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Archive for the ‘Medical Reimbursement News’ Category

CMS Identifies and Prevents $820 Million in Improper Medicare Payments

Thursday, July 16th, 2015

After three years of operations, the Centers for Medicare & Medicaid Services (CMS) reported that the agency’s advanced analytics system, called the Fraud Prevention System, identified or prevented $820 million in inappropriate payments in the program’s first three years. The Fraud Prevention System uses predictive analytics to identify troublesome billing patterns and outlier claims for action.  The Fraud Prevention System identified or prevented $454 million in 2014 alone.

In future years, CMS plans to expand the Fraud Prevention System and its algorithms to identify lower levels of non-compliant health care providers who would be better served by education or data transparency interventions.

For more information, please see the Report under “Guidance and Reports” at: http://www.cms.gov/About-CMS/Components/CPI/Center-for-program-integrity.html


President to Nominate Slavitt for CMS Administrator

Friday, July 10th, 2015

President Obama has announced his intent to nominate Andy Slavitt for Centers for Medicare & Medicaid Services (CMS) administrator. Mr. Slavitt has served as acting administrator since Marilyn Tavenner stepped down in March. The nomination will require Senate confirmation.

For more information, go to https://www.whitehouse.gov/the-press-office/2015/07/09/president-obama-announces-more-key-administration-posts

2016 Medicare Physician Fee Schedule Proposed Rule Issued

Wednesday, July 8th, 2015

The Centers for Medicare & Medicaid Services (CMS) has issued its proposed rule for the physician fee schedule for calendar year 2016. Under the proposal, physicians would have a payment increase of 0.5%, as required by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. CMS also proposes to pay for advanced care planning services, which include explanation and discussion of advance directives by a physician or other qualified health professional, and requests comment on certain provisions of the Merit-based Incentive Payment System to be implemented in 2019 under MACRA. Other provisions in the proposed rule include a proposal to expand required reporting of the Consumer Assessment of Healthcare Providers and Systems survey to group practices of 25 or more eligible professionals; the use of star ratings on Physician Compare; and the proposed application of the value-based payment modifier to groups consisting of only non-physician EPs, such as physician assistants.

The proposed rule was published in the July 15 Federal Register, and comments are due September 8.

The proposed rule can be found at https://federalregister.gov/a/2015-16875

CY 2016 OPPS and ASC Medicare Proposed Rule Released

Thursday, July 2nd, 2015

On July 1, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule for calendar year (CY) 2016 for the hospital outpatient prospective payment (OPPS) and ambulatory surgical center (ASC) payment systems. Under the rule, there would be a net decrease in OPPS payments of –0.1% in CY 2016. The reduction is based on the projected hospital inpatient market basket increase of 2.7% for services paid under the hospital inpatient PPS minus both a 0.6 % adjustment for multi-factor productivity and a 0.2% adjustment to the market basket. There would also be an additional proposed 2.0% adjustment to the payment update to account for excess packaged payment for laboratory tests.

In addition, CMS proposes to alter its two-midnight policy so that certain hospital inpatient services that do not cross two midnights may be appropriate for payment under Medicare Part A if a physician determines and documents in the patient’s medical record that the patient requires reasonable and necessary admission to the hospital as an inpatient.

CMS conducted a comprehensive review of the entire outpatient PPS clinical APCs and proposes to restructure, reorganize and consolidate many APCs. This would result in fewer APCs overall for nine clinical APC families. In addition, the agency is proposing nine new C-APCs including some surgical APCs and a new C-APC for comprehensive observation services that will include all primary procedures found on the observation claim.

The agency also proposes changes to the related enforcement requirements, proposing to use Quality Improvement Organizations (QIO) to conduct first-line medical reviews of the majority of patient status claims rather than Medicare Administrative Contractors (MAC) or Recovery Audit Contractors (RAC).

The proposed rule was published in the July 8 Federal Register. CMS will accept comments until August 31, 2015.

