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HEADLINES
from Medicare and Medicaid Guide Monday, August 25, 2008
Click on a headline below for the full story.
Decisions and Developments
CCH® Reimbursement Integrated Library
The Reimbursement Integrated Library delivers the key performance indicators for maximizing reimbursement. The Library includes three invaluable titles:
- Dennis Barry's Reimbursement Advisor - This monthly newsletter provides all the facts about reimbursement strategies to minimize the adverse effects of DRGs, RBRVs, APCs and capitation to optimize hospital reimbursement.
- Receivables Report - This monthly newsletter includes actual profit-improvement examples from facilities nationwide, secrets for successfully challenging denials, tips for using automation to increase cash flow, and strategies your colleagues are using now to prepare for health care reform.
- Hospital Accounts Receivable Analysis - This quarterly journal is a synopsis of statistical data related to hospital receivables.
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Reimbursement Integrated Library
Dennis Barry’s Reimbursement Advisor
August 2008, Volume 23, No. 12
As the Centers for Medicare and Medicaid Services (CMS) continuously clarifies, amends and revises rules governing the myriad aspects of the Medicare regulations, so do the rules and their transformations continuously receive scrutiny. In the August 2008 issue, authors examine CMS’ final rule revising Provider Reimbursement Review Board (PRRB) appeals as well as the agency’s new additional criteria to define what is considered a new graduate medical education program. In addition, authors examine two recent federal district court decisions in which hospitals’ scrutiny of CMS policy results in rulings with favorable implications for providers.
- What is a “new” GME program for Medicare purposes? CMS applies additional criteria to determine new GME programs. Medicare regulations permit adjustment to applicable resident caps for graduate medical education (GME) payments only if a hospital establishes a “new medical residency training program,” as defined by CMS. In this article, the author examines CMS’ definition of what constitutes a new program, how hospitals may assess whether new GME programs qualify under Medicare policy, and the implications of additional criteria being applied by CMS to determine what is a new program.
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Receivables Report
August 2008, Volume 23, Issue 8
Increased Billing Times. Coding changes may be behind a recent increase in hospital discharge-to-bill times. In this issue of the Receivables Report, we look at the numbers—then look behind them—to see what’s happening with this key performance indicator. You may find that you are experiencing a similar situation.
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Hospital Accounts Receivable Analysis
Fourth Quarter 2007, Volume 22, Number 1
- Major Indicators.
At the end of 2007, US hospitals reported seeing mixed results among their key indicators. In the HARA Report on Fourth Quarter 2007, we break it down for you.
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Headlines
from Medicare and Medicaid Guide
Medicaid Integrity Program emphasizes quality, planning
As the Medicaid Integrity Program (MIP) enters the implementation stage,
providers should prepare for more intensive review by this new group of auditors,
says James G. Sheehan, Medicaid Inspector General for the state of New York.
At a seminar sponsored by the Health Care Compliance Association, Sheehan
and Brian Flood, managing director of KPMG, advised compliance officers to
strengthen their compliance programs. The MIP will focus on quality of care,
patient outcomes and failure to meet professional standards by requiring reporting
of adverse events, denying payment for the costs resulting from “never
events” and mining of databases to identify patterns of poor outcomes,
fraud or abuse. CCH Chicago Bureau, Aug. 14, 2008.
PGP demo advances quality of care for chronic illness
Participants in the Physician Group Practice (PGP) Demonstration earned
$16.7 million in incentive payments, and improved the quality of care for
beneficiaries with congestive heart failure, coronary heart disease, and diabetes
mellitus in the second year of the demonstration, according to CMS. All 10
of the participating physician groups achieved benchmark or target performance
in 25 out of 27 quality measures. The demonstration is one of CMS' value-based
purchasing (VBP) initiatives that tie Medicare payments to performance on
health care cost and quality measures. The physician groups improved their
quality scores by an average of nine percentage points in the diabetes mellitus
measure, by 11 percentage points in the heart failure measures, and by five
percentage points in the coronary heart disease measures. The PGP Demonstration
was extended to a fourth performance year, which will end in March 2009.
CMS Press Release, Aug. 14, 2008
2009 Part D costs issued by CMS
Based on bids submitted by Medicare Part D plans, CMS estimates that
the average monthly premium that beneficiaries will pay for standard Part
D coverage in 2009 will be $28. In addition to the estimated average premium
for 2009, CMS announced that: (1) the 2009 national average monthly bid is
$84.33; (2) the 2009 base beneficiary premium is $30.36; (3) the regional
low-income premium subsidy amounts are available in a spreadsheet entitled “
PartDLowIncomePremiumSubsidyAmounts2009-final.csv,” which can be accessed
on the CMS website; and (4) the Medicare Advantage (MA) regional preferred
provider organization benchmarks are available in a file labeled “MARegionalRate2009-final.csv
” on the CMS website.
CMS Notice to MA Organizations, Medicare Prescription
Drug Plan Sponsors, and Other Interested Parties, Aug. 14, 2008, ¶52,341.
Information security breaches growing in health care
Security breaches in the health care industry have become more widespread
and are affecting health insurers, hospitals, pharmacies, physicians and vendors. “
No part of the industry is exempt,” said Kirk Nahra, a partner with
Wiley Rein & Fielding, Washington, D.C., during a recent teleconference
held by the American Bar Association. Melissa Markey, a shareholder in the
firm Hall, Render, Killian, Heath and Lyman, Troy, Michigan, noted that according
to the Identity Theft Resource Center, in the first half of 2008, there were
56 reported breaches of health care information that exposed almost 3 million
records, which amounts to nearly 15 percent of all reported data breaches.
