1.800.456.4350 info@prgweb.com

Archive for the ‘Medical Reimbursement News’ Category

Draft Recommendations on Low Dose Aspirin Issued

Monday, September 14th, 2015

According to a draft recommendation issued by the U.S. Preventive Services Task Force, certain individuals at increased risk for cardiovascular disease should take low-dose aspirin daily to prevent heart attack, stroke, and colorectal cancer. The recommendation would apply to individuals between 50-59 years old with a greater than 10% chance of developing cardiovascular disease in the next 10 years who are likely to live that long, willing to take aspirin for at least 10 years, and not at increased risk for bleeding. Aspirin also may help individuals between the ages of 60-69. However, according to the Task force Panel, the decision to do so should be an individual one based on the patient’s risk and preferences. Comments on the draft recommendation will be accepted through October 12.

The draft recommendation can be found at http://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services-task-force-opportunities-for-public-comment


MedPAC Discusses Payment Model for Post-acute Care

Thursday, September 10th, 2015

The Medicare Payment Advisory Commission (MedPAC) discussed its progress toward meeting the IMPACT Act mandate to develop a prototype for a new unified payment system for post-acute care services provided by home health agencies, skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals. The commission’s report on the prototype is due to Congress next June, and will be the subject of ongoing analysis and multiple MedPAC sessions until its submission. The commission reviewed an initial framework designed to address wide variation in post-acute care use and costs, a misalignment between payments and costs, and payments based in part on site-of-service rather than patients’ clinical characteristics, among other concerns. The preliminary approach would establish two models: one for SNF, IRF and LTCH patients, which includes an add-on for non-therapy ancillary services such as ventilator services and drugs, and a second component for Home Health (HH) patients that, like current HH payment policy, does not pay for non-therapy ancillaries. Commission staff explained that the separate treatment of HH services was driven by significantly lower HH costs in comparison to those of the other facility-based post-acute settings.

For more information, go to http://medpac.gov/

Medicare Health Equity Plan Released

Tuesday, September 8th, 2015

The Centers for Medicare & Medicaid Services’ (CMS) Office of Minority Health has released a plan to reduce health disparities in Medicare. The CMS Equity Plan for Improving Quality in Medicare aims to expand the collection, reporting, and analysis of standardized data; evaluate disparities impacts and integrate equity solutions across CMS programs; develop and disseminate promising approaches to reduce health disparities; increase the ability of the health care workforce to meet the needs of vulnerable populations; improve communication and language access for people with limited English proficiency or disabilities; and increase physical accessibility of health care facilities.

Further details can be found at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-09-08.html

Value-based Medicare Advantage Model Announced

Tuesday, September 1st, 2015

On September 1st, the Centers for Medicare & Medicaid Services (CMS) announced The Medicare Advantage Valued-Based Insurance Design Model. The model will test whether encouraging plan enrollees with certain conditions to consume high-value clinical services through reduced cost sharing and other approaches improves quality and reduces costs. Interventions will target enrollees with diabetes, chronic obstructive pulmonary disease, congestive heart failure, past stroke, coronary artery disease and mood disorders. Eligible Medicare Advantage and prescription drug plans in Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania and Tennessee may submit proposals to participate in the model. The Model testing is scheduled to being on January 1, 2017.

The announcement can be found by visiting http://innovation.cms.gov/Files/x/mavbid-announcement.pdf


2014 Medicare ACO Results Announced

Tuesday, August 25th, 2015

The Centers for Medicare & Medicaid Services (CMS) has issued 2014 quality and financial performance results showing that Medicare Accountable Care Organizations (ACOs) continue to improve the quality of care for Medicare beneficiaries, while generating financial savings. As the number of Medicare beneficiaries served by ACOs continues to grow, these results suggest that ACOs are delivering higher quality care to more and more Medicare beneficiaries each year.

According to the results, the 20 ACOs in the Pioneer ACO Model and 333 Medicare Shared Savings Program ACOs generated more than $411 million in total savings in 2014, which includes all ACOs’ savings and losses. At the same time, 97 ACOs qualified for shared savings payments of more than $422 million by meeting quality standards and their savings threshold. The results also show that ACOs with more experience in the program tend to perform better over time.

