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Medical Industry Reimbursement News

Joint Commission Issues Annual Report

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/

CMS Announces Medicare CY 2016 Premiums and Deductibles

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

RAC Program Improvements Announced

November 9th, 2015

Effective January 1, the Centers for Medicare & Medicaid Services (CMS) will reduce the number of claims that Recovery Audit Contractors (RAC) may audit for health care providers other than physicians and suppliers. The additional documentation request (ADR) limit will fall from 2% to 0.5% of the provider’s total number of paid Medicare claims from the previous year. RACs will be required to diversify their audits across all claim types for a facility, limiting their ability to target care provided in a particular setting. In addition, CMS will adjust the ADR limit up or down based on the provider’s claim denial rate.

For further details, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Additional-Documentation-Request-Limits-.pdf

2016 MPFS Final Rule Published

October 30th, 2015

On October 30, 2015, the Centers for Medicare & Medicaid Services (CMS) published a final rule updating payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2016. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaced the reduction in the PFS with a 0.5 percent update through the end of this year. The final CF for CY 2016 is $35.8279, down from the current CF of $35.9335. The rule also finalizes changes to several of the quality reporting initiatives that are associated with PFS payments, including the Physician Quality Reporting System (PQRS), the Physician Value-Based Payment Modifier (Value Modifier), and the Medicare Electronic Health Record (EHR) Incentive Program, as well as changes to the Physician Compare website on Medicare.gov.

The following are the major provisions of the rule:

  • CMS maintains most existing policies applicable to the Physician Quality Reporting System (PQRS) for the 2016 performance year. Under most individual reporting options, eligible professionals will continue to report at least nine measures across at least three domains. Failure to successfully report PQRS quality measures in 2016 will continue to result in a -2 percent payment adjustment in 2018.
  • Application of the Value-Based Payment Modifier on 2018 payments will be expanded to eligible non-physician professional solo practitioners and group practices (e.g., physician assistants, nurse practitioners and clinical nurse specialists) based on the 2016 performance period.
  • CMS seeks review of 103 services with Medicare allowed charges of $10 million or more as a prioritized subset of codes under the statutory category of “codes that account for the majority of spending under the physician fee schedule.” This list includes transthoracic echocardiography, electrophysiology device monitoring services and 3-D electrophysiology mapping.
  • CMS will delay the requirement that clinicians ordering advanced imaging services (e.g., CT, MR, SPECT) consult with appropriate use criteria (AUC) through a qualified clinical decision support mechanism starting on January 1, 2017. CMS will issue additional regulations on this program in the CY 2017 and CY 2018 rulemaking cycles.
  • CMS finalized with modifications the process for selecting AUC developed by national professional medical specialty societies and other provider-led entities for the AUC consultation requirement that will apply to professionals ordering advanced imaging services.
  • CMS finalized revisions to physician self-referral (Stark) regulations that will accommodate delivery and payment system reform, reduce burden, and facilitate compliance. The Agency also collected initial comments related to the implementation of the Merit-Based Incentive Payment System and Alternative Payment Model payment pathways and will continue to consider these comments.

The final rule is published at https://federalregister.gov/a/2015-28005

2016 Hospital OPPS/ASC Final Rule Released

October 30th, 2015

On October 30, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2016 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates final rule with comment period. CMS is updating OPPS rates based on the projected hospital market basket increase of 2.4% minus both a 0.5 percentage point adjustment for multi-factor productivity and a 0.2 percentage point adjustment required by law. There is an additional finalized 2.0 percentage point adjustment to the payment update to redress inflation in the OPPS payment rates resulting from excess packaged payment for laboratory tests that continue to be paid separately outside the OPPS. The final rate update will be -0.3 %.

The major provisions are:

  • CMS finalized changes to its existing “rare and unusual” exceptions policy to allow Part A payment on a case-by-case basis for inpatient admissions that do not satisfy the two-midnight benchmark. The Agency will use quality improvement organizations to educate doctors and hospitals about Part A payment policy for inpatient admissions. Certain restrictions on recovery audit contractors’ review of admitting decisions will also be implemented. These include changes to the “look-back period,” limits on additional documentation requests and requirements for timely reviews.
  • CMS continues its policy to package payment for items and services that are integral, ancillary, supportive, or adjunctive to a primary service. Starting in 2016, payment for bivalirudin and abciximab will be packaged into the Ambulatory Payment Classification (APC) payment for the primary procedure, such as a percutaneous coronary intervention or percutaneous transluminal coronary angioplasty.
  • For 2016, CMS will implement nine new Comprehensive APCs (C-APCs), including one new C-APC for comprehensive observation services. This will provide a single payment for all services received during a non-surgical encounter with a high-level outpatient hospital visit or emergency department visit and eight or more hours of observation. All surgical procedures, regardless of the date of service, will be paid separately.
  • CMS finalized updates to the APC structure for imaging services, including the creation of the Level 4 Nuclear Medicine and Related Services group to appropriately recognize the resource costs and clinical distinctions of PET imaging services.
  • For 2017 and subsequent years, hospitals that fail to meet the requirements of the Hospital Outpatient Quality Reporting Program will receive a 2 percent reduction to their annual payment update. CMS will also continue to explore electronic clinical quality measures for use in future years of the program.

