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HEADLINES
from Medicare and Medicaid Guide Tuesday, February 19, 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
February 2008, Volume 23, No. 6
The February 2008 issue of Dennis Barry’s Reimbursement Advisor examines recent compliance issues regarding on-call arrangements for emergency department physician payments, post-acute payment reform, and a formal notice from the Centers for Medicare and Medicaid Services (CMS) regarding the prioritization of its obligations to existing Medicare providers and new providers seeking Medicare certification.
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Receivables Report
February 2008, Volume 23, Issue 2
Fewer Hospitals Offer Certain Patient Finance Programs. Most hospitals offer patients some type of assistance in paying a large bill. Patient finance programs are not new, but some types seem to be declining in popularity among some providers. “Hospitals have stopped using some plans for several reasons, revolving around public relations,” according to Jim Grigsby, Florida-based author and industry consultant. Read Grigsby’s opinions and those of other industry sources in the February Receivables Report.
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Hospital Accounts Receivable Analysis
Second Quarter 2007, Volume 21, Number 3
The second quarter of the year brought some positive changes to US hospitals. Write-offs and aging A/R were down, as was the average GDRO.
- Gross Days Revenue Outstanding. In the second quarterly financial reporting period of 2007, the nation’s hospitals recovered to improve the gross days revenue outstanding average (GDRO) by nearly two days. To be precise, hospitals pared 1.85 days from the first quarter GDRO average of 50.15 days, reporting a second quarter GDRO average of 48.30 days.
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Headlines
from Medicare and Medicaid Guide
Revised interpretive guidelines issued for hospital
conditions of participation
Revised interpretive guidelines
for hospital conditions of participation have been issued that reflect the
regulatory changes that were published on November 27, 2006 for history and
physical examinations, authentication of verbal orders, securing medications,
and post-anesthesia evaluations. The interpretive guidelines also reflect
the newly-adopted changes that were incorporated into the calendar year 2008
outpatient prospective payment system (OPPS) regulation. The OPPS revisions
are intended to clarify the timeframe requirements for the medical history
and physical examination and its update, and the post-anesthesia evaluation
requirements for patients undergoing outpatient surgeries and procedures.
The tag numbers in the interpretive guidelines have been revised and, in some
instances, separate tags have been consolidated. CMS Letter to State
Survey Agency Directors, No. S&C-08-12, Feb. 8, 2008, ¶52,104.
Physicians should submit claims with NPI only
Physicians and providers who are submitting claims with both a National
Provider Identifier (NPI) and a Medicare legacy number, are advised to test
their ability to get paid using only their NPI by submitting one or two claims
for each NPI assigned to them, prior to the May 23, 2008 requirement for only
the NPI on all Health Insurance Portability and Accountability Act (HIPPA)
electronic transactions and their paper versions. If the NPI Crosswalk cannot
match the NPI to a provider's Medicare legacy number, the claim will be rejected.
If the test claims are processed and paid, providers should increase the volume
of claims submitted using only the NPI. If the claims are rejected, providers
should validate that the National Plan and Provider Enumeration System (NPPES)
has the correct Legacy number. If the NPPES information is correct, contact
the Medicare carrier or A/B Medicare administrative contractor (MAC) enrollment
staff. MLN Matters, No. SE0802, Feb. 8, 2008, ¶52,106.
CMS not aggressive in curbing MA marketing abuses
The Centers for Medicare and Medicaid Services is not
doing enough to curtail abusive and aggressive marketing practices by some
Medicare Advantage plan sales agents, according to Senate Finance Committee
Chairman Max Baucus (D-Mont.). Baucus and ranking member Charles Grassley
(R-Iowa) suggested enforcement could be handled better at the state level,
as suggested by the National Association of Insurance Commissioners. Baucus
said that CMS might be too big to be effective. States insurance regulators
are calling for a Medigap approach, in which states are permitted to enforce
national safeguards promulgated by Department of Health and Human Services,
Baucus said. CCH Washington Bureau, Feb. 13, 2008.
Model explanation of benefits for Part D sponsors updated
The 2008 model explanation of benefits (EOB)
that Part D sponsors should use in communicating benefit and formulary change
information to enrollees has been updated by CMS. The new EOB includes: (1)
more complete information about the prescription drug claims processed in
the previous months; (2) a record of total out-of-pocket costs and total drug
payments transferred from previous plans; (3) a table that summarizes the
current coverage period; and (4) contact information for questions about the
EOB, coverage decisions, possible fraud, and qualifying for extra help. In
addition, although CMS regulations specify that an EOB must be provided “
during” any month when prescription drug benefits are provided to a
member, CMS has clarified that it will take no enforcement action against
a sponsor unless an EOB is issued to enrollees later than the end of the month
following the month in which the enrollee utilized his/her prescription drug
benefits. Part D sponsors are not expected to implement the updated model
until after July 1, 2008, with enrollees receiving their first new EOBs in
August 2008. Because the new model EOB will be implemented mid-year, CMS expects
sponsors to send a cover letter to enrollees alerting them to the changes
in the way their year-to-date benefits and formulary change information will
be presented going forward. The new model EOB and proposed cover letter are
attached to the CMS letter. CMS Letter to Part D Sponsors,
Feb. 1, 2008, ¶52,107.
