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Medical Industry Reimbursement News

The Joint Commission Report Shows Improved Quality of Care

November 12th, 2014

Hospitals across the United States continue to improve their rates for complying with evidence-based care processes according to America’s Hospitals: Improving Quality and Safety: The Joint Commission’s 2014 Annual Report. The results are based on data reported by more than 3,300 Joint Commission accredited hospitals in 2013. These hospitals represent rural and urban locations, all U.S. regions, and all sizes and types of hospitals, from small critical access hospitals to large academic medical centers. The release of this report provides the opportunity to gauge progress in health care quality improvement which The Joint Commission has been tracking over the past 12 years. The collective performance of these accredited hospitals on individual accountability measures has steadily improved over the past few years. The data released show improved care for pneumonia, children’s asthma, surgical care, heart failure, and other common conditions.

For more information, go to http://jointcommission.new-media-release.com/2014_annualreport/

CMS Announces Tool to Help Review Health Plan Options

November 10th, 2014

On November 9, the Centers for Medicare & Medicaid Services (CMS) announced that individuals and families can now visit the www.healthcare.gov website to review detailed information about each health plan in their area participating in the 2015 Health Insurance Marketplace. The new tool will enable consumers to compare plans, covered benefits, and physician and hospital networks. CMS is encouraging current enrollees to review and compare health plan options during open enrollment and find out if they are eligible for financial assistance.

For more information, visit www.healthcare.gov

OCR Issues Bulletin on Applying HIPAA Privacy Rule in Emergencies

November 10th, 2014

On November 10, the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) issued a bulletin reviewing the ways in which patient information may be shared under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in emergency situations. This was prompted by the recent Ebola cases. According to the bulletin, the HIPAA Privacy Rule is not suspended during a public health or other emergency, but is balanced to ensure that appropriate uses and disclosures of the information still may be made when necessary to treat a patient, to protect the nation’s public health, and for other critical purposes. If the President declares an emergency or disaster and the secretary declares a public health emergency, the Health and Human Services secretary may waive penalties for violations of certain provisions of the rule for a limited time.

The Bulletin can be found at http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/emergency/hipaa-privacy-emergency-situations.pdf

Veterans Choice Program Interim Final Rule Released

November 4th, 2014

The Department of Veterans Affairs has released an interim final rule implementing the Veterans Access, Choice, and Accountability Act of 2014.  The rule will facilitate the ability of veterans to receive care at a non-VA hospital when a veteran lives more than 40 miles away from or cannot be seen within 30 days at a VA facility.

For more information, go to https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-26316.pdf

2015 MPFS Final Rule Published

October 31st, 2014

The Centers for Medicare & Medicaid Services (CMS) has published the 2105 Medicare Physician Fee Schedule (MPFS), which updates payment policies and payment rates for services furnished to Medicare beneficiaries by physicians and other practitioners. The payment provisions of the final rule are effective January 1, 2015 through March 31, 2015 unless there is legislative intervention.

Provisions of the final rule include:

- Beginning in 2015, CMS will pay for chronic care management (CCM) services separately for Medicare beneficiaries who have two or more significant, chronic conditions. The final rule establishes a payment rate for CCM services that may be billed up to once per month for each qualified patient. CCM services include communication and coordination among a care team, medication management, and consistent review of a patient’s plan of care.

- A new process for determining fee schedule payment rates will be established that will allow for greater public input and transparency prior to payment rates being set. The final rule allows the payment rates to go through notice and comment rulemaking prior to being adopted.

- The telehealth benefit will be expanded to include the annual wellness visits, psychoanalysis, psychotherapy, and prolonged evaluation and management services.

In addition, the final rule establishes new requirements related to the 2017 Physician Quality Reporting System (PQRS) payment adjustment. Beginning in 2015, the program will apply a payment adjustment to professionals who do not report data on quality measures for particular professional services. CMS has also added the new measure that is defined as infection within 180 days of Cardiac Implantable Electronic Device (CIED) implantation, replacement or revision.

The final rule can be viewed at https://www.federalregister.gov/articles/2014/11/13/2014-26183/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory

2015 Hospital OPPS/ASC Final Rule Released

October 31st, 2014

On October 31, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2015 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates final rule with comment period. Overall, OPPS payments are estimated to increase by 2.3 percent for CY 2015. The increase is based on the projected hospital market basket increase of 2.9 percent minus both a 0.5 percentage point adjustment for multi-factor productivity and a 0.2 percentage point adjustment.  Other payment changes are included, such as increased estimated total outlier payments.

