David Lewis
Muncie
September 28, 2009
Why did the Senate vote to keep the health-care bill from being released to the Internet? (click title to entry - thank you) Do you think it is because we Hoosiers can't read? Or would there be some other motive such as protecting us from information we would not want to know?
Isn't this the Senate Bill? (click here)
I believe I left off with Page 700 of the House bill or something like that.
I am more than curious about this topic. Page 704, lines 17 through 20;
Subtitle C—Enhanced Program and Provider Protections
SEC. 1631. ENHANCED CMS PROGRAM PROTECTION AUTHORITY.
This is a quality assurance provision. Basically, after the law is in effect there will be a review of participating entities as decided by the Secretary. This is simply the House giving the Secretary of Health and Human Services the 'right' to conduct whatever review of providers that is needed. It is a way for the House of Representatives saying, they approve any action necessary to be sure providers are well intended and qualified. I don't see that it is a mandate and the Secretary has to institute reveiws. At least now yet. I need to read through a few pages to be sure.
‘‘(a) CERTAIN AUTHORIZED SCREENING, ENHANCED OVERSIGHT PERIODS, AND ENROLLMENT MORATORIA.—
‘‘(1) IN GENERAL.—For periods beginning after January 1, 2011, in the case that the Secretary determines there is a significant risk of fraudulent activity (as determined by the Secretary based on relevant complaints, reports, referrals by law enforcement or other sources, data analysis, trending information, or claims submissions by providers of services and suppliers) with respect to a category of provider of services or supplier of items or services, in15
cluding a category within a geographic area, under title XVIII, XIX, or XXI, the Secretary may impose any of the following requirements with respect to a provider of services or a supplier (whether such provider or supplier is initially enrolling in the program or is renewing such enrollment):
This provision empowers the Secretary to work with states for quality assurance of providers. They can do background checks and unannounced visits, etc. The paragraph here sums up the provision. Page 709, lines 8 through 18:
‘‘(d) PROGRAM INTEGRITY.—A State child health plan shall include a description of the procedures to be used by the State—
‘‘(1) to enforce any determination made by the Secretary under subsection (a) of section 1128G (relating to a significant risk of fraudulent activity with respect to a category of provider or supplier described in such subsection through use of the appropriate procedures described in such subsection); and ‘‘(2) to carry out any activities as required by the Secretary for purposes of such subsection.’’.
The ultimate outcome is on Page 711, lines 8 through 14;
‘‘(3) AUTHORITY TO DENY PARTICIPATION.—If the Secretary determines that there has been at least one such affiliation and that such affiliation or affiliations, as applicable, of such provider or supplier poses a serious risk of fraud, waste, or abuse, the Secretary may deny the application of such provider or supplier.’’.
This is law. This is legislating every detail in order to facilitate the benefits for the people. This is what DC, the State, county and local municipalities are all about. This is being sure the person that will carry out the law is equipped with tools outlined in the legislation. That is what most of this provision provides. It empowers the Secretary the ultimate right to deny participation if a provider is found to be unworthy and/or harmful.
A lot of people involved in the health care industry don't like this empowerment of the government. They like their money no matter what quality of services are provided. Once money changes hands it is too late. The quality has to be in place before payment, otherwise, that will be monies poorly spent. It doesn't have to be fraud either, just plain 'lousy' quality.
They aren't going to like this either. It is a modifer to alter payment amounts to providers if there is duplication of services. Page 713, lines 1 through 14:
‘‘(p) PAYMENT MODIFIER FOR CERTAIN EVALUATION AND MANAGEMENT SERVICES.—The Secretary shall establish a payment modifier under the fee schedule under this section for evaluation and management services (as specified in section 1842(b)(16)(B)(ii)) that result in the ordering of additional services (such as lab tests), the prescription of drugs, the furnishing or ordering of durable medical equipment in order to enable better monitoring of claims for payment for such additional services under this title, or the ordering, furnishing, or prescribing of other items and services determined by the Secretary to pose a high risk of waste, fraud, and abuse. The Secretary may require providers of services or suppliers to report such modifier in claims submitted for payment.’’.
The provision goes on in the usual manner, implementation, assignment of responsibilites, what standards will be applied, enforcement for non-compliance. This is new. There is a 'expiration' to filing for a claim.
SEC. 1636. MAXIMUM PERIOD FOR SUBMISSION OF MEDCARE CLAIMS REDUCED TO NOT MORE THAN 12 MONTHS.
