Med Law Blog

On March 10, 2010, the U.S. Senate passed legislation (H.R.4213) on a 62-36 vote, which would reportedly delay a scheduled 21.2 percent Medicare payment reduction for physician services until October 1, 2010

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Special Medicare payment update: President signs extension of physician payment freeze

Late last night, the president signed H.R. 4691, the Temporary Extension Act of 2010 into law. This legislation includes a provision that freezes Medicare physician payments at their current level until March 31, 2010. The legislation also extends the therapy cap exception process through until March 31, 2010.  The bill passed the Senate by a vote of 78 – 19.  The House of Representatives had unanimously approved a companion bill by voice vote on Feb. 25. 

The Senate is also currently debating H.R. 4213 the American Workers, State, and Business Relief Act of 2010. This legislation extends the freeze on Medicare physician payments until Sept. 30, 2010. It also provides an extension to the therapy cap exception process through Dec. 31 , 2010 and an extension of the geographic practice cost index floor through Dec. 31, 2010.  If approved by the Senate, the bill would have to be approved by the House before transmittal to the president. 

MGMA does not support these continued short-term congressional interventions and urges members to contact their senators and representatives to support permanent repeal of the sustainable growth rate formula.

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The Senate failed to act on The House bill to postpone the Sustainable Growth Rate (SGR) Medicare Physician Fee Schedule cut. Therefore the mandatory 21.5% Medcare cut will happen on March1. Legislators have promised renewed efforts but there is no immediate relief in sight.

However, CMS is suggesting anpther 10 day hold to provide time to resolve this.

The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule. As you are aware, the Department of Defense Appropriations Act of 2010 provided a zero percent (0%) update to the 2010 MPFS effective for dates of service January 1, 2010, through February 28, 2010.

CMS believes Congress is working to avoid the negative update that will take effect March 1. Consequently, CMS has instructed its contactors to hold claims containing services paid under the MPFS for the first 10 business days of March. The holding of MPFS claims will only affect claims with dates of service March 1, 2010, and forward. This hold should have a minimum impact on provider cash flow because, under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt. Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Section 135(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended section 1834(e) of the Social Security Act and required the Secretary to designate organizations to accredit suppliers, including but not limited to physicians, non-physician practitioners and Independent Diagnostic Testing Facilities, that furnish the technical component (TC) of advanced diagnostic imaging services.

MIPPA specifically defines advanced diagnostic imaging procedures as including diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET). The law also authorizes the Secretary to specify other diagnostic imaging services in consultation with physician specialty organizations and other stakeholders.

MIPPA expressly excludes from the accreditation requirement x-ray, ultrasound, and fluoroscopy procedures. The law also excludes from the CMS accreditation requirement diagnostic and screening mammography which are subject to quality oversight by the Food and Drug Administration under the Mammography Quality Standards Act.

In order to furnish the TC of advanced diagnostic imaging services for Medicare beneficiaries, suppliers must be accredited by January 1, 2012.

The Centers for Medicare & Medicaid Services (CMS) approved three national accreditation organizations – the American College of Radiology, the Intersocietal Accreditation Commission, and The Joint Commission - to provide accreditation services for suppliers of the TC of advanced diagnostic imaging procedures. The accreditation will apply only to the suppliers of the images themselves, and not to the physician's interpretation of the image. All accreditation organizations have quality standards that address the safety of the equipment as well as the safety of the patients and staff. To obtain additional information about the accreditation process, please contact the accreditation organizations shown below.

American College of Radiology (ACR)
505 9th St. N.W.
Suite 910
Washington, DC 20004
202-223-1670

Intersocietal Accreditation Commission (IAC)
6021 University Boulevard, Suite 500
Ellicott City, MD 21043
800-838-2110

The Joint Commission (TJC)
601 13th Street, NW
Suite 1150 N
Washington, DC 20005
202-783-6655
 

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http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE1007.pdf

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CMS APPROVES THREE NATIONAL ORGANIZATIONS TO

ACCREDIT SUPPLIERS OF ADVANCED IMAGING SERVICES

MRI, CT AND PET SCANS AMONG SERVICES TO BE AFFECTED

The Centers for Medicare & Medicaid Services (CMS) is designating three national accreditation organizations – the American College of Radiology (ACR), the Intersocietal Accreditation Commission (IAC), and The Joint Commission (TJC) - to accredit suppliers furnishing the technical component (TC) of advanced diagnostic imaging procedures.  The accreditation requirement will apply only to the suppliers furnishing the imaging services, and not to the physician’s interpretation of the images.

As required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), all suppliers of the TC of advanced imaging will have to become accredited by an accreditation organization designated by the Secretary of Health and Human Services by Jan. 1, 2012.  The accreditation requirement applies to physicians, non-physician practitioners, and physician and non-physician organizations that are paid for providing the technical component of advanced imaging services under the Medicare Physician Fee Schedule.

MIPPA specifically defines advanced diagnostic imaging procedures as including diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET).  The details of the accreditation organization selection process went through notice and comment rulemaking in the calendar year 2010 Physician Fee Schedule rule.

“While advanced diagnostic imaging procedures can be useful in identifying health problems that might otherwise require surgery, the rapid growth in their use raises important questions of quality and safety,” said Barry Straube, M.D., CMS chief medical officer and director of the CMS Office of Standards and Quality.  “The three organizations that will be accrediting suppliers have the expertise and authority to set a standard of excellence industry-wide.”

To be designated, the accrediting organizations had to demonstrate that they were experienced in the advanced diagnostic imaging area, and that their accreditation requirements met or exceeded the standards set out in MIPPA, including requirements for:

·         Qualifications of non-physician personnel performing the imaging;

·         Qualifications and responsibilities or medical directors and supervising physicians;

·         Procedures to ensure the safety of the individuals furnishing the imaging procedure and of the persons to whom the services are furnished;

·         Procedures to ensure the reliability, clarity, and accuracy of the technical quality of the diagnostic images produced by the supplier;

·         Procedures to assist the beneficiary in obtaining his/her imaging records on request; and

·         Procedures to notify CMS of any changes to the imaging modalities subsequent to the accrediting organization’s decision.

In addition, the accrediting organizations were required to develop a plan for reducing the burden and cost of accreditation to small and rural suppliers.  The accrediting organizations are also required to provide CMS with detailed information about their survey processes.

MIPPA specifically excluded from the accreditation requirement certain imaging services such as x-rays, ultrasound, and fluoroscopy procedures.  The law also excludes from the CMS accreditation requirement diagnostic and screening mammography, which are subject to quality oversight by the Food and Drug Administration under the Mammography Quality Standards Act.

CMS will issue further guidance to suppliers about meeting the accreditation requirements.  CMS plans to undertake a provider education outreach program to ensure that all affected suppliers understand the requirements and are able to comply with them prior to the Jan. 1, 2012, accreditation deadline.

For more information, please see the CMS Web site at: www.cms.hhs.gov/medicareprovidersupenroll .

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On January 28, the Senate approved legislation that will increase the federal debt limit to $1.9 trillion. Included in this legislation was a provision to reinstate "pay-go" rules mandating that Congress must offset any future increased spending with corresponding spending reductions or revenue increases.  This bill also provides Congress a 5 year exemption from these pay-go rules to address the Medicare physician payment cut. However, this provision does not provide any funding. The current freeze on the 2009 Medicare conversion factor is scheduled to expire on Feb. 28. Any solution still requires House and Presidential approval.
 

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The Department of Health and Human Services has published proposed regulations for the National Practitioner Data Bank (NPDB).  The new regulations are intended to incorporate Section 1921 of the Social Security Act, which was enacted as part of the Medicare and Medicaid Patient and Program Protection Act of 1987 (MMPPA). 

These proposed regulations were first published on March 21, 2006. Over the next several weeks we will provide summaries of the major changes. 

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The stalled healthcare reform initiative leaves the Medicare Physician Fee Schedule problem of the Sustainable Growth Rate (SGR) imposed 21.5% reduction as a stand alone separate issue. The physician fee schedule decrease was postponed for 2 months by an Obama addition to a defense approriation bill, with the expectation that a long term solution would be included in the healthcare reform legislation. That looks unlikely now. Below is the AMA lobbying response to that issue.

eVoice^® Alert

Jan. 20, 2010

Keep your patients, your practice at forefront of Congress' decision on SGR

As the U.S. Senate returns to Capitol Hill today—and continues its deliberations on the floor—now is the time to act.

The 21 percent Medicare physician payment cut that had been scheduled to take effect this month has been delayed until March 1, giving us a short window of opportunity. Now is our chance to help permanently repeal Medicare's sustainable growth rate (SGR) formula. Connect with your senators today by calling (800) 833-6354 and tell them to pass legislation to permanently repeal the SGR formula.

