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The Politics of Health Care

Having Insurance Doesn't Rule Out Social Security Disability Eligibility
July 12, 2012 2:30 PM by Adrianne OBrien
Editor's note: This blog was written by Karen Hercules-Doerr, a healthcare executive and director of Community-Based Representatives at Allsup. Contact: k.hercules-doerr@allsupinc.com. 

It seems reasonable to assume that patients with health insurance are ineligible for Social Security Disability Insurance (SSDI), a program that provides benefits to Americans unable to work because of a disability.

After all, more than 55 percent of Americans aged 26-64 participate in employer-based healthcare coverage, and if they have employer-based insurance, they're able to work, right?

Although working typically disqualifies a patient from SSDI, simply having health insurance does not. Even if patients have health coverage when they are initially treated, that may not be the case in just six months, or later on. When patients have progressive chronic illnesses, they experience increasing difficulty in maintaining work schedules and can lose access to steady income and health insurance. Patients who could be receiving SSDI benefits, but aren't, can become a higher cost patient for the provider.

A 2010 study found that the average SSDI beneficiary visited the doctor seven times per year. That escalated to an average of 22 times per year over the course of three years. As their condition worsens and patients visit healthcare providers more often, they also become increasingly likely to lose employer-based insurance to help pay for care.

Patients with worsening health and rising costs may not be able to pay for their care if they don't file for SSDI in the interim.

However, there is good news for patients: after 24 months on SSDI, patients are eligible for Medicare. The 2-year waiting period underscores the critical importance of identifying at-risk patients and helping them apply for SSDI benefits as early as possible. That's why it's important to look for warning signs with patients who may become SSDI-eligible, so they can begin the process of applying for benefits as soon as they're eligible.

Healthcare professionals find that when their insured patients fully understand the benefits of filing for SSDI with a representative such as Allsup, they are less likely to become uninsured or underinsured later.

It is critically important that hospitals, physician practices and healthcare providers understand that it's never too early to inform their patients that SSDI benefits may be available if they are deemed disabled and cannot work in any capacity for at least 12 months.

Giving patients options regarding their future and offering them help from expert representatives can minimize the tremendous losses they face when they can no longer work because of a disabling condition. This step also can expedite access to benefits that patients have paid into and deserve, and helps minimize providers' exposure to the significant cost demands of treating patients who don't have a steady source of income or insurance.

Reference

1. Ensuring Patients with Disabilities Can Maintain Care and Coverage." Allsup, 2012.

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The Medicaid "Wrinkle"
July 2, 2012 12:17 PM by Adrianne OBrien
Editor's note: This blog was written by Jill Glomsted, editor of ADVANCE for Occupational Therapy Practitioners.

In the June 28 Supreme Court ruling, seven of the nine Justices agreed that it would be unconstitutional for the federal government to force states to participate in the Affordable Care Act's expansion of the Medicaid program. The expansion had been expected to cover roughly 17 million uninsured Americans, mostly low-income adults. The federal government will foot the full bill for the expansion for the first three years; after that the federal share will slowly decline, but it would still be 90 percent in 2020. 

The Court's decision basically renders the expansion a separate animal from the current Medicaid program. If states don't participate in the expansion, they can keep their existing programs (and existing federal money) without consequence. The question now is, what will the states choose to do?

So far seven states and the District of Columbia are already offering expanded coverage, paying for it with state funds until the federal payments via the ACA kick in in 2014, according to CBS News.

However, 26 were plaintiffs in the case the Court heard; the governors of some of them, including Texas, Mississippi and Wisconsin, have already hinted that they will not implement the expansion, while others have refused to say what they're willing to do. Virginia Governor Bob McDonnell isn't saying, but told Politico.com that the expansion would cost his state $2.2 billion over 10 years, even with the federal funds.

It's unsurprising that few want to commit to a decision, given the political hot potato that the Affordable Care Act has become and the huge financial burdens states are already facing due to Medicaid. But if states opt out of the expansion, what's going to happen to their residents?

If all 26 states who were parties to the suit opt out, that's more than half - roughly 9 million people - of those expected to be covered by the expansion who will still be without insurance. What's more, they will be some of the poorest Americans.

"We will have a really strange doughnut hole in this country," said Kevin Outterson, associate professor of law and associate professor of health law, bioethics and human rights at Boston University, during an Association of Health Care Journalists webcast on the Supreme Court decision today. Individuals making up to the federal poverty level (FPL, currently $15,415 for an individual; $26,344 for a family of three in 2012) will have some level of coverage under existing programs. Those making 133 percent of the FPL or more will be able to participate in the state health insurance exchanges that the ACA established, with subsidies to help them purchase affordable coverage. But the people who fall in between are not eligible to participate in the exchanges - the ACA did not include them because it was assumed they would be covered by the Medicaid expansion.

