Browse by Topic
More than 40,000 members value HFMA's thought leadership and practical strategies. HFMA is where you need to be.
Get acquainted with the
healthcare finance industry's leading professional association. Find out why our
members rely on HFMA as their go-to source for insight and
Members have many
options for helping them advance their careers. Conferences, seminars,
eLearning, certification, and more -- our education and events will keep you
Connect the dots on today's big issues, explore collaborations, get career-boosting tips, and network with colleagues nationwide at the leading finance conference. Save $100 off the full conference rate when you register by May 8.
Real-time presentations with nationally recognized experts, networking opportunities, and industry solutions—no travel required!
Learn about timely healthcare finance topics and earn CPEs. Most live webinars are free for HFMA members and $99 for non-members. View the latest schedule.
If you're a subscriber to any of our three newsletters, you have access to online education. Learn more or subscribe.
Get the perspectives of leading healthcare finance professionals on today's hottest issues.
Information about leading vendors helps your buying decisions.
Forum members can network during live webinars or access a library of past webinars on topics such as bundled payment, charity care, and ICD-10.
An ever-expanding collection of spreadsheets, policies, job
descriptions, checklists, and more that you can adopt and adapt.
Forum members can submit vexing questions to a panel of experts
using our Ask the Expert service.
Your source for employment solutions.
Find new employment opportunities or
reach out to qualified candidates.
Distinguish yourself as a
leader among your peers and advance your career by earning certification in our
healthcare finance programs.
Get an objective third-party evaluation of products and services used in the healthcare finance workplace.
MAP App is a web-based application that helps organizations improve revenue cycle performance based on industry-standard metrics called MAP Keys.
Find suppliers and products in this comprehensive vendor directory for healthcare finance professionals.
Guidance for understanding and communicating about the price of health care.
Transformation toward value-based healthcare is reshaping the delivery of care, patient expectations, and payment structures.
Improve your revenue cycle performance through standard metrics, peer comparison, and successful practices.
Early in November, the healthcare provider community was left scratching its collective head upon reading two apparently contradictory opinions from the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) regarding third-party payment of premiums for qualified health plans (QHPs) purchased on the federal and state-based Marketplaces. In a letter dated Oct. 30, 2013, HHS Secretary Kathleen Sebelius issued an opinion implying that third-party reimbursement of QHP premiums for Marketplace consumers is a legally acceptable financial strategy for the provider community. Five short days later—in an apparent contradiction to Sebelius’s position—CMS issued a curious one-paragraph opinion arguing that third-party payment of QHP premiums would be deemed unacceptable.
The HHS opinion was rendered by Sebelius as a response to a question from Rep. Jim McDermott (D-Wash.) as to whether QHP products on the various healrh insurance marketplaces are considered healthcare programs under Section 1128B of the Social Security Act. Specifically, McDermott was looking for clarity as to whether QHPs fall under the scope of the federal Anti-kickback law. Secretary Sebelius, with input from the Department of Justice, argued that QHPs are not federal programs and do not fall under the anti-kickback provisions—which, on balance, means that third-party payment of premiums is acceptable.
Immediately after Sebelius rendered HHS’s opinion, a number of constituencies began to grumble, including the payer community and CMS. Their collective concern centered on the potential risk pool that might be compromised should third-party payers (i.e., hospitals) reimburse QHP premiums. Specifically, payers were concerned that providers would selectively target patient demographics that are levered to the very sick and high utilizers of services (versus younger healthier people). In such a scenario, medical loss ratios could potentially creep higher for payers, compromising the financial sustainability of QHP products on the marketplace and potentially resulting in higher QHP premiums for consumers in year two of the ACA.
An HHS representative has informed us that the HHS views these two opinions as complementary, not contradictory. Specifically, the representative says, the CMS stance was not intended to imply that third-party payment of QHP premiums is unacceptable—rather, the opinion was intended to discourage “hospitals, other healthcare providers, and other commercial entities” from directly paying QHP premiums. Notably, the HHS contact points out that CMS’s position does not preclude third-party arm’s-length not-for-profit foundations and charities from providing QHP assistance, which is a prevailing model that many hospitals have already been exploring—i.e., foundation set up as a 501(c)(3) organization, which could distribute QHP premiums without undue influence from the parent entity.
HHS tacitly recognizes that Secretary Sebelius’ letter may have led to some irrational exuberance on the part of the provider community, necessitating the follow-up guidance from CMS. It seems that HHS and CMS have no plans to issue further guidance or statements on the subject of the third-party payments.
Ultimately, both the HHS and CMS opinions can be seen as guidance documents—documents that are open to interpretation and may not necessarily be considered hard-and-fast regulation. Confusion on the legality of third-party payments of QHP premiums, in terms of what can and can’t be done by the provider community, is likely to continues. Given that HHS and CMS are unlikely to issue any further statements on this matter (at least for now)—and given the dearth of case law and continued legal ambiguity—we might expect, and even encourage, the provider community to compel an Office of Inspector General (OIG) opinion on this issue to force the legal precedent. It is important for provider organizations exploring third-party foundation arrangements for QHP reimbursement to have their general counsels ponder the HHS and CMS position statements. Ultimately, in the absence of explicit federal guidance, we recommend a prudent approach that balances business need against an aegis of risk management.
Junaid Husain is vice president of finance, Cardon Outreach, The Woodlands, Texas.
Publication Date: Tuesday, November 26, 2013
Tom Myers, chief strategy officer, The SSI Group, discusses the shifting payment environment and how it affects providers' patient access and claims management processes.
Jeff Chester, senior vice president and chief revenue officer at Availity, shares his thoughts on "Revenue Cycle 2.0" and how to best meet its challenges.
Mitch Morris, vice chair and global leader, healthcare, Deloitte, and Michael O'Rourke, senior vice president and chief information officer, Catholic Health Initiatives (CHI), share perspectives on the need for transformational IT in health care today.
Brian Kueppers, founder and CEO, Apex, discusses the importance of a robust patient payment strategy in boosting organization revenue and enhancing patient satisfaction.
Brian Grazzini, CFO, HealthPort, describes the importance of efficient and compliant information exchange and audit management in helping HIM staff spend less time on paperwork and more on mission-critical projects.
Cindy Matthews, executive vice president, Community Hospital Corporation, discusses how rural and community hospitals can use collaborative partnering to position for success through tough market conditions.
Rick Heise, senior vice president, revenue cycle, at Cerner Corporation, discusses the importance of integrating clinical and financial data to excel in health care’s changing payment environment.
Russ Graney, founder and CEO for Aidin, and John Laursen, head of business development for Aidin, share insights on how to improve care transitions between acute and post-acute care settings and incentivize high-quality patient outcomes.
Scott Elston, strategic accounts manager, GE Healthcare Services, describes how substantial cost reduction in health care requires rethinking business strategy and asset use.
Robert Williams, MD, director, Deloitte Consulting LLP, and Arielle Freiberger, product strategist, ConvergeHEALTH by Deloitte, explain how sophisticated retrospective, real-time, and predictive data analytics can inform decision making to reduce costs and improve care.
Stuart Hanson, director of business development (healthcare solutions) at Citi Retail Services, discusses how improving the payment experience can benefit consumers and healthcare providers.
©2015 Copyright Healthcare Financial Management Association
HFMA.org is best viewed using IE9 or the latest versions of Chrome, Firefox, and Safari.
Join HFMA today and enjoy: