Medicare Update

Medicare Recovery Audit Contractors: Don't Be Left in the Dark

The Centers for Medicare & Medicaid Services (CMS) intends to implement the permanent Medicare Recovery Audit Contractor (RAC) program in phases beginning in March 2009.  Medicare providers should become informed about the RAC program and prepare for its implementation.  In this post, aspects of the nationwide RAC program are highlighted to assist Medicare providers in understanding the program.

Region C Medicare Recovery Audit Contractor Adds New CMS Approved Audit Issue

Connolly Healthcare, the Medicare recovery audit contractor (RAC) for Region C, recently posted a new CMS approved audit issue for RAC review on its website.

The title of the new CMS approved audit issue is "Medically Unlikely Edit List" and it applies to all states and territories in Region C. The provider type affected is outpatient hospitals.

More information on the new CMS approved audit issue for Region C can be found here.

Region C includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, Virgin Islands and West Virginia.

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Ambulatory Payment Classification Group Advisory Panel to Meet in February 2010

The Centers for Medicare & Medicaid Services (CMS) recently published a Notice announcing the first semi-annual meeting of the Advisory Panel on Ambulatory Payment Classification (APC) Groups for 2010. The first semi-annual meeting is scheduled for February 17-19, 2010.

The agenda for the February 2010 meeting will involve discussion and comment on the following topics:

• Addressing whether procedures within an APC group are similar both clinically and in terms of resource use.
• Evaluating APC group weights.
• Reviewing the packaging of hospital outpatient prospective payment system (OPPS) services and costs, including the methodology and the impact on APC groups and payment.
• Removing procedures from the inpatient list for payment under OPPS.
• Using single and multiple procedure claims data for CMS's determination of APC group weights.
• Addressing other technical issues concerning APC group structure.

CMS reports that it will consider the Advisory Panel's advice when it prepares the proposed and final rules that would update OPPS for calendar year 2011.

See the Notice for information regarding meeting times, deadlines, attendance, location, requirements for presentations and written comments, and other requirements and instructions.

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Senate Passes Health Reform Legislation on Party-Line Vote

On December 24, 2009, the U.S. Senate voted 60-39 to pass health reform legislation (H.R.3590) on a party-line vote. 

In November 2009, the U.S. House of Representatives passed the Affordable Health Care for America Act (H.R.3962).

Now, the challenge will be reconciling the differences between the Senate and House bills and producing a compromise bill that can be passed by both chambers and sent to the President for signature.

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Related Post: House Passes Affordable Health Care for America Act

Senate Set for Final Vote on Health Reform Legislation

On December 23, 2009, the U.S. Senate voted 60-39 to advance the Senate health reform legislation (H.R.3590) past what appears to be the last procedural hurdle before the Senate votes on final passage. It has been reported that the final vote will take place at 7:00 a.m. (EST) on December 24, 2009.

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Senate Republicans Question Health Reform Bills Deficit Neutrality

Today, the U.S. Senate is expected to vote on a procedural matter before a final vote is taken on the Patient Protection and Affordable Care Act (PPACA) on December 24, 2009.

In a related event, Senator Jeff Sessions released a December 23, 2009 memorandum from the Congressional Budget Office (CBO), which addresses the PPACA's effect on the Federal budget and the balance in the Medicare hospital insurance trust fund.

Senate Republicans are reportedly pointing to language in the memorandum and questioning whether the savings from the Medicare program is being double counted to pay for the PPACA.  In particular, they appear to be pointing to portions of the memorandum, which state:

"The key point is that savings to the HI trust fund under the PPACA would be received by the government only once, so they cannot be set aside to pay for future Medicare spending and, at the same time, pay for current spending on other parts of the legislation or on other programs...To describe the full amount of HI trust fund savings as both improving the government's ability to pay future Medicare benefits and financing new spending outside of Medicare would essentially double-count a large share of those savings and thus overstate the improvement in the government's fiscal position."

Developing...

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Region A Medicare Recovery Audit Contractor Adds New CMS Approved Audit Issues

DCS Healthcare (DCS), the Medicare recovery audit contractor (RAC) for Region A, recently posted new CMS approved audit issues for automated RAC review on its website.

