Protect hospital revenues and build patient trust with effective compliance to the No Surprises Act federal requirements. Revise procedures related to out-of-network providers.Continue reading
Information-blocking compliance perpetually changes. Learn how to build a compliance culture across IT, HIM, privacy, legal, medical, and nursing.Continue reading
Recent changes to Stark aim to increase coordination of patient care, modernize, and clarify rules related to the law.Continue reading
The Stark Law creates a whole set of antikickback rules that providers must understand and actively work to comply with. And with all its good intentions, the Stark Law is incredibly restrictive. In fact, even the U.S. Court of Appeals for the 4th Circuit noted that “even for the well-intentioned healthcare provider, the Stark law has become a booby trap rigged with strict liability and potentially ruinous exposure.”
The Centers for Medicare and Medicaid (CMS) and Congress have taken steps to clear up confusion and loosen the rules in some cases (See our article on exceptions for value-based care). Still, your Compliance team has a tremendous responsibility to make sure that policies match the rules and that providers understand and follow the policies.
Policies match the Stark rules
Changes to the Stark Law have been coming out practically since the law was enacted. The law, which aims to protect against kickbacks and self-referrals, has gotten complicated in the details. Congress issues amendments to help the law catch up to changing business practices. Healthcare organizations may have written policies that facilitated compliance originally. However, those may be completely out-of-date if they weren’t keeping up with the changes in the law.
For example, CMS has introduced modifications that addressed challenges with value-based care and resolve issues restricting coordinated care and health data exchange. Another modification to the law was allowing healthcare providers to accept cybersecurity tech donations from stakeholders.
While the compliance officer enforces the policies, he or she doesn’t have to live them the way those in operations do. Getting input from key stakeholders such as providers, Risk Management, and others in the C-suite can help ensure that final policies are clear. This early feedback and engagement can also help identify how the policy or regulatory changes will affect the individuals who must operate under them. Lastly, they can help identify potential operational conflicts with new policies or regulatory changes.
(See how YouCompli delivers model policies and procedures that help your organization comply.)
Providers following the Stark policies
With compliant policies in place, it’s time to help providers understand how to follow them. This is where communicating what certain key terms in a policy or regulation means in the context of the provider’s particular work becomes critically important.
Compliance officers know that “the road to success is going to run through quality of care,” says Harry Nelson, health care attorney at Nelson Hardiman. “Compliance isn’t the internal police that slows things down, but a strategic part of growth.” When it comes to making sure providers understand how to follow policies, the compliance officer has to look at the language of the policy from the providers’ perspective, not that of the compliance officer.
Here are five steps to help providers understand and follow Stark-compliant policies:
- Engage your operational leaders. Make sure the president and CEO understand the nature and intent behind Stark limitations so they can help explain and reinforce them. Give situational examples they can relate to so they understand what the key terminology means.
- Invest in training and communication. One email won’t do it with changes to Stark-related policies. Engage providers in small groups, in writing, and in person to explain nuances and answer questions about tricky scenarios. Whenever possible, use real-world scenarios to help illustrate how the regulations and policies impact them. Education and training should also be routine and ongoing with key stakeholders.
- Get feedback. Regularly check in to gather feedback from your leaders. Find out if the implemented tools and procedures are working for them, as well as to identify challenges they face. This step will help you see areas where the words on paper mean something the compliance officer had not thought of. Adapt procedures and tools if necessary.
- Encourage people to ask questions. Make sure providers and your operational leaders alike know they can use you as a sounding board for grey areas or possible violations. It’s much better if they proactively ask if a proposed arrangement is compliant. Otherwise, they may have to unwind a relationship if they find out it is not compliant.
- Promote awareness to prevent future mistakes. Once an error is made, chances are it will reoccur and lead to additional violations. As you are addressing errors, promote awareness to prevent future mistakes. For example, when you are communicating the fact that a mistake was made, go the extra step to what caused it. This will be an opportunity to find out where their confusion was and use that insight to update policies or training.
Stark compliance starts with knowing about changes to the regulations and continues with crafting policies that providers can understand and follow. Involving stakeholders in policy creation and training, and engaging tech systems to reinforce the lessons will support the long-term success of Stark-compliant policies.
Do you have the tools you need to recognize and manage regulatory change across your organization? Find out how YouCompli can help you manage and coordinate your response to regulatory change or schedule a demo.
