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Health Hippo: Hospitals & Facilities

Health Hippo: Hospitals & Facilities

US CODE || CFR || CASES || REPORTS || CONGRESSIONAL RECORD || BILLS || FEDERAL REGISTER


It is far more important to know what person the disease has than what disease the person has.

In 1946, Congress passed the Hill-Burton Act that gave hospitals, nursing homes and other health facilities grants and loans for construction and modernization. In return, they agreed to provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area. The program stopped providing funds in 1997, but about 170 health care facilities nationwide are still obligated to provide free or reduced-cost care. Although the IRS has not specified charity care as a requirement for non-profit health care entities to maintain their non-profit status, some states have more stringent community benefit requirements.

U.S. Code

  • Protecting Access to Medicare Act of 2014 Extended the current moratorium on RAC audits of hospital inpatient stays through March 31, 2015.
  • Affordable Care Act: Hospital Provisions
    • Sec. 3001. Hospital Value-Based purchasing program.
    • Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs.
    • Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.
    • Sec. 3008. Payment adjustment for conditions acquired in hospitals.
    • Sec. 3025. Hospital readmissions reduction program.
    • Sec. 10301. Plans for a Value-Based purchasing program for ambulatory surgical centers.
    • Sec. 10302. Revision to national strategy for quality improvement in health care.
    • Sec. 10303. Development of outcome measures.
    • Sec. 10304. Selection of efficiency measures.
    • Sec. 10305. Data collection; public reporting.
    • Sec. 10308. Revisions to national pilot program on payment bundling.
    • Sec. 10309. Revisions to hospital readmissions reduction program.
    • Sec. 10312. Certain payment rules for long-term care hospital services and moratorium on the establishment of certain hospitals and facilities.
    • Sec. 10322. Quality reporting for psychiatric hospitals.
    • Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare providers.
    • Sec. 10335. Technical correction to the hospital value-based purchasing program.
  • Balanced Budget Act Hospital provisions.
    • Sec. 4401 PPS hospital payment update.
    • Sec. 4402 Maintaining savings from temporary reduction in capital payments for
      PPS hospitals.
    • Sec. 4403 Disproportionate share.
    • Sec. 4404 Medicare capital asset sales price equal to book value.
    • Sec. 4405 Elimination of IME and DSH payments attributable to outlier
      payments.
    • Sec. 4406 Increase base payment rate to Puerto Rico hospitals.
    • Sec. 4407 Certain hospital discharges to post acute care.
    • Sec. 4408 Reclassification of certain counties as large urban areas under
      medicare program.
    • Sec. 4409 Geographic reclassification for certain disproportionately large
      hospitals.
    • Sec. 4410 Floor on area wage index.
    • Sec. 4411 Payment update.
    • Sec. 4412 Reductions to capital payments for certain PPS-exempt hospitals and
      units.
    • Sec. 4413 Rebasing.
    • Sec. 4414 Cap on TEFRA limits.
    • Sec. 4415 Bonus and relief payments.
    • Sec. 4416 Change in payment and target amount for new providers.
    • Sec. 4417 Treatment of certain long-term care hospitals.
    • Sec. 4418 Treatment of certain cancer hospitals.
    • Sec. 4419 Elimination of exemptions for certain hospitals.
    • Sec. 4421 Prospective payment for inpatient rehabilitation hospital services.
    • Sec. 4422 Development of proposal on payments for long-term care hospitals.
    • Sec. 4451 Reductions in payments for enrollee bad debt.
    • Sec. 4452 Permanent extension of hemophilia pass-through payment.
    • Sec. 4453 Reduction in part A medicare premium for certain public retirees.
    • Sec. 4454 Coverage of services in religious nonmedical health care
      institutions under the medicare and medicaid programs.
    • Sec. 4521 Elimination of formula-driven overpayments (FDO) for certain
      outpatient hospital services.
    • Sec. 4522 Extension of reductions in payments for costs of hospital
      outpatient services.
    • Sec. 4523 Prospective payment system for hospital outpatient department
      services.
  • 42 U.S. Code Chapter 7, Subchapter XVIII HEALTH INSURANCE FOR AGED AND DISABLED
    • Part A Hospital Insurance Benefits for Aged and Disabled (1395c–1395i5)
    • Part E Miscellaneous Provisions (1395x–1395kkk1)
      • Sec. 1395dd Examination and
        treatment for emergency medical conditions and women in labor
      • Sec. 1395tt Hospital providers of extended care services
      • Sec. 1395uu Payments to promote closing or conversion of underutilized hospital facilities
      • Sec. 1395ww Payments to hospitals for inpatient hospital services

