CMS Issues Final Medicare Inpatient Psychiatric Facility PPS Rule for FY 2015

CMS has published a final rule that updates prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs) for FY 2015. Under the final rule, the federal per diem base rate will be increased by 2.1%, reflecting a market basket increase of 2.9%, offset by a 0.3 percentage point reduction and a productivity adjustment reduction of 0.5 percentage points (both reductions were mandated by the ACA). CMS also anticipates that the final update to the outlier fixed-dollar loss threshold amount will provide an additional 0.4% boost in overall payments to IPFs. In light of all payment policies, CMS estimates that total payments to IPFs under the final rule will increase by $120 million (2.5%) compared to FY 2014 payments. The final rule also, among other things, establishes a new methodology for updating the cost of living adjustment (consistent with the inpatient hospital methodology), expands quality measures under the IPF Quality Reporting Program, adopts coding changes related to comorbidity categories and unspecified codes, and discusses CMS’s future plans to propose an IPF-specific market basket. The final rule was published August 6, 2014.

Medicare Intravenous Immune Globulin (IVIG) Demonstration Launched

CMS has announced a new “Medicare Intravenous Immune Globulin (IVIG) Demonstration” that will evaluate the potential benefits of providing payment for items and services needed for in-home administration of IVIG for the treatment of primary immune deficiency disease (PIDD). Under this demonstration, which will last three years, Medicare will provide a bundled Part B payment for items and services that are necessary to administer IVIG in the home to enrolled beneficiaries who are not otherwise homebound and receiving home health care benefits. The demonstration only applies to situations where the beneficiary requires IVIG for the treatment of PIDD, or is currently receiving subcutaneous immune globulin to treat PIDD and wants to switch to IVIG. The demonstration is limited to 4,000 Medicare beneficiaries nationwide, and the statute authorizes up to $45 million to pay for services and administrative costs. Beneficiaries who want to participate in the demonstration must submit an application signed by the beneficiary and his or her physician and meet specified eligibility requirements. The initial enrollment period ends on September 12, 2014; applications received after that date will be considered on a space-available basis only. Services will be covered under the demonstration beginning October 1, 2014.

MedPAC Issues Medicare Delivery Reform Recommendations

On June 13, 2014, the Medicare Payment Advisory Commission (MedPAC) released its June 2014 Report to the Congress on Medicare and the Health Care Delivery System. Among other things, MedPAC addresses ways to align Medicare fee-for-service (FFS), Medicare Advantage, and accountable care organization policies on payment, risk adjustment, and quality measurement. MedPAC also discusses various FFS reforms, including post-acute care reforms to promote payment consistency across settings and bonus payments to support primary care. Finally, MedPAC discusses changing income eligibility standards for the Medicare Savings Programs to help low-income Medicare beneficiaries afford out-of-pocket costs, and it examines the impact of medication adherence on health spending. 

OIG Proposed Rule Would Expand Civil Monetary Penalty Authority

On the heels of its proposed rule to expand its health program exclusion authority, the Office of Inspector General (OIG) of the Department of Health and Human Services has published a proposed rule that would amend the health care program civil monetary penalty (CMP) regulations. The rule would codify the OIG’s expanded statutory authority under the Affordable Care Act to impose CMPs on providers and suppliers and would allow for significant penalties in a variety of scenarios, some of which could extend beyond what is currently permitted.

Reed Smith attorneys have prepared a Client Alert summarizing and analyzing the OIG’s proposed rule, including the various scenarios under which CMPs could be issued under the proposed regulations, such as: failure to report and return an overpayment; failure to grant OIG timely access to records upon request; ordering or prescribing items or services while excluded from a federal health care program, as well as arranging or contracting with an individual or entity who meets this criteria; making false statements or omitting or misrepresenting material facts in an application, bid, or contract; and failing to submit or certify drug-pricing and product information in a timely manner. In addition, the alert covers the changes in technical language proposed by OIG to clarify and more clearly define the scope of CMP regulations.

The Client Alert is available here.

Highlights from Reed Smith's Post-Acute Care Conference

In early April, Reed Smith hosted an enlightening, industry-leading conference on post-acute care in Washington, D.C. The conference, entitled “Reed Smith 2014 Washington Health Care Conference: Focus on Post-Acute Care," brought together a panel of experts to discuss episodic care, bundling models, and alternative payment and delivery systems. The conference also featured other speakers who presented from the perspective of investors and Capitol Hill, along with a keynote address from American Enterprise Institute resident scholar Dr. Norman Ornstein.