The Federal Register can found at https://federalregister.gov/a/2015-16577

IOM Releases Report on Cardiac Arrest Survival Strategies

Tuesday, June 30th, 2015

The Institute of Medicine (IOM) has released a report that recommends strategies and actions to improve survival and quality of life following cardiac arrest. The report states that about 395,000 cardiac arrests occur annually in the community and another 200,000 in hospitals, and about 6% and 24% of those patients survive, respectively. The report recommends that the nation establish a cardiac arrest registry to track performance and identify common goals; train the public to administer CPR and use AEDs; standardize dispatcher-assisted CPR protocols and training for emergency medical technicians; set national accreditation standards related to cardiac arrest for hospitals and health care systems; adopt continuous quality improvement programs; and research and adopt new treatments.

For more information, visit http://iom.nationalacademies.org/Reports/2015/Strategies-to-Improve-Cardiac-Arrest-Survival.aspx

Independence at Home Demonstration Saves $25 million

Tuesday, June 16th, 2015

According to the Centers for Medicare & Medicaid Services (CMS), the Medicare Independence at Home Demonstration has saved more than $25 million, or an average $3,070 per beneficiary, in its first ear. The three-year demonstration is testing whether primary care services delivered at home by multidisciplinary teams improve care and reduce costs for beneficiaries with multiple chronic conditions. CMS will award $11.7 million in incentive payments to nine practices that reduced Medicare expenditures and met quality goals in the first performance year. All 17 participating practices improved on at least three of the six quality measures for the first performance year, and four met all six of the quality goals.

For more on the demonstration, visit http://innovation.cms.gov/initiatives/Independence-at-Home.

AHRQ to Fund Studies on Promotion of Evidence-based Practices

Monday, June 15th, 2015

The Agency for Healthcare Research and Quality (AHRQ) will fund three Centers of Excellence to study how high-performing health care systems promote evidence-based practices in delivering care. The centers will receive about $52 million over five years. The agency also will fund a coordinating center, which will help the three centers collaborate to develop a national compendium of health care system performance.

For more information, go to http://www.ahrq.gov/news/newsroom/press-releases/2015/pcorawards.html

Medicare Payment to Physicians to Increase July 1

Monday, June 15th, 2015

As part of the “Protecting Access to Medicare Act of 2014″, 2014 pricing policy for the Medicare Physician Fee Schedule was extended through March 31, 2015. The “Medicare Access and CHIP Reauthorization Act (MACRA) of 2015″ further extended the 0 percent update and other provisions through June 30, 2015. Starting July 1, the legislation provides for a 0.5 percent update to the Medicare Physicians Fee Schedule by increasing the conversion factor (CF) to 35.9335.

Further details of MACRA of 2015 can be found at https://www.congress.gov/bill/114th-congress/house-bill/2/text

Increased Transparency for Consumers on Health Insurance Coverage

Friday, June 12th, 2015

The Departments of Health and Human Services (HHS), Labor, and the Treasury have issued final regulations to make it easier for people and employers to compare their options when shopping for and renewing health insurance coverage.  These rules also implement streamlined processes to help health insurance issuers and group health plans provide consumers easy to understand information.  The final rules make few changes to the rules proposed in December, 2014. In continuing the goal of providing clear and straightforward information to consumers about health plans available in their area, health insurance issuers and group health plans must still provide a brief Summary of Benefits and Coverage (SBC) that includes coverage examples and a uniform glossary to consumers.  Revisions to the SBC, coverage examples, and a uniform glossary are anticipated to be finalized by January, 2016 after the Departments utilize consumer testing and receive additional input from the public, including the National Association of Insurance Commissioners (NAIC). The revisions will apply to SBCs for coverage beginning on or after January 1, 2017.

To view the Final Rules, visit https://www.federalregister.gov/articles/2015/06/16/2015-14559/summary-of-benefits-and-coverage-and-uniform-glossary


Medicare and Medicaid to Celebrate 50th Anniversary

Wednesday, June 10th, 2015

This summer will mark the 50th anniversary of the enactment of Amendments to the Social Security Act that established the Medicare and Medicaid programs. Over the next 50 days, the Centers for Medicare & Medicaid Services (CMS) will recognize the impact these two programs have had in transforming our nation’s health care system. By sharing daily facts and posts on Twitter (@cmsgov) and Medicaid.gov, CMS will highlight people, places, and progress that represent the Medicare and Medicaid programs. To commemorate this anniversary, in late July, regional CMS offices will host public events in addition to a national event in Washington, D.C.

The press release can be found by going to http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-06-10.html