The healthcare industry is bracing for a wave of new regulations and heightened enforcement in 2024. The U.S. Department of Health and Human Services (HHS) is leading the charge, with backing from other agencies like the Department of Justice (DOJ) and the Federal Trade Commission (FTC). These new measures target a wide range of areas, including anticompetitive practices, private equity ownership in healthcare, the use of artificial intelligence (AI), and cybersecurity measures protecting patient data.

A key focus area is anticompetitive practices within healthcare. The government is concerned about mergers and acquisitions, particularly those involving private equity firms and health insurers, potentially creating monopolies and harming patients. These "roll-up" deals will face intense scrutiny by a newly formed task force composed of the DOJ, FTC, and HHS. This collaboration will involve increased data-sharing between agencies to identify and address potential antitrust violations before they occur.

Private equity firms investing in healthcare, especially nursing homes, will face new transparency requirements regarding ownership structures. New regulations from the Centers for Medicare & Medicaid Services (CMS) require detailed disclosures about governing bodies, officers, and any additional parties with a financial stake in these facilities. This information will be used by CMS to monitor the quality of care provided and hold owners accountable for any shortcomings.

The rapid adoption of AI in healthcare has prompted concerns about responsible implementation. To address these concerns, the HHS established an AI Task Force in January 2024. This task force is tasked with developing a plan that focuses on crucial areas such as ensuring proper human oversight of AI systems and long-term safety monitoring of AI technology in real-world healthcare settings. Mitigating bias within AI algorithms is another critical focus, and the plan will establish data privacy and security standards to protect sensitive patient information used by AI systems.

Healthcare organizations are expected to significantly strengthen their cybersecurity measures to safeguard patient data. The potential for increased penalties for violations of the Health Insurance Portability and Accountability Act (HIPAA) is a strong motivator for improved data security practices. Furthermore, the Cybersecurity and Infrastructure Security Agency (CISA) will play a more prominent role in ensuring robust cybersecurity practices are implemented throughout the healthcare industry.

Healthcare organizations across the board are advised to take proactive steps to comply with these new regulations and enforcement initiatives. Staying informed about guidance documents issued by regulatory agencies will be crucial for navigating this evolving landscape. Chief compliance officers and risk management professionals should conduct a thorough review of existing practices and make adjustments to ensure alignment with the new regulatory environment.

This increased scrutiny signifies the government's commitment to fostering fair competition within the healthcare industry, prioritizing quality care, and ultimately ensuring patient safety. The year 2024 promises to be a period of significant change for the healthcare industry, and how these regulations are implemented will have a lasting impact on patients, providers, and healthcare delivery as a whole.

Sources:

https://www.navex.com/blog/article/healthcare-organizations-are-facing-increased-scrutiny-heres-what-you-need-to-know/

 

 

Virginia's Medicaid landscape is undergoing a significant transformation as Virginia Premier, serving over 300,000 residents, merges with Optima Health. This consolidation, effective July 1, 2023, brings Sentara Health's two Medicaid subsidiaries under one umbrella, creating a plan catering to over 740,000 Virginians.

This move promises several benefits:

• Enhanced Customer Experience: Sentara Health Plans President Colin Drozdowski emphasizes a "superior customer experience" for Medicaid recipients. Optima Health, presumably with its existing infrastructure, aims to deliver a streamlined and efficient service for the combined membership.
• Cost Savings and Efficiency: The merger is expected to generate cost savings for the state by optimizing administrative processes and potentially leveraging economies of scale. Healthcare providers might also benefit from a reduction in administrative burdens associated with dealing with multiple Medicaid plans.
• Community Investment and Seamless Care: Sentara anticipates reinvesting the efficiencies gained into Virginia communities. This could translate into improved outreach programs, community health initiatives, or potentially even expanded healthcare services. Additionally, a unified plan could lead to a more seamless care experience for members, potentially simplifying referrals and coordination between different healthcare providers within the  Sentara network.

Impact on Virginia Premier Members:

For existing Virginia Premier members enrolled before July 1, 2023, the transition appears smooth. They will retain their current health coverage and benefits, becoming Optima Health members automatically. The Virginia Premier D-SNP program, catering to a specific population segment, will continue under the Virginia Premier name, ensuring continuity of care for those enrollees.

However, during future open enrollment periods, Virginia Premier will no longer be a separate option. Members seeking to retain coverage will need to choose Optima Health.