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Telehealth is almost as old as the telephone itself. In 1879 – just three years after Bell patented the telephone – an article in Lancet described the concept and advocated its adoption.
A law that’s even older can trigger many telehealth audits today. The 1863 False Claims Act (FCA) was enacted to keep profiteering contractors from defrauding the Union army. It can trigger serious problems for hospitals that don’t take proactive steps to make sure their telehealth practices are audit-proof.
That’s because the 2010 Affordable Care Act updated the FCA to make healthcare providers liable for “retention of any overpayments” from Medicare and Medicaid. This even includes overpayments resulting from accident or error. Indexing penalties for inflation each year, a requirement added in 2015, increased hospital liabilities. This puts liabilities at three times the amount of the overpayment(s) plus $11,803 to $23,607 for each instance. (Some 29 states and the District of Columbia have additional False Claim laws.)
These laws’ implications and requirements touch every part of the hospital. Keeping the whole organization in compliance means that all departments have to work together.
New laws, new regs, new worries for telehealth
Even before COVID, the government audited claims from what was then a smaller, rural telehealth system. Regulators found a trend of incorrect payments to doctors outside rural areas, who were therefore ineligible to receive them.
Telehealth is on the latest Office of the Inspector General (OIG) work plan, too. The OIG will be addressing remote patient monitoring by telehealth as an area of concern.
The public health emergency, with its series of 90-day waivers, made it possible for telehealth to grow so fast. Now, as the COVID emergency ebbs, Congress is considering making its current, expanded status permanent. (Two bills were introduced in May. One would enable audio-only telehealth services for Medicare enrollee. The other would expand telehealth for Medicaid and Children’s Health Insurance Programs.)
That’s good. But with laws come regulations covering acceptable types, locations and forms of delivery of telehealth services. And with regulations come scrutiny and audits. That can create challenges, especially with the specter of FCA liability in the background.
The best way to cope with audits is to prevent the need for them in the first place. Here are six steps to follow:
- Know what you’re up against. Keep up to date with all the developing federal and state regulations, waivers, and other requirements. That in itself can take up most, if not all, of your personal and your compliance team’s time.
Related: Find out how a team of expert compliance professionals and a nationally respected law firm track and analyze the latest regulatory changes, keep you updated, and give you actionable ways to adapt your process.
- Inventory your waivers. Which waivers do you rely on, in which departments and facilities? Do the providers and staff that they apply to know about them? And who makes sure the requirements are met and documents it?
- Check your records. One of the biggest causes of noncompliance isn’t malice. It’s error. Did an accidental typo in Coding result in an incorrect claim? Does everyone in Billing know which states require what reimbursement levels for telehealth services? Are certain telehealth records missing? Who’s responsible for keeping the signed doctors’ orders and documents that establish medical necessity? Do patients and services meet billing guidelines? Do you have a telehealth compliance policy? Does it need changing? Start conducting spot-checks to find out.
Related: Find out about state requirements for telehealth billing.
- Audit your process. Another big cause of noncompliance is miscommunication – particularly the assumption that someone else is taking care of something. So put together an internal audit team, with each department represented. That way, each can learn from the other. Hold an entrance conference to highlight what you learned from your spot checks, define the internal audit’s scope, set expectations, and assign specific tasks and timelines.
- Fix whatever’s broken. Reconvene the internal audit team and communicate the findings. Together, use that input to find opportunities to correct or cure what’s wrong in your process. Then, create a Corrective Action Plan (CAP) that will include needed education, training, policy, and process changes. Monitor your CAP over time, to see how it’s working and to spot anything else that needs fixing.
- Rebill and repay. If your internal audit and CAP were successful, you’ll have discovered missing or insufficient documentation. Report it. You may have also have found instances of incorrect payments. Rebill and repay. Yes, it will cost your hospital money. But not nearly as much as a full-blown government audit. A Department of Justice investigation could end up costing you time, legal fees, and FCA triple damages.
Patient demand for telehealth isn’t going away. Neither are the costs of noncompliance with telehealth regulations. As the public health emergency expires, fines from regulators and denial of claims from payers are sure to add up. The best way for your healthcare organization to solve these potentially massive financial problems is to work together to prevent them. Proactively partnering with colleagues in all relevant departments, your compliance team can lead the efforts to identify and fix issues before they become major problems. That way, you’ll be able to provide the telehealth services patients want in compliance with what the regulations demand.
