One thing that you will learn in the Compliance and Accreditation role is that there always self proclaimed experts that seem to show up in your organization. They usually tend to be folks who have good intentions but are woefully deficient in the areas they seem to profess expertise in. Usually they've assisted in some type of audit or process review but are just not up on the current requirements. The other type is the free spirited "Requirement Cavalier". OK, I coined this phrase myself... basically this person uses this knowledge to push an idea or concept in order to further their personal agenda. Unfortunately their limited knowledge usually ends up causing organizational harm(usually financial) and take years to fix.
I'll use an example, many years ago a particular client who delegated certain NCQA Health Plan requirements to a vendor also had specific requirements for member satisfaction. These requirements somehow got pushed by an account manager as being NCQA requirements and the vendor began to base programs off these. However several years down the road these requirements had a negative impact on the vendor. The requirements went under review and was later revealed to be requirements not needed for NCQA Health Plan delegation. However among account managers they were told by certain individuals that this was a requirement. The "requirement" was based partially on fact but mostly it was to get the sale for the account manager and keep the account. . The people that had created this perception never actually consulted the accreditation team. They also had left company previously to the issue being discovered.
Bottom line: Poor interpretation of requirements and regulations can seriously impact your company. The compliance department is a sanity check not a road block
Tuesday, January 8, 2013
Friday, January 4, 2013
Accreditation and Compliance pitfall
Over the last couple of years I've heard folks say "Well since we are accredited we are fully compliant..." This should raise the hairs or the back of a compliance officer. Just because your organization maybe accredited with NCQA or URAC that doesn't mean you may be fully compliant will all state and federal regulations. Generally most folks in your organization don't get the complexities of the current regulatory climate. Because many organizations run in a silo mode most don't understand that laws and regulations have changed. While accreditation may have some weight when it comes to regulations(NCQA and Medicare for instance) they always state that Federal and state laws supersede them.
When going for an accreditation you really need to do two things. Make sure that being compliant with an accreditation does not put you at risk with the state of federal regulations. Also you need to educate your peers that getting an accreditation does not insulate from state and federal regulations. Most folks in the compliance role tend not to do much with the accreditation role. There always seems to be this clinical/ non-clinical divide for some reason. Frankly the accreditation role does not need to be a clinical person you just need to make sure that the required clinical works gets completed.
I will give Kudos to NCQA and URAC because when they update their requirements they do take into consideration what regulators are looking for. They do tend to deviate slightly on what they are looking for. Just don't assume they are 100% spot on.
When going for an accreditation you really need to do two things. Make sure that being compliant with an accreditation does not put you at risk with the state of federal regulations. Also you need to educate your peers that getting an accreditation does not insulate from state and federal regulations. Most folks in the compliance role tend not to do much with the accreditation role. There always seems to be this clinical/ non-clinical divide for some reason. Frankly the accreditation role does not need to be a clinical person you just need to make sure that the required clinical works gets completed.
I will give Kudos to NCQA and URAC because when they update their requirements they do take into consideration what regulators are looking for. They do tend to deviate slightly on what they are looking for. Just don't assume they are 100% spot on.
Thursday, January 3, 2013
Quality and Compliance
Even though the fiscal cliff was just kicked down the road for about 2 months the reality is that revenue will be tighter. The new buzz word I think will be "Medical Efficiencies". What does this mean? To me it says we need to better use our limited dollars in the most cost efficient way so by showing better "Quality" i.e targeting the right folks or showing the best results we can increase our income. Where does compliance come into it? Well we have an obligation to show in the most transparent manner that the systems work as designed and in compliance with governing regulations.
