Medical Industry Reimbursement News
April 17th, 2014
According to an announcement by the White House, about 8 million people signed up for private health insurance through a state or federally-facilitated marketplace during open enrollment. About 35% of those enrolling through a federally-facilitated marketplace were under age 35, of which 28% were adults, about the same proportion as Massachusetts experienced in its first year of health reform.
The fact sheet can be found by going to http://www.whitehouse.gov/the-press-office/2014/04/17/fact-sheet-affordable-care-act-numbers
April 10th, 2014
On April 10, President Obama announced that Health and Human Services Secretary (HHS) Kathleen Sebelius stepped down after five years of service. To fill the position, he nominated Office of Management and Budget (OMB) Director Sylvia Mathews Burwell. Ms. Burwell joined OMB last year and previously served as president of the Walmart Foundation and president of the Global Development Program at the Bill & Melinda Gates Foundation. She also held several positions in the Clinton administration, including deputy director of OMB and deputy chief of staff to the president.
For more information, visit http://www.whitehouse.gov/blog/2014/04/11/sylvia-mathews-burwell-nominated-be-next-secretary-health-and-human-services
April 9th, 2014
On April 9, the Department of Health and Human Services (HHS) released a new privacy-protected data set that has information on the number and type of health care services that individual physicians and certain other health care providers furnished in 2012 under the Medicare Part B fee-for-service (FFS) program, as well as information on the amount that Medicare paid them for those services. The new data set has information for over 880,000 distinct health care providers in all 50 states, DC and Puerto Rico who collectively received $77 billion in Medicare payments in 2012. The new data are posted on the website of the Centers for Medicare & Medicaid Services (CMS).
CMS created the new data set using information from the Physician/Supplier Part B Claims File, also known as the Carrier File, which has final action FFS claims that are submitted by physicians and other non-institutional health care providers, such as non-physician practitioners, ambulatory surgical centers, clinical laboratories, and ambulance providers. The new data set does not have information for institutional health care providers, such as hospitals or nursing homes, or for suppliers of durable medical equipment.
To view the new physician data set, please go to: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html
April 7th, 2014
The Centers for Medicare & Medicaid Services (CMS) released final capitation rates and payment policies for the 2015 Medicare Advantage (MA) and Part D prescription drug plans. CMS estimates the overall net change to plan payments between 2014 and 2015 will be 0.4%, up from an estimated -1.9% for proposals in the Advance Notice. Individual plan payments will vary by plan based on, but not limited to, the plan’s location and star rating. Among other changes, CMS modified the phase-in schedule for the new risk adjustment model that began in calendar year 2014 and removed a proposal to exclude certain diagnoses from enrollees’ risk assessments. It also delayed implementation of a new Part D risk adjustment model, refined the risk adjustment methodology to account for the impact of baby boomers, delayed changes to the star ratings system, and withdrew a proposal to require plans to provide additional coverage in the gap between generic and brand drugs. The final call letter requires plans to provide CMS with 90 days’ notice of any significant changes to their provider networks, and allows enrollees to switch plans when their MA organization initiates significant mid-year provider network terminations without cause. The final rate announcement and call letter also limit the permissible increase in total beneficiary costs to $32 per month and maintain existing limits on beneficiaries maximum out-of-pocket spending, but encourage MA organizations to allow enrollees’ dollar contributions toward these limits to be transferable when they move to any plan offered by the same organization.
For more information, visit http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-04-07.html
April 1st, 2014
On April 1, President Obama signed into law the Protecting Access to Medicare Act of 2014. The new law prevented a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking effect on April 1. The bill also extends the Medicare-dependent Hospital Program, low-volume adjustment, and ambulance add-on payments through March 31, 2015; extends the delay in enforcement of the Centers for Medicare & Medicaid Services’ (CMS) two-midnight policy for an additional six months, through March 31, 2015; and prohibits recovery audit contractors from auditing inpatient claims spanning less than two midnights for the six-month period. It also delays implementation of ICD-10 until October 1, 2015, delays the start of the Medicaid Disproportionate Share Hospital (DSH) cuts for one year, until 2017 and extends these cuts for an additional year through 2024.
The bill can be viewed at http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm
March 31st, 2014
On April 1, the new CMS-1500 Claim Form (02-12) became mandatory. The new version includes changes for diagnosis coding and qualifiers which identify ordering, referring or supervising provider roles.
For more facts and information about the new CMS-1500 Claim Form (02-12), please visit the Web site at CMS-1500 Claim Form Completion Instructions
March 24th, 2014
According to a new report from the Food & Drug Administration’s (FDA) Center for Devices and Radiological Health (CDRH), the annual number of medical device recalls increased by 97% between fiscal years 2003 and 2012, to 1,190. The most frequent causes for recalls are related to device design, software, and non-conforming material or component issues. The number of Class I recalls went from 7 in FY 2003 to 57 in FY 2012, while Class II recalls rose from 460 to 1,043. The report states that the increase is due to a greater focus and attention on improving product quality in certain areas, including radiology devices, ventilators, infusion pumps and external defibrillators.
The report can be viewed at http://www.fda.gov/downloads/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/CDRH/CDRHTransparency/UCM388442.pdf.
March 13th, 2014
CMS plans to issue guidance to Medicare Administrative Contractors (MACs), Medicare Recovery Auditors (RACs), and other review contractors. This update will provide further guidance for the determination of the appropriateness of inpatient hospital admission. CMS will instruct Medicare review contractors to assess the hospital’s compliance with three things – the admissions order requirements, the certification requirements, and he two-midnight benchmark.
For further details, the updated guidance can be viewed at http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/ReviewingHospitalClaimsforAdmissionforPosting03122014.pdf.
March 7th, 2014
The Centers for Medicare & Medicaid Services (CMS) has issued a final rule regarding certain payment parameters and standards for health insurers and the Health Insurance Marketplace for the 2015 benefit year. Based on a fact sheet released by CMS, the provisions pertain to premium stabilization programs, the open enrollment period for 2015, annual limitations on cost sharing, consumer protections, financial oversight, and the Small Business Health Options Program (SHOP). According to the final rule, the open enrollment period for the 2015 benefit year will begin on November 15, 2014 and extend through February 15, 2015.
The final rule can be viewed at http://www.ofr.gov/OFRUpload/OFRData/2014-05052_PI.pdf.
The CMS fact sheet can be found at http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-03-05-2.html?DLPage=1&DLSort=0&DLSortDir=descending
February 24th, 2014
The Centers for Medicare & Medicaid Services (CMS) has issued an advanced notice of proposed changes to Medicare Advantage (MA) rates and payment polices for calendar year 2015. The notice includes the preliminary estimates of the national per capita MA growth percentage and Medicare fee-for-service growth percentage, and changes in methodologies governing payment for health plan and prescription drug benefits.
The notice can be viewed at http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-02-21-02.html.