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.
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On July 9, 2009, the Centers for Medicare & Medicaid Services (CMS) announced that it has added data regarding hospital readmission rates to Medicare's Hospital Compare website.
Specifically, the Hospital Compare website now provides hospital readmission rates for patients readmitted within 30 days following admission for a heart attack, heart failure and pneumonia. In doing so, the website compares a hospital's readmission rate for each of these conditions with the U.S. national rate and labels a hospital as being "Better than," "No different than," or "Worse than" the national rate.
Further, in CMS's Press Release, Department of Health and Human Services Secretary Kathleen Sebelius states that "[t]he President and Congress have both identified the reduction of readmissions as a target area for health reform." According to CMS, the U.S. national 30 day readmission rate for the 3 conditions is:
CMS also reports that the Hospital Compare website has been updated to provide better data on previously posted mortality rates. For more information, see CMS's Press Release and Fact Sheet.
A number of news organizations, including the Washington Post, are reporting that White House officials, Senate Finance Committee Chairman Max Baucus and 3 national hospital associations may have reached an agreement to reduce health care spending by $155 billion over 10 years.
According to the Washington Post article, most of the savings (possibly $100 billion) may come from lower than expected Medicare and Medicaid payments to hospitals. Reportedly, the $155 billion in savings would be applied to pay for the expansion of coverage to the uninsured. It has also been reported that a formal announcement may be made by Vice President Biden on Wednesday, July 8.
Although not addressing this apparent development, President Obama released a statement on health care reform today reaffirming the Administration's commitment to a public option and stating:
"I am pleased by the progress we're making on health care reform and still believe, as I've said before, that one of the best ways to bring down costs, provide more choices, and assure quality is a public option that will force the insurance companies to compete and keep them honest. I look forward to a final product that achieves these very important goals."
UPDATE: Vice President Biden's press conference formally announcing the hospitals' commitment to health care reform provides some details on the $155 billion in savings and can be viewed in its entirety here. However, the highlights of the press conference can be viewed below:
The Centers for Medicare & Medicaid Services (CMS) recently published a Notice announcing the second semi-annual meeting of the Advisory Panel on Ambulatory Payment Classification (APC) Groups for 2009. The second semi-annual meeting is scheduled for August 5-7, 2009.
The agenda for the August 2009 meeting will involve discussion and comment on the following topics:
According to the Notice, CMS will be accepting written comments, suggested agenda topics, and may allow individuals or organizations to make 5 minute oral presentations. See the Notice for deadlines and instructions regarding the submission of comments, agenda topics and oral presentations. Also see the Notice for the meeting location and instructions regarding attendance.
CMS reports that it will consider the Advisory Panel's advice when it addresses comments and completes the final rule updating OPPS for calendar year 2010.
The Centers for Medicare & Medicaid Services (CMS) will hold the next Hospital/Hospital Quality Open Door Forum at 2:00 p.m. (ET) on July 16, 2009.
There are 2 ways to participate in the Open Door Forum. To participate by telephone, one must dial 1-800-837-1935 and reference conference ID 16862069. To participate in person, one must RSVP to HOSPITALODF-L@cms.hhs.gov by 2:00 p.m. (EDT) on July 14, 2009 and include "Hospital/Hospital Quality" in the subject line, your name, organization/representation, and telephone number. The Open Door Forum will be held at the Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, DC.
Beginning July 20, 2009, CMS will also make an audio recording of the Open Door Forum available. To access the audio recording, one must dial 1-800-642-1687 and enter the conference ID. The audio recording will be available for 3 business days.
On July 1, 2009, the Centers for Medicare & Medicaid Services (CMS) released a display copy of the Proposed Rule that would update payment policies and rates for hospital outpatient departments (HOPD) and ambulatory surgical centers (ASC) for calendar year (CY) 2010.
In brief, some of the highlights include:
Hospital Outpatient Prospective Payment System
CMS projects a market basket update of 2.1 percent for CY 2010 and estimates total payments of $31.5 billion under the hospital outpatient prospective payments system (OPPS).
However, hospitals that did not participate in the Hospital Outpatient Department Quality Reporting Program (HOP-QDRP) or did not successfully report the quality measures will receive an update in CY 2010 equal to the annual payment update factor minus 2 percentage points (or 0.1 percent).
With respect to the HOP-QDRP, CMS proposes to continue to require hospitals to report the existing 7 chart-abstracted emergency department and perioperative measures and 4 existing claims-based imaging efficiency measures for the CY 2011 payment determination.
CMS is also seeking public comment on possible future quality measures, including measures related to cancer care, emergency department throughput, diabetes, stroke and rehabilitation, osteoporosis, medication reconciliation, respiratory, immunization, health information technology, cataract surgery, overuse/appropriate use, imaging efficiency and surgical care.
Further, CMS proposes a new HOP-QDRP validation requirement to ensure that hospitals are accurately reporting measures using chart-abstracted data and proposes procedures to make HOP-QDRP quality data (beginning with the third quarter of CY 2008) publicly available.
In the Proposed Rule, CMS also proposes several changes to the physician supervision requirements associated with outpatient services.
First, CMS proposes that nonphysician practitioners (such as physician assistants, nurse practitioners, certified nurse specialists and certified nurse-midwives) be able to directly supervise hospital outpatient therapeutic services that they are able to personally perform within their state scope of practice and hospital granted privileges.