For more information, visit https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-08-25.html


Medicare DMEPOS Competitive Bidding Program Timeline Announced

Wednesday, August 12th, 2015

The Centers for Medicare & Medicaid Services (CMS) has announced the bidding timeline for Round 1 of the 2017 competition of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program. The agency is required to re-compete the contracts at least once every three years. Suppliers then submit bids to provide certain equipment and supplies in competitive bidding areas.

For more on the program, including the bidding rules and other resources for suppliers, visit www.dmecompetitivebid.com.


Enforcement Delay Extended

Wednesday, August 12th, 2015

The Centers for Medicare & Medicaid Services (CMS) has extended the partial enforcement delay of the two-midnight policy through December 31st. The current delay was set to expire on September 30. Under the extension, Recovery Audit Contractors (RACs) are prohibited from conducting post-payment patient status reviews for claims with dates of admission from October 1 through December 31, 2015. CMS also provided further details related to changes in the agency’s education and enforcement strategies for patient status claims.

For more on the announcement, visit www.cms.gov

Final FY 2016 IPPS and LTCH PPS Rule Issued

Friday, July 31st, 2015

On July 31, the Centers for Medicare & Medicaid Services (CMS) issued its hospital inpatient prospective payment system (IPPS) and Long Term Care Hospital (LTCH) Prospective Payment System (PPS) final rule for fiscal year (FY) 2016 which increases rates to acute care hospitals by 0.9% after accounting for inflation and other adjustments. Specifically, the final rule includes an initial market-basket update of 2.4% for those hospitals that were meaningful users of electronic health records in FY 2014 and that submit data on quality measures, less a productivity cut of 0.5 percentage point and an additional market-basket cut of 0.2 percentage point. The rule also finalizes a 0.8 percentage point cut that fulfills, in part, the requirement of the American Taxpayer Relief Act of 2012. In addition, the rule includes ACA-mandated Medicare Disproportionate Share Hospital (DSH) reductions, reducing the overall Medicare DSH payments by $1.2 billion in FY 2016. CMS also finalized its proposal to require hospitals to submit certain clinical quality measures electronically in calendar year 2016 for payment in the FY 2018 Inpatient Quality Reporting program. The agency, however, will only require the submission of four electronic clinical quality measures rather than the 16 it had proposed. CMS also expands the patient population of the pneumonia readmission measure used in the Hospital Readmissions Reduction Program beginning in FY 2017. However, it will exclude certain patients from the expanded population. Regarding the two-midnight policy, CMS did not extend the partial enforcement delay that expires on September 30.

The final rule was published in the Federal Register on August 17. Comments are due by September 29. The rule is effective October 1.

The final rule can be found at https://federalregister.gov/a/2015-19049

FY 2016 SNF Final Rule Published

Thursday, July 30th, 2015

On July 30, the Centers for Medicare & Medicaid Services (CMS) published a final rule updating Medicare fee-for-service payments for skilled nursing facilities (SNF) for fiscal year 2016. The rule provides an overall 1.2% update compared to FY 2015 payments, which includes a 2.3% market-basket update, a 0.6 percentage point forecast error reduction that accounts for the difference between the FY 2014 market-basket update and the actual market change for that year, and the statutorily mandated 0.5 percentage point productivity cut. The net update for rural hospital-based SNFs is estimated to be 0.6%, while the net update for urban hospital-based SNFs is 1.4%.

The final rule was published in the Federal Register on August 4. The final rule can be found at https://federalregister.gov/a/2015-18950

Over 55 Million Americans Covered by Medicare

Tuesday, July 28th, 2015

As Medicare and Medicaid celebrate their 50th anniversary, the Centers for Medicare & Medicaid Services (CMS) released updated Medicare state-by-state enrollment numbers, showing that more than 55 million Americans are covered by Medicare.


In 1966, approximately 19.1 million Americans were covered by Medicare; in 2012, there were nearly 52 million beneficiaries. Today’s enrollment numbers represent a three million person increase during the last three years. According to a statement by Andy Slavitt, CMS acting administrator, “Over the last 50 years, Medicare has become part of the fabric of our communities, protecting the well-being and financial security of millions of American families as they age or if they become disabled. In doing so, Medicare has kept up with dramatic demographic changes and led the charge toward improving health care delivery

The press release can be found at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-07-28.html