The final rule can be found at https://federalregister.gov/a/2015-27943

Final Hospital VBP Program Adjustment Factors Posted

October 26th, 2015

The Centers for Medicare & Medicaid Services (CMS) has posted the final incentive payment adjustment factors for the fiscal year 2016 Hospital Value-Based Purchasing (VBP) Program, which are being used to adjust base operating Medicare Severity Diagnosis-Related Group (MS-DRG) payments to eligible hospitals for discharges this fiscal year. Base operating MS-DRG payments to eligible inpatient prospective payment system hospitals are being reduced by 1.75% in FY 2016 to fund an estimated $1.5 billion in incentive payments for the VBP program. The actual VBP amount earned by each hospital depends on its Total Performance Score and incentive payment percentage.

The fact sheet can be found at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-26.html

HHS Advisory Committee on Physician Payment Models Appointed

October 9th, 2015

The Government Accountability Office (GAO) has appointed 11 members to a new committee that will provide recommendations on physician payment models to the Secretary of Health and Human Services. The members of the Physician-Focused Payment Model Technical Advisory Committee are: Jeffrey Bailet, M.D., president of Aurora Health Care Medical Group; Robert Berenson, M.D., Urban Institute fellow; Paul Casale, M.D., chief of cardiology for Lancaster General Health; Tim Ferris, M.D., senior vice president for population health management at Partners HealthCare; Rhonda Medows, M.D., executive vice president of population health at Providence Health & Services; Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform; Elizabeth Mitchell, president and CEO of the Network for Regional Healthcare Improvement; Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University; Kavita Patel, M.D., nonresident senior fellow at the Brookings Institution; Bruce Steinwald, a private consultant; and Grace Terrell, M.D., president and CEO of Cornerstone Health Care. The first appointments are for staggered terms of one to three years; subsequent appointments will be for three years.

The press release can be found at http://www.gao.gov/press/appointments_hhs_advisory_committee_physician_payment_methods.htm


CMS Releases EHR Final Rule

October 6th, 2015

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule with comment modifying the reporting period for the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs in 2015 to a 90-day period to align with the calendar year. The rule also adds other flexibilities, including reducing the share of patients that must use the patient portal from 5% to at least one patient and modifying the summary of care requirements.  In addition, the rule defines Stage 3 meaningful use for the Medicare EHR Incentive Program, and says all participants will be required to meet Stage 3 beginning in 2018. CMS is seeking comments on certain provisions of Stage 3, in particular to support the transition to the Merit-based Incentive Payment System. The Office of the National Coordinator for Health Information Technology also released a companion rule that finalizes new certification criteria, standards, and implementation specifications for EHR technology.

The rule can be found at https://federalregister.gov/a/2015-25595

CMS Awards $110 million in ACA Funding for Patient Safety

September 25th, 2015

On September 25, the Centers for Medicare & Medicaid Services (CMS) awarded $110 million in Affordable Care Act funding to 17 national, regional, and state hospital associations and health system organizations to continue efforts in reducing preventable hospital-acquired conditions and readmissions. Through the Partnership for Patients initiative – a nationwide public-private collaboration that began in 2011 to reduce preventable hospital-acquired conditions by 40 percent and 30-day readmissions by 20 percent – the second round of the Hospital Engagement Networks will continue to work to improve patient care in the hospital setting.


Round two of the Hospital Engagement Networks will continue to work to develop learning collaboratives for hospitals and provide a wide array of initiatives and activities to improve patient safety. They will be required to: conduct intensive training programs to teach and support hospitals in making patient care safer; provide technical assistance to hospitals so that hospitals can achieve quality measurement goals; and establish, implement, and improve the system to track and monitor hospital progress in meeting the Partnership for Patients’ quality improvement goals. The activities of the Hospital Engagement Networks will be closely monitored by CMS to ensure that they are generating results and improving patient safety.

The press release can be found at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-09-25.html


EHR Website Changes Announced

September 24th, 2015

The Centers for Medicare & Medicaid Services (CMS) has reorganized its website for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs to locate all information on requirements and resources for previous years in one place. The new web page contains information from 2011 to 2014, including Frequently Asked Questions and other guidance.

The new web page can be found at https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/RequirementsforPreviousYears.html