ACA Compliance requires an established Compliance Officer

ALERT!  EVERY OFFICE SHOULD DESIGNATE THEIR COMPLIANCE OFFICER.  THIS IS MANDATED RULE AND REMINDER FOR THOSE WHO HAVE NOT DONE SO OR HAVE NOT DONE IN A VERY LONG TIME AS A REFRESHER.

 

Your office, typically the Owner/Office Manager/HR/FD Supervisor, will be your "Designated Compliance Officer"  This Compliance officer must be routed out to all staff in a memo advising of their status and contact information.  The Compliance office should meet with the owner at least once a quarter to discuss issues, compliance checks, and new implementation programs.

 

An effective compliance program requires oversight of the program. Your office or practice needs to establish who will oversee the compliance program as the organizations “watch dog”. A compliance officer and or a compliance committee needs to be put in to place. These employees will report directly to the CEO or other senior management (depending on how the leadership is structured), and are responsible for the compliance program   structure and administration. 

 

These employees must be able to demonstrate that they have involvement in and detailed familiarity with the organization’s operational and compliance activities. The Compliance Officer or committee are responsible for “reasonable oversight” of the program which entails: 

o Approving Standards of Conduct 

o Understanding and administering the compliance program structure   

o Being informed about the outcomes of audits and monitoring  

 o Reporting on compliance enforcement activity   

o Reviewing and performing effectiveness assessments of the compliance program 

 

As discussed before, it is important to note that compliance plans are not one size fits all.  You will needs to establish a plan that works for you and is specifically designed to meet your individual needs.  So, while compliance plans should designate a compliance professional, what that will look like will vary depending on the size and structure of your   organization. For a big hospital or drug company, it might be appropriate to have a VP compliance officer with a large full time staff. For a small clinic or solo practitioner physician’s office, we wouldn’t expect you to have full time staffers just working on compliance. It might make more sense to designate one employee to be the compliance officer in addition to other clinical or administrative responsibilities.

PA Department of Health launches Practitioner Registry for Medical Marijuana Program.

Department of Health: Department of Health launches Practitioner Registry for Medical Marijuana Program.

Text of July 26 press release.

Harrisburg, PA – Acting Secretary of Health and Physician General Dr. Rachel Levine today announced that physicians can now take the first steps to participate in the Pennsylvania Medical Marijuana Program by completing the Practitioner Registry.

“Since April 2016, we’ve been working to implement a patient-focused Medical Marijuana Program for Pennsylvanians in desperate need of medication,” Dr. Levine said. “Many physicians treat these patients every day and understand the impact this medication could have on their treatment. Once these physicians register and complete the required continuing education, they can be approved to participate in the program.”

The department surveyed physicians and found that of the 191 that participated, 75 percent said they would register with the program.

Two continuing education providers have been approved to offer the four-hour training required for practitioners: The Answer Page Inc. and Extra Step Assurance LLC.

The Medical Marijuana Program was signed into law by Governor Tom Wolf on April 17, 2016. Since that time, the department has:

• Completed the Safe Harbor temporary guidelines and Safe Harbor Letter application process, as well as approved 282 applications; 
• Completed temporary regulations for: growers/processors; dispensaries; practitioners; and laboratories, which have all appeared in the Pennsylvania Bulletin; 
• Released applications for medical training providers and laboratories; 
• Issued permits to 27 entities for dispensaries and 12 entities for grower/processers; 
• Developed the Medical Marijuana Physician Workgroup; and
• Awarded a contract to MJ Freeway for electronic tracking of medical marijuana.

The Medical Marijuana Program became effective on May 17, 2016, and is expected to be fully implemented by 2018. The program will offer medical marijuana to patients who are residents of Pennsylvania and under a physician’s care for the treatment of a serious medical condition as defined by Act 16.

Questions about the Medical Marijuana Program can be emailed toRA-DHMedMarijuana@pa.gov. Information is also available on the Department of Health website at www.health.pa.gov.

