November 22, 2013
Volume 57, Issue 47

Insurance Commissioner to Allow Plan Extensions
Insurers can renew policies that don’t comply with ACA rules

On November 21, the state’s Office of the Insurance Commissioner (OCI) released a Bulletin to insurers in Wisconsin authorizing them to renew at their option ACA non-compliant plans that were in effect on October 1, 2013 for a policy year starting between January 1, 2014 and October 1, 2014.

As reported in The Valued Voice November 15, President Obama announced new guidance that would allow insurance commissioners and insurers to continue coverage that would otherwise be terminated or cancelled for benefit year 2014. This new guidance comes after the Administration was criticized when consumers began receiving letters cancelling their previous insurance policies because the policies didn’t meet the requirements of the Affordable Care Act.

According to OCI, Wisconsin didn’t see the same number of cancelled policies as in other states because OCI had allowed insurers to offer early renewals all along. The new OCI bulletin to insurers can be found at this link:

In related news, Governor Scott Walker sent a letter to Department of Health and Human Services Secretary Sebelius and Treasury Department Secretary Lew encouraging them to allow consumers to use the tax subsidies available for Exchange plans to purchase any health care plan from any insurer, including non-ACA compliant plans, in the individual market inside or outside of the Exchange. A copy of the Governor’s letter can be found here:

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WI Hospitals Rank Third Best in Nation in CMS Quality Incentive Program
64% of WI hospitals will receive bonus in round 2 of VBP program

Wisconsin hospitals ranked third best in the country in the second round of the Centers for Medicare and Medicaid Services (CMS) Value-Based Purchasing (VBP) Program. When the penalties and bonuses from the CMS quality incentive programs are combined, nearly two-thirds (64 percent) of the Wisconsin hospitals that are included in the program received a bonus, and no hospital here will receive even half of the possible 1.25 percent penalty. The penalty will continue to grow by a quarter percent until it reaches two percent.

Hospitals in Wisconsin, Maine, Massachusetts, Nebraska, New Hampshire, North Carolina and Utah are faring the best, with 60 percent or more of hospitals getting higher payments, according to a Kaiser Health News analysis. The list below shows how Wisconsin ranked nationally, when compared to all 50 states.

The FFY2014 program includes three new mortality outcome measures. CMS announced the program will shift toward quality outcomes measures in the future—a move that aligns well with Wisconsin hospitals’ focus on improving patient outcomes, according to WHA Chief Quality Officer Kelly Court.

"The data continues to prove that patients in Wisconsin are receiving better care than they would expect to receive in other states," said Court. "The hard work of our health care employees and the proactive quality improvement efforts by our hospitals are showing positive results. WHA is proud to be a partner with Wisconsin hospitals on their quality initiatives. Wisconsin hospitals have been keenly focused on quality improvement for more than a decade. Their continuous attention to delivering high-quality, high-value care is paying off for our patients and for our communities."

Medicare will begin adjusting payments in January through the end of the federal fiscal year in September. The change to payments will be retroactively applied to the last three months of 2013. According to Kaiser Health News, the cumulative gain or loss for each facility will not be clear until the end of the fiscal year, since hospitals do not know exactly how many patients they will end up admitting and for what conditions.

According to Kaiser Health News, the amount of money at stake increases to 1.5 percent of payments in October 2014, Medicare is planning to add new measures next year, including comparisons of how much patients cost Medicare at different hospitals and rates of medical mishaps and infections from catheters.

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Guest Column: Premium Support: A False Start or Progress? Reconciling HHS’ Seemingly Conflicting Guidance
By Attorneys Steve Hahn, Paul Seidenstricker, and Dave Snow of Hall, Render, Killian, Heath & Lyman, P.C.

Our article in the November 1 edition of The Valued Voice explained the U.S. Department of Health and Human Services’ ("HHS") announcement that it does not consider Qualified Health Plans ("QHP(s)") purchased on a federal or state Marketplace established under the Affordable Care Act to be "Federal health care programs." HHS’ clarification appeared to make it possible for a hospital to pay an individual’s QHP insurance premiums through its charity care program without violating the Federal Anti-Kickback Statute.

