Policy & Regulation

The post recommends asking which exchange products include the practice, what the CPT-based fee schedule is, and how many covered lives are enrolled locally. It also advises preparing for high-deductible cash collection and maintaining OIG compliance through audits, updated policies, a compliance officer, staff training, and personnel checks against the OIG database.

The post says a House Energy and Commerce Committee report showed only 67 percent of federally run exchange enrollees had paid for insurance as of April 15, 2014, while CMS estimated 80 to 90 percent. The concern was that practices might provide services without getting paid, or receive payment that later had to be returned.

The post says Section 1557 applies to health programs or activities receiving federal financial assistance or made available by HHS, but the definition is not the same as HIPAA covered entity status. Examples include many providers, health-related schools, state agencies, insurers, third-party administrators, navigators, HHS programs, marketplaces, and some employer health benefit programs.

The post recommends developing a language access plan, providing free and timely language assistance, making disability-related modifications, posting nondiscrimination notices and language taglines, using website notices, and including patient acknowledgements where appropriate. Entities with more than 15 employees also need a compliance coordinator and formal grievance procedure.

The post identifies five priorities for healthcare organizations. These are completing a HIPAA Security Risk Assessment before year end, reviewing MACRA implementation, determining whether ACA Section 1557 applies and acting accordingly, researching systems that support compliance work, and implementing a marketing plan based on the ideal customer.

The post says subsidy disputes, rate increases, higher copays, and $5,000 deductibles created uncertainty for patients and providers. It also frames these challenges as opportunities, because more insured people can expand the customer base while higher deductibles and rate increases may support cash-based or fee-for-service practice models.

The post says the FFCRA notice applied to private-sector employers with fewer than 500 employees under the paid sick leave component, public-sector employers with one or more employees, and employers with fewer than 500 employees under the expanded family and medical leave component. Employers could post it physically, mail it, email it, or place it on an internal or external website visible to current employees.

The post says the No Surprises Act applies when patients unknowingly receive care from out-of-network providers, especially during emergency services. It also applies to certain non-emergency services, out-of-network referrals, and air ambulance services, primarily for patients covered by private insurance plans, with similar protections in some government programs.

The post recommends notifying patients when out-of-network care is involved, giving written notice of potential charges, obtaining signed consent, and negotiating fair rates with insurers. It also recommends transparent billing, patient education about dispute rights, detailed documentation, and staff training on explaining rights and costs clearly.

The post says the rules strengthened OIG authority to exclude providers for obstruction of an audit, failure to supply payment information by individuals who order, refer, or certify services, and false statements or omissions in applications to participate in federal healthcare programs. It also notes that many first-time exclusions involve three years away from federal programs plus monetary fines.

The post uses the Halifax Health settlement to warn that paying doctors in ways tied to the volume or value of Medicare services can create Stark Law risk. It raises questions about whether ACO members are paid based on patients, productivity, referral patterns, or group decisions, and recommends professional help before participating.

The post says the Supreme Court ruled that applying the ACA contraceptive mandate to closely held corporations with sincere religious objections violated the Religious Freedom Restoration Act. It explains that the mandate required certain non-grandfathered health plans to cover contraceptives without cost sharing, but the Court found a substantial burden on religious exercise for the companies involved.

The post argued that insurance plans under the ACA were financially strained, but other ACA provisions affecting providers were likely to remain. It specifically highlighted Section 1557 nondiscrimination requirements and Section 6401 compliance program requirements tied to Medicare, Medicaid, and CHIP enrollment.