MHA's Executive Briefing

Medicare Audit Improvement Act introduced in Senate

Sens. Mark Pryor (D-AR) and Roy Blunt (R-MO) on May 22 introduced a Senate companion to the Medicare Audit Improvement Act (S. 1012 /H.R. 1250), legislation strongly supported by the American Hospital Association to improve the Recovery Audit Contractor program and other Medicare audit programs. AHA applauded the action and encouraged quick passage by Congress.

“Hospitals are inundated with multiple auditing programs (Recovery Audit Contractors, Medicare Administrative Contractors and Comprehensive Error Rate Testing Contractors),” said AHA Executive Vice President Rick Pollack. “These duplicative audits, unmanageable medical record requests and inappropriate payment denials are overwhelming hospitals and diverting resources from patient care. According to an AHA survey, when hospitals decide to commit the time and resources necessary to fight RAC denials in the Medicare appeals process, they are successful at overturning the RAC denial 72% of the time. This legislation provides much needed guidance for auditors while keeping them out of making medical decisions that should be between patients and their physicians. It also will improve recovery auditor transparency and allow denied inpatient claims to be billed as outpatient claims when appropriate.”

Reps. Sam Graves (R-MO) and Adam Schiff (D-CA) introduced the bill in the House.

Hospital CMO: Fighting RACs "Not a Level Playing Field"

At an executive briefing hosted by the American Hospital Association on May 21, four health system leaders described their challenges in dealing with undue denials by Medicare Recovery Auditors, formerly known as recovery audit contractors. Read more from Becker's Hospital Review here.

CMS: Hospitals can still apply to participate in bundled payment model

The Centers for Medicare & Medicaid Services is accepting additional applications from hospitals to participate in Model 1 of the Bundled Payments for Care Improvement Initiative, the agency announced  May 16. The Medicare demonstration includes four models of care that bundle payments for multiple services received during an episode of inpatient and/or post-acute care.

Model 1, open to acute-care hospitals paid under the inpatient prospective payment system, defines the episode of care as an inpatient stay. Participants agree to provide a standard discount to Medicare from the usual Part A hospital inpatient payments.

The CMS notice was published in the May 17th Federal Register. Interested organizations should submit an Information Intake Form to BPModel1@cms.hhs.gov within 75 days.

[ via AHA News ]

Skilled Nursing Facility PPS: Proposed Rule for FY 2014

The Centers for Medicare & Medicaid Services (CMS) on May 6 published its fiscal year (FY) 2014 proposed rule for the skilled nursing facility (SNF) prospective payment system (PPS). Comment letters to CMS are due by July 1.

Under the proposed rule, SNFs would receive a 2.4 percent marketbasket update, which would be offset by a 0.4 percentage point productivity cut required by the Patient Protection and Affordable Care Act (ACA) and a 0.5 percentage point cut to account for the difference between the actual and projected market basket for FY 2012. CMS estimates that, taken together, these proposed changes would increase payments by 1.4 percent ($500 million) over FY 2013 payment levels.

The rule also would revise and rebase the market basket beginning in FY 2014 to reflect FY 2010 cost data, add five cost categories and revise several price proxies. CMS also proposes a more specific Minimum Data Set reporting process to capture distinct calendar days of therapy.

Health Policy Alternatives, Inc., has published a detailed summary of the proposed rule for the American Hospital Association. If you are an MHA member and would like a copy, email Shawn Rossi at srossi@mhanet.org.

AHA urges changes to CMS proposed rule on rebilling

While the Centers for Medicare & Medicaid Services’ proposed rule on Medicare Part B rebilling recognizes that the agency’s prior policy of denying full payment for Part B claims is unlawful, the rule contains a number of restrictions that would compromise hospitals’ ability to rebill for medically necessary patient services, the American Hospital Association told the agency on May 17. “The proposed rebilling rule will require significant modifications in order to provide hospitals with a fair and equitable process for securing payment for the reasonable and necessary services provided to patients when there is a dispute about the setting in which care should have been delivered,” AHA Executive Vice President Rick Pollack wrote in response to CMS’s March 13 proposed rule.

The AHA said the final rule should permit rebilling of any denied claim that originally was timely filed, rather than restrict rebilling to services provided in the prior 12 months; ensure full reimbursement of all reasonable and necessary services provided rather than arbitrarily exclude services that require “outpatient status”; and restore full and fair appeal rights for hospitals that choose to exercise their right to appeal denied claims rather than arbitrarily narrow the scope of that review.

Senate confirms Tavenner as CMS chief

Marilyn Tavenner's confirmation as official administrator of CMS immediately drew positive reactions from nearly every corner of the industry and government, as several health care stakeholders reacted to the 91-7 landslide Senate vote that took place late Wednesday. Tavenner is the first administrator in nine years to receive Senate confirmation.

Read more here.

Meeting the Challenge of a Dual-Eligible Population

While the industry is headed in the right direction in coordinating care for dual eligibles, it still must overcome formidable challenges related to deploying clinical and care utilization management in the settings where it can be most effective: at the point of care. Read more from Hospitals & Health Networks magazine here.

Bill would delay ACA DSH cuts until FY 2016

Rep. John Lewis (D-GA) on May 9 introduced the DSH Reduction Relief Act (H.R. 1920), American Hospital Association-supported legislation that would delay for two years cuts to the Medicare and Medicaid Disproportionate Share Hospital programs under the Patient Protection and Affordable Care Act.

“The [ACA] contains reductions to the DSH programs based on the assumption that many of the uninsured and underinsured would receive coverage under the law,” said AHA Executive Vice President Rick Pollack. “However, the Supreme Court’s decision that the federal government could not compel states to expand their Medicaid programs has negatively impacted projected health insurance coverage. The DSH Reduction Relief Act of 2013 will help hospitals and the patients they serve by delaying the Medicaid and Medicare DSH funding cuts for two years. This will allow for coverage expansions to be more fully realized.”

Provider Roundtable seeks new members

The Provider Roundtable (PRT) was established in 2003 to give CMS the benefit of providers’ input and guidance on critical healthcare delivery issues.

In the last decade, the PRT has provided well-supported, data-driven comments to federal regulators on the operational impacts of proposed rules and established regulations concerning OPPS and IPPS. The PRT regularly provides written comments and oral testimony to CMS, Medicare contractors (FI/MACs), and the HOP (formerly APC) Advisory Panel. These entities have frequently integrated the PRT’s comments and requests into final rule-making.

For more information, click here.

Medicare tries to limit the use of observation status

CMS officials have proposed a new rule aimed at helping more Medicare beneficiaries become eligible for nursing home care after a hospital stay—but hospitals and patient advocates say the rule does not do enough to curb the use of "observation status." Read more from The Advisory Board here.