Weiss Zarett Brofman | Sonnenklar & Levy, P.C. | Attorneys At Law

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StatLaw – May 2014

On Behalf of | May 1, 2014 | New York StatLaw

Private Health Plans Prepare to Make Payment Data Accessible to Public: On the heels of Medicare release its payment data, a new initiative by three of the country’s largest health plans has the potential to transform the accessibility of claims payment data, according to healthcare finance experts. UnitedHealthcare, Aetna and Humana announced a partnership on Wednesday with the Health Care Cost Institute (“HCCI”), a not-for-profit group, to create a payment database that will be available to the public for free. Experts say cost transparency is being spurred by a number of developments in the healthcare sector. The trend towards high-deductible plans is giving consumers a greater incentive to understand how much healthcare costs and to utilize it more efficiently. In addition, the launch of the exchanges under the Patient Protection and Affordable Care Act has brought unprecedented attention to the difficulties faced by individuals in shopping for insurance coverage.

New Proposed Rule Seeks to Revise the Office of Inspector General’s (“OIG”) Exclusion Authorities: The proposed changes to the exclusion regulations at 42 CFR part 1001 to codify authorities under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (“MMA”) and Affordable Care Act (“ACA”) and make technical changes to existing regulations. Specifically, section 949 of MMA and section 6402(k) of ACA amended section 1128(c)(3)(B) of the Act to expand OIG’s waiver authorities. Also, ACA provided that exclusion may be imposed for (a) Conviction of an offense in connection with obstruction of an audit; (b) Failure to supply payment information; and (c) Making, or causing to be made, any false statement, omission, or misrepresentation of a material fact in applications to participate as a provider of services or supplier under a Federal health care program. ACA also established a new authority at section 1128(f)(4) of the Act for OIG to issue testimonial subpoenas in investigations of exclusion cases under section 1128 of the Act. In addition to the changes under the ACA, and pursuant to section 1128(g)(1) of the Act, another proposed change is the modification to the reinstatement rules for individuals excluded as a result of losing their licenses to allow them to rejoin the programs earlier when appropriate.

Office of Medicaid Inspector General (“OMIG”) Releases Compliance Alert for Upcoming Certification Obligations: recently issued a Compliance Alert strongly recommending that all Medicaid providers conduct a self-assessment of their compliance programs annually. A self-assessment will maximize a provider’s opportunity to make improvements, corrections or refinements to their compliance programs prior to the December 2014 certification period. Providers may use OMIG’s Compliance Program Assessment Form, or any other appropriate tool, to assist them in conducting a self-assessment of their compliance program. The results of the Medicaid provider’s self-assessment, among other things, will assist the Medicaid providers determine if it can certify that its compliance program is effective or if its compliance program is not effective. If the self-assessment is completed mid-year and the provider’s self-assessment identifies any element of the SSL § 363-d and Part 521 is not being met, the provider still has time to implement corrective action on a particular element in order to certify that its compliance program is meeting the all the requirements in December. Providers should note that the mandatory compliance program obligation set out in SSL § 363-d and Part 521 is continuous for providers that must have a compliance program. The certification must be completed upon enrollment with New York State in the Medicaid program and during the month of December each year thereafter. The certification must be made to the New York State Department of Health, on a form provided by OMIG on its web site that a compliance program meeting the requirements of the regulation is in place.