Obama Administration Announces Ground-Breaking Public-Private Partnership to Prevent Health Care Fraud

Washington - Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder today announced the launch of a ground-breaking partnership among the federal government, State officials, several leading private health insurance organizations, and other health care anti-fraud groups to prevent health care fraud. This voluntary, collaborative arrangement uniting public and private organizations is the next step in the Obama administration’s efforts to combat health care fraud and safeguard health care dollars to better protect taxpayers and consumers.

The new partnership is designed to share information and best practices in order to improve detection and prevent payment of fraudulent health care billings. Its goal is to reveal and halt scams that cut across a number of public and private payers. The partnership will enable those on the front lines of industry anti-fraud efforts to share their insights more easily with investigators, prosecutors, policymakers and other stakeholders. It will help law enforcement officials to more effectively identify and prevent suspicious activities, better protect patients’ confidential information and use the full range of tools and authorities provided by the Affordable Care Act and other essential statutes to combat and prosecute illegal actions.

“This partnership puts criminals on notice that we will find them and stop them before they steal health care dollars,” Secretary Sebelius said. “Thanks to this initiative today and the anti-fraud tools that were made available by the health care law, we are working to stamp out these crimes and abuse in our health care system.”

One innovative objective of the partnership is to share information on specific schemes, utilized billing codes and geographical fraud hotspots so that action can be taken to prevent losses to both government and private health plans before they occur. Another potential goal of the partnership is the ability to spot and stop payments billed to different insurers for care delivered to the same patient on the same day in two different cities. A potential long-range goal of the partnership is to use sophisticated technology and analytics on industry-wide healthcare data to predict and detect health care fraud schemes.

“This partnership is a critical step forward in strengthening our nation’s fight against health care fraud,” said Attorney General Holder. “This Administration has established a record of success in combating devastating fraud crimes, but there is more we can and must do to protect patients, consumers, essential health care programs, and precious taxpayer dollars. Bringing additional health care industry leaders and experts into this work will allow us to act more quickly and effectively in identifying and stopping fraud schemes, seeking justice for victims, and safeguarding our health care system.”

The Executive Board, the Data Analysis and Review Committee, and the Information Sharing Committee will hold their first meeting in September.  Until then, several public-private working groups will continue to meet to finalize the operational structure of the partnership and develop its draft initial work plan.

The following organizations and government agencies are among the first to join this partnership:

• America’s Health Insurance Plans
• Amerigroup Corporation
• Blue Cross and Blue Shield Association
• Blue Cross and Blue Shield of Louisiana
• Centers for Medicare & Medicaid Services
• Coalition Against Insurance Fraud
• Federal Bureau of Investigations
• Health and Human Services Office of Inspector General
• Independence Blue Cross
• National Association of Insurance Commissioners
• National Association of Medicaid Fraud Control Units
• National Health Care Anti-Fraud Association
• National Insurance Crime Bureau
• New York Office of Medicaid Inspector General
• Travelers
• Tufts Health Plan
• UnitedHealth Group

The partnership builds on existing tools provided by the Affordable Care Act, resulting in:        

• Tougher sentences for people convicted of health care fraud. Criminals will receive 20 to 50 percent longer sentences for crimes that involve more than $1 million in losses;
• Enhanced screenings of Medicare and Medicaid providers and suppliers to keep fraudsters out of the program.
• Suspended payments to providers and suppliers engaged in suspected fraudulent activity.

The administration’s efforts to date have already resulted in a record-breaking $10.7 billion in recoveries of health care fraud over the last three years. For more information on this partnership and the Obama administration’s work to combat health care fraud, please visit:

http://www.healthcare.gov/news/factsheets/2011/03/fraud03152011a.html

www.stopmedicarefraud.gov

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CMS proposes policy and payment rate changes for End-Stage Renal Disease facilities in 2013

Proposals would also strengthen incentives to improve outcomes for patients with ESRD 

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule that would update Medicare policies and payment rates for End-Stage Renal Disease (ESRD) facilities paid under the ESRD Prospective Payment System (PPS) for calendar year (CY) 2013. The proposed rule would also strengthen incentives for improved quality of care and better outcomes for patients through improvements to the ESRD Quality Incentive Program (QIP). Performance scores on the QIP measures during a proposed CY 2013 performance period would affect payments to dialysis facilities in CY 2015.

In addition to other updates, payment rates for outpatient maintenance dialysis treatments are anticipated to increase by 2.5 percent in CY 2013. This reflects the ESRD bundled market basket increase of 3.2 percent reduced by a productivity adjustment of 0.7 percent, as required by statute. CMS estimates that Medicare payments to the 5,633 ESRD facilities in CY 2013 will total $8.7 billion. When all policy changes are considered together, payments to ESRD facilities are expected to increase by 3.1 percent in 2013.

“As we enter the third year of our four year transition to the new fully bundled payment system for certain dialysis facilities, 90 percent of facilities are voluntarily receiving payments under the new system,” said Jonathan Blum, CMS deputy administrator and director of the agency’s Center for Medicare. “We believe that the policies and rate changes proposed today will continue to help ensure that beneficiaries diagnosed with ESRD continue to get the care they need.”

  

The proposed rule would continue to focus on clinical measures and expand the scope of the reporting measures included in the ESRD QIP to encompass a broader range of patient populations who receive dialysis care and to address concerns about the quality of life experienced by patients on dialysis. Specifically, CMS is proposing that ESRD facilities collect data for four reporting measures to capture information about how well each facility:

• Manages patients’ anemia, a common side-effect of hemodialysis;
• Reports dialysis infection events to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN);
• Monitors patients for abnormalities in phosphorous and calcium levels; and
• Surveys patients to learn about their experiences of care.

“The CMS proposals for the Quality Incentive Program aim to improve the quality of dialysis services furnished to people diagnosed with End-Stage Renal Disease,” said Patrick Conway, M.D., CMS chief medical officer and director of the agency’s Office of Clinical Standards and Quality. “The QIP proposal results in 11 measures essential for patient-centered care including anemia management, preventing bloodstream infections, dialysis access and adequacy, and patient experience.”

Both the ESRD PPS and the QIP were mandated by the Medicare Improvements for Patients and Providers Act of 2008. The previous ESRD payment system consisted of a composite rate payment for a defined set of services, including certain laboratory tests, drugs and other supplies, while separate payments were made for any ESRD-related items or services furnished as part of the dialysis treatment but for which no payment was made under the composite rate. The composite rate payment was adjusted to reflect the ESRD facility’s geographic location and a limited number of patient’s characteristics. The new bundled ESRD PPS is intended to improve efficiency and reduce incentives to use more items and services than needed for appropriate care, while the QIP is intended to promote continued improvement in the quality of care provided to Medicare beneficiaries with ESRD.

This proposed rule would also codify provisions of The Middle Class Tax Extension and Job Creation Act of 2012 that require reductions in bad debt reimbursement to all providers eligible to receive bad debt reimbursement; these provisions are specifically prescribed by Congress and thus, are generally self-implementing. 

The proposed rule will appear in the July 11, 2012, Federal Register. CMS will accept comments on the proposed rule until Aug. 31, 2012, and will respond to comments in the final ESRD PPS rule for CY 2013.

  

For more information, see: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

For more information about the ESRD PPS and QIP, please see: https://www.cms.gov/Center/Special-Topic/End-Stage-Renal-Disease-ESRD-Center.html

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HHS Announces 89 New Accountable Care Organizations

2.4 million People with Medicare to receive better, more coordinated care

Health and Human Services (HHS) Secretary Kathleen Sebelius announced today, that as of July 1, 89 new Accountable Care Organizations (ACOs) began serving 1.2 million people with Medicare in 40 states and Washington, D.C. ACOs are organizations formed by groups of doctors and other health care providers that have agreed to work together to coordinate care for people with Medicare.

These 89 new ACOs have entered into agreements with CMS, taking responsibility for the quality of care they provide to people with Medicare in return for the opportunity to share in savings realized through high-quality, well-coordinated care.

“Better coordinated care is good for patients and it saves money,” said Secretary Sebelius. “We applaud every one of these doctors, hospitals, health centers and others for working together to ensure millions of people with Medicare get better, more patient-centered, coordinated care.”

Participation in an ACO is purely voluntary for providers. The Medicare Shared Savings Program (MSSP), and other initiatives related to ACOs, is made possible by the 2010 Affordable Care Act. Federal savings from this initiative could be up to $940 million over four years.

“This new group of ACOs adds to a solid foundation,” said Centers for Medicare & Medicaid (CMS) Acting Administrator Marilyn Tavenner. “The Medicare ACO program opened for business in January and, already, more than 2.4 million beneficiaries are receiving care from providers participating in these important initiatives.”

The 89 ACOs announced today bring the total number of organizations participating in Medicare shared savings initiatives to 154, including the 32 ACOs participating in the testing of the Pioneer ACO Model by CMS’s Center for Medicare and Medicaid Innovation (Innovation Center) announced last December, and six Physician Group Practice Transition Demonstration organizations that started in January 2011. In all, as of July 1, more than 2.4 million beneficiaries are receiving care from providers participating in Medicare shared savings initiatives.