Public and safety-net hospitals in states that opt out could also suffer. Currently hospitals that treat a large number of low-income, uninsured or vulnerable patients receive "disproportionate share" funding to help pay for that uncompensated care. Under the ACA, those hospitals are scheduled to lose about half that funding, on the premise that the expansion of coverage through both the individual mandate and the Medicaid expansion would offset what hospitals will lose. If a state chooses not to participate in the Medicaid expansion, its hospitals will still have to provide care to those populations but with much less funding than they have now to do so.

Providers could lose out too, though that is uncertain. The ACA raises rates for primary care providers in Medicaid up to Medicare levels. It's unclear, based on the Supreme Court ruling, whether providers in states who don't participate in the expansion will get that increase in payments.

Another issue is that "there is nothing out there to give states any sense of when they have to make a decision, because no one thought they would have to," said Alan Weil, executive director of the National Academy for State Health Policy, during the webcast. In states that don't decide, Medicaid programs could be caught in a holding pattern.

Martin Salo, executive director of the National Association of Medicaid Directors, told the New York Times in an article on June 29 that his initial sense is that many states will participate in the expansion. Many Republican governors may be waiting until after the November election to decide, hoping that Mitt Romney will win and make good on his promise to dismantle the entire law - Wisconsin Governor Scott Walker said on Thursday that was his position, CNBC reported. However, governors don't necessarily hold all the cards here. Much of Medicaid is regulated by the legislature, and when state legislatures come back into session in January they may take some or all of this decision out of the governors' hands, said Weil. It's also possible that Congress or HHS could act in the way of new legislation or new regulations to encourage states to participate.

By way of analogy, several Republican governors initially said they would not take federal stimulus money from the American Recovery and Reinvestment Act of 2009, said webcast moderator AHCJ President Charles Ornstein. Eventually, they all did. Americans - especially the poorest - will just have to wait and see if they do the same with the Medicaid expansion.

 

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Mission Deployed: ICD-10
June 25, 2012 3:07 PM by Adrianne OBrien

Executive Insight headed west and is blogging live from HFMA's annual ANI conference, held from June 24-27 this year in Las Vegas. One popular session today was ICD-10 Readiness, a provider panel discussion that emphasized lessons learned from facilities already marching along the not-so-well-worn ICD-10 path.

One panelist, Danielle Reno, CHC, CCD, CCS-P, the ICD-10 program director for northern California's Sutter Health, discussed why Sutter initiated its ICD-10 program in early 2011.

  • There will be a huge decrease in productivity when ICD-10 becomes official. Sutter estimated that drop will be 50 percent. "Backfill staff," said Reno. "Bring in coders and train them internally." Otherwise, that 50 percent dip will kill revenues.
  • AHIMA is "pushing doing education now," said Reno. ICD-10 "is a whole new language."
  • A "huge challenge," noted Reno is physician engagement. Facilities in California cannot employ physicians, so it's tough for those facilities to mandate anything. "Everyone thinks ICD-10 has stopped," said Reno, so the time to bring physicians on board is now. One answer to the what's-in-it-for me question: historical data analysis that will be available with ICD-10.

It was obvious from the audience Q&A that many small and mid-sized hospitals have yet to begin transition work to ICD-10. What has your facility done so far?

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The Trouble with Metadata and Health Privacy
June 13, 2012 11:27 AM by Rebecca Hepp

Advances in technology over the past decade have raised serious concerns for patient privacy, an issue that sparked an intense panel discussion at the Second International Summit on the Future of Health Privacy, held last week in Washington, DC. Panelists debated current legislation’s ability to properly protect patients in the age of smart phones, tablets and electronic records. For James Pyles, a health law attorney who has worked on privacy measures for HIPAA and the HITECH Act, legislation is lagging far behind technology, leaving patients unprotected from potential electronic violations of privacy.

"We now have electronic disclosures of patient privacy that are entirely different from disclosures of paper records," Pyles said. "You can get a paper record back; you cannot get an electronic record back. You can disclose millions of electronic records simultaneously; you cannot do that with paper records."

"The damage that can be done to someone is perpetual," Pyles added. "And the damages that can be awarded are incalculable."

Joy Pritts, chief privacy officer for the Office of the National Coordinator for Health IT (ONC), agrees with Pyles that technology is advancing much quicker than the law, although she did argue that HIPAA still has its strengths. Under HIPAA, enforcement of federal privacy regulations is in the hands of the states, who are free to extend enforcement beyond the floor set by the federal regulation.

"In some states, there are very strict standards on how [health information] can be shared," Pritts said. "In other states, they didn't see a need to do that because they thought patients were comfortable getting care and sharing that information for certain purposes without having to expressly write it down on a piece of paper."

Adding fuel to the fire, Frank Pasquale, a healthcare regulation and enforcement professor at Seton Hall University, brought up the related debate over metadata and its potential to give patients more control over their personal information. "We've got to create new modes, enable modes of granular control over the data in order to make people feel safe,” Pasquale said. “Otherwise, we're never going to have the type of benefits we can get from big data analysis, from observational research."