Sentara Health Plans and Beyond:

This consolidation coincides with Sentara Health's broader rebranding efforts. The company is adopting "Sentara Health Plans" as its official health insurance arm, reflecting its integrated healthcare delivery network (IDN) structure. This rebranding, coupled with the merger, signifies Sentara's commitment to a more unified and streamlined healthcare ecosystem in Virginia.

The rollout of the Sentara Health Plans brand is expected to begin this fall, with new ID cards reaching Virginia plan members by January 1, 2024.

Looking Ahead:

The Virginia Premier-Optima Health merger simplifies Medicaid administration in the state, potentially reducing costs and improving the overall experience for hundreds of thousands of residents. While some transitional adjustments might be necessary, Sentara's commitment to reinvestment and streamlined care bodes well for the future of Virginia's Medicaid landscape. It's important to stay informed about any updates or changes communicated by Sentara Health Plans in the coming months.

 

 

Attention healthcare providers: Blue Cross and Blue Shield of Illinois (BCBSIL) is implementing changes to prior authorization requirements for specific services covered under Blue Cross Medicare Advantage (PPO)SM, Blue Cross Community Health PlansSM, and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM plans.

Effective July 1, 2024, these changes affect:

• Lab Tests: Certain lab tests will require pre-approval review by eviCore healthcare, a contractor for BCBSIL. Additionally, some previously reviewed lab tests will no longer need eviCore's approval.
• Sleep Studies: Prior authorization from eviCore will now be mandatory for certain sleep study procedures.
• Specialty Drugs: BCBSIL will require prior authorization for specific specialty drugs.

Staying Informed:

• Healthcare providers can find a detailed breakdown of the code changes on the BCBSIL website under "Support Materials (Government Programs)".
• The "Utilization Management" section of the BCBSIL website offers further information on these updates.

Important Reminders for Providers:

• Always verify member eligibility and benefits through Availity® Essentials or your preferred vendor portal before providing services. This step confirms prior authorization requirements and the appropriate utilization management vendor (if applicable).
• Obtain prior authorization if necessary. Services rendered without prior approval or not meeting medical necessity criteria may be denied payment, leaving providers unable to collect reimbursement from the member.
• Obtaining prior authorization helps avoid claim processing delays and potential denials due to missing information.

This announcement is for informational purposes only. Verifying eligibility and benefits and/or obtaining prior authorization does not guarantee payment. Final determinations will be made when a claim is submitted and will be based on factors such as member eligibility, their plan's details (including exclusions and limitations), and the date services were provided.

Sources

www.bcbstx.com/provider/standards/standards-requirements/disclosures/2022/05-05-22-prior-auth-code-update-080122-commercial

https://www.bcbsil.com/provider/education/education-reference/news/2024/03-28-2024

 

The Centers for Medicare & Medicaid Services (CMS) has unveiled a new initiative called the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model. This model aims to improve population health, reduce healthcare disparities, and control costs by testing a combination of hospital global budgets (HGBs) and investments in primary care.

What are Hospital Global Budgets?

Under an HGB system, hospitals receive a fixed annual payment for Medicare inpatient and outpatient services. This provides stability and predictability for hospitals' revenue streams. However, the AHEAD model goes beyond simple fixed payments. Here's a breakdown of the key features:

• Baseline Revenue and Adjustments: A hospital's historical Medicare fee-for-service (FFS) data is used to establish a baseline, adjusted for inflation, demographic shifts, and planned service line changes.
• Performance-Based Adjustments: Hospitals can earn bonuses for exceeding quality metrics and reducing avoidable utilization. Conversely, penalties may apply for falling short.
• Social Risk Adjustment: Hospitals serving communities with high social needs receive an upward adjustment to their budget to account for the additional challenges.
• Transformation Incentive Adjustment: An initial 1% increase is provided in the first two years to encourage early participation.

Benefits and Challenges for Hospitals

The predictability of HGBs is a significant advantage, allowing hospitals to focus on improving care quality without worrying about revenue fluctuations. Additionally, the model supports service line redesign by offering financial support for approved service line additions or removals. For Critical Access Hospitals (CAHs), the model includes modifications to ease participation and encourage investment in rural healthcare transformation.

However, there are also challenges to consider. The methodology currently applies only to Medicare FFS, and participating hospitals may face varying reimbursement schemes from other payers. Additionally, pre-approval for service line changes adds an administrative burden, and hospitals might be concerned about factors beyond their control impacting their budgets, such as total cost of care performance in the region.

What's Next?

States interested in participating in the first two cohorts had an application deadline of March 18, 2024. Applications for the third cohort are due on August 12, 2024. Hospitals can express their interest to their state during the application process.

