EisnerAmper Blog

An EisnerAmper Health Care Services Blog

Limited English Proficient Patient Requirements

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September 22, 2016

By Steven Bisciello, MBA, CMPE  

Another requirement that hospitals/health care entities must now be in compliance with begins next month. 

As per the Affordable Care Act (Sec. 1557), beginning October 17, 2016, all “covered entities” must “take steps to provide meaningful access” to Limited English Proficient patients (“LEP”). Covered entities include hospitals, health clinics and nursing homes. 

The entities must post notices of both nondiscrimination and the availability of qualified interpreter services for patients. 

These notices must be posted in 15 languages and must communicate that the hospital, in concordance with said provision, prohibits discrimination based on race, color, national origin, sex, age or disability. These notices must also clearly communicate that the hospital has and will supply language assistance services/ translation services, free of charge, to limited English proficient patients. 

The 15 languages that these notices must be posted in are the top 15 languages spoken in the respective state where the entity is located. The Office for Civil Rights (“OCR”) has already provided 64 translations on its respective website. An example or “tagline” the entity must post reads: “If you speak [insert language], language assistance services, free of charge, are available to you. Call 1-xxx-xxx-xxxx (TTY:1-xxx-xxx-xxxx).” A statement and notice of nondiscrimination must also be posted in those same respective 15 languages. 

These notices/taglines must be posted in physical locations visible to the patients/public, as well as be posted on the entity’s respective website.  

Once posted, the regulations state that the entity, if it is an entity 15 or more employees, must then ensure compliance with these regulations. Ensuring compliance includes the adoption, provision and adherence to grievance procedures.  

Hospitals are also obligated to comply and supply interpreter/translation services as per the Joint Commission’s Effective Communication Standards. These standards simply state that hospitals must be able to communicate with patients “in a manner that meets the patient’s oral and written communication needs.”  

Also, the entities/providers are required “to translate vital medical documents” so that both the patients and the medical staff “can be heard and understood.”  

To assist the health care entities in deciding which languages they should post their notices in as well as translate vital medical documents into, the HHS has provided a formula: “vital medical documents should be translated into any language spoken by 5% of the people served by the facility or 1,000 of them — whichever is less.” 

Given the abundance of documents utilized by health care entities, the Joint Commission also suggests considering whether written documents have “clinical, legal or other important consequences.” Another resource for identifying which documents should be translated is HHS’s Translated Resources for Covered Entities.

MACRA Update

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September 19, 2016

By Michael J. McLafferty, CPA, MBA, FACHE, FACMPE, FHFMA   

The Centers for Medicare and Medicaid (CMS) reported an update last week to the proposed implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). This update offered physicians 4 different approaches in FY 2017 to implement MACRA in their practices.

These 4 options allow physicians to avoid any negative penalties starting in FY 2019:  

  1. Submit enough data to the Quality Payment Program to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019; 
  2. Submit the full set of performance data for less than the full 2017 calendar year; 
  3. Submit the full set of performance data for the full 2017 calendar year; or 
  4. Participate in an Advanced Alternative Practice Model (APM) in 2017. 

The reimbursement provisions of MACRA establish 2 value-based payment pathways for physicians who provide services to Medicare beneficiaries:  

  1. The Merit-based Payment Incentive System (MIPS) and 
  2. Advanced APMs. 

When the new payment system launches in 2019, most physicians are expected to receive Medicare payments through MIPS, which has 4 performance categories:  

  1. Quality; 
  2. Cost; 
  3. Clinical care improvement activities such as boosting care coordination;
  4. Electronic health record capabilities.  

We believe that most of our physician clients will welcome the opportunity to choose one of four options to implement MACRA in 2017.


ICD-10-CM Official Guidelines for Coding and Reporting FY 2017

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August 30, 2016 

By Melissa Pizor, COC, CPC, CPCO, CPMA, CPRC

The 2017 ICD-10-CM Official Guidelines for Coding and Reporting have been released on the Centers for Medicare & Medicaid Services (CMS) website. This latest version includes several notable changes to generalized guidelines. These changes become applicable as of October 1, 2016. 

The beginning of the guidelines includes instructions to help identify the changes and revisions: 

  1. Narrative changes appear in bold text
  2. Items underlined have been moved within the guidelines since the FY 2016 version 
  3. Italics are used to indicate revisions to heading changes  

One of the most significant generalized clarifications is an exception to the Excludes1 definition within Section I.A.12(a). CMS defines an Excludes1 note as an indication “that the code excluded should never be used at the same time as the code above the Excludes1 note.” 

“An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.” 

Several other generalized guideline changes to take note of are as follows:

Item No. 13 clarifies guidelines relating to laterality. Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left side, right side, or both (bilateral). If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. 

When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second treatment encounter, after one side has been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition at the previously treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.  

Item No. 16 clarifies guidelines relating to Documentation of Complications of Care: Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to remember that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification if the complication is not clearly documented. 

It is also very important to note that the Medicare ICD-10 flexibilities agreement will end and will not be extended beyond October 1, 2016. 