Adverse employment claim fails absent protected conduct
A state whistleblower action alleging that
a health care company retaliated against an employee who reported the company's
violations of laws, regulations, and policies with respect to staffing, patient
admissions, and physician certification was properly dismissed. The employee's
complaints, however, did not amount to a protected report under the whistleblower
statute because her job duties as a nursing director and regional nursing
consultant required her to ensure compliance with applicable laws and to expose
unlawful behavior internally. She did not become a statutory whistleblower
by exercising her duties to report compliance problems at her facilities.
Moreover, her denial of admission to a prospective resident was not a protected
action because she did not disobey an order from her employer. The employee,
a regional nurse consultant for eight of the company's nursing facilities,
informed her supervisors that the company could be denied Medicare reimbursement
because it had no licensed administrator at one of its facilities. She also
complained about inappropriate admissions to the facilities, including one
instance in which she denied a patient admission to the facility on the grounds
that the facility could not care for a patient in his condition, but the company
later approved the admission. Subsequently, the employee was relieved of her
position as regional nurse consultant and installed as permanent nursing director
at one of the company's facilities. There, she was advised that the facility
had not obtained physician certifications and recertifications that were required
before the facility could receive Medicare reimbursement. She twice raised
this issue with the facility's administrator and on several occasions expressed
concern that the company was holding beds open for Medicare patients while
unlawfully denying beds to other patients. Shortly thereafter, the employee
resigned. Skare v. Extendicare Health Services, Inc., 8th
Cir., Feb. 8, 2008, ¶302,321.
Carrier immunity from False Claims Act
A Medicare Part B carrier does not enjoy complete statutory immunity under
Social Security Act §1842(e) regardless of its conduct. Rather, a carrier
is only immune from liability for incorrect payments in the absence of gross
negligence or intent to defraud the federal government. Thus, a qui
tam relator could proceed with a False Claims Act lawsuit against
a Part B carrier because the relator had alleged that the carrier acted knowingly
and with gross negligence in processing false claims for Medicare payment.
U.S. ex rel. Conrad v. Blue Cross Blue Shield of Mississippi, S.D.
Miss., Feb. 5, 2008, ¶302,320.
CAH accreditation
The American Osteopathic
Association (AOA) is now recognized as an national accreditor for critical
access hospitals (CAHs) that seek to participate in the Medicare program.
The accreditation also extends to the distinct parts of CAHs. States may treat
CAH distinct part surveys as a Tier 3 priority until otherwise notified. CMS,
however, will not lower the priority for any CAH distinct part in mid-year
actions. The approval for the AOA is from Dec. 28, 2007, through Dec. 28,
2013. CMS Letter to State Survey and Certification Agencies,
S&C-08-12, Feb. 8, 2008, ¶52,105.
Rural community hospital demonstration
Six hospitals are needed to participate in the Rural Community Hospital Demonstration
program. Hospitals wishing to participate must submit an application to CMS
and will participate for no more then two years because the demonstration
will end in 2010. The demonstration is designed to test the feasibility and
advisability of reasonable cost reimbursement for inpatient services to small
rural hospitals. The demonstration is aimed at increasing the capability of
the selected hospitals to meet the needs of their service areas. To be included
in the demonstration, a hospital must be located in Alaska, Idaho, Montana,
Nebraska, New Mexico, North Dakota, South Dakota, Utah or Wyoming, and meet
the criteria for a rural community hospital. Hospitals selected will receive
payment for covered inpatient services, except for services furnished in certain
psychiatric units. For more information see http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/2004_Rural_Community_Hospital_Demonstration_Program.pdf.
Notice, 73 FR 6971, Feb. 6, 2008, ¶261,822.
Employers are spending more on health benefits
Employers spent $537 billion on group health insurance
policies in 2006, an amount that grew more than twenty-fold from $23 billion
in 1960, according to a new analysis by the Henry J. Kaiser Family Foundation.
The share of employee compensation going to health benefits has risen substantially
over time, while the share going to wages has fallen, said the foundation.
Between 2001 and 2007, health insurance premiums rose 78 percent, a much faster
rate of increase than general inflation (17 percent) or workers' earnings
(19 percent), the foundation said in the analysis released in February. While
recent increases have been particularly acute, health benefit costs have risen
rapidly over many years, the foundation said. According to the report, health
benefit costs have increased from 0.6 percent of Gross Domestic Product in
1960 to 4.1 percent in 2006. Large employers are not ready to bail out of
their role of acting as the backbone of health insurance coverage in the United
States, according to an article published on February 7, 2008 by the Employee
Benefit Research Institute. But large employers are pushing for changes they
hope will alleviate the rising costs of health benefits, and the current picture
could shift quickly if one large employer drops benefits, according to the
private, nonprofit research institute based in Washington, D.C. CCH
Washington Bureau, Feb 7 and Feb 12, 2008.
