the case for regulatory reform commitment to quality care health care is people caring for people yet those on the front line delivering health care our doctors nurses and other health-care personnel report increasing frustration with the amount of time spent on paperwork instead of patient care consider the following · a medicare patient arriving in the emergency room must review and sign eight different forms for medicare alone · before home health patients can receive care they must wait until the nurse fills out a questionnaire that takes on average 90 minutes to complete and · because billing is so complicated and the consequences of mistakes are high medical records are reviewed by at least four people to ensure compliance.1 there is no other endeavor where the product is as precious life the issue is not whether to regulate but how and when to regulate regulations often begin with good intentions to enhance the delivery of patient care improve safety or ensure the proper use
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the stakes are high for those who cannot keep pace with the regulatory requirements and changes enforcement comes at a great price charges of fraud and abuse in spite of the complexity of the system a simple mistake in coding could result in charges of fraud monetary fines expulsion from the medicare program and civil or criminal charges given the scope of the regulatory burden it is easy to identify numerous problems with the regulatory environment this report focuses on the key regulations that interfere with the delivery of health care it also makes several recommendations for changes to the regulatory process so new regulations are more productive the stakes are high for those who cannot keep pace with the regulatory requirements and changes enforcement comes at a great price charges of fraud and abuse 6
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adding to the confusion are the number of regulators and administrators of the medicare program who interact with providers beneficiaries and health plans for example a hospital may interact with the center for medicare and medicaid services cms claims processing contractors fiscal intermediaries program safeguard contractors peer review organizations and state health insurance programs regulators may be federal state or private agencies some make national policy while others set rules for a region some may provide education on certain aspects of the medicare program while others are charged with enforcement given the size scope and volume of regulations accompanying the medicare program it is easy to understand why it can overwhelm providers what happened to common sense many health-care providers are frustrated by regulations that are well intended but when implemented in the real world simply do not make common sense here are two examples and recommendations for improvement · advan
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and subsequent on-going costs for regular processing of the transactions hipaa s privacy rules contain an abundance of organizational procedural technical and physical mandates for hospitals as with the transaction rules compliance will consume significant amounts of time and money a study commissioned by the american hospital association estimates hospitals will spend between $4 billion and $23 billion complying with just three of the most difficult pieces the minimum necessary requirement the state preemption analysis and the business associate agreement mandates making privacy compliance even more difficult is the fact that hipaa s security rules have not yet been published in their final form security policies and procedures are an essential part of implementing privacy mandates not knowing the final hipaa security rules puts facilities in the position of having to guess which security rules they must comply with in order to meet the privacy mandates this will lead to an inevitable
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hospital swing beds and significantly streamlined the minimum data set for non-critical access hospital swing beds more can be done for skilled nursing facilities and home health agencies recommended action hospital-based skilled nursing facilities need relief from the minimum data set and home health agencies need relief from the excessive burdens and often irrelevant information requirements imposed by the oasis assessment tool · audits the principles of asking for and using only what is needed to get the job done can be applied to the audit process the medicare program is so large providers do not deal directly with cms but with fiscal intermediaries fi in addition to processing medicare claims and issuing payments one role of the fiscal intermediary fi is to perform occasional routine reviews to assure that a provider is collecting the proper documentation from hospital patients but too often audit guidelines require hospitals to spend staff time and resources producing informatio
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state regulations in addition to the federal government the state of washington and local governments regulate many facets of health care as shown in the chart on page 4 hospitals have to meet the requirements of several local and state agencies before remodeling or adding space the hospital must meet city and county building codes as well as state construction review requirements administered by the state department of health to receive payment from medicaid hospitals have to follow state payment policies administered by the department of social and health services as well as the federal requirements to contract with insurance companies hospitals have to meet the health plan requirements administered by the state office of the insurance commissioner before allowing a physician to practice hospitals have to assure the physician is properly credentialed by verifying graduation from medical/dental/pediatric school completion of residency fellowship training education commission for forei
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· ergonomics hospitals are currently working to improve the safety of the work environment by applying ergonomic principles such as purchasing equipment to move patients instead of requiring staff to physically lift the patient the wsha workers compensation program has developed a voluntary zero lift program that many of its members are in the process of implementing the hospitals implementing this single phase of an ergonomics program report that it takes an average rural hospital about one year to do so this is because there are so many interruptions in the process due to financial barriers and ongoing agency and regulatory surveys and issues moreover carving out time for personnel to work on the zero lift program is very difficult when they are dealing with the challenge of maintaining adequate personnel california and washington are the only states with their own ergonomic regulations washington adopted a state ergonomics rule in may 2000 a business community coalition washington
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· newborn hearing screening congenital hearing loss is the most frequently occurring birth defect affecting about three in 1,000 newborns twenty-seven hospitals have worked with the state department of health to implement voluntarily a comprehensive newborn hearing-screening program which resulted in about 42 percent of newborns in washington state being screened for hearing loss during 2001 this is a significant improvement from 23 percent in 2000 and just seven percent in 1999 the state board of health is considering additions to the list of conditions required for newborn screening newborn hearing screening may be included as one of these potential new requirements this could result in hospitals being mandated to provide universal newborn hearing screening a mandate on hospitals would be unnecessary and detrimental other states are conducting newborn hearing screening on almost all of their newborns without use of a state mandate a recent evaluation by the u.s preventative services
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recommended action several changes can be implemented at the federal and state levels to improve the compliance environment including regulatory agencies should provide providers with ongoing opportunities to receive education on compliance with current rules penalties imposed for non-compliance should reflect the nature of the infraction for example billing mistakes should be treated as such and followed by additional education agencies should not be allowed to launch duplicative investigations the state legislature should revise the revised code of washington 43.20b.695 which requires overpayments must be paid back at a rate of 12 percent per year it should be changed so the interest rate is pegged to current rates and does not unnecessarily penalize providers penalties imposed for non-compliance should reflect the nature of the infraction 23
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case study statewide mobile magnetic resonance imaging mri services it does not make any sense for most rural hospitals to purchase expensive equipment such as mris nevertheless their patients need access to these services instead hospitals want to contract for mobile mri services that drive into town park on the hospital campus provide services for a day and then leave for the next hospital this way patients get access to care close to home based on medicare regulations if hospitals want to bill for the service under their license they have to meet state construction standards this means they have to go through the state department of health s construction review services crs program to bring the physical plant up to code if they are willing to let the imaging company do the billing they do not have to meet any standards the problem is that by doing the billing themselves a rural hospital can make it easier on the patient who has fewer bills to contend with and increase their revenu
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acknowledgements co-authors kristen michal director federal policy and advocacy wsha/awphd contributors/editors johanna allen executive assistant taya briley director legal services/health policy awphd tom byron chief information officer toni fox-corwin manager member/administrative services victoria galanti executive vice president leo greenawalt president troy hutson director legal/clinical policy courtney landes publications coordinator len mccomb lobbyist randy revelle vice president policy and public affairs claudia sanders vice president policy development cassie sauer director advocacy network lisa thatcher lobbyist wendy ray manager member services awphd brenda suiter director rural and public policy wsha we would like to thank the following people for thier assistance with the case studies bart eggen executive manager washington state department of health tom nielsen administrator kennewick general hospital association of washington public hospital districts 28
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