It’s a big effort to keep your compliance champions connected and communicating. See how YouCompli can help you manage the rollout of new regulations and verify best efforts to regulators and your board. YouCompli is the only healthcare compliance software combining actionable regulatory analysis with a simple SaaS workflow.
The beauty of telehealth is that it connects patients and providers through technology that transcends boundaries. But when that connection crosses state lines, your healthcare organization could find itself responsible for complying with regulations from jurisdictions hundreds, maybe thousands, of miles away.
Or from states just down the road.
Many of those are stricter than the federal regulations, and many cover issues that the federal government doesn’t. Here are some of the key issues to look out for.
Differing reimbursement structures and rates
Reimbursement structure and rates vary by state and form of telehealth. For instance, all states pay Medicaid reimbursement for some form of live telehealth, but in different ways, and all states reimburse for interactive, real-time telehealth. However, only 14 reimburse for sessions where the patient records a call for later physician review (store-and-forward), and only 22 reimburse for remote patient monitoring of recently discharged hospital patients. There are eight states that reimburse for all three telehealth methods.
There are two opposite views about reimbursement rates. One view is that a service is a service, so being virtual or in person shouldn’t affect reimbursement.
The other penalizes telehealth for its efficiencies. In face-to-face visits, “there are built-in inefficiencies that isn’t time spending with the person,” says Dr. Katherine Dallow, vice president of Clinical Programs at Blue Shield Blue Cross of Massachusetts. “I probably spend somewhere between two to five minutes per patient moving from one room to another or pausing to document or checking something on their file or handing something off.” With less provider time and less pro rata overhead, some states reason, there should be less reimbursement.
Forty states have their own private payer telehealth reimbursement policies, and six have private payer parity laws requiring the same reimbursement for in-person and telehealth care.
Stricter privacy protections
The Health Insurance Portability and Accountability Act (HIPAA) is the federal umbrella protecting privacy and confidentiality of patient records, but states are allowed to go beyond it. Many do.
For example, if there’s a breach of privacy, HIPAA requires that the patient be notified within 60 days. Some states shorten that to 30 days, and California shortens it to ten. Some states also require hospitals to notify the state attorney general and the three major credit reporting companies: Equifax, Experian, and TransUnion. If there’s a breach of an out-of-state telehealth patient’s confidentiality, do you know what the originating state requires?
Multi-state provider licensure
Almost all states require physician licensure where the patient is (also known as the originating location). Same for nurses, nurse practitioners, physicians’ assistants, clinical psychologists, registered dieticians, and physical therapists. Different states have different licensing procedures, and there’s no federal umbrella. That’s something you’ll need to look out for, not only with faraway states, but also in New York, New York; Chicago/Hammond, Ind.; Texahoma, Texas/Okla.; or any of 84 other communities that straddle state lines.
(Speaking of licensure, is your hospital licensed to provide telehealth services? In how many states?)
Can doctors prescribe online?
State regulations for phone-in prescriptions from the late 1990s adapt pretty well to online prescriptions today. The problem is, they differ from one state to the next. Different states have different regulations on just what a valid prescription is. About whether the doctor can prescribe without seeing the patient first, and whether seeing a patient on a computer screen is really “seeing.” About whether there has to be a previous doctor/patient relationship, and whether that relationship can be remote or has to be face-to-face.
Related: Interstate regulations aren’t the only telehealth complexity. Check out this blog post for more: Telehealth compliance considerations: looking ahead.
Two ways to keep up; one is practical.
Complying with more than 50 sets of regulations takes a lot of attention to detail and a lot of reading. One way to keep up is with sheer effort: health organizations designate one or more people to read and track all the regulations that affect them.
A better, more practical way is to rely on expert compliance professionals and nationally respected law firms to keep you up to date on interstate issues in telehealth regulation. YouCompli users select the agencies that matter to their organizations and receive updates and resources to help them know about new regulations, decide their applicability, manage policy changes, and verify compliance.
Are you looking for ways to track telehealth regulations in all the states your patients receive treatment? Take a look at YouCompli, the only healthcare compliance software combining actionable, regulatory analysis with a simple SaaS workflow.
Jerry Shafran is the founder of YouCompli.