CMS has sharply accelerated its push toward moving outpatient payments from a fee-for-service model to a true prospective payment system with a number of its proposals in the 2016 OPPS proposed rule (https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-16577.pdf), including new comprehensive APCs (C-APC) and extensive APC consolidation and reconfiguration.
Educating coders and clinical documentation improvement (CDI) specialists on CMS claims-based measures is essential in today's value-based payment environment. Empowered with an understanding of measure specifications and risk adjustment methodologies, a strong CDI program can effectively address opportunities to improve quality profiles and associated hospital revenue.
1. The audit is intended as an educational tool, but if auditors discover serious noncompliance issues, they may request OCR conduct an investigation to determine if enforcement action is necessary.
HIPAA originally recognized the business associate (BA) as a contractor of a covered entity (CE), but did not mandate direct accountability to the regulations. This put the onus on a CE to ensure, contractually, that its BAs met applicable requirements and supported their CE clients' compliance. When the Privacy and Security Rules first became effective, many CEs accepted BA contracts (BAC) (sometimes also called BA agreements [BAA]) from their BAs. Some BAs were actually quite adamant about having the CE sign their BAC. Although it was the obligation of a CE to initiated the BAC and the CE was liable under the law for compliance, in most cases, BAs offered a BAC that met the legal requirements and often looked like the model offered by HHS. If this was not the case or if either party wanted additional provisions, the CE and the BA negotiated a contract. No provisions required by HIPAA could be removed or changed, but other provisions could be added.
One of the biggest challenges to the provider community, including hospitals and critical access hospitals (CAH), is keeping up to date with current regulatory requirements, particularly when it comes to rules on coverage, coding, billing, and payment for services provided to beneficiaries under federal healthcare programs, including Medicare and Medicaid. For those of you who have taken one of our hospital or CAH Medicare Boot Camps, you probably remember discussing this early during the week, when we identified the major official sources of authority on Medicare rules, as well as some tips about how to efficiently keep yourselves up to date.
