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Medical Industry Reimbursement News

2017 Medicare Physician Fee Schedule Proposed Rule Released

July 7th, 2016

On July 7, the Centers for Medicare & Medicaid Services (CMS) issued its proposed rule for the Medicare physician fee schedule (MPFS) for calendar year (CY) 2017. After application of the 0.5% payment increase required by the Medicare Access and CHIP Reauthorization Act of 2015 and other budget neutrality cuts, CMS estimates a 0.08% decrease in physician payment rates for 2017 compared to 2016.

CMS proposes to pay for new telehealth services, including end-stage renal disease-related services for dialysis, advance care planning services, and critical care consultations, as well as expanding the Center for Medicare & Medicaid Innovation Diabetes Prevention Program model. In addition, CMS proposes a number of new codes to more accurately pay for primary care, care management and other cognitive specialties, including separate payments to primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions.

The proposed rule can be found by going to https://federalregister.gov/a/2016-16097

CMS Releases 2017 HOPPS/ASC Proposed Rule

July 6th, 2016

On July 6, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule updating payment rates and policy changes for the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. The proposed rule would address physicians’ and other health care providers’ concerns that patient survey questions about pain management in the Hospital Value-Based Purchasing program unduly influence prescribing practices. CMS proposes to remove the pain management dimension from the Hospital Value-Based Purchasing program to eliminate any potential financial pressure clinicians may feel to overprescribe pain medications. In addition, CMS is also currently developing and field testing alternative questions related to provider communications and pain to include in the program in future years.

CMS is also proposing policies to implement section 603 of the Bipartisan Budget Act of 2015, which provides that certain items and services provided by certain hospital off-campus outpatient departments would no longer be paid under the OPPS. Currently, Medicare pays for the same services at a higher rate if those services are provided in a hospital outpatient department, rather than a physician’s office. This payment differential has encouraged hospitals to acquire physician offices in order to receive the higher rates. This acquisition trend and difference in payment has been highlighted as a long-standing issue of concern by Congress, MedPAC, and the Department of Health and Human Services Office of Inspector General. This difference in payment also increases costs for the Medicare program and raises the cost-sharing liability for beneficiaries.

The proposed rule is supporting physicians and other providers by increasing flexibility for hospitals, including critical access hospitals, which participate in the Medicare Electronic Health Records (EHR) Incentive Program. CMS proposed to streamline EHR reporting requirements, increase flexibility, and support improved patient outcomes.

In addition, new quality measures are proposed that will be added to the Hospital Outpatient Quality Reporting Program and the Ambulatory Surgical Center Quality Reporting Program. These measures are focused on improving patient outcomes and experience of care. Other changes in the proposed rule would enhance the outcome requirements for organ transplant programs so that the programs may help more beneficiaries accept more grafts while maintaining compliance with Medicare standards for patient and graft survival.

CMS estimates that the updates in the proposed rule would increase OPPS payments by 1.6 percent and ASC payments by 1.2 percent in 2017.

A fact sheet on this proposed rule is available at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-06.html.

Health Professional Shortage Areas Updated

July 1st, 2016

The Health Resources and Services Administration (HRSA) has announced its Health Professional Shortage Areas (HPSAs) for primary care, mental health, and dental care as of May 13. Qualified providers in HPSAs are eligible for increased levels of Medicare reimbursement, and entities with clinical training sites in these areas are eligible to receive priority for certain residency training program grants administered by HRSA’s Bureau of Health Workforce.

The announcement can be found by visiting https://www.gpo.gov/fdsys/pkg/FR-2016-07-01/pdf/2016-15678.pdf

HHS Releases Proposed Rule on Medicare Appeals Process

June 23rd, 2016

The Department of Health & Human Services (HHS) has released a proposed rule that would make changes to the procedures for Administrative Law Judge (ALJ) appeals of payment and coverage determinations for items and services provided to Medicare beneficiaries, in addition to other Medicare appeals. Specifically, the proposed rule would allow attorney adjudicators to hear appeals in lieu of ALJs in some cases, and allow the HHS Departmental Appeals Board to designate certain decisions as precedential.

The proposed rule can be found at https://federalregister.gov/a/2016-15192

Nine New Members Named to Health IT Advisory Committees

June 23rd, 2016

Health and Human Services Secretary (HHS) Sylvia Burwell has named nine new members to the committees that advise her on health information technology standards and policy. Appointed to the HIT Standards Committee were: Terrence O’Malley, M.D., geriatrician at Massachusetts General Hospital – technical expertise/long-term care representative; Rajesh Dash, M.D., professor of pathology at Duke University School of Medicine – ancillary health care worker representative; Kay Eron, general manager for heath IT and medical devices at Intel – purchaser/employer representative; Peter Johnson, retired chief information officer – technical expertise representative; Kyle Meadors, president of Drummond Group – technical expertise/HIT representative; Andrey Ostrovsky, M.D., CEO of Care at Hand – technical expertise/small innovative provider representative; Wanmei Ou, director of precision medicine product strategy at Oracle – technical expertise/HIT representative; and Larry Wolf, principal at Strategic Health Network – technical expertise representative. Named to the HIT Policy Committee was: Aaron Miri, chief information officer and vice president of government relations at Imprivata – privacy and security representative.