Code of Federal Regulations

  • 42 CFR PART 406 – HOSPITAL INSURANCE ELIGIBILITY AND ENTITLEMENT
    • SUBPART A General Provisions (406.1 – 406.7)
    • SUBPART B Hospital Insurance Without Monthly Premiums (406.10 – 406.15)
    • SUBPART C Premium Hospital Insurance (406.20 – 406.38)
    • SUBPART D Special Circumstances That Affect Entitlement to Hospital Insurance (406.50 – 406.52)
  • 42 CFR PART 412 PROSPECTIVE PAYMENT SYSTEM FOR INPATIENT HOSPITAL SERVICES
    • SUBPART A General Provisions (412.1 – 412.10)
    • SUBPART B Hospital Services Subject to and Excluded From the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs (412.20 – 412.30)
    • SUBPART C Conditions for Payment Under the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs (412.40 – 412.52)
      • Sec. 412.40 General requirements.
      • Sec. 412.42 Limitations on charges to beneficiaries.
      • Sec. 412.44 Medical review requirements: Admissions and quality review.
      • Sec. 412.46 Medical review requirements: Physician acknowledgement.
      • Sec. 412.48 Denial of payment as a result of admissions and quality review.
      • Sec. 412.50 Furnishing of inpatient hospital services directly or under arrangements.
      • Sec. 412.52 Reporting and recordkeeping requirements.
    • SUBPART D Basic Methodology for Determining Prospective Payment Federal Rates for Inpatient Operating Costs (412.60 – 412.64)
    • SUBPART E Determination of Transition Period Payment Rates for the Prospective Payment System for Inpatient Operating Costs (412.70 – 412.79)
    • SUBPART F Payments for Outlier Cases, Special Treatment Payment for New Technology, and Payment Adjustment for Certain Replaced Devices (412.80 – 412.89)
    • SUBPART G Special Treatment of Certain Facilities Under the Prospective Payment System for Inpatient Operating Costs (412.90 – 412.109)
    • SUBPART H Payments to Hospitals Under the Prospective Payment Systems (412.110 – 412.140)
    • SUBPART I Adjustments to the Base Operating DRG Payment Amounts Under the Prospective Payment Systems for Inpatient Operating Costs (412.150 – 412.168—412.169)
    • SUBPART J [Reserved]
    • SUBPART K Prospective Payment System for Inpatient Operating Costs for Hospitals Located in Puerto Rico (412.200 – 412.220)
    • SUBPART L The Medicare Geographic Classification Review Board (412.230 – 412.280)
    • SUBPART M Prospective Payment System for Inpatient Hospital Capital Costs (412.300 – 412.374)
    • SUBPART N Prospective Payment System for Inpatient Hospital Services of Inpatient Psychiatric Facilities (412.400 – 412.434)
    • SUBPART O Prospective Payment System for Long-Term Care Hospitals (412.500 – 412.541)
    • SUBPART P Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units (412.600 – 412.632)
  • 42 CFR PART 482 CONDITIONS OF PARTICIPATION FOR HOSPITALS
    • SUBPART A General Provisions (482.1 – 482.2)
    • SUBPART B Administration (482.11 – 482.13)
      • Sec. 482.11 Condition of participation: Compliance.
      • Sec. 482.12 Condition of participation: Governing body.
      • Sec. 482.13 Condition of participation: Patient’s rights.
    • SUBPART C Basic Hospital Functions (482.21 – 482.45)
      • Sec. 482.21 Condition of participation: Quality assurance.
      • Sec. 482.22 Condition of participation: Medical staff.
      • Sec. 482.23 Condition of participation: Nursing services.
      • Sec. 482.24 Condition of participation: Medical record services.
      • Sec. 482.25 Condition of participation: Pharmaceutical services.
      • Sec. 482.26 Condition of participation: Radiologic services.
      • Sec. 482.27 Condition of participation: Laboratory services.
      • Sec. 482.28 Condition of participation: Food and dietetic services.
      • Sec. 482.30 Condition of participation: Utilization review.
      • Sec. 482.41 Condition of participation: Physical environment.
      • Sec. 482.42 Condition of participation: Infection control.
    • SUBPART D Optional Hospital Services (482.51 – 482.57)
      • Sec. 482.51 Condition of participation: Surgical services.
      • Sec. 482.52 Condition of participation; Anesthesia services.
      • Sec. 482.53 Condition of participation: Nuclear medicine services.
      • Sec. 482.54 Condition of participation: Outpatient services.
      • Sec. 482.55 Condition of participation: Emergency services.
      • Sec. 482.56 Condition of participation: Rehabilitation services.
      • Sec. 482.57 Condition of participation: Respiratory care services.
    • SUBPART E Requirements for Specialty Hospitals (482.60 – 482.104)
      • Sec. 482.60 Special provisions applying to psychiatric hospitals.
      • Sec. 482.61 Condition of participation: Special medical record.
      • Sec. 482.62 Condition of participation: Special staff requirements.
      • Sec. 482.66 Special requirements for hospital providers.
  • 42 CFR PART 488 SURVEY AND CERTIFICATION PROCEDURES SUBPART A – GENERAL PROVISIONS
  • 42 CFR PART 489 PROVIDER AGREEMENTS UNDER MEDICARE SUBPART A – GENERAL PROVISIONS