Second, CMS proposes to define "direct supervision" for on-campus hospital outpatient services to mean that the physician or nonphysician practitioner must be present in the hospital or on-campus provider based department of the hospital and immediately available to furnish assistance and direction throughout the performance of the procedure. However, for services furnished in an off-campus provider based department, "direct supervision" would continue to mean that the physician or nonphysician practitioner must be present in the off-campus provider based department and immediately available to furnish assistance and direction throughout the performance of the procedure.
For the highlights of other changes, see CMS's related Fact Sheet.
Ambulatory Surgical Centers
CMS projects that the percentage increase in CPI for All Urban Consumers (that would update the ASC conversion factor) to be 0.6 percent and that total payments to ASCs will be $3.4 billion in CY 2010.
In the Proposed Rule, CMS proposes to add 28 surgical procedures to the list of procedures that the Medicare program would pay for when performed in an ASC. CMS also proposes to newly designate 6 procedures as office based procedures and update the list of device-intensive procedures and covered ancillary services (and their rates), consistent with proposals in the OPPS update.
CMS reports that it will be accepting comments on the Proposed Rule until August 31, 2009. The Proposed Rule is scheduled to appear in the Federal Register on July 20, 2009. See the Proposed Rule for instructions regarding the submission of comments.
For more information, see CMS's related Press Release and Fact Sheet.
On July 2, 2009, the Senate Health, Education, Labor and Pensions (HELP) Committee announced that the Congressional Budget Office (CBO) has rescored the Affordable Health Choices Act (Act).
According to Senator Christopher Dodd's news release, the CBO now estimates that the Act would cost $611.4 billion over 10 years (2010-2019). In June 2009, the CBO scored an earlier draft of the Act and estimated that it would cost $1 trillion over the same time period (and only cause a net decrease in the number of uninsured of about 16 million).
In the news release, Senator Dodd also reports that, when the Act is combined with expected Senate Finance Committee legislation, 97 percent of Americans will have coverage. However, at this time, it is not clear whether combining the 2 pieces of legislation would dramatically increase the cost of health care reform.
In its current form, the Act includes a public insurance option called the Community Health Insurance Option, which would be run by the Department of Health and Human Services (HHS). A summary of the public plan indicates that HHS would negotiate payment rates and payment rates would be no more than the local average private rates (but could be less). Health care providers would have the choice of participating in the public option.
According to a separate summary, the Act also includes penalties for employers (with 25 or more employees) if they do not offer adequate coverage to their full-time and part-time workers. For full-time workers, an annual fee of $750 would be assessed for each uncovered employee. For part-time workers, an annual fee of $375 would be assessed for each uncovered employee. Further, employers would have to contribute at least 60 percent to the cost of monthly premiums to avoid the assessment.
In a statement, President Obama praised the Act and stated that "[w]hen merged with the Senate Finance Committee's companion pieces, the Senate will be prepared to vote for health reform legislation that does not add to the deficit, reduces health care costs and covers 97% of Americans."
For more information, see Senator Dodd's news release, Act's text, public insurance option summary, employer responsibility summary, and the CBO score document.
The Centers for Medicare & Medicaid Services (CMS) will host the next Physicians, Nurses & Allied Health Professionals Open Door Forum at 3:30 p.m. (ET) on July 9, 2009.
There are 2 ways to participate in the Open Door Forum. To participate by telephone, one must dial 1-800-837-1935 and reference conference ID 16842257. To participate in person, one must RSVP to CMS PHYSICIANODF-L@cms.hhs.gov by 2:00 p.m. (ET) on July 7, 2009 and include "Physician ODF" in the subject line, your name, organization/representation, and telephone number. The Open Door Forum will be held at the Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, DC.
Beginning July 13, 2009, CMS will also make an audio recording of the Open Door Forum available. To access the audio recording, one must dial 1-800-642-1687 and enter the conference ID. The recording will be available for 3 business days.
On July 1, 2009, the Centers for Medicare & Medicaid Services (CMS) released a display copy of the Proposed Rule, which is intended to update the payment policies and rates for the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2010.
According to the Proposed Rule, CMS estimates a physician fee schedule update of -21.5 percent for CY 2010. MPFS rates are updated annually based on a formula that includes the application of the sustainable growth rate (SGR). The formula has resulted in negative updates since CY 2002. However, Congress has typically enacted legislation each year to avoid the negative updates.
Interestingly, CMS proposes removing physician-administered drugs from the definition of "physician services" in the Proposed Rule for purposes of computing the SGR and the levels of allowed and actual expenditures in all future years. CMS does not expect for such a change to impact the estimated -21.5 percent physician fee schedule update for CY 2010. However, CMS believes that it would reduce the number of years in which physicians are expected to experience a negative update.
In brief, the Proposed Rule also proposes to (among other things):
In fact, CMS has released a Fact Sheet highlighting the Proposed Rule changes to the PQRI and E-Prescribing Programs. See the CMS Press Release and Fact Sheet for more details.
CMS reports that it will be accepting comments on the Proposed Rule until August 31, 2009. The Proposed Rule is scheduled to appear in the Federal Register on July 13, 2009. See the Proposed Rule for instructions regarding the submission of comments.
As usual, over the next few days and weeks, more issues and important information will emerge about the Proposed Rule as it is examined in more detail.
The Centers for Medicare & Medicaid Services (CMS) recently updated the Recovery Audit Contractor/Overview page of its website to address CMS's phase-in strategy and clarify certain aspects of the Medicare Recovery Audit Contractor (RAC) program.
In particular, the updated page indicates that:
The updated page also addresses whether other claim types may be affected by a full inpatient denial and if the RACs will deny other claim types associated with the inpatient stay (e.g., physician evaluation and management services). With respect to that issue, the updated page states:
