new jersey chapter - hfma nj · 2013. 12. 20. · scott mariani, partner and healthcare industry...

Fall 2013 • vol 60 • num 2

new jersey chapter

Scott Mariani, Partner and healthcare industry expert, knows how critical it is for hospitals

and healthcare delivery systems to implement the right strategies for financial survival. His

healthcare clients trust his advice and guidance, enabling them to focus on what matters most

—providing quality patient care. Whether with tax, audit or consulting, helping his clients avoid

fiscal trauma is Scott’s specialty.

Scott Mariani, Partner, JD

Practice Leader, Healthcare Services Group

[email protected] • 973.898.9494

Focus 1

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focus•advertisers•focus•features•

focus•points•

Besler

CBIZ KA Consulting Services, LLC

Fox Rothschild LLP

McBee Associates, Inc.

NJ Smart Start Buildings

ParenteBeard, LLC

William H. Connolly & Assoc.

WithumSmith+Brown

How Healthcare Facilities canRespond to Heightened FDA Scrutinyof IT Hardware and Software Products by Jason Sapsin and Shahnam Sharareh .................................................................... 9

“HIPAA Food for Thought:”Three Training Tips to Limit Exposure toViolations and Reap Operational Benefits by Nicole K. Martin .................................................................................................... 14

Luring Business to New JerseyGovernor Chris Christie Signed into Law the New Jersey Economic Opportunity Act of 2013 Which Greatly Expanded Geographic Areas Where Companiescan Qualify for Tax Incentives by James A. Robertson and Brooks E. Doyne................................................................ 18

Keeping Up with Meaningful Use by Krystyna H. Monticello ............................................................................................ 21

NJ Hospitals Gear Up for DSRIP Program* by Suzanne Ianni ........................................................................................................ 25

New Delivery System Reform IncentivePayment (DSRIP) Pool Important toNew Jersey Hospitals* by Stacey Bigos ......................................................................................................... 28

NJ HFMA January bi-monthly meeting ............................................. 30

The Future of Federal Disproportionate Share Program by Robert Gricius ........................................................................................................ 31

WANTED: NJ HFMA Associate Board Member ............................. 36

37th Annual Institute HighlightsChallenges of Healthcare Reform by John J. Dalton, FHFMA .......................................................................................... 37

focus•cover•The cover photo from our March 1996 issue, with Chuck Wilczynski and many other past presidents seated with Bob Shelton, founder of the New Jersey Chapter and first full-time Executive Director of HFMA. The photo was taken at the Armory in Perth Amboy at a dinner to celebrate HFMA’s 50th anniversary, to which all Past NJ Chapter Presidents were invited.

Who’s Who in the Chapter ...... 2

The President’s View by David Wiessel .......................... 3The President's View, 1996 by Chuck Wilczynski ..................... 4

Who’s Who in NJ Chapter Committees ........... 24

New Members .......................... 27

Certification Corner ................ 33

Job Bank Summary ................ 34

Focus on Finance .................... 35

Mark Your Calendar ................ 35

*Editor’s Note: Thank you to Suzanne and Stacey for contributing articles contain-ing distinct descriptions of the DSRIP program. The committee members reviewing the articles appreciated the unique, yet complementary perspectives and information presented.

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2 Focus

focus/hfmaWho’s Who in the Chapter 2012-2013Chapter Website …………………………………..www.hfmanj.org

Communications CommitteeStella Visaggio, FHFMA, CPA, Director .................................... Hackettstown Regional MCElizabeth G. Litten, Esq., Chair ........................................................... Fox Rothschild LLPAl Rottkamp, MBA, Vice Chair .............................. Princeton Healthcare System/AramarkAnthony F. Consoli ................................................................... CBIZ Benefits & InsuranceVictor Correa .................................................................................................... AtlantiCareMark Dougherty, FACHE ........................................................ Energy Systems Group, LLCLaura Hess, FHFMA ............................................................................................ NJHFMAJohn Manzi ................................................................ Panacea Healthcare Solutions, LLCRhonda Maraziti .....................................................................WithumSmith + Brown, P.C.Nicole K. Martin, MPH, Esq. ..................................................................... Martin Law, LLCWilliam McCann ................................................................................................HealthfirstDavid A. Mills ..............................................................................Hinduja Global SolutionsAmina Razanica .............................................................New Jersey Hospital AssociationJames A. Robertson, Esq. ..........................McElroy, Deutsch, Mulvaney & Carpenter, LLPRoger D. Sarao, CHFP ................................................... New Jersey Hospital Association

NJ HFMA Chapter OfficersPresident, David J. Wiessel .................................................................. Ernst & Young, LLPPresident-Elect, Tracy Davison-DiCanto, MBA , FHFMA ........Princeton Healthcare System Secretary, Dan Willis ...................................................... Sutherland Healthcare Solutions Treasurer, Heather Weber ............................................................................ParenteBeard

NJ HFMA Board MembersStacey Bigos – Associate Board Member ........................New Jersey Hospital Association

Steve Bilsky .............................................................................................................. Causey

Anthony F. Consoli ...................................................................... CBIZ Benefits & Insurance

Kevin Joyce .....................................................................................................QualCare Inc.

Scott Mariani ............................................................................WithumSmith + Brown, P.C.

Michael McKeever .................................................................................................... UMDNJ

Rosemary Nuzzo .................................................................................................Atlanticare

Josette Portalatin ...................................................................................The Valley Hospital

Roger Sarao, CHFP – Ex-Officio .......................................New Jersey Hospital Association

Deborah E. Shapiro, MBA ...............................................................................WFS Services

Jennifer Shimek – Associate Board Member ........................................ Ernst & Young, LLP

Stella Visaggio, FHFMA, CPA .....................................................Hackettstown Regional MC

Erica Waller ........................................................................... Princeton Healthcare System

NJ HFMA Advisory CouncilJohn Brault, FHFMA ................................................................................................ AetnaMichael Alwell, FHFMA ....................................................Saint Michael’s Medical Center Mary T. Taylor, MBA, FHFMA .......................................... Southern Ocean Medical CenterBrian P. Sherin, MBA, FHFMA ...................................................................Besler Consulting

Advertising Policy/Annual RatesThe Garden State “FOCUS” reaches over 1,000 healthcare professionals in various fields. If you have a product or service you would like the healthcare financial industry to know

about, please take advantage of this great opportunity!Contact Laura Hess at 888-652-4362 to place your ad or receive a copy of the Chapter’s advertising policy. The Publications Committee reserves the right to refuse any ad not consistent

with the overall mission of the Chapter. Inclusion of an ad in this Newsmagazine does not infer endorsement of the product or service by the Healthcare Financial Management Association or the Publications Committee. Neither the Healthcare Financial Management Association nor the Publications Committee shall be responsible for slight variations in production quality of published advertisements. Effective July 2006 Rates for 5 bi-monthly issues are as follows:

Display Full Page Half Page Quarter PageBack Cover – Full Page Color $4,600 NA NAInside Back & Front Covers – Full Page, Color $4,350 NA NAFirst Inside Ad – Full Page, Color $4,250 NA NAFirst Inside Ad – Full Page, Black & White $3,450 NA NAInside Ad – Color $3,450 $2,600 NAInside Ad – Black & White $2,150 $1,450 $875Center Spread – 2 Full Pages, Color $5,900 NA NACenter Spread – 2 Full Pages, Black & White $3,800 NA NANEW! Web Ads are available to our FOCUS advertisers – $250 for 3 months

Ads should be submitted as print ready (CMYK) PDF files along with hard copy. Payment must accompany the ad. Deadline dates are published for the Newsmagazine. Checks must be payable to the New Jersey Chapter - Healthcare Financial Management Association.

DEADLINE FOR SUBMISSION OF MATERIAL Issue Date Submission Deadline January December 1 April February 28 June April 30 October July 15 December October 15

IDENTIFICATION STATEMENTGarden State “FOCUS” (ISSN#1078-7038; USPS #003-208) is published bimonthly by the New Jersey

Chapter of the Healthcare Financial Management Association, c/o Elizabeth G. Litten, Esq., Fox Rothschild, LLP, 997 Lenox Drive, Building 3, Lawrenceville, NJ 08648-2311

Periodical postage paid at Trenton, NJ 08650. POSTMASTER: Send address change to Garden State “FOCUS” c/o Laura A. Hess, FHFMA, Chapter Administrator, Healthcare Financial Management Association, NJ Chapter, P.O. Box 6422, Bridgewater, NJ 08807

OBJECTIVEOur objective is to provide members with information regarding Chapter and national activities,

with current and useful news of both national and local significance to healthcare financial profes-sionals and as to serve as a forum for the exchange of ideas and information.

EDITORIAL POLICY Opinions expressed in articles or features are those of the author(s) and do not necessarily reflect the view of the New Jersey Chapter of the Healthcare Financial Management Association, or the Communications Committee. Questions regarding articles or features should be addressed to the author(s). The Healthcare Financial Management Association and Communications Committee assume no responsibility for the accuracy or content of any articles or features published in the Newsmagazine. The Communications Committee reserves the right to accept or reject contributions whether solicited or not. All correspondence is assumed to be a release for publication unless otherwise indi- cated. All article submissions must be typed, double-spaced, and submitted as a Microsoft Word document. Please email your submission to:Elizabeth G. Litten, Esq. [email protected]

REPRINT POLICY The New Jersey Chapter of the HFMA will not reprint articles published in Garden State FOCUS Newsmagazine. Individuals wishing to obtain reprint authorization must obtain it directly from the author(s) of the article. The cover of the FOCUS may not be used in the reprint; however, the reprint may note that the article was published in a specific issue. The reprint may not imply endorsement by the HFMA, directly or indirectly.

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The President’s View . . .

Dave Wiessel

To the membership of the New Jersey Chapter:

We are saddened by the recent news of the passing of Chuck Wilczynski, a Past President of the New Jersey Chapter of HFMA. Several pages of this issue of the Garden State Focus are dedicated in his memory, including the page typically held for the message from our Editor, Elizabeth Litten. We have included Chuck’s final Garden State Focus letter from his year as President, Chapter fiscal year 1996. Reflecting on Chuck’s letter and the pages in his memory, it’s clear that our Chapter has a tremendous legacy and deep resources in our Past Presidents, Board members and volunteers.

Later in this issue, another Past President, John Dalton, wrote a summary of our 37th Annual Institute. Thank you to John for contributing the article but more importantly for continuing to serve as our Master of Ceremonies at the Institute – his insights always add to the success of our education sessions. Also, a great deal of thanks goes to the chairs, co-chairs and volunteers participating on the Institute 2013 Committee, Education Committee and Membership Services/ Networking Committee, all of which planned and organized the Institute, and to the Institute’s sponsors. As noted in John’s article, we again had over 500 attendees at the Institute and all the volunteers’ efforts and the support from our sponsors contributed to a wonderful event.

In other Chapter events, we recently held our November education session presented by the Finance Accounting Capital and Tax Committee, led by Megan Byrne, Chair, Karen Henderson, Co-Chair, and Scott Mariani, Board Liaison. The event was very well attended with a variety of speakers and panels.

Please also mark your calendars for several upcoming events over the next few months:

• December 17, 2013: Free Session: 2014 Chargemaster Coding Updates. Presented by the Revenue Integrity Committee, Nora Burdi, Chair, Christine Putterman, Co-Chair, and Steve Bilsky, Board Liaison

• January 14, 2014: The PFS and Pt. Access Committees’ bi-monthly education session, PFS Cornucopia, Presented by the Patient Financial Services Forum, Steven Stadtmauer, Chair, Kathleen Yenco, Co-Chair, and Josette Portalatin, Board Liaison

• February 11, 2014: Strategically Managing Physician Practices in Today’s Regulatory Environment. Presented by the Physician Practice Forum, Jennifer Shimek, Chair, Howard Lasner, Co-Chair, and Deborah Shapiro, Board Liaison.

More information for each event can be located on the Chapter’s website, http://www.hfmanj.org.

As always, please stay connected and involved with our Chapter. I look forward to seeing you at an upcoming event.

Dave Wiessel

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4 Focus

Focus 5

FinancialIncentives

forEnergy

Effi ciency

Our Energy Bill Got a Lot SmallerAre you looking for ways to control costs and energy use in your commercial, industrial or government building? Then follow our lead. We turned to New Jersey’s Clean Energy ProgramTM for a FREE Benchmarking Report, which was a big help in understanding what equipment we needed to upgrade fi rst.

That’s setting a benchmark for saving energy…and money!To learn more about benchmarking for buildings in the public and private sectors,visit NJCleanEnergy.com/BENCHMARKING or call 866-NJSMART to speak with a program representative.

Recover, restore, and rebuild after Hurricane Sandy. Visit NJCleanEnergy.com/SANDY to learn about enhanced incentives for homeowners, government offi cials and business owners.

NJ HFMA Chapter President 1995-1996

Photo courtesy of Dotti Lindstrom

NJ HFMA Chapter President 1995-1996

• IhaveknownChuckover30yearsandalwaysfoundhimtobetheconsummateprofessionalaswellasawonderfulhumanbeing.IworkedcloselywithChuckwhenwerebothofficersoftheHFMAandattendedseveraltrainingsessionswithhim.Chuckhadakeeninsightforthemajorissuesandaverydirectwayoflettinghisopinionbeknown.Hehadalargecircleoffriendsandwasawellrespectedcolleague.Hewillberememberedfondlyandwewillmisshispresence.

–JoeLemaire

• IhavemanyfondmemoriesofChucksincehealsowasaHaskins&Sells(nowDeloitte)alumnus.Therewereafewyearsintheearly‘90swhenhalftheChapterBoardwasChucks(Mowll,TeasenfitzandWilczynski)andJohns(Calandriello,DaltonandForsman).Hewasabigguywithanevenbiggerheart.

–JohnDalton

• I’llthinkofChuckeveryyearattheAnnualInstitute.Hewasdirectlyresponsibleforthegiantshrimpwehave.Helovedthemso!

–DottiLindstrom

• Chuckhasbeenafixtureinthehealthcarecommunityforalongtime.Hispresencewillbesorelymissed.

–DeborahShapiro

• IwassosorrytohearaboutthepassingofChuck,agreatguywho’sheartwasasbigashewas.ChuckandIkneweachotherforthebetterpartof30+yearsthroughtheNJhealthcareindustryandservingtogetherontheNJHFMABoard.IfollowedChuckasaNJHFMAPresidentandlearnedfromhisleadership.

–GregAdams

• Iamsosorryforyourloss.IworkedwithChuckformanyyearsandalwaysfoundhimtobeoneofthenicestCFOsintheindustry.Hewillbesorelymissed.

–RitaRomeu

• OnethingIrememberaboutChuckwashisinsistenceonthebiggestshrimpyoucaneatatourJerseyANIinAtlanticCity.Itbecamearunningjoketomakesuretheywerebigandneverranout.

–RickParker

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8 Focus

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Focus 9

How Healthcare Facilities Can Respond to Heightened FDA Scrutiny of IT Hardware and Software Products

Jason Sapsin

Shahnam Sharareh

by Jason Sapsin & Shahnam Sharareh

continued on page 10

Overview: Information Technology (“IT”) enables the management,

transmission and analysis of data across multiple platforms in a variety of hospital administrative and clinical settings. Hos-pitals and health systems naturally seek to create and imple-ment improved IT solutions to increase data handling effi-ciency and in-house analytic capabilities. These advances offer the promise of greater administrative efficiency and improved patient care.

We increasingly find healthcare entities – through alert com-pliance officers, IT departments or interested providers – raising concerns about heightened U.S. Food and Drug Administra- tion (“FDA” or the “agency”) scrutiny of IT products. Interest- ingly, in our personal experience, FDA regulatory activity has not significantly affected the activities of health care institu-tions on many, or even most, of these occasions. With the re-lease of FDA’s final guidance on Mobile Medical Applications (“MMA”)1, however, many such institutions may find it helpful to revisit core concepts in FDA’s regulation of healthcare IT to help them perform their own “legal triage” for IT products.

Does FDA Regulate IT Products and, If So, Under What Authority?

Hospital and health system personnel sometimes resist the idea that FDA regulates IT products. Typically they do so for two reasons. First, IT departments, physician inno- vators and administrative entrepreneurs within healthcare entities view modifications to or innovations in IT as matters of routine practice rather than regulated activity. Second, it can be difficult – especially when dealing with software IT products – to conceptualize them as medical products. We find that many institutions focus on what a product is (e.g., “it’s a computer program, not a stethoscope”) as opposed to what the product does.

FDA regulates products under the Federal Food, Drug, and Cosmetic Act (“FDCA” or the “Act”) on

the basis of two factors: (1) the intended use of the product (i.e., what the product’s sponsor intends it to do); and (2) how the product works. If a new product (hardware, software, chemical, food or machine) is intended to be used to (a) diagnose, (b) cure, (c) treat, (d) mitigate, or (e) prevent disease or other conditions or to (f ) affect the structure or any function of the body, it is an FDA-regulated product. Analyzing the regulated product’s mode of action (chemical, physical or both) determines its regulatory classification as a drug, device, biologic or “combina-tion” product. Each classification has its own pre-mar-ket requirements.

For example, new standalone software designed by the manufacturer to enhance the real-time image of a patient’s heart to help identify dysfunction is “intended to be used to diagnose” disease. It is, therefore, a product regulated by FDA. Because its diagnostic utility would not derive from chemical action “within or on the body”, or depend on “being metabolized”, the software is a device (as opposed to a drug).2 A similar analysis would apply to computer hardware IT.

The greatest challenge facing hospital IT departments and IT entrepreneurs is that IT products used for or in support of healthcare can potentially, by default, be required to undergo pre-market approval. The FDCA classifies, by default, medi-cal devices not previously marketed as “new” medical devices. New medical devices, under the Act, require pre-market

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10 Focus

continued from page 9

review and approval by the agency before they can be introduced. The failure to secure pre-market approval renders the product “adulterated” and “misbranded”. The institutional manufacturer or developer would consequently and, presum- ably, unintentionally have violated the Act.

Avoiding a Default ClassificationFDA has identified (through a rulemaking and two guid-

ance documents) two new categories of healthcare IT products in order to avoid this result: The Medical Device Data Sys-tem (“MDDS”) and Mobile Medical Applications (“MMA”). FDA’s regulations (for MDDS) and guidance documents (for both MDDS and MMA) explain (a) how to identify a product falling within their categories; and (b) how lawfully to bring that product onto the market (into service) under the Act.

MDDSFDA’s MDDS rule classifies some hardware and software

IT products as Class I medical devices – devices which do not require pre-market approval but which must still comply with other regulatory requirements.3 The rule itself (codified at 21 CFR § 880.6310) has raised concerns among health care entities that their ordinary IT activities involve the in-advertent creation of a MDDS. Equally or even more im-portantly, therefore, the MDDS interpretive guidance at-tempts to “carve out” from the regulation a wide range of “off-the-shelf ”, “general” IT hardware and software.

The heart of a MDDS lies in its ability to transfer, store, format or display data produced by a separate medical device used directly in patient care. The MDDS may be software, hardware, wireless hardware or a communications protocol. Such a device, in FDA’s view, performs one of the four follow-ing functions:

• It electronically transfers medical device data • Itelectronicallystoresmedicaldevicedata • It electronically converts medical device data from one format to another in accordance with a preset specification (e.g., it creates PDF files or HTML) • Itelectronicallydisplaysmedicaldevicedata

A literal application of 21 CFR § 880.6310 could capture a staggering array of ordinary items found in hospital IT de-partments. FDA’s interpretive guidelines therefore restrict the scope of the rule.

The single strongest common factor excluding IT prod-ucts from medical device regulation is that they are standard equipment and/or software fulfilling purposes which include handling medical device data but for which they are not spe-cifically intended.4 The following activities will not constitute “manufacturing” an MDDS, in FDA’s view, and therefore

will not trigger any requirements for medical devices under the Act:

1. Using general-purpose IT infrastructure without altera- tion or reconfiguration.5 “General purpose IT infrastructure” includes, but need not be limited to:

• Network routers • Networkhubs • Wirelessaccesspoints • Networkattachedstorage • Storageareanetwork • PDFsoftware • Virtualizationsystems(e.g.,VMWare) • Computermonitors • Largescreendisplays

2. Building and using a network to monitor the status of medical devices;

3. Using standard software which may have MDDS functionality, but is not sold specifically as MDDS (e.g., barcode readers), and which is not used to provide patient care; or

4. Using off-the-shelf “passive network sniffing software” – disconnected from any medical device – to monitor network performance.

In contrast, FDA has stated that it believes some specific activities will bring health care IT products (and their hospital proponents, or others) under the scope of the MDDS rule to be regulated by FDA. The common factor in these activities is the development or deployment of non-standard, customized or “special use” hardware or software to handle medical device data.6 Examples include:

1. Developing specialized software or hardware expressly created to provide MDDS functions;

2. Writing custom software to interface with medical devices to obtain medical device information; or

3. Modifying hardware or software outside specifications for MDDS functionality.

Categorization as a “MDDS” avoids the default classification of these IT products as medical devices subject to pre-market ap-proval. From the standpoint of compliance burden, it occupies an uneasy middle ground between no regulation and stringent regulation (pre-market approval). However, to maintain its status as an MDDS and enjoy that middle ground, the product: • May not be used in connection with “active patient monitoring”• May not, in FDA’s words, “facilitate[] clinical assess-

ments or monitoring, such as alarm or alert functionality based on preset clinical parameters.”7 More gener-

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Focus 11


ally, it may not “modify, interpret, or add value to the data or the display of the data”8 which includes functions such as “flagging . . . , analyzing, prioritizing, plotting, or graphing data.”9

In these cases FDA would view the product as high risk, demanding pre-market approval, until proven otherwise.

MMAFDA finalized its MMA Guidance since our last article on

the subject of mobile medical applications. FDA uses the term “mobile application” or “mobile app” to describe any software program running on a mobile communication device.10 FDA applies two tests in determining whether a mobile app consti-tutes a “mobile medical application” or “mobile medical app”: first, does it meet the definition of a device (see p.9, above); and second, is it to be used as a “Mobile medical application” or “mobile device”11 or “to transform a mobile platform into a regulated medical device.”12 MMA manufacturers include any person or entity that “creates, designs, develops, labels, re-labels, remanufacturers, modifies, or creates a mobile medi-cal application software system from multiple components.”13 Initiating specifications or requirements for MMA also consti-tutes “manufacturing” for purposes of the FDCA.14

The MMA Guidance points out that identifying a product as a MMA is only the first step to determining which regula-tory obligations will apply to it; for example, the manufacturers of MMA performing MDDS functions (e.g., displaying on a handheld patient-specific medical device data) must comply with MDDS rules. FDA also clearly states that it intends to exercise oversight regarding only a MMA “whose functionality could pose a risk to a patient’s safety” if the application fails to function as intended.15

The MMA Guidance thus reflects FDA’s intention to ap-ply the risk-based approach that the agency historically has used to evaluate safety and effectiveness for medical devices. It points out that the manufacturers of mobile medical applica-tions must follow the same regulatory requirements as other medical device manufacturers, which include properly classi-fying the software and following the proper regulatory path for approval or clearance of such product. The MMA Guid-ance, however, lacks specifics on scenarios when a healthcare facility may wish to incorporate a mobile application into an already existing information technology system.

By the way of example, what would be a healthcare facility’s regulatory obligations if it supplements its existing IT system with an in-house application for smartphones that extracts stored medical device data, identifies an abnormal parameter, performs a patient specific analysis and provides a treatment recommendation? A checklist for deciding might look like this: 1. Is the application a medical device? i.e., is it an instru- ment, apparatus or “contrivance” intended to treat/diag-

nose/prevent/cure/mitigate a disease or other condition? • Yes–thefacilityisamedicaldevicemanufacturerand the product is regulated.

2. Is it a “mobile medical app”? i.e., is it a software device running on a mobile platform which is either to be used as an accessory to a regulated medical device or to transform the mobile platform into a regulated medical device? • Yes–thesoftwareapplicationacceptsandprocesses medical device data and will be considered an “accessory” to a regulated medical device.

3. Is it mobile medical app over which FDA intends to exercise enforcement discretion? i.e., does it pose risks to patient safety were it to fail to function as intended? • No–becausetheapplicationmayberelied-uponin the treatment of patients, it poses a risk to patient safety in the event of malfunction. FDA will probably choose to oversee the product.

4. Is it a MDDS , classified as low-risk and exempted from pre-market clearance or approval? i.e., does it simply display data or is it “adding value” by performing interpretive or analytic functions? •No – the application does more than simply transmit medical device data. It appears to perform interpretive and analytic functions and provides patient-specific treatment recommendations.

5. Is there another existing, marketed, analogous product which will determine the MMA’s risk classification? e.g., is it directly comparable, for example, to an “arrhythmia detector and alarm”, a Class II product under 21 CFR 870.1025? • If there’s an analogous product, the facility’s MMA takes on the regulatory risk classification of that product and will likely undergo pre-market clearance through a 510k pre-market notification. • A510kwouldnotbeappropriateiftheMMAposes new questions of safety or efficacy. Instead it may be a “Class III” medical device requiring pre-market approval.

It may be extremely difficult to answer question (5). In these cases, the MMA Guidance encourages entities devel-oping products to contact FDA to discuss the proper regula-tory requirements.

ConclusionEven though FDA has traditionally taken a fairly passive

role in regulating health related technology systems in the past, over the last two years it has put the industry on notice of what it perceives as good practices. The Medical Device

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Data System (“MDDS”) rule and the Mobile Medical Appli-cations (“MMA”) guidance are important in demonstrating FDA’s thinking on some of the easiest-to-develop IT products – the kinds of products which, at first glance, seem to be the simplest and easiest for healthcare entities to develop. Hospi-tals and health systems can avoid wasting time and money by using FDA’s regulations and associated guidance documents – together with simple analytic protocols – to perform legal tri-age on their innovative IT solutions before deploying them.

Footnotes1.“Mobile Medical Applications” (Guidance for Industry, FDA), September 25, 2013, hereinafter “MMA Guidance”. http://www.fda.gov/downloads/MedicalDevices/DeviceRegu-lationandGuidance/GuidanceDocuments/UCM263366.pdf.2. It is a “contrivance” or “accessory” in the language of the FDCA. (FDCA §201(h)).3.Producing a Class I product would require the health care entity to register as a medical device manufacturer and to list its devices accordingly. Fees for registration and listing are approximately $2200-$2300 annually. Failure to register and list would constitute a violation of the FDCA.

4.By implication, FDA appears to be prepared to allow providers and others to rely on industry-based quality controls and specifications to manage routine medical device data handling tasks. 5.General purpose IT may be altered or reconfigured, however, if the change is within the manufacturer’s specifications. 6.By implication, FDA appears to consider software or equip-ment developed outside “normal”, off-the-shelf IT channels to present higher risk. 7.76 Fed. Reg. 8637, 8644 (February 15, 2011). 8.76 Fed. Reg. at 8641. 9.Id. at 8642.10.MMA Guidance at 7.11.FDA typically regulates even “standalone” software as an “accessory” to the medical device or devices which provide the data. See MMA Guidance at 6.12.MMA Guidance at 7.13.Id. at 9.14.Id. 15.MMA Guidance at 8.

The CommunicationsCommittee would like

to wish our fellowNJ HFMA members

a wonderful holiday seasonand a happy, healthy 2014!

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14 Focus

“HIPAA Food for Thought”:Three Training Tips to LimitExposure to Violations andReap Operational Benefits

by Nicole K. Martin, MPH, Esq. Nicole Martin

Food For ThouGhT. . .Are you confident members of your workforce know and

understand your organization’s HIPAA1 policies? If you answered yes (and even if you answered no or simply cannot answer the question), consider the following:

Does your workforce comply with:

• Your organization’s policy for accessing protected health information (“PHI”)? • Yourorganization’spolicyforimmediatelyreportinga potential HIPAA violation? • Yourorganization’spolicyfortheproperdisposalof PHI? Does your workforce employ best practices to avoid

simple, but common, mistakes in HIPAA compliance such as: • SendingafaxoremailcontainingPHItothewrong recipient? • Failing to log-off of a computer systemcontaining electronic PHI? • UsingordisclosingmorePHI thannecessary fora particular purpose? • Leaving documentation containing PHI in plain view (e.g., on a printer)? • Sharing PHI with individuals who do not have a valid reason to have it? Can your workforce provide the following information:

• Identity of your organization’s HIPAA security officer? • Examples of PHI, other than name, address, and social security number? • Adescriptionofthe“minimumnecessarystandard” under HIPAA?

Now, are you still confident members of your workforce, including management, competently implement your organization’s HIPAA policies? Any doubt equates to unnecessary vulnerability to HIPAA violations.

An organization’s compliance with HIPAA hinges signifi-cantly on its workforce’s compliance with its HIPAA polices and comprehension of the standards prescribed by the HIPAA Privacy and Security Rules2. Thus, a workforce well-versed in how to perform job functions in a HIPAA-compliant manner and trained to appropriately react to situations that could result in a HIPAA violation could be an organization’s saving grace from penalty. Since an organization’s workforce represents the most visible and vital components of its HIPAA compliance efforts, workforce members can either be an entity’s Achilles heel or best defense mechanism.

The landscape of HIPAA enforcement evolved to the disadvantage of covered entities and business associates upon the enactment of the Health Information Technology for Economic and Clinical Health Act (“HITECH”)3 and adoption of the commonly known “Omnibus Rule.”4 Not only did the United States Department of Health and Human Services, Office of Civil Rights (“OCR”) increase its efforts to enforce requirements under HIPAA,5 it commenced a proactive approach to enforcement.6 In addition, State Attorneys General were authorized by HITECH to bring civil actions on behalf of state residents for alleged violations of HIPAA. Also, in this current climate of heightened government enforcement and oversight, consumers are now more aware of their privacy rights and how to report suspected violations of those rights.7 As a result, all covered entities and business associates, regardless of size, are under constant scrutiny.

In light of OCR’s investigations of alleged HIPAA violations, it has become evident that OCR views workforce training as an invaluable component of a HIPAA compliance program. OCR has documented training-related deficiencies in findings from its investigations8 and included mandatory training requirements in corrective action plans issued as part of its resolution agreements with parties alleged to have violated HIPAA.9 Therefore, it is critical for covered entities

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and business associates to have a versatile HIPAA compliance education and training program in their arsenal of defenses against violations of HIPAA.

ThrEE TIPS. . .Outlined below are three tips for how covered entities and business associates can enhance their in-house HIPAA compliance training programs to limit exposure to risk of HIPAA violations and reap certain organizational benefits from compliance with the workforce training requirements under HIPAA.