Case Law

Medicare Participation

  • Tri-County Medical Center (2014)(community health center had grant terminated for failing to comply with conditions calling for periodic review of service utilization and quality)
  • Apollo Behavioral Health Hospital (2014)(psychiatric hosptial with condition-level deficiencies relating to patient rights, infection control, and special staffing requirements for psychiatric hospitals did not meet requirements for participation in the Medicare program)

EMTALA

Hospital Inpatient

  • In the Case of Providence Health Center (MAC 2012) (The Council adopted the ALJ’s decision that services furnished to the beneficiary are not covered under Medicare Part A, but directed the contractor to provide reimbursement for medically reasonable and necessary and otherwise covered items and services on an outpatient basis under Medicare Part B)
  • In the Case of Indiana University Health Methodist Hospital (MAC 2012) (The Council concurred with the ALJ that the beneficiary’s condition was not so critical that an acute level of inpatient care was necessary)
  • In the Case of L.B. (MAC 2011) (The evidence of record demonstrates that the appellant had a qualifying inpatient hospital stay and that the subsequent SNF services provided were medically reasonable and necessary)
  • Illinois Valley Community Hospital (MAC 2011) (Medicare Part B pays for hospital services and supplies furnished incident to a physician service to outpatients, including drugs that cannot be self administered)
  • In the Case of Montefiore Medical Center (MAC 2011) (a state legislature may determine state policy for hospitals, but the Social Security Act sets Medicare payment policy)
  • In the Case of O’Connor Hospital (MAC 2010) (if a Medicare Part A claim is denied, payment may be made for covered hospital services under Medicare Part B)
  • In the Case of St. Francis Hospital (MAC 2009) (consistent with the Medicare Part A and Part B appeals process under the current applicable statutory and regulatory authorities, either a provider/practitioner or a beneficiary may appeal both the findings on coverage and liability to an ALJ following an inpatient hospital admission denial by a quality improvement organization (QIO))
  • In the Case of Triumph Hospital Detroit (MAC 2009) (either a beneficiary or a provider may appeal both the findings on coverage and liability to an ALJ following an inpatient hospital admission denial by a quality improvement organization)
  • In the Case of Alta Bates Summit Medical Center (MAC 2009) (clinical records show the beneficiaries received frequent, direct, and medically necessary physician involvement that was an indicator of the beneficiaries’ need for inpatient rehabilitation hospital services)
  • In the Case of Sacred Heart Hospital (MAC 2009) (while there is no presumption that a treating physician’s judgment establishes Medicare coverage, the evidence of record shows that at the time of admission and throughout the hospital stay, the beneficiary required acute inpatient hospital care)
  • In the Case of Kaweah Rehabilitation Hospital (MAC 2009) (the medical evidence demonstrating the beneficiary’s multiple and complex medical problems satisfies the criteria that she receive rehabilitation services in a hospital-level setting as opposed to receiving services at a skilled nursing facility)
  • In the Case of C.A. (MAC 2009) (the evidence of record meets the criteria for Medicare coverage of a liver transplant for the beneficiary)