National Health Care Fraud Takedown Results in Charges Against Over 412 Individuals Responsible for $1.3 Billion in Fraud Losses

On July 13, the Department of Justice and the Department of Health and Human Services (DHHS) announced the largest ever health care fraud enforcement action by the Medicare Fraud Strike Force, involving 412 charged defendants across 41 federal districts, including 115 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving approximately $1.3 billion in false billings. Of those charged, over 120 defendants, including doctors, were charged for their roles in prescribing and distributing opioids and other dangerous narcotics.

“The United States is home to the world’s best medical professionals, but their ability to provide affordable, high-quality care to their patients is jeopardized every time a criminal commits healthcare fraud.” said DHHS Secretary Tom Price, M.D.

See the full text of this excerpted press release (issued July 13)

Provider Compliance for Chiropractic Claims

Provider Compliance

 

Chiropractic Services: High Improper Payment Rate within Medicare FFS Part B

CMS continues to deny many chiropractic claims because they do not meet Medicare requirements. During the 2015 reporting period, the Medicare Fee-For-Service (FFS) improper payment rate for chiropractic services was 51.7 percent, representing approximately $300 million in improper payments and accounting for 0.7 percent of the overall Medicare FFS improper payment rate. (Source).

The most common reason for the improper payments is insufficient documentation to support the billed services. This type of error occurs when the medical records do not contain enough information for the reviewer to make a decision about medical necessity for the item or service furnished. Avoid denied claims and overpayment recovery by understanding Medicare requirements, especially documentation and medical necessity.

Resources:

MLN Matters® Articles:

 

THE FUTURE OF THE AMERICAN HEALTH CARE ACT OBAMACARE

The next era of U.S. health care reform is underway with a focus on repeal and replace of the Affordable Care Act (ACA). Last week, the House Republicans introduced two different bills, collectively called the American Health Care Act (AHCA). The bills were developed by Republican leadership and are proceeding through the legislative process in the House as approved by the Ways and Means Committee and the Energy and Commerce Committee. The AHCA is the first official piece of draft legislation in the Republican ACA repeal and replace effort.

While the AHCA legislation is not final, it provides a strong indication of the policy direction Congressional Republicans favor. 

The process to repeal and replace

Without bi-partisan support, Congressional Republicans cannot fully repeal the ACA in one action. Therefore, changes to the law likely will happen through a combination of legislative and regulatory efforts. The AHCA most immediately is expected to advance through a process known as budget reconciliation.

The budget reconciliation process accommodates provisions with direct budgetary impact and only requires 51 votes in the Senate — and there are 52 Republican senators. Because of the reconciliation rules, the AHCA will not affect popular ACA patient protections including:

  • Dependent coverage to age 26.
  • Annual out-of-pocket maximums
  • Lifetime and annual limits
  • Essential health benefits
  • Coverage for preexisting conditions

The AHCA creates a transitional period through the end of 2019 before longer-term changes take effect in 2020. The bill contains provisions intended to stabilize the individual market and encourage continuous coverage during the transition. 

The AHCA is only the first step of repealing and replacing the ACA. Additional legislation likely would be required to realize the full Republican vision of repeal and replace, including non-budgetary provisions. That legislation would require 60 votes in the Senate — necessitating support from Democrats. It is expected additional legislation will come by year-end or early 2018. 

AHCA highlights 

While the AHCA may be amended before passage, these are the current primary impacts to the ACA:

  • Repeals individual and employer mandate penalties retroactive to January 1, 2016.
  • Replaces current income-based subsidies
  • Repeals most fees and taxes, but maintains the Cadillac Tax for employer-based health plans, which would be delayed until 2025
  • Ends enhanced funding for Medicaid expansion by end of 2019, then transitions to a state block grant system
  • Makes changes to health savings accounts and flexible spending accounts (increases limits and applies again to over-the-counter products)

How the AHCA can become law: Budget reconciliation process

Budget reconciliation can begin in either the House or Senate, but identical versions of the bill must pass both chambers before it is signed by the President and becomes law. 