Then on November 4, 2013, the Centers for Medicare & Medicaid Services ("CMS"), a department of HHS, issued a question and answer memo described in the November 8 Valued Voice that seemed to go in reverse. The Q&A indicates that CMS has significant concerns with a third-party’s (e.g., a hospital or other provider) payment of an individual’s QHP insurance premiums, "because it could skew the insurance risk pool and create an unlevel field in the Marketplaces." CMS’ memo states that: (i) HHS has broad authority to regulate the Federal and State Marketplaces (e.g., Section 1321(a) of the Affordable Care Act); and (ii) HHS discourages this practice and encourages issuers to reject such third-party payments and that it intends to monitor this practice and take appropriate action, if necessary.

So, how do we in the health care industry reconcile these seemingly conflicting communications from HHS? First, it is important to note that the CMS Q&A does not state that a hospital’s payment, through its charity care program, of an individual’s QHP insurance premium is illegal or that a QHP insurer’s acceptance of such premium payment is illegal. If CMS had clear legal authority to ban this practice, it would have said so. One interpretation is that CMS is communicating that it does not like the idea, even though it may not currently be able to prevent it. Thus, we can expect that HHS will actively monitor the industry to determine whether premium support payments proliferate.

If HHS determines that the practice is negatively impacting the Exchange Marketplaces, it may issue guidance prohibiting a QHP insurer from accepting premium support payments from third parties, such as hospitals or other providers. Such guidance would likely take the form of new regulations under the Civil Monetary Penalty law forbidding such payments. Sanctions under the CMP law could include monetary penalties and possible decertification of the QHP insurer.

In conclusion, the additional guidance is progress, as HHS triangulates in on where it will ultimately come down on these issues. Considering all the information available today, we think that an appropriately crafted premium support program, operated as part of a charity care program, can be utilized by Wisconsin hospitals. If you are considering such a program, we urge you to have the program reviewed by your legal counsel. And most importantly, stay tuned. Changes in the implementation of the Affordable Care Act are happening daily.

CMS’ question and answer memo is available at

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President’s Column: Good News, Bad News from D.C.

There was a glimmer of good news from Washington this week as it became increasing apparent that Congressional leaders do not want another government shutdown to result from gridlock related to either the next debt ceiling hike or expiration of the new budget spending deadline—both of which are fast approaching.

Fortunately, leaders of all political stripes have publicly rejected another shutdown because the last one did little other than roil the financial markets and drive public opinion of lawmakers to unprecedented low levels.

The bad news is that Medicare provider cuts remain a very real option as part of any "deal" that may emerge in early 2014.

The most certain (but not only) area of vulnerability is the very necessary physician payment "fix," also known as the SGR "problem," which unless addressed will cut physician Medicare payments by 25 percent beginning January 1. The question isn’t if the cut will be blocked but whether it will be permanently fixed at a cost of about $175 billion—or—patched over for another year at a significantly lesser cost. In either case, cuts to hospitals are a likely target.

Congressman Michael Burgess (R-Texas) is a leading proponent of a permanent fix, despite the hefty price tag. Burgess, a physician, is cagey about describing how he’ll pay for the repeal but recently said, "I’ve got ‘pay fors’ in mind...but you don’t throw your friends under the bus until the end of the parade." Those are frightening prospects for hospitals and perhaps other Medicare providers as the last two SGR "fixes" both involved substantial hospital cuts. And the "parade" is nearing the finish line.

WHA members have had some success in teeing up the theme that "enough’s enough." A combination of all cuts for Wisconsin hospitals since the passage of OBAMACARE in 2009 is approaching $4 billion. Additional cuts are not sustainable without impacting employment, community services and capital spending, all of which affect the health of the state’s fragile economy.

WHA and our members must continue to make the case that "enough’s enough" through district meetings and Capitol Hill visits.

Steve Brenton

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Register for WHA’s Physician Leadership Development Conference
The American Club, Kohler *** March 14-15, 2014

Early Bird Registration: Register by January 15 to Qualify

More information and online registration can be found at:

Need Hotel Reservations? Contact The American Club at 800-344-2838 before February 20.

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WHA to Lead January 8 DC Trip; Will Participate in AHA Capitol Hill Fly-in

In early January, Congress will likely be in the midst of negotiations on how to fund the federal government and deal with the debt ceiling, which is why the Wisconsin Hospital Association will lead a trip to Washington, DC on January 8, 2014. The trip coincides with the American Hospital Association’s Capitol Hill fly-in that day.

