HEALTHCARE BUSINESS: PRESENT AND FUTURE CHALLENGES

Taino Consultants Inc.

Dr. Jose I. Delgado

www.Tainoconsultants.com

DrDelgado@tainoconsultants.com

INTRODUCTION

Healthcare Reform – Status Update

ICD-10 Preparation and need Compliance

HIPAA Title II Omnibus Rule Meaningful Use

HEALTHCARE REFORM

Calendar of Key Elements Current Events and Interpretations

CALENDAR OF KEY ELEMENTS

Calendar Year 2013Limit FSA Contribution to $2,500.Employer deduction for Part D subsidy eliminated.Increase IRS threshold for itemized deduction for medical expense to 10%.Increase Medicare payroll tax (additional 0.9%)Deduction limit of $500,000 will be applied for current and deferred compensation paid to officers, directors, employees and service providers of health insurance for taxable years beginning after 2012 with respect to services performed after 2009.

CALENDAR OF KEY ELEMENTS

Calendar Year 2014Health Care Reform Individual Mandate State Health Insurance Exchanges Establishment.Summary of Benefits and Coverage (SBC) required Employers with more than 200 employees required to automatically enroll new full time employees.Plan Design Changes and Benefit Mandates apply:

cost-sharing limits state requirement to accept and renew coverage no pre-existing conditions exclusions no individual health status discrimination eligibility waiting period of 90 days or less.

Employer Reporting of Minimum Essential Coverage offering to employees.

CALENDAR OF KEY ELEMENTS

Calendar Year 2014 - ContinuationOffering of Qualified Health Benefit Plans through Cafeteria Plans.State Basic Health Plan Option Offering. Small Business Tax Credit increase to 50% of employer costs.Premium Variation for Participation in Employer - Wellness Insurance Market Reforms.Insurer Fees applied to businesses that provide health insurance.Mental Health and Substance Abuse Benefits Parity.

CURRENT TRENDS AND INTERPRETATION

Business Mandate Extended California exchange experience

Anthem Blue Cross, UnitedHealth and Aetna pulling out Products offered limited

Meaningful Use 21% of meaningful use physician drops after first year attestation

Accountable Health Organizations 9 out of 32 Pioneer ACOs drop out

ICD 10 PREPARATION AND NEED

Recommended Steps Statistics – Readiness Business Opportunities

STATISTICS - READINESS

Impact Assessment Completion: > 40% unknown Complete Business Changes: 40% unknown; 20% maybe

in 2014 Expected date to begin external testing: 50% unknown ICD 10 sources to use as guidance/transition

25% use ICD 10 directly to code > 50% will use crosswalking and direct coding

Note: Based on WEDI’s ltr to HHS Secretary after April 2013 Research

ICD 10 BUSINESS CONCERNS

Systems and procedures not ready Claims to be rejected

EHR notes must match ICD 10 Procedures must match correct ICD 10 Systems must match – different systems may establish different

protocols Providers and Practices downplaying the change

Time frame when ICD 9 and ICD 10 must be used simultaneously

Need for cash reserves (no less than 6 months of operations)

RECOMMENDED STEPS

Conduct Internal Audit to identify coding and business practices

Start training staff into implementation and potential changes

Train Providers on proper coding

GET A LINE OF CREDIT Consider outsourcing coding efforts right now Look for assistance!!! Test system and procedures Study and correct rejected and unpaid claims

BUSINESS OPPORTUNITIES

Small Practices Groups

Independent Hospitals ACOs Billing Agencies Audit Agencies

COMPLIANCE

HIPAA Meaningful Use Medicare and OIG

HIPAA

TITLE II

Preventing health care fraud and abuse;

Administrative simplification; Medical liability reform

TITLE II – PREVENTING HEALTHCARE FRAUD

Fraud and Abuse Program Revisions to Current Sanctions Data Collection Civil Monetary Penalties Revisions to Criminal Law

MONETARY PENALTIES

• Civil penalties– $100 for each violation of the law, to a

limit of $1,500,000 per year for violations of the same requirement.

• Criminal sanctions– $50,000 to $250,000 and one to ten years

imprisonment.

DATA BREACHES PENALTY STRUCTURE

Violation Type Each Repeat/year

Did Not Know $100 – $50,000 $1,500,000

Reasonable Cause  

$1,000 – $50,000 $1,500,000

Willful Neglect Corrected

$10,000 – $50,000 $1,500,000

Willful Neglect Not Corrected

$50,000 $1,500,000

TITLE II – ADMINISTRATIVE SIMPLIFICATION

TITLE II – ELECTRONIC DATA INTERCHANGE

Transactions Identifiers Code Sets

TITLE II - PRIVACY

Uses and Disclosures Treatment and Payment Operations (TPO)

Patient Rights Notice of Privacy Practices (NPP)

TITLE II - SECURITY

Security Safeguards Administrative Technical Physical

Implementation Specifications Required Addressable

HIPAA OMNIBUS RULE

Sep 23, 2013 Compliance Date Key areas to focus

Privacy, Security, and Breach Notification policies and procedures (and in some cases, new workflows and forms)

Notice of Privacy Practices Business Associate (BA) Agreement

Expansion of BA’s obligations

MEANINGFUL USE

More than software Risk Assessment

Stage 2 effective date – Fiscal year 2014 Documentation Requirements – Administration Audits

TC INC. COMPLIANCE SOFTWARE

Module Specific Dashboard – Messages Policies Forms Quarterly Updates Resources

SUMMARY

Healthcare Reform – Status Update

ICD-10 Preparation and need Compliance

HIPAA Title II Omnibus Rule Meaningful Use

SUMMARY

Healthcare Reform – Status Update ICD-10 Preparation and need Compliance

Medicare and OIG HIPAA

Dr. Jose I DelgadoDrDelgado@Tainoconsultants.com

www.tainoconsultants.com