Continuing this game of "kick the can" harms the stability and security of the entire Medicare system and the millions of seniors and military families it is intended to serve. That's why the AMA has made it abundantly clear to members of Congress and the White House that the days for Band-Aids are over. Mobilizing grassroots networks across the country, the AMA has begun an aggressive advertising and publicity campaign this month—and developed a new television ad—to make sure patients and likely voters are aware of and can help address this problem.

But senators need to hear directly from you—America's physicians. Call the AMA's toll-free grassroots hotline at (800) 833-6354 today, and please encourage your colleagues to do the same. An AMA physician flier (PDF) can direct them on how they also can help repeal the Medicare SGR formula.

Time is running out. Call for the future of your practice and the patients in your care.

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American Health Lawyers Assocaition has reported:

President Obama Signs into Law a Temporary Fix to Physicians' Medicare Reimbursement
By Jeffrey Moore , Phelps Dunbar LLP

On December 19, 2009, President Barack Obama signed the Department
of Defense Appropriations Act, 2010 (H.R. 3326), into law, which freezes Medicare physician payments for two months, avoiding a 21% payment cut to physicians' Medicare reimbursement scheduled to go into effect on January 1, 2010. The House previously approved H.R. 3326 on December 16, 2009, while the United States Senate passed H.R. 3326 on December 19, 2009.

Because the Department of Defense Appropriations Act, 2010, is only a temporary fix to the Medicare physician payment issue, Congress will be forced to address this payment issue in early 2010, as the Medicare physician payment cuts are set to go back into effect on March 1, 2010.

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To the extent possible and in consideration of possible legislative changes, the Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule, beginning January 1, 2010.  In this regard, CMS has instructed its contractors to hold claims containing services paid under the Medicare Physician Fee Schedule (MPFS) for the first 10 business days of January (January 1 through January 15) for 2010 dates of service. This should have minimum impact on provider cash flow because, under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt.  Meanwhile, all claims for services delivered on or before December 31, 2009, will be processed and paid under normal procedures.

After 10 business days, contractors will begin releasing held claims into processing under the fee schedule which implements current law.  This, of course, could result in claims being processed with the negative 21.2percent update.  If a new law is enacted which changes the negative update effective January 1, CMS will correctly process claims under the new law and, if necessary, CMS is prepared to automatically reprocess most of those claims which have already been processed at the lower rate. 

Under the Medicare statute, Medicare payments to physicians and other affected providers are based upon the lesser of the actual charge or the MPFS amount.   Providers who submit charges that are greater than the negative 2010 MPFS will automatically have their claims reprocessed.  Physicians who submit charges that are equal to or less than the 2010 MPFS amount will need to request an adjustment.  Submitted charges on claims cannot be altered without a request from the physician/provider.

To the extent possible, providers may hold claims in-house until it becomes clearer as to whether new legislation will be enacted or until cash flow becomes problematic.  This will reduce the need for providers to reconcile two payments (i.e., the initial claim and the reprocessed claim), and it will simplify provider billings of beneficiary coinsurance and payment calculations for payers which are secondary to Medicare.

CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to March 17, 2010– therefore, the enrollment period now runs from November 13, 2009, through March 17, 2010.

The effective date for any Participation status change during the extension, however, remains January 1, 2010, and will be in force for the entire year.

Contractors will accept and process any Participation elections or withdrawals, made during the extended enrollment period that are received or post-marked on or before March 17, 2010.

In addition, be on the alert for more information about other legislative provisions which may affect you.

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NYT reports that there are numerous hidden benefits in the healthcare reform bill designed to "attract" support from various Senators.

http://www.nytimes.com/2009/12/21/health/policy/21healthcare.html?_r=2&pagewanted=2&partner=rss&emc=rss

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This article pertains to Change Request (CR) 6740, which alerts physicians and non-physician practitioners that effective January 1, 2010, the Current Procedural Terminology (CPT) consultation codes (ranges 99241-99245 and 99251-99255) are no longer recognized for Medicare Part B payment. Effective for services furnished on or after January 1, 2010, physicians and non-physician practitioners should code a patient evaluation and management visit with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. For more information, please view the article located at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf on the CMS website.

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Effective January 1, 2010, CPT Consultation Codes ranges 99241-99245 and 99251-99255 will no longer be recognized for Medicare Part B Payment. For services furnished after January 1, 2010, physicians and non-physician practitioners should code patient evaluation and management visits with E/M codes that represent where the visit occurs and identifies the complexity. CMS has published MLN Matters Article No. MM6740 for guidance on the subject. It deals with the following:

• Section of level of evaluation and management services
• Payment for hospital observation services
• Payment for initial hospital care services
• Consultation services
• Emergency department visits
• Nursing facility services
• Prolonged services with direct fact to fact patient contact

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CMS Finalizes Supervision Requirements For Hospital Outpatient Services 

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CMS has issued MAC instructions for processing purchased services. Denials are keyed to the answer to question 20 on CMS-1500 (or ANSI X12 837P – line level PS1), which is the question regarding “Outside Lab.”

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CMS  has issued the final rule for the 2010 Physician Fee Schedule. Among other items, it implements the 21.5% reduction (pending Congressional intervention of course) and eliminates consult billing while enhancing E&M WRVUs. Link to text below. http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3539&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

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At this point, there are three comprehensive healthcare reform bills passed by key United States Congressional Committees, i.e. the Senate Finance Committee, the Senate Health, Education, Labor and Pensions (HELP) Committee, and a consortium of House committees, referred to as the House Tri-Committee, consisting of the Energy and Commerce, Ways and Means, and Education and Labor Committees.

The Med Law Blog will select a key issue of healthcare reform on a weekly basis and attempt to summarize that for the readers. All of the bills include provisions dealing with the following issues:

1.                  Requiring insurance coverage for all Americans who apply (Guaranteed Issue), prohibiting health plans from denying coverage based upon preexisting conditions, and prohibiting premium underwriting for certain conditions;

2.                  Creating health insurance exchanges to provide better access to health insurance coverage;

3.                  Establishing essential benefits standards for health insurance (Minimum Coverage);

4.                  Providing financial subsidies for people who cannot afford health insurance premiums;

5.                  Requiring all individuals to have health insurance (Mandated or Mandatory Coverage); and

6.                  Requiring employers to share the responsibility for health insurance costs (Employer Pay or Play).

An item that is not getting much coverage in the press is provisions in the Senate Finance Committee requiring Physician Transparency and Disclosure. Section 4101 of the Senate Finance Committee Healthcare Reform Bill will require applicable manufacturers and distributors to report payments to physicians and physician ownership in those companies. These provisions will become effective for the year 2011, and require report within 90 days of the close of each calendar year, therefore beginning March 31, 2012. The reports will require the name, business address, physician specialty, NPI number, and the amount, date, description and purposes of any payments to physicians, and the amount invested in the fair market value of any physician investment in those companies.

Section 4102, another physician reform provision, will require certain disclosure statements by physicians providing certain self-referred imaging services. Effective January 1, 2010, physicians providing MRI, CT, PET and any other designated health service specified in Section (h)(6)(D) of the Physicians Self-Referral Statute (i.e. the radiology section), must provide individuals with a written list of supplies who furnish such services in the area in which the individual resides. 

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The AMA has predicted that the proposed Medicare SGR (sustainable growth rate) physician fee schedule decrease will reduce physician Medicare participation in 22 states.  Log onto the Medicare Payment Action Kit and see the predicted impact in your state.

Click here for the Medicare Payment Action Kit.

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Urgent: Call your senators and urge support of legislation repealing SGR

The Senate is scheduled to begin consideration of S. 1776, the “Medicare Physicians Fairness Act of 2009,” on Monday afternoon, Oct. 19. This just-introduced legislation eliminates the 21.5 percent cut in Medicare physician reimbursement for 2010 and repeals the sustainable growth rate (SGR) formula. The Senate leadership has indicated that enactment of this bill will set the foundation for creating a new Medicare payment update system. This will be the first in a series of votes next week before the final bill can be sent to the House.

The Medical Group Management Association has partnered with the American Medical Association to use its toll-free number to focus the collective grassroots efforts of both organizations. It is imperative that you, your physicians and staff call 800.833.6354 and urge support for S. 1776, the “Medicare Physician Fairness Act of 2009”.
 

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Prior to passage of the Medicare Modernization Act of 2003 (MMA), CMS was not restricted in recouping overpayments, despite the provider's ongoing appeal rights.

Finally, as of November 16, 2009, CMS will implement new rules required by MMA to restrict immediate recoupment. Section 1892(f) of the Social Security Act prohibits recoupment of overpayment during a supplier or provider appeal to a Qualified Independent Contractor (QIC), and CMS will also stop recoupment during the first level of appeal (redetermination) upon a timely request.

