According
to authors Jung and Feldman, the introduction of Home Health Compare, a
public reporting program initiated by Medicare in 2003, had a very
small and weak effect on selective exits by home health agencies between
2002 and 2004,. A 10-percent increase in reporting, the equivalent to
reporting one more indicator per agency, increased the probability of a
home health agency leaving an area with less-educated people by 0.3
percentage points, compared with leaving an area with high education.
This small level of market-area exits under public reporting is unlikely
to be practically meaningful, suggesting that Home Health Compare did
not lead to a disruption in access to home health care through selective
exits during the initial year of the program. Read the full paper,
“Medication Days’ Supply, Adherence, Wastage, and Cost Among Chronic
Patients in Medicaid,” published in Volume 2, Issue 4 of the Medicare
& Medicaid Research Review.
Friday, January 18, 2013
Countdown to Affordable Health Insurance
January is the perfect month for looking forward to new and great things around the corner.
I’m feeling that way about the new Health Insurance Marketplace.
Anticipation is building, and this month we start an important
countdown, first to October 1, 2013, when open enrollment begins, and
continuing on to January 1, 2014, the start of new health insurance
coverage for millions of Americans. In October, many of you’ll be able
to shop for health insurance that meets your needs at the new
Marketplace at HealthCare.gov.
This is an historic time for those Americans who never had health
insurance, who had to go without insurance after losing a job or
becoming sick, or who had been turned down because of a pre-existing
condition. Because of these new marketplaces established under the
Affordable Care Act, millions of Americans will have new access to
affordable health insurance coverage.
Over the last two years we’ve worked closely with states to begin
building their health insurance marketplaces, also known as Exchanges,
so that families and small-business owners will be able to get accurate
information to make apples-to-apples comparisons of private insurance
plans and, get financial help to make coverage more affordable if
they’re eligible.
That is why we are so excited about launching the newly rebuilt HealthCare.gov
website, where you’ll be able to buy insurance from qualified private
health plans and check if you are eligible for financial assistance —
all in one place, with a single application. Many individuals and
families will be eligible for a new kind of tax credit to help lower
their premium costs. If your state is running its own Marketplace, HealthCare.gov will make sure you get to the right place.
The Marketplace will offer much more than any health insurance
website you’ve used before. Insurers will compete for your business on a
level playing field, with no hidden costs or misleading fine print.
It’s not too soon to check out HealthCare.gov for new information about the Marketplace
and tips for things you can do now to prepare for enrollment. And,
make sure to sign up for emails or text message updates, so you don’t
miss a thing when it’s time to enroll.
There is still work to be done to make sure the insurance market
works for families and small businesses. But, for millions of Americans,
the time for having the affordable, quality health care coverage,
security, and peace of mind they need and deserve is finally within
sight.
Mental Health Parity Guidance
Today
in connection with the President’s announcement regarding the national
response to the Sandy Hook tragedy, the Centers for Medicare & Medicaid Services (CMS) released a State Health Official letter on the
application of the Mental Health Parity and Addiction Equity Act to
Medicaid managed care organizations, the Children’s Health Insurance
Program, and alternative benefit (benchmark) plans.
The State Health Official letter is available online at http://www.medicaid.gov/
CMS NEWS
Millions of Americans newly eligible for quality, affordable health coverage in 2014
Administration proposes guidance for Medicaid, health insurance marketplaces
Because
of the Affordable Care Act, millions of Americans will be newly
eligible to receive quality, affordable health care through Medicaid and
the new health insurance marketplaces (also known as the Exchanges) in
2014. Health and Human Services (HHS) Secretary Kathleen Sebelius today
released a proposed rule that promotes consistent policies and
processes for eligibility notices and appeals in Medicaid, the
Children's Health Insurance Program (CHIP), and Exchanges and give
states more flexibility when operating their Medicaid programs. HHS
encourages all Americans to review and submit comments on the proposed
rule.
“Before
the health care law was passed, millions of Americans were unable to
obtain or afford quality health coverage,” Secretary Sebelius said.
“Today, we are proposing a rule to provide Americans with access to
affordable, high quality health coverage and give states more
flexibility to implement the law in a way that works for them.”
Beginning
in 2014, the health care law provides new opportunities for Medicaid
coverage for adults who earn up to 133 percent of poverty -- $14,865 for
an individual or $30,656 for a family of four. Other Americans looking
for coverage will be eligible to buy it through a health insurance
marketplace, where many will be eligible for tax credits to make
coverage more affordable. The rules proposed today will help develop
systems that will make it easy for consumers to determine if they are
eligible for Medicaid or tax credits that make insurance more
affordable.
Today’s
proposed rule includes information on how consumers will receive
coordinated communications on eligibility determinations and can appeal
eligibility determinations. It gives states flexibility in designing
benefits and determining cost sharing in the Medicaid program. The
proposed rule also provides flexibility to state-based Exchanges by
allowing them to choose to rely on HHS for verifying whether an
individual has employer-sponsored coverage and conducting some types of
appeals.
For more information on this proposed rule, please visit: http://www.cms.gov/apps/media/
Medicaid Eligibility, Benefits, and Appeals
We are pleased to announce that today CMS put on display in the Federal Register
a Notice of Proposed Rulemaking (NPRM) titled “Medicaid Eligibility
Expansion Under the Affordable Care Act of 2010, Part 2” (CMS-2334-P).
The NPRM provides further guidance to assist states with implementing
the Affordable Care Act’s plan for achieving a simple, streamlined
system of affordable health care for nearly all Americans. It will be
formally published on January 22, 2013. See attached for more
information.
For more information: Download
Health Home Core Quality Measures Guidance
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the
availability of new guidance today related to health homes, authorized
by section 2703 of the Affordable Care Act. Health homes provide an
opportunity to build a person-centered care delivery model that focuses
on improving outcomes and disease management for beneficiaries with
chronic conditions and obtaining better value for state Medicaid
programs. See attached for more information.
Tuesday, January 15, 2013
Medicare doctor pay freeze until 2014 — 26.5% cut averted
Washington Congress on New Year’s Day stopped a massive reduction to Medicare doctor payments by freezing rates at 2012 levels for one year.
Late on Jan. 1, the House voted for a measure the Senate approved early that morning that overrides a 26.5% cut to Medicare pay that technically went into effect at the beginning of the day. The bill preventing the steep reduction in pay for services passed Congress as part of a larger legislative package that also extends certain tax cuts and postpones across-the-board spending reductions.
President Obama had urged Congress to adopt the compromise bill and said he would sign it into law, meaning the Medicare rate cut will not apply to any 2013 claims.
The patch alleviates the problem only temporarily, said American Medical Association President Jeremy A. Lazarus, MD. Congress delayed the cut until 2014, when payment rates will be reduced by about 25% without further congressional action, according to current projections. The unstable Medicare pay system must be dealt with permanently over the coming months, Dr. Lazarus added.