1. “one Size does Not Fit All:” Tailor Your hIPAA Compliance Education and Training Program. As a reminder, a HIPAA-compliant education and train-ing program must provide instruction on an entity’s HIPAA policies to all workforce members (includ-ing management, volunteers and interns). 10 While a pre-packaged HIPAA compliance education program typically provides general information about HIPAA requirements, it is unlikely to offer content specific to an entity’s HIPAA policies or address nuances of its practices. Further, since covered entities and busi-ness associates differ in size, service offerings, business structure and workforce composition, HIPAA train-ing curriculums should be tailored to include content that is specific to the entity implementing the pro-gram. In addition, a curriculum should be comprised of adaptive content that can be modified based on an entity’s needs and target audience for each train-ing session. For example, a training curriculum could include separate education modules for job functions that differ vastly, such as clinical and financial jobs, to address the proper application of HIPAA policies. A customized training curriculum could also offer mod-ules that can be easily adapted to address areas of risk, especially those discovered by an entity during an au-dit or upon notification of a potential HIPAA viola-tion, so an organization can respond expeditiously to training needs.

2. “reach out and Train:” Conduct In-Person Edu-cation and Training Sessions. It is undeniable that computer-based, web-based, and paper-based educa-tion programs enable organizations to conveniently educate a sizeable workforce, employ standardized training content, and maintain a reliable record of each workforce member who has been trained. How-ever, in-person training sessions provide a forum that can offer a multitude of benefits for both a workforce and an organization’s business operations that nei-ther technology-based nor paper-based training can

replicate. For example, in-person sessions provide an environment where: (i) an instructor can respond to questions and hypothetical scenarios posed by a workforce during training and provide relevant, “real-life” examples regarding the application of an orga-nization’s HIPAA policies; (ii) a workforce can have an open dialogue with an instructor regarding best practices for the application of HIPAA policies based on job function; (iii) an organization may learn about departments, job functions, and certain employee practices at a greater risk for HIPAA violations; (iv) an organization could gain insight through feedback from its workforce as to the effectiveness of its HIPAA training program; and (v) an instructor can discuss current government enforcement actions and actual penalties to demonstrate consequences for non-com-pliance with HIPAA -- such as disruption of business operations and significant expenses that could result from an OCR investigation, notification require-ments, defending allegations of HIPAA violations and monetary penalties. In addition to the aforemen-tioned benefits that could be realized, an in-person education and training model is versatile and could be designed to supplement other education programs and accommodate various business needs and mul-tiple education levels and learning styles.

3. “Eyes and Ears of Prevention:” Extend the reach of your Compliance office.

HIPAA compliance education and training programs are expected to train members of a workforce to per-form their respective job functions in accordance with an organization’s HIPAA policies. However, since the responsibility of compliance should be shared by each member of an organization, training programs should provide a workforce with the skills to recognize and avoid potential HIPAA violations, mitigate a breach of PHI, and report alleged violations promptly to a supervisor or compliance officer (or other individu-al with oversight of compliance). When workforce members perform job functions in a HIPAA-compli-ant manner, they become peer leaders and constant reminders of behavior and practices their colleagues should model. In addition, when workforce members know how to appropriately react to potential HIPAA violations, they essentially serve as an extension of an organization’s compliance officer. For example, if a member of a health care provider’s workforce prevents a maintenance vendor from removing a photocopier that retains electronic PHI until he or she confirms that the provider entity has a signed business associ-


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ate agreement with the vendor, he or she has helped the organization avoid a potential HIPAA violation.11 In an effort to maximize the benefits of an education and training program, remember one training objec-tive: a trained workforce will know how to proactively minimize risk of HIPAA violations.

CloSING ThouGhTS. . .Assuming covered entities and business associates have

implemented new or amended HIPAA polices in response to the requirements under HITECH and the Omnibus Rule, there is a need for their workforce to be trained or retrained. Thus, there is no time like the present for these organizations to evaluate their current (or proposed) education and training curriculum and materials to determine whether the training program is HIPAA compliant and effectively trains workforce members on its polices and standards under the HIPAA Privacy and Security Rules.

About the AuthorNicole K. Martin is founder of Martin Law, LLC. In her practice she provides guidance based on a comprehensive understanding of federal and state health care regulations and aids in the development of compliance programs and organization policies. She establishes education programs and conducts workshops on a broad range of health law-related topics, including HIPAA. She is also a faculty member at Rutgers School of Public Health. Nicole can be reached at [email protected].

Endnotes1 Health Information Portability and Accountability Act of 1996, Pub. L. No. 104-191.2 “Privacy Rule” shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 C.F.R. Parts 160 and 164, sub-parts A and E. “Security Rule” shall mean the Security Standards for the Protection of Electronic Health Information at 45 C.F.R. Parts 160 and 164, subparts A and C.3 HITECH was enacted as part of the American Recovery and Rein-vestment Act of 2009, Pub. L. No. 111-5.4 The “Omnibus Rule,” which amends the HIPAA Privacy, Secu-rity, Breach Notification and Enforcement Rules, implements and expands on the requirements of HITECH. 78 Fed. Reg. 5,566 (Jan. 25, 2013).5 Information concerning OCR’s enforcement activity and results of such efforts is available on OCR’s webpage, http://www.hhs.gov/ocr/privacy/hipaa/enforcement/index.html (last visited Septem-ber 9, 2013). For example, the number of cases OCR investigated and resolved each year since 2003 is available; the number of cases OCR investigated and resolved since 2009 is as follows: 8,106 cases in 2009, 9,189 in 2010, 8,363 cases in 2011, and 9,411 cases in 2012, http://www.hhs.gov/ocr/privacy/hipaa/enforcement/data/his-toricalnumbers.html#resol (last visited September 9, 2013). OCR reported that, to date, it has entered into 15 resolution agreements

(in general, a contract signed by OCR and an entity in which the entity agrees to perform certain obligations) with covered entities; while OCR only entered into six of those agreements between 2008 and 2011, it entered into the nine since 2012, http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/index.html (last visited September 9, 2013).6 In accordance with Section 13411 of HITECH (42 U.S.C. § 17940), OCR implemented a pilot audit program in 2011 “to as-sess the controls and processes covered entities have implemented to comply with” the standards for protecting the privacy of PHI, the security of electronic PHI, and notifying consumers about breaches; OCR provides information about the status of the audit program on its website, http://www.hhs.gov/ocr/privacy/hipaa/enforcement/audit/index.html (last visited September 9, 2013). 7 For example, the number of complaints OCR received has steadily increased from 7,587 in 2009, 8,764 in 2010, 9,028 in 2011, and 10, 433 in 2012 http://www.hhs.gov/ocr/privacy/hipaa/enforce-ment/data/complaintsyear.html (last visited September 9, 2013).8 For example, see the resolution agreement between the United States Department of Health and Human Services, OCR and Phoe-nix Cardiac Surgery, P.C., which became effective April 13, 2012, http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/pc-surgery_agreement.pdf (last visited September 9, 2013).9 OCR’s website provides examples of cases OCR investigated and resolution agreements to which OCR is a party, http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/index.html (last vis-ited September 9, 2013).10 The training standard under the HIPAA security rule requires orga-nizationsto“[i]mplementasecurityawarenessandtrainingprogramfor all members of its workforce (including management).” 45 C.F.R. § 164.308(a)(5)(i). The training standard under the HIPAA Privacy Rulerequires“[a]coveredentitymusttrainallmembersofitswork-force on the policies and procedures with respect to protected health information requiredby [subpartsDandEofPart164ofTitle45oftheCodeofFederalRegulations],asnecessaryandappropriateforthe members of the workforce to carry out their functions within the covered entity.” 45 C.F.R. § 164.530(b). Although business associates are not mandated under 45 C.F.R. § 164.530(b) to conduct workforce training related to the privacy rule, business associates should not dis-miss the training requirement based on a technicality due to their com-pliance obligations under HIPAA (including compliance with certain Privacy Rule standards) and business associate agreements. 11 A similar scenario was the subject of a recent OCR investigation and resolution agreement, which was addressed in a press release OCR issued on August 14, 2013. Pursuant to the press release and agreement, Affinity Health Plan agreed to pay $1,215,780 to settle a potential violation of HIPAA involving Affinity Health Plan’s im-permissible disclosure of PHI for “up to 344,579 individuals...when it returned photocopiers to leasing agents without erasing the data contained on the copier hard drives.” http://www.hhs.gov/news/press/2013pres/08/20130814a.html (last visited September 9, 2013). For additional information regarding the matter, the Resolution Agreement between the United States Department of Health and Hu-man Services, OCR and Affinity Health Plan, Inc., which became effective August 7, 2013, http://www.hhs.gov/ocr/privacy/hipaa/en-forcement/examples/affinity_agreement.pdf (last visited September 9, 2013).


Focus 17

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Luring Business to New JerseyGovernor Chris Christie Signed into Law the New Jersey Economic Opportunity Act of 2013 Which Greatly Expanded Geographic Areas Where Companies Can Qualify for Tax Incentives

by James A. Robertson and Brooks E. Doyne

New Jersey is often the butt of many jokes. Whether it is the gorgeous landscape viewed upon arriving in Newark Air-portorwatchingSnookionMTV,NewJerseyisnotalwaysviewed favorably by outsiders.

However, while our lawmakers in the nation’s capital were playing a game of chicken over a government shutdown and the debt ceiling, our New Jersey Legislature and Governor Christie found common bipartisan ground and enacted leg-islation that will greatly benefit the State and those who bring their business to New Jersey.

In an aggressive push by the State to promote job creation and redevelopment of areas impacted by Hurricane Sandy, the New Jersey Economic Opportunity Act was signed into law on September 18, 2013. After several fierce months of nego-tiation, a conditional veto by the governor of an earlier ver-sion of the legislation, the Act will modernize and improve the State’s already successful economic development programs and send a powerful message to private sector employers to open business in the Garden State. Governor Christie has stressed the importance of competing against other states. “This new group of incentives will lead to making us more competitive with other states across the country,” Christie said at a news conference. “Let’s not kid ourselves. We’re competing with other states every day for the economic pie.” Applications should be submitted on or before June 30, 2019.

The purpose of the program is to encourage economic development and job creation and preserve jobs that currently exist in New Jersey but are in danger of being relocated outside the State. To be eligible for tax credits under the Act, a busi-ness must demonstrate, at the time of application, that the grant of tax credits and retention of full-time jobs will yield a net positive benefit to the State. The Act proposes to merge five economic development incentive programs, including the

Business Employment In-centive Program and Urban Transit Hub Tax Credit Pro-gram, into two existing pro-grams: the Grow New Jersey Assistance Program and the Economic Redevelopment and Growth Program, which are both administered by the New Jersey Economic Development Authority.

The Act also provides additional bonuses aimed at helping to rebuild tourism destinations battered by Hurricane Sandy, a priority of both the Christie administration and the Legis-lature. The bill addresses a clean-energy program fund, which is financed by surcharges on customers’ electric and gas bills. The measure will allow developers to be repaid money they pay into that fund, dubbed the societal-benefits charge, and other utility taxes. Lawmakers and past administrations have historically diverted funds from the clean-energy program to help balance the State budget.

The Act, once 47 pages in length, grew to 82 pages. To better help understand the Act it is best to break it down. Sections 1-21 expands three economic development incentive programs administered by the New Jersey Economic Devel-opment Authority (EDA): (1) the Grow New Jersey Assis-tance Program (GNJAP); (2) the Economic Redevelopment and Growth Grant Program (ERGGP); and (3) the Urban Transit Hub Tax Credit Program (UTHTCP). Sections 22-34 of the Act, entitled New Jersey Residential Foreclosure Transformation Act, established the New Jersey Foreclosure Transformation Program as a temporary program within the New Jersey Housing and Mortgage Finance Agency (HMFA) for the purpose of purchasing foreclosed residential properties

James A. Robertson

Brooks E. Doyne

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from institutional lenders and dedicating them for occupancy as affordable housing.

The Act is geared more toward the southern counties in the State. Of the $600 million in tax credits available for resi-dential developments, $175 million will go exclusively to the city of Camden, while another $75 million could only go to projects in Atlantic, Burlington, Camden, Cape May, Cum-berland, Gloucester, Ocean and Salem counties. Developers in the eight southern counties and growth zones would only have to invest one-third in their projects as compared to those in other parts of the State. The southern counties also would have to create or retain 25 percent fewer jobs. Further, the State has decided the definition of a full-time job would be loosened for projects that include a supermarket in Camden and the Atlantic tourism district. The Act also sets aside $100 million for the offshore wind power equipment that is manu-factured in Paulsboro. Lastly, companies would be eligible for a $1,000 bonus tax credit for each job created from projects in the eight southern counties.

A business may apply to the Authority for a grant for any project which will create at least 25 eligible positions in the base years or will create at least 10 eligible positions in the base years if the business is an advanced computing company, an advanced materials company, a biotech company, an electron-ic device technology company, an environmental technology company, or a medical device technology company. In the case where the business is a landlord, the business may apply for a grant for any project in which at least 25 eligible positions are created in the base years.

A business, upon approval, shall be allowed a credit of 100% of its capital investment, made after the effective date but pri-or to its submission of documentation in a qualified business facility within an eligible municipality. To be eligible for tax credits a business must show to the Authority, at the time of application, that the State’s financial support of the proposed capital investment in a qualified business facility will yield a net positive benefit to both the State and the municipality. The value of all credits approved will not exceed $1,750,000,000, but this amount may be increased by the Authority.

A business, other than a tenant, must make or acquire capi-tal investments totaling not less than $50,000,000 in a quali-fied business facility, at which the business must employ not fewer than 250 full-time employees to be eligible for a credit. A business that is a tenant in a qualified business facility, hav-ing acquired capital investments of $50,000,000 must occupy a leased area that represents at least $17,500,000 of the capital investment in the facility and must employ no fewer than 250 full-time employees in the aggregate to be eligible for a credit. The amount of capital investment in a facility must be equal to the percentage of the owner’s total capital investment in the facility. No tax credits are provided if the business participates in a business employment incentive grant relating to the same

capital and employees that qualify the business for this credit. A business that is allowed a tax credit shall not be eligible for incentives if the capital investment or employment was the basis for which a grant was provided to the business.

Full-time employment must be determined as the average of the monthly full-time employment for that period. The capital investment is the percentage of the capital investment made or acquired by the owner of the building that the per-centage of net leasable area of the business facility not leased to tenants. A business shall be allowed a tax credit of 100% in a qualified business facility that is part of a mixed use project provided the facility represents at least $17,500,00 of the total capital investment, the business employs not fewer than 250 full time employees and the total capital investment is not less than $50,000,000.

In determining whether an investment will yield a net posi-tive benefit, the Authority will not consider the transfer of an existing job from one location in the State to another loca-tion in the State as the creation of a new job unless the CEO submits a certification indicating the existing jobs are at risk of leaving the State and that the CEO has reviewed informa-tion and determined the business intends to employ not fewer than 500 full time employees in the qualified business facil-ity. When considering intra-State job transfers, the Authority requires the company to submit the following information: a full economic analysis of all locations under consideration by the company, all lease agreements, ownership documents and all lease agreements, ownership documents for the potential out-of-State location alternatives to the extent they exist.

For a qualified business facility that is located on or adja-cent to the campus of an acute care medical facility a mini-mum number of full-time employees required for eligibility may be employed by any number of tenants and the capital exceeds $100,000,000. The net positive benefit yield shall be based on the benefits generated during a period of up to 30 years following the completion of the project, as determined by the Authority. The tax period ending after July 28, 2017 that remains uncertified shall be forfeited. The credit amount that may be taken for a tax period that exceeds the final liabili-ties of the business for the tax period may be carried forward for use by the business in the next 20 successive tax period. Regarding a partnership, a partnership shall not be allowed a credit. Each owner will have to allocate that proportion of the credit of the business that is equal to the owner of the share, whether or not distributed.

Companies must be aware that the numbers needed to qualify for tax incentives must not falter. If at any point fewer than 200 full time employees are employed, the amount of credit shall be reduced by 20% for that tax period and each subsequent tax period until the 200 full-time employees are accounted for in new full-time positions. If the number

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reduces any lower than 20% of the number of full-time employees the same penalty applies. If located near an urban transit hub, if the number drops below 250 then the business must forfeit its credit for that tax period and each subsequent tax period, until the first tax period for which documentation shows the restoration of the number of full-time employees reach 250.

