Medicare Update

Audio Replay of National PQRI Call Now Available

The Centers for Medicare & Medicaid Services (CMS) has made an audio replay of the March 27, 2007 national provider call on the Physician Quality Reporting Initiative (PQRI) available.  To access the recording, one must call 1-888-348-4629 and enter passcode 549030.  CMS will also post a written transcript of the March 27, 2007 call on the PQRI page of the CMS website.  According to CMS, the next national provider call on PQRI is expected to occur in early April 2007.

CMS Establishes Webpage for Medicare Advantage/Part D Contract and Enrollment Data

The Centers for Medicare & Medicaid Services (CMS) recently established a Medicare Advantage/Part D Contract and Enrollment Data page on the CMS website.  This new page contains contract, service area and enrollment data on Medicare Advantage (MA) and Medicare Part D prescription drug plans, including a plan and MA claims processing contact directory.  CMS will update the contract and enrollment reports on a monthly basis.

CMS Ruling Addresses Own Motion Review of Medicare Part D Cases by Medicare Appeals Council

On March 23, 2007, the Centers for Medicare & Medicaid Services (CMS) published a Notice in the Federal Register announcing a CMS Ruling that establishes a process for own motion review of Medicare Part D prescription drug cases by the Medicare Appeals Council (MAC).

According to the Notice, the CMS Ruling permits CMS or a Medicare Part D independent review entity (IRE) to refer a Medicare Part D case to the MAC, and for the MAC to accept review, if an administrative law judge's (ALJ) decision or dismissal:

• contains an error of law material to the outcome of the case; or
• presents a broad policy or procedural issue that may affect the general public interest.

However, the CMS Ruling does not allow a Medicare Part D plan sponsor to refer a Medicare Part D case to the MAC for own motion review.  Nevertheless, the Notice states that Medicare Part D plan sponsors will "continue to have the opportunity to communicate with the Part D IRE about cases that may warrant such referral."

Further, the CMS Ruling applies many of the provisions in 42 C.F.R. 405.1110 to Medicare Part D cases.  For instance, the CMS Ruling indicates that a 60-day time frame for filing a written referral, and for providing notice to other interested parties, is appropriate for Part D cases.  In the Notice, CMS also cites other existing appeal provisions that would be applicable to the Part D cases.

According to the Notice, the CMS Ruling became effective on March 15, 2007, and after being signed by Acting CMS Administrator, Leslie V. Norwalk.

CMS Releases Medicare Part B Drug Average Sales Price Files

The Centers for Medicare & Medicaid Services (CMS) has released the Medicare Part B Drug and Biological Average Sales Price (ASP) payment amounts for the period April 1, 2007 to June 30, 2007.  The files are located in the "Downloads" section of the CMS website's 2007 ASP Drug Pricing Files page.

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 changed the payment methodology for Medicare Part B covered drugs, that are not paid on a cost or prospective payment basis, when it established the new ASP drug payment system.  The ASP methodology uses quarterly drug pricing data submitted to CMS by drug manufacturers.  CMS provides contractors with the ASP drug pricing files for Medicare Part B drugs on a quarterly basis.

CMS Extends Timeline for Publishing Phase III Physician Self-Referral Final Rule

On March 23, 2007, the Centers for Medicare & Medicaid Services (CMS) published a Notice in the Federal Register extending the time-line for publishing the Phase III physician self-referral final rule (Phase III Rule) from March 26, 2007 to March 26, 2008.

On March 26, 2004, CMS published the Phase II physician self-referral interim final rule (Phase II Rule) in the Federal Register.   According to the Notice, the Phase II Rule will "remain in effect through March 26, 2008 (unless Phase III is published and becomes effective before March 26, 2008)."

In the Notice, CMS reports that it is unable to meet the 3 year time-line for publishing the Phase III Rule because CMS "received extensive public comments requesting clarification of and revisions to the physician self-referral regulations."  According to the Notice, "substantial interagency coordination" between CMS, Office of Inspector General, and the Department of Justice also contributed to the need to extend the time-line for publishing the Phase III Rule.

CMS Releases Options Paper for Listening Session on Medicare Hospital Value-Based Purchasing

On March 22, 2007, the Centers for Medicare & Medicaid Services (CMS) posted an Options Paper on the Hospital Center page of the CMS website.  The Options Paper serves as a draft plan for the Medicare Hospital Value-Based Purchasing (VBP) program.  Among other issues, the Options Paper addresses:

• a performance assessment model to score a hospital's performance;
• methods for computing a hospital's performance score and translating the score into an incentive payment;
• options for the basis and allocation of VBP incentive payments;
• proposed selection criteria for performance measures and candidate measures for fiscal year 2009 and beyond;
• options for transitioning from the Reporting Hospital Quality Data for Annual Payment Update Program to the VBP program;
• a proposed re-design of data submission and validation infrastructure to support the VBP program requirements; and
• public reporting of performance results.

