Health Care Reform is a Journey Not an Event

The recent passage of national health care reform legislation is an important milestone in the process of moving toward providing millions of Americans with access to health insurance. However, significant steps must still be taken in order to achieve the goals established in the legislation.

Specifically, greater clarification is needed to determine how reform will be implemented and, just as important, there is the challenge of effectively dealing with the critical issue of affordability. Health plans and providers have received many questions regarding how they will make the necessary changes within their business to help employers and trading partners comply with the new law.

While most answers are still unclear, we have developed initial comments to many of the questions dealing with the 2010 provisions, including:

  • Annual and lifetime limits
  • Pre-existing conditions
  • Employer penalties
  • Dependent coverage
  • Retirement health care benefits
  • Grandfathering
  • Rescissions
  • Wellness
  • Health care business, process, people and technology changes for payor and provider firms:

  • Eligibility
  • Medical coding standard changes (from ICD-9 to ICD-10)
  • Electronic data interchange (EDI) standards (from 4010 to HIPAA 5010)
  • Personal health information (PHI) data security and confidentiality
  • Electronic health records (EHR)
  • Meaningful Use for providers
  • CORE Operating Rules
  • Changes in Medical Loss Ratio Requirements
  • Cross impacts of different regulatory requirements. i.e. the impact of ICD-10 on meaningful use and EHR standards
  • Potential changes in risk analysis with changes in coverage requirements and population stratification due to coverage rules and ICD-10 definition of population categories of health
  • The impact changes in trending patterns as a result of many requirements simultaneously and identifying trend change causes the impact of the measurement of quality and efficiency in terms of reporting requirements and measurement specification changes.
  • Health Information Exchanges (HIE) and other data exchange requirements/standards
  • Comparative effectiveness research issues around quality of care.
  • We will cover these topics in subsequent releases of our blog. We will continue to monitor the detailed discussions during the lengthy implementation process.  Our focus will be on taking the time to make sure we help our clients get the implementation of reform right and addressing the most significant issue facing our industry – affordability.

    It is important to remember that most of the provisions in the legislation will not go into effect until 2014 or later.  The details of implementing legislation can take months, even years to work through the regulatory process.  Much of what Congress has passed will require additional regulations to bring further clarity to this new law, and those regulations will truly shape the impact on consumers and employers.

    Michael F. Arrigo

    Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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