Policy Discussion on Payment Models

The conference started with a panel discussing bundling initiatives and other alternative payment models. The panel featured Barbara Gage, Ph.D., Fellow and Managing Director of Engelberg Center for Health Care Reform at the Brookings Institution; Judy Feder, Ph.D., Professor at Georgetown University; Vincent Mor, Ph.D., Professor at Brown University School of Medicine; and James Michel, Director for Medicare Research & Reimbursement at the American Health Care Association (“AHCA”). The panel brought with them decades of experience in health care policy and research, and a deep knowledge of post-acute care providers’ current reimbursement systems, in addition to models expected to reform payment for post-acute services in the future.

Dr. Gage spoke first, and introduced bundling by discussing the triple aim adopted by the Centers for Medicare & Medicaid Services (“CMS”): achieve better care for patients, better communities’ health, and lower costs by improving the health care system. She explained how new payment models—including bundled payment initiatives and accountable care organizations—strive to accomplish the above-mentioned triple aim. Gage discussed whether the post-acute setting in which a patient receives treatment distinguishes the patient’s outcome and the level of resources that different post-acute settings (e.g., home health, skilled nursing facilities (“SNF”), inpatient rehabilitation facilities (“IRF”), or long-term acute care hospitals (“LTCH”)) furnish to patients. Gage described in great detail the arguments in favor of bundled payments, emphasizing that one of the benefits of a bundled payment model is that it forces communication across all care settings.

Dr. Feder, on the other hand, urged caution as reimbursement moves to new models. She stressed that bundled payment models, for example, create powerful incentives to potentially reduce or limit the care furnished to patients, and therefore could result in reduced quality of care. Feder explained that bundling is not new, and that, e.g., payers have bundled in the inpatient hospital setting for 30 years. Feder pointed out that when Medicare implemented diagnosis-related groups in the inpatient hospital prospective payment system, hospital length of stay “dropp[ed] like a stone.” Feder underscored that the biggest challenges arise from patients whose health is deteriorating, and explained that the number of home health visits, for instance, are the lowest when patient acuity is the highest. In order to ensure adequate, appropriate, and high-quality care for patients, Feder suggested that policymakers thoughtfully develop and implement any new payment system over time, and incorporate quality mechanisms that serve to protect patients. Feder suggested that good patient data and strong accountability measures are essential to any bundled payment program.

After Feder spoke, Dr. Mor took the podium and analogized capitation versus fee-for-service as being “between the devil and the deep blue sea.” He further explained that fee-for-service reimbursement models have encouraged runaway costs and increased utilization, and that there is a lack of provider accountability and responsibility. In contrast, he explained that in capitation reimbursement models, there is an inherent incentive to deny care. Mor discussed how policymakers can ensure patients receive quality care from providers, and raised a number of thought-provoking questions, such as whether a SNF or other post-acute provider should be responsible for rehospitalization after the discharge of a patient, and whether low rehospitalization reflects overall high-quality care. Mor urged the development of a common assessment tool that includes hospital assessment data in order to more accurately measure post-acute quality and case-mix. He also recommended that CMS use the “Welcome to Medicare” assessment and other periodic beneficiary assessments to obtain risk profiles for patients. Mor ended his presentation by suggesting that while capitation models—such as bundling—are preferable to fee-for-service because one entity is responsible for patients’ care, capitation models face challenges as well, including how to properly measure case-mix and outcomes.

James Michel from AHCA noted the operational challenges associated with bundled payments. For example, it is difficult for post-acute providers to assume the responsibility for patients after the post-acute provider discharges a given beneficiary. Michel also stated that the Center for Medicare & Medicaid Innovation Bundled Payments for Care Improvement initiative’s models incentivize low-cost providers to participate, but providers who recognize they have higher costs than the community average will not participate because of the risk that they will miss the spending target, resulting in a payment to the government. Michel noted that AHCA has developed its own bundled payment proposal, in part to preserve a process in which patients and their families can decide where the patient should be treated after an acute stay. The AHCA bundled payment proposal includes four proposed episodes (e.g., major respiratory condition and septicemia) that would account for approximately 60 percent of all SNF care and more than 50 percent of all post-acute care.

Wall Street Perspective

Jay Barnes, a Senior Vice President for Healthcare Investment Banking at Jefferies, LLC, spoke from the Wall Street perspective, addressing the current appetite for deals in the post-acute space. He described a tepid outlook for post-acute investment stemming from the uncertainty of the future payment models and the changing regulatory landscape, particularly with regard to LTCHs. He informed attendees that the private equity market has been non-existent in the post-acute space because it is challenging to create projection models when future reimbursement for post-acute care remains murky. He explained that the post-acute transactions occurring are largely driven by real estate. For example, Barnes described the recently announced Emeritus Senior Living and Brookdale Senior Living merger as driven by real estate.

