Publisher Guest Article With the New Year comes a new US healthcare insurance system. And already the media wants to know how it’s working. Should you get a request to opine on that, here are a few things to consider: 1. Despite the “Patient Protection and Affordable Care Act” (PPACA aka ObamaCare) being signed into law … Read more
Small physician practices should have received a wake-up call with the most recent fine announced by the Office of Civil Rights HIPAA enforcement division which shows that the feds are going to go after small practices for technical violations, even if no patient data was misused. The official press release states: Adult & Pediatric Dermatology, … Read more
So what about folks with co-pays and large deductible policies? With insurance companies cancelling millions of policies and employers reducing coverage in many instances or cutting folks back to part-time to avoid Obamacare, many of your ED “insured” visits will be severely under-insured and might not even realize that they are going to have to … Read more
What about other plan restrictions? CMS comments included: Payors restricting the number of consults that will be paid for during a hospital encounter/stay, including the use of consults for completing an MSE or providing stabilizing treatment of EMCs. Hospitals must not assume that such a coverage limitation by one or more payors would allow them … Read more
What if the plan looks at the final diagnosis codes and decides not to pay? Payor refusal to pay for emergency department (ED) services because the payor views the diagnosis codes on the hospital’s bill to the payor as representing conditions that are “non-emergent”. In States where such payor practices have been under discussion, some … Read more
Are your plans requiring pre-authorization for admission or transfer following the MSE? Hospitals are not permitted to comply according to CMS. Payors requiring secondary evaluation and approval of individuals with EMCs by insurer/payor-designated personnel as a condition for inpatient admission or transfer, including designation of transfer destination. 42 CFR 489.24(a)(1) requires that the MSE be … Read more
Can Payors Require Pre-authorization For ED Visits? Historically, the answer has been NO. You cannot even ask about the insurance provider before the MSE without risking citation, and especially if that results in the patient being delayed or not being seen at all. CMS has not backed off that position, stating: Section 1001 of the … Read more
In the preceding segment, CMS brought up the topic of “stability”, and they go on in this segment to make it clear that the situation with stability has never been based on “clinical stability” but upon the whether or not the patient was at risk to deteriorate from or during transfer or discharge. 42 CFR … Read more
The new healthcare reform law is causing rampant confusion on many levels, and that includes among payors, plans, employers, and hospital personnel similar to the push for HMO’s and Healthcare planning in the 1990’s. Because of the varied issues, CMS has issued a clarification on EMTALA — and as I predicted, EMTALA is not going … Read more
If a medical staff member reports suspected or alleged EMTALA violations, are they protected by the same Whistleblower provisions of EMTALA as hospital employees? The answer to that question is that they are, according to federal court ruling in Wisconsin in late November. In the case at hand, Dr. Kamal Muzaffar, sued Aurora Health Care … Read more