Metadata, according to the ONC, is data that provides more detail or information about a piece of data, which has the potential to drastically improve the way health organizations communicate electronically. However, without any accepted standards for metadata tags, the National Committee on Vital and Health Statistics (NCVHS), the statutory public advisory body to the U.S. Department of Health & Human Services, recommended that the ONC refrain from including metadata standards in Stage 2 of the Meaningful Use incentive program.

Referring to the NCVHS’s recommendation, Pritts told the panel last week that metadata is currently on hold for electronic health records, at least until metadata standards are better assessed and understood. With such a powerful tool at hand, precautions must be taken to ensure there are no unintended consequences that could infringe on patient privacy. 


http://www.fiercehealthit.com/story/health-privacy-regs-metadata-fuel-heated-debate/2012-06-08

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First ACOs Selected
April 26, 2012 12:55 PM by Adrianne OBrien
Editor's note: This blog was written by Michael LaMagna, a partner at Timins & LaMagna, LLP, practicing health care regulatory, elder /disability/veteran's law, trusts and estates, Social Security and general legal practice in New York and Connecticut. Michael was just appointed to the ACO Task Force of the American Health Lawyers Association. E-mail him at Mlamagna@nyandctlaw.com, call him at 914-819-0663 or visit his website at www.nyandctlaw.com for more information.

Very soon many readers will be part of a new healthcare program that will integrate cutting edge technology, coordinate care amongst many different providers and even take an active interest in your well-being. Curious?

CMS has selected 27 large medical groups to be the first participants as Accountable Care Organizations (ACOs). ACOs are new multi-provider organizations that incorporate hospitals, physician groups, laboratories, and even nursing facilities, coordinating care among the various levels through technology and follow-up. This should reduce unnecessary and harmful duplication of services, improve the overall quality of patient care and lower costs to the healthcare system.

ACOs are required to adhere to 33 quality standards, including patient safety, usage of preventive healthcare and coordination of care. In return, the ACOs will share in the savings and receive up to 25 percent of the savings produced.

In addition, ACOs will be required to carefully monitor chronically ill patients, who are known to be the most expensive participants (i.e., diabetics and those with pulmonary and heart ailments). The monitoring of these patients will be particularly challenging,

If the program works, we will all be part of an ACO in the near future.

This article is provided for informational purposes only. Nothing in this article shall be construed as legal advice or should be relied upon as such.

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Affordable Care Act "Sunshine" Rule Increases Transparency
December 15, 2011 11:12 AM by Lisa Algeo

The Centers for Medicare & Medicaid Services (CMS) announced yesterday a proposed rule that will increase public awareness of financial relationships between drug and device manufacturers and certain health care providers. This is one of many steps under the Affordable Care Act designed to increase transparency in the health care system, which can lead to better care at lower costs.

"When people are faced with the difficult task of choosing the right doctor, they need all the information they can gather. If your doctor is taking money from manufacturers of prescription drugs, suppliers of wheelchairs or other devices, you deserve to know about it," said Peter Budetti, MD, CMS deputy administrator for Program Integrity. "Disclosure of these relationships will discourage the inappropriate influence on clinical decision-making that sometimes occurs while still allowing legitimate partnerships."

The proposed rule would require manufacturers of drugs, devices, biologicals, and medical supplies covered by Medicare, Medicaid, or the Children's Health Insurance Program to report to CMS payments or other transfers of value they make to physicians and teaching hospitals. The proposed rule would also require manufacturers and group purchasing organizations (GPOs) to disclose to CMS physician ownership or investment interests. 

This increased transparency is intended to help reduce the potential for conflicts of interest that physicians or teaching hospitals might face as a result of their relationships with manufacturers.

Drug and biologic manufacturers, medical device or supply manufacturers, and GPOs would be affected by the new reporting requirements. These organizations, as well as the physicians and teaching hospitals, would be allowed an opportunity to review and correct information prior to its publication. 

The Affordable Care Act provides that violators of the reporting requirements will be subject to civil monetary penalties (CMPs), capped at $150,000 annually for failing to report, and $1,000,000 for knowingly failing to report. 

CMS is proposing that data collection will not begin on Jan. 1, 2012 and that manufacturers and GPOs do not need to begin data collection until final regulations are issued. Depending on the timing of the final rule, CMS is proposing that manufacturers and GPOs will be required to submit a partial year on Mar. 31, 2013. Once the data has been submitted, CMS will aggregate manufacturer submissions at the individual physician and teaching hospital level, provide them with a 45-day period to confidentially review and, if necessary, correct the data, and make the data publicly available by Sep. 30, 2013.

CMS will accept comments on the proposed rule until Feb. 17, 2012, and will respond to them in a final rule to be published in 2012.