Markey added that it’s a good time to prepare for e-discovery compliance
and evaluate document management policies and acceptable use policies. “
If you’re letting your doctors use [instant messaging] for patient information,
this might be a really good time to think about how you’re protecting
that information,” she noted. CCH Washington Bureau, Aug. 12, 2008.
Report: reducing administrative demands could cut costs
Streamlining administrative requirements that are often duplicative
or overlapping could prevent hospital resources from being diverted away from
patient care and result in lower health care costs for consumers, according
to a July report by the American Hospital Association (AHA). The report, which
appeared in the AHA's TrendWatch publication, identifies a number of steps
payers and regulators can take to coordinate their practices and procedures,
which often require providers to repeatedly collect and report the same data,
resulting in unnecessary administrative expenses and driving up the cost of
care. The report recommends that public and private payers develop standardized
and simplified protocol that would allow information to be shared more easily.
The report also suggests that CMS adopt consistent standards for the way payers
acknowledge receipt of claims submitted by hospitals and work to eliminate
duplication among auditing and oversight contractors.
American Hospital Association TrendWatch, July 2008.
Decisions and Developments
CMS Manuals
Physician fee schedule record layout changes
Medicare Claims Processing Manual, Pub. 100-04, Transmittal
No. 1574, Aug. 12, 2008, ¶157,468.
Premium content
Part B drug competitive acquisition program (CAP) quarterly drug list update
Medicare Claims Processing
Manual, Pub. 100-04, Transmittal No. 1576, Aug. 15, 2008, ¶157,469.
Premium content
Revisions to the competitive acquisition program (CAP)
for Part B drugs and biologicals
Medicare Claims
Processing Manual, Pub. 100-04, Transmittal No. 1577, Aug. 15, 2008, ¶157,470.
Premium content
Implementation of a new claim adjustment reason code
(CARC) for "Non-compliance with the physician self-referral prohibition
legislation or payer policy"
Medicare Claims
Processing Manual, Pub. 100-04, Transmittal No. 1578, Aug. 15, 2008, ¶157,471.
Premium content
2008 reminder on claims for roster billing and centralized
billing for influenza and pneumococcal vaccinations
One-Time Notification Manual, Pub. 100-20, Transmittal No. 366, Aug.
15, 2008, ¶157,472.
Premium content
Notification to contact the U.S. Department of Treasury
regarding withholding of payments as a result of debts referred to the federal
payment levy program
One-Time Notification Manual
, Pub. 100-20, Transmittal No. 367, Aug. 15, 2008, ¶157,473.
Premium content
Contractor software update to accommodate duplicate check numbers
One-Time Notification Manual,
Pub. 100-20, Transmittal No. 369, Aug. 15, 2008, ¶157,474.
Premium content
Adding a frequency of provider measure to the Program
Integrity Management Reporting System
One-Time Notification
Manual, Pub. 100-20, Transmittal No. 370, Aug. 15, 2008, ¶157,475.
Premium content
DAB Decisions
Immediate jeopardy
A civil money penalty
(CMP) of $3,500 per day and disqualification from a nursing program was properly
imposed on a skilled nursing facility (SNF) that failed to investigate the
causes of numerous apparent bruises sustained by one of the facility's residents,
creating a condition of immediate jeopardy. The SNF had appealed the administrative
law judge's (ALJ) decision, asserting that it was in substantial compliance
with the participation requirements. The ALJ decided that the SNF failed to
meet the participation requirement under 42 C.F.R. §483.13(c)(2)-(4)requiring
a participating SNF's staff to: (1) immediately report to the facility's administrator
all alleged violations involving mistreatment, neglect or abuse of a resident,
including injuries of an unknown origin; (2) thoroughly investigate all such
allegations; and (3) report all such investigation results to an appropriate
official within five working days of the incident and take corrective measures.
The SNF failed to document in the treatment record that the SNF's staff investigated
the cause of the bruise. Additionally, no incident reports, investigative
summaries, statements or documentation were taken by the SNF on the resident's
condition. The SNF's noncompliance rose to the level of immediate jeopardy,
and therefore, the ALJ's decision was proper. Grace Healthcare of
Benton, HHS Departmental Appeals Board, Appellate Division, Doc.
No. A-08-40, Dec. No. 2189, July 30, 2008, ¶121,408.
Premium content
Requirements for petition
The administrative
law judge correctly concluded that a home health agency (HHA) failed to file
a timely request for a hearing on the decision to terminate its Medicare participation
and, therefore, was not entitled to a hearing. The initial letter and attachments
from the HHA's attorney did not constitute a timely hearing request because
it failed to satisfy the requirements of 42 C.F.R. §498.40(b). Although the attorney's
submission disputed some of the surveyors' findings of deficiencies, it did
not specifically request a hearing, state that the HHA was in substantial
compliance with conditions of participation at any particular time, or specify
the bases for its challenge to the survey findings. The submission also contained
admissions that the HHA was not in substantial compliance with certain conditions
of participation. Apple Home Health Services, Inc., HHS Departmental
Appeals Board, Appellate Division, Doc. No. A-08-51, Dec. No. 2188, July 30,
2008, ¶121,407.
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