Saturday, December 5, 2015

Health Care Compliance Association

The Health Care Compliance Association represents professionals working in the roles of compliance officers and allied personnel. They perform a critical role in assuring the accuracy and integrity of health care quality and the health care revenue cycle.

Compliance Today is the main journal publication of the HCCA.

Tom Ealey co-authored an article in the December issue.


Restraints article

Sunday, November 29, 2015

Naughty, Naughty Hospitals

Every major health care conference I attend there are compliance seminars. Sometimes I listen, sometimes I teach the seminar. No serious person in health care has not attended a compliance seminar. Right?

So, does everybody sleep through the compliance programs, or just some executives and some physicians?

The recent Adventist and the Broward Hospital settlements should put fear in the hearts of hospitals employing physicians and also in the physicians themselves.

The two organizations have settled whistleblower qui tam cases with the federal government for more than $200 million with legal fees, [  1  ] both for structuring physician contracts to pay more than fair market value and to reward referrals.

The Broward case started with the Stark statute and bootstrapped onto the anti-kickback and false claims act. The Adventist case started with the Stark statute and hopped onto the false claims act. Adventist was also hit with upcoding and unbundling Medicare charges.

So what was happening?

The physicians were paid more than fair market value, comparing their salaries to local salaries and MGMA salary study numbers. Way more.

The physicians were paid more than the profits-before-compensation from their practices.

Some of the physicians were paid salaries and benefits higher than their entire cash collections!  Never mind operating expenses.

After physician compensation the practices were losing massive amounts of money – made up to the parent hospital with revenue the hospital generated by physician referrals.


[1]  settlements were Broward = $69.5 million, Adventist = $118.7 million

Monday, November 16, 2015

More Rules, More Regulations

The current nursing home surveyors' manual is more than 700 pages.

Apparently, that is not enough.

The Obama administration has draft a new set of regulations covering a wide range of topics. A few may be helpful, many not so much.

The administration thinks it may take up to a year to get the regulations in place.

Stay tuned.

The IRS Muddle

Take one very complex health care law and mix it with the complexity and confusion of the Internal Revenue Service, and what do you get?

Monday, September 21, 2015

Get ready, get set,.................?

October 1st marks the transition to ICD-10. We will roll from using about 13,000 ICD-9 codes to using 68000 ICD-10 codes.

Why? Well, the Europeans do it and ya know they are so much more sophisticated than we are.

Layered on top of a less than successful EMR roll out, this has the potential to be a first rate disaster.

Physician offices will be allowed a year of grace, which may or may not work any better than a cold turkey transition.

For physician offices, the standard will be "close counts." Amazing.

We will be watching this carefully.

Saturday, August 1, 2015

Grading Obamacare

The Affordable Care Act (nee Obamacare) is five years old and controversy still rages on many fronts. The Supreme Court has ratified enough of the Act (mandatory Medicaid expansion was a loser) to keep the Act in place for the foreseeable future, but the nitty gritty details still need attention.

The Act is wildly complicated and convoluted, making implementation incredibly difficult. the Obama administration has displayed an incredible lack of administrative skill and an inability to complete projects in a timely manner. was a symptom of a much bigger problem.

So, the grade card:

Expand coverage

Overall, in process, B-

Medicaid, out of Obama’s control

Disrupt and reform health insurance markets

In process, much more to do, outcome uncertain, C-

Mega merger in process, apparently antitrust is dead?   D

Disrupt and reform employer-employee relationships

In process, hard to measure impact, much more to do, outcome uncertain, C-

“Cadillac tax” – hated by both business and unions, that says something, D

Disrupt and reform provider system, disrupt and reform cost structures

In process, future uncertain, bundling moves forward, D 

Innovation driven by providers, B+

Rural healthcare – big trouble, D


Late with new regs, F

Disrupt and reform information systems (EMR) *

In process, “meaningful use”  a mess, high cost, C-

Disrupt and reform information systems (ICD-10 coding changes) *

Pending October 1, outcome uncertain, providers worried, I for incomplete

* technically not a part of the Affordable Care Act

Wednesday, June 24, 2015

Where Are We At? June 2015

The nation awaits the Burwell decision from the Supreme Court.