The CY 2015 OPPS/ASC final rule with comment period updates Medicare payment policies and rates for hospital outpatient department and ASC services and partial hospitalization services provided by community mental health centers (CMHCs), and refines programs that encourage high-quality care in these outpatient settings. This rule furthers the agency’s goal of delivery system reform by moving the OPPS toward making payments for larger packages of items and services rather than making separate payments for each individual service. In CY 2015, CMS is implementing a policy finalized last year regarding comprehensive Ambulatory Payment Classifications (C-APCs), with some refinements and updates. The new C-APC payment policy makes a single payment for all related or adjunctive hospital items and services provided to a patient receiving certain primary procedures that are either largely device dependent, such as insertion of a pacemaker, or represent single session services with multiple components, such as intraocular telescope implantation.

For CY 2015, CMS will conditionally package all ancillary services assigned to APCs with a geometric mean cost of $100 or less prior to packaging as a criterion to establish an initial set of conditionally packaged ancillary service APCs. When these ancillary services are furnished by themselves, CMS will make separate payment for these services

The final rule can be accessed at  http://www.gpo.gov/fdsys/pkg/FR-2014-11-10/pdf/2014-26146.pdf

New Medicare ACO Model Announced

October 15th, 2014

The Centers for Medicare & Medicaid Services (CMS) has announced the availability of a new model for Accountable Care Organizations (ACO) participating in the Medicare Shared Savings Program (MSSP). The new ACO Investment Model is a pre-paid shared savings model that encourages new ACOs to form in rural and underserved areas and current MSSP ACOs to transition to arrangements with greater financial risk. To participate, existing ACOs can only include a hospital if the hospital has 100 or fewer beds or is a critical access hospital. Eligibility is targeted to ACOs that joined the MSSP in 2012, 2013 and 2014, and to new ACOs joining the Shared Savings Program in 2016. The application deadline for organizations that started the program in 2012 or 2013 will be December 1, 2014. CMS expects applications to be available in summer 2015 for ACOs that started in the program in 2014 or will start in 2016.

For more on the new model, go to http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-10-15.html

2015 Medicare Premiums and Deductibles Announced

October 10th, 2014

The Centers for Medicare & Medicaid Services (CMS) has announced the premiums and deductible for calendar year (CY) 2015. The Medicare Part A deductible for inpatient hospital, skilled nursing facility and home health services will increase by $44 to $1,260.The daily coinsurance amounts will be $315 for days 61-90 of hospitalization in a benefit period; $630 for lifetime reserve days; and $157.50 for days 21-100 of extended care services in a skilled nursing facility in a benefit period. The monthly Part A premium, paid by just 1% of beneficiaries who have fewer than 40 quarters of Medicare-covered employment, will decline by $19 to $407. The base Part B monthly premium and annual deductible for physician and hospital outpatient services, certain home health services, durable medical equipment and other items will be unchanged at $104.90 and $147, respectively.

More information is available at http://www.ofr.gov/OFRUpload/OFRData/2014-24257_PI.pdf

Changes to CoPs for HHA Proposed

October 7th, 2014

The Centers for Medicare & Medicaid Services (CMS) has proposed the first update to the Medicare and Medicaid Conditions of Participation (CoPs) for home health agencies (HHAs) since 1989. The proposed rule would update data transmission requirements for the Outcomes and Assessment Information Set (OASIS) to meet current federal standards; focus the patient assessment requirement on each patient’s physical, mental, emotional and psychosocial condition; expand patient rights requirements; and formalize communication and care coordination structures. In addition, the rule would require each HHA to maintain a quality assessment and performance improvement program based on OASIS and other data, and a program to prevent and control infections and communicable diseases; and require additional supervision and training when an agency suspects that home health aide skills are insufficient.

The proposed rule is available at https://www.federalregister.gov/articles/2014/10/09.

OIG Proposes Revisions to Safe Harbors

October 2nd, 2014

On October 2, 2014, the Department of Health and Human Services Office of Inspector General (OIG) published proposed rules to add new safe harbors to the federal Anti-Kickback Statute (AKS). The OIG’s proposed rules would also codify certain revisions made to the federal Civil Monetary Penalty Law (CMP Law) by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and the Patient Protection and Affordable Care Act (ACA), as amended by the Health Care and Education Reconciliation Act of 2010.The proposed rule makes a technical correction to the AKS’s referral services safe harbor and also proposes new AKS safe harbors that would protect- pharmacy cost-sharing waivers for financially needy Medicare Part D participants; emergency ambulance service cost-sharing waivers when the services are furnished by state- or municipality- owned providers; certain remuneration between federally qualified health centers and Medicare Advantage organizations; discounts by manufacturers on drugs provided under the Medicare Covered Gap Discount Program; and certain free or discounted local transportation. In addition, the OIG would change regulatory definitions as they apply to gainsharing arrangements under the CMP Law to narrow the statute’s application.

The proposed rule is available at https://www.federalregister.gov/articles/2014/10/03/2014-23182/medicare-and-state-health-care-programs-fraud-and-abuse-revisions-to-safe-harbors-under-the