In 2015, both CMS and the American Medical Association (AMA) jointly announced guidance that would allow for “flexibility” in the claims auditing and quality reporting process for the first year of ICD-10 implementation. “ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud.” wrote CMS. This flexibility later became known as the “grace period.” 

CMS also stated that beginning October 1, 2016, review contractors will be able to use “coding specificity as the reason for an audit for a denial of a reviewed claim to the same extent that they did prior to October 1, 2015.” 

The bottom line is it will still be crucial to assign codes that are not only valid but also specific. The use of nonspecific codes may result in claim denials and loss of payment. Please review the new guidelines thoroughly in order to fully understand the impact to coding practices.

Aetna Announces Large Reduction in ACA Exchange Participation

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August 22, 2016

By Tyler Tracewski  

Following in the footsteps of other large insurers UnitedHealth Group and Humana, Aetna announced on August 15 they will be significantly scaling back participation in the Affordable Care Act (“ACA”) insurance exchanges. In 2017, Aetna plans to operate in just 4 States, down from 15 States this year. In Aetna’s press release, CEO Mark Bertolini blames financial losses as the reason for the scale back: 

“Following a thorough business review and in light of a second-quarter pretax loss of $200 million and total pretax losses of more than $430 million since January 2014 in our individual products, we have decided to reduce our individual public exchange presence in 2017, which will limit our financial exposure moving forward.” 

However, Aetna’s decision to reduce its presence in the exchanges may be more complicated than these simple financial losses.  

In July of 2015, Aetna announced its planned $37 billion acquisition of Humana, in a deal that could be the largest merger ever in the insurance industry. The Department of Justice responded by filing suit to block the deal over antitrust issues. The DOJ took similar action to the proposed Anthem, Inc. acquisition of Cigna Corp, stating that these mergers involving 4 of the largest insurers in the country would “harm consumers, employers and health-care providers with an unacceptable reduction in competition.”  

In a July 2016 letter, signed by Bertolini to the Justice Department, Aetna responded with a warning saying if the Humana deal was blocked that  “Instead of expanding to 20 states next year, we would reduce our presence to no more than 10 states” and that “it is very likely that we would need to leave the public exchange business entirely and plan for additional business efficiencies should our deal ultimately be blocked.” 

The Aetna pullback from the exchanges, paired with the previous reductions in participation by UnitedHealth Group and Humana, are seen as blows to the ACA.  Not only will hundreds of thousands be forced to change their insurance from Aetna to another plan, the absence of Aetna and other major players in the exchanges reduces competition and choices for consumers.  

Over the next several months, all eyes will be on this legal battle and the widespread implications it may have on the insurance industry and the ACA insurance exchanges. Coincidentally, all of this will take place as President Obama, the champion the ACA, serves his last few months in office. 

Changing Market for Urgent Care Centers

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August 15, 2016

By Bert Orlov  

Our recent client experience shows that Urgent Care Centers (UCCs) are evolving in terms of their underlying business value proposition. UCCs typically offer extended hours from early morning to after-work evening hours, as well as weekends. Compared to Emergency Rooms (ERs), urgent care offers shorter wait times and far lower costs. For example, co-pays for a UCC visit may be $40-$50, while ER visits may range from $150 to $500 or more. In the NY-NJ-CT metropolitan area, we are seeing UCCs, hospitals/networks and private venture funds playing different roles with different objectives. 

Changing Roles 

Historically in our area, most UCCs were small-scale private enterprises which sought profits by providing a superior service (access and speed) at lower costs. They were often linked to primary care practices. Over the past several years, however, we see a more complex array of divergent potential business roles: 

  • Free-standing profit generator, as it has been in the past.
  • Front-door for practices or systems, as an element of a comprehensive primary care network. This may involve de novo development or acquisition of existing players.
  • Cost-reducer vs. ER for risk contracts. With the rise of “value based purchasing” and Accountable Care Organizations (ACOs), the importance of managing costs has grown dramatically—both direct expenses of ER vs. UCC visits, but also risk of admission and need for follow up.
  • ER decanter, to reduce pressure on hospitals’ ERs, because many ERs operate well above planned capacity, with adverse impact on patient service.  

Changing Market

These potential shifts in the role of UCCs are occurring within a context of a changing market. Overall, as noted above, ever more patients are enrolled in some form of value-based purchasing, driving concerns about ER utilization and costs. Further, payors are seeking to move more patients to UCCs, rather than ER, as a cost savings measure; the payors use increasing ER co-pays vs. UCC co-pays as incentive. Furthermore, the UCC market itself is becoming more mature. For example, in a 10-square mile section of Queens, there are now 10 UCCs; where there were few only 5 years ago. In Manhattan, competition has stepped up, to the extent of competing UCCS located on the same block. Similar explosions in number of centers have occurred in NJ and CT. As a result, the market is more challenging. To cite a few notable examples, 3 years ago, CityMD received capital funding of some $90mm for expansion. As a result of such exemplar growth, some of the smaller chains have been sold themselves; for example, the formerly independent Urgent Care Manhattan enterprise (with 3 sites) is now operating under the umbrella of Northwell. 