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Affordable Care Act Will Help Rebuild Aging Clinics
December 8, 2011 2:45 PM by Lisa Algeo

Thanks to the Affordable Care Act, more than $14 million was awarded today to 45 school-based health centers across the country allowing the number of children served to increase by nearly 50 percent, HHS Secretary Kathleen Sebelius has announced.

Clinics receiving the awards, made possible by the health reform law, are already providing much-needed health care services to 112,000 children. Today's infusion of new money will enable them to expand their capacity and modernize their facilities, which will allow them to treat an estimated additional 53,000 children in 29 States.

"Children are the foundation upon which this country will grow," said Secretary Sebelius. "The Affordable Care Act will help ensure our children get the high-quality health care they need and deserve."

Funds awarded today will help create jobs for Americans across the country. Funds will support job opportunities as more Americans will be needed to meet the clinics' pressing capital needs - including construction, renovation and new equipment. 

School-based health centers enable children with acute or chronic illnesses to attend school, and improve the overall health and wellness of all children through health screenings, health promotion and disease prevention activities.

Typically, a school-based clinic provides a combination of primary care, mental health care, substance abuse counseling, case management, dental health, nutrition education, health education and health promotion activities.

"These grants will enable school-based health centers to establish new sites or upgrade their current facilities, which will increase their ability to provide preventive and primary health care services, and help children improve their health and remain healthy," said HRSA Administrator Mary K. Wakefield, PhD, RN. 

The Affordable Care Act provides $200 million in funding from 2010 - 2013 for the School-Based Health Center Capital Program to address significant and pressing capital needs and to improve delivery and support expansion of services at school-based health centers.

Today's grants are the second in the series of awards that will be made available to school-based health centers under the Affordable Care Act.  The Health Resources and Services Administration (HRSA) oversees the School-Based Health Center Capital Program.

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Impact of an Election Year
December 7, 2011 9:40 AM by Lynn

Republican, Democratic and Independent candidates have been busy relaying their promises toward a healthier America, with proposals for better health plans/coverage to how to create jobs. I’ll be honest and admit that I have very mixed reviews. In my opinion, no one candidate has all the answers. What I hope is that the parties put aside their differences for a change and really focus on rebuilding our infrastructure, healthcare system, job market and more so we have stronger investments and a brighter long-term outlook for maintaining a healthy America, both literally and figuratively.

What are your thoughts on the presidential candidates? How will the election year impact your professional and personal life?

 

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Medicare Gives Employers, Consumers Information to Make Better Health Care Choices
December 5, 2011 12:59 PM by Lisa Algeo
Consumers and employers will have the health care information they need to make more informed choices about their care, thanks to the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) announced in a final rule today.

The rule gives qualified organizations, like employers and consumer groups, access to data that can help them identify high quality health care providers or create online tools to help consumers make educated health care choices. Information that could identify specific patients, however, will not be publicly released and strong penalties will be in place for any misuse of data.

"This is a giant step forward in making our health care system more transparent and promoting increased competition, accountability, quality and lower costs," said Marilyn Tavenner, Acting CMS Administrator. "This provision of the health care law will ensure consumers have the access they deserve to information that will help them receive the highest quality care at the best value for their dollar."

For years, employers, consumers, and health care quality advocates have expressed frustration about the limited and piecemeal availability of Medicare data that could be used to help evaluate health care provider or supplier performance. Although many health plans have created provider and supplier performance reports, these reports are based solely on the health plans' own claims, and do not reflect information from other health plans, including Medicare.

Providers, too, have expressed frustration at receiving performance reports that are piecemeal and produced without an opportunity for review and correction. This final rule creates a framework for providers to receive a single, actionable performance report covering all or most of their practice.

The final rule makes a number of important changes from the original proposed rule. The final rule makes this data less costly for qualified entities, gives qualified organizations more flexibility in their use of Medicare data to create performance reports for consumers, and extends the time period for health care providers to confidentially review and appeal performance reports before they become public. The rule also includes strict privacy and security requirements to protect patients, health care providers, and suppliers as well as stringent penalties for any misuse of Medicare data.

For more information on the final rule, visit:

The final rule on Availability of Medicare Data for Performance Measurement is on display until Dec. 7, 2011 at the Office of the Federal Register at: http://www.ofr.gov/OFRUpload/OFRData/2011-31232_PI.pdf

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We Can’t Wait: Obama Administration Takes New Steps to Encourage HIT Use
November 30, 2011 2:02 PM by Lisa Algeo
Today, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius released a report showing that doctors' adoption of health information technology (IT) doubled in 2 years.  HHS also announced new actions to speed the use of health IT in doctors' offices and hospitals nationwide, which will improve health care and create jobs nationwide.

While protecting confidential personal information, health IT can improve access to care, help coordinate treatments, measure outcomes and reduce costs.  The new administrative actions announced today, which were made possible by the HITECH Act, will make it easier for doctors and other health care professionals to receive incentive payments for adopting and meaningfully using health IT.

"When doctors and hospitals use health IT, patients get better care and we save money," said Secretary Sebelius.  "We're making great progress, but we can't wait to do more. Too many doctors and hospitals are still using the same record-keeping technology as Hippocrates. Today, we are making it easier for health care providers to use new technology to improve the health care system for all of us and create more jobs."

In addition to improving the health care system, data indicate that the national transition to health IT is creating jobs.  Over 50,000 health IT-related jobs have been created since the enactment of the HITECH Ac. According to the Bureau of Labor Statistics, the number of health IT jobs across the country is expected to increase by 20 percent from 2008 to 2018, much faster than the average for all occupations through 2018.

HHS also announced its intent to make it easier to adopt health IT.  Under the current requirements, eligible doctors and hospitals that begin participating in the Medicare EHR (electronic health record) Incentive Programs this year would have to meet new standards for the program in 2013.  If they did not participate in the program until 2012, they could wait to meet these new standards until 2014 and still be eligible for the same incentive payment. To encourage faster adoption, the Secretary announced that HHS intends to allow doctors and hospitals to adopt health IT this year, without meeting the new standards until 2014. Doctors who act quickly can also qualify for incentive payments in 2011 as well as 2012.

These policy changes are accompanied by greater outreach efforts that will provide more information to doctors and hospitals about best practices and to vendors whose products allow health care providers to meaningfully use EHRs.  For example, in communities across the country HHS will target outreach, education and training to Medicare eligible professionals that have registered in the EHR incentive program but have not yet met the requirements for meaningful use.  Meaningful use is the necessary foundation for all impending payment changes involving patient-centered medical homes, accountable care organizations, bundled payments, and value-based purchasing.

These efforts will complement existing outreach efforts to doctors and hospitals including the Obama Administration's work to create a nationwide network of 62 Regional Extension Centers.  The extension centers are comprised of local nonprofits that provide guidance and resources to help eligible health care providers participate in the Medicare and Medicaid EHR Incentive Programs and meaningfully use health IT.

Also released today, a new Centers for Disease Control and Prevention (CDC) survey found 52 percent of office-based physicians in the U.S. now intend to take advantage of the incentive payments available for doctors and hospitals through the Medicare and Medicaid EHR Incentive Programs.  EHR incentive payments for eligible health care professionals can total as much as $44,000 under the Medicare EHR Incentive Program and $63,750 under the Medicaid EHR Incentive Program.  The CDC data also show the percentage of physicians who have adopted basic electronic health records in their practice has doubled from 17 to 34 percent between 2008 and 2011 (with the percent of primary care doctors using this technology nearly doubling from 20 to 39 percent). 

To meet the demand for workers with health IT experience and training, the Obama Administration has launched four workforce development programs that help train the new health IT workforce.  The training is provided through 82 community colleges and nine universities nationwide.  As of October 2011, community colleges have had 5,717 professionals successfully complete their training in health information technology.  Currently there are 10,065 students enrolled in the training programs across the nation.  As of November 2011, universities have graduated over 500 post-graduate and masters-level health IT professionals, with over 1700 expected to graduate by July 2013.

While improving the health care system, health IT can help keep information private and secure.  Federal laws require key persons and organizations that handle health information to have policies and security safeguards in place to protect health information-whether it is stored on paper or electronically.

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States Receive Resources to Implement Affordable Insurance Exchanges
November 29, 2011 12:27 PM by Lisa Algeo

The Department of Health and Human Services (HHS) today awarded nearly $220 million in Affordable Insurance Exchange grants to 13 states to help them create Exchanges, giving these states more flexibility and resources to implement the Affordable Care Act. The health care reform law gives states the freedom to design Affordable Insurance Exchanges - one-stop marketplaces where consumers can choose a private health insurance plan that fits their health needs and have the same kinds of insurance choices as members of Congress.

The Department also released several Frequently Asked Questions providing answers to key questions states need to know as they work to set up these new marketplaces. Critical among these are that states that run Exchanges have more options than originally proposed when it comes to determining eligibility for tax credits and Medicaid.  And states have more time to apply for "Level One" Exchange grants.

Today's awards bring to 29 the number of states that are making significant progress in creating Affordable Insurance Exchanges.  States receiving funding today include: Alabama, Arizona, Delaware, Hawaii, Idaho, Iowa, Maine, Michigan, Nebraska, New Mexico, Rhode Island, Tennessee, and Vermont.

"We are committed to giving states the flexibility to implement the Affordable Care Act in the way that works for them," HHS Secretary Kathleen Sebelius said.  "Exchanges will give consumers more choices and make it easy to compare and shop for insurance plans."

In the new Exchanges, insurers will provide new information such as an easy-to-understand summary of benefits and costs to consumers. The level of detail will sharpen competition between carriers which will drive costs down.