“This last-minute action on the part of Congress is a clear example of how the Medicare program is increasingly unreliable for physicians and patients,” he said. “This instability stalls progress in moving Medicare toward new health care delivery models that can improve value for patients through better care coordination. Physicians want to work with Congress to move past this ongoing crisis and toward a Medicare program that ensures access to care and the best health outcomes for patients, and a stable, rewarding practice environment for physicians.”
The package also delays by two months a separate 2% cut to Medicare physician pay mandated under the automatic spending reduction process known as budget sequestration. Congress must act again by March 1 if it wants to prevent that reduction from taking place.
Spending reductions in other areas of Medicare were used to offset the $25.2 billion cost of stopping the sustainable growth rate cut for 2013. An inpatient prospective payment system adjustment cuts $10.5 billion from hospitals from 2014-18. Revisions to how Medicare calculates bundled payments for end-stage renal disease treatments would save $4.9 billion over 10 years. An expansion of the Medicare payment policy that pays less for multiple therapy services provided to the same patient on the same day secures another $1.8 billion for the program, while another provision reduces pay by $800 million for advanced imaging services. Rebasing state disproportionate share hospital payments in 2022 would produce another $4.2 billion in federal health savings.
The legislation also extends several Medicare payment provisions that were set to expire on Dec. 31, 2012. A $500 million increase to physician rates for doctors working in low-cost states will continue until 2014. Exemptions to caps on therapy services also were extended through the end of 2013.
Late on Jan. 1, the House voted for a measure the Senate approved early that morning that overrides a 26.5% cut to Medicare pay that technically went into effect at the beginning of the day. The bill preventing the steep reduction in pay for services passed Congress as part of a larger legislative package that also extends certain tax cuts and postpones across-the-board spending reductions.
President Obama had urged Congress to adopt the compromise bill and said he would sign it into law, meaning the Medicare rate cut will not apply to any 2013 claims.
The patch alleviates the problem only temporarily, said American Medical Association President Jeremy A. Lazarus, MD. Congress delayed the cut until 2014, when payment rates will be reduced by about 25% without further congressional action, according to current projections. The unstable Medicare pay system must be dealt with permanently over the coming months, Dr. Lazarus added.
“This last-minute action on the part of Congress is a clear example of how the Medicare program is increasingly unreliable for physicians and patients,” he said. “This instability stalls progress in moving Medicare toward new health care delivery models that can improve value for patients through better care coordination. Physicians want to work with Congress to move past this ongoing crisis and toward a Medicare program that ensures access to care and the best health outcomes for patients, and a stable, rewarding practice environment for physicians.”
The package also delays by two months a separate 2% cut to Medicare physician pay mandated under the automatic spending reduction process known as budget sequestration. Congress must act again by March 1 if it wants to prevent that reduction from taking place.
Spending reductions in other areas of Medicare were used to offset the $25.2 billion cost of stopping the sustainable growth rate cut for 2013. An inpatient prospective payment system adjustment cuts $10.5 billion from hospitals from 2014-18. Revisions to how Medicare calculates bundled payments for end-stage renal disease treatments would save $4.9 billion over 10 years. An expansion of the Medicare payment policy that pays less for multiple therapy services provided to the same patient on the same day secures another $1.8 billion for the program, while another provision reduces pay by $800 million for advanced imaging services. Rebasing state disproportionate share hospital payments in 2022 would produce another $4.2 billion in federal health savings.
The legislation also extends several Medicare payment provisions that were set to expire on Dec. 31, 2012. A $500 million increase to physician rates for doctors working in low-cost states will continue until 2014. Exemptions to caps on therapy services also were extended through the end of 2013.
Medicare pay reprieve in place; next threat is 2% cut in March
Washington After another year-end nail-biter on Capitol Hill in which lawmakers made preventing a massive Medicare physician pay cut their last action before adjourning, organized medicine called on Congress to chart a more rational course on the issue in 2013.
Late on Jan. 1, the House voted in favor of a legislative package approved by the Senate in the early hours of the morning that postponed a 26.5% cut to doctors’ pay rates mandated by the sustainable growth rate formula, clearing the way for President Obama’s signature on Jan. 2. Although enactment technically came after the cut officially had taken effect, the result of the retroactive measure is that all 2013 physician claims will be paid at 2012 levels. The House vote on the package was 257-167, and the Senate vote was 89-8.
Organized medicine groups, including the American Medical Association, hailed the passage of the latest SGR patch but reiterated their strong belief that Congress must approve a permanent solution that avoids the recurring year-end drama that ensues from leaving the temporary measure until the eleventh hour. The latest stopgap freezes doctor pay rates only through the end of 2013, after which the formula again will slash rates by about a quarter without a new legislative revision.
“This last-minute action on the part of Congress is a clear example of how the Medicare program is increasingly unreliable for physicians and patients,” said AMA President Jeremy A. Lazarus, MD. “This instability stalls progress in moving Medicare toward new health care delivery models that can improve value for patients through better care coordination. Physicians want to work with Congress to move past this ongoing crisis and toward a Medicare program that ensures access to care and the best health outcomes for patients, and a stable, rewarding practice environment for physicians.”
David L. Bronson, MD, president of the American College of Physicians, said it was regrettable that Congress did not pursue a more lasting solution to the chronic problem of the physician pay formula.
“In the short term, this legislation helps ensure access to high-quality medical care for Medicare beneficiaries, and ensures that physician payments under Medicare will not be cut through 2013,” Dr. Bronson said. “However, a greater bipartisan effort is still needed in the coming year to approve legislation that permanently repeals once and for all the flawed SGR formula, and transitions to payment models that provide predictable annual updates to physicians participating in Medicare, while being aligned with the provision of high-quality and efficient care.”
Medicare sequester cut still looms
The SGR patch was included in a broader legislative tax and spending package designed to address major elements of what lawmakers and others have referred to as the fiscal cliff. The measure extends some tax cuts for many Americans and postpones a series of automatic federal defense and nondefense spending reductions known as sequestration.
Medicare physician pay rates and many other federal expenditures would be affected by the sequester, the consequence of Congress and the Obama administration failing to agree on more targeted spending cuts during 2011 negotiations. If such an agreement or another delay cannot be achieved by March 1, the new sequestration deadline established by the departing 112th Congress, doctor pay will be reduced by 2% under the automatic cuts. Certain non-Medicare health programs, such as clinical research and health professions funding, will be cut by 7.8% for 2013.
“The sequestration’s 2% cut in Medicare physician payment undercuts the positive impact of the 12-month patch to the sustainable growth rate,” said Glen Stream, MD, the American Academy of Family Physicians board chair. “Such a cut perpetuates the cycle of instability that elderly and disabled Americans have suffered for more than 10 years.”
Dr. Stream added that the higher sequester cut on health professions grants would endanger the ability of the primary care work force to meet future patient demand.