The AHCA has already gone through the first step in the House: consideration and approval by the two authorizing committees that received budget reconciliation instructions. The next step is for the House Budget Committee to combine the two bills and hold its own mark-up. After the Committee approves the combined bill, the full House must vote and pass the bill before it moves to the Senate. The Senate can choose to either begin consideration of the House bill or substitute its own version of repeal and replace. It is widely anticipated that the Senate will skip the committee process and raise the bill on the floor for debate and eventual vote. 

On March 13, 2017, the Congressional Budget Office released estimates on the overall cost and coverage impacts of the bill, which is furthering debate. 

If there are differences in the bills approved by the House and Senate, there are two paths forward: 1) the House could pass the Senate bill and send it to the President; or 2) a combined House and Senate conference committee can meet to negotiate a new compromise bill. That negotiated bill would then have to be passed by both chambers, before it is sent to the President for signature. 

Congress is hoping for action on the AHCA in the next few weeks, including a potential vote on the House floor the week of March 20, 2017. The process may slow down to ensure there are enough votes to pass the bill. Outside of deadlines requested by party leadership, there is generally no set legislative timeline. President Trump has expressed strong support of the initial bill.

 

 

 

Don't lose your DEA license! Fewer reminders for renewals

The DEA has updated its process for renewals.

This change eliminates the informal grace period which the DEA had previously allowed registrants to renew their registrations.

The DEA announced that starting 1/1/17, it will only send one renewal notification for each registrant approxiamtely 65 days prior to expiration.

A failure to renew prior to expiration will result in retirement of the DEA.

Please note you will not receive multiple reminders and they will be very strict with any grace period. 

REVISED ANNOUNCEMENT REGARDING RENEWAL APPLICATIONS

Starting January 2017, DEA will no longer send its second renewal notification by mail. Instead, an electronic reminder to renew will be sent to the email address associated with the DEA registration.

At this time, DEA will otherwise retain its current policy and procedures with respect to renewal and reinstatement of registration. This policy is as follows:

  • If a renewal application is submitted in a timely manner prior to expiration, the registrant may continue operations, authorized by the registration, beyond the expiration date until final action is taken on the application.
  • DEA allows the reinstatement of an expired registration for one calendar month after the expiration date. If the registration is not renewed within that calendar month, an application for a new DEA registration will be required.
  • Regardless of whether a registration is reinstated within the calendar month after expiration, federal law prohibits the handling of controlled substances or List 1 chemicals for any period of time under an expired registration.

https://www.deadiversion.usdoj.gov/drugreg/index.html

Medical Marijuana training is here!

It's time!  CME Credits, training, and Conference for Medical Marijuana.

22.5 CME credits available for medical providers (MDs, DOs, NPs, RNs, etc...).  

All staff are encouraged to attend the education class!  Office managers, owners, staff will all benefit from learning about how Medical Marijuana is implemented into an office, how it helps the patient, and what documentation is required for each patient.

Use Promo code:  TripleB

on check out to save $20.00

Buy Here:

https://www.compassionatecertificationcenters.com/conference-overview/ 

 

New PT & OT Cpt codes Effective January 1, 2017

FAREWELL TO 97001, 97002, 97003, 97004  

Welcome New PT and OT Cpt codes!!!  WOW! 

As of January 1, 2017, all PTs and OTs must begin using a new set of CPT codes to bill for therapy evaluations and re-evaluations. 

These codes are similar to E&M codes that will vary by complexity, necessity, and documentation. 