Reimbursement Rates

  • Hillsborough County Hosp. Auth. v. Shalala
    (1995) (denying Florida Hospitals’ claims that they were entitled to an adjustment in their Medicare
    reimbursements based on the “extraordinary circumstances” exception of 42 U.S.C. §1395ww(b)(4)(A))
  • New Jersey Hospital Association v.
    Waldman     (1995) (upholding district court’s denial of injunction sought by NJHA against Medicaid
    reimbursement rates for general inpatient hospital services set by New Jersey Department of Human Services)
  • Shalala v. Guernsey Memorial Hospital (1995) (HHS Medicare regulations do not require reimbursement according to generally accepted accounting principles for
    validity)
  • Thomas Jefferson University v. Shalala (1994) (HHS interpretation of anti-redistribution principle, that Medicare should not pay for costs shifted from
    educational institutions to patient care institutions, was reasonable)

Recovery Audit Contractor

  • In the Case of Memorial Long Beach (MAC 2008) (a contractor’s decision on whether to reopen and whether the contractor met the good cause standards for reopening are not subject to administrative review by ALJs or the Council but lie within CMS’s evaluation and monitoring of the contractor’s performance)
  • In the Case of Holy Cross Hospital (MAC 2009) (Section 1870(b) of the Social Security Act creates a rebuttable presumption of no fault on a provider’s part where an overpayment determination is made subsequent to the third year in which payment notice was issued; section 1870(c) applies to a wavier of overpayments made to a beneficiary, not a provider)
  • In the Case of St. Francis Memorial Hospital (MAC 2009) (only the year of the payment and the year it was found to be an overpayment are considered for calculating the three-year calendar period, not the day and month)
  • In the Case of Valley Presbyterian Hospital (MAC 2009) (while the RAC’s decision to reopen the claim at issue is not subject to review by the ALJ and the Council, the assessed overpayment is not valid as the evidence of record supports payment for the provided inpatient rehabilitation facility services)
  • In the Case of Baptist Health Care (MAC 2009) (limitation of liability under section 1879 of the Social Security Act is not appropriate as the provider had knowledge that Medicare would not pay for the services based on the fact CMS had issued relevant manuals, bulletins, and written guidelines; performance of post payment review itself did not constitute knowledge of noncoverage of services provided and billed for prior to the assessment of the overpayment)

Reports

  • Payment Methods for Certain Cancer Hospitals Should Be Revised to Promote Efficiency (GAO 2015) Because Medicare’s payment methodology for PCHs lacks strong incentives for cost containment, it has the potential to result in substantially higher total Medicare expenditures. If, in 2012, PCH beneficiaries had received inpatient and outpatient services at nearby PPS teaching hospitals—and the forgone outpatient adjustments were returned to the Supplementary Medical Insurance Trust Fund—Medicare may have realized annual savings of almost $0.5 billion. Until Medicare pays PCHs to at least, in part, encourage efficiency, Medicare remains at risk for overspending.
  • Action Needed to Reduce Financial Incentives to Prescribe 340B Drugs at Participating Hospitals (GAO 2015) Approximately 40 percent of all U.S. hospitals participate in the 340B Drug Pricing Program, and the majority of 340B discounted drugs are sold to hospitals. Medicare reimburses hospitals for Part B drugs under a statutory formula regardless of the prices hospitals paid for the drugs.
  • CMS Oversight of Provider Payments Is Hampered by Limited Data and Unclear Policy (GAO 2015) GAO’s assessment of Medicaid payments to government and private hospitals in three selected states was hampered by inaccurate and incomplete data on payments. States must capture but are not required to report all payments they make to individual institutional providers, nor are states required to report ownership information.
  • Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals (OIG 2015) Traditionally, pharmacies compounded a drug upon receipt of a prescription for an individual patient. However, recent trends in drug compounding have included the large-scale production of certain drugs by standalone compounding pharmacies to meet the needs of some hospitals.
  • Inpatient Hospital Settlements (CMS 2015) To more quickly reduce the volume of inpatient status claims currently pending in the appeals process, CMS is now offering an administrative agreement to any hospital willing to withdraw their pending appeals in exchange for timely partial payment (68% of the net allowable amount).
  • Legislative Modifications Have Resulted in Payment Adjustments for
    Most Hospitals     (GAO 2013) These findings suggest that the way Medicare currently pays hospitals may
    no longer ensure that the goals of the IPPS–cost control, efficiency, and access–are being met.

