Medical Industry Reimbursement News

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule implementing changes to the Medicaid Eligibility Quality Control and Payment (MACPAC) Error Rate Measurement programs, which estimate improper payments in Medicaid and the Children’s Health Insurance Program. The rule changes the process for reviewing cases in which states have used simplified enrollment efforts such as self-declaration for eligibility cases, eliminates duplication of effort between eligibility reviews administered in the same fiscal year, extends the timeframe for providers to submit documentation, and gives states additional time to submit corrective action plans.

The rule is available at http://edocket.access.gpo.gov/2010/pdf/2010-18582.pdf.

The Centers for Medicare and Medicaid Services (CMS) has issued a decision memo for PET for initial treatment strategy in solid tumors and myeloma. The memo states that:

1. the National Coverage Determinations (NCD) manual will be changed to remove the current absolute restriction of coverage to ‘only one’ FDG PET scan to determine the location and/or extent of the tumor for the therapeutic purposes related to the initial treatment strategy as described above; 
2. CMS will continue to nationally cover one FDG PET scan to determine the location and/or extent of the tumor for the therapeutic purposes related to the initial treatment strategy as described above; and 
3. local Medicare administrative contractors will have discretion to cover (or not cover) within their jurisdictions any additional FDG PET scan for the therapeutic purposes related to the initial treatment strategy as described above. 

For more information, visit http://www.cms.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=237&

The Centers for Medicare & Medicaid Services’ (CMS) New Issue Review Board has approved the first “medical necessity review” audits for Medicare’s permanent recovery audit contractor (RAC) program. The newly approved audits include 18 types of inpatient hospital claims and one type of durable medical equipment claim. Before issuing requests to hospitals for these reviews, each RAC must post on its website the particular audits it will conduct, including citations for the related Medicare policy. CMS expects the RACs to post the new audits and begin issuing Additional Documentation Requests (ADRs) shortly.

For further information, go to http://www.cms.gov/RAC/Contact information

President Obama recently signed into law the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010″. One of the provisions the law clarifies is Medicare’s policy for payment of outpatient services provided on either the date of a beneficiary’s inpatient admission or during the three calendar days immediately preceding the date of a beneficiary’s admission (known as the 3-day payment window).  Under the payment window policy, a hospital (or an entity that is wholly owned or wholly operated by the hospital) must include the diagnoses, procedures and charges for all outpatient diagnostic services and admission-related outpatient non-diagnostic services that are furnished to the beneficiary during the 3-day payment window on the claim for a beneficiary’s inpatient stay. The new law makes the policy pertaining to admission-related outpatient non-diagnostic services more consistent with common hospital billing practices. 

To view the CMS fact sheet, click here.

The Department of Health and Human Services (HHS) published an interim final rule implementing a temporary program to provide affordable health insurance coverage to uninsured individuals with pre-existing conditions. Required by the Patient Protection and Affordable Care Act (PPACA), the Pre-existing Condition Insurance Plan (PCIP) program will continue until January 1, 2014, when the PPACA’s health insurance exchanges become available. The rule addresses issues such as PCIP administration, eligibility, enrollment, benefits, premiums, funding, appeals and oversight. HHS will accept comment on the rule through September 28.

The final rule is available at http://edocket.access.gpo.gov/2010/pdf/2010-18691.pdf.

The Centers for Medicare & Medicaid Services (CMS) has issued the final rule establishing fiscal year (FY) 2011 policies and payment rates for inpatient services furnished to Medicare beneficiaries by acute care hospitals, long term care hospitals (LTCH) and certain excluded hospitals. The inpatient prospective payment system (IPPS) final rule updates the acute care hospital rates by 2.35%. This update reflects a market basket increase of 2.6% for inflation. The final rule reduces the 2.6% inflation update by 0.25%, as required by the Patient Protection and Affordable Care Act (PPACA). In addition, CMS will apply a “documentation and coding” adjustment of -2.9%. CMS estimates that payments to general acute care hospital for operating expenses will decline by 0.4% in FY 2011.