The selected ACOs operate in a wide range of areas of the country and almost half are physician-driven organizations serving fewer than 10,000 beneficiaries, demonstrating that smaller organizations are interested in operating as ACOs.   Their models for coordinating care and improving quality vary in response to the needs of the beneficiaries in the areas they are serving.  

To ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely, an ACO must meet quality standards. For 2012, CMS has established 33 quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and patient and caregiver experience of care.

Beginning this year, new ACO applications will be accepted annually. The application period for organizations that wish to participate in the MSSP beginning in January 2013 is from Aug. 1 through Sept. 6, 2012. More information, including application requirements, is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Application.html

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CMS Proposes Policy and Payment Changes for Outpatient Care in Hospitals and Ambulatory Surgical Centers

Proposals Also Would Enhance Beneficiary Role in Quality of Care Reviews

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule that would update payment policies and payment rates for services furnished to Medicare beneficiaries in hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) beginning Jan. 1, 2013.  The proposals would affect HOPDs in more than 4,000 hospitals, including general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals, and approximately 5000 Medicare-participating ASCs.

“The policies and payment rates included in the proposed rule are intended to ensure that beneficiaries have access to high quality care in the outpatient setting,” said Jonathan Blum, CMS deputy administrator and director of the agency’s Center for Medicare.

CMS is proposing to increase HOPD payment rates by 2.1 percent.  The increase is based on the projected hospital market basket—an inflation rate for goods and services used by hospitals—of 3.0 percent less statutory reductions totaling 0.9 percent, including an adjustment for economy-wide productivity.  CMS is also proposing to increase ASC payment rates by 1.3 percent – the projected rate of inflation of 2.2 percent minus an adjustment required by law for improvements in productivity of 0.9 percent.  Medicare uses the consumer price index for urban consumers (CPI-U) as the inflation rate for ASCs. CMS is asking for public comment on potential data that Medicare could collect to develop an inflation index that would explicitly measure ASC cost growth.

Based on the proposed updates and other policies in the proposed rule, CMS projects that total payments to hospitals under the Outpatient Prospective Payment System (OPPS) in calendar year 2013 will be approximately $48.1 billion.  CMS also projects that payments to ASCs under the ASC Payment System will be approximately $4.1 billion.

The proposed rule also would streamline the operations of the Quality Improvement Organizations (QIOs) and make them more responsive to beneficiary complaints about quality of care.  Specifically, the proposals would give beneficiaries more information about the QIO’s review process, and would create a new alternative dispute resolution option, called Immediate Advocacy, to resolve beneficiary complaints.  The proposed rule would also give QIOs authority to send and receive secure transmissions of electronic versions of health information.  Finally, the proposals would enable QIOs to release more information about the results of their reviews to affected beneficiaries.

“The proposals would give beneficiaries and their caregivers the ability to participate more actively in the Quality Improvement Organization review process and would promote speedier resolution of quality complaints,” said Patrick Conway, M.D., CMS chief medical officer and director of the Office of Clinical Standards and Quality at CMS.

The proposed rule would make several changes to the quality reporting programs for HOPDs, ASCs and Inpatient Rehabilitation Facilities (IRFs).  Specifically, CMS is not proposing to add measures for the CY 2014 and CY 2015 payment determinations. Thus, CMS is proposing reporting for 23 measures for the CY 2014 payment determination and 24 measures for the CY 2015 payment determination.  The proposed rule also contains proposals for procedures related to retirement and retention of HOPD measures.

For the ASC Quality Reporting (ASCQR) Program, CMS is proposing revisions to the procedural requirements that apply to the reporting of quality data, a policy for updating measures, data completeness requirements, and a methodology for reducing payment to ASCs that do not meet the ASCQR Program reporting requirements.  CMS previously finalized the measure sets that apply to CY 2014-2016 and is not proposing to make any changes to these measure sets.

The OPPS/ASC proposed rule includes several proposals that would affect the IRF Quality Reporting Program.  Specifically, the proposed rule would:

• Adopt updates on a previously adopted measure for the IRF QRP that will affect annual prospective payment amounts in FY 2014;
• Adopt a policy that would provide that any measure that has been adopted for use in the IRF QRP will remain in effect until the measure is actively removed, suspended, or replaced; and
• Adopt policies regarding when notice-and-comment rulemaking will be used to update existing IRF QRP measures.

The proposed rule will appear in the July 30, 2012, Federal Register.  CMS will accept comments on the proposed rule until Sep. 4, 2012, and will respond to all comments in a final rule to be issued by Nov. 1, 2012.