Congressional Activity

Cate McCanless, Senior Policy Analyst at Brownstein Hyatt Farber Schreck, provided an insightful overview of Medicare activity on Capitol Hill. She explained that Congress has focused on post-acute care because of the perceived “comfortable” margins achieved by post-acute providers (according to the Medicare Payment Advisory Commission). McCanless also described the outlook for the discussion draft of the Improving Medicare Post-Acute Care Transformation (“IMPACT”) Act of 2014, released by the House Ways and Means Committee Chairman Dave Camp (R-Mich.) and Ranking Member Sandy Levin (D-Mich.), along with Senate Finance Committee Chairman Ron Wyden (D-Ore.) and Ranking Member Orrin Hatch (R-Utah), March 18, 2014. The IMPACT Act draft includes one measure discussed by Mor during the bundling panel: the reporting of common data across post-acute providers, and the required reporting by acute-care hospitals of patient assessment data gathered in advance of discharge. McCanless also explained that while there has been some Congressional momentum in eliminating Medicare's sustainable growth-rate (“SGR”) formula in order to move to an alternative payment model, such momentum may lose steam this year now that a temporary patch has been enacted, because eliminating the SGR would be expensive, and it is an election year. McCanless pointed out certain post-acute policy proposals that would result in cost savings, such as reducing the SNF payment update by 1.1 percent, which would save an estimated $12 billion, and equalizing certain payments for SNFs and IRFs, which would save an estimated $1 billion; these provisions could be targets for offsets for future Medicare reforms.

Impact of Political Polarization on Health Policy

Dr. Norman Ornstein, noted observer of Congress and politics, and keynote speaker at Reed Smith’s inaugural Health Care Conference, closed the session with a thoughtful discussion regarding the current state of American politics. He described not just the polarization, but also the tribalism, of American politics today, depicting a broken American political system where opposing parties have adopted a mantra of, “if you support it, I am against it.” Despite Ornstein’s bleak description of the current state of politics, he offered some suggestions for reform, including incentivizing citizens to vote. He argued that if more of the American public is engaged, politicians must meet in the middle on at least some policy debates.

In all, the inaugural Reed Smith Health Care Conference led to provocative discussions and a deeper understanding of the political climate and policy recommendations likely to impact—or even transform—post-acute care in the not-so-distant future. We look forward to next year’s conference.

Medicare Paper Claims Must Be Submitted on Revised 1500 Form By April 1, 2014

CMS is instructing Medicare providers and suppliers that the updated version of the Medicare claim form (CMS 1500 form version 02/12) must be used for all Medicare paper claims received on and after April 1, 2014. The new form includes indicators to differentiate between ICD-9 and ICD-10 codes, identifies whether certain providers have performed an ordering, referring, or supervising role in the furnishing of the service, and expands the number of possible diagnosis codes on a claim to 12, among other changes. The old version of the Medicare claims form, version 08/05, will only be accepted through March 31, 2014.

GAO Report Confirms Insurance Coverage Prior to Medicare Linked to Better Health, Lower Program Spending

This post was written by Nancy Sheliga.

The Government Accountability Office (GAO) has released a report examining the effect of prior health insurance coverage on Medicare beneficiaries. The report specifically focuses on the health status, program spending, and use of services by Medicare beneficiaries with and without continuous health insurance coverage before Medicare enrollment. According to the GAO, Medicare beneficiaries with prior insurance initially used fewer or less costly medical services than those without prior insurance. Because the difference in total spending was the greatest during the first year in Medicare, the GAO hypothesizes that beneficiaries without prior continuous insurance may have had a pent-up demand for medical services in anticipation of coverage at age 65. In addition, the report finds that beneficiaries without prior continuous insurance have higher total and institutional outpatient spending but not higher spending for physician and other noninstitutional services, suggesting that they require more costly and intensive medical services or that they are continuing prior patterns of visiting hospitals more than physician offices. Finally, in line with previous research, the GAO found that beneficiaries with continuous health insurance coverage for approximately six years before enrolling in Medicare were more likely than those without prior continuous insurance to report being in good health during their first six years in Medicare.

Medicare Appeals Backlog Prompts Hold on New Provider Appeals

Citing a “rapid and overwhelming increase in claim appeals,” the HHS Office of Medicare Hearings and Appeals (OMHA) has temporarily suspended the assignment of most new provider requests for an Administrative Law Judge (ALJ) hearing. In a memorandum to high-volume appellants dated December 24, 2013, Chief ALJ Nancy Griswold announced that the suspension, which was effective July 15, 2013, is expected to last at least 2 years, during which the OMHA will work through a backlog of appeals involving almost 357,000 Medicare claims and entitlements already assigned to the 65 ALJs. Note that notwithstanding the suspension, OMHA will continue to assign and process requests filed directly by Medicare beneficiaries. As previously reported, the OMHA is hosting a Medicare Appellant Forum on February 12, 2014 to provide additional information to appellants and providers on efforts to make the appeals process work more efficiently.