However, the new rules also allow the assessment of interest dating back to the original overpayment notification.

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This is just a reminder of the effective date for certain new Stark Rules:

1.         CMS prohibits percentage formulae conjunction with space on equipment leases, fair market value exception transactions and indirect compensation effective October 1, 2009.

2.         Per click leases are prohibited effective October 1, 2009.

3.         "Under arrangement" relationships have been changed because the definition of "entity" will, as of October 1, 2009 include both the billing provider and the provider who actually performed the service. Therefore, since the "in-office ancillary service" exception would not apply, these arrangements may no longer comply with existing Stark exceptions.

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 http://www.magnetmail.net/actions/email_web_version.cfm?recipient_id=89011577&message_id=825692&user_id=MGMA

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The Joint Commission has released a revised draft of Hospital Accreditation Standard MS.1.20, which was first proposed in June 2007 and intended to establish a balance of power between hospital administration and hospital medical staffs. Although originally scheduled to become effective January 1, 2009, the controversy and uproar accompanying the proposals in 2007 were so vehement that the Joint Commission withdrew MS.1.20, appointed a task force to review the concept, and replaced it with MS.01.01.01. The Allegheny County Medical Society published an article describing the development of MS.1.20 in its September 2008 Bulletin (“MS.1.20: Opportunity to Restore Medical Staff Governance and Establish Neutral Peer Review,” p. 424, available at www.acms.org). You can view a complete copy of the MS.01.01.01 working draft at www.medlawblog.com.

Now, MS.01.01.01 will replace MS.1.20 in attempting to establish this balance of power by proposing specific performance criteria for hospital medical staffs in three areas:

1.         medical staff bylaw’s content and approval process;

2.         medical staff governance; and

3.         credentialing, peer review and due process.

From a practical viewpoint, MS.01.01.01 is not drastically different from MS.1.20; some have said that the most significant change is the name. The purpose of this article is not to discuss the fine points of MS.01.01.01, but to remind and emphasize to physicians and medical staffs that the bylaw amendment process created by this new standard will require virtually every hospital to revisit and probably revise medical staff bylaws and procedures, and will therefore present a unique opportunity for physicians to define the purpose and authority of the organized medical staff. Some will view this as an opportunity to reestablish the intended function of medical staffs, while others may view this as the same opportunity to further concentrate the authority within hospital administration.

The structure of MS.01.01.01 is very similar to the structure of MS.1.20 and continues to operate in the three critical areas listed above.

Medical Staff Bylaws

The standard will define the composition of medical staff, the voting members of the medical staff and quorum requirements. The standard will require a process that prohibits unilateral amendment of the medical staff bylaws by either the medical staff or the hospital governing body. This process, which prohibits unilateral amendments, will make it absolutely crucial that the physicians “get it right now,” because future changes will not be possible without mutual agreement. This is your chance to define the playing field if, in fact, you believe it has become tilted.

Medical Staff Governance

Based largely on complaints from organized medicine, the Joint Commission perceives that existing governance structures concentrated too much power with the hospital administration and the Medical Executive Committee (MEC), creating entrenched physician leadership appointed by the hospital, either through employment or appointment to medical staff positions that—by definition in the bylaws—were members of the MEC. In fairness, I must note that some observers attribute this entrenchment less to the design of hospital administration and more to that law of nature stating that nature abhors a vacuum, with hospital affiliated physician leadership filling the void created by the apathy of the independent members of the medical staff. The standard will now mandate a process which:

(a)        defines the composition and authority of the MEC,

(b)        provides an avenue of direct access for the medical staff to the governing body when medical staff initiatives are blocked by the MEC, and

(c)        provides an agreed process for the election and removal of officers.

Credentialing and Due Process

Both MS.1.20 and MS.01.01.01 require a credentialing and fair hearing process in which the due process requirements are contained in the bylaws; that means they are subject to the “no unilateral amendment” restriction. The bylaws must contain standards for:
(a) appointment and reappointment of medical staff membership and clinical privileges, (b) suspension of clinical privileges and memberships, (c) the process for both investigation and fair hearings, and (d) the composition of the hearing committee.

Regardless of the detail and complexity of the fair hearing process, the most serious criticism of the investigation and hearing process is that, once started, it is a stacked deck against the target physician because of the rules of confidentiality that are perceived to comply to the investigative and the hearing processes. Setting aside the argument of whether state law provides the level of confidentiality often asserted by the hospitals, you must decide now whether that process will be codified in the medical staff bylaws.

As I suggested in the September 2008 article, I think the key to assuring fairness in the fair hearing process is not to seek to better or more rigidly defined rules, but to provide a system that assures fairness. I suggest that fairness is assured, not by rules, but by truth. I think it is a valid presumption that secret agendas, politics and personal grudges will be eliminated when the investigation and fair hearing are conducted in a transparent manner. I further believe that the best way to assure the transparency of the process is to both define the composition of the investigative and fair hearing committees and to allow the target physician to appoint either a voting member or an observer to those committees. This sole physician representative, whether voting or nonvoting, will not have the voting power to dictate the outcome of either the investigation or the fair hearing, but the physician representative will serve as a witness to the fairness of the process.

Conclusion

The American Medical Association (AMA) is represented on the Joint Commission MS.01.01.0 Task Force and is both reportedly and apparently in general agreement with the new standards. Assuming MS.01.01.01 is implemented substantially as proposed, physicians should actively participate in this unique opportunity to revisit medical staff structures in the hospitals at which they practice.

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The Centers for Medicare & Medicaid Services (CMS) reminds Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers enrolled with the National Supplier Clearinghouse (NSC) they are required to obtain accreditation by September 30, 2009. Without accreditation, DMEPOS suppliers' billing privileges will be revoked on or after October 1, 2009. Further, without accreditation, DMEPOS suppliers will not be eligible to participate in the Route 1 Rebid of the Medicare DMEPOS competitive bidding program.

http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0925.pdf

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• Replacing the scheduled 21.5 percent reduction in 2010 Medicare physician payments with a 0.5 percent increase;
• Requiring that all eligible health professionals participate in Medicare’s Physician Quality Reporting Initiative by 2011;
• Creating a 10 percent bonus payment for primary-care and general-surgery providers who practice in health professional shortage areas. Funding for this five-year bonus, to start in 2011, is offset by reducing payments for all other services;
• Establishing the CMS Innovation Center, which would be required to test and evaluate patient-centered delivery and payment models, including payment incentives for physicians if they are deemed to appropriately order high-cost imaging services. The center would be exempt from budget-neutrality requirements for an initial testing period and would be required to consult outside experts and stakeholders;
• Increasing the imaging utilization rate assumption for advanced imaging equipment from 50 percent to 65 percent for 2010 through 2013, which will result in lower practice-expense payments for the technical component of services using this equipment;
• Creating a nonelected Medicare Commission to develop and submit proposals to Congress that extend Medicare solvency;
• Simplifying healthcare administration by "accelerating the development, adoption and implementation of standard, consensus-based operating rules for four HIPAA* transactions: eligibility verification, claims status, payment/electronic funds transfer and remittance advice";
• Expanding the Medicare physician feedback program in 2012 and, beginning in 2015, reduce payment by 5 percent if an aggregation of a physician’s resource use is at or above the 90th percentile of national utilization;
• Allowing groups of providers, beginning 2012, to form accountable care organizations, improve quality of care and share in half of the savings achieved over a three-year period;
• Requiring all individuals to obtain health insurance by 2013;
• Requiring all employers with more than 50 full-time employees to pay a fee if they don’t offer health insurance, beginning in 2013;
• Creating, no later than 2012 and expiring at the end of 2015, the Consumer Operated and Oriented Plan (CO-OP), comprising "nonprofit, member-run health insurance companies";
• Establishing state-based health insurance exchanges beginning in 2010; and
• Providing assistance to Medicare Part D beneficiaries when they reach the "doughnut hole" in benefit coverage

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Senate Finance Committee Chairman Max Baucus (D-MT) has introduced the America's Healthy Future Act of 2009. It is scheduled for a full Committee markup on September 22, where Democrats hope to obtain more Republican support.

The bill offers initiatives that will help all Americans meet the requirement of having health coverage, such as the expansion of Medicaid and the creation of state co-operatives to provide consumers with options outside of private insurers. Employers would not be required to provide coverage to workers; however, employers who have 50 or more workers and do not offer coverage by 2013 will have to reimburse the government for every full-time worker receiving tax benefits through the government's health care exchange system.

The $856 billion to fund coverage will be obtained through initiatives such as reductions in Medicare and Medicaid spending; taxes on insurers offering high-cost, high-premium health plans; and fees on providers such as device manufacturers.