In allocating all credits the executive director shall take into account, together with other factors deemed relevant, input from the municipality, whether the project contrib-utes to the recovery from Sandy, whether the project fur-thers specific State or municipal planning and whether the project furthers a public purpose, such as catalyzing urban development or maximizing the value of vacant property. A developer shall make or acquire capital investments totaling

not less than $50,000,000 in a qualified residential project. A developer shall be al-lowed a credit of up to 35% of its capital investment, or up to 40% for a project lo-cated in a Garden State Growth Zone.

The State shows employment is a major issue. “Jobs aren’t Republican or Democrat. They’re jobs. And people in this state need jobs,” said Senate President Stephen Swee-ney (D-Gloucester). By adding jobs New Jersey will have a chance to compete with Pennsylvania’s generous tax incentives and NewYork’sdominanceofthetri-statearea.“What we’ve done here is created a bill for the entire state. Not just one region,” Sweeney said. It is hoped the entire state will benefit and more employers will look at New Jersey as a promised land for be-ing successful. The lawmakers in Wash-ington, DC should take heed: New Jersey politicians are figuring out a way to come together and move New Jersey forward in a positive way which will hopefully have a long-term positive effect on the future.

About the AuthorsJames A. Robertson is a Partner and head of the health care practice at McElroy, Deutsch, Mulvaney & Carpenter, LLP, with ten of-fices in New Jersey, New York, Connecticut, Massachusetts, Pennsylvania, Delaware, and Colorado.

Brooks E. Doyne is an associate in the health care practice of McElroy, Deutsch, Mulvaney & Carpenter, LLP.


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Risk Ad_3 7/11/11 5:16 PM Page 1

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Although the Kardashians may be exiting the spotlight to no one’s dismay, the Medicare and Medicaid EHR Incentive Programs (“Meaningful Use”) are not going anywhere. Despite calls from many for CMS to delay the start of Meaningful Use Stage 2, hospitals and eligible professionals (EPs) are working through transitions to the new certified editions of their EHR technology in preparation for Stage 2.

Both Stage 1 and Stage 2 present new challenges and objectives for hospitals and EPs. For those providers either continuing Stage 1 from a previous reporting period, certain of the core and menu objectives have changed. While hospitals and EPs that are beginning their second, third or fourth year of demonstrating Meaningful Use have already been around the block at least once should be fairly well positioned for their 2014 reporting year, Meaningful Use has changed significantly.

CMS permits a one-time shortened reporting period (quarterly for Medicare providers, 90 days for Medicaid providers), regardless of Stage, for those demonstrating Meaningful Use in 2014. In order to work through the upgrades with their certified EHR vendors and the new requirements in Stages 1 and 2, most hospitals and EPs will likely take advantage of the shortened reporting period and wait until the spring or summer to start the clock for their reporting. All hospitals and EPs are required to use the new 2014 certified editions going forward, regardless of the Stage of Meaningful Use they may be in.

The bar will only get higher as Meaningful Use advances. Participation in Meaningful Use remains a substantial cost to providers, and although they may recoup amounts through the incentive payments they receive for successful demonstration of Meaningful Use, they may not realize the full value of time and resources they expended to participate. Furthermore, early-bird providers who began Meaningful Use in 2011 will see their last Medicare incentive payment (and likely Medicaid as well) for participation in 2014.

Participate or face Medicare payment adjustments While there are substantial costs to participate in

Meaningful Use, there can also be costs for not participating, as 2014 represents the beginning of potential payment reductions for Medicare providers. A Medicare hospital or

EP that does not successfully demonstrate Meaningful Use in 2014 and each subsequent year will face payment adjustments to the applicable Medicare fee schedule. For EPs, this means a cumulative reduction under the physician fee schedule (PFS) for each year an EP does not demonstrate Meaningful Use starting at 1% and potentially increasing to 5%. Medicare EPs must begin Meaningful Use in 2014 in order to avoid payment adjustments for 2015 and subsequent years.

For Medicare subsection (d) hospitals, payment adjustments will be applied beginning with the 2015 cost reporting period, affecting the increase to standard payment amounts a hospital would ordinarily receive each year. Therefore, a hospital that does not successfully demonstrate Meaningful Use will face a reduced update to the Inpatient Prospective Payment System (IPPS) rate starting with a 25% reduction and cumulative thereafter for each year up to 75%. Critical access hospitals likewise face similar reductions, calculated differently, however, from Medicare subsection (d) hospitals.

Notably, these payment adjustments apply to hospitals or EPs that have successfully demonstrated Meaningful Use in the past as well as to those that have not yet begun participation. As such, any Medicare provider that decides in 2014 that it will not continue with Stage 2 of Meaningful Use will be subject to payment adjustments going forward. The adjustments would also apply to Medicare providers who choose to “skip” a payment year (i.e., will not demonstrate Meaningful Use in 2014 but will demonstrate Meaningful Use again in 2015). In addition, Medicare providers who “skip” Meaningful Use in 2014, for example, in order to buy extra time for performance under the more onerous Stage 2 requirements, will be forced into the full year reporting period for Stage 2, as if they had already demonstrated Stage 2 in 2014.

However, providers who are only participating in the Medicaid Meaningful Use program are not faced with payment adjustments. Therefore, choosing not to continue participation in 2014 and subsequent years will only affect the total amount of incentive payments a Medicaid provider can receive. In addition, Medicaid providers can “skip” performance in any

Keeping up with Meaningful Use

By Krystyna H. Monticello, Esq.

Krystyna H. Monticello


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year and pick up exactly where they left off, unlike Medicare providers. For example, a Medicaid provider entering year 2 of Stage 1 in 2014 that chooses to “skip” participation will pick up with year 2 of Stage 1 in 2015 as if it had never left, whereas a Medicare provider would be required to resume in 2015 with Stage 2.

It’s not the Stage 1 you remember. Hospitals and EPs continuing with their second year of

Stage 1 will see changes to their core and menu objectives, as will hospitals and EPs demonstrating Meaningful Use for the first time in 2014. Although minor changes took effect or were mandatory in 2013, most of the changes to Stage 1 which were adopted by the Stage 2 Final Rule become mandatory for 2014 going forward. Therefore, providers will need to ensure that they are complying with the latest and greatest for Stage 1 when using the 2014 edition of their certified EHR technology.

There are changes to the CPOE and vital signs objectives and measures for both hospitals and EPs, and EPs may qualify for additional exclusions under the eRx (EPs only) and vital signs objectives. In addition, providers in Stage 1 must report electronically on the new and improved clinical quality measures (CQMs) which have been finalized for Stage 2. Objectives previously requiring production of electronic copies of health information and discharge information for patients have been replaced with the objective requiring patients be given the ability to view online, download or transmit their health information to a third party. The objective requiring a test of the exchange of key clinical information was eliminated with this past year’s reporting periods.

For the three public health menu objectives (reporting to immunization registries, syndromic surveillance databases or reportable lab results), the hospital or EP is required not only to conduct a test with the public health agency, but also actually follow up submission unless specifically prohibited by law from doing so (or unless the test was not successful). A provider must again conduct a test or submit data in its 2014 reporting period even if the hospital or EP already did so for its 2013 reporting period. All other objectives and their measures are the same for Stage 1 in 2014, and must againbesuccessfullydemonstratedfor2014.(Yes,thatmeansperforming another or reviewing and re-assessing a previously performed Security Risk Assessments!)

Because providers in Stage 1 are now required to report on the same Stage 2 CQMs as those providers beginning Stage 2, this may result in a substantial amount of work for providers to ensure new data elements are appropriately captured. Electronic health information exchange (HIE) also represents a bigger role and providers must additionally struggle with implementing patient PHRs and portals so that their patients have the ability to obtain information online, even though for

Stage 1, there is no requirement that patients actually access their information.

Ramping up for Stage 2Providers beginning Stage 2 in 2014 not only have to

contend with implementing and rolling out the new 2014 editions of their certified EHR technology, but also more robust objectives and measures. Stage 1 objectives, such as drug-drug and drug-allergy check functionality and maintaining updated problem lists, medication lists and medication allergy lists, are collapsed into new measures, and several Stage 1 menu objectives (i.e., public health objectives) have found their way into the required set of core objectives. Electronic medication tracking and administration (eMAR) is a new core objective as are the HIE objectives requiring patient access, exchanges of clinical information, and secure electronic messaging (EPs only), and there are new menu objectives for both EPs and hospitals.

Of much concern are the new HIE-related requirements which will require addressing the challenge of how to get patients to actually access their health information online or communicate with their providers electronically. For larger hospitals with diverse patient populations, it may be less problematic to get patients engaged in accessing their health information. However, for smaller EPs that serve older patient populations or hospitals in remote or rural areas, this could be a make-or-break objective that stands in the way of successfully demonstrating Meaningful Use in Stage 2. Likewise, EPs may struggle with engaging patients to use electronic messaging for communicating about relevant health information.

Stage 1 originally required a “test” between unaffiliated providers of their capacity to “exchange key clinical information,” and many providers resulted to message boards and other networking in order to find another provider to conduct a test with. Although this test was eliminated in 2013 going forward for Stage 1, Stage 2 creates a similar HIE objective, requiring providers not only provide a summary of care record to a third party provider for transitions of care or referrals through HIE, but also that for at least one of those exchanges, that the provider have in place certified EHR technology from a different EHR vendor (for example, so that an exchange would occur between a hospital with Cerner certified EHR technology and a hospital with McKesson certified EHR technology) or conduct a test with a designated CMS tester.

The Bottom Dollar: Getting your Meaningful Use Incentive Payments (and keeping them!)

The attestation requirement and the incentive payment structure have not changed for Meaningful Use going forward.


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Although CQMs will no longer be reported through attestation, EPs and hospitals must still attest that they have successfully demonstrated each element of Meaningful Use for the Stage they are in before they may receive their incentive payments for the reporting period. By attesting, a provider is making a legally binding affirmation that all requirements have been met to the best of its knowledge. If a provider knows or should reasonably know that it did not meet all of the requirements for Meaningful Use, it should not attest.

Of equal importance to getting incentive payments is keeping CMS from taking those payments back, which requires not only attesting properly in the first place, but also having the documentation to support each objective for each reporting period. Because Meaningful Use is all or nothing, failure on one objective can result in loss of everything. A critical area that providers may be more likely to fail, especially for providers who attested in 2011 and 2012, is the required Security Risk Assessment. Although CMS has released guidance illustrating more clearly what is required since Meaningful Use’s inception, some providers may have been too quicktoanswer“Yes”inthepasttocompletingtheSecurityRisk Assessment, and could potentially face recoupment in the event of an audit for failure to demonstrate this objective to CMS’ satisfaction.

Providers may also be more likely to have insufficient documentationforMeaningfulUse“Yes/No”objectives,giventhat many certified EHRs do not include these objectives on reports generated to demonstrate compliance with other Meaningful Use objectives. For example, the Stage 1 objective requiring drug-drug and drug-allergy checks requires documentation, whether screenshots, audit logs or otherwise, to support that such function was actually enabled in the certified EHR during the applicable 90 or 365-day reporting period. Likewise, the menu objective requiring generation of patient lists by specific condition requires documentation to support that the list was actually generated during the reporting period, such as a copy of a daily or monthly report that was run.

CMS began audits in 2012 and plans on targeting 5% of all participating providers, both randomly and based on a series of red flags or other targeted behavior or anomalies. Documentation supporting each year’s attestation must be retained to survive a 6 year look-back by auditors. Supporting documentation that should be retained by providers includes: • ReportsgeneratedfromthecertifiedEHRforcoreand menu objectives, as well as CQM reporting, dated for current reporting period and identifying certified EHR system and provider;

• Screenshots or audit logs demonstrating functionalities were enabled during reporting period (i.e., screenshot taken during the reporting period, or audit log showing when functionality was enabled during);

• Screenshots or test scripts demonstrating performance of test or data submission during reporting period for public health reporting objectives, letters from public health agency confirming test or data submission during reporting period;

• Copy of reports and lists generated during reporting period supporting clinical decision support rules and patient lists generated by specific condition;

• Copy of report demonstrating Security Risk Assessment was performed or reviewed prior to (i.e., performed during adoption and/or upgrades of the certified EHR, and within reasonable period before applicable reporting period) or during reporting period, for each reporting period

Providers should retain hard copies or PDFs of all reports generated from the certified EHR at the time of attestation in the event reports are not available in the same form or format down the road in the event of an audit.

Despite these documentation challenges, preliminary audit results from this past spring suggest that providers are doing well, with attesters scoring at “very high levels.”1 Providers should not hesitate to request additional assistance from their certified EHR vendors to help demonstrate compliance with a given objective, including working to obtain additional documentation where possible to support previous attestation periods.

About the AuthorKrystyna is a corporate and regulatory attorney with Attorneys at Oscislawski LLC. She focuses extensively on advice and representation for clients in the health care industry in the areas of HIPAA and HITECH, EHRs and HIE, “Meaningful Use,” privacy and security of patient information, fraud and abuse, and other federal and state standards governing health care providers and entities. Krystyna has volunteered with the American Bar Association’s HITECH Task Force and is a regular author on the Legal Health Information Exchange, (www.legalhie.com),a nationally recognized health law blog on legal matters related to electronic health information exchange and privacy and security. Krystyna can be reached at [email protected]

Footnote1. http://www.fierceemr.com/story/providers-struggling-document-meaningful-use-attestation/2013-04-20

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24 Focus

•Who’s Who in NJ Chapter Committees•

2013-2014 Chapter Committees and Scheduled Meeting Dates*NOTE: Committees have use of the NJ HFMA Conference Call line.

If the committee uses the conference call line, their respective attendee codes are listed with the meeting date information below.

PLEASE NOTE THAT THIS IS A PRELIMINARY LIST - CONFIRM MEETINGS WTH COMMITTEE CHAIRS BEFORE ATTENDING.