CMS is similarly updating LTCH rates by 2.5% for inflation but reducing the inflation update by 0.5 percentage points as required by the PPACA. CMS estimate that aggregate payment to LTCHs would increase by approximately 0.5%.

The final rule adds 12 measures to the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) set, and retires one current measure. However, only 10 of the new measures will be considered in determining a hospital’s FY 2012 update. The remaining 2 measures would be considered in determining the hospital’s 2013 update. Under current law, hospitals that successfully report quality measure will received the full update. Hospitals that do not participate in the quality-reporting program will receive the updates less two percentage points.

The final rule was published in the August 16 Federal Register which can be found at http://edocket.access.gpo.gov/2010/pdf/2010-19092.pdf.

The Department of Health and Human Services (HHS) has issued a final rule to complete the adoption of an initial set of standards, implementation specifications and certification criteria, and to more closely align these items with final meaningful use Stage 1 objectives and measures. Adopted certification criteria establish the required capabilities and specify the related standards and implementation specifications that certified electronic health record (EHR) technology will need to include to, at a minimum, support the achievement of meaningful use Stage 1 by eligible professionals, eligible hospitals, and/or critical access hospitals (hereafter, references to “eligible hospitals” in this final rule shall mean “eligible hospitals and/or critical access hospitals”) under the Medicare and Medicaid EHR Incentive Programs. Complete EHRs and EHR Modules will be tested and certified according to adopted certification criteria to ensure that they have properly implemented adopted standards and implementation specifications and otherwise comply with the adopted certification criteria. The final rule is effective August 27, 2010.

The rule can be found by going to http://edocket.access.gpo.gov/2010/pdf/2010-17210.pdf

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule that will change how Medicare will reimburse for dialysis services for Medicare beneficiaries who have end-stage renal disease (ESRD).  In addition, CMS issued a proposed rule that would establish a new quality incentive program (QIP) to promote high quality services in dialysis facilities. This would be accomplished by linking a facility’ s payments to performance standards.   

 The final rule establishes a new prospective payment system (PPS) that provides for payment adjustment for home dialysis training when clinically appropriate.  This adjustment will help ensure that ESRD patients are learning the skills and techniques they need to properly receive their dialysis treatment at home. 

 To view the ESRD PPS Final Rule and the QIP Proposed Rule, see: http://www.ofr.gov/OFRUpload/OFRData/2010-18466_PI.pdf  or www.ofr.gov/inspection.aspx

The Centers for Medicare & Medicaid Services (CMS) announced the final rule to implement the provisions of the American Recovery and Reinvestment Act (ARRA) of 2009 that provide incentive payments for the adoption and meaningful use of certified electronic health record (EHR) technology. The rule requires hospitals to comply with 14 core objectives to be deemed “meaningful users” of EHRs and eligible for Medicare and Medicaid incentive payments in 2011. It also requires providers to meet five additional meaningful use objectives, which they can choose from a “menu” of 10 objectives. 

The final rule can be access at http://www.ofr.gov/OFRUpload/OFRData/2010-17207_PI.pdf

In addition, the Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology issued a final rule identifying the standards and criteria for certifying EHRs. This rule can be found at http://www.ofr.gov/OFRUpload/OFRData/2010-17210_PI.pdf

The Centers for Medicare & Medicaid Services (CMS) named CIGNA Government Services (CGS) the Medicare administrative contractor (MAC) for Part A and B fee-for-service claims in Jurisdiction 15, comprised of Kentucky and Ohio. CGS will also administer home health and hospice claims in Colorado, Delaware, the District of Columbia, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia and Wyoming. CGS will take over the work from the current fiscal intermediaries and carriers over the next several months. The contract was rebid by CMS after the Government Accountability Office (GAO) sustained a protest of the original January 2009 award to Highmark Medicare Services, Inc.

More information can be viewed at http://www.cms.gov/MedicareContractingReform/downloads/J15AwardBackgroundSheet.pdf.