Health Care Today | Health Law Blog

As of Nov. 1, 2019, hospitals — as well as other types of health care providers — submitting claims to Missouri or Illinois Medicaid programs will be subject to a new restrictive rule concerning ordering, referring and prescribing providers (ORP). The ORP rule may result in hospitals unexpectedly having some Medicaid claims denied. Below is a description of the rule, some differences between Missouri and Illinois, where the rule comes from, and what claims it applies to.

The Office of Civil Rights (OCR) within the Department of Health and Human Services (HHS) has been able to hold “business associates” directly liable for certain HIPAA violations since 2009, with the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Under HIPAA, a “business associate” is an entity that receives protected health information (PHI) in order to provide services to a “covered entity” (such as a health care provider, a health plan, or a heath care clearinghouse).

Many hospitals share space with other health care entities. Despite this, the Centers for Medicare & Medicaid Services (CMS) has given mixed signals — and never issued formal guidance — concerning the permissibility of shared spaces under the Medicare Conditions of Participation (CoP). This has created great confusion and uncertainty for hospitals as they try to meet the challenges of a rapidly changing health care system.

That’s all about to change!

The Centers for Medicare & Medicaid Services (CMS) has found that hospitals are increasingly operating “off-campus, outpatient, provider-based” departments. Services provided at these off-campus facilities are required to be billed using the off-campus facility’s address so that payment can be accurately made under the Medicare Physician Fee Schedule (MPFS) or the Outpatient Prospective Payment System (OPPS).

The battle over health benefits rages on. In the latest salvo, a group of states scored a major court victory against the Trump administration’s new “Association Health Plan” Final Rule, which was finalized in 2018. While this decision will have major ramifications, it is important to remember that association health plans may still be established under old rules that existed long before the final rule.

The case is styled New York v. United States Dep’t of Labor, No. CV 18-1747 (JDB), 2019 WL 1410370 (D.D.C. Mar. 28, 2019).