For more information on the CY 2013 proposals for the OPPS and the ASC payment system, as well as proposed changes to the QIO program, please see: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

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CMS Proposed Rule Would Increase Payment to Family Physicians By 7 Percent

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule that would increase payments to family physicians by approximately 7 percent and other practitioners providing primary care services between 3 and 5 percent.  The increase in payment to family practitioners is part of the proposed rule that would update payment policies and rates under the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2013.  Under the MPFS, Medicare pays more than 1 million physicians and nonphysician practitioners that provide vital health services to Medicare beneficiaries.

“Helping primary care doctors will help improve patient care and lower health care costs long term,” said CMS Acting Administrator, Marilyn B. Tavenner.

The 7 percent increase for family physicians comes from a proposal that continues the Administration’s policies to promote high quality, patient-centered care.  For CY 2013, CMS is proposing for the first time to explicitly pay for the care required to help a patient transition back to the community following a discharge from a hospital or nursing facility. The proposals calls for CMS to make a separate payment to a patient’s community physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.  The proposed rule also asks for public comment on how Medicare can better recognize the range of services community physicians and practitioners provide as part of treating patients either through face-to-face services in the office or coordinating care outside the office when the patient does not see the physician.

As has been the case every year since CY 2002, CMS projects a significant reduction in MPFS payment rates under the Sustainable Growth Rate (SGR) methodology due to the expiration of the adjustment made for CY 2012 in the statute.  For CY 2013, CMS projects a reduction of 27 percent and is required by law to include this reduction in these calculations. However, Congress has acted to avert the cuts every year since 2003.  The Administration is committed to fixing the SGR formula in a fiscally responsible way.

The proposed rule would also continue the careful implementation of the physician value-based payment modifier (Value Modifier) that was included in the Affordable Care Act by providing choices to physicians regarding how to participate.  The Value Modifier adjusts payments to individual physicians or groups of physicians based on the quality of care furnished to Medicare beneficiaries compared to costs.  The law allows CMS to phase in the Value Modifier over three years from CY 2015 to CY 2017.  For the CY 2015 physician payment rates, the proposed rule would apply the Value Modifier to all groups of physician with 25 or more eligible professionals.  The proposed rule also provides an option for these groups to choose how the Value Modifier would be calculated based on whether they participate in the Physician Quality Reporting System (PQRS).  For groups of 25 or more that do not participate in the PQRS, CMS is proposing to set their Value Modifier at a 1.0 percent payment reduction.  For groups that wish to have their payment adjusted according to their performance on the value modifier, the rule proposes a system whereby groups with higher quality and lower costs would be paid more, and groups with lower quality and higher costs would be paid less. The performance period for the CY 2015 Value Modifier was established as CY 2013 in the MPFS Final Rule for CY 2012.

The proposed rule continues efforts by CMS to align quality reporting across programs to reduce burden and complexity. The proposed rule proposes changes to two quality reporting programs that are associated with the MPFS – the PQRS and the Electronic Prescribing (eRx) Incentive Program – as well as the Medicare Electronic Health Records (EHR) Incentive Pilot Program which promotes the use of health information technology.  The PQRS proposal includes simplified, lower burden options for reporting and the proposed rule aligns quality reporting across the various programs in support of the National Quality Strategy.  The proposed rule also addresses the next phase in a plan to enhance the Physician Compare Website to foster transparency and public reporting of certain information to give beneficiaries more information for purposes of choosing a physician.

The proposed rule also includes:

• A proposal to include additional Medicare-covered preventive services on the list of services that can be provided via an interactive telecommunications system;
• A proposal to implement a durable medical equipment (DME) face-to-face requirement as a condition of payment for certain high-cost Medicare DME items;
• A proposal to apply a multiple procedure payment reduction (MPPR) policy to the technical component of the second and subsequent cardiovascular and ophthalmology diagnostic services furnished by the same doctor to the same patient on the same day;
• A proposal to collect data on patient function to improve how Medicare pays for physical and occupational therapy, and speech language pathology services;
• A request for public comments on payment for advanced diagnostic molecular pathology services;
• A proposal to revise a regulation that only allows Medicare to pay for portable x-rays ordered by an MD or DO.  The revised regulations would allow Medicare to pay for portable x-ray services ordered physicians and non-physician practitioners acting within the scope of their Medicare benefit and state law;
• A proposal to clarify when Medicare will pay for interventional pain management services provided by Certified Registered Nurse Anesthetists (CRNAs) when permitted by State law.  This proposal will foster access to pain management services in areas where states have determined that CRNAs may provide these services.

