The groundbreaking public-private anti-fraud initiative
unveiled by HHS in July will focus for now on sharing information about already
identified fraud schemes and billing codes, putting off its aggressive goal of
creating a system for broad sharing of claims data among public and private
payers -- the latter raising legal issues, including patient privacy
restrictions, that must be worked out, according to a source familiar with a closed-door
meeting the group held late last week. CMS had planned to hold a public meeting
to discuss updates to the program on Sept. 27, but a CMS spokesperson said the
meeting has been postponed.647 words
Congressional advisers are looking into whether a legislative
fix is needed to stem the churn between Medicaid and private coverage that is
likely to occur when states are no longer able to lock in Medicaid eligibility
for residents with income fluctuations after the health law's MAGI standard
takes effect in 2014. This is just one of the many issues MACPAC commissioners
are struggling with as they anticipate how coverage, benefits and cost sharing
will pan out in 2014.594 words
The Office of Personnel Management intends to allow
multi-state plans -- created by a health reform law provision that says at
least two health insurance plans will eventually be offered nationwide -- to
initially participate in part of a state rather than in all of the state,
according to a draft multi-state plan application the office recently released
for comment. A source tracking the issue says this is somewhat surprising given
that the health reform law says multi-state plan issuers need to offer the plan
in all geographic regions, and the phase-in approach could mean the
administration is having difficulty finding two plans that are willing to
operate nationally.766 words
Democratic Sen. Dick Durbin (IL) told Inside Health Policy
on Thursday (Sept. 20) that "any honest plan for deficit reduction puts
everything on the table," comments that come as he and seven other senators
from both parties continue to discuss a grand bargain on deficit reduction and
as stakeholders are gearing up for a battle to avert the automatic payment cuts
required under budget sequestration. Durbin would not provide any specifics on
health sector cuts, but the framework unveiled last year by the "Gang of Six"
had asked the Senate Finance Committee to find more than $200 billion in
savings in addition to fixing and fully off-setting the Medicare physician pay
formula.493 words
American Academy of Family Physicians Board Chair Roland
Goertz is pushing back against the premise that broadening scope of
practice laws would always create cost savings, saying that a better approach
is to quickly implement physician-led, patient-centered medical homes. Goertz'
comments to Inside Health Policy come as a growing number of health
policy experts are saying restrictive state scope of practice laws -- which
prevent nurse practitioners, physician assistants and other non-physician
providers from practicing at the top of their skill level -- are driving up
health care costs and should be modified.749 words
Manual medical pre-approval reviews for therapy over $3,700
will only last as long as the funds earmarked for the program after which
Medicare Administrative Contractors have been instructed to treat the claims as
though the cap was never reached, CMS told Inside Health Policy. The
manual medical reviews are set to be phased in starting on Oct. 1 for patients
receiving more than $3,700 in therapy, as CMS works to clear up providers'
unanswered questions.774 words
Some children's hospitals are looking to states to set up
Medicaid accountable care organizations because such ACO's are authorized but
not funded by the health reform law, leaving CMS to focus its ACO efforts on
Medicare shared savings programs, hospital sources said. The agency has in some
instances awarded innovation grants that let states negotiate with hospitals on
sharing Medicaid savings for pediatric ACOs, and those negotiations will
produce the first Medicaid shared savings terms.785 words
The American Hospital Association told Obama administration
officials Monday that it agrees fraudulent billing practices -- such as
inappropriately "upcoding" the intensity of care -- should not be accepted but
said some of the onus falls on HHS for failing to develop national guidelines for
reporting Evaluation and Management (E/M) codes despite "numerous requests."
