Unlocking Opportunities for Inmates, ACA May Be the Key to Better Health

Over 10 million individuals enter the jail system in the United States each year. Statistically speaking, jail inmates are disproportionately male, people of color and poor.  An article by Maura Ewing, published recently in The Nation, noted that “this population suffers from higher rates of many health problems, including chronic and infectious disease, injuries, mental illness and substance abuse. And people are often at their sickest when detained. Eighty percent of detained individuals with a chronic medical condition have not received treatment in the community prior to arrest.”

Jails can be considered an “emergency room” of sorts, in that individuals often are very sick and require immediate treatment. Once individuals becomes inmates, they may have access to health care that they would never have had before. As these individuals receive treatment and get healthy during their incarceration, many people are realizing that jails offer an opportunity to identify and treat people who might not otherwise seek or have access to healthcare.

The problem, though, is that the treatment inmates receive in jail ends once they are released. According to The Nation, “health records are hard to transfer in and out, leaving patients who have received care prior to arriving in jail with siloed histories, creating inefficient, costly and potentially inconsistent treatment.” Currently, there are very few processes in place to  follow-up care once someone is released.  And the brief average jail stay of approximately three months is not enough time to get the individual on the road to recovery. With 96 percent of these individuals returning to their home communities, the need for continuity of care is stark.

Ewing points out in her article that the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) provides a unique opportunity to address this problem. Before the ACA was enacted, 90 percent of those released from prison or jail each year were uninsured. Like many others, former inmates tended to use the ER. However, Ewing contends, “with the ACA’s Medicaid expansion in full swing in twenty-six states and Washington DC, 5.3 million people who are or have been incarcerated are newly eligible for Medicaid. The opportunity for continuity in treatment is palpable, and across the country, a movement is brewing among forward-looking jail administrators and healthcare providers to bridge this gap.”

It is time for the government to step up and ensure that individuals are provided care once they re-enter the community. State governments need to ensure that there is a process in place to transition people to coverage via the state Health Insurance Exchange or state Medicaid program. This will provide individuals with a healthy return to their communities and workforce.


Kusserow’s Corner: House Hearing on Medicare Fraud and Abuse

The U.S. House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing on “Medicare Program Integrity: Screening Out Errors, Fraud, and Abuse.” During the hearing, subcommittee members heard testimony from CMS Deputy Administrator and Director of the Center for Program Integrity Dr. Shantanu Agrawal, HHS Office of Inspector General (OIG) Deputy Inspector General for Investigations Gary Cantrell, and Government Accountability Office (GAO) Director of Health Care Kathleen M. King.

CMS Testimony

The CMS testimony revolved around how it is applying three operational principles to guide all of its initiatives: (1) aiming to achieve operational excellence in addressing the full spectrum of integrity causes, in taking swift administrative actions, and in the performance of audits, investigations and payment oversight; (2) providing leadership and coordination in program integrity efforts across the health care system; and (3) focusing on impacting the cost and appropriateness of care across health care programs. Some of CMS’s efforts to reduce fraud, waste and abuse were noted, including: (1) strengthening provider enrollment; (2) ensuring proper and accurate claims payment; (3) facilitating leadership and coordination across the health care system; and (4) improving payment data transparency.

CMS acknowledged the failure to meet its target goal of a reduced improper payment rate for Medicare fee-for-service, and that the improper payment rate had actually worsened over the last fiscal year. CMS noted that it recovered about $19.2 billion in fraudulent payments over the past five years, including $210 million through a new system that uses analytics to probe billing patterns; however, the recovered sum is dwarfed by the size of the problem, projected to be up to $50 billion a year.

The subcommittee cited one news outlet that reported that several doctors who had lost a medical license were still able to bill the Medicare program for millions of dollars. In addition, it noted that at least 14 individuals convicted of FDA-related crimes and debarred by the FDA do not appear to be excluded from the Medicare program; six doctors debarred by the FDA were paid over $1 million in Medicare payments in 2012. Another issue raised in the hearing was that a Medicare card has the patient’s social security number (SSN), creating serious risk of identity theft. Both the GAO and OIG identified fixing this SSN issue as an important step in preventing Medicare fraud.

