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					Louisiana Department of Insurance
 Eighth Annual Health Care Conference
          Hospitals, Physicians, Carriers
           The Effects of Regulation


     Errol J. King, Esq. - Moderator
      McGlinchey Stafford, PLLC
                         Errol J. King, Esq. Moderator
                McGlinchey Stafford, PLLC
                           Brenda Denman HIPAA Coordinator
          Centers for Medicare & Medicaid Svcs
                           Douglas Jerome Director, EDI Operations
          Blue Cross and Blue Shield of LA
                        Dr. Vincent Culotta
                  LA State Medical Society
                    Claire I. Lemoine, Esq. Chief Health Attorney
               LA Department of Insurance
                               Pam Williams Asst. Deputy Commission
               LA Department of Insurance
Louisiana Department of Insurance
  Eighth Annual Health Care Conference
           Hospitals, Physicians, Carriers
            The Effects of Regulation


   Brenda Denman, HIPAA Coordinator
Centers for Medicare and Medicaid Services
                          Errol J. King, Esq. Moderator
                 McGlinchey Stafford, PLLC
                            Brenda Denman HIPAA Coordinator
           Centers for Medicare & Medicaid Svcs
                            Douglas Jerome Director, EDI Operations
           Blue Cross and Blue Shield of LA
                         Dr. Vincent Culotta
                   LA State Medical Society
                     Claire I. Lemoine, Esq. Chief Health Attorney
                LA Department of Insurance
                                Pam Williams Asst. Deputy Commission
                LA Department of Insurance
Louisiana Department of Insurance
 Eighth Annual Health Care Conference
          Hospitals, Physicians, Carriers
           The Effects of Regulation


Douglas Jerome, Director EDI Operations
Blue Cross and Blue Shield of Louisiana
                         Errol J. King, Esq. Moderator
                McGlinchey Stafford, PLLC
                           Brenda Denman HIPAA Coordinator
          Centers for Medicare & Medicaid Svcs
                           Douglas Jerome Director, EDI Operations
          Blue Cross and Blue Shield of LA
                        Dr. Vincent Culotta
                  LA State Medical Society
                    Claire I. Lemoine, Esq. Chief Health Attorney
               LA Department of Insurance
                               Pam Williams Asst. Deputy Commission
               LA Department of Insurance
Louisiana Department of Insurance
 Eighth Annual Health Care Conference
         Hospitals, Physicians, Carriers
          The Effects of Regulation


           Dr. Vincent Culotta
    Louisiana State Medical Society
                         Errol J. King, Esq. Moderator
                McGlinchey Stafford, PLLC
                           Brenda Denman HIPAA Coordinator
          Centers for Medicare & Medicaid Svcs
                           Douglas Jerome Director, EDI Operations
          Blue Cross and Blue Shield of LA
                        Dr. Vincent Culotta
                  LA State Medical Society
                    Claire I. Lemoine, Esq. Chief Health Attorney
               LA Department of Insurance
                               Pam Williams Asst. Deputy Commission
               LA Department of Insurance
Louisiana Department of Insurance
 Eighth Annual Health Care Conference
          Hospitals, Physicians, Carriers
           The Effects of Regulation


        Claire I. Lemoine, Esq.
     Chief Health Attorney - LA DOI
                         Errol J. King, Esq. Moderator
                McGlinchey Stafford, PLLC
                           Brenda Denman HIPAA Coordinator
          Centers for Medicare & Medicaid Svcs
                           Douglas Jerome Director, EDI Operations
          Blue Cross and Blue Shield of LA
                        Dr. Vincent Culotta
                  LA State Medical Society
                    Claire I. Lemoine, Esq. Chief Health Attorney
               LA Department of Insurance
                               Pam Williams Asst. Deputy Commission
               LA Department of Insurance
Louisiana Department of Insurance
 Eighth Annual Health Care Conference
         Hospitals, Physicians, Carriers
          The Effects of Regulation