While this decision could negatively impact the Affordable Care Act, it may not have such a big impact on health care reform.

So what is the difference?

Health care reform is a bit like an avalanche, once it was started by ACA it picked a momentum of its own.

Reform was driven by ACA, but is no longer totally dependent on ACA. We cannot turn back the clock. We cannot return to 2010, with or without ACA.

Friday, June 5, 2015

Medicare ACOs - The Next Generation

The first generation ACOs, the so-called Pioneer model, have been a minor success.
The Affordable Care Act needs ACOs to be big success in order to achieve long-term goals.

The next generation of Medicare ACOs will allow bigger rewards for the ACO participants, as long as the participants are willing to share risk.

CMS has been tinkering with the regulations, finally published on June 4, 2015, for fear the first generation might drop out and the second generation might be a bust.

Stay tuned.

Thursday, April 16, 2015

SGR is Dead, Long Live MIPS!

Passed in 1998, the Sustainable Growth Rate (SGR) system had been “patched” 17 times, as it was an orphan system no one wanted to implement. Lobbyists feasted on the ritual maneuvering to defer SGR because no one could justify cutting Medicare physician fees.

In a collision of politics, problems and opportunities, and driven by the Affordable Care Act, the feds have now passed a reasonable interim solutions to the problem of  Medicare physician fees.

Oh, and no delay on ICD-10.

The political bargaining chips included a two year extension for funding CHIP (Children’s Health Insurance Program) and also increases to seniors’ out-of-pocket expenditures. The bill also gives a few years of respite to post-acute care facilities facing reimbursement cuts.

The package fell short on being revenue neutral but provides physicians and Congress with a five year respite from the ridiculous SGR bickering. This issue is not finished though, but it is a starting point on a different path.

Merit-Based Payment Incentive System (MIPS)

The new program starts with a five year fee schedule, with .05% increases each year. No much, but much better than a 21.5% cut. Payments to physicians will be adjust based on MIPS data starting in 2019 and running through 2025.

Key take away – alternate payment systems are coming - fast.

MIPS folds in and improves  three current programs:
1) the Physician Quality Reporting System (PQRS)
2) the Value-based Modifier (VBM), and
3) the EMR meaningful use rules

And what are the pieces of the MIPS puzzle?  Quality, resource use, EMR meaningful use, and clinical practice management headed for alternate payment methods.

So in one fell swoop the feds have folded  many of the pet theories and pet projects for improving results and lowering costs into the new era of MIPS.

Let's not be too cynical, this could work, or at least have some major positive impacts.

The MIPS payment adjustment process is incredibly complicated, too complicated for a brief explanation. The system will push alternate payment methods very hard, and will  push physician risk sharing models.

Make no mistake, this is a giant piloted lab experiment looking for a sustainable model for physician reimbursement. The next ten years are going to be very difficult but very interesting.

The next ten years will be really interesting.

Saturday, March 7, 2015

The Anthem Hack

Anthem Inc., the giant health insurer and service company for many Blue Cross and Blue Shield plans, was subject in January to what may be the largest data hack ever.

Anyone with a primary or secondary plan from any of these carriers may have data in jeopardy.

The find out what Anthem Inc., is doing to protect victims log on to

cross posted:

Thursday, March 5, 2015

Disruption is Disruptive!

The hottest word in business today is “disruption” as in “the I-phone disrupted the cell phone business” or “Uber is disrupting the taxi cab business.”

The Affordable Care Act was clearly intended to be disruptive, Obama administration denials to the contrary. The administration has quit with the denials, finally, but has never really informed the general public how massive the disruption has been and will be.

The ACA was designed to disrupt most of clinical medicine, including the physician-patient relationship, but we really do not talk about that so much.

One theory floated by ACA supporters is a massive wave of innovation has been started that will eventually creates higher quality and lower cost in U.S. health care.

Good news – there is a great deal of innovation in the system, sort of a do it to survive operation.

Bad news – not every practice can be the Mayo Clinic, with primary care and rural care seemingly on the short end of the innovation train.

Disruption sometimes fails – think Pontiac Aztek or Windows 8. There are no guarantees, and the stakes here are incredibly high.