  • Co-Located Long-Term Care Hospitals Remain Unidentified, Resulting in Potential Overpayments (OIG 2013) Nearly half of the 211 LTCHs whose co-located status we have determined have not reported this information to contractors. This prevents CMS from applying two payment policies specific to co-located providers and thus could result in Medicare overpaying for LTCH services.
  • Hospital Incident Reporting Systems Do Not Capture Most Patient Harm (OIG 2012) Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm.
  • Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems (OIG 2012) We found that an estimated 60 percent of adverse and temporary harm events nationally occurred at hospitals in States with reporting systems, yet only an estimated 12 percent of events nationally met State requirements for reporting. We also found that hospitals reported only 1 percent of events.
  • Medicare Provider Utilization and Payment Data: Outpatient Hospital-specific charges for 30 Ambulatory Payment Classification (APC) Groups paid under the Medicare Outpatient Prospective Payment System (OPPS) for Calendar Years (CY) 2011 and 2012.
  • Medicare Provider Utilization and Payment Data: Inpatient Hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the Medicare Severity Diagnosis Related Group.
  • MedPac: Hospital Acute Inpatient Services (2013) Medicare’s inpatient hospital benefit covers beneficiaries for 90 days of care per episode of illness, with a 60-day lifetime reserve. Illness episodes begin when beneficiaries are admitted and end after they have been out of the hospital or a skilled nursing facility for 60 consecutive days. In 2013, beneficiaries are liable for a deductible of $1,184 for the first hospital stay in an episode, and daily copayments— currently $296—are imposed beginning on the 61st day.
  • MedPac: Ambulatory Surgical Center Services (2014) ASCs are distinct facilities that furnish ambulatory surgery; the most common procedures in 2011 were cataract removal with lens insertion, upper gastrointestinal endoscopy, colonoscopy, and nerve procedures. Each of the approximately 3,600 procedures approved for payment in an ASC is classified into an ambulatory payment classification (APC) group on the basis of clinical and cost similarity. There are several hundred APCs.
  • MedPac: Inpatient Psychiatric Facility Services (2014) Medicare beneficiaries with serious mental illnesses or alcohol- and drug- related problems may be treated in specialty inpatient psychiatric facilities (IPFs), either freestanding hospitals or specialized hospital-based units. The services furnished by IPFs are intended to meet the urgent needs of those experiencing an acute mental health crisis.
  • MedPac: Inpatient Rehabilitation Facilities (2014) After an illness, injury, or surgical care, some patients need intensive inpatient rehabilitation services, such as physical, occupational, or speech therapy. Relatively few beneficiaries use intensive rehabilitation therapy because they generally must be able to tolerate and benefit from three hours of therapy per day to be eligible for treatment in an inpatient rehabilitation setting. Inpatient rehabilitation facilities (IRFs) may be freestanding hospitals or specialized, hospital-based units.
  • MedPac: Long-Term Care Hospitals (2014) Patients with chronic critical illness— those who exhibit metabolic, endocrine, physiologic, and immunologic abnormalities that result in profound debilitation and often ongoing respiratory failure—frequently need hospital-level care for relatively extended periods. To qualify as an LTCH for Medicare payment, a facility must meet Medicare’s conditions of participation for acute care hospitals and have an average length of stay greater than 25 days for its Medicare patients.
