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Medical Industry Reimbursement News

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

CMS Administrator Resigns

January 16th, 2015

In an email to her staff on January 16, the Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner announced that she will be leaving the agency at the end of February. Andy Slavitt, currently principal deputy administrator, will become acting administrator. Tavenner has been with the agency for five years and was confirmed as administrator in May of 2013.

Nearly 6.8 Million Enrolled in 2015 Federally-facilitated Marketplace

January 14th, 2015

According to preliminary data released by the Department of Health and Human Services (HHS), nearly 6.8 million individuals and families selected a health plan or were automatically re-enrolled through the federally-facilitated Health Insurance Marketplace (FFM) between November 15 and January 9.  The HHS update also includes an estimate of plan selections for each state in the FFM. Open enrollment in the Marketplace runs through February 15.

For more information, go to http://www.hhs.gov/healthcare/facts/blog/2015/01/open-enrollment-week-eight.html

MedPAC Finalizes 2016 Payment Recommendations

January 14th, 2015

The Medicare Payment Advisory Commission (MedPAC) has announced its final recommendation that Congress increase Medicare payment rates for the 2016 hospital inpatient and outpatient prospective payment systems by 3.25%. In addition, the commission recommended that Congress reduce or eliminate payment differences between physician office and hospital outpatient departments for certain  procedures, and reimburse long-term care hospitals the same rates as acute-care hospitals for patients who are not deemed “chronically critically ill”. The commission also recommended to freeze Medicare payments to physicians in 2016 in place of the sustainable growth rate formula (SGR), to establish a per- beneficiary prospective payment to replace the Primary Care Incentive Payment Program, and to freeze 2016 payments for home health, skilled nursing facilities (SNF), ambulatory surgical centers, dialysis facilities, hospice, inpatient rehabilitation facilities (IRF), and long-term care hospitals.

For more information, visit www.Medpac.gov

Joint Commission Launches Infection Prevention and HAI Portal

January 13th, 2015

On January 13, The Joint Commission announced that it is merging its two online infection prevention resources into one convenient, expanded tool: The Infection Prevention and Healthcare-associated Infection (HAI) Portal.

Previously, The Joint Commission offered both the Infection Control Page and the HAI Portal as separate resources. The new Infection Prevention and HAI Portal will contain information from The Joint Commission, Joint Commission Center for Transforming Healthcare and Joint Commission Resources. In addition, it will offer links to other nationally recognized resources on infection prevention issues.

The press release can be found at http://www.jointcommission.org/joint_commission_launches_infection_prevention_and_hai_portal/

 

RAC Program Changes Announced

January 5th, 2015

The Centers for Medicare & Medicaid Services (CMS) has announced changes to its Recovery Audit Contractor (RAC) Program. CMS believes these changes will reduce provider burden, enhance CMS’s oversight, and increase transparency in the program.  One major change will be the limitation on the RAC look-back period for patient status reviews to six months after the date of service if the hospital has submitted its claim within three months of the date of service. CMS believes this addresses concerns regarding its policy that limits hospitals’ ability to rebill certain denied Medicare Part A claims under Part B to one year after the date of service. These changes will be effective with each new RAC contract.

For more details, visit http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/RAC-Program-Improvements.pdf