OIG Calls for Greater Scrutiny of Clinicians with High Cumulative Medicare Payments

The OIG has issued a report focusing on individual clinicians who generated high cumulative Medicare Part B payments (defined for purposes of this report as more than $3 million in Part B services) in 2009. Out of 303 such clinicians identified by the OIG, 34% had been identified for improper payment reviews, and as of December 31, 2011, they were tied to $34 million in overpayments, three of the clinicians had their medical licenses suspended and two were indicted. Since existing procedures may not always identify clinicians responsible for high cumulative payments in a timely manner, the OIG recommends that CMS: (1) establish a cumulative payment threshold above which a clinician’s claims would be selected for review, and (2) implement a procedure for timely identification and review of clinicians’ claims that exceed the cumulative payment threshold. While CMS noted that “[h]igh cumulative payments are not necessarily indicative of improper payments or fraud,” the agency partially concurred with the OIG recommendations and stated that it would work with its contractors to develop an appropriate, cumulative payment threshold.

House Panel to Examine Medicare "Extenders" Policy

On January 9, 2014, the House Energy and Commerce Health Subcommittee is holding a hearing on “The Extenders Policies: What Are They and How Should They Continue Under a Permanent SGR (Sustainable Growth Rate) Repeal Landscape?” The so-called extenders are measures that secure the continuation of various temporary Medicare payment and policy revisions impacting hospitals, physicians, therapy providers, and certain other provider types that are routinely extended by Congress (most recently as part of the Pathway for SGR Reform Act).

CMS Boosts Provider Enrollment Fee for 2014

CMS has announced the 2014 application fee for institutional providers that are initially enrolling in the Medicare or Medicaid program or the Children's Health Insurance Program (CHIP); revalidating their Medicare, Medicaid or CHIP enrollment; or adding a new Medicare practice location (unless a hardship exemption applies). The fee for 2014 is $542, up from $532 in 2013. CMS uses a broad definition of institutional entities subject to the application fee; it applies to “any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A, CMS-855B (not including physician and non-physician practitioner organizations), CMS-855S or associated Internet-based PECOS enrollment application,” along with additional categories of Medicaid-only and CHIP-only institutional providers.

CMS Releases Medicare Deductible, Coinsurance Amounts for 2014

CMS published notices on October 30, 2013 announcing the 2014 Medicare inpatient hospital deductible and hospital and extended care services coinsurance amounts. The 2014 Part A deductible for hospital inpatient admissions for the first 60 days of care will be $1,216, followed by $304 per day for days 61-90 and $608 per day for stays beyond the 90th day in a benefit period. The daily skilled nursing facility coinsurance for days 21 through 100 in a benefit period will be $152 in 2014.  CMS also released the 2014 Medicare Part A premium amounts for the uninsured aged and disabled individuals who have exhausted other entitlement.  Finally, CMS has announced that for 2014, Part B premium rates and the Part B deductible are the same as the respective amounts for 2013. Specifically, the 2014 premium varies by income from $104.90 to $335.70 per month, and the Part B deductible is $147.00 for all Part B beneficiaries.
 

Government Shutdown Update: Medicare Claims Processing Continues, but Other Key Functions on Hold

The ongoing partial federal government shutdown that began on October 1, 2013 due to the government funding impasse is having a varied impact on health care provider operations. CMS has ordered Medicare Administrative Contractors (MACs) to continue to perform all Medicare claims processing and payment functions during the government shutdown. Some providers may experience the impact of the shutdown, however, in the form of curtailed survey and certification activities. In short, CMS is directing state survey agencies to continue to investigate and enforce only complaints involving immediate jeopardy or harm to individuals and revisit surveys necessary to prevent provider termination. Many other survey activities are being suspended during the federal government shutdown, including Medicare recertification surveys, revisits that are not required to prevent termination of Medicare participation, Medicare initial surveys, validation surveys, complaint investigations that do not allege immediate jeopardy or actual harm, Patient Safety Initiative Pilot Surveys, MDS or OASIS activities, informal dispute resolutions, or new improvement projects funded by collected civil monetary penalty funds. The shutdown also has hampered federal rulemaking activities; a lengthy shutdown could throw a wrench into CMS efforts to finalize annual Medicare payment rules for systems updated on calendar year basis (including the Medicare physician fee schedule, the hospital outpatient prospective payment system, and the ambulatory surgical center payment system), increasing uncertainty about major proposed policy changes. The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) is continuing Medicare and Medicaid oversight and enforcement activities, including maintaining its fraud and abuse hotline, while most other OIG activities will be suspended during this period. In other areas, the HHS shutdown contingency plan estimates that the shutdown will result in 52% of HHS employees being furloughed, with the Administration for Children and Families, the Substance Abuse and Mental Health Services Administration, the Administration for Community Living, and the Agency for Healthcare Research and Quality having the vast majority of their staff on furlough. A wide range of HHS activities are also being curtailed, including payments under the Children’s Hospital GME Program and Vaccine Injury Compensation Claims, most new National Institutes of Health admissions and grant awards, the Centers for Disease Control and Prevention annual seasonal influenza program, and routine Food and Drug Administration activities not funded through user fees, among many other programs. There is no clear sign of when a deal on a funding bill will be reached.