CHAIRMAN/EMAIL/ CO-CHAIR/EMAIL/ SCHEDULED MEETING MEETING BOARDCOMMITTEE PHONE PHONE DATES*/TIME LOCATION LIASON Lisa Hartman Dara Quinn First Thursday of the Month Meeting in person at Deloitte & Touche, Erica WallerCARE (Compliance, [email protected] [email protected] (888) 269-3831 9:00 AM Princeton, NJ for Oct., Jan., April and July [email protected], Risk, & Ethics) (609) 853-7140 (973) 972-8942 Attendee Code: 5952498 Balance are calls. Please call to confirm (609) 620-8335

Elizabeth Litten Al Rottkamp First Thursday of each month Fox Rothschild offices Stella VisaggioCommunications [email protected] [email protected] (888) 269-3831 9:30 AM 997 Lenox Dr Bldg 3 [email protected] (609) 896-3600 (609) 584-6508 Attendee Code: 7844155 Lawrenceville, NJ (908) 850-6928

Mike McKeever Mary Cronin & Stacey Bigos First Friday of each month John BraultEducation [email protected] [email protected] / (888) 269-3831 10:00 AM Conference Calls [email protected] (973) 972-6859 [email protected] Attendee Code: 7363742 (973) 244-3536 (732) 839-1217 / (609) 275-4017

Certification Eric S. Fishbein Cheryl Cohen First Friday of each month Mike McKeever(Sub-committee [email protected] [email protected] (888) 269-3831 10:00 AM Conference Calls [email protected] Education) (860) 677-7888 (609) 259-3363 Attendee Code: 7363742 (973) 972-6859

FACT (Finance, Megan Byrne Karen Henderson Second Wednesday of each Month Scott MarianiAccounting, Capital [email protected] [email protected] (888) 269-3831 8:00 AM Conference Calls [email protected]& Taxes) (732) 516-4696 (973) 532-8879 Attendee Code: 8730600 (973) 898-9494 x420

Erica Waller Jennifer Vanegas Fourth Thursday of each Month Tracy Davison-DiCantoInstitute 2014 [email protected] [email protected] (888) 290-0578 8:00 AM Conference Calls [email protected] (609) 620-8335 (585) 643-3377 Attendee Code: 8788393 (609) 853-7503

Belinda Doyle Puglisi John Brault 3/6/13, 4/3/13, 6/5/13, 7/10/13, 9/3/13 Kevin JoyceManaged Care [email protected] [email protected] 10/14/13, 12/16/13 [2014 dates TBD] New Jersey Hospital Association [email protected] (908) 301-5458 (973) 244-3536 (888) 290-0549 2:00 PM Board Room (732) 562-7823 Attendee Code: 7775069

Kevin Margolis Jennifer Barr & Tim Bialek & Maria Facciponti Call for meeting arrangements Locations alternate Tony ConsoliMembership Services/ [email protected] [email protected] / (888) 269-3831 by month - [email protected] (609) 662-2422 [email protected] / Attendee Code: 5495569 please contact the chairs (732) 794-2662 [email protected] (551) 996-3376 / (908) 243-8640 / (973) 614-9100

William Hunt Dara Derrick 8/19, 10/11, 12/13, 2/14/13, 4/11/13 Deborah ShapiroPatient Access Services [email protected] [email protected] (888) 269-3831 9:30 AM CBIZ KA Consulting offices [email protected] (201) 996-2897 (908) 850-6870 Attendee Code: 8942192 in East Windsor, NJ (201) 617-7100

Steven Stadtmauer Kathleen Yenco Second Friday of each Month Josette PortalatinPatient Financial [email protected] [email protected] (888) 290-0578 10:00 AM New Jersey Hospital Association [email protected] (973) 778-1771 Ext. 146 (925) 226-1805 Attendee Code: 6748634 Board Room (201) 291-6017

Jennifer Shimek Howard Lasner 9/12, 11/14, 1/9/14, 3/13, 5/8 Conference Calls Deborah ShapiroPhysician Practice [email protected] [email protected] (888) 287-5336 9:00 AM Sept. & Jan. meetings will also be in person [email protected] Form (732) 516-4676 (201) 608-2136 Attendee Code: 6137784 Room TBD (201) 617-7100

Brian Herdman Vicki Ozmore Third Tuesday of each Month Monmouth Shores Corp. Park Rosemary NuzzoRegulatory & [email protected] [email protected] (888) 269-3831 9:00 AM Meridian Conf. Room 1C [email protected] (609) 918-0990 (609) 677-7171 Attendee Code: 9169098 1350 Campus Pkwy, Neptune (609) 383-2114

Nora Burdi Christine Putterman First Wednesday except Jan which is 1/8 Steven BilskyRevenue Integrity [email protected] [email protected] (888) 269-3842 9:00 AM New Jersey Hospital Association [email protected] (201) 291-6384 609-620-8339 Attendee Code: 8687753 (303) 672-9896

Lew BivonaCPE Designation [email protected]

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Focus 25

NJ Hospitals Gear Up for DSRIP Program

By Suzanne Ianni

Suzanne Ianni

For those in New Jersey’s hospital industry, DSRIP has certainly become a common acronym over the past year and is of particular importance to hospital finance departments. DSRIP stands for Delivery System Reform Incentive Payment, and thoroughly reflects changes in hospital reimbursement based on a “Pay for Performance” system. This article provides further perspective on the history of New Jersey’s DSRIP program and delivers guidance on how your hospital can budget for what is to come.

Why DSRIP? A little history...As a result of NJ’s Comprehensive Medicaid Waiver

effective October 1, 2012, the State was at risk to lose the 50% federal match both for Graduate Medical Education (GME) funds (now funded at $100 M) and the $166.6 M Hospital Relief Subsidy Fund (HRSF). Through negotiation, the State was able to maintain GME dollars. However, in order to maintain the matching funds associated with the HRSF, NJ had to “repurpose” those dollars as DSRIP.

The CMS directive towards DSRIP supports the Triple Aim goals for better health and better care at lower cost. At its core, it is an “incentive” program that rewards hospitals for initiating innovative population health programs. Unlike other states that were allocated new funding for DSRIP, NJ’s DSRIP Program is funded with the existing “repurposed” HRSF dollars.

Over the past year, hospital representatives have worked directly with the State and its consultant, Myers and Stauffer, to craft a DSRIP program that attempted to merge CMS’ theme of innovation with projects that are feasible for the industry. Using experience from other state’s DSRIP programs (whereby hospitals set their own metrics deemed to be “easily met”), CMS addressed NJ’s program with greater criticism and an idealistic expectation for hospitals to meet true “population health” goals.

DSRIP StagesNJ’s DSRIP program is comprised of four stages: Stages

1 and 2 focus on infrastructure development; Stage 3 focuses on your hospital’s individual chronic disease project and Stage 4 focuses on reporting universal metrics applicable to all participating hospitals.

The activities under Stages 1 and 2 pertain to the establishment of your hospital’s selected project. An example

of a Stage 1 activity is staff education and training sessions on all applicable project tools, checklists, processes and interventions. An example of a Stage 2 activity is the evaluation of the project’s pilot program and redesign based on pilot results. There are 15 activities under Stage 1, and 6 activities under Stage 2. In DemonstrationYears(DY)2,3and4,alargeportionofyourhospital’s DSRIP funding is based on Stage 1 and 2 Activity Achievement.For instance, inDY3 (SFY2015),75%of ahospital’s base DSRIP funding derives from achieving Stage 1 and Stage 2 Activities. Each activity is weighted equally in determining the payment associated with each hospital’s Stage 1 and 2 Activity Achievement.

Stage 3 of the DSRIP Program focuses on particular processes and Pay for Performance metrics for each participating hospital’s selected chronic disease project. The Program includes a “menu” of 17 projects. Each of the 17 hospital-specific projects has a unique set of metrics. Hospitals will be graded, and ultimately reimbursed, based on their ability to report each metric. Hospitals will also be reimbursed based on the ability to achieve an increase in baseline measurements for certain metrics deemed to be “Pay for Performance.” The reimbursement associated with Stage 3 metrics increases with each demonstration year. Forinstance,inDY5(SFY2017)50%ofahospital’sDSRIPfunding is based on Stage 3 Pay for Performance metrics.

To establish thresholds for the State 3 metrics, Myers and Stauffer hired a subcontractor, Alliance. Alliance is currently examining Medicaid Management Information System (MMIS) data from 2010 through 2012. The DSRIP Quality and Measures Subcommittee will evaluate this data to set thresholds and select substitution criteria for those metrics for which hospitals may be “locked out*.” This Subcommittee will also determine the Attribution Model, which will set the parameters of each metric’s numerator and denominator. To achieve the Pay for Performance goal for Stage3inDY3,DY4andDY5,eachmetricmustincreaseby 10% of the gap between your hospital’s baseline and the threshold set by the Subcommittee. The State hopes to make the first cut of MMIS data available to the industry by the beginning of December.


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26 Focus

While Stage 3 of the DSRIP Program focuses on particular processes and Pay for Performance metrics for each participating hospital’s selected chronic disease project, Stage 4 requires all participating hospitals to address the same 45 measurements (excep- tion: hospitals without obstetrics can replace those metrics with specific cardiac metrics). The payments associated with Stage 4 reporting metrics also increase over the life of the DSRIP Program. Forinstance,inDY5(SFY2017),25%ofahospital’sbaseDSRIPpayment pertains to the reporting of the 45 Stage 4 metrics.

There are DSRIP dollars skimmed from each hospital’s initial target amount and set aside for a Universal Performance Pool(UPP)inDY3,DY4andDY5.AUPPwillexistinDY2 with dollars from hospitals that did not submit applications, had denied applications or failed to meet metrics. Out of the 45 Stage 4 metrics, 12 metrics are related to the UPP. Hospitals receive additional UPP funding by maintaining or improving current performance levels associated with each of the 12 metrics. Conversely, hospitals receive less UPP funding if any the 12 performance levels decrease from the respective hospital’s baseline. Total UPP dollars are redistributed based on each hospital’s overall score combined with the proportion of care the hospital provides to New Jersey’s low income population.

The Field of Applicants and Next StepsFifty-five hospitals submitted applications by the September

20th deadline in the following areas: Asthma – 4, Behavioral Health – 5, Substance Abuse – 5, Pneumonia – 1, Obesity – 1, Diabetes – 17 and Cardiac – 22.

Hospitals should expect to hear from Myers and Stauffer within the next few weeks with questions on the content of their respective application. Applications will be assessed based on hospitals’ performance in four areas: Budget, Executive Summary, Application Description/Materials and Stage 1 & 2 Activities.

The State has offered to hold individual face-to-face meetings as well as phone calls in order to assist hospitals in the approval process. The State must complete its review process by December 13th and then forward the applications to CMS. CMS will then have until the end of January to approve or deny the applications.

Flow of paymentsThisisafive-yearpilotprogramwherebyDY1(SFY2013)

was considered a “transition year”. During DY 1, hospitalscontinued to receive monthly payments in the same amount of theirHRSFpayments.WearenowinDY2,anditisexpectedthat consistent monthly payments will continue for all hospitals that applied for DSRIP until the end of the calendar year.

A significant outstanding issue pertains to whether hospitals will receive January 2014 DSRIP payments, as only those hospitals with an approved application may qualify for a January payment (and CMS may not approve applications until the end of January). In recent conversations with the State, Hospital Alliance stressed the need for hospitals to maintain a consistent cash flow. The State agreed to advocate for no disruption of payments, however, it will likely be CMS’ determination as to whether a January payment will be issued.

Magnitude of PaymentsAs previously discussed, the payments associated with each

stage of each demonstration year are weighted differently. In other words, a different percentage of DSRIP funding is tied to a hospital’s performance in each respective stage. The chart below details the associated payment within each stage for each of the respective demonstration years. (Please note that this chart represents available funding after UPP dollars are carvedoutfromyourhospital’sinitialtargetamount.InDY3,10%willbeskimmedoff,inDY415%andinDY525%.)

It is the State’s intention to provide a consistent flow of monthly payments for the funding related to Stages 1 and 2. However, as the years progress, the funding tied to Stages 3 and 4 will be held back until each metric evaluation is completed. Some metrics will provide for quarterly evaluation, while other metrics will be evaluated semi-annually or annually. Hospital Alliance has created a DSRIP Financial Impact Model to assist hospitals in anticipating DSRIP annual budget amounts. If you are interested in learning more about this model, please contact Hospital Alliance’s Director of Finance, Fred Fisher at [email protected].

About the authorMs. Ianni has worked for the Hospital Alliance of New Jersey, a coalition of safety net and teaching hospitals that strive to advance healthcare for New Jersey’s most vulnerable populations since 1994. As President and CEO, she has addressed urban public health problems by devising strategies to improve healthcare for New Jersey’s poor and uninsured. Ms. Ianni has served as a member of numerous state committees and served as Volunteer Staff Advisor for Governor Christie’s Transition Team for Health. Last October she was appointed to the state’s DSRIP Steering Committee and named one of its Tri-Chairs. Ms. Ianni can be reached at [email protected].

(*Note: Once the thresholds are set, hospitals have to be 20 points below in order to use that metric in the project. Otherwise replacements measures must be used. If a hospital is “locked out” of all measures, it must select a different project, unless it is a cardiac project. Cardiac projects can use replacement measures from the Million Hearts program.)

Stages Payment DY2 DY3 DY4 DY5 Mechanism Approved Pay for DSRIP Plan Achievement 50%

Stages 1 & 2 Pay for Project Achievement 45% 75% 50% 25% Activities Stage 3 Pay for Measures Reporting 2.5% 15% Pay for Performance 35% 50%

Stage 4 Pay for Measures Reporting 2.5% 10% 15% 25%


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Focus 27

Rhonda VieiraAtlantic Health SystemAccounting Manager973) [email protected]

Yuliya RoptanovaManager Patient Financial Services(201) [email protected]

Brandon DrukerRobert Wood Johnson Univ HospitalFinancial Analyst(732) [email protected]

Heather StanisciKadent CorporationVP of Sales and [email protected]

Jacqueline O’SullivanCHCCDirector-Finance & Administration(201) [email protected]

Scott EberHuron Consulting Group(917) [email protected]

Joanne MackayAtlantiCare Regional Medical CtrMgr. of Denial/Unresolved Pymt(609) [email protected]

Chris SonntagAugusta Healthcare(732) [email protected]

Elizabeth J. CaissieUniversity of PhoenixProfessor(201) [email protected]

Cathyann WorekDivisional Director of Finance Clinical Services and Managed Care(609) [email protected]

Kathleen Loria, CPAAtlantic NeuroSurgical SpecialistsDirector of Finance(973) [email protected]

Hollie N. ButlerInspira Medical Centers, Inc.Staff Accountant(856) [email protected]

Annabelle LandiAergo SolutionsManager, Manager Care Services(732) [email protected]

Kam MinhasFIMESPractice Administrator(908) [email protected]

Lesly K. BerrocalSaint Clare’s HospitalDirector, Patient Access(973) [email protected]

Catherine FosterAtlantiCare Regional Medical CenterManager, Patient Access(609) [email protected]

Thomas RussoWells Fargo Bank, N.A.VP BDO(201) [email protected]

Cynthia A. HamelMultiPlanRegional Director, Network Development(212) [email protected]

Patricia PintoCapital Health SystemManager, Patient Accounts(609) [email protected]

Justin M. DavisOptumField Director, New Jersey(908) [email protected]

Rebecca A. HurleyErnst & YoungSenior(732) [email protected]

Nancy ClarkEisnerAmper LLPHealthcare Manager(732) [email protected]

Aleksandr FrenkelHackensack UMCReimbursement Specialist(551) [email protected]

Brian HeneghanMeridian HealthReimbursement Analyst(732) [email protected]

Stacey R. BrennertRobert Wood Johnson University HospitalSenior Revenue Integrity Specialist(732) [email protected]

Wendy J. GrzadzielewskiKennedy University HospitalsAVP Patient Financial Services(856) [email protected]

Robert HadickCare OneFinancial Analyst(201) [email protected]

Lindsay DruckerCare One(201) [email protected]

Denise SchmidtHillmann Consulting, LLCBusiness Development Manager(908) [email protected]

Oliver JosztErnst & Young(732) [email protected]

Christopher D. ProvinesAdjunct Professor(908) [email protected]

Bhumi P. Patel(732) [email protected]

Mary T. SiegertRutgersAdjunct Assistant Professor(609) [email protected]

Maria I. GalowiczHoly Name Medical CenterSr. Accountant(201) [email protected]

Jill M. HurleyHoly Name Medical CenterAccounting Manager(201) [email protected]

Maria R. LaurelHoly Name Medical CenterAccountant(201) [email protected]

William D. RogersAmerican WaterTreasurer(856) [email protected]

Salvatore Scelsi(856) [email protected]

New Members

Fall 2 0 1 3

28 Focus

New Delivery System Reform Incentive Payment (DSRIP) Pool Important to New Jersey Hospitals

By Stacey Bigos Stacey Bigos

On Oct. 1, 2012 the Centers for Medicare and Medicaid Services (CMS) approved New Jersey’s application for a Section 1115 Demonstration Comprehensive Waiver (Waiver) for the state’s Medicaid program. The Waiver, which will redesign key areas of the Medicaid program, was approved for a five year demonstration period, ending June 30, 2017. One of the provisions in the Waiver with a direct effect on hospital reimbursement was the creation of the Delivery System Reform Incentive Payment (DSRIP) pool.

