health centers |

$100,000 Penalty Warning To Fulfill HIPAA Access Requirements

November 21, 2024

The $100,000 penalty paid by a mental health facility alerts health plans, health care providers and health care clearinghouses (“covered entities”) to the perils of failing to timely deliver health records access as required by the Health Insurance Portability and Accountability Act (“HIPAA”).

The $100,000 civil monetary penalty against California mental health provider Rio Hondo Community Mental Health Center (“Rio Hondo”) announced by the U.S. Department of Health and Human Services (“HHS”) Office for Civil Rights (“OCR”) on October 19, 202 is the fifty-first OCR enforcement action under its HIPAA Right of Access enforcement initiative.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rules’ right of access provisions generally require covered entities to provide individuals access to their protected health information within 30 days, with the possibility of one 30-day extension and prohibits charging more than a reasonable, cost-based fee for this access.

The penalty against Rio Hondo resolves an OCR investigation into Rio Hondo over a failure to provide a patient with timely access to their medical records. OCR enforces the right of access and other requirements of the HIPAA Privacy Rule.

OCR launched an investigation after receiving a complaint from a patient that Rio Hondo did not provide timely access to their medical records, despite multiple requests in writing and by telephone.

OCR’s investigation found that it took nearly seven months from the time the patient first requested the records until Rio Hondo provided them.

The patient made multiple telephone calls in July and August 2020, regarding the status of her request, but still did not receive the requested records until it produced the records in response to the investigation.

The late delivery of the records access did not end the enforcement action. Based on the facts, OCR found that Rio Hondo failed to take timely action in response to the patient’s right of access in accordance with the HIPAA Privacy Rule.

In July 2024, OCR issued a Notice of Proposed Determination to impose a $100,000 civil monetary penalty. After Rio Hondo waived its right to a hearing and did not contest the findings of OCR’s Notice of Proposed Determination, OCR issued a Notice of Final Determination imposing the penalty.

OCR’s announcement of the penalty includes a strong warning to other covered entities to comply with HIPAA’s access requirements. It quotes OCR Director Melanie Fontes Rainer. As stating:

Ensuring patients’ rights to timely access to medical information continues to be a HIPAA enforcement priority. Healthcare providers are legally obligated to provide patients with timely access to their medical records. If they fail to provide that access, OCR will not hesitate to do everything in its power, including imposing civil monetary penalties, to ensure compliance with the law.”

While this penalty applied to a health care provider, health plans also are required to comply with the right of access rules.

With OCR promising to continue to prioritize enforcement, all covered entities should take documented steps to confirm the adequacy of their existing processes to ensure compliance with OCR’s Right of Access guidance and other applicable federal and state legal and ethical requirements like the Employee Retirement Income Security Act (“ERISA”) claims and appeals and Patient Protection and Affordable Care Act (“ACA”) adverse benefit procedures applicable to health plans and State ethical and statutory medical records delivery requirements applicable to providers. Health care providers also should consider including processes for tracking and monitoring access requests in these processes that provide for review every 30 days.Covered entities should keep records of these efforts for the six-year period required by HIPAA’s record retention rules.

Covered entities that receive follow up access requests or otherwise discover a potential failure to timely provide access should engage a HIPAA knowledgeable attorney for help and advice. Obviously, covered entities should correct any oversight promptly by delivering the records access. However legal counsel can assist by helping the covered entity assess if a violation actually occurred, avoid added violations or inflammatory communications or actions that could enhance exposures to complaints or penalties and suggest actions to help mitigate risks of an OCR investigation and penalties. For instance, past enforcement actions suggest a covered entity should consider foregoing requiring payment of charges HIPAA otherwise might allow for the records access to avoid further delay of access that could heighten penalty exposures. Covered entities also should document their delivery of access and their investigation and corrective actions addressing the source of the compliance failure.

The author of this update, Cynthia Marcotte Stamer has worked extensively with health plans on HIPAA, ERISA, the ACA on these and other HIPAA and other compliance and risk management. If you have questions or need advice or help evaluating or addressing your HIPAA compliance or other concerns, contact her.

For More Information

We hope this update is helpful. For more information about the or other health or other employee benefits, human resources, or health care developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452-8297.