"Hospitals need to remain vigilant and visible to their Members of Congress during these ongoing fiscal negotiations," said WHA President Steve Brenton. "That is why WHA is leading this trip to DC—to remind legislators Wisconsin hospitals are already seeing an estimated $4 billion in reductions over 10 years from previously enacted laws, and that we need them to protect the high-value care provided by our hospitals to patients."

The WHA will coordinate, schedule and staff Hill visits on January 8, 2014 with Wisconsin’s Members of Congress. If you are planning to travel to DC for this event, please let WHA’s Jenny Boese know at 608-268-1816 or

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Audit Activity Update: WHA Medicaid RAC Webinar, Two Midnights Policy

The much-anticipated Medicaid Recovery Audit Contractor is now live in Wisconsin. The Wisconsin Hospital Association recently met with Wisconsin’s Medicaid RAC, HMS, and the Wisconsin Office of Inspector General (WI OIG) to discuss the roll-out of the Medicaid RAC program. While this program is just being implemented in Wisconsin, a few details are now available:

Additionally, WHA is pleased to announce it will host a webinar—The Medicaid RAC: What Your Hospital Needs to Know as HMS Goes Live in Wisconsin—with HMS to take place on December 9 from 3-4 p.m. This one-hour webinar will include representatives from HMS who will discuss their work with the WI OIG to analyze and review Medicaid claims. As Wisconsin’s Medicaid RAC, HMS will provide information about its audit process and what hospitals can expect during the process. The webinar is free, but registration is required and is limited to WHA members and corporate members. WHA members may register for this webinar at

In related news, the onset of the Medicare RACs several years ago continue to have other downstream impacts on hospitals. One example has been the RACs focus on short stays and inpatient admission versus observation status. Due to the growing confusion, the Centers of Medicare & Medicaid Services finalized new policy under the FY 2014 Inpatient Prospective Payment System rule known as the "two midnights" rule. Under the policy, if the ordering practitioner expects a beneficiary to stay in the hospital over two midnights, and admits the beneficiary as an inpatient based on that expectation, it is generally appropriate that the hospital receive Medicare Part A payment.

There has been significant questions and concerns related to the "two midnights" policy, its application and whether audits will be forthcoming. CMS has released some guidance on these issues available at the links below:

Finally, as a reminder, to remain current on RAC, audit and related activities, WHA members are invited to join our RAC email list. RAC updates and information are provided regularly to this list. If you would like to join please contact WHA’s Jenny Boese, vice president, external relations & member advocacy, at

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WHA Information Center Celebrates Tenth Anniversary

November marked the tenth anniversary of the WHA Information Center (WHAIC), a subsidiary of WHA. The WHAIC has been authorized by the Wisconsin Department of Administration since 2003 to collect and report hospital and freestanding ambulatory surgery center data. Using their web-based data collection software, WHAIC collects data quarterly and produces public use data sets, custom data sets and four annual publications that are available on the WHAIC web site at

The Information Center has made several changes over the years to improve efficiency and increase customer service. The most notable changes are three upgrades to their data collection software, implementation of PricePoint (, which was one of the first web-based pricing sites of its kind in the country. Today, ten states have contracted with WHAIC and implemented PricePoint. WHAIC also collects line-item revenue code detail and hospital outpatient ancillary services data.

"We are fortunate to have a dedicated and talented team that not only meets our contractual requirements, but WHAIC also identifies and provides value-added data services for our customers, which helps to fulfill our mission of being the respected source for health care data in Wisconsin," according to WHAIC Vice President Debbie Rickelman.

"I see a promising future for the Information Center," said WHA President Steve Brenton. "The Information Center has grown and advanced their mission to become an even more valuable resource. At a time when the industry is facing some of its biggest challenges, access to timely and accurate health care data is critical to providers, payers, and policymakers. Even to consumers, WHAIC has advanced the Wisconsin health care transparency agenda and will continue to be a valued source of information."

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WHA and RWHC Launch Quality Residency Program

The quality staff from the Wisconsin Hospital Association (WHA) and the Rural Wisconsin Health Cooperative (RWHC) are partnering to develop and host a Quality Improvement Residency Program. This program is designed to engage new and novice hospital quality improvement directors in a two-year track of education, leadership training and networking—resources that are currently sorely lacking.