Replacement CPT Codes for 97001

Physical therapists will no longer use the same evaluation code for every single patient. Instead, they will choose from a set of three different evaluative codes that are tiered according to complexity. Those codes are:

97161

Physical therapy evaluation: low complexity

97162

Physical therapy evaluation: moderate complexity

97163

Physical therapy evaluation: high complexity

Replacement CPT Codes for 97003

Occupational therapists also must select from a new set of three tiered codes when billing for patient evaluations. And like the new PT codes, these codes are organized by complexity:

97165

Occupational therapy evaluation: low complexity

97166

Occupational therapy evaluation: moderate complexity

97167

Occupational therapy evaluation: high complexity

Replacement CPT Codes for 97002 and 97004

This update also affects the codes for PT and OT re-evaluations. However, unlike the evaluation codes, the re-evaluation codes are not tiered according to complexity. Instead, there is one replacement code for 97002 and one for 97004, as shown below.

97164

Re-evaluation of physical therapy established plan of care requiring:

  1. An examination (including a review of history and use of standardized tests and measures)
  2. A revised plan of care (based on use of a standardized patient assessment instrument and/or measurable assessment of functional outcome)

97168

Re-evaluation of occupational therapy established plan of care requiring:

  1. An assessment of changes in patient functional or medical status, along with a revised plan of care
  2. An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals
  3. A revised plan of care (a formal re-evaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required)

Selecting the Right Level of Evaluation Complexity

 Here are the four main evaluation complexity factors, along with a few sub-factors:

  1. Patient history
    1. Personal factors
      1. Patient age
      2. Education level
      3. Coping style
      4. Social background
      5. Lifestyle
      6. Character
      7. Attitudes
    2. Comorbidities
      1. Past medical history (examples below)
        1. Obesity
        2. Diabetes
        3. Hearing loss
        4. Visual deficits
        5. Cognitive deficits
  2. Depth and results of examination and use of standardized tests and measures
    1. Expected progression
    2. Objective findings
  3. Clinical presentation
    1. Status of current condition
    2. Mechanism of current condition
  4. Clinical decision-making
    1. Goal establishment
    2. Prognosis and probable outcome

Vocabulary

  • Body Regions: Refers to areas of the body, such as head, neck, back, lower extremities, upper extremities, and trunk.
  • Body Systems: Includes the circulatory, skeletal, muscular, nervous, respiratory, immune, excretory, integumentary, lymphatic, cardiovascular, reproductive, and digestive systems.
  • Body Structures: Refers to the body’s structural or anatomical parts (e.g., organs or limbs), which are classified according to body systems.
  • Body Functions: Refers to physiological functions of body systems.

Characteristics of a Low-Complexity Evaluation

PT (97161)

Duration

Typically, the PT spends 20 minutes face-to-face with the patient and/or family.

History

The patient has a history of the present problem without any personal factors and/or comorbidities that impact the plan of care.

Examination

The PT completes an examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.

Clinical Presentation

The clinical presentation is stable and/or uncomplicated.

Decision-Making

The PT exercises clinical decision-making of low complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

OT (97165)

Duration

Typically, the OT spends 30 minutes face-to-face with the patient and/or family.

History

The patient’s occupational profile and medical and therapy history includes a brief history with review of medical and/or therapy records related to the presenting problem.

Examination

The OT completes an assessment(s) identifying 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.

Decision-Making

The OT exercises clinical decision-making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. The patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.

Characteristics of a Moderate-Complexity Evaluation

PT (97162)

Duration

Typically, the PT spends 30 minutes face-to-face with the patient and/or family.

History

The patient has a history of the present problem with a history of 1-2 personal factors and/or comorbidities that impact the plan of care.

Examination

The PT completes an examination of body systems using standardized tests and measures addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.

Clinical Presentation

The clinical presentation is evolving with changing characteristics.

Decision-Making

The PT exercises clinical decision-making of a moderate complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

OT (97166)

Duration

Typically, the OT spends 45 minutes face-to-face with the patient and/or family.

History

The patient’s occupational profile and medical and therapy history includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.

Examination

The OT completes an assessment(s) identifying 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.

Decision-Making

The OT exercises clinical decision-making of a moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. The patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable completion of evaluation component.

