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Archive for July, 2012

Medicare Prepayment Review Demonstration to Begin

Monday, July 30th, 2012

On August 27th, the Centers for Medicare & Medicaid Services (CMS) plans to launch its Recovery Audit Prepayment Review Demonstration. The three-year demonstration will audit medical records for claims after the claims are submitted but before they are paid. As with other medical necessity audits, the outcome for this demo will be based on the reviewer’s clinical judgment about whether an item or service was eligible for Medicare coverage and was medically reasonable and necessary.

More information is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Demonstrations.html

88 New ACOs Announced

Monday, July 9th, 2012

Health and Human Services (HHS) Secretary Kathleen Sebelius announced that 88 new Accountable Care Organizations (ACOs) have begun serving 1.2 million Medicare beneficiaries in 40 states and Washington, D.C. The new ACOs have entered into agreements with the Centers for Medicare & Medicaid Services (CMS), taking responsibility for the quality of care they provide to Medicare beneficiaries in return for the opportunity to share in savings realized through high-quality, well-coordinated care.

Beginning this year, new ACO applications will be accepted annually. The application period for organizations that wish to participate in the MSSP beginning in January 2013 is from August 1 through September 6, 2012.

The press release can be found by going to this link.

More information, including application requirements, is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Application.html


2013 MPFS Proposed Rule Published

Friday, July 6th, 2012

The Centers for Medicare & Medicaid Services (CMS) published a proposed rule that would increase payments to family practitioners by approximately 7 percent and other practitioners providing primary care services between 3 and 5 percent.  The 7 percent increase for family practitioners continues the Administration’s policies to promote high quality, patient-centered care.  For CY 2013, CMS is proposing to explicitly pay for care required to assist a patient transition back to the community following a discharge from a hospital or nursing facility. In addition, the proposed rule states that CMS would make a separate payment to a patient’s community physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.

CMS also projects a significant reduction in MPFS payment rates under the Sustainable Growth Rate (SGR) methodology because of the expiration of the adjustment made for CY 2012 in the statute.  For CY 2013, CMS projects a reduction of 27 percent.

The proposed rule would also continue the careful implementation of the physician value-based payment modifier (Value Modifier) that was included in the Affordable Care Act (ACA) by providing choices to physicians regarding how to participate.  The Value Modifier adjusts payments to individual physicians or groups of physicians based on the quality of care furnished to Medicare beneficiaries compared to costs.

The proposed rule continues efforts by CMS to align quality reporting across programs to reduce burden and complexity. Also, proposed are changes to two quality reporting programs that are associated with the MPFS – the PQRS and the Electronic Prescribing (eRx) Incentive Program – as well as the Medicare Electronic Health Records (EHR) Incentive Pilot Program which promotes the use of health information technology. .

The proposed rule also includes:

  • A proposal to include additional Medicare-covered preventive services on the list of services that can be provided via an interactive telecommunications system;
  • A proposal to implement a durable medical equipment (DME) face-to-face requirement as a condition of payment for certain high-cost  DME items;
  • A proposal to apply a multiple procedure payment reduction (MPPR) policy to the technical component of the second and subsequent cardiovascular and ophthalmology diagnostic services furnished by the same doctor to the same patient on the same day;
  • A proposal to collect data on patient function to improve how Medicare pays for physical and occupational therapy and speech language pathology services;
  • A request for public comments on payment for advanced diagnostic molecular pathology services;
  • A proposal to revise a regulation that only  allows Medicare to pay for portable x-rays ordered by an MD or DO.  The revised regulations would allow Medicare to pay for portable x-ray services ordered physicians and non-physician practitioners acting within the scope of their Medicare benefit and state law;
  • A proposal to clarify when Medicare will pay for interventional pain management services provided by Certified Registered Nurse Anesthetists (CRNAs) when permitted by state law. This proposal will foster access to pain management services in areas where states have determined that CRNAs may provide these services.

The proposed rule will appear in the July 30, 2012 Federal Register.  CMS will accept comments on the proposed rule until September 04, 2012. The final rule with comment period will be issued by November 1, 2012.

For more information, visit


2013 HOPPS and ASC Proposed Rule Issued

Friday, July 6th, 2012

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update payment policies and payment rates for services furnished to Medicare beneficiaries in hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) beginning January 1, 2013.  CMS is proposing to increase HOPD payment rates by 2.1 percent.  The increase is based on the projected hospital market basket—an inflation rate for goods and services used by hospitals—of 3.0 percent less statutory reductions totaling 0.9 percent, including an adjustment for economy-wide productivity.  CMS is also proposing to increase ASC payment rates by 1.3 percent – the projected rate of inflation of 2.2 percent minus an adjustment of 0.9 percent required by law for improvements in productivity. Medicare uses the consumer price index for urban consumers (CPI-U) as the inflation rate for ASCs.

Based on the proposed updates and other policies in the proposed rule, CMS projects that total payments to hospitals under the Hospital Outpatient Prospective Payment System (HOPPS) in calendar year 2013 will be approximately $48.1 billion.  CMS also projects that payments to ASCs under the ASC Payment System will be approximately $4.1 billion.

The proposed rule would also streamline the operations of the Quality Improvement Organizations (QIOs) and make them more responsive to beneficiary complaints about quality of care.  Specifically, the proposals would give beneficiaries more information about the QIOs’ review process, and would create a new alternative dispute resolution option, called Immediate Advocacy, to resolve beneficiary complaints.  The proposed rule would also give QIOs authority to send and receive secure transmissions of electronic versions of health information.

The proposed rule will appear in the July 30, 2012 Federal Register.  CMS will accept comments on the proposed rule until September 4, 2012. The final rule will be issued by November 1, 2012.

For more information on the CY 2013 proposals for the OPPS and the ASC payment system, go to: