Wednesday, March 20, 2013

A Pyrrhic Victory: CMS Agreement to Pay
Part B When Part A Denied Falls Short in
Addressing Hospital Concerns

On March 13, 2013, the Centers for Medicare & Medicaid Services (CMS) announced a policy ruling [1] that, while on the surface appearing promising, likely fails to address concerns raised by the American Hospital Association (AHA) and other stakeholders related to CMS' position on reimbursement for Part B services when a hospital’s Part A inpatient claim is denied. In addition to the ruling, CMS released a proposed rule to permanently revise its Part B inpatient billing policy to be consistent with the ruling. [2]

The CMS ruling, CMS-1455-R, follows numerous Medicare Appeals Council and Administrative Law Judge decisions allowing Part B payments in this circumstance. In addition, the ruling comes in the wake of a lawsuit filed by the AHA in November 2012 over CMS' refusal to reimburse hospitals for Part B services when Recovery Auditors (f/k/a as Recovery Auditor Contractors) deny hospitals’ Part A inpatient claims for reasonable and necessary care.

Tuesday, March 19, 2013

An Analysis of Urinalysis:
Considerations for Health Providers

Urinalysis, also referred to as urine drug screening, is an important procedure that health providers use for several reasons: to monitor patients’ medication compliance, detect drug abuse, or identify the presence of disease. There are numerous implications that accompany a urinalysis examination though, and health providers are sometimes left wondering if they should hand over the cup to patients.

First, physicians and providers should anticipate the entire continuum of possible test results, including results outside the original purpose of the urinalysis.  For example, an ob-gyn may perform a urinalysis during a pregnant patient’s routine prenatal visit to determine hormone levels but test results may also indicate recent patient drug use. Further, if the results reveal that the mother is using marijuana, the ob-gyn must be prepared to deal with that information. A patient, even a consenting one, may feel uncomfortable or violated if the provider discusses what the test reveals outside the agreed-upon test purpose. Providers should clearly communicate why they are testing the urine and advise the patient that the test can reveal other things.  This can be accomplished through intake forms or treatment contracts, as well as communications informing the patient through the course of treatment, but it is advisable that the provider disclose the purpose and potential outcomes before testing.

Kentucky Health Cooperative One Step Closer

The Kentucky Department of Insurance just approved Kentucky Health Cooperative’s (“KYHC”) entry into the Commonwealth of Kentucky’s HMO insurance market. With this endorsement, KYHC will now be allowed to offer health plans to hundreds of thousands of Kentuckians beginning in October 2013. Benefits are set to begin in January 2014—the deadline for when most citizens will be required to have health insurance under the Affordable Care Act (“ACA”).

KYHC, based in Louisville, was previously selected by the United States Department of Health and Human Services (“HHS”) to receive loans to create and operate a Consumer Oriented and Operated Plan (“CO-OP”) in the state.  The ACA has appropriated $3.8 billion to finance the CO-OP program and award loans and grants to establish CO-OP entities. A CO-OP performs the same functions as an insurance company, but is a non-profit, member-run organization that focuses on a single state market. The goal of the CO-OP program is to increase competition among insurers, reduce premiums, and raise the standard of health care insurance.

Tuesday, March 12, 2013

Medicaid Expansion in Kentucky

The Supreme Court upheld much of President Obama’s Patient Protection and Affordable Care Act (“PPACA”) in National Federation of Independent Business et al v. Sebelius, but overturned a key element of PPACA’s Medicaid expansion provisions. Originally, PPACA required states to expand Medicaid coverage to individuals at or below 133 percent of the federal poverty level or risk forfeiting existing federal funding for the state’s Medicaid program.  In National Federation, the Supreme Court held that PPACA could not withdraw existing Medicaid funding from states choosing not to expand their programs. This change presents each state with a meaningful choice to opt in or out of PPACA’s Medicaid expansion.