HHS also released today a set of Frequently Asked Questions (FAQs) in anticipation of state legislative sessions beginning in January. Answers will help advance state policy development for Exchanges.  For example, they clarify that Exchange grants can be used to build a state Exchange that is operational after 2014; that state-based Exchanges will not be charged for accessing Federal data needed to run Exchanges in 2014; and that state insurance rules and operations will continue even if the Federal government is facilitating an Exchange in the state.  HHS will also allow greater flexibility in eligibility determinations, allowing, for example, a state-based Exchange to permit the Federal government to determine eligibility for premium tax credits. 

Of the 13 states awarded grants today, 12 are receiving Level One grants, which provide one year of funding to states that have already made progress using their Exchange planning grant.  The 13th state, Rhode Island, is receiving the first Level Two grant, which provides multi-year funding to states further along in the planning process.

Forty-nine states and the District of Columbia have already received planning grants, and 45 states have consulted with consumer advocates and insurance companies.  Thirteen states have passed legislation to create an Exchange. 

States have many opportunities to apply for funding. To accommodate state legislative sessions and to give states more time to apply, HHS also announced a six-month extension for Level One establishment grant applications.  Applications now will be accepted until June 29, 2012 (the original deadline was Dec. 30, 2011).

For the FAQs, visit http://cciio.cms.gov/resources/regulations/index.html#hie.

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HHS Expands Initiative to Protect Medicare and Seniors From Fraud
November 22, 2011 11:52 AM by Lisa Algeo

The U.S. Department of Health and Human Services (HHS) announced today the award of $9 million from the Centers for Medicare & Medicaid Services (CMS) to help Senior Medicare Patrol (SMP) programs across the nation continue their work fighting Medicare fraud. This is part of President Obama's initiative to educate people with Medicare about how to protect themselves and Medicare from fraud. SMPs rely on approximately 5,000 volunteers nationwide to enhance their efforts.

"CMS is committed to working with partners like the Administration on Aging to develop and implement long-term solutions and a collaborative approach to eliminating health care fraud and abuse," said Peter Budetti, CMS deputy administrator and director of the Center for Program Integrity. "We've dedicated $9 million in grants this year on top of another $9 million last year to expand the state-based Senior Medicare Patrol Programs, which are vital to empower seniors to identify and fight fraud."

The SMP program is operated by the Administration on Aging (AoA) in close partnership with CMS and the HHS Office of Inspector General. In June 2010, CMS announced funding for the SMP expansion initiative in conjunction with President Obama's appearance at a senior center in Wheaton, MD, along with HHS Secretary Kathleen Sebelius. The 2011 grants will provide additional funds for SMPs to increase awareness among Medicare beneficiaries about how to prevent, detect, and report health care fraud. Increased funding levels for states identified with high-fraud areas will support additional targeted strategies for collaboration, media outreach and referrals. The Administration on Aging will continue to administer these grants in partnership with CMS.

"This demonstrates AoA's and CMS' shared commitment to educate beneficiaries so they can protect themselves and Medicare as a whole," said Assistant Secretary for Aging Kathy Greenlee. "I thank the Centers for Medicare & Medicaid Services for their continued partnership in this effort to educate seniors about health care fraud."

The SMP volunteers work in their communities to educate Medicare beneficiaries, family members, and caregivers about the importance of reviewing their Medicare notices, and Medicaid claims if dually-eligible, to identify errors and potentially fraudulent activity. Program volunteers also encourage seniors to make inquiries to the SMP Program when such issues are identified, so that the project may ensure appropriate resolution or referral.

Since 1997, HHS has funded Senior Medicare Patrol projects to recruit and train retired professionals and other senior volunteers about how to recognize and report instances or patterns of health care fraud. More than 4 million Medicare beneficiaries have been educated since the start of the program, through more than 1 million one-on-one counseling sessions with seniors or their caregivers. More than 25 million people have already participated in community outreach education events.

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CMS Announces New Programs to Help Curb Improper Medicare, Medicaid Payments
November 16, 2011 11:10 AM by Lisa Algeo

In 2010, the President announced three goals for cutting improper payments by 2012: reducing overall payment errors by $50 billion, cutting the Medicare fee-for-service error rate in half, and recovering $2 billion in improper payments. 

To help achieve these goals, the Centers for Medicare & Medicaid Services (CMS) has announced it will launch demonstration programs beginning in January 2012 targeting some of the most common factors that lead to improper payments.

Cost Saving Projects will Help Protect Medicare and Medicaid

Beginning on Jan. 1, 2012, CMS will conduct demonstration projects that will strengthen Medicare by aiming at eliminating fraud, waste and abuse.  Reductions in improper payments will help ensure the sound future of the Medicare Trust Fund and protect Medicare beneficiaries who depend upon it.