  • MedPac: Outpatient Hospital Services (2014) Medicare beneficiaries receive a wide range of services in hospital outpatient departments, from injections to complex procedures that require anesthesia. Medicare originally based payments for outpatient care on hospitals’ costs, but the Centers for Medicare & Medicaid Services (CMS) began using the outpatient prospective payment system (OPPS). When CMS began using the OPPS, the new payment system had the potential to substantially reduce hospital payments below the amounts under the cost-based system. In response, the Congress partially protected hospitals that experienced financial losses by providing “transitional corridor” and “hold harmless” provisions.
  • Hospital Emergency Departments: Crowding Continues to Occur, and Some Patients Wait Longer than Recommended Time Frames (GAO 2009) Hospital emergency departments are a major part of the nation’s health care safety net. Of the estimated 119 million visits to U.S. emergency departments in 2006, over 40 percent were paid for by federally-supported programs. The average wait time to see a physician for emergent patients–those patients who should be seen in 1 to 14 minutes–was 37 minutes in 2006, more than twice as long as recommended for their level of urgency.
  • Issues and Challenges Related to How Hospitals Submit Data and How CMS Ensures Data Reliability (GAO 2008) Hospitals submit data on a series of quality measures to the Centers for Medicare & Medicaid Services (CMS) and receive scores on their performance. CMS instituted the Reporting Hospital Quality Data for Annual Payment Update Program (APU program) to collect the quality data from hospitals and report their rates on the measures on its Hospital Compare Web site.
  • Nonprofit Hospital Systems: Survey on Executive Compensation Policies and Practices (GAO 2006) As a part of Congress’s continuing efforts to oversee the activities of the nonprofit sector, it asked us to review executive compensation issues at selected private, nonprofit hospital systems to gain an understanding of the policies and practices related to the salaries, benefits, travel, gifts, and entertainment expenses paid by these hospital systems.
  • Hospital Accreditation: Joint Commission on Accreditation of Healthcare Organizations’ Relationship with Its Affiliate (GAO 2006) GAO was asked to provide information on the relationship between the Joint Commission and JCR. This report describes (1) their organizational relationship, and (2) the significant steps they have taken to prevent the improper sharing of information.
    .
  • Supplemental Compliance Program Guidance for Hospitals (OIG 2005) This document supplements, rather than replaces, the OIG’s 1998 CPG for the hospital industry.
  • Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response (GAO 2003) In the event of a large-scale infectious disease outbreak, as could be seen with a bioterrorist attack, hospitals and their emergency departments would be on the front line. Federal, state, and local officials are concerned, however, that hospitals may not have the capacity to accept and treat a sudden, large increase in the number of patients, as might be seen in a bioterrorist attack.
  • Hospital PPS: How DRG Rates Are Calculated and Updated (OIG 2001) This system is a per-case reimbursement mechanism under which inpatient admission cases are divided into relatively homogeneous categories called diagnosis-related groups (DRGs). In this DRG prospective payment system, Medicare pays hospitals a flat rate per case for inpatient hospital care so that efficient hospitals are rewarded for their efficiency and inefficient hospitals have an incentive to become more efficient.
  • Compliance Program Guidance for Hospitals (OIG 1998) Intended to assist hospitals develop effective internal controls that promote adherence to applicable federal and state law.
  • The Emergency Medical Treatment and Labor Act: Survey of Hospital Emergency Departments (OIG 2001) Almost all directors say they regularly receive information about EMTALA, however, only
    65 percent were aware of the 1998 Interpretive Guidelines and only 27 percent knew of the proposed Advisory Bulletin which had been published in the Federal Register.