            Pam Williams
  Asst. Deputy Commissioner, LA DOI
                         Errol J. King, Esq. Moderator
                McGlinchey Stafford, PLLC
                           Brenda Denman HIPAA Coordinator
          Centers for Medicare & Medicaid Svcs
                           Douglas Jerome Director, EDI Operations
          Blue Cross and Blue Shield of LA
                        Dr. Vincent Culotta
                  LA State Medical Society
                    Claire I. Lemoine, Esq. Chief Health Attorney
               LA Department of Insurance
                               Pam Williams Asst. Deputy Commission
               LA Department of Insurance
    The Effects Of Regulation



Hospitals                 Physicians




            On…Carriers
Laws & Regulations
       • 3 State Laws…
         – MNRO
         – Timely Claims Payment
         – Balance Billing


        2 Federal Regs…
          ERISA DOL    Claims
           Payment Rule
          HIPAA Administrative
           Simplification Rule
       State Laws & Regulations
• Medical Necessity Review Organizations (MNRO)
    Effective 1999
    DOI Regulation 74

 Standards for health insurance coverage …
  Timely Claims Payment
    Effective 1999
    DOI Regulation 77

        Health Care Consumer Billing & Disclosure Act
           Effective January 1, 2004
           Known as the Balance Billing Legislation
       Federal Laws & Regulations
• DOL Claims Regulation
    Effective January 1, 2002
    Applies to all group health plans…insured or self-funded
    Does not supercede state law that regulates insurance
       Unless such law prevents application of DOL rule

 HIPAA Electronic Health Care Transactions and
  Code Sets Standards
          Effective October 16, 2003
             Implements requirements under administration
              simplification subtitle of HIPAA
Louisiana Department of Insurance
  Eighth Annual Health Care Conference

           Hospitals, Physicians, Carriers
            The Effects of Regulation



   Brenda Denman, HIPAA Coordinator
Centers for Medicare and Medicaid Services
H
Health
Insurance
I
Portability
P
Accountability
A
Act
A          CENTERS for MEDICARE & MEDICAID SERVICES
          HIPAA of 1996

    Title I                 Title II


 Portability      Administrative Simplification
 COBRA                 Privacy
                        Security
                        Transactions & Code Sets
                        Unique Identifiers
              Electronic Transactions
 Claim/Encounter                  • Claim Status Inquiry & Response
   Coordination of Benefits       • Enrollment & Disenrollment in a
   Payment & Remittance Advice      Health Plan
   Eligibility Inquiry & Response • Health Plan Premium Payments
   Referral Certification &       • Claims Attachment (pending)
    Authorization                  • First Report of Injury (pending)
             Standard Code Sets
• Medical                            Non-medical
    ICD-9-CM (diagnosis &              Claim Adjustment Reason
     procedures)                         Codes
    CPT-4 (physician procedures)       Remittance Advice Remark
    HCPCS (ancillary                    Codes
     services/procedures)               Claim Status Codes
    CDT (dental terminology)           Provider Taxonomy
    NDC (national drug codes)           (specialty)
           Compliance
 Covered entities must comply
 Compliance dates…
   10/16/02 (no extension filed)
   10/16/03
      Extension filed