GAO Testimony

The GAO testimony spoke to their strategies to combat fraud through examining: (1) the ability of CMS’ information system to prevent and detect enrollment of ineligible or fraudulent Medicare providers and suppliers; (2) the possible use of electronic-card technologies; (3) the oversight of program integrity efforts for prescription drugs; and (4) the oversight of certain contractors who conduct post-payment claims reviews. The GAO has focused on the following strategies: (1) provider and supplier enrollment; (2) prepayment and post payment claims review; and (3) addressing identified vulnerabilities. Based upon its work, the GAO recommended:

  • Requiring additional provider and supplier disclosures of information;
  • Establishing core elements for provider and supplier compliance programs as authorized in the Patient Protection and Affordable Care Act (ACA);
  • Increasing use of prepayment edits to help prevent improper payments;
  • Improving oversight of the information systems analysts use to identify claims for post payment, as well as the contractors responsible for the reviews;
  • Implementing mechanisms to resolve vulnerabilities that could cause improper payments; and
  • Removing SSNs from beneficiaries’ Medicare cards to help prevent identify theft.

OIG Testimony

The OIG testimony provided an overview of current health care fraud trends and challenges that impede effective oversight, as well as recommendations on how to address such trends and challenges that could result in billions of dollars being saved, along with a more efficient and effective programs. These included:

  • Providing the OIG with authority to execute federal warrants for the seizure of assets for forfeiture to curb the profitability of healthcare fraud, which will exert a deterrent effect.
  • Removing SSNs from Medicare cards to help protect the personally identifiable information of Medicare beneficiaries.
  • Strengthening the Medicare contractor’s monitoring of pharmacies and its ability to identify for further review of pharmacies with questionable billing patterns.
  • Requiring Part D plans to verify that prescribers have the authority to prescribe.
  • Increasing monitoring of Medicare claims for home health services.
  • Creating a standardized form to ensure better compliance with the face-to-face encounter documentation requirements for home health agencies (HHAs).
  • Implementing the surety bond requirement for HHAs.
  • Monitor hospices that depend heavily on nursing facility residents.
  • Modifying the hospice payment system for care in nursing facilities, seeking statutory authority if necessary.
  • Taking action to provide States with data for identifying overpayments for physician certification statement (PCS) claims when beneficiaries are receiving institutional care paid for by Medicare or Medicaid.
  • Mandating the use of the audit log feature in all electronic health records (EHRs).
  • Working with contractors to identify best practices and develop guidance and tools for detecting fraud associated with EHRs, with specific guidance to address documentation and electronic signatures in EHRs.
  • Amending regulations to require Medicare Advantage and Part D plans to report to CMS, or its designee, their identification of and response to incidents of potential fraud and abuse.
  • Establishing a deadline for when complete, accurate, and timely Transformed Medical Statistical Information System (T-MSIS) data will be available.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.

Cutting Costs: Medical Homes, Urgent Care Centers, or Both?

The New York Times recently published adjacent stories about two very different ways to cut health care spending. On one hand, health insurers and other payers are increasingly moving toward accountable care organizations (ACOs) and patient-centered medical homes (PCMH) to replace the former fee-for-service method of payment. Medicare and some Medicaid agencies are making similar choices. What these arrangements have in common is care coordination—capitated payments to the physician, practice, or organization, additional compensation for coordinating the care of patients with complex or chronic medical conditions, and incentive payments based upon cost savings and health outcomes.

Medical Homes and Value-Based Purchasing

The Blue Cross Blue Shield Association (BCBSA)  announced on July 9, 2014 that its member organizations participated in 350 locally-developed programs in 49 states, involving ACOs, PCMHs, value-based purchasing, and pay-for-performance arrangements. BCBSA reported that these programs saved it $500 million in 2012, while the member associations reported reductions in emergency room visits, especially “primary care-sensitive” visits, hospital admissions, and use of radiological imaging. At the same time, management of patients’ diabetes improved, and the use of preventive services, such as breast cancer screenings and pneumonia vaccinations, increased.

The story also profiled a physician who used the incentive payments he received for care coordination to provide preventive services. He even used them to offer Weight Watchers meetings at his office at a reduced cost.

Urgent Care Centers

In the same issue, the Times reported that investors are increasingly attracted to urgent care centers.  These facilities are walk-in clinics that cater to people with medical problems that are relatively simple and can be addressed quickly. They may offer evening and weekend hours.  People often use them instead of the emergency room to get treatment for minor injuries. Both the wait and the cost are significantly lower than a visit to the emergency room. Other patients may be attracted to UCCs because they can see a doctor when they want to rather than within typical business hours.

