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Medical Industry Reimbursement News

Sequestration to Continue Through March 31, 2016

March 17th, 2015

For the Medicare Fee-For-Service (FFS) program, claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will continue to incur a two percent reduction in Medicare payment through March 31, 2016. Claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), including claims under the DMEPOS Competitive Bidding Program, will continue to be reduced by two percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013. The claims payment adjustment will continue to be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.

Although beneficiary payments for deductibles and coinsurance are not subject to the two percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the two percent reduction. The Centers for Medicare & Medicaid Services (CMS) is encouraging Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to continue discussions with beneficiaries on the impact of sequestration on Medicare’s reimbursement.

More information can be found at http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~95XLW67354?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

Next Generation ACO Model Announced by CMS

March 10th, 2015

On March 10, the Centers for Medicare & Medicaid Services (CMS) announced its Next Generation Accountable Care Organization (ACO) Model. According to CMS, the Next Generation ACO Model will be added to its existing portfolio of ACO models, which are the Medicare Shared Savings Program, the Pioneer ACO Model, the Advance Payment ACO Model, the ACO Investment Model, and the Comprehensive End Stage Renal Disease (ESRD) Care Initiative. The new model is intended for ACOs that are experienced in coordinating care for populations of patients, and will allow them to assume higher levels of financial risk and reward than under the Pioneer Model and Shared Savings Program. The agency expects from 15 to 20 ACOs to participate in the new model.

The fact sheet is available at http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-03-10.html

CMS Launches the Health Care Payment Learning and Action Network

February 27th, 2015

The Centers for Medicare & Medicaid Services (CMS) has launched the Health Care Payment Learning and Action Network to provide a forum for public-private partnerships. The network was created to help the U.S. health care payment system meet or exceed recently established Medicare goals for value-based payments and alternative payment models. Health care payers, providers, employers, purchasers, state partners, consumer groups, and others are invited to join the network. The network will be supported by an independent contractor that will act as a convener and facilitator, and will synthesize and document best practices across a variety of topic areas. A Guiding Committee will be created to prioritize discussion topics and make recommendations to the contractor.

For more information, go to http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-02-27.html

End-to-end Testing of ICD-10 Successful Overall

February 26th, 2015

According to recent results from end-to-end testing, the health care community will be ready for ICD-10 on October 1. About 660 health care providers and billing companies submitted nearly 15,000 test claims, and according to the Centers for Medicare & Medicaid Services (CMS), participants in the January 26 to February 3 testing were able to successfully submit ICD-10 claims and have them processed.  The testing was the first of three end-to-end testing weeks scheduled before October 1, when health care providers and others must begin using ICD-10 diagnosis and procedure codes.

For more on details, go to http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2015-Jan-End-to-End-Testing.pdf

PCORI Awards $64.1 Million to Support Five Pragmatic Clinical Studies

February 24th, 2015

On February 24th, the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved awards totaling more than $64 million to fund five large patient-centered comparative effectiveness research (CER) studies that will answer critical clinical questions about care for cancer, back pain, and stroke.

The awards are the first to be made through PCORI’s Pragmatic Clinical Studies Initiative, an effort to produce results that are broadly applicable to a greater variety of patients and care situations and can be more quickly taken up in routine clinical practice.

For further details, visit http://www.pcori.org/content/pcori-awards-641-million-support-five-pragmatic-clinical-studies

Basic Health Program Funding Methodology Final Notice Published

February 19th, 2015

The Centers for Medicare & Medicaid Services (CMS) published a final notice establishing the methodology for determining federal funding for the Basic Health Program in program year 2016. The Basic Health Program provides states with the option to establish a health benefits coverage program for lower-income individuals as an alternative to Health Insurance Marketplace coverage under the Affordable Care Act. This voluntary program enables states to create a health benefits program for residents with incomes that are too high to qualify for Medicaid through Medicaid expansion in the Affordable Care Act, but are in the lower income bracket to be eligible to purchase coverage through the Marketplace. This final notice is substantially the same as the final notice for program year 2015.