      Small health plans
                     Background
 On 7/24/03, CMS’ Office of HIPAA standards
  provided guidance regarding its
  enforcement approach for compliance
 Law is clear…10/16/03 is deadline
  that Congress gave
 HHS has heard the concerns
  expressed by the health care
  industry
     Significant number of covered entities will not be ready to
      transmit / process HIPAA compliant transactions
                         Guidance
 CMS will focus on obtaining voluntary
  compliance & use a complaint-driven approach
 Guidance is directed at entire health industry …
  emphasis on health plans
      Compliant transactions require participation by two
       covered entities
      Health plans have a special role in achieving compliance
 After 10/16/03, on a case by case basis, CMS intends to
  look at both covered entities’ good faith efforts to come into
  compliance with transactions and code sets standards
        Complaint-Driven Approach
 CMS will notify the covered entity that a
  complaint has been filed
 CMS will evaluate the entity’s good faith efforts
  to comply and give the opportunity to…
      Demonstrate compliance
      Document its good faith efforts to comply
      Submit a Corrective Action Plan
 If entity has made diligent efforts to comply,
  CMS will not impose penalties on covered
  entities that deploy contingencies to ensure the
  smooth flow of payments
                 “Good Faith Efforts”
 Prior to the deadline … and after the deadline …
  sustained and demonstrable progress is made
  toward becoming HIPAA compliant
 For a health plan, includes efforts to
  assure they can exchange transactions
  successfully with their provider network
      Demonstrated outreach activities
       (letters, conferences, phone calls,
       mailings, website, etc.
                   Encouraged providers to schedule
                    testing, providing testing schedules
                    and statistics showing testing results
                 Why This Approach?
 If a health plan can demonstrate its active
  outreach and testing efforts … it can continue
  processing payments to providers
      e.g., accept a non-standard transaction
       after 10/16/03 to allow more time to “test”
 This flexibility will permit health plans to
  mitigate unintended adverse effects on …
      Cash flow
      Business operations
      Availability and quality of patient care
                     Key Messages
 CMS’s approach to enforcement is to move all
  covered entities to compliance
 Health plans have special responsibilities to get
  processes and systems HIPAA compliant
      Work with trading partners and conduct outreach
      Ensure adequate testing opportunities
      Develop contingencies
 All covered entities must document
  their “good faith efforts” to comply with
  the standards
                       CMS’ Role
 CMS will work with health plans
  and their associations between
  now and October
      Discuss operations, progress,
       contingency plans
 Work with the NCVHS to assess the extent to which we
  are achieving a smooth transition to HIPAA standards
 Continue to provide information to covered entities, via …
      Website                        CMS HIPAA hotline
      HIPAA roundtable calls         AskHIPAA email
        CMS’ Resources
 Audio conferences for target audiences
 Conferences and roundtable calls
 Fax-back service and blast faxing
 Webcasts available 24/7
 CDs, videos, transcripts
 Websites, listservs, blast emails
 CMS approved HIPAA articles,
  advertisements & informational papers
          Where To Get Help!
 Look to state associations or
  specialty organizations for
  information specific to your needs
 Websites…
          CMS       www.cms.hhs.gov/hipaa/hipaa2
           HHS      http://aspe.hhs.gov/admnsimp/
          OCR       www.hhs.gov/ocr/hipaa
SHARP Workgroup     www.sharpworkgroup.com
     WEDI/SNIP      www.wedi.org/snip/
     CMS Hotline:
     866-282-0659
      CMS Email:
askhipaa@cms.hhs.gov

OCR Hotline (Privacy):
   866-627-7748
Louisiana Department of Insurance
 Eighth Annual Health Care Conference

          Hospitals, Physicians, Carriers
           The Effects of Regulation



        Claire I. Lemoine, Esq.
     Chief Health Attorney - LA DOI
Act LSA-R.S. 22:3070 et seq
Regulation 77

            M
            Medical
            N
            Necessity
            Review
            R
            Organization
            O
          Why Enact MNRO?
 Nationwide perception that non-medical personnel
  were making medical necessity determinations
 MNRO provides …
   Uniform state-wide procedure
    for making medical necessity
    determinations
   Regulation of entities making
    those determinations
                Major Provisions
 Establishes authorization and licensure
 Mandates minimum standards for MNROs
 Establishes standards governing the medical
    necessity review process
   Establishes process requirements for conducting appeals
   Outlines minimum notification requirements and standards
   Mandates an external review process
   Specifies minimum qualifications for an independent review
    organization
   Creates a cause of action for negligence & gross negligence
Act LSA-R.S. 22:250.31 et
seq
Regulation 74