The Options Paper will be the focus of an upcoming Listening Session.  The Listening Session will be held on April 12, 2007 from 10:00 a.m. to 5:00 p.m. (EDT).   Persons interested in attending the Listening Session or participating by telephone must register by completing an on-line registration.

CMS expects to post the agenda and a PowerPoint slide presentation for the Listening Session on the Hospital Center page of the CMS website by April 6, 2007.  CMS will also post an audio podcast of the Listening Session on the CMS website by April 16, 2007.

During the Listening Session, attendees and persons participating by telephone will have an opportunity to present questions and comments.  However, CMS will also be accepting written comments on the Options Paper until April 19, 2007 at 5:00 p.m. (EDT).   On the Hospital Center page of the CMS website, CMS explains how to submit written comments for consideration. 

CMS Announces New Arizona Collaborative in the Value-Driven Health Care Initiative

On March 22, 2007, the Centers for Medicare & Medicaid Services (CMS) announced in a Press Release that Arizona State University's Center for Health Information and Research (CHIR) will participate in the Better Quality Information to Improve Care for Medicare Beneficiaries (BQI) project.

The BQI project is part of the Value-Driven Health Care Initiative, which is intended to provide the public and providers with reliable and consistent quality of care measures.  As part of the BQI project, performance information will be given to physicians to assist them in improving the quality of care rendered to beneficiaries, and given to beneficiaries to help them with physician selection.

The CHIR joins 5 other collaboratives that were previously announced by CMS, including: California Cooperative Health Care Reporting Initiative, Indiana Health Information Exchange, Massachusetts Health Quality Partners, Minnesota Community Measurement, and Wisconsin Collaborative for Healthcare Quality.

CMS Issues New Medicare Conditions of Participation for Transplant Centers

On March 22, 2007, the Centers for Medicare & Medicaid Services (CMS) issued a Press Release announcing that it has released a display copy of the final rule setting forth the requirements that transplant centers must meet to participate in the Medicare program (Final Rule).

According to the Press Release, the Final Rule "contains comprehensive conditions of participation for transplant programs serving Medicare beneficiaries," and "will move Medicare-covered transplant programs toward an outcome-focused system that reflects the clinical experience, resources and commitment of the transplant program."  The Press Release also states that the Final Rule will "ensure effective oversight of transplant centers by advancing coordination between CMS, State survey agencies, the Health Resources and Services Administration, the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients."

CMS previously issued coverage decisions related to heart transplants in 1987, liver transplants in 1991, lung transplants in 1995, and intestine transplants in 2001 and 2006.  Further, kidney transplant centers have been subject to federal regulations since 1976.  The Final Rule will consolidate all transplant center requirements  into one regulation. 

The Final Rule is expected to be published in the Federal Register on March 30, 2007, and become effective 90 days after appearing in the Federal Register.

CMS Establishes DMEPOS Competitive Bidding Implementation Contractor Website

The Centers for Medicare & Medicaid Services (CMS) recently established a DMEPOS Competitive Bidding Implementation Contractor (CBIC) website.  The CBIC website will serve as an information source for suppliers, providers and beneficiaries on the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program.

The DMEPOS Competitive Bidding Program (Program) was established by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, and requires that CMS replace the current DMEPOS payment methodology for certain items with a competitive bidding process.  CMS has contracted with Palmetto GBA to serve as the CBIC for the Program. 

As the CBIC, Palmetto GBA will perform certain functions, including preparing the request for bids, performing bid evaluations, and ensuring that suppliers meet all applicable financial and quality standards.  Palmetto GBA will also support CMS efforts to conduct education programs, and assist CMS and its contractors in monitoring the Program's effectiveness, access and quality.

CMS to Host Conference Call on 2007 Physician Quality Reporting Initiative

The Centers for Medicare & Medicaid Services (CMS) will host the first in a series of national provider conference calls on the 2007 Physician Quality Reporting Initiative (PQRI). 

The first PQRI national provider conference call will take place from 3:00 p.m. to 5:00 p.m. (EST) on March 27, 2007.   During the conference call, CMS will present an overview of the 2007 PQRI program, including a discussion on eligible professionals, reporting, measures and codes, and analysis and payment.  Following that presentation, persons participating in the conference call will have an opportunity to ask questions of CMS subject matter experts.

According to a document posted on the CMS website, CMS will post a PowerPoint slide presentation for the conference call on the PQRI's Educational Resources webpage prior to the call.  The document indicates that persons interested in participating in the March 27, 2007 conference call will need to register by completing an on-line registration.  The document explains how to register and participate in the March 27, 2007 conference call.