I'll do a real world example. Let's do a HEDIS measure Glaucoma Screening Older Adults(GSO). Your plan is trying to in increase the rates on this. Your score was originally a 78 and you've been wanting to increase this. You've made efforts increase the number optometrists and ophthalmologists who accept you insurance. You've made better efforts to process claims internally and have been able to maintain a 98% accuracy rate. However you've also been able to use HEDIS supplemental data this year to increase the score. This area since it is new for your plan will need extra scrutiny and review. You'll need to work with your HEDIS auditor to make sue you are in compliance with the technical specifications plus since you are using this data for reporting this may get reviewed by other external auditors. This is a tricky area since most compliance professionals aren't DBA's and rely upon the IT staff for support. Can this be smooth and work perfectly? Absolutely but it takes time planning and review.
I'll do a real world example. Let's do a HEDIS measure Glaucoma Screening Older Adults(GSO). Your plan is trying to in increase the rates on this. Your score was originally a 78 and you've been wanting to increase this. You've made efforts increase the number optometrists and ophthalmologists who accept you insurance. You've made better efforts to process claims internally and have been able to maintain a 98% accuracy rate. However you've also been able to use HEDIS supplemental data this year to increase the score. This area since it is new for your plan will need extra scrutiny and review. You'll need to work with your HEDIS auditor to make sue you are in compliance with the technical specifications plus since you are using this data for reporting this may get reviewed by other external auditors. This is a tricky area since most compliance professionals aren't DBA's and rely upon the IT staff for support. Can this be smooth and work perfectly? Absolutely but it takes time planning and review.
Monday, December 31, 2012
New Medical Taxes for 2013- 1 Trillion Tax hike
On January 1, regardless of the outcome of fiscal cliff negotiations, Americans will be hit with a $1 trillion Obamacare tax hike.
Obamacare contains twenty new or higher taxes. Five of the taxes hit for the first time on January 1. In total, Americans face a net $1 trillion tax hike for the years 2013-2022, according to the Congressional Budget Office.
The five major Obamacare taxes taking effect on January 1 are as follows:
The Obamacare Medical Device Tax: Medical device manufacturers employ 409,000 people in 12,000 plants across the country. Obamacare imposes a new 2.3 percent excise tax on gross sales – even if the company does not earn a profit in a given year. In addition to killing small business jobs and impacting research and development budgets, this will increase the cost of your health care – making everything from pacemakers to artificial hips more expensive.
The Obamacare Flex Account Tax: The 30-35 million Americans who use a pre-tax Flexible Spending Account (FSA) at work to pay for their family’s basic medical needs will face a new government cap of $2500. This will squeeze $13 billion of tax money from Americans over the next ten years. (Currently, the accounts are unlimited under federal law, though employers are allowed to set a cap.)
There is one group of FSA owners for whom this new cap will be particularly cruel and onerous: parents of special needs children. There are several million families with special needs children in the United States, and many of them use FSAs to pay for special needs education. Tuition rates at one leading school that teaches special needs children in Washington, D.C. (National Child Research Center) can easily exceed $14,000 per year. Under tax rules, FSA dollars can be used to pay for this type of special needs education. This Obamacare tax provision will limit the options available to these families.
The Obamacare Surtax on Investment Income: This is a new, 3.8 percentage point surtax on investment income earned in households making at least $250,000 ($200,000 single).
The Obamacare “Haircut” for Medical Itemized Deductions: Currently, those Americans facing high medical expenses are allowed a deduction to the extent that those expenses exceed 7.5 percent of adjusted gross income (AGI). This tax increase imposes a threshold of 10 percent of AGI. By limiting this deduction, Obamacare widens the net of taxable income for the sickest Americans. This tax provision will most harm near retirees and those with modest incomes but high medical bills.