These shifts in market penetration and roles indicate the importance and changing business realties of UCCs in the region. All health care stakeholders will be impacted: 

  • Investors will need to become more selective about new start-ups and value of established mini-chains.
  • Payors will further consider means to shift patients from ERs.
  • Hospitals/networks will become increasingly involved in the operations of UCCs, including finding effective means of communicating clinical information and managing utilization patterns.
  • Patients will see opportunities to avoid ERs and, over time, greater integration between UCCs and their overall care management.

Competitive dynamics are changing in local markets; we’re advising all clients to pay attention. 


Phase 2 -- HIPAA Security Audit Program

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August 10, 2016

By Steven Bisciello, MBA, CMPE  

In June and July of 2016, the Office for Civil Rights (“OCR”) had notified a number of health care covered entities (“CEs”) and their respective business associates (via notification letters/emails) that they will next be performing individual audits of said entities/associates through their Phase Two HIPAA Security Audit Program. 

The goal of this audit program is “to examine mechanisms for compliance, identify best practices, and discover risks and vulnerabilities” to ensure compliance with HIPAA privacy/security, protected health information, and breach notification guidelines. In short, this audit will take place to ensure the CEs/business associates have documented, provided training, and implemented HIPAA Privacy and Security Compliance Plans within their organization.   

The audits are scheduled to begin in the fall of 2016. The CEs to be audited will be selected by the OCR through random sampling. As stated above, the CEs to be audited have been/will be sent notification letters/emails from the OCR (example letter), addressed to the respective CE’s primary contact person. The respective CE will have 14 days to respond to the notification letter. The notification letter/email will provide the CE’s contact person a link to a pre-screening questionnaire  to be filled out; the responses will be saved.  

In preparation for these upcoming audits, the OCR also released, on July 27, 2016, their Phase Two HIPAA Audit Guidance. The guidance is to assist CEs in preparation for OCR’s upcoming entity audits and answers questions in regards to preparation for said audits, timing of the audits, explanation of the audit process and next steps upon completion. 

CEs to be audited include: 

  • Both individual and organizational providers of health care services
  • Health insurance plans
  • Clearinghouses
  • A “range” of business associates for the CEs  

CEs will be asked to identify their current business associates for the auditors to review. The auditors will and then select business associates from this list for individual audit. The audits will be performed in both “desk audit” and “onsite audit” versions. 

The OCR states “covered entities that are the subject of an audit must submit requested information via OCR’s secure portal within 10 business days of the date on the information request. All documents are to be in digital form and submitted electronically via the secure online portal.”

Upon receipt of these requested documents, “the auditor will review the information submitted and provide the auditee with draft findings. Auditees will have 10 business days to review and return written comments, if any, to the auditor. The auditor will complete a final audit report for each entity within 30 business days after the auditee’s response. OCR will share a copy of the final report with the audited entity.” 

For more information on these audits and HIPAA in general for CE’s, please visit hhs.gov.

CMS Reports $42 Billion in Savings

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August 1, 2016
By Nancy Clark, CPC, COC, CPB, CPMA, CPC-I 

CMS recently announced that their Center for Program Integrity’s activities are beginning to save money for the Medicare program, potentially reaping rewards for taxpayers and beneficiaries.  Analysis of dates spanning October 1, 2012 through September 30, 2014 indicates that each dollar invested towards these efforts saved $12.40 for the program .

Multiple initiatives contribute to these savings:
  • Provider enrollment and screening standards
    • Utilization of the Affordable Care Act’s tools  to allow for better screening of providers and suppliers that may be at risk for committing fraud
    • Increasing site visits to enrolled providers and suppliers
    • Enhanced address verification via the Provider Enrollment, Chain, and Ownership System (“PECOS”) software
    • Deactivation of providers and suppliers that have not billed Medicare in the last 13 months  
  • Predictive analytics to prevent fraud, waste, and abuse 
    • Implementation of a Fraud Prevention System using data connections with public and private analytics experts to identify issues and take corrective action
    • Predictive analytics technology contributed to more than $1 billion in savings from 2014 to 2015.
    • Predictive analysis allows CMS to proactively deny claims that may not be appropriately reimbursable, and therefore saves the expense and time of “going after” the provider to return the inappropriate monies.  In fiscal year 2013, savings from these preventive actions represented about 68% of total savings.  In 2014, the savings rose to nearly 74%. 
    • Analyses are run on 4.5 million Medicare claims daily.
    • CMS is now working on a next-generation predictive analytics system with improved efficiency.  
  • Coordination of anti-fraud efforts with federal and external partners
    • CMS provides a forum for information exchange between federal, state, and private partners, receiving and disseminating data that will both reduce duplication of efforts and identify potential fraudulent activity across multiple payers.
    • The Office of Inspector General Work Plan continues to identify additional areas in which CMS is reviewing claims.
    • CMS contractors, state Medicaid agencies, and law enforcement partners offer and receive assistance in fraud prevention.
CMS estimates that the CPI has saved nearly $42 billion since inception.  They continue to seek out more comprehensive and expansive ways to fight incorrect and fraudulent payments. 
EisnerAmper is an independent member of Allinial Global.
EisnerAmper is an independent member of EisnerAmper Global.