  • Recovery Audit Prepayment Review: The Recovery Audit Prepayment Review demonstration will allow Medicare Recovery Auditors (RACs) to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments. These reviews will focus on seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. This demonstration will also help lower the error rate by preventing improper payments rather than the traditional "pay and chase" methods of looking for improper payments after they have been made.
  • Prior Authorization for Certain Medical Equipment: The second demonstration announced today will require Prior Authorization for certain medical equipment for all people with Medicare who reside in seven states with high populations of fraud- and error-prone providers (CA, FL, IL, MI, NY, NC and TX). This is an important step toward paying appropriately for certain medical equipment that has a high error rate. This demonstration will help ensure that a beneficiary's medical condition warrants their medical equipment under existing coverage guidelines. Moreover, the program will assist in preserving a Medicare beneficiary's right to receive quality products from accredited suppliers.

The Prior Authorization demonstration will be implemented in two phases. During the first phase (the first three to nine months), the Medicare Administrative Contractors will conduct   prepayment reviews on certain medical equipment claims. The second phase, for the remainder of this three-year demonstration, will implement prior authorization, a tool utilized by private-sector health care payers to prevent improper payments and deter the fraudulent provision of items or services. 

  • Part A to Part B Rebilling: The third initiative will allow hospitals to rebill for 90 percent of the Part B payment when a Medicare contractor denies a Part A inpatient short stay claim as not reasonable and necessary due to the hospital billing for the wrong setting. Currently, when outpatient services are billed as inpatient services, the entire claim is denied in full.

This demonstration will be limited to a representative sample of 380 hospitals nationwide that volunteer to be part of the program. This demonstration will allow hospitals to resubmit claims for 90 percent of the allowable Part B payment when a Medicare Administrative Contractor, Recovery Auditor, or the Comprehensive Error Rate Testing Contractor finds that a Medicare patient met the requirements for Part B services but did not meet the requirements for a Part A inpatient stay.  In addition, this demonstration is expected to lower the appeals rate which will protect the trust fund and reduce hospital burden.  Beneficiaries will be held harmless with respect to changes in hospital coinsurance liability.

This past May, HHS announced a pilot project under the Partnership Fund for Program Integrity Innovation to test an automated tool to screen providers for the risk of fraud. Currently, HHS and States lack standardized Medicaid provider data, which hampers detection of potential fraud. If successful, this tool will not only help prevent improper payments by weeding out fraudulent providers, but it will help States focus their resources where fraud is most likely to occur.

New Projects Build on 2011 Savings

The 2012 projects announced today will build on accomplishments in 2011 to reduce Medicare and Medicaid improper payment rates.

For example, the Medicare fee-for-service improper payment rate dropped to 8.6 percent, or $28.8 billion in estimated improper claims payments.  This rate was calculated using a refined methodology, after consulting with the Office of the Inspector General, that reflects the impact of late documentation and the results of appeal activities that typically occur after the cut-off date.  For consistency and comparison purposes, CMS adjusted the 2010 error rate to 9.1 percent or $29.7 billion. When comparing the adjusted rates, the 8.6 percent error rate for 2011 represents a 0.5 percentage point reduction in the improper payment rate from 2010.

In addition, for 2011:

  • The Medicare Advantage (Part C) improper payment rate, based on the 2009 payment year, is 11.0percent, or $12.4 billion, a reduction from last year's rate of 14.1 percent, or $13.6billion. The Part C improper payment rate dropped 3.1 percentage points (or 21 percent) from 2010, a result of the Administration's aggressive corrective actions, including ongoing audits - with an emphasis on contract-level risk adjustment data validation audits - designed to recover overpayments to Part C plans.
  • The Medicaid improper payment rate is 8.1 percent, or $21.9 billion in estimated improper payments.  This rate reflects a three-year average of the 2009, 2010, and 2011 cycle rates.  The Medicaid improper payment rate declined by 1.3 percentage points, reflecting ongoing efforts by the States and the Department of Health and Human Services (HHS) to educate providers on the root causes of improper payments.

CMS is also reporting for the first time a composite improper payment rate for the Medicare Part D prescription drug program.  Based on payment year 2009, the improper payment rate is 3.2 percent, or $1.7 billion.  The Part D payment improper payment rate combines five component payment error measures: Medicare Advantage prescription drug payment system error; payment error related to low income subsidy status; payment error related to incorrect Medicaid status; payment error related to prescription drug event data validation; and payment error related to direct and indirect remuneration.

The improper payment rate for the Children's Health Insurance Program (CHIP) will not be published until 2012.  CMS was prohibited from calculating or publishing a rate until six months after the August 2010 Payment Error Rate Measurement (PERM) program rules went into effect.  Due to the timing , HHS began measuring CHIP improper payments under the new program rules in 2011, and will publish the results in 2012.  

While improper payment rates are not necessarily an indicator of fraud in Medicare, Medicaid or CHIP, they do provide HHS, CMS and States with a more complete assessment of  factors leading to error rates and new ways to help prevent them.

CMS is continuing to invest time and resources to work with providers across the country and eliminate errors through increased and improved training, education, and outreach.