Ways and Means Committee Invites Public Comment on Medicare Cost Sharing Proposals

The House Ways and Means Committee is seeking comments on three bipartisan proposals intended to “modernize” Medicare cost-sharing policies. The proposals, which were included in President Obama’s proposed FY 2014 budget, include: (1) reducing premium subsides for wealthier seniors in Medicare Parts B and D (10-year savings of at least $50 billion); (2) increasing the annual Medicare Part B deductible (10-year savings of $3.3 billion); and (3) establishing a home health co-payment (10-year savings of $700 million - $730 million). The Committee is seeking comments on these proposals through August 16, 2013.

Medicare Trustees Forecast Longer Medicare Solvency

On May 31, 2013, the Medicare Board of Trustees released its annual assessment of the financial condition of the Social Security and Medicare trust funds. The Board projects that the Medicare hospital insurance trust fund will remain solvent until 2026, which is two years later than forecast last year. The Board attributes the improved outlook in part to lower-than-expected Medicare Part A spending in 2012 (particularly for skilled nursing facilities) and lower projected Medicare Advantage costs. The Board points out, however, that projections of Medicare costs are highly uncertain due to a number of factors, including questions about whether Congress will continue to override the Medicare physician fee schedule/sustainable growth rate (SGR) formula and how the ACA will impact spending.

Improper Medicare Payments for Unlawfully Present, Incarcerated Beneficiaries

The OIG has discovered that Medicare has paid millions of dollars in benefits for aliens who are not lawfully present in the country and for incarcerated beneficiaries, contrary to program rules. Specifically Medicare made $91.6 million in payments to health care providers for services to approximately 2,600 unlawfully present beneficiaries during calendar years 2009 through 2011 because CMS did not always receive the unlawful presence information promptly. Likewise, because CMS did not always receive incarceration information promptly, Medicare paid $33.6 million for services to approximately 11,600 incarcerated beneficiaries during 2009 through 2011, even though prisons generally are responsible for paying for care (Medicare will make payments for incarcerated patients if state or local law requires the individuals to repay the cost of the services, but providers must submit such claims with an "exception code"). The OIG recommends that CMS ensure that its contractors recoup any improper payments, implement various policies and procedures to detect and recoup future improper payments, and standardize contractor processing of exception codes for incarcerated beneficiaries. Additional details can be found in the complete reports, Medicare Improperly Paid Providers Millions of Dollars for Unlawfully Present Beneficiaries Who Received Services During 2009 Through 2011 and Medicare Improperly Paid Providers Millions of Dollars for Incarcerated Beneficiaries Who Received Services During 2009 Through 2011.

Obama Administration's Regulatory Agenda Points to Busy 2013 for HHS

On January 8, 2013, the Obama Administration published its latest semiannual regulatory agenda, outlining planned regulatory initiatives in a number of policy areas. The Federal Register version of the agenda includes only a portion of the regulations in the pipeline, however; the full agenda has been posted on the Office of Management and Budget (OMB) web site. Major Department of Health and Human Services (HHS) regulations are highlighted after the jump.

  • An HHS Office of Inspector General (OIG) proposed rule that would add new/modify existing safe harbors under the anti-kickback statute; add new/revise existing regulations governing OIG's authority to impose civil money penalties and assessments; add new/revise existing regulations governing OIG's exclusion authority; and codify new exceptions to the beneficiary inducement prohibition (expected July 2013);
  • A final Centers for Medicare & Medicaid Services (CMS) rule implementing Affordable Care Act (ACA) provisions related to Medicaid reimbursement for covered outpatient drugs (expected in August 2013);
  • A CMS proposed rule to establish Medicare payment safeguards to prevent providers and suppliers that do not meet Medicare requirements from remaining enrolled in or submitting claims to Medicare (expected May 2013);
  • Proposed emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers (expected in July 2013);
  • A final CMS rule establishing requirements for disclosure of skilled nursing facilities' ownership (expected May 2013);
  • A final rule on long-term care facility agreements with hospice agencies (expected October 2013);
  • A proposed rule to establish a prospective payment system for Federally Qualified Health Centers (expected June 2013);
  • Annual Medicare payment update rules (various dates);
  • Various rules implementing insurance-related provisions of the ACA (various dates);
  • A final rule modifying HIPAA privacy, security, enforcement, and breach notification rules (expected but not released in December 2012);
  • An advance notice of proposed rulemaking to establish a methodology allowing an individual harmed by an offense punishable under HIPAA to receive a percentage of any civil money penalty or monetary settlement collected (expected March 2013);
  • A final rule to enhance human subjects research protections (expected April 2013); and
  • A Food and Drug Administration (FDA) final rule establishing a unique device identification system for medical devices (expected May 2013).