AHA's letter came after HHS Secretary Kathleen Sebelius and Attorney General
Eric Holder warned hospital groups that the administration "will not tolerate"
health care fraud and specifically pointed out that CMS has the authority to
address inappropriate coding intensity adjustments through its payment rules if
warranted.744 words
Health care stakeholders are hopeful a new bipartisan bill
that would allow the Congressional Budget Office to provide out-year savings
projections for initiatives aimed at wellness and disease prevention will
become part of an expected effort to overhaul Congressional Budget Office rules
next session during larger tax reforms and deficit reduction negotiations.482 words
House legislation that would repeal the premium tax on
insurance has garnered enough co-sponsors to pass through the chamber, the
bill's author Charles Boustany (R-LA) announced, a marker that an industry
source suggests puts the issue in a good position to be addressed next session
through tax reform or other large legislative efforts.499 words
The Bipartisan Policy Center is gathering claims data and
other information on new approaches to health care payment and delivery in the
public and private sectors as part of a year-long effort to craft proposals to
contain costs and improve quality, and a report released by the group Thursday
(Sept. 20) lays the groundwork for the upcoming cost-containment
recommendations by listing reasons for the country's overspending on health
care that span from fee-for-service pay models to overuse of medical technology
and medical malpractice costs.1534 words
Two additional hospital groups pushed back a day after the Justice
Department and HHS sent a letter Monday (Sept. 24) alleging hospitals may be
using upcoding to game the system, with the Federation of Hospitals denying
wrongdoing by hospitals and the Association of Academic Health Centers asking
for a meeting to clear up what CMS views as proper coding for evaluation and
management (E/M). The American Hospital Association was the first to turn the
tables on the administration, arguing Monday that lack of HHS guidance is
leading to coding confusion, after HHS officials warned they were willing to
use payment policies as a tool to stem improper coding practices.637 words
Top Senate Finance Committee Republican Orrin Hatch (UT) says
he is concerned that HHS has set a Nov. 16 deadline for states to tell the
department which type of exchange it intends to pursue but the administration
has not provided any details about what the federally facilitated exchange will
require of states. In a letter Hatch sent Monday (Sept. 24) to HHS, the senator
writes that "it is not only common-sense, but necessary, that states receive
full and detailed information about how an FFE will be implemented."496 words
Rep. Aaron Schock (R-IL) warned physicians on Friday (Sept.
20) that Congress is unlikely to allow for an increase in the debt limit in the
coming months without a trade-off in spending cuts, and indicated lawmakers
likely will look to Medicare and Medicaid because defense and discretionary
spending is already taking a huge hit under budget sequestration.654 words
CMS is in the early stages of launching a Medicaid program
integrity workgroup that states for months have been pushing the agency to set
up as part of a holistic approach to overhauling the Medicaid program integrity
arena. An agency official briefly mentioned the workgroup at a Sept. 20 House
Oversight health subcommittee hearing where lawmakers highlighted billions of
dollars in federal Medicaid overpayments to New York developmental centers.
State Medicaid sources are closely watching to see if CMS' plan will match
their call for a national effort to elevate the conversation about how Medicaid
program integrity works -- or in some cases does not work -- and how the
federal government and states can increase their collaboration.771 words
The Senate aging committee's top Republican, Sen. Bob Corker
(TN), said he remains skeptical that CMS' prior authorization demonstration
that went into effect on Sept. 1 will effectively solve the waste, fraud and
abuse problems plaguing the power mobility device industry, and warned that if
CMS does not lower the error rate on the program into the single digits,
Congress may step in. Durable Medical Equipment providers, however, say the
error rate comes more from CMS intentionally denying as many applications for
power mobility devices as possible in order to avoid paying for the equipment.653 words
CMS will soon reach out to stakeholders to gauge their
overall level of satisfaction with the Medicaid program as part of the agency's
effort to establish performance standards, the agency's Medicaid chief said in
a recent teleconference. The upcoming request for comments on how applicants,
enrollees and providers feel about the program comes as CMS is finalizing
regulations proposed last April that aim to ensure beneficiaries have access to
Medicaid providers, CMS' Cindy Mann said.421 words
A House committee approved 26-14 Thursday, with one Democrat
on board, legislation long opposed by consumer and patient advocates that would
exempt broker and agent compensation from the health law's medical loss ratio
requirement and also require HHS to defer to states regarding exemptions from
the provision. The Energy and Commerce Committee also approved by voice vote a
bipartisan bill that would aims to make the Medicare Secondary Payer (MSP)
program more efficient.531 words
A CMS official said Thursday (Sept. 13) that CMS is no longer
discussing a "blended" federal Medicaid matching rate that would ax the
existing varying federal payments in order to create a streamlined rate
encompassing existing and newly eligible Medicaid beneficiaries, but a state
Medicaid source was not assuaged, saying the agency has little control over
such decisions. The White House floated the proposal, estimated to save the
federal government about $18 billion over 10 years, last September and also
included it in the fiscal year 2013 budget request, which a White House
official recently told Inside Health Policy was the deficit reduction
plan the president referred to in his convention acceptance speech last
Thursday (September 6).414 words
The Federal Trade Commission is honing in on a drug patent
settlement case involving the testosterone gel Androgel while the drug industry
and free-market advocates are plugging a separate case involving K-Dur
potassium chloride supplements in their competing quests for the Supreme Court
to rule on the constitutionality of so-called "pay for delay" settlements
between brand and generic drug makers.1630 words
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