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Little Known Medicare Rule on Observation Days Has Big Effect
November 15, 2011 12:45 PM by Lisa Algeo

(Editor's note: This guest blog is written by Michael LaMagna, Esq.)

Last week, a group of Medicare beneficiaries filed a lawsuit, Bagnall v. Sebelius, against Kathleen Sebelius, the Secretary of Health and Human Services in U.S. District Court, citing that they were wrongfully deprived of their Medicare coverage. The group, which is looking for class action status, is suing because of a little known policy, which allows hospitals to classify patients under observational status instead of officially admitting, thereby denying Medicare beneficiaries from accessing their Part A benefit. A Medicare beneficiary can access their Part A benefit after three consecutive nights as a hospital inpatient. The benefit is generous, paying for up to 100 days in a nursing home, 100% for day 1-20, 80% for day 21-100. The benefit lapses after 100 days of skilled care if the beneficiary no longer requires skilled nursing or rehabilitation. The 100 day "bank" gets replenished after 60 days lapses without receiving skilled care.

The policy is meant to protect hospitals from unnecessary Medicare admissions, shifting the cost of the stay from Part A (mainly hospital coverage) to Part B, which covers physicians' services and outpatient facilities. It appears that the hospitals are using the observation days to extend their own length of stays, which could last as long as a week. The result can be catastrophic, costing co-pays and possibly nursing home costs, as the Part A benefit cannot be accessed unless the 3-day hospital inpatient qualifier is met. The lawsuit cited that from 2006 to 2008, the number of observation status claims increased by 22.4 percent, and the claims for stays of 48 hours or longer increased by 70.3 percent.

With many more patients requiring rehabilitation prior to returning home, many are shocked to find that Medicare will not cover their post-hospitalization because the hospital misclassified their stay. The lawsuit, brought in federal court, seeks to change the Medicare policy to include observation days toward the 3-day qualifier.

This article is provided for informational purposes only. Nothing in this article shall be construed as legal advice or should be relied upon as such. Michael LaMagna is a partner at Timins & LaMagna, LLP, practicing Health Care Regulatory, Elder /disability/veteran's law, trusts and Estates, Social Security and general legal practice in both New York and Connecticut. Michael was just appointed to the ACO Task Force of the American Health Lawyers Association. Visit Attorney LaMagna's website at http://www.nyandctlaw.com/, email him at Mlamagna@tllawoffices.com or call him at 914-819-0663 for more information.

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Medicare Expands Coverage of Cardiovascular Disease Prevention Services
November 14, 2011 11:09 AM by Lisa Algeo

The Centers for Medicare & Medicaid Services (CMS) last week announced that Medicare is adding coverage for a number of preventive services to reduce cardiovascular disease. This new coverage policy will add to the existing portfolio of free preventive services that are now available for people with Medicare, thanks to the Affordable Care Act. It contributes to the Million Hearts initiative led jointly by CMS and the Centers for Disease Control and Prevention in partnership with other HHS agencies, communities, health systems, nonprofit organizations, and private sector partners across the country to prevent one million heart attacks and strokes in the next 5 years.

"Access to preventive services helps Medicare beneficiaries identify health risk factors and disease early to provide greater opportunities for early treatment," said CMS Administrator Donald M. Berwick, MD. "CMS continues to carefully and systematically review the best available medical evidence to identify those preventive services that can keep Medicare beneficiaries as healthy as possible for as long as possible."

Under this coverage decision, CMS will cover one face-to-face visit each year to allow patients and their care providers to determine the best way to help prevent cardiovascular disease. The visit must be furnished by primary care practitioners, such as a beneficiary's family practice physician, internal medicine physician, or nurse practitioner, in settings such as physicians' offices. During these visits, providers may screen for hypertension and promote healthy diet as part of an overall initiative to reduce the burden of cardiovascular disease in the United States.

Cardiovascular disease characterizes conditions affecting the heart and blood vessels, including hypertension, coronary heart disease, heart failure and stroke. Cardiovascular disease is also the leading cause of mortality in the United States. This new coverage policy does not change current Medicare coverage for beneficiaries diagnosed with cardiovascular disease to receive assessment and intervention services.

Earlier this year, the U.S. Department of Health and Human Services announced its Million Hearts national initiative, aimed at preventing a million heart attacks and strokes in the U.S. by 2017. Through Million Hearts, CMS, the CDC and other HHS agencies are working together with public and private sector organizations to make a long-lasting impact against cardiovascular disease.

"This coverage decision reinforces CMS' commitment to the work of the Million Hearts initiative," said Patrick Conway, MD, CMS chief medical officer and director of the Agency's Office of Clinical Standards and Quality. "One of the main ways we will prevent cardiovascular disease in this country is to empower Americans to make heart-healthy lifestyle changes, and Medicare's new cardiovascular disease preventive services will allow more beneficiaries to do just that."

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