  • The Emergency Medical Treatment and Labor Act: The Enforcement Process (OIG 2001) The EMTALA enforcement process is compromised by long delays and inadequate feedback. Timely processing of EMTALA cases is a longstanding problem. Delays have worsened in recent years, despite a decline in dumping cases.
  • Not-for-Profit Hospitals: Conversion Issues Prompt Increased State Oversight (GAO 1997) Reviews the process that some not-for-profit hospitals have used in converting to for-profit status, focusing on: (1) the method used to value assets; (2) the process used to solicit interest and obtain bids; (3) the terms negotiated as part of the sales agreement, including provisions for continued charity care; (4) the extent of community involvement in the process; (5) how the proceeds from the sale were used to fulfill charitable missions; and (6) the role state and federal governments play in regulating and monitoring hospital conversions.
  • Psychiatric Hospital Oversight (GAO 1996) Failure to evaluate a patient’s strengths when developing a treatment plan, specify each patient’s treatment goals, and
    indicate the methods of treatment were the most common deficiencies cited in surveys of psychiatric hospitals that
    failed to satisfy HCFA certification requirements.

  • FHA Hospital Mortgage Insurance Program: Health Care Trends and Portfolio Concentration Could Affect Program Stability (GAO 1996) Pursuant to a legislative requirement, GAO reviewed the Federal Housing Administration’s (FHA) Hospital Mortgage Insurance Program.
  • Medical Liability: Impact on Hospital and Physician Costs Extends Beyond Insurance (GAO 1995) As Congress considers proposals to reduce to tort liability in the health care industry, little consensus exists on the extent to which medical liability-related spending boosts hospital and physician expenditures, a central issue in the debate over health care reform.
  • Health Care: Employers Urge Hospitals to Battle Costs Using Performance Data Systems (GAO 1994) Many large employers have become increasingly concerned about the wide variation in hospital costs across their communities.
  • Hospital Costs: Cost Control Efforts at 17 Texas Hospitals (GAO 1994) This report provides information on how the increased use of managed care may have influenced cost control efforts at 17 urban hospitals in Texas.
  • Hospital Compensation: Nationally Representative Data on Chief
    Executives’ Compensation     (GAO 1994) Hospital-reported data showed that chief
    executives received an average of $129,000 in compensation for overseeing hospital operations in 1991.

  • Hospitals: Chief Executives’ Compensation, 1989-1991
    (GAO 1993) In recent years, the media have scrutinized the high salaries–some approaching $1 million annually–paid to health care executives, in some cases linking them to the rising cost of health care.

  • OIG: Medicare’s Reimbursement for Interpretations of Hospital Emergency Room X-Rays (OIG 1993) According to Section 2020G of the Medicare Carriers Manual (MCM) the service of the radiologist, even if performed after the patient is discharged, almost always constitutes patient care and, thus, would qualify as a physician’s service.
  • Public Health Service’s Oversight of the Hill-Burton Program (OIG 1992) To be eligible for Hil-Burton funds, the applicant had to be a public or not-for-profit entity. The Hil-Burton Act required that the applicant maintain this status for a period of 20 years. These facilties were to make available a reasonable volume of free servces to persons unable to pay (uncompensated care obligation).
  • Office for Civil Rights’ Oversight of the Hill-Burton Program (OIG 1992) Recipients of Hil-Burton grants agree to make available, in perpetuity, the servces offered by the constructed facility to all persons residing in their servce area. This agreement is commonly known as the Hil-Burton community servce obligation and prohibits a facilty from discriminating practices. Such practices include discrimination against patients when providing non-emergency servces and denial of emergency servces to persons unable to pay.
  • Patient Dumping After COBRA: U.S. Department of Health and Human Services Response to Complaints (OIG 1988) This inspection assessed internal procedures for handling complaints of patient dumping. The HHS has jurisdiction concerning patient dumping under two different statutory authorities, the Consolidated Omnibus Budget Reconcilation Act (COBRA) of 1985, and the Hil-Burton Act of 1946. The HCFA and OIG are responsible for enforcing the COBRA provisions, while OCR is responsible for Hil-Burton enforcement in this area.
  • Patient Dumping After COBRA: Assessing the Incidence and the Perspectives of Health Care Professionals (OIG 1988) The purose of this study was to gain additional information and insight into the issue of patient dumping 1 1/2 years after the enactment of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 which prohibited the practice. The inspection sought to determine if objective measurment of the problem of patient dumping could be made using existing reord and if perspectives of health care professionals identified vulnerabilties in the current process of identiyig and reportng alleged cases.
  • Inappropriate Discharges and Transfers (OIG 1986) Based on the findings of this inspection, it apparent that occurrences of premature discharges and inappropriate transfers do exist and must continue to be addressed aggressively by the Health Care Financing Administration (HCFA) and the Peer Review Organizations (PROs).

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