Medical Industry Reimbursement News
January 17th, 2016
The Medicare Payment Advisory Commission (MedPAC) has finalized its recommendations to provide no updates in fiscal year 2017 for Medicare payments to home health (HH) agencies, skilled nursing facilities (SNF), inpatient rehabilitation facilities or long-term care hospitals. The commission has also recommended rebasing the HH payment system over a two-year period starting in 2018, and eliminating therapy as a factor in setting HH payments. In addition, it has recommended that the Department of Health and Human Services (HHS) reform the SNF prospective payment system and report to Congress in 2019 on the impacts of those reforms and need for further payment system changes. The recommendations will be presented to Congress in March.
The commission also provided an update on its research on a unified payment system for post-acute care, which was legislatively mandated and will be presented to Congress in June. MedPAC and HHS would develop the new payment approach to replace the current prospective payment systems for post-acute care, with this work slated for presentation to Congress in 2022. Services would be paid for based on patients’ clinical characteristics, rather than care setting.
For more information, visit www.medpac.gov
January 16th, 2016
Effective January 1, 2016, there will be two possible place of service codes (POS) to choose from for outpatient hospital settings: new POS code 19 and revised POS code 22. POS 19 is defined as a portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation to services to sick or injured persons who do not require hospitalization or institutionalization. POS 22 is defined as a portion of a hospital’s main campus hospital provider based department which provides diagnostic therapeutic (both surgical and nonsurgical), and rehabilitation to services to sick or injured persons who do not require hospitalization or institutionalization
Reporting outpatient hospital POS code 19 or 22 is a minimum requirement to trigger the facility payment amount under the Medicare Physician Fee Schedule (MPFS) when services are provided to a registered outpatient.
The MLNMatters Article can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9231.pdf
January 11th, 2016
The Centers for Medicare & Medicaid Services (CMS) has announced 121 new Medicare Accountable Care Organization (ACO) participants, which include 21 that will begin participating this year in a new Next Generation ACO model. The new model includes a prospectively set benchmark which allows beneficiaries to choose to be aligned to the ACO and tests beneficiary incentives for seeking care at participating providers. Also, 39 ACOs will join two existing participants in the ACO Investment Model (AIM), which builds on the Advance Payment ACO model to encourage ACOs to form in rural and underserved areas. The AIM model is expected to provide $83 million in upfront and ongoing investments to participants, which are repaid from the ACO’s shared savings.
The news release can be found at http://www.hhs.gov/about/news/2016/01/11/new-hospitals-and-health-care-providers-join-successful-cutting-edge-federal-initiative.html
January 8th, 2016
On January 8, the Centers for Medicare & Medicaid Services (CMS) has issued a Change Request (CR) 9495 that amends the payment files that were issued to the contractors based on the CY 2016 Medicare Physician Fee Schedule (MPFS) Final Rule. The Agency amended these payment files in order to correct technical errors to the MPFS update files, and to include corrections described in the CY 2016 MPFS Final Rule Correction Notice.
For more information, go to https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3438CP.pdf
December 30th, 2015
On December 30, the Centers for Medicare & Medicaid Services (CMS) has issued a final rule establishing a prior authorization process for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) that are frequently subject to unnecessary utilization. The process will not create new clinical documentation requirements, but will try to ensure that existing documentation, coverage and coding requirements are met before items are furnished to beneficiaries and claims submitted for payment. The final rule has created a Master List of 135 DMEPOS items that are potentially subject to prior authorization because they have an average purchase fee of at least $1,000; or an average rental fee of at least $100. These items have also been the subject of certain reports by the Department of Health and Human Services Office of the Inspector General, Government Accountability Office, or Comprehensive Error Rate Testing Program
The final rule can be found at https://www.gpo.gov/fdsys/pkg/FR-2015-12-30/pdf/2015-32506.pdf
December 18th, 2015
On December 18, President Obama signed into law the $1.8 trillion Consolidated Appropriations Act of 2016, which included a two year suspension of the medical device excise tax. Originally passed as part of the funding for the Affordable Care Act, the medical device excise tax was set at 2.3% of the sales price of taxable medical devices and assessed on sales beginning in January of 2013. The Congressional Budget Office estimated that the tax would raise up to $29.1 billion over the course of a decade.
The Consolidated Appropriations Act of 2016 can found at https://www.congress.gov/bill/114th-congress/house-bill/2029/text
December 15th, 2015
The Government Accountability Office has named seven new members to the Medicaid and CHIP Payment and Access Commission (MACPAC). They are Brian Burwell, vice president of community living systems for Truven Health Analytics; Toby Douglas, a senior advisor for consulting firm Sellers Dorsey; Leanna George, the parent of a Medicaid/CHIP enrollee; Kit Gorton, M.D., president of public plans at Tufts Health Plan; Stacey Lampkin, a principal with Mercer Government Human Services Consulting; Penny Thompson, a consultant; and Alan Weil, editor-in-chief of Health Affairs. Commissioner Sara Rosenbaum, chair of the health policy department at George Washington University School of Public Health, will serve as MACPAC chair.
The press release can be found by visiting http://www.gao.gov/press/macpac_appointments_2016.html
December 4th, 2015
According to a new report by the Centers for Disease Control and Prevention (CDC), the share of U.S. adults with high cholesterol has declined 3.3 percentage points between 2007 and 2014 to 11%. However, the agency estimates that about half of adults who should take cholesterol-lowering medications or make diet and exercise changes to lower their cholesterol do not. Carla Mercado, a scientist in the CDC’s Division for Heart Disease and Stroke Prevention stated that nearly 800,000 people die in the U.S. each year from cardiovascular diseases – that’s one in every three deaths – and high cholesterol continues to be a major risk factor.
For further details, go to http://www.cdc.gov/nchs/data/databriefs/db226.htm
November 17th, 2015
On November 17, The Joint Commission announced the release of America’s Hospitals: Improving Quality and Safety: The Joint Commission’s Annual Report 2015, summarizing data on 49 accountability measures reported by more than 3,300 Joint Commission-accredited hospitals in 2014. The 2014 data shows how well hospitals are performing on evidence-based care processes for the treatment of conditions such as heart attack, pneumonia, and stroke. The report also includes the recognition of 1,043 hospitals that are performing exceptionally well on these patient care processes, earning them special recognition as a Top Performer on Key Quality Measures® based on 2014 data.
The press release can be found by visiting http://jointcommission.new-media-release.com/2015_annual_report_release/
November 10th, 2015
On November 10, the Centers for Medicare & Medicaid Services (CMS) announced that the Medicare Part A deductible for inpatient hospital services will increase by $28 in calendar year 2016, to $1,288. The Part A daily coinsurance amounts will be $322 for days 61-90 of hospitalization in a benefit period; $644 for lifetime reserve days; and $161 for days 21-100 of extended care services in a skilled nursing facility in a benefit period. The monthly Part A premium will increase by $4 in CY 2016, to $411. For Medicare Part B, most of the Medicare beneficiaries with will not experience an increase in their monthly premium in CY 2016 because there was no increase in their Social Security cost-of-living adjustment (COLA). However, for approximately 30% of beneficiaries, the standard Part B premium will increase to $121.80.
The fact sheet is available at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-11-10.html