The bill offers various changes to the Medicare and Medicaid systems that are intended to increase efficiency, lower costs, and maintain a level of quality and care.

Health Care Quality Improvements

The bill directs the Secretary of Health and Human Services (HHS) to create a national strategic plan for improving the quality of care. The strategy will focus on goals such as reducing medical errors, maintaining hospital infection-control, addressing preventable hospital admissions, and an overall look at increasing efficiency and quality in the healthcare system.

In order to prioritize these strategies, the Secretary of HHS will seek the input of various stakeholders in the healthcare system including representatives of hospitals, physicians, credentialing and accrediting bodies, allied health professions, health plans, and other industries.


A copy of the Chairman's mark-up can be found here.

Source: NAMSS Blog
 

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The new consignment closet billing and compliance rules reported in the Med Law Blog on August 17, 2009 and intended to be effective on September 8, 2009 have been delayed until March 1, 2010 by Transmittal 300. 

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

CMS has issued Compliance Standards for Consignment Closets and Stock and Bill Arrangements. The purpose of Change Request 6528 was to define and prohibit certain arrangements where an enrolled supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) maintains inventory at a practice location which is not owned by the enrolled DMEPOS supplier, but rather owned by a physician, non-physician practitioner or other healthcare professional, which arrangements are sometimes referred to as "consignment closets" or "stock and bill arrangements."

The CMS announcement does not prohibit these arrangements, but indicates that they must comply with the following requirements:

1.         The title to the DMEPOS shall be transferred to the enrolled physician, non-physician practitioner or practice at the time the DMEPOS is furnished to the beneficiaries;

2.         The physician or non-physician practitioner shall bill for the DMEPOS supplies and services using their own enrolled DMEPOS billing number;

3.         All services provided to a Medicare beneficiary concerning fitting or use of the DMEPOS shall be performed by individuals being paid by the physician or non-physician practitioner's practice, and not by any other DMEPOS supplier;

4.         The beneficiary shall be advised that if he or she has a problem or question regarding the DMEPOS, then the beneficiary should contact the physician or non-physician practitioner and not the DMEPOS supplier who placed the DMEPOS at the physician or non-physician practitioner's practice; and

5.         The National Supplier Clearinghouse Medicare Administrative Contractor (NSC-MAC) shall verify that two or more enrolled DMEPOS suppliers shall not be enrolled and/or located at the same practice location and that each practice location shall have a separate entrance and separate post office address.

In addition to these requirements, the Anti-Kickback and Stark rules would still apply to the financial arrangement between the DMEPOS supplier and the physician.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

According to Bloomberg News it takes six lobbyists per lawmaker; on August 14, 2006, Bloomberg reported that $3,300 lobbyists have lined up to work on health reform. "That six lobbyists for each of the 535 members of the House and Senate, according to Senate records, and three times the number of people registered to lobby on defense." 

According to Bloomberg, the group spent approximately $263.4 million lobbying during the first six months of 2009. 

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The Office of Inspector General of the Department of Health and Human Services has just released a report examining problems with incident to billing by physicians, and seeking restrictions on the use of that billing arrangement. The report, titled "Prevalence and Qualifications of Non-Physicians Who Performed Medicare Physician Services" was posed by the OIG on August 6, 2009. The OIG believes that incident to services may be vulnerable to over-utilization and may put beneficiaries at risk of receiving services that do not meet professionally recognized standards of care. For the audit, OIG reviewed the data for the first quarter of 2007 and identified all the days during which Medicare allowed services for physicians in a single day that exceeded 24 hours of physician work time, which would be measured by RVUs. They selected 250 of these "physician day combinations" and requested that the physicians identify who performed each service that Medicare allowed on those selected days, using a variety of audit and physician contact techniques. OIG concluded that unqualified non-physicians performed 21% of the services that physicians did not perform personally.

OIG recommended as follows:

1. CMS should see revisions to the incident to rule and require that physicians who do not personally perform the services they bill to Medicare ensure that no persons do perform such services except non-physicians who have the necessary training, certification, and/or licensure in accordance with state laws and regulations.

2. CMS should require physicians who bill incident to services to identify the services on their Medicare claim forms by using the service code modifier.

3. CMS should specifically address claims for services detected and billed by physicians but performed by non-physicians that were "not incident to" and were for rehabilitation therapy services performed by non-physicians without the training of a therapist.
 

| Posted By Michael Cassidy In Compliance , Medicare & Reimbursement | 0 Comments | Permalink

A bill introduced into the U.S. House of Representatives in June that would close the in-office ancillary service exemption for MRI, CT and PET allowed under the Start anti-self-referral law may be added to a healthcare reform package currently under consideration in Congress.

Rep. Jackie Speier (D-CA) introduced HR 2962, or the Integrity in Medicare Advanced Diagnostic Imaging Act of 2009, as a standalone bill on June 19. Now, Rep. Anthony Weiner (D-NY) and Rep. Bruce Braley (D-IA), members of the House Energy and Commerce Committee, are planning to offer Speier's bill as an amendment to the healthcare reform package currently being debated in their committee, which is one of three House committees debating the legislation, according to the American College of Radiology (ACR) of Reston, VA.

In a July 20 letter to ACR membership, ACR chair Dr. James Thrall urged radiologists to register their support of the amendment with Congress.

"Please be aware that passage of this amendment will be extremely difficult," Thrall wrote. "There is no issue in medicine that is as divisive as ownership within a physician's office. We can expect the full force of organized medicine to fight [it]."

Even if the self-referral amendment passes, Speaker of the House Nancy Pelosi (D-CA) and House leadership could choose not to hold a floor vote on the bill if too many amendments have been added to it, Thrall said.

"They could instead schedule a floor vote on the healthcare bill from the Ways and Means Committee, whose Health Subcommittee Chairman, Congressman Pete Stark [D-CA], opposes amending the Stark law," Thrall wrote. "If that happens, the ability to offer a self-referral amendment to that bill on the House floor is doubtful."

In an action alert, also on July 20, the ACR encouraged its members to recommend that their congressional representative contact Reps. Weiner and Braley and offer support for the amendment. Reported by AuntMinnie.com, 07/21/09.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Reprinted from Physician News Briefs

By Ceci Connolly and Michael D. Shear

Washington Post Staff Writer
Wednesday, July 15, 2009; 2:42 PM

After a key Senate committee pushed forward with an overhaul of the nation's health care system, President Obama today sought to reassure Americans satisfied with their current health insurance that the plans passed by Congress in the last two days are a step toward more efficient care.

"Let me be clear: If you like your doctor or health care provider, you can keep them. If you like your health care plan, you can keep that too," he said in a Rose Garden event. "But here's what else reform will mean for you: you'll save money. If you lose your job, change your job, or start a new business, you'll still be able to find quality health insurance you can afford."

Criticism of the Democratic health reform efforts has increasingly centered on the threat to health services for people who already have insurance. That criticism has forced the White House and congressional leaders to revise their message to sell those who are satisfied with the health care they already receive.

Surrounded by nurses today, Obama insisted that no one should be satisfied with the current system.

"Health insurance premiums have risen three times faster than wages. Deductibles and out-of-pocket costs are skyrocketing. And every single day we wait to act, thousands of Americans lose their insurance, some turning to nurses in the emergency room as their only recourse," he said. "So make no mistake: The status quo on health care is not an option for the United States of America."

The president praised the Senate's passage this morning of its health reform bill, calling it the result of "unyielding passion and inspiration provided by Senator Edward M. Kennedy, and the bold leadership of Senator Chris Dodd."

He vowed to reject the "naysayers and cynics" who say the government can't finish health care reform.

"We're going to get this done. These nurses are on board. The American people are on board," he said. "It's up to us now."

The Senate's health committee approved legislation earlier today that, if enacted, would vastly expand health insurance coverage in America and tighten restrictions on the way the industry operates.

The 13-10, party-line vote gives Obama an important victory in what promises to be a lengthy and contentious drive to enact a comprehensive health-care overhaul this year.

The bill, named "Quality, Affordable Health Coverage for All Americans," would create a controversial new government-sponsored health program that would compete with the private sector. It requires that every American carry health insurance and provides generous discounts to people who cannot afford a plan. Millions more Americans would also be eligible for Medicaid, the joint federal-state health program for the poor.

In a statement issued before the Rose Garden even, Obama said the proposal would "bring down costs, expand coverage, and increase choice." The committee vote, he added, "should . . . provide the urgency for both the House and Senate to finish their critical work on health reform before the August recess."

Under the legislation, most businesses would be required to offer insurance to workers or pay a $750 annual fee per full-time employee. Companies with fewer than 25 employees would be exempt from the mandate, which faces fierce opposition by the Chamber of Commerce and National Federation of Independent Businesses.

