Medicare and Medicaid programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; physician-owned hospitals: data sources for expansion exception; physician certification of inpatient hospital services; Medicare Advantage organizations and Part D sponsors: CMS-identified overpayments associated with submitted payment data. Final rule with comment period

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2015 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. In this document, we also are making changes to the data sources permitted for expansion requests for physician-owned hospitals under the physician self-referral regulations; changes to the underlying authority for the requirement of an admission order for all hospital inpatient admissions and changes to require physician certification for hospital inpatient admissions only for long-stay cases and outlier cases; and changes to establish a formal process, including a three-level appeals process, to recoup overpayments that result from the submission of erroneous payment data by Medicare Advantage (MA) organizations and Part D sponsors in the limited circumstances in which the organization or sponsor fails to correct these data.

The general NFP hospital model

Throughout the past 30 years, there has been a lot of controversy surrounding the proliferation of new forms of health care delivery organizations that challenge and compete with general NFP community hospitals. Traditionally, the health care system in the United States has been dominated by general NFP (NFP) voluntary hospitals. With the number of for-profit general hospitals, physician-owned specialty hospitals, and ambulatory surgical centers increasing, a question arises: “Why is the general NFP community hospital the dominant model?” In order to address this question, this paper reexamines the history of the hospital industry. By understanding how the “general NFP hospital” model emerged and dominated, we attempt to explain the current dominance of general NFP hospitals in the ever changing hospital industry in the United States.

Back in business. Heartland Spine & Specialty Hospital showed that a small, physician-owned hospital can beat the big guys in court

It's too soon to tell if a precedent has been set, officials say, but the Heartland Spine settlement could serve as a "guidepost" for other physician-owned hospitals feeling squeezed out of their markets. But Jeff Micklos, left, the Federation of American Hospitals' general counsel, said: "I don't think this settlement or any settlement changes the underlying influence of conflict of interest of physician-owners who self-refer.

Recruitment predicament. Tenet settles with feds for $21 million in kickback case, but hospitals still wait for clear guidance on what's allowed

Under a $21 million settlement between Tenet Healthcare Corp. and the federal government, there will not be a third trial for Alvarado or its former chief. Tom McNamara, left, the lawyer who represented former Alvarado CEO Barry Weinbaum, says the exec is elated to hear that. The industry, on the other hand, still has reservations. It wants clear guidance on what is legal in physician recruiting.

Not-for-profit versus for-profit health care providers--Part II: Comparing and contrasting their records

The debate over which health care providers are most capably meeting their responsibilities in serving the public's interest continues unabated, and the comparisons of not-for-profit (NFP) versus for-profit (FP) hospitals remain at the epicenter of the discussion. From the perspective of available factual information, which of the two sides to this debate is correct? This article is part II of a 2-part series on comparing and contrasting the performance records of NFP health care providers with their FP counterparts. Although it is demonstrated that both NFP and FP providers perform virtuous and selfless feats on behalf of America's public, it is also shown that both camps have been accused of being involved in potentially willful clinical and administrative missteps. Part I provided the background information (eg, legal differences, perspectives on social responsibility, and types of questionable and fraudulent behavior) required to adequately understand the scope of the comparison issue. Part II offers actual comparisons of the 2 organizational structures using several disparate factors such as specific organizational behaviors, approach to the health care priorities of cost and quality, and business-focused goals of profits, efficiency, and community benefit.

All's fair in healthcare? Heartland Spine & Specialty Hospital alleges HCA Midwest Division conspired with local payers to drive it out of business

A Kansas specialty hospital is accusing HCA of pressuring managed-care companies to exclude rivals from networks and is suing the chain. "This is another mechanism by which (specialty hospitals) can get relief from the conduct of larger hospitals that are doing everything they can to put them out of business," says Norman Siegel, left, attorney for Heartland Spine & Specialty Hospital.

Doctor group sues to keep capitation arrangement

An independent practice association has sued Humana Kansas City Inc. over the health plan's decision to terminate its capitated contract. The suit alleges breach of contract and seeks an injunction to keep the flow of capitated dollars coming.