On November 10, 2016, the Office of Inspector General (“the OIG”) of the U.S. Department of Health and Human Services (“DHHS”) released its 2017 Work Plan. Published annually and updated throughout the year, the Work Plan identifies the OIG’s key areas of focus as it carries out its mission of protecting the integrity of programs within DHHS. The OIG is charged with ensuring the integrity of more than 100 programs administered by DHHS, including those within the Centers for Medicare and Medicaid Services, Center for Disease Control and Prevention, the Food and Drug Administration, and the National Institute of Health. The OIG Work Plan summarizes the OIG’s current activities – comprised of both new and revised activities — along with information regarding previously identified activities that have been completed, postponed, or cancelled.
The Work Plan highlights new and continuing priorities applicable to various provider types, including hospitals, nursing homes, hospices, home health, clinical laboratories, physicians and other health professionals, medical equipment suppliers and manufacturers, pharmaceutical manufacturers and other providers and suppliers.
The 2017 Work Plan is available here.
The following is a sampling of some of the new and ongoing efforts highlighted in the Work Plan:
In a letter dated March 17, 2016, Richard Brajer, Secretary of the North Carolina Department of Health and Human Services, announced that the Local Management Entity-Managed Care Organization (“LME/MCO”) merger process would be moving forward beginning this summer. Currently, there are eight LME/MCOs that manage Medicaid- and State-funded mental health, intellectual and developmental disability, and substance abuse services through a federal waiver. After the newly announced mergers, these eight LME/MCOs will be organized into four regional organizations to include: an East Regional LME/MCO (consisting of a merger between Trillium Health Resources and Eastpointe); a North Central Regional LME/MCO (consisting of a merger between Cardinal Innovations and CenterPoint); a South Central Regional LME/MCO (consisting of a merger between Alliance Behavioral and Sandhill Center); and a Western Region LME/MCO (consisting of a merger between Smoky Mountain Center and Partners Behavioral Health).
The Department believes these mergers will decrease the administrative burden on providers, who are currently required to follow the requirements and deal with the credentialing and billing systems of as many as eight LME/MCOs and will result in better coordination of care and scalability of services. However, providers who have previously experienced these types of transitions know that such a massive process will almost certainly have some negative short-term effects on business and clinical operations. Providers should look to actively engage in the planning and transition process as much as possible over the coming months and keep a close eye on potential pitfalls that may arise during this process. Parker Poe will be closely monitoring this processing going forward as well and are happy to work with providers to best manage these uncertain times in the life of their business.
Narrow networks (managed care provider networks that include a limited choice of participating healthcare providers and suppliers) have been widely criticized by consumers and consumer-rights groups, particularly in light of the number of narrow network products that are included in the ACA exchange marketplace. Use of narrow networks by self-insured businesses is also growing more prevalent. For consumers who have multiple options for insurance coverage, the question is often one of choice – am I willing to pay more in premiums in order to continue to see my existing doctor, go to the hospital of my choice, or have a wider range of options if I need to see a specialist?
From the doctor’s perspective, however, narrow networks are very confusing. In many cases, it is unclear why a particular doctor is, or is not, allowed to participate in the network. In some cases, only certain physicians are invited to participate in the network, leaving other physicians without knowledge that the plan even exists until a patient calls to find out why the physician does not participate.
While willingness by the physician or physician group to accept the reimbursement rates offered by the payor is one criterion for participation in the narrow network plans, other criteria come into place as well. An invitation to participate in a narrow network may be based upon the payor’s rating of the ability of the physician to offer quality of care and to provide care efficiency (a cost-based rating system). The tier and rating systems, however, are not consistent among payors and often criticized for producing inaccurate, irrelevant and unreliable results. Physicians also worry that there may be a loss of professional autonomy if physicians are pressured, in the course of providing care, to meet the tier and rating criteria developed by the payors in order to participate in the narrow networks rather than to exercise independent medical judgement.
A number of measures have been recently introduced to address consumer-driven concerns with narrow networks. The Patient Protection and Affordable Care Act – HHS Notice of Benefit and Payment Parameters for 2017 (available here: https://www.federalregister.gov/articles/2015/12/02/2015-29884/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2017) proposes that states should be required to develop rules to test the adequacy of provider participants in payor networks. In addition, the National Association of Insurance Commissioners has been working to update model legislation regarding plan network access and adequacy. Finally, legislation regarding network adequacy has been adopted or proposed in a number of states. Typically, state laws incorporate rules regarding maximum travel distances for a patient to see a participating provider, maximum wait-times and/or acceptable provider-to-beneficiary ratios.
If you have questions regarding your relationship with third-party payors, such as managed care contracting, billing audits, or inclusion in narrow networks, Parker Poe has a number of experienced attorneys able to assist.
On Tuesday, May 26, 2015, the Centers for Medicare & Medicaid Services (“CMS”) released the pre-publication proposed rule that updates Medicaid and Children’s Health Insurance Program (CHIP) managed care regulations. In the accompanying press release, Andy Slavitt, Acting Administrator of CMS, indicated that “[t]his proposal will better align regulations and best practices to other health insurance programs, including the private market and Medicare Advantage plans, to strengthen federal and state efforts at providing quality, coordinated care to millions of Americans with Medicaid or CHIP insurance coverage.”Read More