Sen. Mike Enzi, (R-Wyo.), the highest-ranking Republican on the committee, delivered a bitter speech decrying the "partisan bill" as one that increases the deficit, "kills jobs and cuts wages."

More than anything, the vote this morning by the panel, formally named the Senate Health, Education, Labor and Pensions Committee, gives Democrats a bit of forward motion in a legislative effort that has sputtered in recent weeks.

"Health care reform is now one step closer to reality," said Senate Majority Leader Harry M. Reid (D-Nev.). He added, "This action is a positive step toward quality and affordable health care that Americans need and deserve."

The Senate Finance Committee, which has jurisdiction over the financing of health reform, has fallen behind its schedule as Chairman Max Baucus (D-Mont.) searches for bipartisan consensus on the politically difficult issue.

Three members of the panel scheduled a news conference for this afternoon to put pressure on the insurance industry to contribute up to $100 billion over the next decade toward the cost of expanded health coverage. House Democrats have announced a plan that would force the richest 2 million U.S. taxpayers to shoulder much of the cost of an expansion of the nation's health-care system, by imposing a surtax of as much as 5.4 percent on income above $350,000 a year.

Also today, the Democratic Party's Organizing for America released new television ads touting the urgent need for health reform. The 30-second spot, dubbed "It's Time," features average Americans who say they have been negatively affected by the current system.

Democratic Sen. Christopher J. Dodd (Conn.) is filling in as chairman of the health committee for the ailing Edward M. Kennedy (D-Mass.), a longtime proponent of health-care reform who has devoted decades to the cause of universal health coverage.

The absent senator, who is battling terminal brain cancer, issued an emotional statement to the committee from his sickbed, recalling that his two slain brothers announced their candidacies for the presidency in the Russell Caucus Room, where today's vote took place.

"As you vote today, know that I am with you in heart and mind and soul, and I wish very much that I could be with you in person," Kennedy said. "The American people are on the march once more, and they will not stop until quality, affordable health care is the birthright of every American. And we are with them every step of the way."

Dodd told his colleagues that Kennedy, a close friend, is "ecstatic about our efforts here."

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

In the proposed changes to the Hospital Outpatient Prospective Payment System, CMS is proposing to change the physician supervision requirements applicable to hospital outpatient services described in the 2009 Hospital Outpatient Prospective Payment System (OPPS) final rule. In the proposed rulemaking release, issued July 1, 2009, CMS indicates that physician supervision requirements requiring "direct supervision" will be met so long as the supervising physician is physically present on the hospital campus and immediately available to offer assistance during the service. This is similar to the "incident to" direct supervision requirement, but the question will continue to be the definition of "Hospital Campus" when combined with "immediately available." CMS also indicates that non-physician practitioners can satisfy supervision requirements consistent with their state-defined scope of practice.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

This proposed rule would update the revised Medicare Ambulatory Surgical Center (ASC) Payment System to implement applicable statutory requirements and changes arising from CMS's continued experience with administrating that system. The proposed rule sets forth applicable relative payment weights and amounts for services furnished in ASCs, the specific HCPCS codes to which these proposed changes would apply, and other pertinent rates setting information for the CY 2010 ASC system. 

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The Centers for Medicare and Medicaid services released its proposed Medicare Physician Fee Schedule for 2010. The press release and the entire 1,200 fee schedule are attached. CMS is projecting a 21.5% physician fee schedule decrease based upon the application of the sustainable growth rate (SGR) formula. Of course, Congress has intervened in each of the last five or six years to override the automatic fee schedule revision based upon SGR, which has been uniformly negative for the last six years. No one expects a 21.5% decrease! 

CMS highlights several key areas in the press release:

1.         Elimination of consultation services;

2.         CMS proposes to eliminate consult payments to specialists and replace them with the application E&M Code to reduce payments.

3.         Initial Preventative Physician Exam (IPPE):

            CMS proposes to increase the payment for the "Welcome to Medicare" visit to be more in line with payment rates for higher complexity services.

4.         Chronic disease:

            The new fee schedule proposes to implement new Medicare benefit categories for cardiac and pulmonary rehabilitation services, and chronic kidney disease education.

5.         Imaging accredation in physician office: CMS has resuscitated the proposal that imaging services and physician offices must be subject to the same quality or standards or accredation applicable to independent diagnostic testing facilities. The accreditation requirement would be effective as of January 1, 2012 and would apply to mobile units, physician offices, and independent diagnostic testing facilities, but would only apply to the technical component aspect and not to the physician who interprets them. The general accounting office (GAO) has stated "Spending on advanced imaging services, such as computed tomography (CT), magnetic residents imaging (MRI) and positron emissions tomography (PET) is growing almost twice as fast as the spending on other types of imaging services, and is a significant contributor to the rapid growth in health care pending in recent years, but there is little administrative oversight to ensure the quality of care." I wonder how much CT, MRI and PET is actually being provided in physician offices.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

President Obama signed the Fraud Enforcement and Recovery Act of 2009 on May 28, 2009, which is the effective date of the Act. 

I am attaching a compared version identifying all the changes, but I would like to direct your attention to what I believe is the most significant change impacting typical healthcare providers.

Retentions of Overpayments. 

This has always been a troublesome issue, and it has been unclear whether the False Claim Act, and its significant civil money penalties, would be applicable to overpayments not arising out of obviously false claims. FERA resolves this doubt by defining a false claim as "knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to the government." This situation is often referred to as a "reverse false claim," because no false claim has been filed, but obvious overpayments exist. The language still has subjective elements, i.e. "knowingly conceals" or "knowingly and improperly avoids or decreases," and that raises questions regarding obligations to audit, extrapolate, refund, etc. 

We can say at this point that healthcare providers have been put on notice that the Government intends reverse false claims or retention of overpayments to be included within the scope of the False Claims Act. 

The civil penalties associated with the false claims remain at $5,000 to $10,000 per claim, plus treble damages for the unpaid amounts.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The Centers for Medicare & Medicaid Services (CMS) has become aware of a scam where perpetrators are sending faxes to physician offices posing as the Medicare carrier or Medicare Administrative Contractor (MAC).  The fax instructs physician staff to respond to a questionnaire to provide an account information update within 48 hours in order to prevent a gap in Medicare payments.  The fax may have the CMS logo and/or the contractor logo to enhance the appearance of authenticity.

Medicare FFS providers, including physicians, non-physician practitioners, should be wary of this type of request.  If you receive a request for information in the manner described above, please check with your contractor before submitting any information.  Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov website found at http://www.cms.hhs.gov/MLNGenInfo/ or http://www.cms.hhs.gov/MedicareProviderSupEnroll .

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Highmark Medicare Services will be hosting a teleconference on May 15, 2009 at 12:00 p.m. Eastern to discuss the billing of time units for physical and occupational therapy services. The teleconference may reference issues such as CMS Online Manual, Pub. 100-2, Chapter 15, Sections 220 and 230; Change Request CR6321; Frequently Asked Questions; Social Security Act, Section 1862(a)(1)(A) of the Social Security Act, Exclusions from Coverage; and PT/OT modalities is Local Coverage Determination (LCD) L27513, Physical Medicine and Rehabilitation Services, PT and OT. To participate in the teleconference, the dial-in number is 1-888-276-8689 and the Access Code is 487794. Highmark Medicare Services has indicated that the teleconference does have limited capacity.

| Posted By Paul Welk In Medicare & Reimbursement | 0 Comments | Permalink

In a potentially striking blow to the Pennsylvania Medicaid (Medical Assistance)Third Party Liability (“TPL”) collection practices, the Honorable Joy Flowers Conti, Judge for the United States District Court for the Western District of Pennsylvania, issued a Memorandum Opinion dated March 25, 2009 in the Tristani v. Richman et al. proposed class action. PAWD Civil Action No. 06-694. The Tristani Opinion fills the gap left by the United States Supreme Court’s Ahlborn Decision regarding a presumed “exception” in Federal Law permitting State Medicaid Agencies to effectuate mandatory TPL recovery through the imposition of liens on Medicaid recipients’ personal injury proceeds. 
 

The United States Supreme Court’s Ahlborn Decision "assumed" that Federal Law created an exception to the Anti-Lien and Anti-Recovery provisions because the parties therein had stipulated as much. The Tristani Opinion squarely addresses validity of such assumed exception, which the United State Supreme Court expressly noted it was forced to “leave for another day”. 547 U.S. 268, 284 n. 13 (2006)
 

In an opinion as dense as any law school hypothetical wrought with interpretations on due process, civil procedure, qualified immunity, takings and interpretations of Congressional intent, Tristani reasons that the Federal Anti-Lien and Anti-Recovery provisions, 42 U.S.C. §§1396p(a)(1) and 1396p(b)(1), preempt Pennsylvania State Law at 62 Pa. C.S. §§ 1409, et seq. under the Supremacy Clause of the United States Constitution inasmuch as Pennsylvania’s TPL statute permits liens on the personal injury actions/proceeds of Medicaid recipients.

