The Legal/Regulatory Framework: Implementing Policies for Caring for the Uninsured as a Healthcare Compliance Strategy

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The Legal/Regulatory Framework Implementing
Policies for Caring for the Uninsured as a
Healthcare Compliance Strategy

• Suzie Draper
• Chief Compliance and Privacy Officer
• Intermountain Healthcare

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Current Climate

• Era of increased social responsibility for large
  businesses
• Hospitals are stuck between a rock and a hard
  place because
• Healthcare utilization is increasing
• The number of uninsured is increasing
• The reimbursement rate is decreasing
• Social responsibility takes on a whole new
  meaning in the healthcare environment
• Accurately reporting and quantifying the
  community benefit that healthcare provides is
  increasingly critical with increased public
  scrutiny

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Social Responsibility

• Society expects a certain degree of
  accountability from big businesses
• A clear message when sent after Enron
• Jobs were lost
• Pensions went by the wayside
• Investors were misled

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A Rock and a Hard Place

• Utilization of healthcare is exploding
• To address this, hospitals are working to improve
  how care is delivered to each patient
• Providing the right care at the right time, every
  time, is critical
• Hospitals that achieve top standards in care
  could reduce patients time in the hospital and
  complications

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A Rock and a Hard Place

• Rates of those with healthcare coverage is
  rapidly decreasing
• Fewer employers can afford to provide coverage
• Individuals may not be able to afford coverage on
  their own

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Uninsured and uncompensated care track parallel
trends
Non-elderly Uninsured
(in millions)
Uncompensated Care
(in billions)
Source Census Bureau, American Hospital
Association
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Compliance Issues and the Uninsured

• The healthcare environment is the most regulated
  industry in the nation
• Several of these regulatory issues take on a new
  life when the uninsured are involved
• Emergency Room treatment requirements
• Section 1101 Federal Reimbursement for Emergency
  Services Provided to Undocumented Aliens
• Identity Theft
• Language Services

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Emergency Room Care
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Emergency Room Care

• The uninsured are heavy users of the ER
• Makes the already overcrowded ERs even more so
• If the hospitals ER is at capacity, it may go on
  diversionary status, forcing individuals arriving
  via ambulance to go elsewhere for care
• Under federal law, patients that enter the ER
  cannot be turned away, regardless of their
  ability to pay

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Problems with both Supply and Demand

• Decreased supply caused by
• Hospital closures and mergers
• Reimbursement constraints
• Nursing shortage
• Less profitable services have been replaced by
  higher revenue producing services such as
  cardiovascular care
• Reduced discharge options

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Increased Demand

• More patients without insurance seeking care in
  the ER
• Increased delay in being able to make an
  appointment to see a primary care provider
• Stricter enforcement of the Emergency Medical
  Treatment and Labor Act (EMTALA)

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Specifically, EMTALA

• Sets forth requirements for medical screening
  examinations (MSE) for medical conditions,
• Sets forth requirements for necessary stabilizing
  treatment or appropriate transfer, and
• Prohibits a delay in providing required screening
  or stabilization services in order to inquire
  about the individual's payment method or
  insurance status

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Results of EMTALA

• In effect, its Americas answer to universal
  access to health careand a huge unfunded mandate
  on emergency physicians, trauma surgeons, on-call
  specialists and hospitals.
• Dr. Art Kellermann, an emergency physician who
  testified at the early Congressional hearings on
  patient dumping

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Section 1101

• Federal Reimbursement for Emergency Services
  Provided to Undocumented Aliens
• Covered services are the same as those required
  by EMTALA
• 250 million is available annually
• Payment is only provided for services that were
  not otherwise reimbursed

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Section 1101
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Identity Theft

• Accurate identification of patients who choose to
  provide false information
• Illegal aliens may think they need a SSN for
  treatment
• Patients with drug seeking behavior
• Insurance fraud
• Ramifications include
• Inaccurate medical history
• Uncollectible services
• Law enforcement involvement

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Language Barriers and the Uninsured

• One particularly challenging portion of the
  patient population is both
• Uninsured
• Considered to be limited English proficient
• More than half of immigrants are uninsured
• Providing language services and healthcare
  services can be costly to organizations

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Regulations Related to Language Services

• Examples of regulations that pertain to the
  provision of language services include
• Title VI of the Civil Rights Act of 1964
• Americans with Disabilities Act (ADA)

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Language Services Regulations

• TITLE VI of the 1964 CIVIL RIGHTS ACT
• "No person in the United States shall, on the
  ground of race, color or national origin, be
  excluded from participation in, be denied the
  benefits of, or be subjected to discrimination
  under any program or activity receiving federal
  financial assistance."

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Requirements of Title VI

• Must offer language services at no cost to each
  patient with limited English proficiency during
  all hours of operation.
• Must notify patients of their rights to receive
  such services

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Title VI (cont.)

• Must assure high quality language services are
  provided
• Family and friends should not be used to provide
  interpretation services (except on request by the
  patient/consumer)
• Must provide translated patient-related materials
  and signage, based on the population served

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ADA

• Protects against discrimination of individuals
  with disabilities
• Emphasizes the provision of effective aids so
  that they may have full and equal enjoyment of
  all healthcare services

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ADA (cont.)

• Examples of accommodations
• Use of qualified interpreters
• Provision of written materials
• Closed captioning
• Video Relay Services

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Keep in Mind

• While challenging for healthcare systems,
  regulations such as Title VI, ADA, and EMTALA
  serve a needed purpose
• To ensure that no one is denied emergency care
• Regardless of
• Their ability to pay or
• The language they speak or
• Any disabilities they may have

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Community Benefit

• Demonstration of steps the provider is taking to
  support its nonprofit charitable mission
• However, it receiving increased scrutiny by the
  IRS
• As a result, proper documentation of community
  benefit is critical

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IRS Interim ReportTax-Exempt Hospitals and
Community Benefit

• The lack of consistency or uniformity in
  classifying and reporting uncompensated care and
  various types of community benefit often makes it
  difficult to assess whether a hospital is in
  compliance with current law.
• Lois Lerner
• Director of IRS Exempt Organization Division

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Community Benefit Industry Response

• American Hospital Association is encouraging its
  members to actively report their community
  benefits through
• Encourage Public Reporting
• Retain the Community Benefit Standard
• Increased Financial Accountability

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Community Benefit Programs Types
Community benefit operations Dedicated staff Community health needs and assessments Health professionals education, including scholarships Community health services Health education Clinical services
Subsidized health services Emergency and trauma services Hospital outpatient services Behavioral health services Palliative care and hospice Financial contributions Cash donations Grants In-kind donations Community building Physical improvements and housing Economic development Environmental improvements Coalition building
Subsidized health services Emergency and trauma services Hospital outpatient services Behavioral health services Palliative care and hospice Research Community building Physical improvements and housing Economic development Environmental improvements Coalition building
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Beyond the Numbers

• Community benefit programs, while not necessarily
  revenue producing, tie what healthcare systems do
  back to their missions
• Providing compassionate healthcare to all
• Promoting the health of communities
• Paying special attention to those who need it the
  most, including those who are the most vulnerable

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The Future of Healthcare

• The number of unfunded government mandates is
  increasing
• Extensive requirements for hospitals strain the
  amount of resources available to provide care to
  the communities they serve
• Ongoing sustainability of healthcare requires
  innovative approaches
• This will no doubt shape politics in America for
  years to come

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Other Tax Considerations

• IRS 990 Revisions
• Conflict of Interest Processes
• Boards
• Officers
• The Future of Property Tax Exemption

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Questions/Discussion