Characteristics of a High-Complexity Evaluation

PT (97163)

Duration

Typically, the PT spends 45 minutes face-to-face with the patient and/or family.

History

The patient has a history of the present problem with 3 or more personal factors and/or comorbidities that impact the plan of care.

Examination

The PT completes an examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.

Clinical Presentation

The clinical presentation is unstable with unpredictable characteristics.

Decision-Making

The PT exercises clinical decision-making of a high complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

OT (97167)

Duration

Typically, the OT spends 60 minutes face-to-face with the patient and/or family.

History

The patient’s occupational profile and medical and therapy history includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.

Examination

The OT completes an assessment(s) identifying 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.

Decision-Making

The OT exercises clinical decision-making of a high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and

consideration of multiple treatment options. The patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable completion of evaluation component.

WEBPT:  https://www.webpt.com/blog/post/farewell-97001-how-to-use-the-new-pt-and-ot-evaluation-codes  

 

New Labor Law changes how we pay Overtime; New FLSA Updates

I understand that many doctors have numerous items to concerns themselves with and that often Human Resource compliance is the last thing on their mind.

However, with this new law signed by Obama, you will need to pay attention as it DRASTICALLY changes the landscape of wages paid in America and is going to affect the mass majority of employees and employers.

As most are aware, there are employees titled EXEMPT and NON EXEMPT.

NON EXEMPT employees are paid an hourly wage.  If they work over 40 hours per week, you must pay them overtime.

EXEMPT Employees are paid Salary.  You are not required to pay them overtime payments and they may work well over 40 hours without earning any extra wage.  

There have always been tests to determine if you qualify for Exempt status , in addition to the testing criteria to qualify for salary status, an employee also had to be paid a minimum of $455 per week or $11.38/hour.

THIS IS WHERE THE MAJOR CHANGE IS!!!

EFFECTIVE DECEMBER 1, 2016, IN ORDER TO QUALIFY FOR EXEMPT STATUS - BE PAID A SALARY WITH NO OVERTIME - YOU AS THE EMPLOYER MUST PAY THEM AT LEAST $913 PER WEEK OR $22.83/HOUR. 

This means - that unless your Office Manager or Director or any other salary employee (hopefully not your front desk) - is making at least $913 per week OR $47,476 Annually from you - YOU NEED TO START PAYING OVERTIME. 

I will outline a related portion of the criteria to qualify for exempt status below. 

Please contact me with any questions.

Executive Exemption

To qualify for the executive employee exemption, all of the following tests must be met:

  • The employee must be compensated on a salary basis (as defined in the regulations) at a rate not less than $913 per week;
  • The employee’s primary duty must be managing the enterprise, or managing a customarily recognized department or subdivision of the enterprise;
  • The employee must customarily and regularly direct the work of at least two or more other full-time employees or their equivalent; and
  • The employee must have the authority to hire or fire other employees, or the employee’s suggestions and recommendations as to the hiring, firing, advancement, promotion or any other change of status of other employees must be given particular weight. 

Administrative Exemptions

To qualify for the administrative employee exemption, all of the following tests must be met:

  • The employee must be compensated on a salary or fee basis (as defined in the regulations) at a rate not less than $913 per week;
  • The employee’s primary duty must be the performance of office or non-manual work directly related to the management or general business operations of the employer or the employer’s customers; and
  • The employee’s primary duty includes the exercise of discretion and independent judgment with respect to matters of significance.

Professional Exemption

To qualify for the learned professional employee exemption, all of the following tests must be met:

  • The employee must be compensated on a salary or fee basis (as defined in the regulations) at a rate not less than $913 per week;
  • The employee’s primary duty must be the performance of work requiring advanced knowledge, defined as work which is predominantly intellectual in character and which includes work requiring the consistent exercise of discretion and judgment;
  • The advanced knowledge must be in a field of science or learning; and
  • The advanced knowledge must be customarily acquired by a prolonged course of specialized intellectual instruction.