Urgent care centers (UCCs) may meet the needs of patients for whom an emergency department is not an appropriate care setting.

So can overworked, underfunded emergency departments refer their Medicaid patients with nonemergency conditions to UCCs? Not necessarily.

Unlike hospitals with emergency departments, UCCs  have no obligations under the Emergency Medical Treatment and Active Labor Act (EMTALA). They may refuse service to Medicaid beneficiaries, the uninsured, or anyone else who cannot pay the entire bill before they receive treatment.

Apparently, private equity firms see high profit potential from clinics that serve a high volume of patients with simple problem. The ability to cherry-pick patients gives these businesses an edge over the competition. Venture capital firms have invested $2.3 billion in UCCs since 2008.  Insurance companies and health systems also are investing in UCCs.

UCCs are inexpensive and convenient, but they’re not for everyone. According to the American Academy of Urgent Care Medicine (AAUCM), the UCC is not meant to replace the office of a primary care physician. They’re not looking to build long-term relationships with patients.The AAUCM encourages patients to use their members’ facilities when their primary physician is not available, and it emphasizes the UCC’s commitment to send records on to the primary care physician when the urgent problem has been addressed.

If a primary care physician’s office is a medical home,  perhaps the UCC could be considered the medical motel.



CMS Warns: Stop Using Federal Marketplace to Process all Medicaid Applications

Tennessee’s Medicaid agency (TennCare) essentially stopped processing Medicaid applications for children and nondisabled adults when the modified adjusted gross income (MAGI) eligibility standards became effective. Nine months after open enrollment began for the newly eligible adult group, TennCare cannot take or process applications under the standards required by law. It has relied on the Federally Facilitated Marketplace (FFM) to perform these functions for all MAGI-based Medicaid applications since the requirements of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) became effective on October 1, 2013. On June 27, 2014, CMS sent a letter to Darin Gordon, director of TennCare, the state’s program, giving the state ten business days to submit a plan to comply with the law.

The State’s Obligations

Under Soc. Sec. Act sec. 1943, all states were required to streamline their Medicaid eligibility determination systems to share information with the Health Insurance Exchange and to enroll individuals whom the Exchange identified as eligible. The statute and related regulations set seven requirements for state eligibility determination systems. Specifically, the state system must be able to:

  • Accept a single, streamlined application;
  • Convert the 2013 income eligibility standards to the modified adjusted gross income; (MAGI) rules required by Soc. Sec. Act sec. 1902(e)(14);
  • Communicate the state’s eligibility standards to the FFM as needed;
  • Process applications based on the MAGI rules;
  • Transfer application files to and from the FFM as needed;
  • Respond to inquiries from the FFM on current coverage through Medicaid and the children’s health insurance plan (CHIP); and
  • Verify eligibility information using electronic sources.

According to the letter, Tennessee has met only one of those requirements, the ability to transfer application files.

Temporary Mitigations

States were required to use the MAGI standards for children and their parents beginning October 1, 2013. Many states were not able to update their systems by that deadline, and CMS required them to develop mitigation strategies to be used until the updates were complete. Tennessee was permitted to rely on the FFM, www.healthcare.gov, for these purposes through December 31, 2013, but it remains in place. The state also placed kiosks in its Medicaid offices so that residents could apply for Medicaid at those locations. However, it has not provided any help to applicants who are using the kiosks.

Effects on Tennessee Residents

The Tennessean reports that at least one woman could not access prenatal care because of delays and mistaken determinations of ineligibility. Her baby was born six weeks early and spent time in neonatal intensive care. Eventually, she was found eligible, and Medicaid paid the bill.

Presumptive Eligibility Problem

The ACA also required states to allow hospitals to make presumptive determinations of Medicaid eligibility. Tennessee has not met that requirement, either. The CMS letter mentioned that compliance with this requirement also could serve as a mitigation strategy until the system updates were complete.

The Agency’s Statements

According to the Tennessean, Darin Gordon, the TennCare director, said that the agency has enrolled 95,000 individuals in Medicaid since January 1, 2014, the highest number since the program started. He attributed some of the delays to the changes in the federal requirements for the project and others to its contractor, Northrup Grumman. Gordon said that the company has not achieved most of the deliverables under its $35 million contract, so it has been paid only $5 million so far. He also said that the agency was becoming “skeptical” about the contractor’s ability to predict when it could meet benchmarks, and that the agency was hiring another contractor to audit Northrup Grumman’s performance and project delivery dates.