Even if the 113th Congress forges an agreement with the White House over alternative spending reductions to the across-the-board cuts, federal health programs are likely to shoulder a significant portion of the load. Medicaid spending, as well as Medicare benefits and eligibility, cannot be touched by sequestration, but lawmakers are under no such restrictions when crafting an alternative plan.
Obama acknowledged Medicare as a major driver of the national debt in remarks after House approval of the fiscal cliff package.
“I agree with Democrats and Republicans that the aging population and the rising cost of health care makes Medicare the biggest contributor to our deficit,” Obama said on Jan. 1 after the House vote. “I believe we’ve got to find ways to reform that program without hurting seniors who count on it to survive. And I believe that there’s further unnecessary spending in government that we can eliminate.”
Deep partisan disagreements over allowing tax rates to rise on higher-income earners nearly torpedoed the entire Jan. 1 package, including the Medicare pay freeze. Congressional observers predicted another bruising fight over spending in the months leading up to the new sequestration deadline.
“The bill sets Congress and the White House up to revisit these battles and a major deficit reduction effort in two months,” said Eric Zimmerman, a partner in the Washington office of McDermott Will & Emery. “Sometime between now and March 1, 2013, Congress and the White House will need to come to agreement on how to reapportion sequestration, fund the federal government for the balance of [fiscal] 2013 and raise the debt ceiling, and Medicare and Medicaid spending will feature prominently in those debates.”
Hospital, dialysis, imaging pay take hits
The passage of the latest physician payment patch only delays the SGR cut by a year, but the move did not come without a significant cost. Other areas of Medicare, some of which might impact doctors’ pay directly, were subjected to cuts to help pay for the temporary solution. The $25.2 billion cost of freezing Medicare doctor pay rates at 2012 levels — as well as the roughly $4 billion cost of extending certain expiring Medicare and other health payment provisions — was paid for in large part by reducing payments to hospitals, dialysis providers and Medicare private plans.
Hospital organizations expressed disappointment at being hit with cuts that were used as offsets for the across-the-board physician pay freeze and Medicare extensions. One offset involves changing the inpatient prospective payment system to reduce hospital payments by $10.5 billion.
“It is not in the best interest of patients or those who care for them to rob hospital Peter to pay for fiscal cliff Paul,” said Chip Kahn, the Federation of American Hospitals president and CEO. “These cuts could impact hospital services for those who need them the most.”
In addition, revisions in the way Medicare calculates the expected use of certain drugs when bundling payments for end-stage renal disease treatment providers also will result in $4.9 billion in pay reductions that the ACP’s Dr. Bronson noted will affect compensation for physicians providing care to kidney disease patients.
The American College of Radiology blasted Congress for approving an offset provision that will reduce payments for certain advanced imaging services by $800 million to help pay for the SGR patch.
“Reverting to continuous provider cuts to help pay for a morbidly flawed payment policy, in an environment that resembles more ‘Alice in Wonderland’ than ‘Mr. Smith Goes to Washington,’ is an embarrassment to our country and a disservice to our nation’s seniors,” said Paul Ellenbogen, MD, chair of the ACR Board of Chancellors. “These cuts will ultimately damage patient access to medical imaging care and may drive up long-term costs by delaying diagnosis of illness and disease to later stages where more expansive, and expensive, treatments are required.”
Dr. Bronson noted, however, that lawmakers did not pursue some ideas for savings that were floated during budget negotiations, such as rescinding a health system reform law provision that raises Medicaid rates for primary care physicians to Medicare levels in 2013 and 2014. Congress also steered clear of cuts to graduate medical education as well as evaluation and management changes that would have reduced hospital pay further.
Late on Jan. 1, the House voted in favor of a legislative package approved by the Senate in the early hours of the morning that postponed a 26.5% cut to doctors’ pay rates mandated by the sustainable growth rate formula, clearing the way for President Obama’s signature on Jan. 2. Although enactment technically came after the cut officially had taken effect, the result of the retroactive measure is that all 2013 physician claims will be paid at 2012 levels. The House vote on the package was 257-167, and the Senate vote was 89-8.
Organized medicine groups, including the American Medical Association, hailed the passage of the latest SGR patch but reiterated their strong belief that Congress must approve a permanent solution that avoids the recurring year-end drama that ensues from leaving the temporary measure until the eleventh hour. The latest stopgap freezes doctor pay rates only through the end of 2013, after which the formula again will slash rates by about a quarter without a new legislative revision.
“This last-minute action on the part of Congress is a clear example of how the Medicare program is increasingly unreliable for physicians and patients,” said AMA President Jeremy A. Lazarus, MD. “This instability stalls progress in moving Medicare toward new health care delivery models that can improve value for patients through better care coordination. Physicians want to work with Congress to move past this ongoing crisis and toward a Medicare program that ensures access to care and the best health outcomes for patients, and a stable, rewarding practice environment for physicians.”
David L. Bronson, MD, president of the American College of Physicians, said it was regrettable that Congress did not pursue a more lasting solution to the chronic problem of the physician pay formula.
“In the short term, this legislation helps ensure access to high-quality medical care for Medicare beneficiaries, and ensures that physician payments under Medicare will not be cut through 2013,” Dr. Bronson said. “However, a greater bipartisan effort is still needed in the coming year to approve legislation that permanently repeals once and for all the flawed SGR formula, and transitions to payment models that provide predictable annual updates to physicians participating in Medicare, while being aligned with the provision of high-quality and efficient care.”
Medicare sequester cut still looms
The SGR patch was included in a broader legislative tax and spending package designed to address major elements of what lawmakers and others have referred to as the fiscal cliff. The measure extends some tax cuts for many Americans and postpones a series of automatic federal defense and nondefense spending reductions known as sequestration.
Medicare physician pay rates and many other federal expenditures would be affected by the sequester, the consequence of Congress and the Obama administration failing to agree on more targeted spending cuts during 2011 negotiations. If such an agreement or another delay cannot be achieved by March 1, the new sequestration deadline established by the departing 112th Congress, doctor pay will be reduced by 2% under the automatic cuts. Certain non-Medicare health programs, such as clinical research and health professions funding, will be cut by 7.8% for 2013.
“The sequestration’s 2% cut in Medicare physician payment undercuts the positive impact of the 12-month patch to the sustainable growth rate,” said Glen Stream, MD, the American Academy of Family Physicians board chair. “Such a cut perpetuates the cycle of instability that elderly and disabled Americans have suffered for more than 10 years.”
Dr. Stream added that the higher sequester cut on health professions grants would endanger the ability of the primary care work force to meet future patient demand.
Even if the 113th Congress forges an agreement with the White House over alternative spending reductions to the across-the-board cuts, federal health programs are likely to shoulder a significant portion of the load. Medicaid spending, as well as Medicare benefits and eligibility, cannot be touched by sequestration, but lawmakers are under no such restrictions when crafting an alternative plan.
Obama acknowledged Medicare as a major driver of the national debt in remarks after House approval of the fiscal cliff package.