(a) PURPOSE.—In general, the 36-month period currently allowed for claims filing under parts A, B, C, and, D of title XVIII of the Social Security Act presents opportunities for fraud schemes in which processing patterns of the Centers for Medicare & Medicaid Services can be observed and exploited. Narrowing the window for claims processing will not overburden providers and will reduce fraud and abuse.
I am a little concerned. There is a loophole that needs to be closed with this provision, unless, I simply haven't read it yet. I think the provision is good. Twelve months is more than enough time for providers to file a claim for payment, HOWEVER, what if that time period goes by and individuals lose their benefits because it. Can the provider then bill and insist payment from the client/individual without the benefit of any insurance payment?
There needs to be more incentive to be sure providers file for payment in a timely fashion. There has to be an understanding that if their claim period expires and this is a claim that would carry a payment with the insurance, then the provider loses all income from that lost opportunity to receive payment.
To ignore billing an insurance in a 'reasonable' time period should also become part of a review process with brevity. It is a form of negligence. It is equivalent to 'financial abuse.' As an example, the elderly can be protected from people that care for them when they are being exploited for money. There are criminal penalites for such abuse of the elderly. That same logic should apply to this provision. If a provider is negligent in sending in claims for payment and then in turn attempts to collect the debt portion of the cost that would normally be billed to the insurance it is fiscal abuse of the insured.
The provision goes on with the usual statements, effective date, enforcement and submitting documentation, including a copy of a written order, of claims upon request of the Secretary.
Section 1640 delegates investigation authority to the Inspector General of Health and Human Services. That is pretty much standard throughout these provisions. I just hadn't stated it before, so I wanted to be sure I mentioned it at least once. There is no sense in making this entry as boring as the reading of the law itself. So, there it is. The Inspector General will carry out investigations.
Ah, a provision that requires honesty. Overpayment. Gee, they have to give it back? Not like Christmas or anything? A birthday surprise maybe? No?
Page 726, lines 7 through 12;
‘‘(c) REPORTS ON AND REPAYMENT OF OVERPAYMENTS IDENTIFIED THROUGH INTERNAL AUDITS AND REVIEWS.—
‘‘(1) REPORTING AND RETURNING OVERPAYMENTS.—If a person knows of an overpayment, the person must—
Ya got sixty days to give the monies back to the Secretary. So, that should happen, take the money to Goldman Sachs and have them backroll it into some derivitive and make a few bucks. If you lose the money, however, it might not be insured, ya know? Sixty days to make it all happen for yourself.
Page 726, lines 21 through 26 and Page 727, lines 1 and 2.
"(2) TIMING.—An overpayment must be reported and returned under paragraph (1)(A) by not later than the date that is 60 days after the date the person knows of the overpayment. Any known overpayment retained later than the applicable date specified in this paragraph creates an obligation as defined in section 3729(b)(3) of title 31 of the United States Code.
A little bit of an enforcement issue here, page 727, lines 3 through 13;
‘‘(3) CLARIFICATION.—Repayment of any overpayments (or refunding by withholding of future payments) by a provider of services or supplier does not otherwise limit the provider or supplier’s potential liability for administrative obligations such as applicable interests, fines, and specialties or civil or criminal sanctions involving the same claim if it is determined later that the reason for the overpayment was related to fraud by the provider or supplier or the employees or agents of such provider or supplier.
There must be a significant amount of 'double dipping' with the ownerships of these free standing, speciality clinics. Page 728, lines 18 through 25 and 729, lines 1 through 6;
SEC. 1643. ACCESS TO CERTAIN INFORMATION ON RENAL DIALYSIS FACILITIES.
Section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)) is amended by adding at the end the following new paragraph:
‘‘(15) For purposes of evaluating or auditing payments made to renal dialysis facilities for items and services under this section under paragraph (1), each such renal dialysis facility, upon the request of the Secretary, shall provide to the Secretary access to information relating to any ownership or compensation arrangement between such facility and the medical director of such facility or between such facility and any physician.’’.
Let me see if I can explain this clearly, because it is very important. This isn't government being difficult, it is being vigilant of the USA Treasury and the cost of private health insurance.
Let's say my name is Dr. Zebra. I am making rounds in the hospital during the early morning hours and have ordered 'hemo' dialysis on a patient for the very first time in an outpatient facility, as they are being discharged and are to report to their dialysis facility after leaving the hospital for their first outpatient treatment.
