The final 2011-12 state budget, Chapter 59 of the Laws of 2011, requires a 2% across the board reduction to most Medicaid payments. Such payment reductions will apply for dates of service on or after April 1, 2011. The reduction will remain in effect for dates of service through March 31, 2013. These provisions were enacted to meet the target of the Medicaid Redesign initiative authorized by the Governor

Every healthcare provider claiming $500,000 per year or more from the NYS Medicaid program is required to adopt and implement an effective compliance program.  Providers should be aware that the $500,000 in billings requirement includes claims submitted to the Medicaid program, whether billed directly or through various third-party managed care organizations.  The Compliance Program applies to billings, payments, medical necessary and quality of care, governance, mandatory reporting, credentialing, and other risk areas that are or should with due diligence be identified by every healthcare provider. Putting together a  Compliance Program that meets the requirements of the NYS Department of Health and the Office of Medicaid Inspector General involves a comprehensive professional review of your operations and compiling an extensive set of requisite documentation.

The NYS Medicaid Compliance Program must satisfy specific requirements set forth in relevant NYS codes and regulations.  When applying for initial provider enrollment in the NYS Medicaid program, in transfer of ownership applications and once per year thereafter, during the month of December, every NYS healthcare provider must demonstrate that an adequate and effective Compliance Program has been implemented, which includes properly drafted policies and procedures that describe compliance expectations.  The Compliance Program shall provide guidance to owners and employees on dealing with potential compliance issues, identify how to communicate these issues and describe how these problems are investigated and resolved.  The Compliance Program must designate and employee responsible for its daily operations and it should provide for training & education of all affected employees on compliance issues, expectations, and the operation of the Compliance Program.

It is important for every NYS healthcare provider to remember that upon applying for enrollment in the NYS Medicaid Program and every December thereafter, a provider claiming over $500,000 per year must to the Department that an adequate Program is in place!

The Commissioner of Health and  the Medicaid Inspector General will determine the adequacy of a provider's compliance program. In the event that the Commissioner or OMIG finds that a provider's compliance program is unsatisfactory or inadequate, the provider may face serious consequences.

The HIPAA Privacy Rule provides federal protections for personal health information held by health care providers and other covered entities.  The rule places constraints on disclosure fo private patient data, and sets limits on the uses and disclosures that may be made of such information.  HIPAA Privace Rule is balanced so that to permit the disclosure of PIH when necessary for patient care and other important purposes. 

For an average health care provider, the HIPAA Privacy Rule mandates compliance in several specific areas such as notifying patients about their privacy rights and how their information may be used, adopting and implementing privacy procedures, training employees in privacy procedures, designating an individual responsible for ensuring that the proper privacy procedures are followed and securing patient records containing identifiable PHI.

Typically, a HIPAA violation involves a doctor or other health care practitioner improperly divulging medical history or other protected patient information.  While compliance with HIPAA may seem fairly straightforward at first glance, many situations involving possible violations can be multi-faceted and ambiguous.  Since violations can result in various serious sanctions and even criminal proceedings, health care providers are advised to carefully review and evaluate the propriety of all requests to release PHI received by their practices. 

In light of the complexity of relevant patient privacy regulations and frequent ambiguity of requests to release patient information, guidance of qualified legal counsel can prove to be invaluable to a physician confronted with a request for PHI.  Counsel with expertise in the area of healthcare law can evaluate whether the form of the request is proper and complies with applicable laws, whether procedural requirements have been met, and whether the scope of information sought is appropriate. Furthermore, qualified counsel can guide a health care provider in the process of responding to subpoenas and court orders.  In sum, any physician unsure of propriety of a response to a request for patient information would be well-advised to protect him or herself from failure to comply with HIPAA and other federal and state laws by seeking advice of a knowledgeable attorney.

In actuality, what does this mean for healthcare providers?  If you are a physician orderign a CT, CTA, MRI, MRA, Cardiac Nucler or PET procedure for a Medicaid fee for service patient, you or your office staff are required to obtain a prior approval number through the RadConsult program.   If you are a provider performing one of the above diagnostic imaging tests you must verify that an approval has been obtained for the Medicaid beneficiary.  The prior approval will be required for claim payments and failure to obtain an approval number may delay or prevent payment of a claim for such radiology services.

Providers must keep, for a period of six years from date of payment, records and information regarding a submitted claim and the related payment (if any), and must furnish this documentation upon request of the relevant agencies.