The Breach Notification Rule

On September 23, 2009, Section 164.408 of the breach notification interim final rule became effective, which implements section 13402(e)(3) of the HITECH Act.

If you are reading this blog, chances are you know what this means. However, if you don't necessarily know the ins and outs of the regulations, this section requires covered entities to provide notification of breaches of unsecured protected health information directly to the Secretary of HHS.

More importantly, breaches that affect 500 or more individuals must be reported to HHS within sixty days and covered entities must provide this notification via the online form on the Office for Civil Rights (OCR) website. (Note - A covered entity is any health plan or company who transmits health information, this includes Merrill Corp.) By posting this information on the HHS website, OCR has met its HITECH Act obligation of making this information public. The list of the covered entities that have reported such breaches, along with other relevant information about each breach, is consistently updated and available here.

This new rule is just another example of the tightening regulations affecting the healthcare industry as HHS, CMS and other regulatory bodies continue to focus on data management. Because of this increasing regulation, health plans are going to need and experienced partner- like Merrill- now, more than ever before.

Merrill is uniquely positioned to help health plans remain compliant in the execution of their member communications. While our compliance-driven message is new to the industry, it is one that has been resonating.

For more information on this regulation, visit the OCR website, and also, continue to visit this blog as I continue my ongoing research to offer new insight into the inner workings of the Health Reform and the future of the healthcare industry.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

News from the World Healthcare Congress

Among the many announcements made at the 7th Annual World Healthcare Congress, acting director of the Center for Drug and Health Plan Choice Jonathan Blum was introduced as the new Policy Director for the Centers for Medicare and Medicaid, reporting directly to HHS Secretary Kathleen Sebillius.

In his presentation, Jonathan made several key statements:

• On the Medicare side, CMS will take the lead in payment reform and quality improvement measures, stressing a desire to partner with State Medicaid and Private Payers to reduce cost, improve quality outcomes, and maximize available dollars.
  
• His first priorities are dealing with Part D, where the "donut hole" will be closed in a ten year period.
• CMS is also looking to contract for discounts. Changes to payments for Medicare Advantage (MA) plans will occur and have basis of payment on quality and outcomes in 2012. When plans have an increase in their quality rating and elevate outcomes, they will receive a reward of higher payments.
• The CMS Center for Innovations has been established to open in January 2011 with funding of $10 million. They are planning on creating an Accountable Care Organization (ACO) policy for Medicare Programs, Pay for Performance Systems (PPS) for hospitals. However, bundled payment will take more time. With the Center for Innovations, CMS now has the authority to take successful demonstration projects from inception to reality without having to return to Congress for approval. For unsuccessful projects, there will still be valuable information learned.
• Next steps for MA include streamlining the process for beneficiaries, developing best-care models (with an emphasis on coordination of care for members), and creating better quality and more competitive plans.
• There has not been a substantial change in the number of PFFS plans leaving the market place, however, there is an all-time high of beneficiary satisfaction in their MA plans and are increasing their request of geographical areas.
• Fraud and abuse continue to be a huge area for CMS and will continue to be addressed.
  

Jonathan clearly has both the credentials and contacts to be successful in his new role, and his remarks indicate that he has a firm grasp on the process to develop and implement many of the new regulations that will be addressed in the upcoming months and years.

CMS Releases 2011 Draft Medicare Marketing Guidelines

As a follow-up to our blog on the CMS 2011 Call Letter draft, a draft of the 2011 Medicare Marketing Guidelines has also been released. The summary of significant changes included within are as follows:

Summary of Significant Changes

• Clarified guidance related to requirements for plan sponsors with non-English speaking or special needs populations (section 30.7).
• Added guidance related to material status and date stamp for file & use materials (section 40.1).
• Clarified guidance related to customer service hours of operation requirements and added a new section on agent/broker customer service number requirements (sections 40.11 and 40.11.1).
• Significantly restructured and consolidated disclaimer requirements (section 50).
• Clarified and restructured guidance related to advertising/explanatory marketing requirements (sections 50.1 and 50.1.1).
• Clarified plan mailing statements (section 50.2; formerly section 50.6).
• Clarified the responsibility for the summary of benefits review on the comprehensive statement in section 4 regarding accuracy of SNP benefits (section 60.1).
• Clarified guidance related to provider and pharmacy directory mailing requirements (sections 60.4.1 and 60.4.2).
• Clarified that door hangings are considered unsolicited contacts (section 70.4).
• Revised our policy with regard to outbound enrollment verification (OEV) requirements, including applicability of OEV requirements to enrollment changes within organizations and to agents when acting as customer service representatives only, operational timeframes, and guidance on recording and retaining verification calls. We also added Medicare Medical Savings Account OEV requirements to this section (sections 70.6 & 70.6.1).
• Restructured and revised guidance regarding educational events and sales/marketing events to encompass relevant topics or examples from current Guidelines sections 70.7.1-70.8.3 (sections 70.7 and 70.8; formerly 70.8 and 70.9).
• Added guidance on resubmitting previously disapproved marketing pieces (section 90.4).
• Revised the submission of template materials (section 90.10).
• Extended website requirements to Part C organizations and to social networking sites (section 100.1).
• Added requirements regarding the prohibition of charging additional marketing fees (section 120.5.4.1).
• Added and clarified requirements with respect to the charge back for agents and brokers (section 120.5.6).
• Clarified that the Medicare Mark will be incorporated in the contract management module in HPMS and that further guidance will be forthcoming as part of the annual contracting process (section 150).
• Added previously released policy guidance on the use of Federal funds and the use of Medicare beneficiary information obtained from CMS requirements (sections 160 and 170).
  

If you would like more information on the guidelines, click HERE (as a note, at the time of this blog, the CMS website was being updated).

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

Communicating the Healthcare Reform Bill

As a continuation on the brief synopsis we supplied on last week’s blog on the Healthcare Reform Bill, we wanted to share some additional components of the law, but also share ideas on how to convey the information to the public.

There have literally been thousands of articles written over the past week on different aspects of the legislation. I've been reading many of them for both personal and professional reasons to learn about the law, review the different opinions, and most importantly, research the best ways to communicate it. I found that this one which discusses the most well-known changes that will take effect either immediately or eventually, as well as a brief description on some of the lesser known components of the bill, including:

Transparency in Insurance Companies

• Insurers must now reveal how much money is spent on overhead

New Insurance Plans must include Preventative Care

• New plans must cover checkups and other preventative care without co-pays. All plans will be affected by 2018

Deductions for non-profit organizations

• Non-profit organizations will be required to maintain a medical loss ratio -- money spent on procedures over money incoming -- of 85 percent or higher to take advantage of IRS tax benefits

Encouraging Investment in New Therapies

• A two year temporary credit (up to a maximum of $1 billion) is in the bill to encourage investment in new therapies for the prevention and treatment of diseases

Strengthened Fraud and Abuse Checks

• New screening procedures will be implemented to help eliminate health insurance fraud and waste

Medicare Expansion to Rural Areas

• Medicare payment protections will be extended to small rural hospitals and other health care facilities that have a small number of Medicare patients

Customer Appeals Process

• Any new plan must now implement an appeals process for coverage determinations and claims

Of the many articles I’ve read, this is an example of one that not only presents the key information that different segments of the population need to know (with the potential to expand on it in the future), but as a communications professional, an example of method that organizations should consider when developing their own collateral on behalf of their clients.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.