Finding the Federal Anti-Lien and Anti-Recovery provisions to be unambiguous, the District Court gave no deference to the interpretations of the Department of Health and Human Services on which the State Medicaid Agency and Pennsylvania General Assembly ostensibly relied in passing the Pennsylvania TPL statute. The District Court found that Federal Law requires State Medicaid Agencies to commence direct actions against liable third parties for the cost of Medicaid to recipients, stating in no uncertain terms that the Pennsylvania Department of Public Welfare’s “free ride” was over. 
 

The District Court noted, however , that Federal Law did not leave State Medicaid Agencies without recourse. The Court reasoned that the Pennsylvania TPL statutory scheme permits the Department of Public Welfare to assert its own interests in personal injury actions against third party tortfeasors without violating the Federal Anti-lien and Anti-Recovery Provisions. Indeed, while the Court found that intervention in, rather than “liening”, settlement actions was the proper method of recovery, it also found that Pennsylvania’s statutory default calculation of 50% for “unallocated” settlements was a valid amount of recovery. 
 
The Tristani action also asked the District Court to, inter alia, determine whether Pa. C.S. § 1409(b)(7)(iii) contravenes Section 1396k(b).   Finding neither named plaintiff able to establish a cause of action in this regard, the Court left whether Pennsylvania’s statutory authorization for the collection of managed care organization expenditures, as opposed to capitation payments, open for another day.
 

The Tristani Opinion shakes the traditional method of TPL recover y in Pennsylvania to its core, and is likely to ultimately have long reaching effects for TPL recovery nationwide. A review of the docket reveals that steps are already in place to appeal the Opinion, and that some uncertainly exists as to the force of the Opinion inasmuch as it lacks the force of an "order".

Pending review of the Tristani Opinion and its effect, the State Medicaid Agency and Plaintiffs’
Counsel, in need of recouping monies for the fiscally strained Medicaid Program and for their wronged clients, respectively, may find themselves in a precarious position with tenuous options in situations which unfortunately demand action.    

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Highmark has issued four new local coverage determinations, as follows:

• Intraoperative Neurophysiological Testing
• Sleep Disorders Testing
• Posterior Tibial Nerve Stimulation (PTN)
• Electromyography (EMG) and Nerve Conduction Studies

The following is the link of the full text of those LCDs: http://www.highmarkmedicareservices.com/policy/draft-status.html

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The 2009 Medicare Physician Fee Schedule made some changes regarding physician enrollment. The most significant change is the elimination of retroactive billing. Prior to the 2009 changes, Medicare permitted retroactive billing for up to 27 months following the effective date of a physician's Medicare enrollment, to allow physicians to bill for services that they provided while the application was pending. Although there were usually significant delays in physician approval, mostly due to simple time delays in a very inefficient system, that rarely reached 27 months.

The retroactive billing date has now been almost totally eliminated. Rather than 27 months, the physician is now permitted to bill as of the date of the application that was approved (which is interpreted to mean the last version of the application after any additional information submitted pursuant to CMS's request) or the date that services are actually provided, whichever is later. There are two exceptions allowing retroactive billing for just 30 days if the application could not be submitted for some good reason and the physician satisfied all requirements or 90 days in the event of a presidential declaration of disaster. 

A similar change has been made regarding the revocation of participation. In the event of certain enumerated serious events, i.e. conviction of the felony, the suspension/revocation of a license, or program debarment, in which case the billing rights are terminated immediately.

In all other termination circumstances, the physician will have 60 days to bill for services that were provided prior to the termination date, rather than the 27 months that was previously available.

Finally, physicians now must report changes in the ownership of the enrolled entity or the practice address of the enrolled entity, within 30 days of the change.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

On March 3, 2009, CMS published the "Decision Memo for Sleep Testing for Obstructive Sleep Apnea." A summary of the decision follows:

"CMS finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary's treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.

Therefore:

      1.   Type I Polysomnography (PSG) is covered when used to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab facility.

      2.   A Type II or a Type III sleep testing devise is covered when used to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

      3.   A Type IV sleep testing devise measuring three or more channels, one of which is airflow, is covered when used to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

      4.   A sleep testing device measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone is covered when used to aid the diagnosis of obstructive sleep apnea (OSA) if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility."

Check out the complete decision memo and you can read a detailed explanation of sleep testing issues in the post "Medicare to Cover Sleep Disorder Treatments" in the PA Elder, the State and Fiduciary Law Blog.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

CMS recently published a resource reference listing the internet resources available for fraud and abuse research and reference. Below is a link to the Medicare Learning Network publication and direct links to the fraud and abuse web resources cited therein.

Medicare Learning Network

http://www.cms.hhs.gov/MLNProducts/downloads/Fraud_and_Abuse.pdf

OIG Listserv

http://www.oig.hhs.gov/mailinglist.asp

CMS Website

http://www.cms.hhs.gov/

CMS Mailing Lists

http://www.cms.hhs.gov/AboutWebsite/EmailUpdates/list.asp

Anti-Kickback Statute

http://oig.hhs.gov/fraud.asp

Physician Self-Referral

http://www.cms.hhs.gov/PhysicianSelfReferral/

OIG AOs

http://oig.hhs.gov/fraud/advisoryopinions.asp

CMS AOs

http://www.cms.hhs.gov/PhysicianSelfReferral/07_advisory_opinions.asp#TopOfPage

EPLS

http://www..epls.gov/

Medicare Contractor Information

http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

CMS has aggregated the various web pages pertaining to Medicare fee-for-service providers.  The link to that website is included below and is also included separately in the links section on the title page of the Blog. 

http://www.cms.hhs.gov/MLNProducts/Downloads/FFS_Provider_Web_Pages.pdf

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Medicare has announced the January 2009 ASC payment updates. It covers new surgical procedures, new and updated codes for drugs and biologicals, and additional services. The link is attached. 

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6323.pdf

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

As required by Section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), CMS is replacing its current claims payment contractors, previously known as Fiscal Intermediaries or Carriers, with new contract entities called Medicare Administrative Contractors (MACs). 

The responsibility for paying Medicare Part A and Part B claims is divided into 15 jurisdictions, known as A/B MAC Jurisdictions. Highmark Medicare Services, Inc. was awarded the contract for Jurisdiction 12 in October 2007. Jurisdiction 12 encompasses Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania. In January 2009, Highmark was awarded the contract for Jurisdiction 15, which encompasses Ohio and Kentucky, with the intent of assuming full claims responsibility by March 2010.

A complete explanation of A/B MAC Jurisdictions and the contracting process can be accessed at the following link.

http://www.cms.hhs.gov/MedicareContractingReform/

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Thanks to Claire Miley of Bass, Berry & Sims in Nashville, Tennessee for posting an alert regarding the final DMEPOS Surety Bond requirements. Below is the text of the American Health Lawyers Association e-mail alert.

CMS Issues Final Rule Requiring Surety Bonds for DMEPOS

On December 29, 2008, the Centers for Medicare & Medicaid Services (CMS) announced regulations requiring suppliers of certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) to post a surety bond as a condition of new or continued Medicare enrollment. Specifically, the final regulations require:

• For DMEPOS Suppliers Seeking Enrollment or with a Change in Ownership. Beginning May 4, 2009, DMEPOS suppliers seeking to enroll or to change the ownership of a supplier of DMEPOS must submit to the National Supplier Clearinghouse (NSC) a $50,000 surety bond for each assigned NPI for which the DMEPOS supplier is seeking to obtain Medicare billing privileges.

• For Existing DMEPOS Suppliers. Beginning October 2, 2009, each Medicare-enrolled DMPOS supplier must submit to the NSC a $50,000 surety bond for each assigned NPI to which Medicare has granted billing privileges.

• Enrolling New Practice Locations. A DMEPOS supplier enrolling a new practice location must submit to the NSC a new surety bond or an amendment or rider to the existing bond, showing the new practice location is covered by an additional base surety bond of $50,000.

• Elevated Surety Bond Amounts. Suppliers who have certain adverse legal actions imposed against them in the past may be required to post a higher bond amount. The final regulations permit the NSC to require DMEPOS suppliers to obtain a base surety bond of $50,000 and an elevated surety bond of $50,000 for each occurrence of an adverse legal action within ten years preceding enrollment, revalidation, or reenrollment in the Medicare program.