To qualify for the creative professional employee exemption, all of the following tests must be met:

  • The employee must be compensated on a salary or fee basis (as defined in the regulations) at a rate not less than $913 per week;
  • The employee’s primary duty must be the performance of work requiring invention, imagination, originality or talent in a recognized field of artistic or creative endeavor.

DEPARTMENT OF LABOR FACTSHEET, SHOULD BE UPDATED AFTER DECEMBER 1ST: https://www.dol.gov/whd/overtime/fs17a_overview.htm 

A NOTE ON THE FINAL RULE:  https://www.dol.gov/WHD/overtime/final2016/ 

 

On May 18, 2016, President Obama and Secretary Perez announced the publication of the Department of Labor’s final rule updating the overtime regulations, which will automatically extend overtime pay protections to over 4 million workers within the first year of implementation. This long-awaited update will result in a meaningful boost to many workers’ wallets, and will go a long way toward realizing President Obama’s commitment to ensuring every worker is compensated fairly for their hard work.

In 2014, President Obama signed a Presidential Memorandum directing the Department to update the regulations defining which white collar workers are protected by the FLSA's minimum wage and overtime standards. Consistent with the President's goal of ensuring workers are paid a fair day's pay for a hard day's work, the memorandum instructed the Department to look for ways to modernize and simplify the regulations while ensuring that the FLSA's intended overtime protections are fully implemented.

The Department published a Notice of Proposed Rulemaking (NPRM) in the Federal Register on July 6, 2015 (80 FR 38515) and invited interested parties to submit written comments on the proposed rule at www.regulations.gov by September 4, 2015. The Department received over 270,000 comments in response to the NPRM from a variety of interested stakeholders. The feedback the Department received helped shape the Final Rule.

Key Provisions of the Final Rule

The Final Rule focuses primarily on updating the salary and compensation levels needed for Executive, Administrative and Professional workers to be exempt. Specifically, the Final Rule:

  1. Sets the standard salary level at the 40th percentile of earnings of full-time salaried workers in the lowest-wage Census Region, currently the South ($913 per week; $47,476 annually for a full-year worker);
  2. Sets the total annual compensation requirement for highly compensated employees (HCE) subject to a minimal duties test to the annual equivalent of the 90th percentile of full-time salaried workers nationally ($134,004); and
  3. Establishes a mechanism for automatically updating the salary and compensation levels every three years to maintain the levels at the above percentiles and to ensure that they continue to provide useful and effective tests for exemption.

Additionally, the Final Rule amends the salary basis test to allow employers to use nondiscretionary bonuses and incentive payments (including commissions) to satisfy up to 10 percent of the new standard salary level.

The effective date of the final rule is December 1, 2016. The initial increases to the standard salary level (from $455 to $913 per week) and HCE total annual compensation requirement (from $100,000 to $134,004 per year) will be effective on that date. Future automatic updates to those thresholds will occur every three years, beginning on January 1, 2020.

ADP PAYROLL COMPANY ALSO HAS A NICE EXPLANATION OF THE NEW RULE HERE: http://sbshrs.adpinfo.com/flsa 

Billing for Influenza: New CPT Code 90674

Billing for Influenza: New CPT Code 90674 

The American Medical Association issued a new Current Procedural Terminology (CPT) code for influenza vaccine Flucelvax, CPT 90674, effective August 1, 2016 for Medicare claims. However, Medicare claims processing systems will not be able to accept the new code until January 1, 2017. Until this time, you may hold claims containing CPT 90674. Alternatively, Medicare Administrative Contractors (MACs) may direct use of a Not Other Classified (NOC) code to allow billing for the vaccine for dates of service on or after August 1, 2016, and before January 1, 2017. Check with your MAC for this information and other interim billing instructions. Finally, if you bill institutional claims, note that code CPT 90674 will be implemented on February 20, 2017.