“I agree with Democrats and Republicans that the aging population and the rising cost of health care makes Medicare the biggest contributor to our deficit,” Obama said on Jan. 1 after the House vote. “I believe we’ve got to find ways to reform that program without hurting seniors who count on it to survive. And I believe that there’s further unnecessary spending in government that we can eliminate.”
Deep partisan disagreements over allowing tax rates to rise on higher-income earners nearly torpedoed the entire Jan. 1 package, including the Medicare pay freeze. Congressional observers predicted another bruising fight over spending in the months leading up to the new sequestration deadline.
“The bill sets Congress and the White House up to revisit these battles and a major deficit reduction effort in two months,” said Eric Zimmerman, a partner in the Washington office of McDermott Will & Emery. “Sometime between now and March 1, 2013, Congress and the White House will need to come to agreement on how to reapportion sequestration, fund the federal government for the balance of [fiscal] 2013 and raise the debt ceiling, and Medicare and Medicaid spending will feature prominently in those debates.”
Hospital, dialysis, imaging pay take hits
The passage of the latest physician payment patch only delays the SGR cut by a year, but the move did not come without a significant cost. Other areas of Medicare, some of which might impact doctors’ pay directly, were subjected to cuts to help pay for the temporary solution. The $25.2 billion cost of freezing Medicare doctor pay rates at 2012 levels — as well as the roughly $4 billion cost of extending certain expiring Medicare and other health payment provisions — was paid for in large part by reducing payments to hospitals, dialysis providers and Medicare private plans.
Hospital organizations expressed disappointment at being hit with cuts that were used as offsets for the across-the-board physician pay freeze and Medicare extensions. One offset involves changing the inpatient prospective payment system to reduce hospital payments by $10.5 billion.
“It is not in the best interest of patients or those who care for them to rob hospital Peter to pay for fiscal cliff Paul,” said Chip Kahn, the Federation of American Hospitals president and CEO. “These cuts could impact hospital services for those who need them the most.”
In addition, revisions in the way Medicare calculates the expected use of certain drugs when bundling payments for end-stage renal disease treatment providers also will result in $4.9 billion in pay reductions that the ACP’s Dr. Bronson noted will affect compensation for physicians providing care to kidney disease patients.
The American College of Radiology blasted Congress for approving an offset provision that will reduce payments for certain advanced imaging services by $800 million to help pay for the SGR patch.
“Reverting to continuous provider cuts to help pay for a morbidly flawed payment policy, in an environment that resembles more ‘Alice in Wonderland’ than ‘Mr. Smith Goes to Washington,’ is an embarrassment to our country and a disservice to our nation’s seniors,” said Paul Ellenbogen, MD, chair of the ACR Board of Chancellors. “These cuts will ultimately damage patient access to medical imaging care and may drive up long-term costs by delaying diagnosis of illness and disease to later stages where more expansive, and expensive, treatments are required.”
Dr. Bronson noted, however, that lawmakers did not pursue some ideas for savings that were floated during budget negotiations, such as rescinding a health system reform law provision that raises Medicaid rates for primary care physicians to Medicare levels in 2013 and 2014. Congress also steered clear of cuts to graduate medical education as well as evaluation and management changes that would have reduced hospital pay further.
Source: http://www.ama-assn.org/amednews/2013/01/07/gvl10107.htm
Wednesday, January 2, 2013
CMS Announces 90-Day Period of Enforcement Discretion for Compliance with Eligibility and Claim Status Operating Rules
Today, the Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services (OESS) announced that to reduce the potential of significant disruption to the health care industry, it will not initiate enforcement action until March 31, 2013, with respect to HIPAA covered entities (including health plans, health care providers, and clearinghouses, as applicable) that are not in compliance with the operating rules adopted for the following transactions as required by the Affordable Care Act: eligibility for a health plan and health care claim status. Notwithstanding OESS’ discretionary application of its enforcement authority, the compliance date for using the operating rules remains January 1, 2013.
Industry feedback suggests that HIPAA covered entities have not reached a threshold whereby a majority of covered entities would be able to be in compliance with the operating rules by January 1, 2013. This enforcement discretion period does not prevent applicable HIPAA covered entities that are prepared to conduct transactions using the adopted operating rules from doing so, and all applicable covered entities are encouraged to determine their readiness to use the operating rules as of January 1, 2013 and expeditiously become compliant. Although enforcement action will not be taken, OESS will accept complaints associated with compliance with the operating rules beginning January 1, 2013. If requested by OESS, covered entities that are the subject of complaints (known as “filed-against entities”) must produce evidence of either compliance or a good faith effort to become compliant with the operating rules during the 90-day period. HHS will continue to work to align the requirements under Section 1104 of the Affordable Care Act to optimize industry’s ability to achieve timely compliance.
OESS is the U.S. Department of Health and Human Services’ (HHS) component that enforces compliance with HIPAA transaction and code set standards, including operating rules, identifiers and other standards required under HIPAA by the Affordable Care Act.
For copies of the operating rules for the eligibility for a health plan and health care claim status transactions, visit the Council for Affordable Quality Healthcare (CAQH) CORE website at http://www.caqh.org. Links to information on the operating rules for eligibility for a health plan and health care claim status are available at http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/OperatingRulesforEligibilityandClaimsStatus.html
Friday, December 28, 2012
Statistical Uncertainty in the Medicare Shared Savings Program
- Title: Statistical Uncertainty in the Medicare Shared Savings Program
- First Author: DeLia, Derek
- Date of Article: 2012 Q4
Full Title: Statistical Uncertainty in the Medicare Shared Savings Program
Other Authors: Donald Hoover, Joel C. Cantor
Volume: 2012
Issue: Q4
Summary:
According to analysis reported in “Statistical Uncertainty in the
Medicare Shared Savings Program” published in Volume 2, Issue 4 of the
Medicare & Medicaid Research Review, the role of random fluctuations
in year-to-year healthcare spending may play a larger role in savings
measurement than previously anticipated. Although CMS is fairly well
protected from the chance that an Accountable Care Organization (ACO)
would be rewarded inappropriately for savings that did not truly occur,
ACOs are much less protected from the analogous chance that they are
inappropriately denied rewards for savings that do occur. Smaller ACOs
are especially vulnerable to the chance of being inappropriately denied
credit for achieved savings. The article concludes with a discussion of
strategies that can be used to anticipate and minimize the role of
chance variation in ACO savings measurement.
Keywords:
Medicare, Econometrics, Health Care Organizations and Systems, Health
Economics, Health Policy / Politics / Law / Regulation, Incentives in
Health Care, Payment Systems: FFS / Capitation / RBRVS / DRGs / Risk
Adjusted Payments etc., Health Care Costs, Health Care Financing /
Insurance / Premiums
For More information Click Here
Monday, August 20, 2012
CMS Announces Primary Care Practices to Participate in Historic Public-Private Partnership to Strengthen Primary Care
In support of more effective, more affordable, higher quality health
care, 500 primary care practices in seven regions have been selected to
participate in a new partnership between payers from the Centers for
Medicare & Medicaid Services (CMS), state Medicaid agencies,
commercial health plans, self-insured businesses, and primary care
providers. This partnership is designed to provide improved access to
quality health care at lower costs.