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for her more than 35 years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications including leading edge work on PBM, pharmacy and pharmaceutical and other health care, managed care, insurance, and insured and self-insured contracting, design, administration and regulation..

Author of numerous highly regarded works on PBM and other health plan contracting and design, Immediate Past Chair of the ABA International Section Life Sciences Committee and the Tort Trial and Insurance Practice Section Medicine and Law Committee, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group and past Group Chair and current Welfare Benefit Committee Co-Chair of the ABA RPTE Employee Benefits & Other Compensation Group, Ms. Stamer is most widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health and other privacy and data security and other health industry legal, public policy and operational concerns.

Ms. Stamer’s work throughout her career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with HIPAA and other legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns.

As a part of this work, she has continuously and extensively worked with domestic and international health plans, their sponsors, fiduciaries, administrators, and insurers; managed care and insurance organizations; third party administrators and other health benefit service providers; hospitals, health care systems and other health care providers, accreditation, peer review and quality committees and organizations; billing, utilization management, management services organizations, group purchasing organizations; pharmaceutical, pharmacy, and prescription benefit management and organizations; consultants; investors; EMR, claims, payroll and other technology, billing and reimbursement and other services and product vendors; products and solutions consultants and developers; investors; managed care organizations, self-insured health and other employee benefit plans, their sponsors, fiduciaries, administrators and service providers, insurers and other payers, health industry advocacy and other service providers and groups and other health and managed care industry clients as well as federal and state legislative, regulatory, investigatory and enforcement bodies and agencies.

Author of many highly regarded compliance, training and other resources on HIPAA and other risk management and compliance, Ms. Stamer is widely recognized for her thought leadership on HIPAA and many other health care, health plan and other health industry matters.

In addition, Ms. Stamer serves as a Scribe for the American Bar Association (“ABA”) Joint Committee on Employee Benefits annual agency meetings with OCR and shares her thought leadership as International Section Life Sciences Committee Vice Chair, and a former Council Representative, Past Chair of the ABA Managed Care & Insurance Interest Group, former Vice President and Executive Director of the North Texas Health Care Compliance Professionals Association, past Board President of Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency, past North Texas United Way Long Range Planning Committee Member, and past Board Member and Compliance Chair of the National Kidney Foundation of North Texas, and a Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also shares her extensive publications and thought leadership as well as leadership involvement in a broad range of other professional and civic organizations.

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general information and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation considering the specific facts and circumstances presented in their unique circumstance at the particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author reserves the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law constantly and often rapidly evolves, subsequent developments that could impact the currency and completeness of this discussion are likely. The author and Solutions Law Press, Inc. disclaim and have no responsibility to provide any update or otherwise notify anyone of any fact or law specific nuance, change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication.

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2024 Cynthia Marcotte Stamer. Non-exclusive right to republish granted to Solutions Law Press, Inc.™ For information about republication, please contact the author directly. All other rights reserved.

Comments Off on $100,000 Penalty Warning To Fulfill HIPAA Access Requirements | ACA, Association Health Plan, Brokers, Claims, Claims Administration, Corporate Compliance, corporate governance, Electronic Medical Record, Employee Benefits, enforcement, ERISA, Fiduciary Responsibility, health benefit, Health Benefits, health Care, health centers, health insurance, health insurance marketplace, Health IT, health plan, Health Plans, HIPAA, Human Resources, Managed Care | Permalink
Posted by Cynthia Marcotte Stamer

Children’s Hospital Pays $45K To Resolve COVID Vaccine Religious Discrimination Suit

December 22, 2023

Pandemic’s End Doesn’t End COVID-19 Employer Headaches

Children’s Healthcare of Atlanta, Inc. (“CHOA”) is paying $45,000 to settle a religious discrimination lawsuit arising from its failure to grant a religious exemption from its COVID-19 vaccination requirements for a maintenance worker. The lawsuit highlights the continuing importance of all employers to use care when handling request for religious accommodation to vaccine or other workplace requirements.

The lawsuit filed by the U.S. Equal Employment Opportunity Commission (“EEOC”) arises from the 2019 denial of a request for a religious exemption to CHOA’s COVID-19 vaccine mandate made by a maintenance worker. CHOA previously had granted the same employee a religious exemption for vaccine mandates in 2017 and 2018. In 2019, however, CHOA denied the employee’s request for a religious accommodation and fired him, despite the employee working primarily outside and his position requiring limited interaction with the public or staff the EEOC said.