The AHEAD model presents a unique opportunity for hospitals to improve population health and manage costs within a predictable revenue framework. However, careful consideration of the model's features and potential challenges is crucial before opting in.

Source

https://www.jdsupra.com/legalnews/understanding-cms-ahead-model-medicare-2966298/

 

Millions of Americans will find it easier to enroll in and keep Medicaid, Children's Health Insurance Program (CHIP), and Basic Health Program (BHP) coverage under a new rule finalized by the Centers for Medicare & Medicaid Services (CMS). The Streamlining Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes Final Rule aims to reduce red tape and administrative burdens, promoting greater access to healthcare for underserved populations.

The new rule builds upon President Biden’s Executive Orders to strengthen Medicaid and CHIP access. It specifically targets reducing unnecessary administrative burdens and paperwork that can lead to coverage gaps or loss of coverage for eligible individuals.

Key Changes for Easier Enrollment and Retention

• Reduced in-person requirements: States can no longer require in-person interviews for individuals applying for Medicaid based on age (65 or older), blindness, or disability.
• Simplified information sharing: The rule emphasizes using electronic data verification systems to streamline the income and asset verification process.
• Elimination of unnecessary hurdles: Applying for other benefits will no longer be a mandatory step for Medicaid eligibility.
• Streamlined eligibility determination: States can now consider projected medical expenses when determining financial eligibility.
• Extended renewal periods: Renewals for eligible individuals will be conducted no more than once every 12 months, with a minimum 90-day reconsideration period in case of missed information.
• Multiple renewal options: Renewals can now be submitted online, by phone, mail, or in-person.
• Clearer transition process: A smoother transition process is established for individuals who may become eligible for either Medicaid or CHIP based on income changes.
• Improved address tracking: States are required to utilize available data sources to update beneficiary addresses when they move within the state.
• More time for submitting information: Individuals will have a minimum of 15 days to respond to initial application requests and 30 days to provide documentation when needed for renewal.

Focus on Children’s Health Coverage

This final rule also includes specific measures to remove barriers to CHIP enrollment for children:

• Elimination of lock-out periods: CHIP beneficiaries can now re-enroll without penalty if their families previously failed to pay premiums.
• Removal of waiting periods: States can no longer impose waiting periods before CHIP enrollment.
• Prohibition on coverage limits: Annual and lifetime limits on CHIP benefits are no longer allowed.

Enhancing Program Integrity

The rule also includes updates to record-keeping requirements for state Medicaid and CHIP agencies. These updates aim to improve program oversight and reduce improper payments. Key changes include:

• Clearer documentation standards: The rule defines the types of information and documentation required for eligibility determination.
• Standardized record retention: Records must be retained for at least three years.
• Electronic record storage: Outdated storage methods are phased out, requiring electronic record-keeping.
• Improved access to records: States must make records available within 30 days upon request.
• Timely eligibility determinations: States are required to establish minimum timeframes for determining eligibility at renewal and following changes in circumstances.

This new final rule is expected to significantly reduce administrative burdens for both individuals seeking coverage and state agencies administering Medicaid, CHIP, and BHP programs. By simplifying the enrollment and renewal processes, millions of eligible Americans will have easier access to affordable health insurance.

Sources

1. healthcaretoday.news/its-public-benefits-week-in-the-federal-register/
2. www.hhs.gov/about/news/2024/03/27/biden-harris-administration-builds-success-affordable-care-act-streamlining-enrollment-medicaid-chip-coverage

 

Meridian Health Plan of Illinois, a Medicaid health plan provider, announced a new initiative to address health equity within its network. The plan will reimburse hospitals for a portion of the application fee associated with The Joint Commission's Health Care Equity Certification program.

"We're thrilled to be the first Medicaid health plan in the country to leverage this program," said Cristal Gary, president and CEO of Meridian Plan. "This initiative aligns with our mission to transform the health of our communities."

The Joint Commission's Health Care Equity Certification program offers a framework for healthcare organizations to assess and improve their efforts toward achieving health equity. The program launched in July 2023 and guides participants in embedding health equity into their strategies, collaborating with community organizations, and setting measurable goals.

Meridian will cover 25% of the annual application fee for hospitals designated as safety net or critical access facilities within their network. Other in-network hospitals will receive a 15% reimbursement.
"Health equity is paramount to patient safety and quality care," said Dr. Jonathan B. Perlin, CEO of The Joint Commission. "This certification program recognizes organizations prioritizing health equity and collaborating with stakeholders to improve patient outcomes."

