiring new workers.”

Republicans believe the Democrats are vulnerable on the issue of healthcare reform, but at the same time the Democrats apparently have plans to make the Republican votes a major issue in the 2014 mid-term elections.

The post Congress Agrees: Change How Healthcare Providers Get Paid appeared first on insidePatientFinance.

Community health centers, which consist of some 9,000 locations that serve 21 million patients across the country, can apply for a grant to add staff, train existing staff, and conduct outreach and education, all with the purpose of making the uninsured aware of the new insurance options that soon will be available as a result of the Patient Protection and Affordable Care Act.

“Health centers will help consumers understand their coverage options, determine their eligibility and enroll in new affordable health insurance options,” according to an announcement by Health and Human Services Secretary Kathleen Sebelius. “Community health center staff will provide unbiased information to consumers about health insurance, the new Health Insurance Marketplace, qualified health plans, Medicaid, and the Children’s Health Insurance Program.”

The grant program will be administered through the Health Resources and Services Administration (HRSA). “Health centers work in communities across the country, giving them a unique opportunity to reach the uninsured in their communities and help connect them with the benefits of health insurance coverage under the health care law,” said HRSA Administrator Mary Wakefield in the announcement.

For information on applying for this grant, visit http://bphc.hrsa.gov/outreachandenrollment/.

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The more data errors you have, the lower the quality of your data integrity. The lower your data integrity, the more consumer complaints you can expect. In this new healthcare climate where patient satisfaction is critical, these are not complaints you can afford.

Your patient financial services function is at the mercy of your data integrity. How many times have you heard from a patient who claims they never knew they owed you money until they received a call from your collection partner? And upon investigation, how often is it because someone keyed the wrong address or failed up to update the patient’s insurance?

The source can be human error or a programmatic flaw in the system or a combination of both. Many times the error can occur in a handoff of the patient record from one department to another. Finding the root cause of poor data integrity can be a challenge, but it is one that can be critical to your effectiveness. One of the best way to hunt down these data exceptions is to begin tracking them on a regular basis.

Tracking exceptions requires tremendous discipline, but the value can be immeasurable to your reputation. Your patient financial services staff will not like it because it holds them accountable and measures their accuracy. Your IT staff won’t like it because it may reveal flaws within the technology landscape that they may not be able to fix. And you won’t like it because exceptions require that you take action, and your plate is already full.

But by tracking exceptions you can find root cause or causes, and address them. By improving your data integrity, you will in turn improve the integrity and standing of your organization among your patients. It’s that simple.

The post Maintaining Your Integrity through Healthcare Data Integrity appeared first on insidePatientFinance.

April Wilson
Rev Spring

Understanding the detailed requirements for 501(r)(4)(6)

While the debate continues as to when and how compliance will be enforced, there are steps that healthcare revenue cycle management professionals can take to get ready. Here are five steps you can take right now to better meet the requirements of 501(r). 

Step 1: Be Understandable

Your Financial Assistance Policy is the first thing you’ll want to review. Is it written in a language that is easy for everyone to understand? If your policy is written in Legal or Business language, you will need to revise it to a 9^th-grade reading level. If you want to get a feel for how difficult your policy is to read, try putting it into one of the many free online tools that are available to help you with this task. For example, this paragraph scores at a 9^th grade level, according to one website. 

Step 2: Be Everywhere.

You want your patients to be able to find the Financial Assistance Policy, now that you’ve edited it to be easier to read. This means you need to promote it, everywhere. You should include it with all of your patient communications, particularly with every billing statement. (If you don’t include it with your statement, your statement will need to include clear instructions on where to find it or request a copy.)

It should be easy to find on your website, preferably available right from your main website navigation. If you aren’t sure if the link to your financial assistance policy is easy to find, consider asking a friend or family member to find it while you sit next to them and watch their process. While 501(r) compliance doesn’t require that level of testing, it’s a quick way to spot any issues with where you’ve put the policy on your website. 

Step 3: Be Upfront

Before someone leaves your hospital, make sure that they are provided with a written copy of your Financial Assistance Policy and a Charity Application. Best practices suggest that you provide this even if you do not have enough information on the patient to determine eligibility for financial assistance. If you might take Extraordinary Collections Actions for non-payment, make sure those actions are explicitly detailed in that communication packet. If more than 10% of your residents speak a language other than English, you will need to make all of these materials available in that language as well. 

