MedPAC Calls For Cancellation Of Medicare Pay Raise For Nursing Homes

In a proposed rule published in the April 20 Federal Register, CMS said it is seeking a 1.4% net hike in the nursing home Medicare payment rate. The rate increase would reflect a market basket increase of 2.6% and two deductions, including a 0.6% cut for productivity adjustment and a 0.6% cut as a forecast error adjustment. However, in a letter to CMS, MedPAC has said that it believes no update is warranted because “Medicare’s current level of payments appears more than adequate to accommodate cost growth, even before any update.”

MedPAC argues that the aggregate Medicare margin for freestanding nursing homes in 2013 was 13.1%, the 14th consecutive year it exceeded 10%. However, the American Health Care Association is now shooting back at MedPAC’s decision, claiming MedPAC’s own research shows that nursing homes operate at an overall margin of only 1.9%.

MedPAC is now calling for CMS to move toward value-based purchasing and quality reporting programs. Additionally, MedPAC has recommended that Congress eliminate the market basket update, revise the prospective payment system, and rebase payments beginning with a 4% reduction to the base rate. Comments to CMS’ proposed rule are due on June 19.

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OIG Report: Poorly Coded Doctor Claims Cost Medicare $33 Million

A new OIG report has found that more than $33 million Medicare funds might have been overpaid to physicians as a result of poorly coded doctor claims between January 2010 and September 2012. The OIG discovered this after an audit of claims for services physicians performed in ambulatory care centers and other outpatient settings. The coding errors, however, led Medicare contractors to believe they were performed in physicians’ offices or clinics and have been attributed to “internal control weaknesses at the physician billing level and to insufficient post-payment reviews at the Medicare contractor level to identify potential place-of-service billing errors.” So far, most of physicians cited have expressed their intent to refund potential overpayments for incorrectly coded services.

Click here to see the OIG report.

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Report: Medicare Fee-For-Service Consumes Most Medicare Outlays

According to a new report from the Catalyst for Payment Reform, more than half of the $360 billion in Medicare payments made two years ago were based on traditional fee-for-service models without regard to quality or value.

However, as the government moves toward outcomes-based payment models, the number is expected to shrink significantly. The U.S. Department of Health and Human Services (HHS) is pushing to tie at least half of all traditional fee-for-service Medicare payments to quality or value through alternative payment models by the end of 2018.

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CMS Delays Requirement That Part D Prescribers Be Enrolled In Medicare Or In Valid Opt-Out Status

CMS has released an interim final rule delaying a regulatory requirement that prescribers of Part D medications that are eligible to enroll in Medicare either be enrolled in Medicare approved status or in a valid opt-out status.

The enrollment requirement was scheduled to go into effect on December 1, 2015 but now will go into effect on January 1, 2016. Furthermore, “in cases where Part D enrollees submit prescriptions for processing through Part D that are not prescribed by an eligible professional that is either enrolled in Medicare in an approved status or is in a valid opt-out status, the Part D plan must provide a provisional prescription (3 month supply) for the Part D enrollee to allow the prescriber time to either enroll in Medicare or to allow the patient time to secure a prescription from another professional.”

Click here to see the regulation.

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Senators Hold Hearing On Reducing Medicare Appeals Backlog

The U.S. Senate Finance Committee held a hearing on how to make the Medicare audits and appeals process more efficient. Currently, the Medicare appeals system is backlogged with at least 500,000 cases pending review. During the hearing, Senators heard testimony from three witness – each representing a different level of appeal.

Some Senate members raised concern about the fact that the majority of payment appeals are found in favor of the defendant. High rates of reversals, they said, raises questions about “how the initial decisions are being made and whether providers and beneficiaries are facing undue burdens on the front end.”

From NAHC:

“In its 2015 Regulatory Blueprint for Action, the National Association for Home Care & Hospice (NAHC) provides recommendations to eliminate delays in Medicare Appeals to ALJs.  NAHC recommends that: 1) CMS take all necessary steps to improve the quality and accuracy of initial claim determinations to limit need for an administrative appeal; 2) CMS monitor its contractors that handle early-stage administrative appeals to ensure a high degree of accuracy and to reduce the number of appeals that end up before an ALJ; 3) CMS provide a settlement option to all appellants with claims pending before an ALJ in order to reduce the backlog. That settlement should be based on historical data on ALJ reversal rates and the cost savings achieved by Medicare coming through the avoidance of an ALJ appeal; 4) OMHA increase its resources to handle the level of demand and establish alternative dispute resolution processes to resolves some appeals.”

Click here to read more from NAHC.

CMS Clarifies Ordering & Certifying Documentation Requests

CMS has issued Change Request (CR) 9114 that provides instructions and clarification on their existing policy for ordering and certifying maintenance requirement.

In May 2010, CMS issued an interim final rule (CMS-6010-IR) and on April 27, 2012, a final rule (CMS-6010-F) which established Medicare Ordering and Referring, and Documentation Maintenance Requirements.

CMS required that any provider and supplier that furnishes covered home health services, items of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), clinical laboratory, or imaging services, is required to maintain documentation for 7 years from the date of service, and that the provider give access to that documentation upon request. This requirement also applied to a physician ordering/certifying home health services, items of DMEPOS, clinical laboratory, or imaging services.

In the CR, CMS clarifies the term “access to documentation” to mean that the documentation is actually provided or made available in a the manner requested by CMS or a Medicare contractor. CMS provides examples of sufficient and deficient access to documentation in the CR.

Click here to view the CR.

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CMS To Remove Social Security Numbers From Medicare Beneficiary Cards

CMS has a new mandate to remove Social Security numbers from enrollees’ cards after being warned for more than 10 years by government investigators to remove them. The new requirement is part of a major Medicare payment reform bill signed in law just last week. CMS now has four years to begin issuing new Social Security cards without the numbers, and up to eight years to issue replacement cards to more than 50 million existing enrollees. The conversion is expected to cost $320 million and will be paid from Medicare trust funds. Social Security numbers on the Medicare cards will be replaced by a randomly generated identifier, according to officials.

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