All posts in Technology

The Beginning of Health Care Reform Nears Its End

This article was first published in the Los Angeles Daily Journal on December 16, 2013.

Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.” — Sir Winston Leonard Spencer Churchill

The countdown to 2014 has begun. In the days to come, millions of Americans will choreograph exactly where to be at midnight on New Year’s Eve, full of resolutions and expectations for the coming year. This January 1 holds a special significance for our country, as the dropping of that massive 11,875-pound ball in New York City’s Times Square represents what many have for four years hoped to be the heralding of an epic transformation in our nation’s health care. Though unable to predict the future as in fairy tales of old, the descent of that Waterford crystal ball marks the coming of age of the Affordable Care Act, still shrouded in controversy and fighting for a foothold on which to support itself. Continue reading →

Health Care Reform Goes Live: Day Three

Roadblocks to Reform: The Influence of HIPAA and HITECH on the Affordable Care Act

This article was first published at Michigan Business Professional Association on April 30, 2013.

When it comes to health care, our nation has reached a crossroads.  President Obama’s fledgling Affordable Care Act is a multifaceted, aggressive program designed to overhaul the delivery of health care by effectively restructuring its foundations from the inside out.  In doing so, it seeks to reduce the number of uninsured patients who have for so long been a burden to a struggling health care system that must provide medical care as a service while also turning a profit as a business.  But such a far-reaching plan has little chance of success if it is forced to evolve while fettered with the restrictions placed upon providers by certain grandfathered programs, most notably the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH).  As a result, we as a nation must now consider whether the ACA’s fundamental mission or patient privacy should rule the day. Continue reading →

Modern American Health Care (in 83 slides)

This presentation provides an overview of the Affordable Care Act three years after its passage. It explains how the landmark legislation evolved, what provisions are in place today, and what can we expect in the years to come. The implications for patients, providers and payers are massive, and this presentation is designed to provide a comprehensive overview for anyone interested to learn about health care reform.

Navigating The Rapids of Health Care Reform Without a Paddle

This article first appeared in Corporate Compliance Insights on March 28, 2013.

“The only fence against the world is a thorough knowledge of it.”  – John Locke, philosopher (1632-1704)

In its bid to restructure the nation’s health care system, the 2010 Patient Protection and Affordable Care Act (the “ACA”) has created both challenges and opportunities in the areas of corporate compliance, governance and risk communities. In three short years, myriad regulatory clarifications have swollen this 906-page statutory giant into a 70,000-page behemoth whose might has been enough to overcome the judicial and electoral challenges of 2012, eliminating any doubts as to whether reform is here to stay.

At its core, the ACA means different things to different people. Patients typically focus on the promise of new guarantees and protections for health insurance for the populace, as well as the penalties for those who remain without coverage. But the ACA has also captured the attention of health care providers as they shift from a formerly cost-based system toward one that gauges success or failure primarily on patient experience. Even the insurance industry must yield to the new law and wend its way through a changing landscape complete with medical loss ratio requirements, the end of lifetime limitations, challenges to any increase in premiums over a certain percentage, and the soon to be introduced Health Insurance Exchanges.

While the infusion of elements such as innovation, preventative care and overall wellness provide the Federal Government with a new and as yet untested backup plan to ensure the success of health care reform, plenty of room still exists within the ACA to combat health care fraud, abuse and waste. The False Claims Act stands at the forefront in the government’s battle to preserve the integrity of health care resources, although the law has evolved considerably since first signed into effect by President Lincoln in 1863.  By ensuring the legacy of the FCA for future generations, however, the ACA has also created several compliance risks for companies across the nation.  Here are the top five: Continue reading →

Winter Journal 2013

I am pleased to share with you a collection of my most recent writings on the Affordable Care Act, all of which can be accessed through this link: Click Here for the Winter Journal 2013

The recent changes to the core structure of modern American health care are nothing short of epic, rivaled in historic scale only by the introduction of Medicare in 1965.  Although each decade over the past 50 years has in some way used government programs and incentives in an attempt to urge health care to undergo recalibration as a means to establish industry stability, by the end of the first decade of the 21st Century it had become evident that health care in the United States was fast becoming unsustainable as it existed.