         Payment Of
            Health
          Insurance
            Claims
Application Of Law
 Health insurers
 Health Maintenance
  Organizations (HMOs)
 Preferred Provider
  Organizations (PPOs)
               Major Provisions
 Insurer claims turnaround standards…
    Electronic claims …   25 days
                                     Can elect 30 days
    Paper claims      …   45 days
                                       for both upon
 Limitations on claim filing          notification to
  and audit of claims                Commissioner of
                                         Insurance
DOL’s Final Regulation On ERISA
Claims
29 CFR Part 2560


    Problem occurs when insured plans are
     subject to both state and federal law
    If laws are different … and state law
     prevents applications of federal law …
     state law is preempted
          E
          X  Conflicts regarding specific
          A   content or language of notices
          M
          P  Time periods
          L
          E
          S  Terminology
Louisiana Department of Insurance
 Eighth Annual Health Care Conference

         Hospitals, Physicians, Carriers
          The Effects of Regulation




            Pam Williams
  Asst. Deputy Commissioner, LA DOI
       Regulation of Health Claims
    HIPAA           Administrative Simplification,
                     Transactions and Code Set Standards
    ERISA           Rules and Regulations for Administration
                     and Enforcement ; Claims Procedure
     Ch. 7          Medical Necessity Review Organizations
 LA Ins. Code        & Regulation 77
Ch. 1, Part VI-D    Standards for Health Insurance
 LA Ins. Code        Coverage & Regulation 74

 Act No. 1157       Health Care Consumer Billing &
                     Disclosure Protection Act
HIPAA’s Electronic Transactions & Code
                 Sets
  Potential Impact Of Non-Compliance…
  Disruption of business
   transactions and payments
  Reversion to paper submissions to
   avoid non-compliance (except
   Medicare claims)
  Increased complaints to DOI
     Workgroup For Electronic Data
             Interchange
           Suggested Courses Of Action

 Allow acceptance of standard
  transactions during a short
  transitional period … even if data
  content is partially incomplete … if
  transaction can be processed to
  completion
 Allow acceptance of current electronic transactions by
  compliant covered entities during a brief transitional
  period … in lieu of reversion to paper transactions
CMS Enforcement Approach
    Voluntary compliance
    Complaint-driven approach
      Demonstrating compliance
      Good faith policy
      Corrective action plan
              Applicability - Claims
                   Procedures
           ERISA                          Regulation 77

 Employer group plans                  Determinations of what
 Disability benefits                    medical services or
 Denials involving ineligibility to
                                         procedures will be covered
  participate in a plan                  under a health plan based
                                         on medical necessity
 Medical judgment - experimental
  … investigational
                   ERISA
             Notice Requirements
 Applies only to …
     Adverse benefit determinations
 Time periods vary for …
   Urgent / concurrent care
   Pre-service / post-service claims
   Incomplete claims
   Appeals
              Regulation 74
             Notice Requirements
 Applies to …
     All benefit determinations
 Time periods vary for …
   Electronic claims
   Non-electronic claims
   Optional 30-day standard
            Regulation 77
           Notice Requirements
 Applies only to …
      Medical necessity determinations
 Time periods vary for …
    Initial determinations
    Prospective, concurrent and
     retrospective reviews
    Informal reconsideration
    Standard first and second level reviews
    External review … and expedited
     external review of urgent care requests
                 Notice Content
         ERISA                       Regulation 77

 Specific reasons, detailed      Varies, depending upon
  explanations                       level of appeal
 Reference to plan provisions  No reference to plan
 Description of review              provisions … all
  procedures, applicable time        determinations based on
  limits and right to civil action   medical necessity
                                    Requires instructions and
                                     description of subsequent
                                     appeal rights
Incomplete Claims
            ERISA