The EEOC alleged the denial of the vaccine exemption violated Title VII of the Civil Rights Act of 1964, which prohibits firing an employee because of their religion and requires that employers reasonably accommodate the sincerely held religious beliefs of their employees.

Under the consent degree entered in Ciil Action No. 1:22-CV-04953-MLB-RDC in U.S. District Court for the Northern District of Georgia, CHOA will pay $45,000 in monetary damages to the former employee. CHOA will also adjust its influenza vaccine religious exemption policy to presume the exemption eligibility of employees with remote workstations or who otherwise work away from the presence of other employees or patients, and to protect the ability of such employees to seek alternative positions within CHOA if their religious exemption request is denied. The decree further provides that CHOA will train relevant employees on religious accommodation rights under Title VII.

The EEOC announcement of the consent degree alerts employers of the continuing need to use care when handling religious accommodation requests to vaccine or other workplace policies. “ It is the responsibility of an employer to accommodate its employees’ sincerely held religious beliefs,” the announcement quotes Marcus G. Keegan, the regional attorney for the EEOC’s Atlanta District Office. “Unless doing so would require more than a minimal cost, an employer may not deny requested religious accommodations, let alone revoke those previously granted without issue. The EEOC is pleased that the employee has been compensated and that CHOA has agreed to take steps to ensure that it meets its obligation to evaluate religious accommodation requests in a manner consistent with federal law.”

Likewise, the announcement quotes Darrell Graham, district director of the Atlanta office, as saying , “The arbitrary denial of religious accommodations drives religious discrimination in the workplace. The EEOC remains committed to enforcing the laws that protect employees’ religious practices.”

CHOA’s denial of the exemption happened at the height of the COVID-19 pandemic. Federal COVID – 19 vaccination mandates now are all ended. While federal mandates initially dictated COVID-19 vaccination as a condition of participation in Medicare by healthcare providers, for government contractors and others, the original mandates were quickly revised to include religious exemption requirements before court rules, agency action and the end of the Pandemic put an end to these mandates. During and after the federal mandates, however, employers were required to negotiate a minefield of competing concerns and potential liabilities when deciding what and how to mandate and enforce safety, leave and other rules without running afoul of employment discrimination and whistleblower claims. See, e.g., EEOC COVID Guidance, Enforcement Highlights Need To Brace For COVID-Related ADA & Other Claims; Texas Private Employer COVID-19 Vaccination Mandates Prohibited Effective February 6, 2024; IRS Warns Of Fraudulent Promotion of COVID Employee Retention Credits; OSHA Enforces Whistleblower Rights Of Worker Terminated For Expressing COVID-19 Safety Concerns; Biden-⁠Harris Administration Ending COVID-⁠19 Vaccination Requirements For Federal Employees, Contractors, International Travelers, Head Start Educators & CMS-Certified Facilities; SCOTUS To Hear Oral Arguments on OSHA COVID-19 Vaccination Rule Enforceability On January 7; COVID-19 Vaccination Rule Injunctions Leave Employers With Significant Liability Challenges Even As OSHA Extends Comment Period on OSHA COVID-19 Vaccine ETS; Manage Heightened Retaliation Exposures Arising From COVID-19 Safety, Return-To-Work & Other Practices

While the federal COVID-19 vaccine mandate is gone, many healthcare and other employers continue to impose mandate requirements with appropriate disability and religious exemptions as part of their workplace safety and patient safety protocols. Additionally, beyond the Covid – 19 vaccination protocols, many workplace vaccination and other rules also can create conflicts with certain religious beliefs that prompt religious accommodation requests.

Employers administering these vaccination, and other policies must keep in mind that the duty to offer religious accommodation and the EEOC emphasis on enforcing accommodation rights for workers whose deeply held religious beliefs conflict with workplace rules lives on. The perils remain, even if the requirement is supported by well, established patient or workplace safety protocols. Employers need to evaluate and be prepared to defend their inability to accommodate the safety and other concerns underlying the workplace mandate against a potential religious discrimination challenge.

