News Briefs
News Briefs
APC honest mistakes’ won’t be criminalized
The federal Office of the Inspector General (OIG) says it won’t take civil or criminal action for billing errors due to what it calls "honest mistakes" or negligence during the implementation of the new outpatient prospective payment system (OPPS).
"The hospital will be asked to return the funds erroneously claimed, but without penalties," said Inspector General June Gibbs Brown in a letter to American Hospital Association (AHA) president Dick Davidson.
Among the mitigating factors OIG will consider are the rule’s clarity, the complexity and novelty of the OPPS billing system, the quality of guidance issued by the Health Care Financing Administration (HCFA) and/or fiscal intermediaries, the extent to which the provider has tried to understand the rule, and whether the provider has an effective compliance program.
The letter can be viewed at http://www.hhs. gov/oig/new.html.
Meanwhile, HCFA appears to be serious about its new targeted implementation date of Aug. 1, 2000, for the OPPS, says Larry Ott, CPA, senior director of 3M HIS Consulting Services. That’s the case, Ott says, despite expected beneficiary and payer confusion about coinsurance and deductibles.
On June 2, HCFA sent letters to the AHA and other industry groups acknowledging that delays in implementing the claims processing infrastructure made it virtually impossible for Medicare intermediaries or hospitals to implement OPPS on July 1, as originally scheduled. HCFA is urg-ing providers not to collect deductibles or coinsurance from Medicare beneficiaries beginning Aug. 1 until HCFA can notify the beneficiaries of the new amounts, Ott says. He advises providers who are unfamiliar with the new coinsurance rules and potential opportunities to review them as soon as possible. A copy of the final regulations and a summary may be downloaded from http://www. apc-solutions.com/regulations/index.html. For more on the one-month postponement of OPPS and ambulatory payment classifications, visit http://www.aha.org/info/releasedisplay.asp?passreleaseid=290.
A good hint as to what happens if HCFA still has claims processing problems after the Aug. 1 implementation can be found in the contingency plan circulated in June among various health care groups, Ott points out. Basically, he adds, HCFA indicates that if computer glitches prevent accurate claims processing, HCFA would make accelerated payments to hospitals that request them, following the Provider Reimbursement Manual, section 2412.
The payments, which would be equal to 70% of the estimated Medicare payment, would be made every two weeks, he says. Once the OPPS is fully operational, the payments would be adjusted to actual claims. To study section 2412 in detail, visit http://www.hcfa.gov/pubforms/ provreim/prvretoc.htm.
Rules have off-campus’ EMTALA application
Hidden in the hundreds of pages of regulations for the outpatient prospective payment system (OPPS) are important definition and language changes that create new hospital EMTALA obligations, says Stephen A. Frew, a Rockford, IL, health care lawyer who advises hospitals on the 1986 law.
Those obligations are based on off-campus, satellite, and remote site operations, Frew says. "HCFA [Health Care Financing Administration] has been warning hospitals about EMTALA applying to urgent care and other services located apart from the main hospital, but for the first time, these regulations create specific guidelines and require specific actions," he notes.
Under the new regulations, a hospital’s campus is defined as the main hospital building, a zone of 250 yards around the hospital (including parking lots, driveways, and hospital buildings), and HCFA-approved "provider-based services" (off-site locations, satellites, and remote hospital sites) that participate in the new OPPS, he adds.
Rules of the game
Included, he says, are these EMTALA rules:
1. Covered sites must have policies and procedures for medical screening exams, including stabilization and either a response from the main hospital or a transfer to the main hospital, as appropriate.
2. Covered sites that do not have physicians must go through a formal process to designate a qualified medical person at the site.
3. Hospital policies must include response plans to areas within the 250-yard zone of the hospital.
4. Remote sites that might transport to a closer facility than the home hospital must have transfer agreements in place covering these circumstances.
"While not all hospitals have remote or satellite facilities to worry about, all hospitals do have to be concerned with the 250-yard exterior zone and formulate policies to deal with it," Frew says.
Additional information on the requirements and a link to the full text of the HCFA publication area available at Frew’s Web site at http://www. medlaw.com.
Clinton proposes fix for Balanced Budget Act
President Clinton has proposed a Balanced Budget Act (BBA) relief package totaling $21 billion over five years. The proposal would give hospi-tals the full inpatient market basket for fiscal year 2001, repeal the Medicare reduction scheduled for Disproportionate Share Hospitals (DSH), and freeze further Medicaid DSH payments for 2001, according to reports from the American Hospital Association’s (AHA) news service. Clinton said it is possible to give BBA relief to hospitals and fund a Medicare prescription drug benefit.
Meanwhile, it’s likely that the House Ways and Means Committee will consider legislation to give hospitals and health care providers additional relief from the BBA this year, according to Health Subcommittee Chairman Bill Thomas (R-CA). Thomas said in late June that the committee would consider a BBA relief bill this year, and he expects cooperation from the White House, according to AHA staff. A House Ways and Means spokesman said Thomas intends to "look at further BBA refinements" once the Congressional Budget Office releases figures that are expected to show a Medicare surplus.
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