The Obamacare Medicare Payroll Tax Hike: The Medicare payroll tax is currently 2.9 percent on all wages and self-employment profits. Under this tax hike, wages and profits exceeding $200,000 ($250,000 in the case of married couples) will face a 3.8 percent rate instead. This is a direct marginal income tax hike on small business owners, who are liable for self-employment tax in most cases. The table below compares current law vs. the Obamacare Medicare Payroll Tax Hike:
First $200,000 ($250,000 Married) Employer/Employee
All Remaining Wages Employer/Employee
Current Law
1.45%/1.45% 2.9% self-employed
1.45%/1.45% 2.9% self-employed
Obamacare Tax Hike
1.45%/1.45% 2.9% self-employed
1.45%/2.35% 3.8% self-employed
Obamacare contains twenty new or higher taxes. Five of the taxes hit for the first time on January 1. In total, Americans face a net $1 trillion tax hike for the years 2013-2022, according to the Congressional Budget Office.
The five major Obamacare taxes taking effect on January 1 are as follows:
The Obamacare Medical Device Tax: Medical device manufacturers employ 409,000 people in 12,000 plants across the country. Obamacare imposes a new 2.3 percent excise tax on gross sales – even if the company does not earn a profit in a given year. In addition to killing small business jobs and impacting research and development budgets, this will increase the cost of your health care – making everything from pacemakers to artificial hips more expensive.
The Obamacare Flex Account Tax: The 30-35 million Americans who use a pre-tax Flexible Spending Account (FSA) at work to pay for their family’s basic medical needs will face a new government cap of $2500. This will squeeze $13 billion of tax money from Americans over the next ten years. (Currently, the accounts are unlimited under federal law, though employers are allowed to set a cap.)
There is one group of FSA owners for whom this new cap will be particularly cruel and onerous: parents of special needs children. There are several million families with special needs children in the United States, and many of them use FSAs to pay for special needs education. Tuition rates at one leading school that teaches special needs children in Washington, D.C. (National Child Research Center) can easily exceed $14,000 per year. Under tax rules, FSA dollars can be used to pay for this type of special needs education. This Obamacare tax provision will limit the options available to these families.
The Obamacare Surtax on Investment Income: This is a new, 3.8 percentage point surtax on investment income earned in households making at least $250,000 ($200,000 single).
The Obamacare “Haircut” for Medical Itemized Deductions: Currently, those Americans facing high medical expenses are allowed a deduction to the extent that those expenses exceed 7.5 percent of adjusted gross income (AGI). This tax increase imposes a threshold of 10 percent of AGI. By limiting this deduction, Obamacare widens the net of taxable income for the sickest Americans. This tax provision will most harm near retirees and those with modest incomes but high medical bills.
The Obamacare Medicare Payroll Tax Hike: The Medicare payroll tax is currently 2.9 percent on all wages and self-employment profits. Under this tax hike, wages and profits exceeding $200,000 ($250,000 in the case of married couples) will face a 3.8 percent rate instead. This is a direct marginal income tax hike on small business owners, who are liable for self-employment tax in most cases. The table below compares current law vs. the Obamacare Medicare Payroll Tax Hike:
First $200,000 ($250,000 Married) Employer/Employee
All Remaining Wages Employer/Employee
Current Law
1.45%/1.45% 2.9% self-employed
1.45%/1.45% 2.9% self-employed
Obamacare Tax Hike
1.45%/1.45% 2.9% self-employed
1.45%/2.35% 3.8% self-employed
Fiscal Cliff less than 17 hours to go...
With less than 17 hours to go and both sides being pretty far apart I suspect we will being going off the cliff. I'm frankly pretty disgusted with the US Senate and Harry Reid. The Senate hasn't done a budget in 4 years and is blaming the house(who has sent a budget to the senate every 4 years)????? Harry Reid is really playing games with the US. It's so bad the Republicans went to Joe Biden to try and get a deal done. The truth is upping taxes on the top 1% only raises 60 billion more. Guess what that is 7 days worth of Federal Spending. I think folks realize that taxes might have to go up(unfortunately) however spending needs to go down. The automatic tax cuts are going to hit the defense side(and cost 800,000 jobs) but entitlements are going to be safe(though 99 weeks of unemployment will be gone)? Seriously how many stories do we hear about EBT cards being used to buy alcohol, cigarettes and lap dances and this isn't being looked at? Everyone agrees that people need help once in a while but entitlements are not a lifestyle. Just look at Greece and see how that is working out.... Healthcare at the state levels will get hit and state revenue will get reduced. Plus don't expect new pilot programs for the 2013-14 fiscal years. Money is going to be tight.