There are also some surprises on the Administration’s list of “long-term actions” – including the long-overdue final ACA “Sunshine Act” rule requiring applicable manufacturers of drugs, devices, biologicals, or medical supplies to annually report certain payments to physicians or teaching hospitals (“final action” listed as December 2014). Other long-term actions include a final rule implementing ACA requirements related to reporting and returning of overpayments (February 2015); a variety of rules dealing with the 340B discount drug program (timing listed as “to be determined”); and a final HIPAA privacy rule on accounting for disclosures under the Health Information Technology for Economic and Clinical Health Act (TBD).

GAO Calls for Improvements in Use of Medicare Prepayment Edits

In light of a continued high rate of Medicare fee-for-service improper payments (8.6% in FY 2011), the GAO recently assessed the use of Medicare prepayment edits and CMS's oversight of Medicare Administrative Contractors (MACs) that process claims.  In the report, "Medicare Program Integrity: Greater Prepayment Control Efforts Could Increase Savings and Better Ensure Proper Payment," the GAO estimates that while the use of prepayment edits saved Medicare at least $1.76 billion in FY 2010, it believes savings could have been greater if prepayment edits had been more widely used. For instance, the GAO found more than $100 million in Medicare payments that were inconsistent with a sample of three local coverage determinations (pertaining to monitored anesthesia care, parathormone, and noninvasive cerebrovascular studies) and that could have been identified using automated edits. The GAO also found weaknesses associated with CMS edit processes based on national policies, such as lack of specific time frames for implementing edits, flaws in the structure of some edits, and lack of centralized implementation. GAO recommends that CMS take a series of steps to strengthen its use of prepayment edits, such as implementing medically unlikely edits that assess all quantities provided to the same beneficiary by the same provider on the same day; encouraging more information sharing about effective edits, and assessing the feasibility of increasing incentives for edit use. HHS generally agreed with the recommendations.

OIG Highlights Vulnerabilities in CMS Oversight of the Medicare EHR Incentive Program

The Medicare electronic health record (EHR) incentive program is vulnerable to paying incentives to professionals and hospitals that do not fully meet meaningful use requirements due to gaps in CMS oversight, according to a recent OIG report. Based on a review of CMS’s oversight of self-reported meaningful use of certified EHR technology in 2011, the OIG found that CMS did not have strong prepayment or postpayment safeguards. The OIG also noted that CMS cannot use EHR reports to verify all self-reported meaningful use information because the Office of the National Coordinator for Health Information Technology (ONC) does not require certified EHR technology to be capable of producing reports for all measures. As a result of these findings, the OIG recommends that CMS: (1) obtain and review supporting documentation from selected professionals and hospitals prior to payment to verify self-reported information (although CMS argued that this would increase the burden on providers); and (2) issue more detailed guidance on documentation requirements (CMS agreed). The report also contained recommendations for ONC, including recommendations that the agency: (1) require that certified EHR technology be capable of producing reports for yes/no meaningful use measures where possible; and (2) improve the certification process for EHR technology to ensure accurate EHR reports (ONC concurred with both recommendations). For more information, see the full report, “Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program."

CMS Final Decisions on Recommendations of the Hospital Outpatient Payment Panel on Supervision Levels for Select Services

CMS has released its Final Decisions on the August 2012 Recommendations of the Hospital Outpatient Payment Panel on Supervision Levels for Select Services. The document provides CMS’s final determinations regarding the appropriate supervision levels for 29 individual hospital outpatient therapeutic services, effective January 1, 2013. CMS has determined that 22 of the considered services may be furnished with a minimum of general supervision and the remaining 7 services will maintain their current designation as non-surgical extended duration therapeutic services.

