Cherilyn Murer, who founded Murer Consultants 25 years ago in February of 1985, will celebrate this milestone on February 25, 2010, in an unexpected, but most appropriate, way when she will be inducted into the UIC Entrepreneurship Hall of Fame at a dinner to be held at the Chicago Hilton & Towers.  
 
The Hall of Fame, established by the University of Illinois at Chicago's Institute for Entrepreneurial Studies, honors the Chicago area's most innovative leaders who have demonstrated entrepreneurial spirit and business talent by founding and/or growing a business. 

In October 2009, the Department of Health and Human Services, Office of Inspector General ("OIG") released its FYE 2010 OIG Work Plan.  The OIG releases an annual work plan that details its upcoming/ongoing enforcement initiatives for the upcoming fiscal year.  This year, the OIG is indicating that it intends to continue its ongoing efforts to analyze and assess the provider-based process and its participants.  Specifically, the 2010 Work Plan indicates that the OIG "will determine the appropriateness of the provider-based designation and the potential impact on both the Medicare program and its beneficiaries of hospitals improperly claiming provider-based status for inpatient and outpatient facilities.  Therefore, it is critical that hospitals ensure that all provider-based departments (that receive hospital reimbursement) are in compliance with the provider-based criteria.

An often overlooked requirement that must be met by Provider-Based Departments (PBD), except in limited circumstances, pertains to the distribution of notices of coinsurance liability forms.  In a physician office setting, a patient receives one bill and must make a coinsurance payment to one entity, the physician office.  Because hospital outpatient services generally carry a coinsurance requirement, patients of PBDs often times incur two bills and two coinsurance payments for a service received in a PBD - one payment for the outpatient hospital service and one payment for the physician service.    As a result, patients generally have to pay more out-of-pocket expenses related to services obtained at a PBD.  To ensure that patients understand this, CMS requires PBDs to provide patients advance written notice of this additional hospital coinsurance.  The provider-based regulations provide very specific requirements related to the content and timing of distribution of these notices.  Often times, providers are either not aware of the notice requirement, or simply do not provide enough information to comply with the regulations.     (Continued under "Provider-Based Enforcement" below)

Over the past year Murer Consultants has assisted several clients with the preparation of various levels of Medicare appeals, including redetermination and reconsideration appeals.  These appeals have been for determinations in Medicare Administrative Contractor (MAC) and  Long Term Care Hospital (LTCH) demonstration project audits.   Murer Consultants' experienced legal and clinical team has developed a thorough process that incorporates a complete medical necessity review and critical argument appeal strategies.  As such, Murer Consultants has successfully appealed Medicare denials on behalf of several clients, including one which resulted in a repayment of over $111,000.  Murer Consultants continues to work with clients across the country on all levels of Medicare appeals from MAC audits and ready to work on any denials from the Recovery Audit Contract (RAC) audits as they fully transition implementation in 2010.  Please feel free to contact our offices for more information on how Murer Consultants can assist your facility with any Medicare appeals.

 

Lyndean Brick and her husband, Myron, (far right) were co-chairs of the 16th Annual Provena St. Joseph Medical Center Foundation Gala on November 7, 2009.  Other co-chairs were George and Donna Barr (far left) and hospital CEO, Jeffery Brickman, and his wife, Elaine (center).  The Gala was able to raise $131,873 for the Foundation.  Ms. Brick was appointed in January to serve as Vice-Chair of the hospital Board of Trustees.

Illinois State Senator, A. J. Wilhelmi, senior consultant with Murer Consultants, Inc., has been appointed by Senate President John Cullerton to serve on the Illinois Steel Development Board.  This appointment is effective immediately for a term which will expire on January 17, 2011.

 

It is critical that all hospital outpatient PBDs assess the sufficiency of their notices of coinsurance as well as all other provider-based requirements. In assessing compliance with the notice of coinsurance provisions, providers should keep in mind that several exceptions dictate whether or when the notice needs to be provided to a patient.  For example, notices are not required for inpatient services received at a provider-based hospital.  This becomes a factor when multiple hospitals under common ownership operate under one Medicare provider number.  However, if ED or other outpatient services are provided at a provider-based remote hospital, those services are subject to the notice of coinsurance requirements.  Also, please keep in mind that the notice requirement is triggered by services that result in two bills.  Therefore, generally, PT, ST, and OT services do not require coinsurance notices as the patient is not billed by a physician.

 
As many providers are aware, there are opportunities for enhanced reimbursement through the conversion of physician practices/clinics to hospital-owned PBDs.  42 CFR 413.65 provides the regulatory basis/criteria for achieving provider-based status.  The regulations outline the various integration tests that must be met in order to bill an outpatient hospital department as a PBD and achieve a higher level of reimbursement.  Specifically, CMS requires the hospital and PBD to be administratively, clinically, financially and operationally integrated.  To ensure compliance with the provider-based regulations and to reduce risk-related potential overpayments, Murer Consultants, Inc., assists hospital clients with filing provider-based attestations that document how facilities comply with the various criteria.