Thursday, December 20, 2012
Good Bye 2012 and Welcome 2013. The only constant is change
As 2012 sets into the sunset(and hopefully the world doesn't end tomorrow) Health Care is face with even more uncertainties. Medical device companies are facing increasing taxes, 25 states have decided not to build Health Information exchanges, the ACA has yet another legal challenge going to the supreme court. The one certainty is that performance measures are not going to go away and will have even more expanded importance. Federal and State dollars will hinge on getting the best results. With the Federal government being even more intractable with RAC audits every dollar will need to be fought for. Every state will be faced with finding "cost-savings" which means the private sector will be under increased pressure. Compliance will take a greater role as every company will need to manage risk aversion.
With every gloomy cloud I do think there are some rays of sunshine. I think the public is slowly starting to realize that good health means taking responsibility for yourself. Wellness is starting to gain traction in employer groups. While it is hard to measure in the short term, living healthy has long term positive effects. Also I think in light of everything that has happen I think mental health may get serious consideration. Its awful that a tragedy has to happen but as a country we really have failed here. Even HEDIS began tracking more mental health measures this year.
I'm hoping 2013 ushers in new strength,joy and certainty.
Happy Holidays, Merry Christmas, Happy Hanukkah, and Merry Kwanza
Andy
With every gloomy cloud I do think there are some rays of sunshine. I think the public is slowly starting to realize that good health means taking responsibility for yourself. Wellness is starting to gain traction in employer groups. While it is hard to measure in the short term, living healthy has long term positive effects. Also I think in light of everything that has happen I think mental health may get serious consideration. Its awful that a tragedy has to happen but as a country we really have failed here. Even HEDIS began tracking more mental health measures this year.
I'm hoping 2013 ushers in new strength,joy and certainty.
Happy Holidays, Merry Christmas, Happy Hanukkah, and Merry Kwanza
Andy
Wednesday, December 12, 2012
Next 6 months in Health Care
Next 6 months in Health Care
My gut feeling is that we will fall off the fiscal cliff and then reach some sort of resolution in 2013 but what are the implications for Health Care? Well we've already seen a few, medical device companies are laying people off because of the new taxes hitting January 1, 2013. Not surprisingly 18 US Senators(All democrats) have sent a letter to the White House asking them to not enforce the tax. I guess they noticed they stuck it to their own constituents finally with that tax. Plus your premiums are going up another $65 as an added fee gets started this year(to pay for the uninsured). I think its only the start and the confusion will get worse. I suspect a lot of grant programs will get gutted in HHS as the money disappears. Plus you will see more RAC audits take place as the federal government wants to pay out less money. The ACA Act I think will undergo some revision as the economy did not recover in time to lessen the blows of the new provisions. It's going to be a messy ride.
My gut feeling is that we will fall off the fiscal cliff and then reach some sort of resolution in 2013 but what are the implications for Health Care? Well we've already seen a few, medical device companies are laying people off because of the new taxes hitting January 1, 2013. Not surprisingly 18 US Senators(All democrats) have sent a letter to the White House asking them to not enforce the tax. I guess they noticed they stuck it to their own constituents finally with that tax. Plus your premiums are going up another $65 as an added fee gets started this year(to pay for the uninsured). I think its only the start and the confusion will get worse. I suspect a lot of grant programs will get gutted in HHS as the money disappears. Plus you will see more RAC audits take place as the federal government wants to pay out less money. The ACA Act I think will undergo some revision as the economy did not recover in time to lessen the blows of the new provisions. It's going to be a messy ride.
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