Under the Comprehensive Primary Care Initiative, CMS will pay primary care practices a care management fee, initially set at an average of $20 per beneficiary per month, to support enhanced, coordinated services on behalf of Medicare fee-for-service beneficiaries. Simultaneously, participating commercial, state, and other federal insurance plans are also offering enhanced payment to primary care practices that are designed to support them in providing high-quality primary care on behalf of their members.
For patients, this means these physicians may offer longer and more flexible hours, use electronic health records; coordinate care with patients’ other health care providers; better engage patients and caregivers in managing their own care, and provide individualized, enhanced care for patients living with multiple chronic diseases and higher needs.
The initiative started in the fall of 2011 with CMS soliciting a diverse pool of commercial health plans, state Medicaid agencies, and self-insured businesses to work alongside Medicare to support comprehensive primary care. Public and private health plans in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley region, Ohio and Kentucky’s Cincinnati-Dayton region, and the Greater Tulsa region of Oklahoma signed letters of intent with CMS to participate in this initiative. The markets were selected in April, 2012 based on the percentage of the total population covered by payers who expressed interest in joining this partnership.
Eligible primary care practices in each market were invited to apply to participate and start delivering enhanced health care services in the fall of 2012. Through a competitive application process, primary care practices within the selected markets were chosen to participate in the Comprehensive Primary Care initiative. Practices were chosen based on their use of health information technology, ability to demonstrate recognition of advanced primary care delivery by leading clinical societies, service to patients covered by participating payers, participation in practice transformation and improvement activities, and diversity of geography, practice size, and ownership structure. CMS estimates that over 300,000 Medicare beneficiaries will be served by over 2,000 providers through this initiative.
“Primary care practices play a vital role in our health care system and we are looking at ways to better support them in their efforts to coordinate care for their patients” said Acting CMS Administrator Marilyn Tavenner.
The Comprehensive Primary Care initiative is a four-year initiative administered by the Center for Medicare and Medicaid Innovation (CMS Innovation Center). The CMS Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models that have the potential to reduce program expenditures while preserving or enhancing the quality of care.
Under the Comprehensive Primary Care Initiative, CMS will pay primary care practices a care management fee, initially set at an average of $20 per beneficiary per month, to support enhanced, coordinated services on behalf of Medicare fee-for-service beneficiaries. Simultaneously, participating commercial, state, and other federal insurance plans are also offering enhanced payment to primary care practices that are designed to support them in providing high-quality primary care on behalf of their members.
For patients, this means these physicians may offer longer and more flexible hours, use electronic health records; coordinate care with patients’ other health care providers; better engage patients and caregivers in managing their own care, and provide individualized, enhanced care for patients living with multiple chronic diseases and higher needs.
The initiative started in the fall of 2011 with CMS soliciting a diverse pool of commercial health plans, state Medicaid agencies, and self-insured businesses to work alongside Medicare to support comprehensive primary care. Public and private health plans in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley region, Ohio and Kentucky’s Cincinnati-Dayton region, and the Greater Tulsa region of Oklahoma signed letters of intent with CMS to participate in this initiative. The markets were selected in April, 2012 based on the percentage of the total population covered by payers who expressed interest in joining this partnership.
Eligible primary care practices in each market were invited to apply to participate and start delivering enhanced health care services in the fall of 2012. Through a competitive application process, primary care practices within the selected markets were chosen to participate in the Comprehensive Primary Care initiative. Practices were chosen based on their use of health information technology, ability to demonstrate recognition of advanced primary care delivery by leading clinical societies, service to patients covered by participating payers, participation in practice transformation and improvement activities, and diversity of geography, practice size, and ownership structure. CMS estimates that over 300,000 Medicare beneficiaries will be served by over 2,000 providers through this initiative.
“Primary care practices play a vital role in our health care system and we are looking at ways to better support them in their efforts to coordinate care for their patients” said Acting CMS Administrator Marilyn Tavenner.
The Comprehensive Primary Care initiative is a four-year initiative administered by the Center for Medicare and Medicaid Innovation (CMS Innovation Center). The CMS Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models that have the potential to reduce program expenditures while preserving or enhancing the quality of care.
Thursday, August 16, 2012
People with Medicare Save Over $4.1 Billion on Prescription Drugs Thanks To the Health Care Law
As a result of the Affordable Care Act – the health care law enacted in
2010 – nearly 5.4 million seniors and people with disabilities have
saved over $4.1 billion on prescription drugs since the law was enacted,
Health and Human Services (HHS) Secretary Kathleen Sebelius announced
today. Seniors in the Medicare prescription drug coverage gap known as
the “donut hole” have saved an average of $768.
In addition, during the first seven months of 2012, the new health care law has helped nearly 18 million people with original Medicare get at least one preventive service at no cost to them.
“The health care law has saved people with Medicare over $4.1 billion on prescription drugs, and given millions access to cancer screenings, mammograms and other preventive services for free,” said Secretary Sebelius. “Medicare is stronger thanks to the health care law, saving people money and offering new benefits at no cost to seniors.”
The health care law includes benefits to make Medicare prescription drug coverage more affordable. In 2010, anyone with Medicare who hit the prescription drug donut hole received a $250 rebate. In 2011, people with Medicare who hit the donut hole began receiving a 50% discount on covered brand-name drugs and a discount on generic drugs. These discounts and Medicare coverage gradually increase until 2020 when the donut hole is closed.
The health care law also makes it easier for people with Medicare to stay healthy. Prior to 2011, people with Medicare had to pay extra for many preventive health services. These costs made it difficult for people to get the health care they needed. For example, before the health care law passed, a person with Medicare could pay as much as $160 for a colorectal cancer screening. Thanks to the Affordable Care Act, many preventive services are offered free of charge to beneficiaries, with no deductible or co-pay, so that cost is no longer a barrier for seniors who want to stay healthy and treat problems early.
In 2012 alone, 18 million people with traditional Medicare have received at least one preventive service at no cost to them. This includes 1.65 million who have taken advantage of the Annual Wellness Visit provided by the Affordable Care Act – over 500,000 more than had used this service by this point in the year in 2011. In 2011, an estimated 32.5 million people with traditional Medicare or Medicare Advantage received one or more preventive benefits free of charge.
For state-by-state information on savings in the donut hole, please visit: http://www.cms.gov/apps/files/donut-hole-data-chart.pdf
For state-by-state information on utilization of free preventive services, please visit: http://www.cms.gov/apps/files/preventive-data-chart-first-seven-months-2012.pdf
In addition, during the first seven months of 2012, the new health care law has helped nearly 18 million people with original Medicare get at least one preventive service at no cost to them.