The final regulations are effective March 3, 2009. Some companies or organizations that supply DMEPOS are exempt from the surety bond requirements, including certain physician and non-physician practitioners, physical and occupational therapists, state-licensed orthotics and prosthetic personnel, and government-owned suppliers.

http://edocket.access.gpo.gov/2009/pdf/E8-30802.pdf

| Posted By Michael Cassidy In Medicare & Reimbursement | 5 Comments | Permalink

The Congressional Budget Office has prepared two remarkably thorough analyses regarding the fundamental issues confronting healthcare policy and the projected costs of more than 100 different reform proposals. Great summer vacation reading -- if you start now, you might finish by summer vacation. Check the links below:

http://www.cbo.gov/doc.cfm?index=9925

http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

CMS has established a Medicare learning network web page dedicated to Medicare fee for services advance practice nurses and physician assistants. It includes definitions, licensing requirements, enrollment procedures, reimbursement guidelines, and links to related materials. The website is accessible at the following link:

http://www.cms.hhs.gov/MLNProducts/70_APNPA.asp

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Independent Diagnostic Testing Facility Developments

            The 2009 Medicare Physician Fee Schedule Regulations include two provisions regarding Independent Diagnostic Testing Facilities. 42 CFR §410.33 has been supplemented with two additional subsections.

            First, Section (16) states all entities that provide diagnostic imaging services to Medicare beneficiaries will be required to enroll as IDTFs regardless of whether the services furnished are mobile or from a fixed base location. 

            Second, Section (17) requires registered Independent Diagnostic Testing Facilities to bill directly for all mobile diagnostic services furnished to Medicare beneficiaries, unless the mobile diagnostic service is part of a hospital service provided under arrangements with that hospital. This clarifies that IDTFs may not provide services under arrangements to non-hospital entities, such as physician practices. 

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

The revised Anti-Markup Final Rules were published by CMS on November 19, 2008 in the Federal Register, as part of the Medicare 2009 Physician Fee Schedule. The entire text of the 2009 Medicare Physician Fee Schedule and the related rules, i.e. Anti-Markup, Independent Diagnostic Testing Facility, physician referral issues, etc. were posted by the Med Law Blog on November 21, 2008. The 2009 Anti-Markup Rules are a simpler version of the 2008 and 2007 proposals. Rather than defining the details of purchased technical components and purchased professional components, based upon the location and employment status of the physicians and technicians, CMS has stated that the Anti-Markup Rules will apply to diagnostic tests [as defined in Social Security §1861(s)(3),] ordered by the billing physician or supplier, or by a related party [as defined by CFR §413.17] unless the test is performed by a physician who shares the practice with the billing physician or supplier.

2009 Anti-Markup Rules

The financial provisions of the 2009 Anti-Markup Rules provide that compliant arrangements may bill globally for the full physician fee schedule amount but noncompliant transactions will be paid the lowest of the following:

(a) the billing physician or suppliers net cost to purchase the diagnostic test;

(b) the actual charge to the patient/beneficiary; or

(c) the Physician Fee Schedule amount.

The technical components of the tests are deemed to be performed by the physician who supervises the performance of the technical components (as defined in 42 CFR §410.32) and the professional component is performed by the interpreting physician. Note that the supervision requirements of §410.32 are independent of the supervision requirements imposed upon Independent Diagnostic Testing Facilities (IDTFs) and that CMS has decided that physician entities and organizations performing diagnostic tests need not register as Independent Diagnostic Testing Facilities in 2009.

There are two categories of shared practice, i.e. substantial services and same office.

First, CMS defines a shared practices as a situation in which a performing physician furnishes substantially all of his professional services (which is defined as at least 75% of the total professional services provided by that physician to coincide with the substantially all definitions of the physicians self-referral regulations) through the billing physician or other supplier. This "substantially all" test can be measured either prospectively or retrospectively, so that it will be satisfied if the billing physician or other supplier has a reasonable belief that either:

(a) for the twelve months prior to and including the month in which the service was performed, the performing physician furnished substantially all of his or her professional services through the billing physician or supplier; or

(b) the performing physician will furnish substantially all of his or her professional services through the billing physician or other supplier for the next twelve months, including the month in which the service is performed.

Note that this arrangement will not prohibit temporary or locum tenens arrangements, because under locum tenens arrangements the services of the substitute physician will be billed in the name of the billing physician whom that substitute physician is replacing.

Second, a physician will also be deemed to share a practice with the billing physician or other supplier if the physician i s an owner, employee or independent contractor of the billing physician or other supplier and the technical component or the professional component is performed in the office of the billing physician or other supplier. The "office of the billing physician" is any medical office space, regardless of number of locations, in which the ordering physician regularly furnishes patient care, it includes space where the billing physician furnishes diagnostic testing if the space in located in the same building in which the ordering physician regularly furnishes patient care. Note that the "same building" is defined by §411.351 of the Physician's Self-Referral Regulations.

The same office requirement eliminates the need to measure the relative professional services of the performing physician. The performing physician could provide services to multiple physician practices, without regard to the substantially all test, so long as the performed services are performed in the office of the billing physician. Although this would eliminate the use of a centralized building to provide diagnostic tests, it would not eliminate arrangements known as "pod laboratories" for multiple practices, provided all of the pod laboratories are located in the same building in which those other practices regularly perform patient services.

The effective date of the 2009 Anti-Markup Provisions will be January 1, 2009.

Shared Practices

General Rules

| Posted By Michael Cassidy In Long Term Care , Medicare & Reimbursement | 2 Comments | Permalink

CMS published the final rule containing the Medicare Physician Fee Schedule for 2009 on November 19, 2008. Included in the final rule are:

1.         Confirmation of the 1.1% Physician Fee Schedule increase for 2009.

2.         Designated Health Service list for 2009 for Stark/Physician Self-Referral purposes.

3.         Final performance standards for Independent Diagnostic Testing Facilities to be effective January 1, 2009.

4.         Anti-Markup Provisions.

I will be posting separate explanations of the IDTF and Anti-Markup rules next week.

http://edocket.access.gpo.gov/2008/pdf/E8-26213.pdf

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

CMS says physicians will receive a 1.1 percent Medicare pay increase starting in 2009.

Modern Healthcare (10/31, Lubell) reports, "Physicians will receive a 1.1 percent increase to their Medicare payments in 2009 under a final rule issued by" the Centers for Medicare and Medicaid (CMS). This "update reflects a provision included in the Medicare Improvements for Patients and Providers Act of 2008, which halted a 10.6 percent pay cut scheduled for July 1, providing doctors with a 0.5 percent payment bump for the remainder of 2008." The final rule (pdf) also "establishes a new incentives program for eligible providers that adopt and use qualified electronic e-prescribing systems to transmit prescriptions to pharmacies."

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

On October 6, 2008 CMS announced its intent to aggressively enhance its efforts to find and prevent waste, fraud and abuse in Medicare. In particular, CMS indicated that it intends to work directly with beneficiaries to insure that they are properly receiving the durable medical equipment and home health services for which Medicare was billed and that the items or services are medically necessary. CMS also indicated that it will be taking additional steps in Florida, California, Texas, Illinois, Michigan, North Carolina and New York to fight fraud and abuse in the home health setting. Nationally, CMS will be implementing further medical review procedures by recovery audit contractors (RACs) in an effort to identify improper payments. As in the past, these RACs will be paid on a contingency basis. 

Paul Welk
412-594-5536
pwelk@tuckerlaw.com

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

In an MLN Matters announcement, a copy of which is attached at the Link below, CMS has added False Claims Act implications to reporting purchased technical components of diagnostic services. While admittedly any intentional misreporting of the purchased services would be subject to False Claims Act implications, CMS has taken the uncertainly out of this matter by stating that all services will be presumed not to be purchased technical services unless reported otherwise. Therefore, if Block 20 on the 1500 form was blank before, there might have been the argument the service was not reported incorrectly. However, now that all claims presume the technical services have not been purchased, failing to report it as a purchased service will clearly be a false claim, at least under this administrative policy. 

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6122.pdf

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The PROMETHEUS Payment(R) Model is a new program which is designed to pay providers fairly, improve quality, enhance transparency and still be more efficient than what we have today.  At www.prometheuspayment.org, you will find much information about this not-for-profit, tax exempt program which has received more than $6 million  from the Robert Wood Johnson Foundation to pilot test the concepts.  In connection with development of more of the Evidence-informed Case Rates(R) which are the basis for payment, the program is seeking input from practicing physicians who are familiar with its basic concepts, to provide input on the case rate development process.  If you are not familiar with this new approach, do go to the website and read about it.  If you are further interested in contributing, feel free to respond as below.

