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The CMS has announced that it has added several more items in the will not pay category. One is for post operative knee or hip surgery blood clots and another is diabetes problems related to poor control. The hospitals got stiffed in the bargain. Not only do they now have to do more reporting but the CMS also stated that as far as physician owned hospitals they just need to have full disclosure to the patient. This is a good thing so the patient realizes he/she does not have to deal with the nonsense of a community hospital. The CMS also is looking into not paying for drugs to treat anemia, proton beam therapy for prostate cancer and drug eluting stents.
CMS also released new EMTALA regs for hospitals trying to set up community call plans. The CMS also stated that EMTALA does not cover stabilized inpatients.
CMS has issued a new advisory opinion (09-09B) regarding allowing both orthopedic surgeons and neurosurgeons to participate in gainsharing with a hospital.
The San Francisco Business Times reported that CMS has decided to put the QIOs up for bid. One of the first casualties was Lumetra, formally CMRI. It had many entities wanting it to stay but it lost the competitive bid to an Arizona company. Lumetra got over half of its funding from CMS. Gee, it may have to close. Too bad. So sad. It's always good to see one who thinks he can do whatever he wants to get skunked.
The recent law enacted over President Bush's veto changes the private fee for service HMO plans known as Medicare Advantage. They will now have physician networks to try and control costs unless they live in rural areas. This may cost the plans since most people do not want networks. Top
New York has fined Capital District Physicians Health Plan $500,000 for not telling their insured they could appeal denied claims. The insurer also must tell all those they denied about the right to appeal. The company also sent rate increases to its insureds falsely stating the state had approved the increase.
California has finally come to its senses and dropped its faulty plan to cover all. They will instead increase the cost of individual policies by mandating what must be covered no matter if the person wants it or not. It is another example of government interference with people's choice.
California's Department of Managed Care has issued a regulation that forbids the billing of patients when their HMO does not pay the full amount for uncontracted services. The reg states the parties must first try to settle what the usual and customary charges are between themselves and if they can't then send the issue to the Department. This will delay payments for long periods of time but the Department may assess interest on payments owed. Top
The People's Republic of Massachusetts has a new law (don't they always) that will require the University of Massachusetts to increase its primary care residency slots. This will not make these students do anything different than the students now who are leaving the state following their residencies. Also all hospitals and community medical centers will be required to have CPOE by 2015. The law will give $25 million to help physicians have EMR in their offices. It also allows the regulators to hold hearings when insurers want to raise their rates. Physicians will have to demonstrate competence in CPOE and EMR by 2015 for their licensure.
The Republic has also stirred a hornet's nest when it passed a law putting much of the underfunding of their ill thought out healthcare plan on businesses. The proposed rules that take effect October 1 will lead many small businesses to drop health insurance for its employees. As is usual for governments that find they have erred the Republic is changing the rules as it goes along. Instead of either paying 33% of full time workers insurance within the first 90 days or having at least 25% of their full time workers covered the Republic has changed the or to and as well as quarterly reporting instead of annual.
New Jersey has passed a law that puts caps on hospital charges for low and middle income patients. If the patient has 500% more income than the poverty level they can only be charged Medicare plus 15%. Top
As I am sure all know by now the JC has added a new Sentinel Event. It is that the hospital must have a definition of disruptive behavior and policies and procedures to curb the behavior through help and if necessary discipline. This will become interesting in California where there is a state law protecting physicians as well as employees who whistle blow for patient welfare. The hospitals in their definitions can not go against the law. Many physicians are afraid that hospitals will attempt to use this to get rid of physicians who rankle administration or who invest in competing institutions. It is imperative that medical staffs put this into their bylaws to protect the individual physicians and allow them due process. Top
DISCLAIMER: Although this
article is updated periodically, it reflects the author's point of view at the
time of publication. Nothing in this article constitutes legal advice. Readers
should consult with their own legal counsel before acting on any of the
information presented.