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McBrayer Blogs
Showing 179 posts in Health Care Law.
Fraud, Waste and Abuse Controls Under The Affordable Care Act
The Affordable Care Act (“ACA”) strives to improve our health care system in three main areas; by expanding consumer protections, strengthening Medicare and reducing health care costs. One key way the government hopes to achieve these goals is through tougher fraud and waste controls. Given the focus on prevention, penalty and recovery, compliance plans are of the utmost importance for all health care providers. First we examine all of the elements incorporated in the ACA that pertain to fraud, abuse and waste before we can begin to develop a compliance plan for our facilities. The new law contains a host of tools aimed at enforcing fraud and waste prevention. Let’s review: More >
Affordable Insurance Exchanges
Affordable Insurance Exchanges seek to ease the navigation and financial burdens of both individual and small business health insurance. As part of the Affordable Care Act (“ACA”), State-based exchanges are a “one-stop-shop” to compare and find affordable health coverage in a competitive insurance market. The transparency of Exchanges allows consumers to compare private and public health plans based on price and quality. The ACA created the notion, but on August 12, 2011 the Department of Health and Human Services and Treasury awarded establishment grants to 13 states and the District of Columbia, to facilitate the implementation of the exchanges. More >
Accountable Care Organizations Program Models
The Supreme Court’s decision upholding the Affordable Care Act supports The Centers for Medicare and Medicaid Services (CMS) different programs for the development of Accountable Care Organizations (ACOs). In Kentucky, we are beginning to see these organizations emerge in different models. More >
Supreme Court Decision Legitimizes Accountable Care Organizations
With its decision upholding the Affordable Care Act, the Supreme Court has authorized the use of Accountable Care Organizations (“ACO”) as one of the principal tools for addressing health care costs and improving care. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely by reducing the rate of growth in the cost of health care, the ACO will share in the savings it achieves for the Medicare program. The Centers for Medicare and Medicaid Services (“CMS”) announced the selection of 88 ACOs to participate in the first round of the Medicare Shared Savings Program. These ACOs will take responsibility for coordinating care for nearly 1.2 million Medicare beneficiaries in 40 states. Three ACOs have been approved for Kentucky and include Quality Independent Physicians (Louisville), Southern Kentucky Health Care Alliance (Smithsgrove), and Deaconess Care Integration (Serving Indiana and Kentucky). In late July, CMS announced 15 new ACOs to participate in the Advance Payment ACO Model Program including Jackson Purchase Medical Association PSC, which is an ACO that includes 6 physician practices in Paducah and Ballard County Kentucky that covers 6000 Medicare beneficiaries. This brings the total participation in the program to 20. With the 32 systems approved to participate in the Pioneer ACOs Program in February 2012, CMS announced there are now 153 organizations participating in Medicare Shared Savings initiatives, serving over 2.4 million beneficiaries. More >
THE PERILS OF PRESCRIBING CONTROLLED SUBSTANCES
As the Kentucky Board of Medical Licensure’s (“KBML”) implementing regulations for House Bill 1 are now effective on an emergency basis for the next six months, physicians, nurse practitioners, and other licensed prescribers have specific statutory and regulatory requirements establishing when and how they may prescribe controlled substances. These rules must be followed or physicians and others may face serious consequences that include criminal misdemeanor offenses, loss of prescribing privileges, and disciplinary actions against professional licenses. All practitioners must pay careful attention to these rules because even minor violations may create problems. Because the KBML’s regulations are more comprehensive than the requirements of House Bill 1, a great deal of confusion exists concerning what physicians and practitioners are required to do and when. Recognizing that compliance with its emergency regulations may mean major changes in the way physicians practice medicine, the KBML has announced that it expects full compliance by October 1, which creates a welcome grace period. While the ambiguities and details will be worked out over the course of the next six months, physicians should take heed and incorporate these things into their practices. More >
Federal Medicaid Opt-Out Effect on Hospitals
The mandatory expansion of Medicaid was an important element of the Affordable Care Act as providing health care benefits to uninsured was intended to achieve equity. The expansion of Medicaid rolls was also intended to reduce the cost of providing care for the uninsured and the need for disproportionate share hospital funding, which is an adjustment to account for the needs of hospitals serving a large number of low-income patients. With the ability to opt out of the Affordable Care Act’s expansion of Medicaid eligibility (read more: The Federal Medicaid Apple: Poison or the Cure?), the opt-out states may create financial problems for hospitals that depend on disproportionate share payments to cover part of their costs for providing non-reimbursed services to the indigent and uninsured. The Affordable Care Act’s decrease in disproportionate share payments to hospitals is not changed by the Supreme Court’s ruling. More >
The Federal Medicaid Apple: Poison or the Cure?
As the uncertainty about healthcare reform was extinguished by the Supreme Court in its 5-4 decision upholding the Affordable Care Act, with the provision that the Department of Health and Human Services may not withhold Medicaid funding from states that refuse to adopt the Medicaid expansion, all states, including Kentucky, now have important decisions to make about expansion of Medicaid to a projected 22.3 million uninsured eligible individuals. Under the Affordable Care Act, the federal government will pay the full cost of covering the newly eligible Medicaid participants for three years from 2014 to 2016. Thereafter the federal share will gradually decline until it reaches 90% in 2020. For traditional Medicaid, the federal government now pays, on average, about 57% of a state’s total Medicaid costs. With 826,941 Kentucky Medicaid beneficiaries in January 2012, and an additional 290,000 individuals that would be covered under the expansion, Governor Steve Beshear has announced that he is studying the issues and the costs. More >
House Bill 1
Kentucky’s General Assembly passed House Bill 1 during the 2012 Special Session. House Bill 1 will become effective July 20, 2012. More >
Supreme Court Ruling on the ACA
Writing for the majority, in the Supreme Court of the United States’ decision upholding the health care law, Chief Justice John Roberts wrote, “[t]he Affordable Care Act is constitutional in part and unconstitutional in part.” The Court held that even though “[t]he individual mandate cannot be upheld as an exercise of Congress’s power under the Commerce Clause,” that “it is reasonable to construe what Congress has done as increasing taxes on those who have a certain amount of income, but (who) choose to go without health insurance. Such legislation is within Congress’s power to tax.” Roberts made a point of noting that he and the other justices “possess neither the expertise nor the prerogative to make policy judgments. Those decisions are entrusted to our Nation’s elected leaders, who can be thrown out of office if the people disagree with them. It is not our job to protect the people from the consequences of their political choices.” So, in other words, the Court held that Congress cannot require individuals to enter into an activity so that it could regulate it but that the individual mandate passed muster under the taxing power. The Court also held that the States cannot be coerced into expanding their Medicaid programs and that States are free to opt of the expansion, which is projected to add nearly 30 million more people to the insurance program for our nation’s indigent, if they choose. More >
The New Business of Prescribing Controlled Substances
Out of the heated debate between the Attorney General representing law enforcement and the Kentucky Medical Association representing physicians, the Legislature enacted Kentucky’s “Pill Mill Bill,” which is sweeping legislation designed to combat prescription drug abuse through increased regulation of pain clinics and greater scrutiny of prescribing practices by various agencies of state government. The Pill Mill Bill becomes effective on July 20, 2012 and imposes requirements not just for doctors practicing pain medicine, but for all practitioners who prescribe controlled substances. In addition to placing significant limits on who can own a pain clinic and how a pain clinic is operated, the legislation requires Kentucky’s licensing boards, including the Kentucky Board of Medical Licensure and the Kentucky Board of Nursing, to enact new regulations that impose standards for physicians, nurses and other practitioners when a Schedule II or Schedule III controlled substance is prescribed. Because the Pill Mill Bill imposes sweeping changes for pain clinics and prescribing practices, all health care providers and their patients will face new challenges as procedures change. Regardless of whether the legislation stops the shifting pattern of drug abuse from illicit to prescription drugs, physicians are at the center of the Pill Mill Bill and are now required to reduce the risk of diversion and abuse of prescription drugs when treating a patient’s pain. Whether the collateral effect of the Pill Mill Bill is the serious under treatment of pain is yet to be seen. More >
