Mind your marketing p's and q's
August 1, 1998 2 minutes read
Mind your marketing p's and q's
PSOs particularly subject to marketing conflicts
The Health Care Financing Administra tion's proposed Medicare+Choice regulations essentially mirror current Medicare rules prohibiting practice groups from giving patient participants cash or other monetary inducements to enroll in their plan.
However, "the marketing rules do not appear to address the issue of how providers who are owners or members of the provider-sponsored organization can conduct marketing, and to what extent the current Medicare managed care marketing guidelines remain applicable," notes Wendy Krasner, JD, with McDermott, Will and Emery in Washington, DC.
Risk higher when providers are owners
Because of the unique status of provider-sponsored organizations, in which providers are also owners of the health care plan, they may run a higher risk of having affiliated providers accused of improperly steering healthier patients to enroll in their plan until HCFA issues more precise guidelines on allowable provider marketing activities.
A critical requirement of the proposed rule is that a plan's chief executive officer or chief financial officer must certify that every one of the beneficiaries has been legally enrolled in a Medicare+Choice plan offered by the organization, and that the information that HCFA uses to determine their payment is accurate.
The downside is if there is just one invalid enrollee, then HCFA could declare this certification to be a false statement subject to the False Claims Act - in other words, a major compliance violation.
What constitutes a 'claim'?
Here is another wrinkle to this requirement: Before now, the False Claims Act has never been applied to HMO reimbursements because they have not been considered to be claims payments.
Because of the potential financial liability of capitated HMO payments being subjected to scrutiny under the False Claims Act, look for managed care plans to try to redefine which data have to be certified, as well as what is considered a "claim" under the Medicare+ Choice program.
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