The press release can be found at http://www.hhs.gov/about/news/2016/06/23/new-members-named-to-serve-on-federal-health-information-technology-policy-and-standards-committees.html

Final Rule Issued for Laboratory Tests Payment System

June 17th, 2016

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule revising the Medicare payment system for clinical diagnostic laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS). Based on the final rule, CMS will implement the new approach to setting CLFS payment rates on January 1, 2018, a one-year delay from the date the agency originally proposed. Also, CMS will use the national provider identifier to apply the statutory requirements to determine whether a laboratory is considered an applicable laboratory.

The final rule can be found by going to https://federalregister.gov/a/2016-14531

MedPAC Issues June Report to Congress

June 16th, 2016

The Medicare Payment Advisory Commission (MedPAC) has released its June report to Congress, which reports on issues affecting the Medicare program. The June report also recommends prototype designs for a unified prospective payment system for skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals. Currently, the prototype would be designed to pay for post-acute care services based on a patient’s clinical characteristics rather than the site of service. The report also recommends reducing dispensing and supplying fees for Medicare Part B drugs to rates similar to other payers, and giving isolated rural hospitals the option to convert to an outpatient-only model. In addition, the Commission recommends changes to the Part D program to lower program costs and protect beneficiaries with high costs. Also included in the report is an analysis of Medicare telehealth services, including use of telehealth in Medicare Advantage plans. The Commission recommends expanding the use of waivers in Center for Medicare & Medicaid Innovation programs to include a broader range of telehealth services.

The report can be found at http://medpac.gov/documents/reports/june-2016-report-to-the-congress-medicare-and-the-health-care-delivery-system.pdf

CMS Announces $10 million in Grants

June 10th, 2016

On June 10, the Centers for Medicare & Medicaid Services (CMS) launched the second round of the Support and Alignment Networks under the Transforming Clinical Practice Initiative (TCPI). This opportunity will provide up to $10 million over the next three years to leverage primary and specialist care transformation work and learning that will catalyze the adoption of Alternative Payment Models on a large scale. The Support and Alignment Networks represents a significant enhancement to the TCPI network expertise and will help clinicians prepare for the proposed new Quality Payment Program. Eligible applicants include health care delivery systems and plans that provide quality improvement support to a large number of clinicians. CMS expects to award up to five grants of $500,000 to $2.5 million through cooperative agreements.

The fact sheet can be found at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-10.html

GAO Report Recommends Steps to Reduce Medicare Appeals

June 9th, 2016

On June 9, the Government Accountability Office (GAO) issued a report that stated that the Department of Health and Human Services (HHS) should take certain steps to reduce the number of Medicare appeals and strengthen oversight of the Medicare fee-for-service appeals process. The report, which was requested by leaders of the Senate Finance Committee, examines trends in appeals for fiscal years 2010 through 2014, data HHS uses to monitor the appeals process, and HHS efforts to reduce the number of appeals filed and backlogged. It concludes by stating that without more reliable and consistent information, HHS will continue to lack the ability to identify issues and policies contributing to the appeals backlog, as well as measure the funds tied up in the appeals process.

The report can be found at http://www.gao.gov/products/GAO-16-366

CMS Provides Additional Information on Two-midnight Review

June 6th, 2016

The Centers for Medicare & Medicaid Services (CMS) has provided additional information on its temporary pause of Quality Improvement Organization (QIO) claim audits under the two-midnight inpatient admissions policy. During the pause, which began May 4, CMS will improve standardization around the QIO review process. This will include retraining the QIOs on the two-midnight policy, a re-review of claims denied by the QIOs, and any needed provider outreach and education. CMS advises hospitals to work with their QIOs to determine whether denied claims have been re-reviewed prior to appealing a claim denial. If a denied claim has been appealed, and upon re-review the QIO determines it was denied inappropriately, the QIO will share its re-review findings with the appeals adjudicators to be taken into consideration during the appeal process. CMS anticipates that QIOs will resume audit activities within 60-90 days, but will formally advise stakeholders once the pause is lifted.

For further details, go to http://qioprogram.org/temporary-pause-qio-short-stay-reviews