Older Entries

December 17, 2012 — OIG Releases 2012 Compendium of Unimplemented Recommendations

November 29, 2012 — CMS Seeking Comments on Revisions to Coverage with Evidence Development (CED) Policy

November 29, 2012 — CMS Announces 2013 Medicare Deductible, Coinsurance Amounts

November 29, 2012 — ACA Medicare Data Sharing Provision Implementation Proceeds

November 29, 2012 — CMS Highlights Potential National Coverage Determination (NCD) Topics

November 29, 2012 — OIG Calls for Improvements in Medicare Appeals Process

November 28, 2012 — OIG Reports Almost $7 Billion in Audit/Investigation Recoveries for FY 2012

October 16, 2012 — OIG Issues FY 2013 Work Plan

October 15, 2012 — Adjustment to the 2013 Amount in Controversy Thresholds for Medicare Appeals

September 27, 2012 — CMS Invites Comments on Preliminary Supervision Level Decisions for Selected Hospital Outpatient Services

September 27, 2012 — CMS Releases Medicare Beneficiary Ombudsman Report

September 27, 2012 — GAO Reviews Medicare Special Needs Plans for Dual-Eligible Beneficiaries

September 5, 2012 — Final FY 2011 State Allotments for Medicare Part B Premiums for Qualifying Individuals (QIs)

September 5, 2012 — Preliminary 2013 Medicare Clinical Laboratory Fee Schedule Determinations

September 4, 2012 — MedPAC Meeting on Medicare Policy Issues (Sept. 6-7)

August 31, 2012 — CMS Open Door Forum on Manual Medical Review of Therapy Claims (Sept. 5)

August 20, 2012 — CMS Updates Medicare Inpatient Psychiatric Facility Rates for FY 2013

July 30, 2012 — CMS Announces FY 2013 Medicare IRF PPS Update

July 30, 2012 — CMS to Increase Medicare SNF PPS Rates by 1.8% for FY 2013

July 27, 2012 — CMS Publishes FY 2013 Medicare Hospice Wage Index/Rate Update Notice, Comorbidity Diagnosis Reminder, Quality Update

July 27, 2012 — CMS Provider Call on New Medicare Preventive Services (August 15)

July 19, 2012 — CMS Proposes Face-to-Face Encounter Requirement for Medicare DME Orders

June 18, 2012 — CMS Correction Notices (IPPS, LTCH-PPS, MA, PDP)

May 14, 2012 — Medicare Payment for Vision-Loss Drugs Reviewed by OIG

May 8, 2012 — CMS Finalizes Changes in Medicare/Medicaid Provider and Supplier Enrollment, Ordering, Documentation Requirements

April 23, 2012 — April Congressional Health Policy Hearings and Markups

April 23, 2012 — OIG Finds Limited Benefit of Medicare-Medicaid Data Match Program

April 2, 2012 — House Approves GOP Budget with Medicare, Medicaid Provisions

April 2, 2012 — MedPAC Issues March 2012 Medicare Recommendations

March 29, 2012 — Congressional Health Policy Hearings

March 26, 2012 — CMS Call on Medicare Preventive Services (March 28)

March 14, 2012 — CMS Releases Redesigned Medicare Benefit Statements

February 28, 2012 — CMS Proposed Rule on Reporting and Returning of Medicare Overpayments Under the ACA

February 28, 2012 — CMS Upgrades to PECOS Enrollment System

February 13, 2012 — OIG Highlights Lack of Data Regarding Physicians Opting Out of Medicare

December 13, 2011 — CMS Final Rule on Availability of Medicare Data for Performance Measurement

November 29, 2011 — CMS Hosts Orlando Symposium on Empowering Minorities (Dec. 14-16)

November 15, 2011 — CMS Posts 2012 Medicare DMEPOS Fee Schedule Files

November 14, 2011 — CMS Announces $523 Medicare, Medicaid, & CHIP Enrollment Application Fee for 2012

November 14, 2011 — CMS Announces Medicare Providers with Revalidation Requests; Updates EFT Requirement

October 28, 2011 — CMS Describes Predictive Modeling Program to Detect Medicare Fraud

October 28, 2011 — Upcoming MedPAC Meeting (Nov. 3-4)

October 12, 2011 — Hearings this Week on Medicare Reform, Chronic Care, Employer-Provided Insurance

September 29, 2011 — Congressional Hearings Examine Variety of Health Industry Issues

September 1, 2011 — Revised Medicare Provider-Supplier Enrollment Application, New Application for Ordering/Referring Released

August 9, 2011 — CMS "Provider Compliance Group Outreach Calls" to Focus on Medicare Vulnerabilities (Aug. 23-25, 2011)

July 29, 2011 — Medicare Hospice Rule Correction Notice

July 29, 2011 — OIG Report and "Spotlight" on Medicare Hospice Services

July 18, 2011 — July Congressional Health Policy Hearings/Markups

June 27, 2011 — CMS Proposes CoPs for Community Mental Health Centers

May 13, 2011 — CMS Seeks to Help States Coordinate Care for Dual Eligibles

May 13, 2011 — CMS Proposes Influenza Vaccination Standard for Medicare/Medicaid Providers and Suppliers