Employers must remain diligent in their management of responses to request for accommodations keeping in mind that EEOC COVID-19 – era guidance imposes a heavy burden on an employer to justify its refusal of a request. For this reason, employers that receive a request for religious of accommodation from an employee should seek the advice of experienced legal counsel as soon as possible if any question exists about whether the employer will grant the request. Employers also should ensure their policies clearly communicate the availability of religious and disability accommodation from these other requirements, establish clear protocols for requesting and processing those requests and prohibit and prevent retaliation.

To promote defensibility, employers also should consult with experienced legal counsel about the use of attorney, client, privilege, and other protocols to prevent or minimize the risk that discussions and actions in response to, or following a request for accommodation creates evidence of discrimination or retaliation.

For More Information

We hope this update is helpful. For more information about these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297.

Solutions Law Press, Inc. invites you to receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 35 plus years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

A Fellow in the American College of Employee Benefit Counsel, Co-Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee and Vice-Chair Elect of its International Employment Law Committee, Chair-Elect of the ABA TIPS Section Medicine & Law Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, and Chair of the ABA Intellectual Property Section Law Practice Management Committee, Ms. Stamer is most widely recognized for her decades of pragmatic, leading-edge work, scholarship and thought leadership on heath benefit and other healthcare and life science, managed care and insurance and other workforce and staffing, employee benefits, safety, contracting, quality assurance, compliance and risk management, and other legal, public policy and operational concerns in the healthcare and life sciences, employee benefits, managed care and insurance, technology and other related industries. At her career, she has worked extensively with healthcare and other employers to manage discrimination and other workplace and employee benefit compliance and risks. She speaks and publishes extensively on these and other related compliance issues.

Ms. Stamer’s work throughout her career has focused heavily on working with health care and managed care, life sciences, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. Scribe for the ABA JCEB Annual Meeting with the HHS Office of Civil Rights, her experience includes extensive involvement throughout her career in advising health care and life sciences and other clients about preventing, investigating and defending EEOC, DOJ, OFCCP and other Civil Rights Act, Section 1557 and other HHS, HUD, banking, and other federal and state discrimination investigations, audits, lawsuits and other enforcement actions as well as advocacy before Congress and regulators regarding federal and state equal opportunity, equity and other laws.

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested in reviewing some of our other Solutions Law Press, Inc.™ resources available here such as:

IMPORTANT NOTICE ABOUT THIS COMMUNICATION

NOTICE: These statements and materials are for general informational and educational purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstances at any particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author and Solutions Law Press, Inc.™ reserve the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving and rapidly evolving rules make it highly likely that subsequent developments could impact the currency and completeness of this discussion. The author and Solutions Law Press, Inc.™ disclaim, and have no responsibility to provide any update or otherwise notify anyone of any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access to this publication.

Comments Off on Children’s Hospital Pays $45K To Resolve COVID Vaccine Religious Discrimination Suit | Academic Medicine, Accommodation, ADA, Affirmative Action, board of directors, Corporate Compliance, corporate governance, COVID-19, Disability, Disability Discrimination, Discrimination, Diversity, EEOC, employee, Employee Benefits, Employee Handbook, Employer, Employers, Employment, Employment Discrimination, Employment Policies, Employment Termination, health Care, health centers, health plan, Health Plans, HR, Human Resources, Insurance, insurers, Internal Controls, Internal Investigations, Managed Care, religious accommodation, Religious Organization, Religous Discrimination, Risk Management, Worker, Workforce | Tagged: COVID, Health Care, religious accommodation, vaccine mandates | Permalink
Posted by Cynthia Marcotte Stamer

Prepare Feedback! Tri-Agencies Plan To Reopen Surprise Billing Proposed Dispute Resolution Rule Comment Period

December 22, 2023

Got issues with the most recent articulation of the proposed rule on “Federal Independent Dispute Resolution (IDR) Operations” (“Rule”) that governs the independent dispute resolution process for resolving to disputes over out-of-network claims between health plans and heath care providers under the No Surprises Act?

The Departments of Health and Human Services, Labor, and the Treasury (the “Departments”) and the Office of Personnel Management intend to reopen the comment period for submitting comments on the proposed rule “Federal Independent Dispute Resolution (IDR) Operations.”

