The first day of school. The first day of a new job. Both tend to come with jitters and apprehension. Yesterday marked the first Monday in office for President Donald J. Trump.
From what has been reported throughout the tumultuous presidential campaign about the brashness and self-assuredness of candidate Donald Trump, it is unlikely that America’s newly elected president will be walking into the Oval Office with any sense of uncertainty.
Meanwhile, for America’s healthcare professionals, yesterday was also the first day on the job under the Trump administration. And among them, a sense of uncertainty would not be surprising.
Last Thursday’s Senate confirmation hearings exposed uncertainty among Republican lawmakers over the yet-to-be revealed Patient Protection and Affordable Care Act (PPACA) replacement plan that President Trump has said would offer insurance for “everybody.” Meanwhile, U.S. Rep. Tom Price (R-Ga.), Trump’s nominee for secretary of the U.S. Department of Health and Human Services (HHS) – who has yet to be confirmed by the Senate – told lawmakers during the hearings that repealing the PPACA would not leave millions without healthcare, yet he offered no details. Price, a former orthopedic surgeon, was among several other Republican lawmakers opposed to the implementation of ICD-10.
As the stock market abhors uncertainty, so too does the healthcare industry, including the insurance markets. So today, RACmonitor asked several of its contributing editors what initiatives will warrant attention today and in the coming days.
Tim Powell, CPA: Center for Medicare & Medicaid Innovation
“There are a myriad of compliance provisions included in the (PPACA) that may or may not be repealed, including the requirements for long-term care to have a compliance plan. Zone Program Integrity Contractors, or ZIPCs, and similar compliance groups were unpopular with Republicans and could also be peeled back or eliminated. I also feel the the Center for Medicare & Medicaid Innovation (CMMI), also known as the Innovation Center, may not be popular with the incoming administration and may face changes in direction. It will also be interesting to watch whether the move toward value-based purchasing will continue.”
Frank Cohen, MPA: CMS Compliance Strategies
“It’s difficult to know what to expect with respect to the PPACA and the supporting CMS compliance strategies because of what appear to be differences between Trump’s ideas and those of the Republican leadership. From a financial perspective, I am interested to see what happens to deductible levels under rules that will likely affect insurance policy costs and payments. From a taxation perspective, I am curious to see what happens to the mandate, (which mandated that) those without insurance had to pay a penalty – and if it is wiped out, whether it will be retroactive for the 2016 tax year. Of great interest to me and likely to providers is what happens with regard to CMS compliance strategies.
I am really hoping that the new administration will address the abhorrent record of Office of Medicare Hearings and Appeals (OHMA) in holding administrative law judge (ALJ) hearings for recoupment and recovery appeals. When you look at the huge disconnect between (the rate of) reversals at the ALJ level (which is high) compared to reversal decisions at the reconsideration and redetermination levels, it becomes obvious that the first two levels are nothing more than a rubber stamp for the auditors – and that has to stop. If an ALJ finds 50 or 60 percent or more of claims should have been paid, then one would expect to see near that level of reversals at earlier appeals levels, and one hopes that Congress will find a way to hold the reviewers accountable for this. Same goes for the auditors. I am hopeful that some type of accountability metric will be put into place that will create a disincentive, if not a penalty, for auditors that end up with high reversal rates; say, greater than 10 percent. Finally, I would like to see Congress change the Recovery Audit Contractors’ (RACs’) contracts so that they don’t get their bounty fee until after the final hearing; whether that is at the ALJ, MAC, or federal court levels.”
David Glaser, Esq.: CJR Program
“U.S. Rep. Price, Trump’s nominee for secretary of the U.S. Department of Health and Human Services (HHS), has strong feelings about health policy. In his testimony last Thursday (confirmation hearings), he expressed concern that CMMI was requiring physicians to participate in new programs rather than offering voluntary demonstration projects. In particular, he objects to the compulsory nature of the Comprehensive Joint Replacement (CJR) program. It will be interesting to see if there are changes to CJR and cardiac bundling programs.”
Janelle Ali-Dinar, PhD: Rural Health
“For rural America, with a population estimated at more than 62 million, 700 critical access hospitals could be put at risk of imminent closure due to continued cuts with the repeal of the PPACA. The 1.7 million rural Americans who purchased health insurance on government exchanges in 2016 would be at greater risk of having no subsidies. It could put states and cash-strapped hospitals that received Medicaid expansion even more at risk because the financial assistance would be eliminated.”
Stanley Sokolove, CPA, ALJ Emeritus: Revenue Loss
“The repeal or dismantling of the PPACA could cost hospitals as much as $166 billion from 2018 to 2026 relating to reductions in Medicare and Medicaid inpatient payments. Revenue growth could be in outpatient expansion strategies for provider-based facilities over the next few years.”
Duane Abbey, PhD: Provider-Based Clinics
“The implementation of the Section 603 of the Bipartisan Budget Act of 2015 (BiBA) has been further complicated by Section 16001 of the 21st Century Cures Act. Hospitals that are considering establishment of new off-campus provider-based clinics and/or those that have established new provider-based clinics during 2016 (or at least after the enactment of BiBA 2015 in November 2015) will need to fully understand how this congressional intervention has affected the provider-based landscape. We must also await sub-regulatory guidance on proper billing and reimbursement through the use of the PN modifier.”
Edward Roche, PhD, JD: DME Documentation Requirements
“During 2017, providers need to keep a careful watch on durable medical equipment (DME) suppliers. A large number continue to go bankrupt, and the three-year lock-in enforced by CMS will continue to raise questions about the introduction of new DME technologies. Finally, providers need to stay on top of changes in DME documentation requirements. For hospitals and integrated delivery systems that have provider-based clinics, this is a good time to carefully review whether or not any of these changes affect any operations, both new and old provider-based clinics/operations.”
Looking Ahead
Our country has traditionally characterized any new president by the familiar metric of the “first 100 days.” Monday, Jan. 23 was the first of those 100, and there appears to be no clear way to predict what will unfold during the next 99.
Stay tuned.
About the Author
Chuck Buck is publisher of RACmonitor and is the executive producer and program host of Monitor Mondays.
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