“The health care law has saved people with Medicare over $4.1 billion on prescription drugs, and given millions access to cancer screenings, mammograms and other preventive services for free,” said Secretary Sebelius. “Medicare is stronger thanks to the health care law, saving people money and offering new benefits at no cost to seniors.”
The health care law includes benefits to make Medicare prescription drug coverage more affordable. In 2010, anyone with Medicare who hit the prescription drug donut hole received a $250 rebate. In 2011, people with Medicare who hit the donut hole began receiving a 50% discount on covered brand-name drugs and a discount on generic drugs. These discounts and Medicare coverage gradually increase until 2020 when the donut hole is closed.
The health care law also makes it easier for people with Medicare to stay healthy. Prior to 2011, people with Medicare had to pay extra for many preventive health services. These costs made it difficult for people to get the health care they needed. For example, before the health care law passed, a person with Medicare could pay as much as $160 for a colorectal cancer screening. Thanks to the Affordable Care Act, many preventive services are offered free of charge to beneficiaries, with no deductible or co-pay, so that cost is no longer a barrier for seniors who want to stay healthy and treat problems early.
In 2012 alone, 18 million people with traditional Medicare have received at least one preventive service at no cost to them. This includes 1.65 million who have taken advantage of the Annual Wellness Visit provided by the Affordable Care Act – over 500,000 more than had used this service by this point in the year in 2011. In 2011, an estimated 32.5 million people with traditional Medicare or Medicare Advantage received one or more preventive benefits free of charge.
For state-by-state information on savings in the donut hole, please visit: http://www.cms.gov/apps/files/donut-hole-data-chart.pdf
For state-by-state information on utilization of free preventive services, please visit: http://www.cms.gov/apps/files/preventive-data-chart-first-seven-months-2012.pdf
Tuesday, August 14, 2012
HHS Partners With Pharmacies to Educate Medicare Beneficiaries about New Health Benefits
Today, Health and Human Services (HHS) Secretary Kathleen Sebelius
announced partnerships with several pharmacies to help customers learn
about new Medicare benefits available to them under the Affordable Care
Act – the health care law. These partnerships – with CVS Caremark,
Walgreens, Thrifty White, Walmart, and Sam’s Club – will provide
Medicare beneficiaries a range of educational materials on newly
available preventive services, as well as savings on prescription drug spending
in the “donut hole” coverage gap. At a CVS in Jacksonville, Secretary
Sebelius discussed the new preventive services and received a free blood
pressure reading at the CVS MinuteClinic.
“Our pharmacy partners are helping their customers make informed health care decisions,” said Secretary Sebelius. “These partnerships will help people with Medicare learn more about new preventive services such as mammograms, and the new Annual Wellness visit that are available at no charge for everyone with Medicare.”
Some examples of how pharmacy partners are working to increase awareness of preventive services available under Medicare include the following:
“Our pharmacy partners are helping their customers make informed health care decisions,” said Secretary Sebelius. “These partnerships will help people with Medicare learn more about new preventive services such as mammograms, and the new Annual Wellness visit that are available at no charge for everyone with Medicare.”
Some examples of how pharmacy partners are working to increase awareness of preventive services available under Medicare include the following:
- CVS Caremark is distributing material about new preventive services covered at no cost to beneficiaries at its more than 7,300 CVS/pharmacy stores and 600 MinuteClinic locations, through brochures, register receipt messages and online.
- Thrifty White Pharmacy is providing information on preventive services through its 85 locations throughout the Midwest.
- Walgreens is distributing information in nearly 8,000 pharmacies and over 350 Take Care Clinic locations, as well as using in-store announcements and providing this information as part of its Walgreens Way to Well Health Tour with AARP.
- HHS is working with Walmart and Sam’s Club to provide healthcare information to their shoppers online.
Other pharmacies or partners can find information on how to work with
CMS to educate consumers about the benefits available to them at: http://www.cms.gov/Outreach-and-Education/Outreach/Current-Partnership-Opportunities/index.html
To learn more about Medicare, visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. This announcement is available on the CMS web site at: http://www.cms.gov/apps/media/press_releases.asp.
To learn more about Medicare, visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. This announcement is available on the CMS web site at: http://www.cms.gov/apps/media/press_releases.asp.
Friday, August 10, 2012
HHS Adopts Operating Rules for Electronic Funds Transfers/Remittance Advice
ACTION
The Centers for Medicare & Medicaid Services (CMS) today announced an interim final rule with comment period (IFC) under which the Department of Health and Human Services (HHS) adopts operating rules for the health care electronic funds transfers (EFT) and remittance advice transaction under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Section 1104 of the Affordable Care Act (the Affordable Care Act) requires HHS to issue a series of regulations over the next five years for the purpose of streamlining health care administrative transactions, encouraging greater use of standards by providers, and making existing standards work more efficiently. On July 8, 2011, HHS published the first regulation, an IFC that adopted operating rules for two electronic health care transactions to make it easier for physician practices and hospitals to determine whether a patient is eligible for coverage and the status of a health care claim submitted to a health insurer. On January 10, 2012, HHS published a second regulation, an IFC adopting standards for health care claim payments made via EFT and for electronic remittance advice (ERA).
The regulation announced today is the third in the series. It adopts EFT and ERA operating rules that, when implemented by health plans, are estimated to save the industry, primarily physician practices, between $300 million and $3.3 billion over the next ten years.
Some of the future administrative simplification rules will address the adoption of:
The Centers for Medicare & Medicaid Services (CMS) today announced an interim final rule with comment period (IFC) under which the Department of Health and Human Services (HHS) adopts operating rules for the health care electronic funds transfers (EFT) and remittance advice transaction under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Section 1104 of the Affordable Care Act (the Affordable Care Act) requires HHS to issue a series of regulations over the next five years for the purpose of streamlining health care administrative transactions, encouraging greater use of standards by providers, and making existing standards work more efficiently. On July 8, 2011, HHS published the first regulation, an IFC that adopted operating rules for two electronic health care transactions to make it easier for physician practices and hospitals to determine whether a patient is eligible for coverage and the status of a health care claim submitted to a health insurer. On January 10, 2012, HHS published a second regulation, an IFC adopting standards for health care claim payments made via EFT and for electronic remittance advice (ERA).
The regulation announced today is the third in the series. It adopts EFT and ERA operating rules that, when implemented by health plans, are estimated to save the industry, primarily physician practices, between $300 million and $3.3 billion over the next ten years.
Some of the future administrative simplification rules will address the adoption of:
- A standard unique identifier for health plans;
- A standard for claims attachments; and
- Requirements that health plans certify compliance with all HIPAA standards and operating rules.
BACKGROUND
Congress addressed the need for a consistent framework for electronic health care transactions and other administrative simplification issues through HIPAA. HIPAA amended the Social Security Act (the Act) by adding Part C—Administrative Simplification—to Title XI of the Act, requiring HHS to adopt standards for certain electronic administrative health care transactions to enable health information to be exchanged more efficiently and to achieve greater uniformity in the transmission of health information.