Meridian's initiative aims to reduce cost barriers for hospitals seeking health equity certification. This will incentivize healthcare providers within their network to take concrete steps towards reducing healthcare disparities and improving patient care for all.

Source:

https://healthpayerintelligence.com/news/medicaid-health-plan-will-reimburse-health-equity-certification

 

 

UnitedHealth Group has confirmed the successful restoration and rebuilding of critical healthcare functions handled by its subsidiary, Change Healthcare. This comes roughly a month after a cyberattack crippled operations and sent shockwaves through the U.S. healthcare system.

The attack, which occurred on February 21st, targeted Change Healthcare's cloud-based services, specifically their Assurance and Relay Exchange applications. Assurance is a vital software for managing medical claims and remittances, while Relay Exchange acts as a clearinghouse to verify insurance claims.

Amazon's cloud infrastructure, which hosted these applications, was compromised. However, UnitedHealth reports successful restoration from backups with the help of cybersecurity firms Palo Alto Networks and Mandiant. The company emphasizes the implementation of "several rounds of security protocols" to ensure platform integrity and ongoing monitoring with multiple scanning services.

Impact of the Breach

Change Healthcare plays a critical role in the U.S. healthcare landscape, processing roughly half of all medical claims nationwide. Their services reach an extensive network of healthcare providers, including nearly 1 million physicians, 33,000 pharmacies, 5,500 hospitals, and 600 laboratories.

The cyberattack, attributed to the hacking group ALPHV (also known as BlackCat), significantly disrupted healthcare operations across the country. The U.S. Department of Health and Human Services is currently investigating the incident.

Recovery Efforts and Path Forward

UnitedHealth has taken steps to mitigate the financial impact on healthcare providers affected by the disruption. On March 18th, the company announced plans to release its medical claims processing software and has already distributed over $2 billion in advanced payments as financial assistance.

To provide additional support during the recovery phase, UnitedHealth previously suspended requirements for paperwork needed for outpatient insurance approvals and reviews of inpatient admissions for Medicare Advantage plans.

The restoration of Change Healthcare's cloud services marks a significant step towards restoring normalcy in the U.S. healthcare system. However, the incident serves as a stark reminder of the vulnerabilities within the healthcare infrastructure and the need for robust cybersecurity measures.

Source

https://finance.yahoo.com/news/1-unitedhealth-says-unit-change-194046892.html

 

 

The Biden administration has announced a new initiative aimed at strengthening primary care for Medicare beneficiaries. The five-year voluntary program, named ACO Primary Care Flex, will provide financial incentives to participating healthcare organizations.

Increased Investment in Primary Care

The program, overseen by the Centers for Medicare & Medicaid Services (CMS), will offer two key financial benefits to accountable care organizations (ACOs) that participate. First, ACOs will receive a one-time upfront payment to invest in infrastructure and care improvements. Second, they will receive regular monthly payments instead of waiting for a lump sum at the end of a performance period, which is the current system.

This shift to predictable monthly payments is expected to improve cash flow for primary care practices, many of which operate on tight budgets. Industry leaders see this as a positive step. "Shifting to prospective payments will give primary care practices a more stable and predictable cash flow," said National Association of ACOs President and CEO Clif Gaus.

Improved Patient Care Through Team-Based Approach

The ACO Primary Care Flex program also aims to enhance patient care by encouraging a team-based approach. This means primary care physicians will have more flexibility to collaborate with other healthcare professionals to manage their patients' needs. This could include specialists, nurses, and social workers.

According to CMS Administrator Chiquita Brooks-LaSure, patients whose primary care doctors participate "may get care in more convenient ways, like care based at home or through virtual means, extra help managing chronic diseases, and more preventive health services to keep them healthy."

Selection Process and Concerns

The CMS plans to select approximately 130 ACOs to participate in the program. However, there have been concerns raised about eligibility. The program is limited to "low-revenue ACOs," which are defined as organizations with Medicare revenue below a specific threshold.

This exclusion has been criticized by some who believe it prevents larger, established healthcare systems from participating. The National Association of ACOs has urged the CMS to reconsider this limitation.

Program Timeline and Next Steps

The ACO Primary Care Flex program will be implemented within the existing Medicare Shared Savings Program, a major value-based payment program. Applications for the program are expected to open in the second quarter of 2024.

This initiative reflects the Biden administration's broader goal of expanding value-based care models in Medicare. The Center for Medicare and Medicaid Innovation (CMMI), established by the Affordable Care Act, is leading this effort. The CMMI aims to have all 34 million traditional Medicare beneficiaries enrolled in value-based care arrangements by 2030.