In Wisconsin, and likely nationwide, many nurses are hired or "promoted" from within to fill a quality director vacancy, either by virtue of employment tenure or superior performance in their direct care position. There is no formal program to train a new hospital quality director; so WHA and RWHC have "built our own."

"We are very excited about the new program. This is a unique and innovative program that will continue to build the improvement capacity in our state," said Kelly Court, WHA chief quality officer.

The program will include ten learning modules that will be delivered as all-day in-person learning events, every other month, for a 24-month period. The WHA Foundation has provided a grant to help fund the program and provide scholarships for several participants. Contact Kelly Court at or Beth Dibbert at for an application package and additional information.

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Wisconsin Hospitals Community Benefits – Charity Care

Fear of a bill should never prevent a patient from seeking care at a Wisconsin hospital. Wisconsin hospital charity care programs provided $232 million to more than 700 patients each day last year. The stories that follow illustrate the deep commitment and continuing concern that hospitals have to their patients to ensure they receive the care they need regardless of their ability to pay.

Aurora Helping Hand helped put the focus back on school

A college student was fighting off severe pain in his back and side for two days in order to study for and complete his college final exams. After that, he arrived at the emergency department of Aurora Medical Center Oshkosh and was admitted to the Intensive Care Unit (ICU) for observation. Upon further evaluation, his ICU doctor determined that he needed an emergency appendectomy. The emergency surgery took place later that evening.

The student was not working, and neither of his parents’ employer-provided health plans provided coverage for their son. While the student was recovering in the hospital as an inpatient, the financial counselor walked him through a financial assessment. On the morning of his discharge, the counselor visited once again and was sorry to inform him that he did not qualify for any state or federal programs, but explained that he may be eligible for the Aurora Helping Hand Patient Financial Assistance Program.

A few hours after his discharge, the student returned to the financial counselor’s office with all the documentation needed to apply to the Helping Hand program. The student was approved for a 100 percent discount on his medical expenses, which totaled well over $35,000. The financial counselor later received the following note from the student:

"I am forever grateful for the Aurora Health Care Helping Hand program for helping me regain focus on my education rather than on how I was going to pay my major medical expenses, which was worth more than three years of my college tuition."

Aurora Medical Center Oshkosh

Charity Care gives compassionate service to a worried family

Like many mothers, Darnelle Kaishian is constantly worried about the health of her children. When her oldest daughter, Shelby, collapsed in January, she didn’t know what to do.

Shelby Kaishian follows the path of many college students in this generation - balancing school, work, and other activities. As a costume and film student at the University of Wisconsin-Milwaukee, her projects can get really intense, demanding 20 hours straight without a break. While focusing on trying to make the grade, Shelby also works part-time to help carry her weight in the household. All of this stress was draining her mentally and physically. She was having severe migraines two to three times a week among other health issues.

All of this came to a head one night in January when Shelby physically collapsed. Her body had had enough. She was slurring her words, her leg was going numb, and she couldn’t walk.

Distraught, Darnelle immediately called her family physician for help. Since the symptoms were alarming and indicated the possibility of a stroke, the doctor recommended that Shelby be treated right away at Wheaton Franciscan - Wisconsin Heart Hospital’s Emergency Department.

"I was a mess when I got there," said Darnelle. "We were of course worried about Shelby, but we were also nervous because she was between insurance, and I didn’t know how we would pay for these services. The staff was very compassionate and let us know that making sure our daughter was ok was the only thing to worry about," Darnelle remembered.

It turns out that Shelby was not having a stroke. Her symptoms came from the migraines, a hormonal imbalance, and just plain exhaustion. That was a major relief, but Darnelle was still concerned about finances. Without her even asking, she was referred to Wheaton’s Community Care Program, which provides free or discounted care for those who cannot afford to pay. The family’s medical bills were growing. In addition Shelby’s medical situation, Darnelle, her eight-year old daughter, and her husband all had health issues of their own. "We don’t have a lot of money," Darnelle expressed.

Bessie Washington, a Wheaton financial counselor came to their rescue. "We were very blessed; the hospital took care of the whole bill. And Bessie was awesome!" proclaimed Darnelle. Wheaton Franciscan Healthcare provided services at no cost to Shelby through Community Care, the System’s charity care program that assists patients with financial need.

Wheaton Franciscan Healthcare, Milwaukee

Submit community benefit stories to Mary Kay Grasmick, editor, at

Read more about hospitals connecting with their communities at

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