HEALTH CARE INDUSTRY PERSPECTIVES ON HEALTH CARE RE[医疗保健行业PERSPECTIVES医疗改革](PPT73).ppt

1,healthcareindustryperspectivesonhealthcarereform,mississippichapterhealthcarefinancialmanagementassociation2010ethics,accountingb.disclosureofcoveragewaitingperiodlength;c.disclosureofinformationonlowest-costoptionineachenrollmentcategory;d.disclosureofemployersshareoftotalplancosts;e.disclosureofnumberandnamesofemployeesreceivinghealthcarecoverage,34,consequences,verylargeemployersmaydropemployer-sponsoredcoverageat10kfundedbyemployerotherinsurancereformswillresultinincreasedpremiumscreditsexpirewhenindustryfeesescalate,36,taximplications:tax-exempthospitals,37,tax-exempthospitalimplications,section9007oftheppacaaddedyetanotherlayerofrequirementsthatmustbemetinordertomaintaintax-exemptstatusandavoidexcisetaxpenalties.exceptforthecommunityhealthneedsassessmentrequirementandimpositionofexcisetaxpenalties,section9007appliestotaxableyearsbeginningaftermarch23,2010.,38,tax-exempthospitalimplications,cont.,section9007hasfiveprimarycomponents:9007(a)addsnewrequirementsfor501(c)(3)hospitalsthroughtheadditionofsection501(r)(1)-(7)totheirc;9007(b)amendsirssection4959toimposeanexcisetaxfornoncompliancewith501(r)(3);9007(c)providesformandatoryfederalreviewofthecommunitybenefitactivitiesof501(c)(3)hospitals;9007(d)addsreportingrequirements;9007(e)requiresthesecretaryofthetreasurytomakeannualreportstocongress.,39,tax-exempthospitalimplications,cont.,section9007(a)addssection501(r)(1)-(7)totheircandimposessignificantnewobligationsontax-exemptorganizations.applicability:section9007appliestoorganizationsthatoperatefacilitiesrequiredbythestatetobelicensed/registered/recognizedasahospitalandtootherorganizationswithhospitalcareasaprincipalfunction.mustbetax-exemptunder501(c)(3),sogovernmentalfacilitiesarenotincluded.formulti-hospitalsystems,therulesapplyseparatelytoeachfacility.,40,tax-exempthospitalimplications,cont.,newsection501(r)hasfourprimarycomponents:communityhealthneedsassessment-501(r)(3)financialassistancepolicy-501(r)(4)limitsoncharges-501(r)(5)changestobillingandcollectionmethods-501(r)(6)treasuryhasrequestedcommentsonthe501(r)requirements.,41,tax-exempthospitalimplications,cont.,newsection501(r)components:componentone:communityhealthneedsassessment(501(r)(3):effectivedate:taxableyearsbeginningaftermarch23,2012.requirements:mustconductacommunityhealthneedsassessmentinthetaxableyearoreitherofthetwopriortaxableyears.musthaveadoptedastrategytoimplementtheidentifiedneeds.theassessmentmusttakeintoaccounttheinputofabroadspectrumofstakeholdersinthecommunityservedbythefacilityanditmustbemade“widelyavailabletothepublic”.,42,tax-exempthospitalimplications,cont.,and,fornotcomplyingwithsection501(r)(3),section9007(b)imposesanexcisetax.section9007(b)imposesanexcisetaxof$50,000forfailingtomeetthechnarequirementsinsection501(r)(3).effectivedate:theexcisetaxtechnicallyappliesforfailurestocomplyoccuringaftermarch23,2010,butthechnarequirementdoesntbecomeeffectiveuntiltaxableyearsaftermarch23,2012.,43,tax-exempthospitalimplications,cont.,newsection501(r)components:componenttwo:financialassistancepolicy(501(r)(4):theorganizationmusthaveawrittenfinancialassistancepolicyand“widelypublicize”thepolicywithinthecommunityserved.policyrequirements:eligibilitycriteria,includingwhetherfinancialassistanceofferedincludesfreeordiscountedcare;thebasisforcalculatingpatientcharges;iftheorganizationdoesnothaveaseparatebillingandcollectionspolicy,theactionsthatmaybetakenintheeventofnon-payment(i.e.,collectionsactions,creditreporting,etc.).additionally,theorganizationmusthaveawrittenpolicyrequiringtheorganizationtoprovide,withoutdiscrimination,careforemergencymedicalconditionstoindividualsregardlessoftheireligibilityforfinancialassistance.,44,tax-exempthospitalimplications,cont.,newsection501(r)components:componentthree:limitsoncharges(501(r)(5):ifapersonmeetstherequirementsofthefinancialassistancepolicy,thentheirchargesforemergencyorothermedicallynecessarycaremustbelimitedtonotmorethanamountsgenerallybilledtoindividualswithinsurancecoverage.theuseofgrosschargesisprohibited.,45,tax-exempthospitalimplications,cont.,newsection501(r)components:componentfour:changestobillingandcollectionmethods(501(r)(6):thehospitalcannotengagein”extraordinary”collectionactionsuntilithasmade“reasonableefforts”todetermineiftheindividualiseligibleforfinancialassistanceunderitspolicy.regulationsaretobeissuedtodefine“reasonableefforts”.,46,tax-exempthospitalimplications,cont.,section9007(c)providesformandatoryfederalreview:section9007(c)requiresthatthesecretaryofthetreasuryreviewthecommunitybenefitactivitiesofeachhospitalsubjectto501(r)atleastonceevery3years.schedulehimplicationsandanewdefinitionof“communitybenefit”?,47,tax-exempthospitalimplications,cont.,andsection9007(d)providesforadditionalreportingrequirements:section9007(d)addressesseveralissuesofrecentlegislativeconcernbyaddingtothereportingrequirementsfor501(c)(3)hospitals.thissectionamendstheform990reportingrequirementstoincludethefollowing:adescriptionofhowthehospitalisaddressingtheneedsidentifiedinthechna,adescriptionofanyneedsnotbeingaddressed,andanexplanationasto“whynot”;theauditedfinancialstatementsofthehospitalortheconsolidatedfinancialstatement,ifapplicable.implications,48,tax-exempthospitalimplications,cont.,tocompletethecircle,section9007(e)requiresthesecretaryofthetreasurytoprovideannualreportstocongress.section9007(e)reportswillincludeinformationforprivate,tax-exempt,andgovernmentalhospitalsregarding:levelsofcharitycareprovided;baddebtexpenses;andunreimbursedcostsforservicesprovidedwithrespecttonon-meanstestedprograms.additionally,9007(e)reportswillincludeinformationregardingcostsincurredbytax-exempthospitalsforcommunitybenefitactivities.morever,9007(e)requiresthatthisinformationwillbecompiledintoastudyontrendsandsubmittedtocongresswithin5years.,49,othernotabletaxchanges,50,othernotabletaxchanges,section9001:excisetaxon“cadillac”planssection9002:inclusionofcostofemployer-sponsoredhealthcoverageonw2section9003and9004:“qualified”distributions/reimbursementsfromhsas,fsas,hrasandarchermsasandincreasesintaxesonnon-qualifieddistributionssection9005:limitsonhealthflexspendingarrangementsundercafeteriaplanssection9012:eliminationofdeductionforexpensesallocabletomedicarepartdsubsidysection9013:modifiestheitemizeddeductionformedicalexpensessection9015:changestoficasection9017:(nullifiedandreplacedwith10907(b):taxonindoortanningsection1402:taxonnetinvestmentincome,51,impactofhealthreformandfraudenforcementandrecoveryactof2009,52,healthcarereform:abigdeal,53,fraudenforcementandrecoveryactof2009(fera),ferasignedintolawmay20,2009expandsthescopeofthefalseclaimsact(fca