The fact sheet can be found at http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-02-19.html, and the display copy can be found by going to http://www.ofr.gov/(S(rlcweqsfmlqgban3r2idg11w))/OFRUpload/OFRData/2015-03662_PI.pdf

GAO Issues Report on CMS’ ICD-10 Efforts

February 9th, 2015

The Government Accountability Office (GAO) has issued a report summarizing efforts by the Centers for Medicare & Medicaid Services (CMS) to support the October 1 transition to the ICD-10 coding system. The reports findings are based on information collected from CMS and a sample of 28 stakeholder organizations, between July 2014 and January 2015. The agency has scheduled end-to-end testing with 2,550 covered entities during three weeks in 2015, and has plans to issue an updated version of the Medicare-Severity Diagnosis-Related Groups (MS-DRG) to reflect the inpatient prospective payment system rule for fiscal year 2016. According to the GAO, CMS also plans to issue updated clinical quality measures for hospitals and ambulatory surgical centers in April.

More information can be found by going to http://www.gao.gov/products/GAO-15-255

NCD for Screening for Lung Cancer Issued

February 6th, 2015

On February 5th, the Centers for Medicare & Medicaid Services (CMS) issued a final national coverage determination (NCD) that provides for Medicare coverage of Screening for Lung Cancer with Low Dose Computed Tomography (LDCT). The coverage is effective immediately.

Medicare will now cover lung cancer screening with LDCT once per year for Medicare beneficiaries who meet all of the following criteria:

  • Are age 55-77, and are either current smokers or have quit smoking within the last 15 years;
  • Have a tobacco smoking history of at least 30 “pack years” (an average of one pack a day for 30 years);
  • Receive a written order from a physician or qualified non-physician practitioner that meets certain requirements.

Medicare coverage includes a visit for counseling and shared decision-making on the benefits and risks of lung cancer screening. The NCD also includes required data collection and specific coverage eligibility criteria for radiologists and radiology imaging centers, consistent with the National Lung Screening Trial protocol, U.S. Preventive Services Task Force recommendation, and multi-society multi-disciplinary stakeholder evidence-based guidelines.

The NCD can be found by going to http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274

CMS Intends to Modify Requirement for Meaningful Use

January 30th, 2015

On January 29, the Centers for Medicare & Medicaid Services (CMS) announced its intent to engage in rulemaking to update the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs beginning in 2015. The new rule, expected this spring, would be intended to be responsive to provider concerns about software implementation, information exchange readiness, and other related concerns in 2015. It would also be intended to propose changes reflective of developments in the industry and progress toward program goals achieved since the program began in 2011.

CMS is considering proposals to:

  • Realign hospital EHR reporting periods to the calendar year to allow eligible hospitals more time to incorporate 2014 Edition software into their workflows and to better align with other CMS quality programs.
  • Modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.
  • Shorten the EHR reporting period in 2015 to 90 days to accommodate these changes.

CMS also clarified that they are working on multiple tracks to realign the program to reflect the progress toward program goals and be responsive to stakeholder input. This announcement regarding the intention to pursue changes to meaningful use beginning in 2015 through rulemaking, is separate from the forthcoming Stage 3 proposed rule that is expected to be released by early March.

More information can be found by going to http://blog.cms.gov/2015/01/29/cms-intends-to-modify-requirements-for-meaningful-use/

HHS Announces Goals and Timeline for Shifting Medicare Payments

January 26th, 2015

On January 26, the Department of Health and Human Services (HHS) announced measureable goals and a timeline to move the Medicare program toward paying providers based on quality rather than quantity of care. HHS has set a goal of tying 30% of Medicare fee-for-service payments to alternative payment models, such as Accountable Care Organizations (ACOs), by the end of 2016, and 50% by the end of 2018. HHS also set a goal of tying 85% of all traditional Medicare payment to a quality or value basis by 2016, and 90% by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs.

In addition, HHS announced the creation of a Health Care Payment Learning and Action Network to make the goals scalable. HHS plans to work with private payers, employers, consumers, providers, state Medicaid programs, and other partners to expand alternative payment models into their programs.

For more information, visit http://www.hhs.gov/news/press/2015pres/01/20150126a.html