the legal/regulatory framework: implementing policies for caring for the uninsured as a healthcare...
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The Legal/Regulatory Framework:
Implementing Policies for Caring for the Uninsured as a Healthcare
Compliance Strategy
Suzie DraperChief Compliance and Privacy Officer
Intermountain Healthcare
Current Climate
• Era of increased social responsibility for large businesses• Hospitals are stuck between a rock and a hard place
because: Healthcare utilization is increasing The number of uninsured is increasing The reimbursement rate is decreasing
• Social responsibility takes on a whole new meaning in the healthcare environment
• Accurately reporting and quantifying the community benefit that healthcare provides is increasingly critical with increased public scrutiny
Social Responsibility
• Society expects a certain degree of accountability from big businesses
• A clear message when sent after Enron Jobs were lost Pensions went by the wayside Investors were misled
A Rock and a Hard Place
Utilization of healthcare is exploding To address this, hospitals are working to
improve how care is delivered to each patient Providing the right care at the right time,
every time, is critical Hospitals that achieve top standards in care
could reduce patients’ time in the hospital and complications
A Rock and a Hard Place
• Rates of those with healthcare coverage is rapidly decreasing Fewer employers can afford to provide
coverage Individuals may not be able to afford
coverage on their own
Uninsured and uncompensated care track parallel trends
35
37
39
41
43
45
47
1999 2000 2001 2002 2003 2004
Non-elderly Uninsured
(in billions)Uncompensated Care
(in millions)
Source: Census Bureau, American Hospital Association
Compliance Issues and the Uninsured
• The healthcare environment is the most regulated industry in the nation
• Several of these regulatory issues take on a new life when the uninsured are involved: Emergency Room treatment requirements Section 1101: Federal Reimbursement for
Emergency Services Provided to Undocumented Aliens
Identity Theft Language Services
Emergency Room Care
Emergency Room Care
• The uninsured are heavy users of the ER
• Makes the already overcrowded ERs even more so
• If the hospital’s ER is at capacity, it may go on diversionary status, forcing individuals arriving via ambulance to go elsewhere for care
• Under federal law, patients that enter the ER cannot be turned away, regardless of their ability to pay
Problems with both Supply and Demand
• Decreased supply caused by: Hospital closures and mergers
Reimbursement constraints Nursing shortage Less profitable services have been replaced
by higher revenue producing services such as cardiovascular care
Reduced discharge options
Increased Demand
• More patients without insurance seeking care in the ER
• Increased delay in being able to make an appointment to see a primary care provider
• Stricter enforcement of the Emergency Medical Treatment and Labor Act (EMTALA)
Specifically, EMTALA:
• Sets forth requirements for medical screening examinations (MSE) for medical conditions,
• Sets forth requirements for necessary stabilizing treatment or appropriate transfer, and
• Prohibits a delay in providing required screening or stabilization services in order to inquire about the individual's payment method or insurance status
Results of EMTALA
• “In effect, it’s America’s answer to universal access to health care–and a huge unfunded mandate on emergency physicians, trauma surgeons, on-call specialists and hospitals.”
Dr. Art Kellermann, an emergency physician who testified at the early
Congressional hearings on patient dumping
Section 1101
• Federal Reimbursement for Emergency Services Provided to Undocumented Aliens Covered services are the same as those
required by EMTALA $250 million is available annually Payment is only provided for services that
were not otherwise reimbursed
Section 1101
Identity Theft
• Accurate identification of patients who choose to provide false information
• Illegal aliens may think they need a SSN for treatment
• Patients with drug seeking behavior
• Insurance fraud
• Ramifications include: Inaccurate medical history Uncollectible services Law enforcement involvement
Language Barriers and the Uninsured
• One particularly challenging portion of the patient population is both Uninsured Considered to be limited English proficient
• More than half of immigrants are uninsured
• Providing language services and healthcare services can be costly to organizations
Regulations Related to Language Services
• Examples of regulations that pertain to the provision of language services include: Title VI of the Civil Rights Act of 1964 Americans with Disabilities Act (ADA)
Language Services Regulations
TITLE VI of the 1964 CIVIL RIGHTS ACT
"No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance."
Requirements of Title VI
• Must offer language services at no cost to each patient with limited English proficiency during all hours of operation.
• Must notify patients of their rights to receive such services
Title VI (cont.)
Must assure high quality language services are provided
Family and friends should not be used to provide interpretation services (except on request by the patient/consumer)
Must provide translated patient-related materials and signage, based on the population served
ADA
• Protects against discrimination of individuals with disabilities
• Emphasizes the provision of effective aids so that they may have “full and equal enjoyment” of all healthcare services
ADA (cont.)
• Examples of accommodations: Use of qualified interpreters Provision of written materials Closed captioning Video Relay Services
Keep in Mind …
• While challenging for healthcare systems, regulations such as Title VI, ADA, and EMTALA serve a needed purpose: To ensure that no one is denied emergency
care Regardless of:
Their ability to pay or The language they speak or Any disabilities they may have
Community Benefit
• Demonstration of steps the provider is taking to support its nonprofit charitable mission
• However, it receiving increased scrutiny by the IRS
• As a result, proper documentation of community benefit is critical
IRS Interim ReportTax-Exempt Hospitals and Community
Benefit
“The lack of consistency or uniformity in classifying and reporting uncompensated care and various types of community benefit often makes it difficult to assess whether a hospital is in compliance with current law.”
Lois Lerner
Director of IRS Exempt Organization Division
Community Benefit Industry Response
American Hospital Association is encouraging its members to actively report their community benefits through: Encourage Public Reporting Retain the Community Benefit Standard Increased Financial Accountability
Community Benefit Programs: Types
Community benefit operations• Dedicated staff• Community health needs and
assessments
Health professionals education, including scholarships
Community health services• Health education• Clinical services
Subsidized health services• Emergency and trauma services• Hospital outpatient services• Behavioral health services• Palliative care and hospice
Financial contributions• Cash donations• Grants• In-kind donations
Community building• Physical improvements and
housing• Economic development• Environmental
improvements• Coalition buildingResearch
Beyond the Numbers
• Community benefit programs, while not necessarily revenue producing, tie what healthcare systems do back to their missions: Providing compassionate healthcare to all Promoting the health of communities Paying special attention to those who need it
the most, including those who are the most vulnerable
The Future of Healthcare
• The number of unfunded government mandates is increasing
• Extensive requirements for hospitals strain the amount of resources available to provide care to the communities they serve
• Ongoing sustainability of healthcare requires innovative approaches
• This will no doubt shape politics in America for years to come
Other Tax Considerations
• IRS 990 Revisions
• Conflict of Interest Processes Boards Officers
• The Future of Property Tax Exemption
Questions/Discussion