Section 1104(b)(2)(A) of the Affordable Care Act amended section 1173(a)(2) of the Act by adding the electronic funds transfers (EFT) transaction to the list of electronic health care transactions for which the Secretary must adopt a standard under HIPAA. Section 1104(b)(2)(C) of the Affordable Care Act further requires the adoption of operating rules for all HIPAA electronic health care transactions.
Standards include implementation specifications for electronic formats as well as requirements for the data included in that format. By contrast, operating rules include best business practices on how electronic transactions are transmitted and often target obstacles that physician practices, hospitals and health plans encounter in using electronic transactions. For instance, the EFT & ERA Operating Rule Set adopted in today’s rule requires health plans to offer a standardized, online enrollment for EFT and ERA so that physician practices and hospitals can more easily enroll with multiple health plans to receive those transactions electronically. Among other requirements, the EFT & ERA Operating Rule Set requires health plans to send the EFT within a certain number of days of the ERA, making it easier for physician practices and hospitals to reconcile their accounts. The EFT & ERA Operating Rule Set also includes requirements for the initial set-up for the electronic communication between providers and health plans.
In general, the savings and benefits related to use of EFT for business and consumer payments are well established. The most common savings are in paper, printing, and postage costs, as well as savings in staff time to manually process and deposit paper checks. Yet adoption and use of EFT by the health care industry has been low, resulting in administrative savings that go unrealized. The obstacles to greater use of EFT by the health care industry can be lessened by standardization of the EFT transaction and operating rules that target difficulties for physician practices and hospitals in using EFT and ERA. Beyond the material and administrative time savings for health care providers and health plans, the time and resources that physician practices and hospitals spend on billing and related tasks will be better spent delivering health care to patients.
On March 23, 2011, the National Committee on Vital and Health Statistics (NCVHS) sent a letter to the Secretary recommending that the Council for Affordable Quality Healthcare's Committee on Operating Rules for Information Exchange (CAQH CORE) be named as the authoring entity for operating rules for all health care EFT and ERA transactions. Between March and August 2011, CAQH CORE held more than 30 open calls and over 15 straw polls with industry and government representatives to discuss and develop operating rules for EFT and ERA. Over 80 health care entities, including health plans, clearinghouses, providers, and financial institutions, were represented at weekly meetings and worked hard to build consensus on the operating rules. On Dec. 7, 2011, the NCVHS sent a letter to the Secretary recommending that the CAQH CORE EFT & ERA Operating Rule Set be adopted. Based on that recommendation, HHS is adopting the CORE EFT & ERA Operating Rule Set and transaction.
The goal for adopting these operating rules is to support and enhance the health care EFT and ERA transactions and improve the transaction's functionality by applying necessary business rules and guidelines for the electronic exchange of information.
PROVISIONS OF THE IFC ANNOUNCED TODAY
In this interim final rule with comment period (IFC), we are adopting the Phase III Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) EFT & ERA Operating Rule Set, including the CORE v5010 Master Companion Guide Template, for the health care EFT and remittance advice transaction (hereinafter referred to as the EFT & ERA Operating Rule Set), with one exception: We are not adopting Requirement 4.2, titled "Health Care Claim Payment/Advice Batch Acknowledgement Requirements," of the Phase III CORE 350 Health Care Claim Payment/Advice (835) Infrastructure Rule because that requirement requires the use of the Accredited Standards Committee (ASC) X12 999 acknowledgement standard, and the Secretary has not adopted standards for acknowledgements.
Covered entities must be in compliance with the EFT & ERA Operating Rule Set by January 1, 2014.
COSTS/BENEFITS
The EFT & ERA Operating Rule Set is expected to have the most substantial cost and benefit impacts on physician practices, hospitals and health plans. For physician practices and hospitals, there is little to no cost to implement the health care EFT & ERA Operating Rule Set, as providers are the receivers of the transaction and not the senders.
This IFC is estimated to have a net savings of between $300 million and $3.3 billion over ten years. Both costs and benefits are calculated within four areas of administrative tasks:
Congress addressed the need for a consistent framework for electronic health care transactions and other administrative simplification issues through HIPAA. HIPAA amended the Social Security Act (the Act) by adding Part C—Administrative Simplification—to Title XI of the Act, requiring HHS to adopt standards for certain electronic administrative health care transactions to enable health information to be exchanged more efficiently and to achieve greater uniformity in the transmission of health information.
Section 1104(b)(2)(A) of the Affordable Care Act amended section 1173(a)(2) of the Act by adding the electronic funds transfers (EFT) transaction to the list of electronic health care transactions for which the Secretary must adopt a standard under HIPAA. Section 1104(b)(2)(C) of the Affordable Care Act further requires the adoption of operating rules for all HIPAA electronic health care transactions.
Standards include implementation specifications for electronic formats as well as requirements for the data included in that format. By contrast, operating rules include best business practices on how electronic transactions are transmitted and often target obstacles that physician practices, hospitals and health plans encounter in using electronic transactions. For instance, the EFT & ERA Operating Rule Set adopted in today’s rule requires health plans to offer a standardized, online enrollment for EFT and ERA so that physician practices and hospitals can more easily enroll with multiple health plans to receive those transactions electronically. Among other requirements, the EFT & ERA Operating Rule Set requires health plans to send the EFT within a certain number of days of the ERA, making it easier for physician practices and hospitals to reconcile their accounts. The EFT & ERA Operating Rule Set also includes requirements for the initial set-up for the electronic communication between providers and health plans.
In general, the savings and benefits related to use of EFT for business and consumer payments are well established. The most common savings are in paper, printing, and postage costs, as well as savings in staff time to manually process and deposit paper checks. Yet adoption and use of EFT by the health care industry has been low, resulting in administrative savings that go unrealized. The obstacles to greater use of EFT by the health care industry can be lessened by standardization of the EFT transaction and operating rules that target difficulties for physician practices and hospitals in using EFT and ERA. Beyond the material and administrative time savings for health care providers and health plans, the time and resources that physician practices and hospitals spend on billing and related tasks will be better spent delivering health care to patients.
On March 23, 2011, the National Committee on Vital and Health Statistics (NCVHS) sent a letter to the Secretary recommending that the Council for Affordable Quality Healthcare's Committee on Operating Rules for Information Exchange (CAQH CORE) be named as the authoring entity for operating rules for all health care EFT and ERA transactions. Between March and August 2011, CAQH CORE held more than 30 open calls and over 15 straw polls with industry and government representatives to discuss and develop operating rules for EFT and ERA. Over 80 health care entities, including health plans, clearinghouses, providers, and financial institutions, were represented at weekly meetings and worked hard to build consensus on the operating rules. On Dec. 7, 2011, the NCVHS sent a letter to the Secretary recommending that the CAQH CORE EFT & ERA Operating Rule Set be adopted. Based on that recommendation, HHS is adopting the CORE EFT & ERA Operating Rule Set and transaction.
