CMS releases OPPS, ASC proposed rule with changes to two-midnight policy
The Centers for Medicare & Medicaid Services late today issued a proposed rule for calendar year 2016 for the hospital outpatient prospective payment and ambulatory surgical center payment systems. Under the rule, there would be a net decrease in OPPS payments of 0.2%. This net decrease largely results from a proposed 2.0 percentage point cut intended to account for CMS’s overestimation of the amount of packaged laboratory payments under the OPPS for laboratory tests that were previously paid under the Clinical Laboratory Fee Schedule. AHA Executive Vice President Rick Pollack expressed disappointment with the negative update, saying AHA was “dismayed that miscalculations by the actuaries are resulting in penalties to hospitals and the patients they care for” and urged CMS to reevaluate the actuaries’ estimates. 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 does not propose any changes for stays that are expected to last more than two midnights. The agency also proposes changes to the related enforcement requirements, proposing to use Quality Improvement Organizations to conduct first-line medical reviews of the majority of patient status claims rather than Medicare Administrative Contractors or Recovery Audit Contractors, which would focus only on those hospitals with consistently high denial rates. However, CMS does not propose to reverse the 0.2% payment cut associated with the two-midnight policy. Pollack called the proposals a “good first step,” saying hospitals “appreciate today’s proposal to maintain the certainty that patient stays of two midnights or longer are appropriate as inpatient cases.” However, he expressed dismay that CMS did not propose to withdraw the 0.2% cut and urged the agency to extend the partial enforcement delay beyond Sept. 30. AHA members will receive a Special Bulletin with further details tomorrow.
News Item - 06/29/2015
CBPP: A Medicaid at 50 Q & A
In the 50 years since Medicaid was launched, it has made health care more accessible to low-income people in the United States.
We've updated our FAQ on the program, focusing on queries that have arisen in debates over the program's expansion under health reform, such as:
• How efficient is Medicaid? • How much flexibility do states have to design their own programs? • Do beneficiaries have adequate access to health care? • How does health reform's Medicaid expansion affect work incentives? • How does the Medicaid expansion affect state budgets?
We unpack answers to these questions and more in the FAQ.
In mid-April, President Obama signed into law the much anticipated Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. MACRA – nicknamed “the doc fix” – repeals Medicare’s current physician payment formula and replaces it with a new one that focuses on quality and value. But while the doc fix grabbed all the headlines, MACRA is worthy of a closer look.
Since Medicare was signed into law in 1965, there have been 116 bills passed that have added to or amended Medicare. Some of the bills have been narrow in scope; some have been sweeping.
The broadest law changing Medicare was the Medicare Modernization Act of 2003, which added 27 new sections and amended 55 others. Second broadest was the Patient Protection and Affordable Care Act of 2010, which created 12 new sections and amended 48.
Ironically, the third broadest was the Balanced Budget Act of 1997, which created the flawed payment system that MACRA kills.
Increased provider exposure to False Claims liability
Health economists have pegged the amount of healthcare spending at risk in this decision at between $15 billion and $22 billion—a huge amount of federal dollars that Epstein, Becker & Green attorney George Breen says should serve as a reminder to providers of the enforcement mechanisms available to government through the exchanges.
"The ACA provides that the False Claims Act applies to payments by, through or in connection to an exchange if the payments involve federal funds," Breen told Healthcare Dive. Because federal dollars are now indelibly connected to the exchanges through tax credits, there is an "increased risk of enforcement to the provider community," he says. And under the ACA, the damages that providers could be subjected to in a False Claims case connected to an exchange increases to not less than three times—and up to as many as six.
"Today's ruling, given that it has validated both federal and state exchanges, can be used as a reminder to providers of the increased exposure to False Claims Act liability," Breen said.
News Item - 06/26/2015
CMS responds to AHA concern that Hospital Compare update omitted CAH data
The Centers for Medicare & Medicaid Services anticipates that the July update to the Hospital Compare website will include performance data reported voluntarily by critical access hospitals, the agency told AHA, quickly responding to an AHA letter expressing “deep disappointment” that the website’s April update failed to include most of the CAH data. “The fact that so many CAHs are engaged in voluntary quality reporting demonstrates their commitment to sharing information with the communities they serve, and to identifying opportunities to improve care,” wrote Nancy Foster, AHA vice president of quality and patient safety policy. “Moreover, many payers – including some Medicaid programs and private insurers – use Hospital Compare data reported by CAHs in their pay-for-performance programs. For these reasons, it is critical that CMS post voluntarily reported data in a timely fashion.” CMS said it regrets that the data were not posted in April and is taking steps to help ensure future updates of the data are timely.
ACO Chart via PulsePilot
Interactive ACO Chart via PulsePilot
News Item - 01/26/2015
HHS seeks to have 85 percent of Medicare fee-for-service payments in value-based purchasing categories 2 through 4 by 2016 and 90 percent by 2018
Improving the quality and affordability of care for all Americans has always been a pillar of the Affordable Care Act, alongside expanding access to such care. The law gives us the opportunity to shape the way health care is delivered to patients and to improve the quality of care system-wide while helping to reduce the growth of health care costs.
When it comes to improving the way providers are paid, we want to reward value and care coordination – rather than volume and care duplication. In partnership with the private sector, the Department of Health and Human Services (HHS) is testing and expanding new health care payment models that can improve health care quality and reduce its cost.