The titles of the new CMS approved audit issues are listed below and apply to DMEPOS suppliers in all states within Region A:

• Solid Insert with Seat or Back Wheelchair Cushions
• Lower Limb Suction Value Prosthesis
• Prosthetic Additions with Initial or Preparatory Knee Prosthesis
• Multiple DME Rentals within a Month
• Headrest with a Power Operated Vehicle or a Power Wheelchair with a Captain's Chair Seat
• Wheel Attachment with New Non-Wheeled Walker

Region A includes Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

For more information, see the CMS approved audit issues for Region A, which can be found here.

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President Signs Legislation Delaying Medicare Physician Payment Reductions

Yesterday, the Obama Administration announced that the President signed the Department of Defense Appropriations Act, 2010 (H.R.3326) into law.

Among other things, H.R.3326 delays the scheduled 21.2 percent Medicare payment reduction for physician services until March 1, 2010.  The payment reduction was scheduled to take effect on January 1, 2010. 

In the Final Rule updating the Medicare Physician Fee Schedule (MPFS) for calendar year 2010, the Centers for Medicare & Medicaid Services (CMS) adopted an update of -21.2 percent. MPFS rates are updated annually based on a formula that includes the sustainable growth rate (SGR) formula.  The SGR formula has resulted in negative updates since 2002. However, CMS has taken action or Congress has enacted legislation each year to avoid the negative updates.

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CMS Publishes Final Rule on Medicare Part A/B Claims Appeal Procedures

On December 9, 2009, the Centers for Medicare & Medicaid Services (CMS) published a Final Rule addressing its March 8, 2005 Interim Final Rule on Medicare Part A/B claims appeal procedures.

In the Final Rule, CMS responds to various comments on the March 8, 2005 Interim Final Rule (Interim Final Rule). However, it appears that CMS makes few (if any) substantive changes from the Interim Final Rule. Instead, CMS makes numerous technical changes (e.g., adding the word "calendar" in front of the word "day" or "days"). However, the devil is often in the details and substantive changes could possibly emerge.

The Final Rule is effective on January 8, 2010.

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Round 1 Rebid Window for Medicare DMEPOS Competitive Bidding Program Closes

On December 21, 2009, the bidding window for the Round 1 Rebid of the Medicare durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) competitive bidding program closed.

According to a Centers for Medicare & Medicaid Services (CMS) timeline, DMEPOS suppliers (that submitted bids) now have to wait until September 2010 to find out if they will be awarded a contract. The Medicare competitive bidding program has an implementation date of January 1, 2011.

In a recent article by the on-line edition of Homecare magazine, it is suggested that the DMEPOS accreditation and surety bond requirements may have resulted in far fewer bidders than the original Round 1 bid. Some DMEPOS suppliers also express their concern about suppliers possibly submitting "lowball bids that are unsustainable" in an effort to keep their Medicare business.

As previously reported, Representative Kendrick Meek has introduced legislation (H.R.3790) that would eliminate the DMEPOS competitive bidding program. H.R.3790 would also reduce Medicare reimbursements to home medical equipment providers in 2010, 2011, 2012, 2014 and 2015.

The American Association for Homecare (AAHomecare) is urging DMEPOS stakeholders and Congress to support H.R.3790. For more information on this advocacy effort, visit the AAHomecare website.

The Medicare DMEPOS competitive bidding program was established by the Medicare Prescription Drug Improvement and Modernization Act of 2003. However, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) delayed the program and mandated certain changes. In fact, the MIPPA required CMS to terminate the Round 1 contracts and conduct the Round 1 Rebid in 2009. 

For more information on the Round 1 Rebid, visit the CMS competitive bidding program page and the Competitive Bidding Implementation Contractor website.

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Related Post: Legislation Introduced to End Medicare DMEPOS Competitive Bidding Program

Region D Medicare Recovery Audit Contractor Adds New CMS Approved Audit Issues

HealthDataInsights, Inc. (HDI), the Medicare recovery audit contractor (RAC) for Region D, recently posted new CMS approved audit issues for RAC review on its website. 

The titles of the new CMS approved audit issues are listed below and apply to all states within Region D:  

• SNF Consolidated Billing
• A4221 Excessive Units
• Prosthetic Bundling

See the HDI website for more details regarding the new CMS approved audit issues.

Region D includes Alaska, Arizona, California, Hawaii, Iowa, Idaho, Kansas, Missouri, Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Guam, American Samoa, and Northern Marianas. 

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