Step 4: Be Ready

You may not have collected enough information at intake to make the determination whether or not someone is eligible for financial assistance. However, according to 501(r), this does not exempt you from providing assistance. You cannot deny any patient charity because you are missing information – even if you have sent several communications requesting it. Leverage tools like Presumptive Charity Scoring to help make those determinations. Charity scores pull information from various sources about your patient to give you most of the data you need to make a decision for financial assistance. 

Step 5:  Be Proactive

Based on April 2013 guidelines from the IRS, making a good faith effort to comply with 501(r) can prevent your hospital from being penalized. Additionally, if a health system is comprised of multiple hospitals, if one hospital fails to comply, the entire system will not be penalized.

About the Author

April Wilson has a long history of measuring and optimizing customer communication for top brands, and she has built her career around evangelizing the power of data and using consumer insights to change behavior.

The post 5 Ways to Get Ahead of 501(r) Now appeared first on insidePatientFinance.

“The government’s sixth national crackdown on healthcare fraud since 2010 involved $223 million in fraudulent claims in jurisdictions including Miami, Detroit, Los Angeles and Brooklyn, New York, the Justice Department said.”

Hooray! we all say, because those are Bad People and they’re not helping the price of healthcare go down just like shoplifters do nothing to make things cheaper but wait!

“Holder said efforts to expand the battle against fraud is being affected by automatic across-the-board federal budget cuts, known as sequestration, which have stripped $1.6 billion in funding from the Justice Department for the fiscal year ending September 30.”

Wanna see more bad guys get in trouble for pocketing funds that aren’t theirs? Too bad! Sequestration!

“Since 2007, officials say the government’s Medicare Fraud Strike Force has charged more than 1,500 defendants who have falsely billed the Medicare program for the elderly and disabled for $5 billion.”

What’s sad about that figure, just from looking at the headlines over the past year: that 1,500 number should be a LOT higher, right? Because it seems like everyone and his brother is bilking Medicare out of millions.

Wednesday’s Headlines

Good News for Old(er) People!: “Healthcare costs put a big squeeze on retiree pocketbooks, but the grip may be relaxing a bit.” [Reuter]

Every Good Deed Has a Hook: “A healthcare company that provided aid to disabled Miami-Dade students may have overbilled the school district by more than $1 million, according to the district’s chief auditor.” [Miami Herald]

You’re Making Healthcare Worse By Not Using the Cloud: “Healthcare delivery in the United States is high cost and suffers from inconsistent quality. A primary cause of these issues has been the reliance on antiquated, paper-based clinical records. These paper records have been an enormous barrier to high quality care — making it virtually impossible to deliver coordinated care, locking away in paper data needed to analyze what works and doesn’t in healthcare. For years lack of available data structured a system that pays for activity, rather than results. Now with the introduction of Electronic Healthcare Records (EHR), technology has stepped in to lead healthcare reform.” [Computer World]

The post Healthcare Digest 5/15: Jail Time for Healthcare Fraud appeared first on insidePatientFinance.

But then Medicare pays it anyway. And while the provider has no idea why, they are grateful that they now don’t have to chase secondary insurer or the patient to collect.

In 2011 the Centers for Medicare and Medicaid Services (CMS) paid almost $750 million in claims with G modifiers, and the Office of Inspector General believes that was too much. “We found that vulnerabilities exist in how Medicare pays for these claims,” the report states. “When processing claims, contractors often do not consider the modifiers that providers use to indicate that they expect the services or items to be denied as not reasonable and necessary. Contractors also do not always consider the modifiers that providers use to indicate that services or items are not covered by Medicare. Although contractors have checks that affect some of these claims, such as determining whether the services and items met Medicare frequency limitations, they do not specifically check for claims providers expect not to be paid.”

The Inspector General has asked CMS to order it’s claims processing contractors to apply greater scrutiny on claims that use G modifiers, writing:

We are aware that CMS developed a GU modifier for providers to use on claims for items and services for which the routine use of ABNs is appropriate, such as for services that are subject to frequency limitations. This is one way to address the problem in that it would allow providers to use the GA modifier solely for other items and services that they expect to be denied. CMS would then need to instruct contractors to automatically deny or review claims with GA modifiers before paying them. To date, however, CMS has not issued any instructions about the GU modifier or how contractors should process these claims. CMS needs to either issue such instructions or develop other methods of addressing these program vulnerabilities.

In addition, CMS needs to ensure that all contractors are following its instructions to automatically deny claims with GZ modifiers. CMS also needs to instruct contractors to automatically deny claims with GY modifiers and ensure that contractors follow these instructions. Further, CMS should decide whether to implement the GX modifier for Part Bclaims, since providers are already using it. Lastly, CMS should ensure that contractors do not pay for claims with inappropriate combinations of G modifiers. OIG will continue to monitor claims with G modifiers and will undertake a review in the future if it appears that CMS has not addressed the problems presented in this report.