The announced plan to reopen the comment period on the Proposed Rule follows the Departments’ recent reopening of the dispute resolution portal and announcement of a $115 user fee for providers and health plans participating in the process beginning in February. See No Surprises Act Independent Dispute Resolution Portal Fully Reopened, New Fees Announced; No Surprises Act Dispute Resolution Portal For All Covered Health Claims

Concerned persons should begin preparing comments to submit while awaiting the Departments publication of official notice in the Federal Register of the reopening of the comment period.

For More Information

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 35 plus years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

A Fellow in the American College of Employee Benefit Counsel, Co-Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee and Vice-Chair Elect of its International Employment Law Committee, Chair-Elect of the ABA TIPS Section Medicine & Law Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, and Chair of the ABA Intellectual Property Section Law Practice Management Committee, Ms. Stamer is most widely recognized for her decades of pragmatic, leading-edge work, scholarship and thought leadership on heath benefit and other healthcare and life science, managed care and insurance and other workforce and staffing, employee benefits, safety, contracting, quality assurance, compliance and risk management, and other legal, public policy and operational concerns in the healthcare and life sciences, employee benefits, managed care and insurance, technology and other related industries. She speaks and publishes extensively on these and other related compliance issues.

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested in reviewing some of our other Solutions Law Press, Inc.™ resources available here such as:

Comments Off on Prepare Feedback! Tri-Agencies Plan To Reopen Surprise Billing Proposed Dispute Resolution Rule Comment Period | compliance, Corporate Compliance, EBSA, Employee Benefits, Employer, Employers, ERISA, Excise Tax, fiduciary duty, Fiduciary Responsibility, health Care, health care transparency, health centers, health insurance, health insurance marketplace, Health IT, health plan, Health Plans, health reform, HR, Human Resources, Insurance, insurers, Internal Revenue Code, Managed Care, self insured health plan, Surprise Billing, third party administrators | Permalink
Posted by Cynthia Marcotte Stamer

Annual Review of Proposed Medicare Quality Measures Excellent Opportunity For Insight, Input on What Health Care Quality Means

September 15, 2022

Employer and other health plan sponsors, fiduciaries and plan members hear a lot about about health care quality and its measures. However few understand what the quality data and ratings relied upon by health plans, Medicare or Medicaid, accreditation agencies or others making assertions about health care quality or how that data is measured.

While quality measures and meanings take many forms, one key measure used by Medicare, Medicaid and many other health plans, lawmakers, health quality commentators and others evaluating health care provider “quality” is the Department of Health and Human Services Office of the National Coordinator for Healthcare Information (“ONC”) electronic clinical quality measures (“eCQMs”) that the Centers for Medicare & Medicaid Services (“CMS”) requires many health care providers participating in Medicare or Medicaid to report for purposes of program participation and reimbursement.

eCQMs As Measure of HealthCare Quality

Electronic clinical quality measures or “eCQMs” are tools that ONC develops with stakeholder input to help Medicare and Medicaid measure and track the quality of health care services that eligible hospitals and critical access hospitals (CAHs) provide, as generated by a provider’s electronic health record (EHR). CMS Measuring and reporting eCQMs helps to ensure that our health care system is delivering effective, safe, efficient, patient-centered, equitable, and timely care. CMS’ eCQMs measure many aspects of patient care, including:

Patient and Family Engagement
Patient Safety
Care Coordination
Population/Public Health
Efficient Use of Healthcare Resources
Clinical Process/Effectiveness

To successfully participate in the Medicare and Medicaid Promoting Interoperability Programs, the Centers for Medicare and Medicaid Services (“CMS”) requires eligible providers, eligible hospitals, critical access hospitals and dual-eligible hospitals electronically to report on eCQMs determined by CMS that require the use of data from the provider’s certified electronic health record (“EHR”) technology (CEHRT) or other health information technology systems to measure and report quality measures in a standardized manner. For calendar year (CY) 2022, Medicare Promoting Interoperability Program participants arerequired to report on three self-selected eCQMs and the Safe Use of Opioids – Concurrent PrescribingeCQM from the set of nine available for at least three self-selected quarters of CY 2022 data. To report eCQMs successfully, health care providers must use an EHR and adhere to the requirements identified by the CMS quality program. Failing to meet these eCQM reporting requirements can prevent the provider from meeting meaningful use requirements and trigger reductions in reimbursements for care.