The DSRIP pool was created in the Waiver to replace the Hospital Subsidy Relief Fund (HRSF). Established in the wake of hospital deregulation the HRSF provided additional annual funding to approximately 30 hospitals that treated a disproportionate share of “problem billed” patients, such as HIV,mentalhealthorcomplexneonates.Beginninginstatefiscalyear(SFY)2012thestatemodifiedtheHRSFformulato provide funding for every New Jersey acute care hospital based on the hospital’s percent to statewide total volume of childbirth or behavioral health services to Medicaid beneficiaries. Statewide funding for HRSF was $166.6M annually and as the DSRIP pool will replace HRSF it will be funded at the same level.

Although DSRIP will have the same funding as HRSF, the programs have separate goals and methods for distributing the funds. The DSRIP pool will provide funding for the development of programs that supports hospitals’ efforts to enhance access to healthcare, the quality of care, and the health of the patients and families they serve. Each hospital that wishes to draw from the DSRIP pool is required to develop and submit to the state a hospital-specific DSRIP plan that is “rooted in intensive learning and sharing that will accelerate meaningful improvement,” according to CMS. All New Jersey acute care hospitals were deemed eligible to submit a DSRIP application, as they were all eligible for and receiving money from the previous HRSF. Each hospital’s DSRIP application will need to be approved by both the state of New Jersey and CMS.

When designing care improvement projects for DSRIP, hospitals were instructed to focus on one of the following areas:

•BehavioralHealth•HIV/AIDS•ChemicalAddiction/SubstanceAbuse•CardiacCare•Asthma•Diabetes•Obesity•Pneumonia•Anothermedicalconditionthatisuniquetothehospital (must be approved by CMS)

Within the eight pre-defined conditions above, the DSRIP program outlined 17 CMS-approved quality projects for hospitals to choose from. All DSRIP projects will have four stages:• Stage 1: Infrastructure Development – the development

of the hospital’s chosen project through investments in technology, tools and human resources.• Stage 2: Chronic Medical Condition Redesign and Man-

agement – piloting and testing care redesign models.• Stage 3: Quality Improvements – measuring the out-

come of stages 1 and 2 as well as the clinical performance of the hospital DSRIP project.• Stage 4: Population Focused Improvements – reporting

measures across various areas of care.

These four stages will drive each hospital’s payment allocation from the DSRIP pool. Within the DSRIP application, each hospital was required to select from a pre-populated menu of activities (tailored to the specific project chosen by the hospital) for each stage and specify the specific actions and milestones associated with them. Actions and milestones describe the activities needed to achieve the activities. For example, a stage 1 activity may be “procure staff education needs” and the actions/milestones to achieve this would be items such as “determine the education method” or “determine education duration and frequency and timelines.” The hospital specified in the application a target date for the completion of the activities. The evaluation of the hospital’s ability to meet and exceed these goals will eventually help to determine their

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Focus 29

DSRIP funding. The Department of Health (DOH) outlines the projects, activities, actions and milestones available in its DSRIP toolkit found on the DSRIP website: http://dsrip.nj.gov/.Thestateconsidereddemonstrationyearone(DY1)ofthe

Waiver(SFY2013:July2012–June2013),tobeatransitionyear. During the transition year each hospital received the same fundingitreceivedundertheHRSFduringSFY2012.Itwasoriginally planned that DSRIP funding would begin effective demonstration year two (DY2, or SFY 2014: July 2013 –June 2014). However the approval by CMS for the Funding Mechanics and Planning Protocols (outlining items such as the structure of the DSRIP application and the methodology behind hospital funding for the DSRIP program) was delayed. Due to this delay, DSRIP applications from the hospitals were not due to the state until Sept. 20, 2013. Following receipt and approval by the state, the applications were then moved to CMS for their approval, due no later than January 2014. Because of these delays the state has agreed to extend the monthlytransitionpayments(equal totheSFY2012HRSFallocations) through Dec. 31, 2013, with DSRIP payments commencing in January 2014.

When DSRIP payments commence the amount received by the hospital may vary over the course of the demonstration. For stability in the transition from HRSF to DSRIP, in each year the starting point for a hospital’s DSRIP payment will be the hospital’s most recent HRSF amount, with a floor of $250,000 for those hospitals that were receiving minimal amounts of HRSF. This amount is referred to as a hospital’s DSRIP Target Funding Amount. Adjustments will be made each year on top of the starting point to get to the final DSRIP payment. For DY2 a hospital will earn 50 percent of its DSRIP

payment, or the payment for the 6 month period of January 2014 – June 2014, solely by submitting an approved DSRIP plan and application. The remaining 50 percent of its DSRIP allocation for that six-month period will be dependent upon the hospital’s achievement of certain stage 1 and 2 activities and the performance and reporting of the stage 3 and 4 measures. Since DY2 is the beginning of the project andmost of the hospital’s efforts will be geared towards building the project, 90 percent of this portion of the DY2DSRIPpayment will be based on stage 1 and 2 activities, with only 10 percent based on stages 3 and 4. As the project moves forward through the demonstration years, the payment will become more contingent on meeting stage 3 and 4 criteria and less dependent on stage 1 and 2.DuringDYs3–5,aportionofeachhospital’sDSRIPTarget

Funding Amount will be carved out to create a “Universal Performance Pool” (UPP). Ten percent of a hospital’s DSRIP Target Funding Amount will be allocated to the UPP starting inDY3,withthepercentageincreasingto15percentinDY4and25percentinDY5.TheUPPwillalsoreceivefundingfrommoney that was previously allocated to hospitals that choose not participate in the DSRIP program (after the floor of $250,000 is

established), as well as dollars forfeited by participating hospitals that do not satisfy certain performance metrics. A hospital can earn extra money from the UPP by meeting or exceeding the 12 pre-determined UPP measures. Hospitals will be assigned anAchievementValue (AV) for eachUPPmeasure based onits performance compared to its baseline, with a 1 indicating performance at or above the baseline and -0.5 indicating performancebelow thebaseline.TheAVswill be summed tocreatethehospital’sTotalAchievementValue(TAV),whichwillthen be calculated as a percentage of the maximum available TAV(12).Thispercentagewilladjustedbythehospital’sLowIncome Discharge Percentage. The final result is a hospital’s UPP percentage, which is multiplied by the total available UPP funding to get the hospital’s share of the UPP.

Following the Sept. 20, 2013 deadline the DOH released a list of hospitals that submitted a DSRIP application. In total, 56 acute care hospitals submitted an application and will be eligible to receive DSRIP funding starting in January 2014. The funding that would have been made available for the hospitals that did not apply will first be used to set a floor funding minimum of $250,000 per participating hospital ($125,000forDY2asDSRIPwillbepaidforsixmonthsofDY2)withtheremainingbeingplacedintotheUPP.Intotal,55 acute care hospitals submitted an application and will be eligible to receive DSRIP funding starting in January 2014. Of the applications submitted, the following was the distribution: •CardiacCare–22hospitals •Diabetes–17hospitals •BehavioralHealth–5hospitals •Asthma–4hospitals •ChemicalAddiction/SubstanceAbuse–5hospitals •Obesity–1hospital •Pneumonia–1hospital •HIV/AIDS–0hospitals

A strong response was received to the DSRIP program as this funding is vital for many of our state’s hospitals. The DOH continues to show commitment to the state’s acute care hospitals in the development of the DSRIP program and by maintaining the subsidy level of $166.6M. As the program is vastly different and more complex than its predecessor, the HRSF, the following years will include a steep learning curve for all involved. It will remain to be seen the program is successful in achieving its goal of improving the quality of care across New Jersey hospitals.

About the authorStacey Bigos is Director of Economic and Financial Information in the Health Economics department of the New Jersey Hospital Association based in Princeton, NJ. Stacey performs economic modeling and financial impact analysis for the association’s members on state and federal healthcare issues, including charity care and national healthcare reform. She is an Associate Board Member on the HFMA NJ Board of Directors and is co-chair of the Education committee. Stacey can be reached at [email protected].

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30 Focus

REGISTER TODAY!NJ HFMA Patient Financial Services and Patient Access Forums Present:

PFS Cornucopia, Featuring National Speaker, Bob (dr. Bob) Nelson, Ph.d.Tuesday, January 14, 2014 at the Woodbridge Hilton

Register online at www.hfmanj.org Registration and breakfast begin at 8am. The full agenda can be viewed online.

Common Practices for Medical Debt Collection (9:00am –9:50am)Learn more about the HFMA initiative to develop a common set of medical debt collection practices with input and guidance from ACA International, The Association of Credit and Collection Professionals. Speaker: Keith Kettelkamp; President and CEO; REMEX

“This is Not a Bill” (9:50am to 10:40am)A patient’s decision to pay their healthcare bill is frequently related to their ability to understand what they owe. Often, multiple ambiguous statements create confusion and patients delay payment. In this session, we discuss how healthcare administrators can prepare for the emerging challenges associated with consumer-driven healthcare and how self-service portals and virtual terminals can help improve patient satisfaction and the bottom line. Speakers: David Geiger; Director of Marketing & Corporate Development; ePay Healthcare Dan Peterson; President; ePay Healthcare

Creating a Culture of Recognition (10:50am –12:30pm)“Dr. Bob” grabs the audience’s attention with an interactive presentation that has helped 80% of the Fortune 500 and over 100 hospitals improve management practices, programs and systems. Recognition for performance represents the single most validated principle for driving desired behavior and performance in today’s challenging times. Dr. Nelson will show you how to create a culture of recognition, regardless of the size or type of business you are in.

He is the author of a number of books which have sold over 4 million copies. He has appeared extensively on national media including CBS’s 60 Minutes, NPR, PBS, CNN and MSNBC and he has been featured in most prominent national newspapers and business magazines. Speaker: Bob Nelson, Ph.D.; President; Nelson Motivation, Inc.

The first 100 to register for this quarterly meeting will receive a free, autographed copy of Dr. Bob’s book 1501 Ways to Reward Employees, courtesy of liberty Billing and Consulting Services, Inc. Additional books will be available for purchase and autograph at a cost of $12.

Healthcare Political Update (1:10pm to 2:00pm)Hear the up-to-date review of the healthcare political landscape in Washington D.C. Existing and upcoming healthcare regulations and resolutions are explained in conjunction with the immediate and future impacts for individuals and healthcare providers. The Affordable Care Act will be reviewed subject to legislative changes and revisions. Speakers: Kyle Mulroy; Founder; Washington Strategic Consulting and Spencer Perlman; President; Washington Strategic Consulting

Executive Health Resources (EHR) (2:10pm –3:00pm)This expert physician advisor discusses her experience with technology-enabled Physician Adviser teams that focus on Medicare and Medicaid regulatory compliance. She will discuss compliance in conjunction with minimizing medical necessity denials and working towards realistic lengths of stay in acute care hospitals and health systems. Speaker: Dr. Alice So, Senior Director of Audit, Compliance and Education: EHR

Silent PPO’s and their Impact on Hospitals (3:10pm – 4:00pm) This session will identify current managed care trends as it pertains to the access of Silent PPOs and inappropriate discounting. Providers will learn to identify inappropriate PPO behavior and abuse and misuse of their managed care contracted rates. Participants will be shown how to recognize language loopholes and where to strengthen contract language to prevent future abuse. Speaker: Sherry Gunderman; Director, Silent PPO Services; MedAssets, Inc.

The event will offer 7 CPE credits, 12 AAHAM CEUs and 6 hours of ACHE credit.

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Focus 31

The Future of Federal Disproportionate Share Program

By Robert Gricius

Robert GriciusAfter much, speculation the “New” version of Federal

DSH regulations has been finalized and hospitals will be reimbursed for FFY 2014 and forward under amodel thatsegregates this funding into two components; the empirically justified amount, (“EJA”) or 25% of the “OLD DSH” calcu-lation and an Uncompensated Care Payment (UCP) that will be distributed to DSH hospitals based on their proportion of Uncompensated Care costs (UCC) compared to the sum of UCC for all DSH Hospitals.For FFY 2014, projected national DSH funding will

be $12.2B, a 4.7% reduction from the pre-ACA budget of $12.8B. The most pressing issues for hospitals are what they can do now to prepare themselves to succeed under this new paradigm and what will happen to Federal DSH funding in FFY2015andforward.Regrettably,theanswertothesecondpart of this question is an unsatisfying “it depends”.

The variables that will most materially impact Federal DSH funding in the future are:

1. The number of new Medicaid members under the ACA in the first years of the law.

a. Originally projected at 18 million new Medicaid members;currentlyitlooksmorelike9-10MforFFY 2015, but this number will probably increase over time as providers put more pressure on State legisla- tures to accept the 100% Federal matching funds for the first 3 years under the ACA. i. This value will positively impact both components of the ACA model; the EJA through an increase in the numerator of the Medicaid fraction; and ii. Factor 1 which is the 75% of the “OLD DSH” model excluded from the EJA that sets the initial baseline for the UCP; and iii. As is displayed below, the total $ Impact on Fed- eral DSH from these new members is $4.8B FFY15 toFFY19basedon a graduated increase from 9 to 18 million new Medicaid members in the first three years of the ACA.

2. The number of roughly 48 million uninsured that will obtain coverage through either Medicaid expansion or the new Healthcare exchanges under the ACA. a. Of all the variables that will drive future Federal DSH funding from FFY 2015 forward, this may be the most important as it will generate the value for Factor 2 of the UCP calculation. b. Factor 2 is the primary deflating factor for Federal DSH funding and is equal to 1 minus the percentage change in the uninsured Americans under 65. c. Of significant concern is that this number will be a “blackbox”numberforFFY2015andFFY2016that will be published by the Congressional Budget Office (CBO). d. In Table 1 on next page, we can see the inverse impact that Factor 2 has on overall Federal DSH funding post FFY2014;inshortasthe%oftheuninsureddeclines the amount of money for the UCP is reduced, as much as $12B between the conservative and aggressive model. Of particular note, even under the “Ag- gressive” UCP model, total DSH funding for FFY19 (EJA and UCP) will be $11.4B; a 7% reduction from FFY 2014.


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32 Focus


3. The length of time that the proxy for UCC used in FFY 2014 will be used to distribute the UCP pool; or, said differ-ently the timeframe required for the adoption of Worksheet S-10 as the mechanism to distribute the UCP Pool.

a. Under thismethod adopted for FFY2014, a proxy for UCC was implemented that uses the same metrics historically employed for “OLD DSH” to distribute these funds. Although this resulted in some hospitals seeing large variances, they paled compared to what would have happened if Worksheet S-10 (WS10) had been employed.

b. The question here is not whether CMS will use WS10 for this purpose, the issue is when it will happen and when it does, will it be phased in over time or will the switch be 100%.

c. AneartermadoptionofWS10(FFY15or16)will favor those hospitals in States that did and will not expand Medicaid as the resulting relative increase in Charity Care and Bad Debt they will see will generate a higher UCP payment. i. Near term adoption will also favor those hospitals that have invested or are going to invest the resources required to optimize the allow- able Charity Care and Bad Debt. For most hospitals, it will take 6-9 months to put systems in place to capture the data necessary to report, document and support through audit the claim level detail/logic necessary to maximize these metrics. ii. One the most common and dangerous mispercep- tions emanating from the Final rule is that because CMS deferred the use of WS10 for UCP distribution, hospitals don’t need to focus on this challenge for the next couple of years; nothing could be further from the truth.

iii. If one examines the methodology just employed byCMS to distribute the FFY2014UCPpay- ments, it is clear that they are going to look retro- spectively, probably 3 years, and that once they obtain the necessary values, hospitals will not have an opportunity to modify them. iv. HenceaFFY2016adoptiondatewilllookback to 2013 values that are being compiled and reported by hospitals today.

d. Although this issue will not impact the total funding available in the UCP, it will be the driver behind the relative portion each hospital will receive from this pool and represents the most systemic change in Federal DSH funding by moving to a zero-sum model that pits every DSH hospital against all others in a competition for a fixed and declining funding source.

