Published 1/1/2015

Second Look—Advocacy

HIPAA privacy provisions
In response to Ebola outbreak concerns, the U.S. Department of Health and Human Services (HHS) has issued a bulletin regarding Health Insurance Portability and Accountability Act (HIPAA) rules in emergency conditions. HHS states that if the president of the United States announces an emergency, the secretary of HHS may waive certain provisions under the Project Bioshield Act of 2004 and section 1135(b)(7) of the Social Security Act. HHS states that if such a waiver is issued, it only applies in the emergency area and for the emergency period identified in the public health emergency declaration; to hospitals that have instituted a disaster protocol; and for up to 72 hours from the time the hospital implements its disaster protocol.

ICD-10 conversion costs
Information published online in the Journal of AHIMA suggests that converting to ICD-10 is likely to cost small medical practices (defined as three physicians and two affected staff) between $1,960 and $5,900, based on data from surveys, published reports, and ICD-10 conversion experience with various stakeholders. The researchers note that a recent 2014 update of a 2008 report by Nachimson Advisors to the American Medical Association estimated the cost for a small practice to implement ICD-10 to be in the range of $22,560 to $105,506.

Scrutiny of ASC quality, safety likely to increase
An article in HealthLeaders magazine (October 2014) looks at recent growth in the number of ambulatory surgery centers (ASCs). The number of Medicare-certified ASCs increased by 19 percent between 2006 and 2013, and approximately 3.4 million fee-for-service Medicare beneficiaries had a procedure done in an ASC during 2011. Procedures for Medicare beneficiaries are performed in ASCs at payment rates that are about 55 percent of the level reimbursed by Medicare to hospital outpatient departments. However, the number of adverse events reported by ASCs is “significantly below the rates reported for inpatients in the hospital setting,” according to a spokesperson from the Ambulatory Care Accreditation Program at The Joint Commission.

GAO: CMS needs to improve websites
A report from the U.S. Government Accountability Office (GAO) recommends that the U.S. Centers for Medicare & Medicaid Services (CMS) take steps to improve the information in its transparency tools, and develop procedures and metrics to ensure that those tools address the needs of consumers. Based on data from the five online transparency tools operated by CMS, GAO found that all tools lacked relevant information on cost and provided limited information on key differences in quality of care. None of the tools allow consumers to combine cost and quality information to assess the value of healthcare services or anticipate the cost of such services in advance. Finally, the tools lack clear language and symbols, do not summarize or organize information to highlight patterns, and do not enable consumers to customize how information is presented.

APCs more likely than physicians to request imaging
According to a study in JAMA Internal Medicine, nurse practitioners and physician assistants (advanced practice clinicians [APCs]) may be more likely to order imaging services than primary care physicians (PCPs) for similar patients during evaluation and management (E&M) office visits. Based on a 5 percent sample of Medicare beneficiaries from 2010 to 2011 claims data, APCs ordered imaging in 2.8 percent of episodes of care, compared to 1.9 percent for PCPs.

CMS unveils final fraud oversight rule
CMS has announced a new rule designed to strengthen oversight of Medicare providers and protect taxpayer dollars from bad actors. The agency estimates that the rules will save more than $327 million annually. Under the rules, CMS may:

  • Deny enrollment to providers, suppliers, and owners affiliated with any entity that has unpaid Medicare debt.
  • Deny or revoke the enrollment of a provider or supplier if a managing employee has been convicted of a felony offense that CMS determines to be detrimental to Medicare beneficiaries.
  • Revoke enrollments of providers and suppliers that demonstrate a pattern or practice of billing for services that do not meet Medicare requirements.
  • Make consistent the effective date of billing privileges across certain provider and supplier types.

Under a program that went into effect in August 2014, CMS may now require providers of durable medical equipment (DME) to undergo an FBI background check and/or fingerprinting in certain specific situations, including an application to become a new DME provider or to reactivate a DME application after deactivation or revocation of a license.

These items originally appeared in AAOS Headline News Now, a thrice-weekly enewsletter that keeps AAOS members up to date on clinical, socioeconomic, and political issues, with links to more detailed information. Subscribe at www.aaos.org/news/news.asp (member login required)