April 29, 2011 — CMS Updates RY 2012 Medicare Inpatient Psychiatric Facility PPS Rates

April 29, 2011 — OIG Report on Part D Drugs for Dual-Eligible Beneficiaries

April 13, 2011 — President Obama Outlines Plans for Deficit Reduction/Entitlement Reform

April 13, 2011 — CMS Rule Increases Medicare Payments to ESRD Facilities

April 13, 2011 — Medicare EHR Attestation Begins April 18, 2011

April 13, 2011 — Agreement Reached on FY 2011 Spending Bill

March 29, 2011 — CMS Establishes $505 Provider/Supplier Application Fee for 2011

March 29, 2011 — FY 2010 & 2011 State Allotments for Medicare Part B Premium Costs for Qualifying Individuals (QIs)

March 29, 2011 — CMS Hosts Forum on Advanced Diagnostic Imaging (ADI) Accreditation

March 29, 2011 — Compendium of Unimplemented OIG Recommendations

March 29, 2011 — MedPAC Report to Congress on 2012 Payment Recommendations

March 29, 2011 — CBO Presents Budget Options, Including Potential Health Policy Savings

March 7, 2011 — CMS Clarifies Standards for Provision of Diabetes Self-Management Training Services (DSMT)

March 7, 2011 — GAO Reports on Duplications in HHS and Other Federal Programs

February 18, 2011 — CMS Final Rule Expands Medicare/Medicaid/CHIP Provider and Supplier Screening Requirements Under Affordable Care Act Authority

February 4, 2011 — Congressional Hearings on ACA Implementation Issues (Feb. 9-10)

January 28, 2011 — CMS Finalizes Sweeping Provider/Supplier Screening Rule

January 28, 2011 — Revised Medicare Supplier Standards FAQs

January 28, 2011 — CMS Continues to Delay Implementation of PECOS Ordering/Referring Claim Edits

January 13, 2011 — CMS Revises CY 2011 Medicare Physician Fee Schedule Payments

January 13, 2011 — HHS Establishes Office to Coordinate Policies for Dual Eligibles

December 30, 2010 — CMS Announces Final 2011 Medicare Physician Fee Schedule Rates

December 29, 2010 — Correction of 2011 Home Health PPS Rule

December 29, 2010 — CMS Postpones Signature Requirement for Clinical Diagnostic Laboratory Test Orders

December 22, 2010 — APC Advisory Panel Meeting (Feb. 28-March 2, 2011)

December 17, 2010 — CMS Sets July 5, 2011 Target for Implementation of PECOS Ordering/Referring Edits

December 15, 2010 — CMS Reminder on ACA Timely Claims Filing Requirement

December 6, 2010 — CMS Releases 2011 Medicare Clinical Lab Fee Schedule Files

December 2, 2010 — CMS Releases 2011 Medicare DMEPOS Fee Schedule

December 1, 2010 — President Signs Short-Term Medicare Physician Fee Schedule Fix, Outpatient Therapy Policy Update

November 29, 2010 — Congress Clears One-Month Medicare Physician Fee Schedule Fix, Therapy Policy Change

November 29, 2010 — CMS Final Rule on Hospital COPs/Visitation Rights

November 29, 2010 — CDC Seeks Comments on ACA Health Risk Assessments

November 29, 2010 — CMS Update on PECOS & Ordering/Referring Edits

November 29, 2010 — MSP Mandatory Insurer Reporting under MMSEA -- Delay for Liability Insurance Mandatory Reporters

November 16, 2010 — 2011 Medicare Deductibles and Coinsurance Amounts Released

November 15, 2010 — Upcoming Congressional Hearings, Markups

October 29, 2010 — CMS Proposes Medicare/Medicaid Requirements for Long Term Care Facilities Providing Hospice Services

October 29, 2010 — Upcoming Medicare Hospital Outpatient, Physician Fee Schedule Final Rules

October 27, 2010 — SNF PPS RUG-IV Provider Call (Nov. 9)

October 15, 2010 — CMS Launches New Medicare Provider Compliance Newsletter

October 15, 2010 — OIG FY 2011 Work Plan

October 15, 2010 — CMS Use of Error Rate Data To Focus on Error-Prone Providers

October 7, 2010 — CMS Proposes Broad Expansion of Medicare/Medicaid/CHIP Provider and Supplier Screening Requirements Under Affordable Care Act Authority

September 30, 2010 — Amount in Controversy Thresholds for 2011

September 29, 2010 — National Supplier Clearinghouse (NSC) Updates DMEPOS Supplier Standards

September 17, 2010 — MedPAC Policy Meeting

August 31, 2010 — CMS Finalizes New DMEPOS Supplier Standards