  Time period for notification …
   varies by type of claim…
       Urgent
       Pre / Post-service
  Allows for one time extension
  Must specify information needed
  45-days allowed for response by
   claimant
                Incomplete Claims
    Regulation 74                       Regulation 77

 Notice within 2 days of reviewing  Requires request by
  a claim for completeness            telephone, within one day of
 Advise all known reasons claim      determining additional
  cannot be processed                 information needed
 No time period set for claimant    No time period set for
  response                            response
         Incomplete Claims
Health Care Consumer Billing & Disclosure
               Protection
              Act No. 1157
 Notification to provider and insured
   regarding information needed
 No response from insured within
  “45 days” allows provider to bill
  insured
DOI Is Working Hard
Questions & Answers
Break … Viewing of Exhibits … Lunch
         *** 30 minutes ***
Louisiana Department of Insurance
 Eighth Annual Health Care Conference

          Luncheon Keynote Speaker




            John Maginnis
         Syndicated Columnist
Louisiana Department of Insurance
 Eighth Annual Health Care Conference

          Health Care … Then & Now




     Errol J. King, Esq. - Moderator
      McGlinchey Stafford, PLLC
Health Care In 1803
    Health Care In 1803




The Age of Reason   vs.   The Age of Romanticism
Health Care In 1803

Scientific (Heroic) Medicine
             vs.
          Quackery
           Heroic Medicine
 Maintained that all diseases resulted from
  excess body fluids
 Famous practitioners…
    Dr. Benjamin Rush
    Benjamin Franklin

 Treatment
    Blood letting
                                   “DEFENCE OF
    Blistering
                                 BLOOD-LETTING.”
    Purging

        • Some in 2003 have referred to this as …
                    ”Managed Care”
                    Quackery
 Comes from Dutch word “quacksalver”…
   Someone   who sold salves by fast talking or quacking
 Involved bizarre treatments
   Water  cures
   Electrical garments
   Fueled by age of romanticism


         • Some in 20th century have
           referred to “quackery” as …

            Hillary Clinton’s 1990’s version of health care
    Types of Medical Quackery in
 Electromagnetics 1803 Phrenology
                      
     Discovered in 1791                     Believed the brain had 26
     Use of direct current created           organs
      when certain metals in                 A person’s character was
      contact with each other were            made up of 37 faculties
      placed in sea water                     which could be read on
                                              the cranium
          • Patent Medicines
              – Patent medicine comes              Interesting products…
                from Britain where it was              Vital Sparks
                possible to apply for a                Tiger Fat
                patent to protect a product            Liver Pads
                or medicine and give it                Dr. Hostetter’s
                prestige                                Stomach Bitters
                                                       Kopp’s Baby Friend
Smoking Was Good For You In
          1803
 Chewing tobacco was believed to protect
  against the plague

• Tobacco Resuscitator Kit used in 1803 to
  blow tobacco smoke up the patient’s
  bottom, nose or mouth to revive persons
  “apparently dead”
 This health care “fad” was rumored to be
  started by an organization which would later
  evolve into the…
            Trial Lawyers Association
          Surgery In 1803
 Surgery was extremely
  painful and dangerous
     Major operations were
      not possible
     Surgeons gave patients
      opium or got them drunk
      before an operation
     In 1799, nitrous oxide
      (laughing gas) was
      discovered as an
      anesthetic
     Surgeon Robert Liston…
      “time me gentlemen, time me”
      Mental Health In 1803
 Care for the mentally ill was almost non-existent


• Moral treatment was the predominating
  philosophy to cure the insane
   – Developed by Dr. Benjamin form
 Early efforts are made toRush
  state hospitals for the insane
                            Indiana Hospital for the
                             Insane…Indianapolis
Health Care In 1803
                Catherine
            Beecher’s theory
              of the effect of
             tight corsets on
               the internal
            organs of women
Health Care In 1803

				
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