Sources

www.healthcaredive.com/news/cms-launches-primary-care-medicare-model-aco/710738/

 

 

In the quest for healthcare price transparency, recent regulations have aimed to empower consumers with information crucial for making informed decisions about their care. However, compliance with these regulations has been a challenge for many hospitals, raising concerns about the effectiveness of current policies.

The Hospital Price Transparency rule, implemented by the Centers for Medicare and Medicaid Services (CMS) since January 2021, mandated hospitals to disclose prices for a list of 200 shoppable services in a machine-readable format on their websites. Despite the potential benefits, compliance has been lacking, with studies revealing that only a fraction of hospitals are fully adhering to the regulations.

A recent study conducted by Mittler and colleagues sheds light on the reasons behind hospitals' failure to comply. While some hospitals have embraced the regulations, others have deliberately skirted around them, opting for partial compliance or outright refusal. Reasons cited for non-compliance range from the need for additional time and high data generation costs to concerns about competitive disadvantage in rate negotiations with payers.

To address these compliance challenges, policy changes have been proposed. CMS has significantly increased monetary penalties for violations, with larger hospitals now facing penalties of up to $2,007,500 per year. This move aims to incentivize compliance by making the potential cost of non-compliance higher than the cost of adhering to the regulations.

Moreover, the Transparency in Coverage regulation, which extends beyond hospitals to include insurers and group health plans, requires the disclosure of negotiated rates and cost-sharing data for covered services. This broader scope of transparency initiatives aims to provide consumers with comprehensive pricing information across various healthcare settings.

Despite these efforts, further improvements are needed to enhance the usability and effectiveness of price transparency data. Standardizing data reporting across payers and providers, eliminating unused billing codes, and centralizing data collection are recommended strategies to streamline information access and reduce data redundancies.

Additionally, mandating the reporting of volume information alongside pricing data can offer consumers insights into the frequency of services provided by healthcare facilities, correlating higher volumes with better outcomes.

In conclusion, while hospital price transparency is a crucial step towards healthcare reform, ensuring compliance and enhancing data usability are ongoing challenges. With continued policy refinement and enforcement, coupled with efforts to raise public awareness about the benefits of price transparency, the healthcare system can move closer to achieving its goals of empowering consumers and driving competition in the marketplace.

Reference

• https://www.healthaffairs.org/content/forefront/improving-hospital-compliance-price-transparency-rules

 

The latest Long-Term Care Hospital (LTCH) Provider Preview Reports have been released, offering insights into provider performance scores for various quality measures. These scores are set to be published on Care Compare and the Provider Data Catalog (PDC) during the June 2024 refresh, marking a significant milestone in healthcare transparency.

Derived from quality assessment data submitted by LTCHs from Quarter 4, 2022 through Quarter 3, 2023, the reports also incorporate data for the LTCH Change in Mobility measure spanning from Quarter 4, 2021 through Quarter 3, 2023. Additionally, measures from the Centers for Disease Control and Prevention (CDC), including Clostridium Difficile Infection (CDI), Catheter-Associated Urinary Tract Infections (CAUTI), Central Line-Associated Bloodstream Infections (CLABSI), Healthcare Personnel (HCP) Influenza, and COVID-19 Vaccination Coverage among Healthcare Personnel (HCP), are based on data ranging from Quarter 3, 2022 through Quarter 2, 2023.

Providers now have until April 15, 2024, to thoroughly review their performance data. It's crucial to note that only updates or corrections made to the underlying assessment data before the final submission deadline will be reflected in the publicly reported data on Care Compare. Any updates submitted after this deadline will solely impact the Facility-Level Quality Measure (QM) report and the Patient-Level QM report.

In cases where providers believe the displayed quality measure scores are inaccurate, they have the opportunity to request a review of their data by the Centers for Medicare & Medicaid Services (CMS) during the preview period. However, it's imperative to act swiftly, as updates made after the final data submission deadline will not be reflected in the Provider Preview Reports or on the Care Compare website.

This release underscores the ongoing commitment to transparency and accountability within the healthcare sector, empowering both providers and patients with valuable insights into the quality of care delivered by LTCHs. As the industry continues to prioritize patient outcomes and safety, these reports serve as a vital tool for fostering continuous improvement and driving positive change in long-term care settings. Stay tuned for further updates as we approach the June 2024 refresh on Care Compare.

Reference

• https://southfloridahospitalnews.com/ltch-provider-preview-reports-now-available/