Health Reform’s Impact on Imaging

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imagePlenty remains unknowable about the incipient impact of the Patient Protection and Affordable Care Act of 2010 (PPACA), but the act does stand to affect imaging providers, specifically through its compliance, fraud, and payment provisions, many of which have already taken effect or will take effect in the near future.

imageThe statute gives an unprecedented level of authority to the secretary of HHS, relying on that office to define and narrow the scope of broad concepts. For instance, the bill states that the DHHS may impose a series of requirements for Medicare-reimbursed providers, ranging from criminal background checks to unannounced site visits.

Although it could take years for HHS to determine how it will interpret some of the bill’s mandates, imaging providers should begin preparing now for what is already shaping up to be an environment of increased scrutiny and oversight.

Compliance and Enrollment

Although enrollment and credentialing for Medicare are no small feats under current regulations, PPACA mandates that HHS issue new, more stringent regulations to screen all providers and suppliers receiving Medicare, Medicaid, and TRICARE reimbursement. The bill suggests that the HHS consider imposing criminal background checks, fingerprinting, unannounced site visits, and application fees for providers not yet in the programs, for newly enrolled providers, and for providers revalidated as of September 23, 2010.

Providers may also have to disclose any affiliations they have with other providers or suppliers that have uncollected debt, that have been suspended or excluded from any of the above programs, or that have had their billing privileges revoked.

One thing is clear: PPACA requires providers’ participation in federally reimbursed health plans to be subject to the precondition of having a compliance program of some nature. Imaging providers can prepare for this eventuality by establishing a compliance plan as soon as possible, ensuring that they will be able to meet whatever requirements HHS issues within a short time.

Providers should also begin sanctions screening of their affiliated providers and suppliers to ensure that their enrollment is not denied based on another organization’s debt or billing issues. Practice managers should keep an ear to the ground, staying up to speed on any statements issued by CMS and by their local Medicare audit contractor.

Upping the stakes, penalties for failing to meet new enrollment requirements will also be steeper under PPACA: Anti-kickback civil monetary penalties will be increased to $50,000 per false statement in any application, bid, or contract to participate in a federal health-care program, and the secretary of HHS will have the ability to exclude individuals from participation.

Fraud and Abuse

In keeping with these new provisions, PPACA mandates an expansion of the Recovery Audit Contractor (RAC) program to Medicaid; by 2011, all state Medicaid agencies must contract with a RAC, with the goal of identifying and recovering all under- and overpayments associated with services provided under Medicaid plans. Providers not up to date on their state’s Medicaid policies should prepare for increased scrutiny and ensure that they are billing correctly, understanding that Medicaid billing requirements do occasionally differ from those of Medicare.

PPACA also adds a new provision to Stark self-referral regulations, applying them to MRI, CT, PET, and any other diagnostic health services deemed appropriate by the secretary of HHS. According to the new regulation, which became effective January 1, physicians performing these ancillary diagnostic services in their offices must provide written notice to beneficiaries that they may obtain the services elsewhere, complete with a list of alternative sites in the area where the patient resides.

Payment and Overpayment

Already in effect are new requirements for reporting overpayments from CMS. Although overpayments have always been subject to the False Claims Act, which required providers to report them and return the balance to CMS, PPACA updated this requirement to specify that surplus payment must be returned within 60 days and must be accompanied by a written explanation of the discrepancy. Some (but not all) Medicare carriers currently require submission of an overpayment refund form, and Medicaid carriers rarely do. An example of an overpayment form can be seen here:

imageA sample overpayment refund/notification