I am paid for that service. I am paid for my evaluation of the necessity of the order and its brevity to the patient.
I have late evening office hours where I will see patients. I have late evening office hours once per week. So, I leave the hospital, after making rounds, at about 1:00 PM.
I stop at the Hemodialysis Clinic that I have a partnership in ownership with another physician. While there, the patient I discharged comes into the facility. I review the orders I wrote and might modify them a bit to change the amount of fluid that is being removed considering the blood pressure of the patient.
I am paid for that service. I am paid for my evaluation of the necessity of the order and its brevity to the patient.
I leave the facility, grab a bite to eat and head to the office. While the patient was receiving hemodialysis, she had an adverse reaction, but, not so severe that she needs to return to the hospital, so I tell the clinic, which I own in partnership with another physician, to have the patient come to the office for evaluation. The patient complies and stops into the office where I examine the patient and realize there was too much fluid removed and she needs replacement, so I order her to take three glasses of water while in my office.
I am paid for that service. I am paid for my evaluation of the necessity of the order and its brevity to the patient. I incurred expenses at the office with support personnel that are periodically checking the patient's blood pressure for a reasonable recovery.
The patient then goes home and she is to report for re-evaluation after her next dialysis treatment in two days.
Dr. Zebra received three payments from three different locations for his services regarding one patient. As a partner to the Dialysis Clinic he also was paid for the time the patient was receiving dialysis. Now, one can debate as to whether that is abuse of the system or not, but, it seems fairly clear to me there needs to be a better way of tracking the actual practice of a physican and the monies received to them, especially when there is a huge conflict of interest in their ownership of free standing clinics or nursing homes.
Are there ethical issues? Good question.'
The 'key' to the issue, in my opinoin, is 'the quality of a physician's practice' and 'the trend in the practice' in treatment of patients. In other words, is this a routine that frequently appears.
Page 729, lines 12 through 18;
‘‘(D) BILLING AGENTS AND CLEARING HOUSES REQUIRED TO BE REGISTER UNDER
MEDICARE.—Any agent, clearinghouse, or other alternate payee that submits claims on behalf of a health care provider must be registered with the Secretary in a form and manner specified by the Secretary.’’.
Okay. This is a provision to bring brevity to accuracy by billing agents. By having them register with the government, they can be tracked to their performance by a simple code or registration number. The volume of billing they do and how many times the same service is being billed will make finding and prosecuting fraud a lot easier.
Page 731, lines 3 through 9;
‘‘(13) knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to a Federal health care program, or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to a Federal health care program;’’; and
There a many definitions to this section, as well as improvements in the wording of the law. Page 735, lines 3 thorugh 6;
‘‘(9) The term ‘material’ means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.’’.
This is a compliance issue. It provides for access to records.
Page 735, lines 7 through 11;
Subtitle D—Access to Information Needed to Prevent Fraud, Waste, and Abuse
SEC. 1651. ACCESS TO INFORMATION NECESSARY TO IDENTIFY FRAUD, WASTE, AND ABUSE.
Page 740, lines 1 through 8 (of the same provision).
SEC. 1653. COMPLIANCE WITH HIPAA PRIVACY AND SECURITY STANDARDS.
The provisions of sections 262(a) and 264 of the Health Insurance Portability and Accountability Act of 1996 (and standards promulgated pursuant to such sections) and the Privacy Act of 1974 shall apply with respect to the provisions of this subtitle and amendments made by this subtitle.
I wish Congress would review the HIPPA laws. I don't believe they are good laws. I believe the old standards were far better. The enforcement of HIPPA laws requires more paperwork and more personnel time and in some instances can delay patient care. They aren't good laws. An understanding about privacy, enforcable through negligence of abiding by a patient's right to privacy is all the public needs. In my opinino, HIPPA adds to health care 'overhead' costs.
Page 740, lines 9 through 17;
TITLE VII—MEDICAID AND CHIP
Subtitle A—Medicaid and Health Reform
SEC. 1701. ELIGIBILITY FOR INDIVIDUALS WITH INCOME BELOW 133-1⁄3 PERCENT OF THE FEDERAL POVERTY LEVEL.