Having survived last summer’s monumental challenge before the United States Supreme Court and a presidential election in November, the Affordable Care Act has not only emerged as the law of the land, it has cemented its place as health care’s blueprint throughout America for decades to come. Unfortunately, the speed at which health care reform appears to move can at times be dizzying, and its demands are often draconian at first glance.

History has shown that health care in the United States is resilient, and often finds ways to surprise even its toughest critics. Though it is too soon to predict the future of health care in the United States, the value of historical information pertaining to the evolution of our health care system should not be discounted.  Only through the combination of historical perspective and modern-day analysis have I been able to understand the essence of the Affordable Care Act.

It is my hope that the following articles will provide the reader with similar guidance.

Very truly yours,

Craig B. Garner

Redefining the Valuation Methods of Modern Day Hospital Care

This article was first published in the New York State Bar Association’s Health Law Journal, Vol. 17, No. 3 (Summer/Fall 2012).

Due to the sensitive nature of the industry it services, the American hospital must rightfully operate under copious federal and state regulations, in addition to volumes of rules and ordinances established by separate, non-governmental entities. Though policing policies such as accreditation, certification and periodic review come from a variety of both public and private sources, the goal is generally consistent: develop uniform standards to ensure that hospitals in the U.S. operate at an acceptable safety level while delivering quality patient care.

The Many Paths to Accreditation

Though its primary function is without question the delivery of accurate and effective medical treatment, health care is also big business. Continue reading →

A Modern Day Compliance Program

60 Days to Pay – Has Medicare Reached the Point of No Return?

This article first appeared in the September 2012 issue of Compliance Today, a publication of the Health Care  Compliance  Association.

In February the Centers for Medicare & Medicaid Services (“CMS”) clarified an oft quoted existing rule: Providers must return overpayments to Medicare within 60 days “after the date on which the overpayment was identified,” or in the alternative, “the date any corresponding cost report is due, if applicable.”[1]

For providers of any size, failure to report and return Medicare overpayments pursuant to these temporal requirements may result in potential liability under the Federal False Claims Act[2], resulting in substantial monetary penalties and the risk of being denied future claims for reimbursement.

Dating back to the American Civil War, the False Claims Act (FCA) has over time become the “primary litigative tool for combating fraud” for both federal and state governments.[3] At its core, the FCA imposes liability on anyone who “knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval.”[4]  While most providers have worked within a similar time frame after identifying an overpayment, it appears that the statutory requirements under the 2010 Patient Protection and Affordable Care Act [5], as amended by the Health Care and Education Reconciliation Act[6] (collectively referred to as the Affordable Care Act or health care reform) were not enough.[7] In reaction, the February 2012 regulations now leave nothing to chance, imposing upon the health care industry detailed definitions with numerous examples to assist providers in determining exactly when the 60-day clock begins.[8] Continue reading →

The Spectacular Aspect of Contemporary Health Care

This article first appeared in the Daily Journal on September 11, 2012.

Spectacular – adj.: of or like a public show; striking, lavish (spek ‘tækjulə(r))[1]

As images of NASA’s 2012 “Curiosity” expedition continue to capture public interest, the word “spectacular” has been getting a lot of play in recent national media. By replacing images of our nation’s beloved hero Neil Armstrong bouncing on the lunar surface[2] with “a one-ton, automobile-size piece of American ingenuity” that is destined to spend the next two years “examining rocks within the 96-mile crater” into which it landed[3], NASA has proven how far we as a unified nation can come in under fifty years with a well-designed, properly funded and tightly executed plan.

Unlike with space travel, gauging the progress of the evolution of a health care system is not nearly so cut and dry. While advances in modern medicine since the introduction of Medicare[4] have in many ways been equally riveting from a technological, political and sociological standpoint, each new period of change has brought with it a divisiveness that has forced individuals to decide whether the system’s latest step is spectacular in its success or failure. When it comes to health care, Americans tend to see things in black and white.

Much of what we now take for granted the field of modern medicine was unthinkable fifty years ago. Technologically, the jumps have been astounding. From its humble origins in the 1970s, X-ray computed tomography has evolved from being able to give a reading that included 160 images, each taking 2.5 hours to process, into today’s 256-slice CT scanner which can in seconds measure subtle changes in blood flow or blockages in blood vessels the width of a toothpick within the heart and brain.[5] Continue reading →

 

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