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 Arrigo brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health IT, and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations who provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and medical billing, fraud damages, as well as electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, medical malpractice, insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software SA (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls IT audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and is published in Healthcare IT News.

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