Health care quality, credentialing, accreditation, and other provider, health plan and other organizations also use the eCQMs data alone or with other quality measures and tools to set standards and assess and enforce quality goals and performances.

2022 eCQMs Updates

Each year, CMS makes updates to the eCQMs approved for CMS programs to reflect changes in:

Evidence-based Medicine
Code Sets
Measure Logic

Conducted annually as part of OCN’s eCQM Issue Tracker project, the CRP provides eCQM users the opportunity to review and comment on draft changes to the eCQM specifications and supporting resources under consideration by the measure stewards. The goal of the CRP is for eCQM implementers to comment on the potential impact of draft changes to eCQMs so CMS and measure stewards can make improvements to meet CMS’s intent of minimizing provider and vendor burden in the collection, capture, calculation, and reporting of eCQMs.

Every Fall, health care providers, health plans and insurers and other stakeholders concerned about these eCQMs have the opportunity to review and comment on draft changes to the eCQM specifications and supporting resources under consideration by ONC as part of ONC’s 2022 Change Review Process (CRP) for the ONC Project Tracking System. Interested stakeholders must monitor the posting of issues and act quickly to share their feedback, however, as stakeholders have only two weeks to comment after a ONC posts a new proposed eCQm change.

Stakeholders with an account on the ONC Project Tracking System can monitor, review and comment on proposed eCQM changes through the eCQM Issue Tracker project during the two week period following the date the issue is posted in the eCQM Issue Tracker. To participate in the CRP, users must have an ONC Project Tracking System account. New users can create an account via the ONC Project Tracking System website.

The following table reflects the eCQM issues open on the eCQM Issue Tracker as of September 14, 2022 and their scheduled comment closing dates

Issues Open for Public Comment As of 9/14/2022

CMS eCQM Identifier and Measure Title	CRP Issue Title	Issue Number and Link	Issue Type	Goal of Review	Public Comment Open Date	Public Comment Close Date
Multiple measures	Incorporate ‘Diagnosis’ datatype to capture Hospice Care	CQM-5561	Logic; Value Set	Obtain clinical and technical feedback	09/07/2022	09/21/2022
CMS128: Anti-depressant Medication Management; CMS136: Follow-Up Care for Children Prescribed ADHD Medication (ADD); CMS156: Use of High-Risk Medications in Older Adults	Update Cumulative Medication Duration function to calculate maximum daily frequency	CQM-5562	Logic	Obtain technical feedback	09/07/2022	09/21/2022
Multiple measures	Expand codes using ‘Diagnosis’ datatype to capture Palliative Care	CQM-5563	Logic; Value Set	Obtain clinical and technical feedback	09/07/2022	09/21/2022
Multiple measures	Require 2 indications of frailty to meet exclusion	CQM-5564	Header; Logic; Measure Intent Clarification	Obtain clinical feedback	09/07/2022	09/21/2022
CMS127: Pneumococcal Vaccination Status for Older Adults	Expand numerator to allow for pneumococcal vaccination since 19 years of age	CQM-5565	Header; Logic; Measure Intent Clarification	Obtain clinical feedback	09/07/2022	09/21/2022

eCQM Issue Tracker Open Issues As Of September 14, 2022

As proposed eCQM changes are posted for public comment as CRP issues. ONC informs eCQM accountholders of the proposed change or eCQM issue by posting for review in the ONC Project Tracking System. Accountholders only have two weeks after ONC posts a proposed eCQM to comment on the posted issue. Stakeholders interested in commenting on a particular issue must submit their comment in accordance with the directions within this two week period.

Depending on the nature of the proposed change, the proposed changing could impact the meaning, or significance of a eCQM by changing the way it is measured, the level or reporting or other aspects of the data and its magnitude. Consequently, understanding both what a eCQM measures and how that measurement is made and reported is important both to understand what actually is measured and to distinguish between changes in the measure resulting from a change in the actual delivery of the care the measure purports to measure versus changes in the result impacted by changes in measurement or reporting. For this reason, employer and other health plan sponsors, fiduciaries, insurers, administrators and other impacted stakeholders should use care to critically evaluate the eCQM and othe quality claims armed with a clear understanding both of the elements of the measurement and of any changes made to the measures across time that could influence the reported data and its significance in measuring and reporting quality and quality trends.

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297.