The post Inspector General Wants CMS to Scrutinize G Modifiers appeared first on insidePatientFinance.

Supporters and critics of the Affordable Care Act seem to agree on at least one thing: Allowing young adults to stay on their parents’ health plans until they reach age 26 is a smart move. The change, which took effect in the fall of 2010, has resulted in more than 3 million young people gaining health insurance.

Starting next year, young adults will have more options for coverage in addition to their parents’ plans. But despite the expanded choices, some may continue to face problems commonly associated with their age group—coverage for mental health issues, substance abuse and maternity care.

A recent study illustrated the extent to which young people may previously have had difficulty obtaining care. It found that those who enrolled in their parents’ plan after the health law passed were more likely to have claims for maternity, mental health and substance abuse services than adult children who were already covered by their parents’ plans. Experts note that adult children who joined their parents’ plans may have had unmet treatment needs before they had the option to join Mom and Dad’s plan. Individual health plans they might have applied for typically refuse to cover people with preexisting conditions. They also generally don’t cover maternity care.

The study, published by the Employee Benefit Research Institute, examined the 2011 claims of one large employer that covered more than 200,000 workers and their family members. Before the health law provision went into effect, unmarried student dependents could remain on the worker’s coverage until age 23, but most non-students had to find other insurance after they turned 19.

The EBRI study found that nearly 700 young adults enrolled in their parents’ plan after the health law was passed. The average health-care spending for those adult children was $2,866 in 2011, 15 percent higher than spending by dependents who were already on their parents’ plan. This newly enrolled group was also more likely to have costs related to pregnancy, mental health and substance abuse than their peers.

Next year, health plans will no longer be able to turn people down because they have preexisting medical conditions. This will free young people to shop around for individual coverage on state-based exchanges or the private market if they don’t want to stay on their folks’ plan. All non-grandfathered individual and small-group plans will have to cover 10 “essential health benefits,” including maternity and newborn care and mental health and substance abuse services.

In addition to the comprehensive plans available on the exchanges, young people up to age 30 will have the option of choosing a catastrophic plan there. The plan will cover preventive services without any cost sharing as well as three primary care doctor visits. The plan covers the essential health benefits, though only after a $6,350 deductible is met.

Despite such requirements, some coverage isn’t assured. For example, employers in the large-group market don’t have to cover the essential health benefits. Young women enrolled in such plans might find themselves without maternity coverage if they become pregnant. The Pregnancy Discrimination Act of 1978 requires employers with 15 or more workers that offer insurance to cover maternity care. But the law doesn’t cover dependent children. Dan Priga, who heads the performance audit group at human resources consultant Mercer, estimated that roughly 70 percent of self-funded employers who pay their workers’ claims directly don’t offer maternity coverage for dependent children.

Medicaid may be an option for some of these women. The joint state-federal health program for low-income people generally provides coverage for pregnant women with incomes up to 185 percent of the federal poverty level. By counting a pregnant woman as a household of two, that ceiling is $28,693 in 2013.

If she meets income requirements, the Medicaid program can also “wrap around” a young woman’s parents’ policy and provide maternity coverage her parents’ plan lacks, says Karen Davenport, director of health policy at the National Women’s Law Center. “It’s not necessarily a seamless, easy thing to do,” says Davenport, “but it would cover the gaps.”

Potential gaps in mental health and substance abuse coverage under the health law are addressed to a large degree by the Mental Health Parity and Addiction Equity Act of 2008, experts agree. The law requires employers with more than 50 workers to ensure that patient costs and coverage for mental health and substance abuse services are equivalent to those of other covered medical services. Providers are awaiting final federal regulation on implementation of that law.

But there’s a catch: Many mental health counselors and addiction specialists who provide outpatient services don’t participate in any health insurance plans. So even though a health plan may offer coverage, some people must pay out of pocket for their care.

For example, up to half of physicians who specialize in treating addiction don’t take insurance, estimates Stuart Gitlow, president of the American Society of Addiction Medicine and a psychiatrist in private practice.

“I could get more money by taking insurance, but I’d also have greater expenses,” he says.

Insurance coverage does make a difference in inpatient care, says Gitlow, such as when someone enters a facility to go through a process of detox and rehab.

But most people with addiction problems don’t require that level of care, he says.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

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