In what feels like a final drive to exercise authority prior to the election, and a potential shift in control of the presidency and administration, over the last month the federal government has taken several steps to enhance oversight and regulation in the healthcare sector.
These actions reflect what the current administration hopes will be viewed as efforts to make good on commitments to protect consumers and ensure fair practices in the rapidly evolving landscape of healthcare services, in areas ranging from the Affordable Care Act (ACA) exchanges to healthcare company mergers and acquisitions to mental health parity.
For example, it seemed notable last week when the Centers for Medicare & Medicaid Services (CMS) released a proposed rule to empower the agency to review and suspend health insurance agents and brokers for violating rules on enrolling beneficiaries in ACA plans. These brokers, also known as marketers, operate within the ACA marketplace to assist consumers in selecting health insurance plans from the federal exchanges.
According to some experts, CMS wants to be seen taking a firmer stance against health insurance marketers that fraudulently switch exchange enrollees’ plans without their consent. CMS notes that many of these brokers operate with minimal oversight, which can lead to misinformation and a lack of transparency in choices presented to consumers.
This comes as CMS announced last month that it would continue monitoring agents for marketplace fraud after receiving over 200,000 complaints in the first half of the year.
The proposed rule also contains provisions requiring ACA insurers to review networks for certain providers, offer multiple standardized plans, and pay increased user fees.
On the antitrust front, a final rule recently approved by the Federal Trade Commission (FTC) aims to prevent anti-competitive practices that can arise from industry consolidation. Healthcare companies pursuing mergers and acquisitions will be required to submit additional information about their proposals when the rule goes into effect, likely next year.
These companies, when involved in such proposals, will have to list other acquisitions that occurred within the last five years, disclose private equity stakeholders with decision-making authority, and report supplier relationships shared by the merging parties to the FTC. According to the FTC Chair, the rule “will provide antitrust agencies with probative intelligence as to whether a proposed deal risks violating antitrust laws.”
However, it will likely take time to see how the guidelines laid out in the rule, which are not legally binding, will be adhered to by companies and interpreted by the courts.
Meanwhile, last month, the U.S. Department of Health and Human Services (HHS), in conjunction with the Labor and Treasury Departments, issued new mental health parity standards to address what HHS has suggested is a pattern by health plans of imposing stricter limits on mental health coverage. As such, the regulation finalized requirements for health plans to cover mental health and substance use disorder services to the same degree they cover medical benefits, and to develop comparative analyses to inform coverage improvements.
It also eliminates “discriminatory practices such as higher co-pays, restrictive treatment limits, and lower reimbursement rates” for mental health providers, which means that in order to comply, health plans may need to add more mental health providers to their networks, markedly raise reimbursements, or curtail prior authorization constraints.
In sum, recent crackdowns by the feds signal the intent to enhance healthcare regulation and consumer protection priorities before time expires on the Biden Administration. We’re seeing this play out via stricter rules, tighter scrutiny, and more complex, onerous requirements in areas of healthcare that have been recognized for their importance to the larger industry.
As these regulations take shape, they are likely to have lasting impacts on the quality and accessibility of healthcare, fostering what the government hopes will be a more informed and empowered consumer base before a new administration comes in.
Rule 9(b) of the Federal Rules of Civil Procedure states that, in all averments of fraud, such as allegations concerning the False Claims Act, (FCA)
There have been important developments in recent weeks on the 340B drug pricing program. Those who are familiar with 340B will know that it works
Please log in to your account to comment on this article.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
This webcast, presented by Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, a recognized expert with over 30 years of experience, offers essential strategies to improve outpatient clinical documentation integrity. You will learn how to enhance the accuracy and completeness of patient records by adopting best practices in coding and incorporating Social Determinants of Health (SDOH). The session also highlights the role of technology, such as EHRs and CDI software, in improving documentation quality. By attending, you will gain practical insights into ensuring precise and compliant documentation, supporting patient care, and optimizing reimbursement. This webcast is crucial for those looking to address documentation gaps and elevate their coding practices.
ICD10monitor has teamed up with renowned CDI expert Dr. Erica Remer to bring you an exclusive webcast on how to recognize sepsis, how to get providers to give documentation that will support sepsis, and how to educate to avert sepsis denials. Register now and become a crucial piece of the solution to standardizing sepsis clinical practice, documentation, and coding at your facility.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
This webcast, presented by Tiffany Ferguson, LMSW, CMAC, ACM, addresses the critical gap in Social Determinants of Health (SDoH) reporting for pediatric populations. While SDoH efforts often focus on adults, this session emphasizes the unique needs of children. Attendees will gain insights into the current state of SDoH, new pediatric Z-codes, and the importance of interdisciplinary collaboration. By understanding and applying pediatric-specific SDoH factors, healthcare professionals can improve data capture, compliance, and care outcomes. This webcast is essential for those looking to enhance their approach to pediatric SDoH reporting and coding.
Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, VP of CDM, for a webcast addressing oncology service coding challenges. Learn to navigate coding for infusions and injections alongside Evaluation and Management (E/M) services, ensuring compliance and accurate reimbursement. Gain insights into documenting E/M services for oncology patients and determining medical necessity. This webcast is essential to optimize coding practices, maintain compliance, and maximize revenue in oncology care.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