The goal for adopting these operating rules is to support and enhance the health care EFT and ERA transactions and improve the transaction's functionality by applying necessary business rules and guidelines for the electronic exchange of information.
PROVISIONS OF THE IFC ANNOUNCED TODAY
In this interim final rule with comment period (IFC), we are adopting the Phase III Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) EFT & ERA Operating Rule Set, including the CORE v5010 Master Companion Guide Template, for the health care EFT and remittance advice transaction (hereinafter referred to as the EFT & ERA Operating Rule Set), with one exception: We are not adopting Requirement 4.2, titled "Health Care Claim Payment/Advice Batch Acknowledgement Requirements," of the Phase III CORE 350 Health Care Claim Payment/Advice (835) Infrastructure Rule because that requirement requires the use of the Accredited Standards Committee (ASC) X12 999 acknowledgement standard, and the Secretary has not adopted standards for acknowledgements.
Covered entities must be in compliance with the EFT & ERA Operating Rule Set by January 1, 2014.
COSTS/BENEFITS
The EFT & ERA Operating Rule Set is expected to have the most substantial cost and benefit impacts on physician practices, hospitals and health plans. For physician practices and hospitals, there is little to no cost to implement the health care EFT & ERA Operating Rule Set, as providers are the receivers of the transaction and not the senders.
This IFC is estimated to have a net savings of between $300 million and $3.3 billion over ten years. Both costs and benefits are calculated within four areas of administrative tasks:
- Provider enrollment in EFT and ERA;
- Implementing connectivity between trading partners;
- Reassociation of the payment information with the remittance information; and
- Posting payment adjustments and claim denials.
Costs will be borne by the health plans, with much of the benefits coming to providers.
-
CMS estimates that the cost to implement the EFT & ERA Operating
Rules is $1.2 to $2.7 billion for government and commercial health
plans, third party administrators (TPAs), and hospitals and physician
practices over ten years.
- CMS estimates that the savings and cost benefit to using EFT & ERA Operating Rules is $3 to $4.5 billion for government and commercial health plans, TPAs, hospitals and physician office over ten years.
We anticipate that the use of operating rules may help foster
electronic payments. We had previously estimated that use of the health
care EFT standards would save an estimated 800,000 pounds of paper over
ten years.
The operating rules build upon industry-wide health care EFT standards adopted in January of this year. Together with the health care EFT standards, the EFT and ERA operating rules are estimated to save between $2.7 billion and more than $9 billion in administrative costs over ten years by reducing inefficient manual administrative processes for physician practices, hospitals, and health plans.
REGULATION EFFECTIVE DATE/COMPLIANCE DATE
The effective date of this regulation is August 10, 2012. All HIPAA-covered entities must be in compliance with the EFT & ERA Operating Rule Set by January 1, 2014.
The IFC announced today may be viewed at www.ofr.gov/inspection.aspx. The IFC will be published in the Federal Register on Aug. 10, 2012, and comments are due on Oct. 9, 2012.
A news release on the rule may be viewed at http://www.hhs.gov/news and at http://www.cms.gov/apps/media/press_releases.asp.
The operating rules build upon industry-wide health care EFT standards adopted in January of this year. Together with the health care EFT standards, the EFT and ERA operating rules are estimated to save between $2.7 billion and more than $9 billion in administrative costs over ten years by reducing inefficient manual administrative processes for physician practices, hospitals, and health plans.
REGULATION EFFECTIVE DATE/COMPLIANCE DATE
The effective date of this regulation is August 10, 2012. All HIPAA-covered entities must be in compliance with the EFT & ERA Operating Rule Set by January 1, 2014.
The IFC announced today may be viewed at www.ofr.gov/inspection.aspx. The IFC will be published in the Federal Register on Aug. 10, 2012, and comments are due on Oct. 9, 2012.
A news release on the rule may be viewed at http://www.hhs.gov/news and at http://www.cms.gov/apps/media/press_releases.asp.
Wednesday, July 11, 2012
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
Monday, July 9, 2012
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:
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
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
Saturday, July 7, 2012
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:
“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
For more information, see: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1
Sunday, June 24, 2012
CMS Announces Partnership to Improve Dementia Care in Nursing Homes
Government partnering with providers, caregivers, patients to ensure appropriate use of antipsychotic medications
Today, Centers for Medicare & Medicaid Services (CMS) Acting Administrator Marilyn Tavenner announced the Partnership to Improve Dementia Care, an initiative to ensure appropriate care and use of antipsychotic medications for nursing home patients. This partnership – among federal and state partners, nursing homes and other providers, advocacy groups and caregivers – has set a national goal of reducing use of antipsychotic drugs in nursing home residents by 15 percent by the end of 2012.
Unnecessary antipsychotic drug use is a significant challenge in ensuring appropriate dementia care. CMS data show that in 2010 more than 17 percent of nursing home patients had daily doses exceeding recommended levels.
“We want our loved ones with dementia to receive the best care and the highest quality of life possible,” said Acting Administrator Marilyn Tavenner. “We are partnering with nursing homes, advocates, and others to improve the quality of care these individuals receive in nursing homes. As part of this effort, our partnership has set an ambitious goal of reducing use of antipsychotics in nursing homes by 15 percent by the end of this year.”
CMS and industry and advocacy partners are taking several steps to achieve this goal of improved care:
Enhanced training: CMS has developed Hand in Hand, a training series for nursing homes that emphasizes person-centered care, prevention of abuse, and high-quality care for residents. CMS is also providing training focused on behavioral health to state and federal surveyors;
Increased transparency: CMS is making data on each nursing home’s antipsychotic drug use available on Nursing Home Compare starting in July of this year, and will update this data;
Alternatives to antipsychotic medication: CMS is emphasizing non-pharmacological alternatives for nursing home residents, including potential approaches such as consistent staff assignments, increased exercise or time outdoors, monitoring and managing acute and chronic pain, and planning individualized activities.
“A CMS nursing home resident report found that almost 40 percent of nursing home patients with signs of dementia were receiving antipsychotic drugs at some point in 2010, even though there was no diagnosis of psychosis,” said CMS Chief Medical Officer and Director of Clinical Standards and Quality Patrick Conway, M.D. “Managing dementia without relying on medication can help improve the quality of life for these residents. The Partnership to Improve Dementia Care will equip residents, caregivers, and providers with the best tools to make the right decision.”
These efforts will help achieve the 15 percent reduction goal by the end of this year. In addition, to address this challenge in the long-term CMS is conducting research to better understand the decision to use or not to use antipsychotic drugs in residents with dementia. A study is underway in 20 to 25 nursing homes, evaluating this decision-making process. Findings will be used to target and implement approaches to improve the overall management of residents with dementia, including reducing the use of antipsychotic drugs in this population.
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