Medicare demonstration improving quality of health care
Participants in the Medicare's Physician Group
Practice (PGP) Demonstration have faced challenges, including lags in receiving
and reporting data, limited reimbursement for non-physician care, and the
often substantial upfront investments required for care innovations, according
to a Commonwealth Fund report. Despite these challenges, all the participating
groups have achieved their performance targets for at least seven of 10 diabetes
quality measures, according to the fund. Participants in the PGP demonstration,
launched in 2005, are charged with improving the coordination of care for
their fee-for-service beneficiaries, investing in administrative and process
improvements to increase efficiency, and improving the quality of patient
care. Practices earn performance payments based on their success in meeting
these goals. PGPs believe that involving patients more deeply in pre-visit
processes and self-management support has the potential to improve quality
while containing costs, said the authors, adding that demonstration PGPs are
working on a number of patient education and coaching programs to promote
improved patient self-management. CCH Washington Bureau,
Feb. 8, 2008.
Decisions and Developments
CMS Manuals
Independent laboratory billing changes under 2007 legislation
Medicare Claims Processing Manual,
Pub. 100-04, Transmittal No. 1440, Feb. 7, 2008, ¶157,118.
Premium content
New code for replacement interface material
Medicare Claims Processing Manual, Pub. 100-04, Transmittal
No. 1441, Feb. 7, 2008, ¶157,119.
Premium content
January 2008 update of hospital outpatient prospective payment system
Medicare Benefit Policy Manual,
Pub. 100-02, Transmittal No. 82, Feb. 8, 2008, ¶157,121.
Premium content
January 2008 update of hospital outpatient prospective payment system
Medicare Claims Processing Manual
, Pub. 100-04, Transmittal No. 1445, Feb. 8, 2008, ¶157,126.
Premium content
Service description reporting for hospice claims
Medicare Claims Processing Manual, Pub. 100-04, Transmittal
No. 1447, Feb. 12, 2008, ¶157,129.
Premium content
Update to common working file (CWF Edits) to check
for Medicare part A entitlement for social admissions with Indian Health Service
providers
Medicare Claims Processing Manual,
Pub. 100-04, Transmittal No. 1446, Feb. 8, 2008, ¶157,127.
Premium content
Inpatient hospital prospective payment claims are
to be included in the nightly universe files generated for the comprehensive
error rate testing (CERT) program
Medicare Program
Integrity Manual, Pub. 100-08, Transmittal No. 240, Feb. 8, 2008, ¶157,128.
Premium content
Home health prospective payment system (HH PPS) refinement
and rate update for calendar year (CY) 2008
Medicare
Claims Processing Manual, Pub. 100-04, Transmittal No. 1443, ¶157,120.
Premium content
Additional instructions for the execution of the Medicare
provider enrollment demonstration for home health agencies (HHAs) in high-risk
areas
Medicare Program Integrity Manual,
Pub. 100-08, Transmittal No. 239, Feb. 8, 2008, ¶157,122.
Premium content
Flagging health insurance claim numbers (HICN) in
the Medicare carrier system (MCS) for pre-payment review/audit
Medicare Program Integrity Manual, Pub. 100-08, Transmittal
No. 241 Feb. 8, 2008 ¶157,123.
Premium content
Merger of jurisdiction 3 workloads for Part A claims
One-Time Notification Manual, Pub. 100-20,
Transmittal No. 320, Feb. 8, 2008, ¶157,124.
Premium content
Modification to existing Medicare Summary Notice (MSN)
procedures regarding the MSN customer service information box, beneficiary
estate information and the appeals address
Medicare
Claims Processing Manual, Pub. 100-04, Transmittal No. 1444, Feb.
8, 2008, ¶157,125.
Premium content
Changes to national coordination of benefits agreement
crossover process
Medicare Claims Processing Manual
, Pub. 100-04, Transmittal No. 1436, Feb. 5, 2008, ¶157,113.
Premium content
Change in amount-in-controversy requirement for ALJ
hearings and federal court appeals
Medicare Claims
Processing Manual, Pub. 100-04, Transmittal No. 1437, Feb. 5, 2008, ¶157,114.
Premium content
New contractor number for Riverbend, New Jersey
One-Time Notification Manual, Pub. 100-20, Transmittal
No. 317, Feb. 5, 2008, ¶157,115.
Premium content
Revision of list for off-label uses of drugs and biologicals in anti-cancer regimen
Medicare Benefit Policy Manual
, Pub. 100-02, Transmittal No. 81, Feb. 7, 2008, ¶157,116.
Premium content
Removal of Christian Science sanatoria references
Medicare Claims Processing Manual, Pub.
100-04, Transmittal No. 1439, Feb. 7, 2008, ¶157,117.
Premium content
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