The proposed rule will appear in the July 30, 2012 Federal Register.  CMS will accept comments on the proposed rule until Sep. 04, 2012, and will respond to them in a final rule with comment period to be issued by Nov. 1, 2012.

For more information, see:  http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

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Strong Start Amended Funding Opportunity Announcement

As part of the Strong Start for Mothers and Newborns initiative, (“Strong Start”) CMS has released a funding opportunityfor providers, states, managed care organizations, and conveners to test the effectiveness of specific enhanced prenatal care approaches to reduce preterm births in women enrolled in Medicaid. The goal of the initiative is to determine if these approaches to care can reduce the rate of preterm births, improve the health outcomes of pregnant women and newborns and decrease the anticipated total cost of medical care over the first year of life for children born to mothers enrolled in Medicaid and/or CHIP.

CMS received a high level of interest in the Strong Start Funding Opportunity Announcement (“FOA”), and also received numerous questions and suggestions about this initiative from organizations throughout the country interested in testing new models of prenatal care. In order to address concerns about the requirements for a successful application, CMS has revised the Strong Start FOA.

The key changes to the FOA are as follows:

• CMS revised the FOA to remove the requirement for States to link vital records and Medicaid claims data in the Strong Start funding opportunity. Instead, applicants must be able to provide gestational age and birthweight data on births of intervention infants and from a baseline period that spans at least 2 years prior to the start of the intervention; thereby, removing the requirement to supply a Letter of Agreement from the applicant’s state(s).
• CMS is committed to a rigorous model evaluation and, therefore, will pursue linked State vital records and Medicaid claims and encounter data through a parallel effort to the Strong Start funding opportunity.
• In order to make these program changes, CMS has extended the program timelines and eliminated the Letter of Intent (LOI) requirement in order to allow potential applicants the opportunity to modify or develop applications that are consistent with the new information. The new application deadline for the Strong Start funding opportunity is August 9, 2012 with optional LOIs due August 8, 2012. The anticipated award date is October 5, 2012.

To assist stakeholders interested in applying for the Strong Start initiative,CMS will host a technical assistance meeting via conference call or webinar tentatively scheduled for July 11 at 3:00pm EDT. We will be sending out call-in and other information shortly.

We encourage potential applicants to review the amended FOA at http://www.innovations.cms.gov/Files/x/Strong-Start-for-Mothers-and-Newborns-Funding-Opportunity-Announcement.pdf.

More information about the Strong Start initiative can also be found at http://innovations.cms.gov/initiatives/Strong-Start/index.html.

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What does a Doctor Expect From his Medical Billers & Coders?

A significant challenge that care providers face in the US today is unrealized account receivables stemming from rejected insurance claims by Medicaid and Medicare officials. Physicians often find this challenge daunting because it requires them to handle what they are not meant to: administrative responsibilities

The medical billing and coding cycle requires thorough knowledge and deft handling of the entire process and related procedures including familiarity with electronic platforms and the ability to handle sensitive medical data.

The above scenario, if broken in terms of skills doctors expect their billers and coders to have, will demarcate the following areas:

• Knowledge of billing life cycle
• Theoretical and working knowledge of data collection, data entry, paper claims, creating and editing reports, patient demographic forms, etc
• Usage and understanding of codes
• Knowledge of electronic platforms in use

This makes medical billing and coding among the most knowledge-driven and challenging disciplines which needs keeping up with the changing trends of the industry to effectively handle billing and coding responsibilities for care providers, so that they can concentrate on quality of care even as they enjoy a steady flow of revenue.

Accuracy vs. Productivity – Medical Coder

Recently, AAPC conducted a survey to find out from billing and coding professionals which among the two (accuracy and productivity) is preferred over the other by billing and coding managers and the survey revealed a mixed response establishing the supremacy of neither of the two over the other, leading to the conclusion that a billing and coding manager expects his/her team of billers and coders “to efficiently produce accurate work”.

Medical Coding with MBC

Medicalbillerandcoders.com believes, that when it comes to billing and coding, certifications help bridge this gap. Most of MBC’s billers and coders are certified in CPC, CCS which CPAT, all of which require passing a coding certification examination which involves questions to examine the ability of billers and coders to accurately apply CPT and HCPCS procedures and supply ICD-9-CM diagnosis codes. This helps MBC’s coding professionals to refresh and renew their skills and be assured of them.

MBC the largest billing and coding consortium in the US with a countrywide network of highly experienced billers and coders takes particular care of keeping their team updated with the current changes in the industry. With changes taking place in the change-prone areas of medical coding, like - codes, software applications and forms.

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