4. The outcome of the Allina case pertaining to inclusion of Medicare Advantage days in the SSI ratio and dual-eligible Medicare Advantage days in the Medicaid fraction. a. This group appeal has been segregated into two different appeals by CMS, one dealing with the SSI ratio and another with the dual-eligible Medical Advantage days. b. Although the SSI ratio will be largely positive for most hospitals, with some notable exceptions in the State of Pennsylvania, Louisville, KY and other re- gions of the country where Medicaid members with Medicare Part A coverage were automatically moved into a Medicare Advantage plan, there is little providers can do other than to protect their appeal rights within 180 days of an NPR and consider joining a group appeal. In most cases, moving forward, the most significant impact from this case will be the ability to include the dual-eligible Medicare Advan- tage days in the Medicaid fraction.

Table 1 – Factor 2 Scenarios & UCP Funding Impact

FFY15 FFY16 FFY17 FFY18 FFY19 UCP Pool FFY14-19

Conservative Factor 2: 89.0% 85.0% 79.0% 71.0% 66.0%

Conservative Newly Insured: 5.3M 7.2M 10.1M 13.9M 16.3M

Conservative UCP Pool: $9.9B $9.7B $9.6B $8.7B $8.7B $46.6B Moderate Factor 2: 85.0% 77.5% 68.5% 65.0% 60.0%

Moderate Newly Insured: 7.2M 10.8M 15.1M 16.8M 19.2M

Moderate UCP Pool: $9.4B $8.8B $8.3B $8.0B $7.9B $42.5B Aggressive Factor 2: 80.0% 70.0% 58.0% 45.4% 40.0%

Aggressive Newly Insured: 9.6M 14.4M 20.1M 26.2M 28.8M

Aggressive UCP Pool: $8.9B $7.9B $7.1B $5.6B $5.3B $34.8B

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Focus 33

c. As with the Medicaid expansion issue, this will increase both the EJA and Factor 1 by increasing the numerator of the Medicaid fraction with no adjust- ment to the denominator. i. The key to tracking this metric and reporting is properly is obtaining the periodic durational Medicare Advantage eligibility data via data exchange with HETS 270/271 EDI network as opposed to relying solely on capturing admit specific Medicare Advantage information at admission.

SummaryTo paraphrase Mark Twain as it pertains to this issue,

“reports of my death have been greatly exaggerated”. Fed- eral DSH is still here and will continue in one form or another for the foreseeable future; the difference is that the rules have changed on how this $60-$80 Billion hospital subsidy will be distributed over the next five years to par-ticipating hospitals.

Those hospitals that take action today to ensure that they have the systems and process infrastructure in place will be better positioned to be one the “winners” under this new paradigm.

About the authorRobert Gricius is a nationally recognized authority, speaker and expert witness in the area of Healthcare Finance on third party claims adjudication, managed care contract compliance/anti-trust and Medicare and Medicaid reimbursement issues. He holds a B.A. in Computer Science from the University of California, Berkeley, an MBA in Finance, and is a Certified Public Accoun-tant in the Commonwealth of Virginia.

After a career as a hospital Chief Financial Officer and Corporate Director of Managed Care for a $1 Billion+ multi-hospital system in the Mid-Atlantic region, Mr. Gricius founded DSH Manage-ment Solutions LLC (now NAVEOS®), in 2006. As CEO, he has led the development and deployment of the industry’s only fully integrated DSH/340B software system with the associated ad-ministrative, regulatory and technical support. His leadership has resulted in the creation of electronic data interchange networks between his clients and States that have over 93% of the Medicaid membership and 100% of all Medicare beneficiaries. Mr. Gricius can be reached at [email protected].

•Certification Corner•

Beginning in November 2013, candidates who wish to take the CHFP examination will be offered the option of taking the exam at either Castle’s Proctored Test Sites or via secure in-ternet-based testing. The option of online testing eliminates travel time and costs, as well as allows for increased flexibility in exam scheduling. The online system will allow candidates to take the exam at any time, subject to proctor availability. The $395 cost (exam and CHFP application fee) remains un-changed regardless of which option a candidate chooses.

Be sure to check the HFMA website for additional details on this new testing option as they become available.

New CHFP Testing OptionQuestions concerning certification can be directed to the NJ HFMA Chapter Certification Co-Chair Eric Fishbein; [email protected]

New CHFPCongratulations to the NJ Chapter’s newest certified member:

Eyo Effiong, CHFP

Fall 2 0 1 3

34 Focus

•Focus on...New Jobs in New Jersey•

JOB BANK SUMMARY LISTINGHFMA-NJ’s Publications Committee strives to bring New Jersey Chapter members timely and useful information in a convenient, accessible manner. Thus, this Job Bank Summary listing provides just the key components of each recently-posted position in an easy-to-read format, helping employers reach the most qualified pool of potential candidates, and helping our readers find the best new job opportunities. For more detailed information on any position and the most complete, up-to-date listing, go to HFMA-NJ’s Job Bank Online at www.hfmanj.org.

[Note to employers: please allow five business days for ads to appear on the Web site.]

Job Position and OrganizationREVENUE CYCLE BUSINESS SYSTEMS ANALYST Kennedy Health System Southern NJ

SUBSIDIARY CONTROLLER JFK Health System Edison, NJ

SENIOR BUYER Memorial Sloan-Kettering Cancer Center New York, NY

REIMBURSEMENT ANALYST III(CORP. FINANCE REIMB.) Meridian Health MANAGER, STRATEGIC FINANCIAL PLANNING Hospital for Special Surgery New York, NY

SENIOR ACCOUNTANT – FULL TIME JFK Health System Edison, NJ

REVENUE CYCLE MANAGER Besler Consulting Princeton, NJ

DIRECTOR OF FINANCE Robert Wood Johnson University Hospital Rahway, NJ

ACCOUNTANT – PART TIME JFK Health System Edison, NJ

AVP PATIENT FINANCIAL SERVICES Hospital for Special Surgery New York, NY

SENIOR VICE PRESIDENT, FINANCE & CFO Glen Falls Hospital Glen Falls, NY

DIRECTOR OF BUDGET & REIMBURSEMENT Saint Peter’s Healthcare System New Brunswick, NJ

DIRECTOR OF ACCOUNTING Catholic Charities – Diocese of Trenton Trenton, NJ

SOURCING SPECIALIST CORPORATE PROCUREMENT Memorial Sloan Kettering Cancer Center New York, NY

BILLING & COLLECTIONS SPECIALIST/FINANCE COORDINATOR Hovnanian Senior Housing Services Toms River, NJ

DIRECTOR OF FINANCE St. Luke’s Warren Campus Phillipsburg, NJ

DIRECTOR FINANCIAL REPORTING Barnabas Health Oceanport, NJ

DIRECTOR OF REVENUE CYCLE MANAGEMENT PHYSICIAN SERVICES Holy Name MC Teaneck, NJ

DIRECTOR OF BUSINESS DEVELOPMENT Samaritan Healthcare & Hospice Mt. Holly, NJ

PATIENT ACCOUNTING MANAGER University Radiology Group East Brunswick, NJ

MEDICARE BILLER Besler Consulting Princeton, NJ

Fall 2 0 1 3

Focus 35

A.Q.How does the recent modification to the IRS ‘use-it-or-lose-it’ rules affect health flexible spending accounts?

With the issuance of Notice 2013-71, the Internal Revenue Service (“IRS”) has modified its use-it-or-lose-it rules related to health flexible spending accounts (“FSAs”). Internal Revenue Code (“IRC”) §125 cafeteria plans can now be amended to allow up to $500 of unused health FSA amounts remaining at the end of a plan year to be reimbursed to participating employees for qualified medical expenses incurred during the following plan year.

Under previous IRS rules and regulations, employers had the option to provide employees participating in its health FSA a grace period. This grace period allows participating employees up to two-and-a-half months following the end of the plan year to utilize remaining dollars in their health FSAs.

Employers now have the option to relax the use-it-or-lose-it rules for the 2013 plan year but they must amend their plan document prior to the end of 2013 to include the carryover provision. This amendment must be adopted on or before the last day of the plan year and can be effective retroactive to the first day of the plan year. However, it

is important to note that, in accordance with this Notice, employers are not permitted to allow both the grace period and the carryover provision. The carryover provision does not affect the maximum amount of salary reduction contributions applicable to each plan year under IRC §125(i), limited to $2,500 for 2013.

Employers have three options when it comes to their health FSA plan document. Employers can:• Allow participating employees the two-and-a-half

month grace period;• Notallowthegraceperiod,butprovideuptoa$500

carryover; or• Offerneithertoparticipatingemployees.

About the AuthorAnthony J. Panico, CPA, MS, is a partner with Withum Smith+Brown, Certified Public Accountants and Consultants. He is an active member of the firm’s Healthcare Services Group, and Team Leader of the Healthcare Reform Advisory Team. Tony can be reached at [email protected].

USE IT OR LOSE IT?The IRS has modified its use-it-or-lose-it

rules related to health flexiblespending accounts.

Anthony J. Panico

•Focus on Finance•

mark your calendar . . .

PLEASE NOTE: NJ HFMA offers a discount for those members who wish to attend Chapter events and who are currently seeking employment.

For more information or to take advantage of this discount contact Laura Hess at [email protected] or 888-652-4362. The policy may be viewed at: http://hfmanj.orbius.com/public.assets/A02-Unemployed-Discount/file_168.pdf

January 14, 2014 all dayWoodbridge Hilton Education Series: Patient Financial Services PFS Cornucopia

February 11, 2014 all dayWoodbridge Hilton Education Series: Strategically Managing Physician Practices in Today's Regulatory Environment

March 11, 2014 all dayWoodbridge Hilton Education Series: Compliance, Audit, Risk & Ethics

36 Focus

Fall 2 0 1 3

WANTED

Associate Board Member

Are you driven, innovative, and committed to promoting the health care financial management field?

The NJ Chapter of HFMA is currently seeking individuals that are

interested in becoming an Associate Member of the Board of Directors.

As an Associate Board Member you will bring new vision and energy into HFMA, and in return, receive mentoring by seasoned professionals resulting in invaluable experience and an in-depth knowledge of the workings of HFMA.

The requirements for application include:

* Current Membership in HFMA * The New Jersey Chapter of HFMA Selected as Your Primary Chapter

* Membership in HFMA 5 Years or Less * A Referral from a Senior Administrator

* A Letter Stating Why You Would Like to be an Associate Board Member of the Board of Directors

* Copy of Your Resume * Willingness/Ability to Attend the Majority of the Monthly Board Meetings held at the

Woodbridge Hilton on the Second Tuesday of the Month from 7:30am - 9:00am. * Willingness to Participate in a New Jersey Chapter Committee

There are two Associate Board Member positions on the New Jersey Chapter Board of Directors. Each position has a two year appointment. The Associate Board Member position is a non-voting position. One Associate Board Member

position will be available.

If interested, please forward the above requested requirements to Maria Facciponti, [email protected]

The deadline for your submission is February 15, 2014

Fall 2 0 1 3

Focus 37

37th Annual Institute Highlights Challenges of Healthcare Reform

By John J. Dalton, FHFMA

John J. Dalton

The expanded educational opportunities of a 2-1/2 meeting drew more than 500 registrants to the 37th Annual Institute at Atlantic City’s Borgata Hotel. Cosponsored by the Metropolitan Philadelphia and New Jersey Chapters, the Institute’s Wednesday morning start provided added opportunities for attendees to garner as much as 15.5 CPEs and gain a deeper understanding of the challenges ahead. Chapter President Dave Wiessel welcomed attendees, thanked Institute Chair Dan Willis and co-chairs Erica Waller, Jennifer Vanegas andMikeRuizdeSomocurcio for theirHerculeanefforts in coordinating the event. He encouraged attendees to download the ANI app (NJ/PA AI) to their smart phones. This innovative addition not only guided attendees to education sessions and vendor booths, but also included handouts for the breakout sessions.

Dave also thanked Mike McKeever’s Education Committee and Kevin Margolis’s Membership Services/Networking Committee for their roles in planning for the Institute, and introduced former Chapter President John Dalton as Master

of Ceremonies. Dalton thanked the sponsors and exhibitors for their financial support, without which a program of this quality, breadth and depth would not be possible.

The Institute opened with an interactive webinar on implementation of CMS’s proposed “Two-Midnight Rule,” hosted by the New Jersey Hospital Association and featuring Priya Bathija of the American Hospital Association, followed by Day Egusquiza’s delineation of why ICD-10 changes everything in the revenue cycle. First introduced in 1990, the U.S. is the only industrialized country not yet using ICD-10. Scheduled for October 1, 2014 implementation, its rollout has broad impact well beyond Health Information Man-agement. Although CMS estimates implementation will cost the private sector $130 million, Day pointed out numerous “hidden costs” likely to emerge next Fall, including rejected claims from payors, claim edits that need correction, lost productivity due to rebills, denials, rejections, added physician queries, and the like. Not a pretty picture.

Following a buffet lunch at the Homestead (albeit with diminished appetites), three one-hour breakout sessions offered attendees their choice of four technical topics each hour on topics that included HITECH Final Rules, New Claims Paradigms, Changes to Medicare DSH Payments, Revenue Cycle Audits, and others.

Wednesday evening’s Tricky Tray Fundraiser produced more than $11,000 for the Make-A-Wish Foundation as dozens of lucky attendees held winning tickets for a wide

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38 Focus

variety of prizes including iPads, sports tickets, restaurant dinners, and golf foursomes.

THURSDAY EVENTSThursday morning’s plenary sessions opened with an address

from Melinda Hancock, who currently serves as Secretary/Treasurer of HFMA during the 2013-2014 term and is CFO andseniorvicepresident,BonSecoursVirginiaHealthSystem,Richmond,VA.MelindaupdatedattendeesonHFMANational’skey initiatives and how they affect our membership.Kevin Brennan, Executive Vice President, Finance and

CFO, Geisinger Health System, provided illuminating insights into “ACO’s and Population Health,” drawing on Geisinger’s extensive experience as an integrated delivery system. With over $4.6 billion in revenues, Geisinger is comprised of provider facilities ($1,760M) including five hospitals with 1,623 licensed inpatient beds, a multispecialty physician practice group ($825M) with 1,020 physician FTEs and 700 advanced practitioners at 78 sites throughout northeast Pennsylvania and a managed care company ($2,093M) with

463,000 members (including 77,000 Medicare Advantage and 112,000 Medicaid members). In June 2009, President Obama praised Geisinger, asking why it “can offer high quality care at costs well below average…We need to identify the best practices across the country, learn from the success, and replicate that success elsewhere.”

Geisinger spends 4.6% of annual revenue on IT, has a fully integrated electronic health record, a networked patient portal with 217,000 active users and “Outreach Health IT” with 7,030 users in non-Geisinger practices. Geisinger’s success results from focusing on patient-centered quality and innovation. However, it didn’t happen overnight. ProvenHealth Navigator, a patient centered care system is Geisinger’s advanced medical home to 80,000 enrollees in 44 locations. Key principles include: • An“embedded”nursemanager, fundedbythehealth plan, coordinates care and; • Explains medications, develops care plans, monitors compliance, schedules appointments, and arranges for community support services;

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Focus 39

• Helpspatientavoidunnecessaryhospitalizations/trips to the ER; • Usesremotemonitoringtechnology.