)increasesfundingforenforcement,54,falseclaimsactamendments-fera,fraudenforcementandrecoveryactof2009(fera)retentionofoverpaymentsviolationto“knowinglyandimproperlyavoidordecreaseanobligation”topaymoneytotheunitedstates,includinganobligationbasedon“anestablishedduty,whetherornotfixedarisingfromtheretentionofanyoverpayment.”mustbe“knowingandimproper”whetherornot“fixed”amounts,55,ferabroadensfcatoreachmoretypesoftransactions,pre-fera,fcarequiredthatallegedlyfalseclaimsforpaymentmustbepresenteddirectlytoanofficeroremployeeofthegovernmentferaeliminates“presentment”requirementextendsliabilitytofalseclaimsforpaymentongovernment-fundedprojects,regardlessofwhethertheclaimispresentedtoorprocessedbyagovernmentofficialexpandsdefinitionofa“claim”underthefcatoincludeanyrequestordemandformoneyorpropertyregardlessofwhethergovernmenthastitletothemoneyorpropertyincludesrequestsformoneytoacontractor,grantee,oranyotherrecipientofgovernmentfundsusedtoadvanceagovernmentprogram,56,ferapermitsnon-employeestobringretaliationclaims,pre-ferafcaallowedemployeestosueemployerfordamagesandotherreliefifdiscriminatedagainstasaresultoftheiractionsinconnectionwithafalseclaimslawsuitorinvestigationferamakesretaliationclaimsavailabletocontractorsandagentswhocontendthattheyhavebeendiscriminatedagainst,57,patientprotectionandaffordablecareactprovisionsaffectingfalseclaimsact,patientprotectionandaffordablecareact(ppaca)(march2010)publicdisclosurebarcurtailedenhancedinfluenceofwhistleblowerplaintiffsbar60-dayperiodtoreportandreturnoverpaymentsrunsfromthepointatwhichtheoverpaymentis“identified”orthedateanycorrespondingcostreportisdue,whicheverislaterafterthe60-dayperiod,theoverpaymentbecomesan“obligation“underthefca“identified”isnotdefinedferaincludesexpansionoffcadefinitionof“obligation”toamountsthatarenot“fixed”60-dayperiodforrepaymentofamountsreceivedinviolationofstarklawalreadyinplace(triggerforcivilmonetarypenalties),58,patientprotectionandaffordablecareactprovisionsaffectingfalseclaimsactanti-kickbackstatute,claimssubmittedinviolationofanti-kickbackstatutearefalseclaims,regardlessofcertificationtheintentelementoftheanti-kickbackstatutehasbeenrevisedtoexplicitlyreject9thcircuitcaselawundercurrent9thcircuitcaselaw,thegovernmentisrequiredtoshowthatadefendant:hadactualknowledgethattheconductwasprohibited,andhadaspecificintenttoviolatetheaksresolvessplitamongcourtstheactrevisestheakstostatethat,tomeetthe“knowingandwilling”intentelement,“apersonneednothaveactualknowledge”thattheaksprohibitsaparticularconduct,59,practicalconsiderations,implicationsofchangesretentionofoverpayments/reversefalseclaimsnorequirementoffalsityorfraudulentconductnodefinitionof“improper”avoidanceofanobligation,sowhatdoesitmean?is“knowing”retentionenough?whenisanoverpayment“identified”forpurposesofthe60-daytimeperiod?does“identified”mean“quantified”?underferaamendmentstothefca,an“obligation”toreturnfundsneednotbe“fixed”,60,practicalconsiderations,publicdisclosurejurisdictionalbargovernmentnowcontrolswhetheritappliesthebarapplies,unlessthegovernmentobjectsenablesgovernmenttopermitprivatewhistleblowercounseltofileandpursueparasiticlawsuitsunderthefcaenablesgovernmenttoretainprivatecounseltopursuethesecasesenhancedinfluenceofwhistleblowerplaintiffsbaringovernmentenforcementformerdojcounselcommentthatshouldexpecttoseeargumentsthatgovernmentwouldnotmake,andtacticsthegovernmentwouldnotuseprofitmotiveonlylackofgovernmentoversightofconductoflitigationorofplaintiffscounsel,61,ppacaamendmentstostarklaw,in-officeancillaryservicesagreementexceptionrevisedtorequirereferringphysiciantoinformpatientsthattheymayobtainspecifiedservicesfromapersonotherthanthereferringphysicianorhis/herpracticeappliesto:mri,ctpet,otherdesignatedhealthservicesspecifiedbythehhssecretarywrittenlistofsupplierswhofurnishservicesintheareainwhichthepatientresidesmustbeprovidedatthetimeofthereferraleffectivejanuary1,2010(actuallydatelawsignedbypresident,march24),62,ppacarevisionstostarklaw“wholehospital”andruralproviderexceptions,bothexceptionsnarrowedtoapplyonlytophysician-ownedhospitalsthathavephysicianownershipandprovideragreementsinoperationondecember31,2010mustnowmeetcertainotherrequirementshospitalsmustnowreporttohhsannuallytoidentifyphysicianownershospitalsmusthaveproceduresinplacetorequirephysicianownerdisclosureownershiptopatientsownershipandinvestmentcannotbeconditionedonreferralsfromthephysicianlimitedopportunitiesforfurtherexpansionhhswillconductauditsbeginningnovember2011todetermineifhospitalsarecomplyingwithnewrevisionstotheexceptions.,63,canyousyndicateahospitaltophysiciansnow?,$%*!no,youcant!,64,ppaca-starklawself-disclosuresandsettlements,withinsixmonths,hhsmustdevelopandimplementadisclosureprotocolforactualandpotentialstarkviolationsincollaborationwiththeoig.secretarynowhasauthoritytoreducetheamountdueforastarkviolationbyconsidering:thenature/extentoftheimproper/illegalpracticethetimelinessofself-disclosurethecooperationinprovidingadditionalinformationrelatedtothedisclosure,65,presidentialmemorandum,66,presidentialmemorandum,“findingandrecapturingimproperpayments”issuedmarch10,2010toheadsofexecutivedepartmentsandagenciesreferencesexecutiveorder13520,november20,2009,“reducingimproperpayments”obamaadministrationfocusesonhospitalbillingtomedicare:announcesexpansionof“paymentrecaptureaudits”directsheadsofexecutivedepartmentsandagenciestoexpanduseofpaymentrecaptureaudits:totheextentpermittedbylawwhencosteffectivedirectsofficeofmanagementandbudgettodevelopmentguidanceandcoordinatewithcouncilforinspectorsgeneralonintegrityandefficiency,67,expansionofracprogram,patientprotectionandaffordablecareexpandsscopeofracprogramto:statemedicaidprogramsby12/31/2010medicarepartscanddby12/31/2010statedivisionsofmedicaidmustcontractwithauditingfirmsby12/31/2010hhsrequiredtosubmitannualreportonracprogramtocongress,68,starklaw&anti-kickbackenforcementunderthefalseclaimsact,recentcaseshighlightaggressivedojlitigationpolicytoseekmassivedamagesppacaredefinedkickbacks(overpaymentsbythegovernment=obligationsowedtothegovernment)aspredicatesforfcaviolationscmsrequiredtoofferaself-disclosureprotocolbeforetheendof2010whattodo?reviewphysicianagreementnegotiationprocessfor:documentationonvaluationissuestimelinessofexecutionunderstandtheenormouswhistleblowerriskpresentedbyphysicians(anddisgruntledemployees),69,starklaw&anti-kickbackenforcementunderthefalseclaims,nexusbetweenstarkandfalseclaimshasbecometighterdojandoigarepursuingstarkandanti-kickbackquitamsagainsthospitalsasfalseclaimscaseswithoutregardtosizeofthefacilityanentitymaynotpresentorcausetobepresentedamedicareclaimorabilltoanyindividual,thirdpartypayor,orotherentityforstarkdhsfurnishedpursuanttoastark-prohibit