(a) ELIGIBILITY FOR NON-TRADITIONAL INDIVIDUALS WITH INCOME BELOW 133 PERCENT OF THE FEDERAL POVERTY LEVEL.—
This is the reference to The Public Option. These words appear several times to each of the defining paragraphs of the updates to existing laws. Page 743, lines 9 through 24 and Page 744, lines 1 abd 2:
(C) by adding at the end the following new subclause:
‘‘(IX) who are under 65 years of age, who would be eligible for medical assistance under the State plan under one of subclauses (I) through (VII) (based on the income standards, methodologies, and procedures in effect as of June 16, 2009) but for income and who are in families whose income does not exceed 1331⁄3 percent of the income official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable to a family of the
size involved;’’.
One hundred and thirty-three and a third of the poverty level is in the ballpark of about $23,000 annually. Right? One hundred percent would be about $17 - $18,000 annually. Then add one third more as qualifying income brings it to somewhere around $23,000. That is a very low income for folks under 65 years of age and an exceptionally low income for any family. That is ridiculous. There should be access to free health care, without question, to these people. Absolutely.
This is basically adding the parents of SCHIP children. That's what it seems like to me.
I could tell you a story here, but, I don't know if I want to. Give me a minute.
Okay, what the heck. This is protecting the 'innocense' of the unborn. This goes back to mid-1990s in Newark, New Jersey at UMDNJ's obstetric HIV/AIDS clinic. Yes, it is about AIDS again, but, it is a stark example.
Oh, what about the news about a vaccine? Pretty good, ah?
Okay. I stated before the children in Lowell, Massachusetts were receiving gammaglobulin in transfusions to stop the effects of HIV/AIDS on their growth and development. Well, the MD that headed up the clinics at UMDNJ in regard to women and children took that one step further. When a woman was diagnosed with HIV and was pregnant, they would get gammaglobulin transfusions for the length of the pregnancy. The idea was to bring relief to the fetus while developing in utero.
The hope was that infants would be born without the disease. In fact, there were some infants born positive, but, converted to negative about a month after their birth. In other words, when they started producing their own blood through their own bone marrow outside the uterus of the mother. Truly. It didn't happen every time, but, there were occassions when it did. Now, whether they remained healthy is another question. They might have reinfected after a long time.
But, this isn't about them. It is about their parents.
It was almost ludicrous to walk into the OB Clinic at UMDNJ. There were healthy mothers waiting to be seen and there were HIV mothers waiting to be seen. There was no difference in their appearance, because the HIV mothers were relatively healthy during their pregnancy. Good body weight, 'secondary' diseases in check. In appearance they looked no different than the healthy mothers.
So, then what was so ludicrous, right?
What was so ludicrous was the appearance of the fathers. They were usually under weight and appearing rather ill. There were remarkable differences between the healthy fathers and the HIV fathers. Of course, there was also the sadness the HIV fathers might not live to see their children born if they became ill with a severe secondary infection. It was a stressor to the HIV mothers and difficult to live with knowing their transfusions would end with the birth of the child. They were discouraged at all costs not to breastfeed. The HIV parents had a very different reality than the healthy parents. It was a tough environment to be in somedays.
Oh, yes, the fathers would accompany the mothers. This was Newark. There were safety issues and bonding issues. The fathers were absolutely a part of this picture.
The point is, where there are children there is a need for parents. If we as a society state the children are important enough to provide health care for, then aren't we obligated, MORALLY, to provide every opportunity for the well being of their parents? Isn't a child allowed to be raised by parents that will be healthy and able to support them? Do they have to live in a parallel universe whereby their parents may not be healthy enough to participate in their lives all their lives?
There are many eligibility certification statements under this provision. Admitting 'non-traditional' patients to Medicaid/Medicare is a mutual relationship between the federal and state governments. Both the states and federal government provide benefits to some predetermined formula. The provision in this part of the bill tells the states about certification of people eligible for benefits. How they can certify, where the law changes and how often people certify.
There is a special set of statements regarding non-traditional newborns. In other words, a newborn can receive benefits immediately until certification processes are complete and they are either covered by the Public Option or another form of insurance.
The purpose of this section is obvious.
A child has to receive medical care immediately at the time of birth. There may not be any insurance in place when the child is born, so this provides coverage at the time of birth so any child will not be compromised. The eligibilty is waved at this point until all the certifications can be completed. I would think that would be accomplished 'in house' by the Social Service department in the facility in a day or so.
This is page 750 and I am going to end here for tonight. I do read other things than bills.
Until later...