From 2006 to 2012, Medicare Ad- vantage risk adjusted acute admissions per thousand dropped by 28%, from 296 to 214. Not surprising- ly, medical expenses also declined. Proven Care Acute Episodic Bundles have been key to improving quality and clinical efficiency for coro-

nary artery bypass surgery, bariatric surgery, knee and hip replacements, perinatal care and others. ProvenCare’s chronic disease programs include diabetes, congestive heart failure, coronary artery disease, hypertension and a prevention bundle. In less than three years, the chronic disease program prevented 306 heart attacks, 141 strokes and 166 cases of retinopathy.

Mr. Brennan briefed attendees on the CMS Physician Group Practice demonstration project, noting that despite some design flaws, quality scores were uniformly improved. Even in low cost areas of the country, costs were reduced and quality improved. As providers prepare for accountable care, workflow redesign is vital: • Eliminatenon-valueaddedwork; • Automateworkthatcanbedonebycomputerordone outside an office encounter; • Delegateworkthatisdoneatanofficevisittotrained non-physician staff when possible; and • Incorporatenewworkflows intotheproviderpractice and “hardwire” with reminders and HER tools to enhance the reliability and efficiency of care.

The core competencies crucial to success include the organization’s leadership and culture, physician alignment, operational excellence, care integration and technology enablement. Mr. Brennan concluded with some practical suggestions for the future.

The keynote address, “Healthcare Reform and the Future of AmericanMedicine,”wasdeliveredbyDr.EzekielEmanuel,ViceProvost for Global Initiatives at the University of Pennsylvania, and former Special Advisor on Health Policy to the Office of Management and Budget and National Economic Council. In 2012, the US spent $2.87 trillion on health care, more than the gross domestic product of every country except China, Japan and Germany. With per capita health care spending about double that in France and Germany, these rising health care costs jeopardize: • Coverageandaccess; • Statebudgetsandsupportforeducation • Middleclasswages;and • America’slong-termfiscalstabilityandstatusasaworld power.

High health care costs put a heavy strain on state budgets, limiting funding for other programs. Over the last decade, in-state tuition at public colleges increased 72%. After adjusting for inflation, net worker income in private industries declined by 4% while health insurance premiums increased by 300% and corporate profits by 200%. As an optimist, Dr. Ezekiel is confident that, by 2020, health care will be much better than it is today. All American citizens will have health insurance; there will be fewer unnecessary services and more coordinated care, especially for people with chronic conditions. There will be fewer medical errors, including hospital-acquired infections and medication errors, and more information on physician and

In 2012, the uS spent $2.87 trillion on health care, more than the gross domestic product of every country except China,

Japan and Germany.

Fall 2 0 1 3

40 Focus

hospital quality performance. The vast majority of Americans will have interoperable electronic health records, and providers will have better information about the effectiveness of medical decision-making.

To emphasize the need to reengineer the health care delivery system, Dr. Ezekiel showed a chart that proves the Pareto principle: 20% of the population consumes 79.8% of health care spending. Echoing Kevin Brennan’s advice, he advocated prevention: not just primary prevention (e.g., vaccines, cancer screening), but tertiary prevention to keep people with chronic illnesses healthier and out of the ED and hospital. He illustrated the point with data from CareMore, with 30 care centers throughout the southwest serving Medicare Advantage enrollees. Begun 15 years ago as a medical group practice serving seniors, it has evolved into a health plan with documented positive results: • Hospitalizationrates24%belowaverage; • Hospitalstays38%shorter • Readmission rates 25% less than Medicare gee-for- service; • Amputation rate among diabetics 60% lower than average; and • Overallmembercosts18%belowtheindustryaverage.

Dr. Ezekiel predicted a resurgence in house calls, citing Microsoft and Costco’s use of Carena Telemedicine Solutions to provide urgent care to their employees in the home. He reviewed results of theVeteran’s Administration’sHospital atHome (H@H) program that uses interdisciplinary, interagency teams to deliver care to frail, homebound veterans in their homes. At Presbyterian Health Services, Albuquerque, NM, H@H patients had lower lengths of stay, mortality, and fall rates, and higher quality metric compliance and patient satisfaction scores. As a result, mean H@H patient costs were 19% lower than the inpatient comparison group. The savings result from fewer tests and treatments and faster recovery.

Ironically, Dr. Ezekiel noted that “The next big hurdle for the law is the rollout of the Exchanges.” Most of the states

will have much lower premiums than HHS’s estimate of 2014 premiums derived from CBO publications. Premiums are below estimates in states where 94% of the uninsured live. Ultimately, the real test of PPACA will be:

1. What happens to premiums?2. How many people will enroll?3. How is the user experience?

With Healthcare.gov not functional as of this writing, the jury is out. To be successful, the exchanges will need 7,000,000 enrolled in the first year, including 2,700,000 young people. Nonetheless, Dr. Ezekiel predicted that “By 2016 buying insurance on the exchanges will be like shopping on Amazon.” We shall see.Following Dr. Al Vicere’s presentation on “Strategic

Leadership: Managing the Cycles of Change,” attendees had their choice among 18 topics, six each hour of the afternoon

20% of the populationconsumes 79.8%

of health care spending.

Fall 2 0 1 3

Focus 41

breakout sessions. Thursday evening’s President’s Reception had to be moved from the Borgata Pool due to threatening weather, but still was enjoyed by all.

FRIDAY’S FINISHFriday’s opening session featured David Knowlton,

Chairman of the Leapfrog Group, addressing “Quality Issues in the Healthcare Environment.” He founded and served as Executive Director of the Health Care Payers Coalition of New Jersey; a non-profit corporation representing business and labor organizations that provide healthcare. He is President and CEO of the New Jersey Health Care Quality Institute.

Founded by the coalition, the Institute is dedicated to eliminating medical errors and improving health care quality. Most recently, he was appointed Chairman of the Board at St. Francis Medical Center in Trenton.

Knowlton served as New Jersey’s Deputy Commissioner of Health from 1987 to 1990 during the Chapter 83 years (all but Medicare DRG payment system). He recalled his first HFMA appearance at the 1988 NJHFMA Institute when Chapter President Ray Kaden had to exercise crowd control as Dave articulated the Department of Health’s position on a particularly volatile issue. Although there were some heated exchanges, it all ended well. His presentation focused on his passion, patient protection, describing the Leapfrog Group’s Hospital Safety Score which uses letter grades of “A,” “B,” “C,” “D” or “F” to rate the patient safety efforts and outcomes of more than 2,500 general acute care hospitals across the United States.

He pointed to examples such as the Cancer Treatment Centers of America that provide a medical home in oncology. They receive great quality scores and provide a patient-focused approach to treating cancer. On each visit, the patient meets with the entire medical team (medical oncologist, clinic nurse, registered dietitian, naturopathic oncology provider and nurse care manager). The team communicates in real time about treatment options, and makes adjustments or orders additional testing during the appointment.

Knowlton predicted that we soon will be seeing real time data on patient experience similar to Amazon.com and Trip Advisor reviews. Those interested in the ratings can download the app (Safety Score).Richard Silveria, Senior Vice President of Finance and

CFO of Boston Medical Center provided his perspective on Massachusetts’ healthcare reform. Boston Medical Center is $2.3 billion health system primarily comprised of a 511 bed Academic Medical Center, the Boston Medical Center Healthnet Health Plan, the Faculty Practice Foundation and an insurance captive. He walked attendees through the evolution of Massachusetts healthcare reform, and how it will change with PPACA implementation. He reviewed

traditional payment systems and speculated that “the future will likely involve a new payment ‘ecosystem’ where each structure plays a role,” giving the following examples:

• Fee-for-Servicecouldbeusedtopayforitemsthatare unlikely to be over-utilized such as immunizations, or where utilization is incented (follow up on chronic care);

• PayforPerformanceshouldhavearoleinfuturesystems to incent quality, such as screening for hyperlipidemia; • Bundlesorepisodebasedpaymentscanbeusedtolean out processes, to improve costs and outcomes such as joint replacement;

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42 Focus

• Shared Savings could be used to incent appropriate utilization with decreased provider risk; • Sub-capitation systems place providers at risk for aspects of population management such as primary care, Psych or sub-specialty services; and • Capitationcanbeusedtomanagepopulationsacross most or all of the continuum of care, via assumption of risk.

To eliminate inpatient inefficiencies, he suggested case rates/bundles for hospital and physicians. To reduce adverse events during inpatient care he suggested creating an inpatient warranty for hospital and/or physician costs, and walked

attendees through an example. To encourage efficient and appropriate use of inpatient acute and post-acute care, bundle them. To reduce readmissions and post-discharge problems, create a warranty for readmissions and post-discharge com-plications. To shift treatment to lower cost options, use diagnosis-specific payments and use of sub-caps.

He concluded by posing a number of questions about the risks and implications of reform.

The Institute concluded with a panel of providers and payors responding to five questins that had been provided in advance. Panelists were Steven Blumberg, Senior VicePresident and Executive Director of AtlantiCare Health Solutions, AtlantiCare’s accountable care organization; Kevin

Conlin, Executive Vice President, Healthcare Managementand President and Chief Executive Officer of Horizon Healthcare, Horizon Blue Cross Blue Shield of New Jersey’s statewide HMO; Cliff Frank, consultant, Shore Medical Center; Mike Munoz, senior vice president of sales and marketing for AmeriHealth New Jersey; and Garrick Stoldt, Chief Financial Officer of St. Peter’s Healthcare System, New Brunswick and a former President of the New Jersey HFMA Chapter. John Dalton served as moderator. Questions the panel addressed were:

1. Both plans and hospitals acknowledge we have a cost issue in healthcare - what are your organizations doing to make healthcare more affordable for the individual consumer?

2. How is your organization marketing to these exchange members, or are you?

3. How are you using data and technology to change the member experience?

4. What are some of the challenges your organization may face under healthcare reform?

5. Where are you investing your organization’s dollars and are you restructuring at all because of reform - more direct sales, more clinicians?

Although diverse viewpoints were articulated, panelists agreed on several points: • Software to support managing population health is in- adequate; • Chronic care management requires changing patient behavior, which took years at Geisinger; • Collaboration between payors and providers will be essential; • Patient balances after insurance will increase as the uninsured enroll in bronze or catastrophic coverage plans; • The volume to value transition will be difficult.

From 2006 to 2012,Medicare Advantage

risk adjusted acute admissionsper thousand dropped

by 28%, from 296 to 214.

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Focus 43

Other comments included speculation that the business to business model of insurance sales currently prevalent will move rapidly to a business to consumer model, posing challenges for carriers whose legacy systems do not adequately support product design. Over the long term, we may see a more rapid shift away from employer-based health insurance. It will be interesting to see where the marketplace is a year from now.

About the AuthorJohn J. Dalton, FHFMA, is Treasurer of the St. Joseph’s Healthcare System. A former Chapter President and National Board member, Mr. Dalton was HFMA’s 2001 Morgan Award winner for lifetime achievement in healthcare financial management. From 1974-77 he served as Project Manager for design and implementation of New Jersey’s first hospital rate setting and cost reporting system (SHARE) and the conceptual design of the all-payor DRG system that became the model for Medicare’s Inpatient Prospective Payment System. In 1985, he served on an American team assessing health care delivery in the Kingdom of Saudi Arabia. As part of an HFMA delegation to Russia in 2009, he spoke on “U.S. Health Quality Indicators” at the National Research Institute of Public Health of the Russian Academy of Medical Sciences in Moscow. Now retired, he remains involved in healthcare at St. Joseph’s and as Honorary Trustee at Children’s Specialized Hospital.

Audit | Accounting | Tax | Business AdvisoryParenteBeard.com | 732.388.5210 | 856.330.8100© ParenteBeard LLC

Healthcare is a complex industry – a balancing act of meeting patient demands while managing costs. When you work with ParenteBeard, that balancing act becomes a little easier. By understanding all of your short and long term goals we can identify success factors that will both meet your needs and set you apart from the competition.

That’s confidence through clarity.

They had the right mix of industry knowledge and client service to keep us ahead of the curve and get the focus back on our patients.

See what we can do for you.

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Advertiser FocusPlease consider supporting our sponsoring companies

Since 1986, BESLER Consulting has been assisting healthcare providers in enhancing revenue, gaining operational efficiencies and achieving compliance. BESLER Consulting clients benefit from a team of highly experienced, dedicated professionals. They bring to each engagement in-depth knowledge in a wide range of financial, operational and compliance issues. Telephone 1.877.4BESLER • Web site Beslerconsulting.com

Established in 1973, McBee Associates, Inc., one of the nation’s largest, independent health care consulting practices, provides managerial and financial consulting services to health care organizations. The firm’s consultants maintain an extensive array of financial and managerial expertise, enabling them to resolve any financial chal-lenge that faces a health care provider today. Visit: www.mcbeeassociates.com

For over twenty-five years, CBIZ KA Consulting Services has provided customized financial solutions to healthcare providers. Our staff blends industry knowledge and practical experience to provide services in the fields of reimbursement optimization, Medicare and Medicaid recovery, managed care, decision support, benchmarking and clinical resource management. For informa-tion, visit www.kaconsults.com.

ParenteBeard is the Mid Atlantic’s leading regional certified public accounting and con-sulting firm with over 1,200 employees serv-ing middle market and small business clients

across the region. The 170 partner firm has 24 offices located in Pennsylvania, New Jersey, New York, Maryland, Delaware and Texas. The firm is ranked among the Top 20 firms in the USA and is an independent member of Baker Tilly Inter-national. For more information, please visit ParenteBeard at www.parentebeard.com.

Founded in 1974, WS+B is one of the largest regional accounting and consulting firms in the mid-Atlantic area with office locations in New Jersey, New York, Pennsylvania and Maryland. With over 375 employees, the firm ranks among the top 35

CPA firms nationwide. WS+B services hundreds of health care providers in the areas of accounting & auditing, consulting, tax, corporate governance and risk management. Contact Scott Mariani at [email protected] or 973.898.9494. www.withum.com

Ranked among the 200 largest law firms in the country, Fox Rothschild is a full-service firm that provides a complete range of legal services to public and private business entities, charitable, medical and educational institutions and indi-viduals. The firm has three locations in New Jersey and offices across the country in New York, Pennsylvania, Delaware, Washington, DC, Florida, California, Nevada and Colorado. www.foxrothschild.com

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Fox Rothschild's Health Law Practice reflects an intimate knowledge of

the special needs, circumstances and sensitivities of providers in the

constantly changing world of health care. Because of our significant

experience and comprehensive, proactive approach to issues,

health care providers — including institutional, group and individual

practices of all types and sizes — turn to us to successfully meet

the challenges of their competitive, highly regulated environment.

After all, we're not your ordinary health care attorneys.

RESPONDING TO AN INDUSTRY IN TRANSITION

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A Pennsylvania Limited Liability Partnership

ATTORNEY ADVERTISING

Elizabeth G. Litten, Esq. [email protected]

Princeton Pike Corporate Center997 Lenox Drive, Building 3Lawrenceville, NJ 08648-2311

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Is revenue integrity a component of your physician practice management strategy?

(877) 4BESLER | www.besler.com

Reimbursement | Revenue Cycle | Coding and Compliance | Software Solutions

©2013 BESLER Consulting

BESLER Consulting provides pre-acquisition and existing practice revenue integrity services. Our clients find our services invaluable in the practice acquisition due diligence process and

for ensuring that existing practices are compliant in their billing and operations.

Contact us today to learn why our hospital clients have integrated BESLER physician practice revenue integrity services into their practice management model.

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