As you know, from your interest in the PROMETHEUS Payment® model, one of the hallmarks of our approach is building our Evidence-informed Case Rates® (ECRs) by starting with clinical practice guidelines or expert opinion, and then determining what services and resources must be brought to bear to provide that care. To do this properly and credibly, we need input from practicing clinicians with expertise in the clinical conditions around which the ECRs are constructed.

To help us with that work, we are hoping to identify practicing physicians around the country who would help us with input, review and comment. If such physicians contribute to our work, their names will be listed as having participated, if they so choose.

The conditions for which we are looking for physician input are the following:

• Asthma
• Hypertension
• COPD
• Coronary Artery Disease
• CABG
• Coronary Revascularization Heart Cath
• Bariatric surgery
• Hernia surgery

If you are a practicing physician and would like to participate, there will be scheduled phone calls and emails, but that is it, in terms of time commitments. If you know of physicians who would like to contribute, please feel free to share this note with them.

Anyone who seeks to participate must provide the following information:

• Name and Degree (MD, DO, Ph.D., etc)
• Specialty
• Affiliation [name of group]
• Address
• Phone
• Email
• ECRs for which you would like to volunteer

Click here to participate

At this point we are soliciting an interest level. Thank you for your consideration.

Alice Gosfield
Chairman of the Board
agosfield@gosfield.com

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

1.         Medicare Physician Fee Schedule. The sustainable growth rate (SGR) automatic physician compensation reduction of -10.6% was retroactively replaced with a .5% increase, essentially maintaining the .5% conversion factor increase implemented for January-June 2008.

2.         Incentive Payments. Extends through 2010 incentive payments for implementation of electronic prescription systems (EPS).

3.         Medicare Advantage Plan. 

·        Essentially eliminates funding for 2014

·        Begins phase out of IME costs in 2010

·        Requires private fee for service contractors to negotiate specific contracts, rather than merely "match" Medicare

4.         DMEPOS Bidding.

·        Invalidates the Round 1 competitive bidding on contracts and requires rebidding

·        Delays bidding of Round 2 until 2011

5.         Accreditation. Authorizes the Secretary to recognize hospital accreditation by bodies other than the Joint Commission.

6.         Miscellaneous

·        Extends the 60-day locum coverage period if the covered doctor is in the active military

·        Doctors adopting EPS will be eligible for a 2% bonus

·        The 5% physician scarcity bonus will be eliminated while the 10% HPSA bonus remains

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The CMS Medical Learning Network ("MLN") has posted an Evaluation and Management Services Guide for billing and coding. The Guide is a useful explanation of this complicated area and provides links to the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, as well as the Medicare Claims Processing Manual and the Current Procedure Terminology book. 

http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

In follow up to a previous posting, the Wall Street Journal recently reported that the Medicare Recovery Audit Contractor Program has identified 1.03 billion dollars of improper payments over the past three years, about 992.7 million dollars of which were over-payments by Medicare. While the Recovery Audit Contractor Program is currently underway in six states, Medicare is in the process of expanding the program's scope nationally. With this increasing scope, the risk of being audited is also likely to increase.

In the event a provider is subject to a Medicare or other third party payor audit, it is important to review the documentation provided by the auditor and take the steps necessary to prepare an appropriate and timely response. If the steps required to respond to an audit are not properly followed, there is a risk that the provider may forfeit certain rights. If a provider is subject to an audit, the services of an attorney or other professional familiar with the audit process can be of significant benefit. 

Paul Welk
412-594-5536
pwelk@tuckerlaw.com

| Posted By Michael Cassidy In Medicare & Reimbursement | 2 Comments | Permalink

CMS is acknowledging the continued interest in Pay for Performance ("P4P") and gainsharing ideas, and is issuing a specific self-referral exception in Anti-Kickback Safe Harbor to permit these programs.  P4P programs are being hereinafter referred to as incentive payments, and gainsharing programs are now being referred to as shared savings programs. 

The links below contain both the actual regulatory proposals and the CMS discussion of the proposals, which comprises pages 261-316 of the July 7, 2008 Medicare Fee Schedule Proposals for 2009. 

CMS indicates that its concerns for both programs are the withholding of quality care ("stinting"), the selection of only healthier patients for programs ("cherry picking"), the redirection of sicker patients to other providers ("steering") and premature discharge to reduce length of stay ("quicker-sicker"),

CMS is proposing one set of standards, i.e. new 42 CFR § 411.357(x), to apply to both shared savings and incentive programs and has outlined a philosophy requiring three elements, i.e. transparency, quality controls and safeguards against payments for referrals. 

Quality. 

The program must include patient care quality or cost saving measures (or both) supported by objective, independent medical evidence indicating that the measures would not adversely affect patient care.  Specifically, all performance measures must use an objective methodology, be verifiable, be supported by credible medical evidence, and be individually tracked.  The measures must reasonably relate to the hospital's practices and patient population in the interest of creating clear, bright line rules, we are proposing specifically that patient care quality measures be listed in CMS's Specifications Manuel for National Hospital Quality Measures. 

CMS is proposing that the programs must review prior to the implementation and at least annually thereafter to ascertain the program's impact on the quality of patient care services provided by the hospital.  The reviews must be conducted by an independent person or organization with relevant, clinical experience.

Independence requires an individual organization that is not (i) affiliated with the hospital operating the program under review; (ii) not affiliated with any participating physician or with any physician organization with which a participating physician is affiliated; and (iii) at the time of the review, not participating in any incentive payment or shared savings program operated by the hospital.  The reviews must be objective, accurate and complete and result in written findings.  These reviews should require contemporaneous documentation that would be made available to the secretary upon request. 

Self-Referral Payments.

The proposals apply only to payments by hospitals to physicians or physician organizations.  The proposals note that the programs involving non-physician practitioners ("NPP") might be possible, but also are not governed by the physicians self-referral statute.  Physician organizations, such as an existing private practice, could include physicians who are non-participating in the program.  All payments must be made to pools of five or more physicians who are members of the medical staff at the commencement of the program.  The pre-existing membership requirement is imposed out of the concern that these programs will be used to recruit physicians from competing hospitals.  CMS will consider comments on how to establish an appropriate process for the addition of physicians who join the medical staff in the normal course of business.

The hospital may not determine eligibility for physician participation in a program based on the volume or value of referrals or other business generated between the parties. 

To qualify for protection under the proposed exception, an incentive payment or shared savings program may not limit the discretion of physicians to make medically appropriate decisions for their patients, including, but not limited to, decisions about tests, treatments, procedures, services, supplies or discharge.

Payments made to physicians participating in either the incentive payment or shared savings program must be distributed on a per capita basis, although CMS will consider alternative proposals.

Medical Devices.

CMS is proposing that a physician (or qualified physician organization) could not receive a payment under an incentive payment or shared savings program for the use of an item, supply or device if the physician or physician organization has an ownership or investment interest, or a compensation arrangement with, a manufacturer or distributor of the item, supply or service, or GPO that arranges for the purchase of the item, supply or devise. 

Transparency.

To implement transparency and foster accountability, CMS has proposed that the arrangement require written disclosure to patients affected by the program regarding the nature of the program and the physician or qualified physician organization participation in the program prior to admission to the hospital, or, if preadmission disclosure is not feasible, prior to the procedure or other treatment to which the program is applicable.  CMS is also inviting comments on whether patients should have the opportunity to op-out of the program.  However, it would seem that patients always have the opportunity to opt-out of any treatment program, and the issue should be whether the opt-out opportunity is specifically disclosed in the program disclosure. 

www.medlawblog.com/Comments.pdf

www.medlawblog.com/Regs.pdf

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

New 2008 Medicare Physician Fee Schedule Payment Rates Effective for Dates of Service July 1, 2008 through December 30, 2008

The Medicare Improvements for Patients and Providers Act of 2008 was enacted on

July 15, 2008.  As a result, the mid-year 2008 Medicare Physician Fee Schedule (MPFS) rate of -10.6 percent has been replaced with a 0.5 percent update, retroactive to July 1, 2008.    

Physicians, non-physician practitioners and other providers of services paid under the MPFS should begin to receive payment at the 0.5 % update rates in approximately 10 business days, or less.  Medicare contractors are currently working to update their payment system with the new rates.

In the meantime, to avoid a disruption to the payment of claims for physicians, non-physician practitioners and other providers of services paid under the MPFS, Medicare contractors will continue to process the claims that have been on hold on a rolling basis (first in/first out) for payment at the -10.6% update level.  After your local contractor begins to pay claims at the new 0.5% rate, to the extent possible, the contractor will begin to automatically reprocess any claims paid at the lower rates.   

Under the Medicare statute, Medicare pays the lower of submitted charges or the Medicare fee schedule amount.  Claims with dates of service July 1 and later billed with a submitted charge at least at the level of the January 1 – June 30, 2008, fee schedule amount will be automatically reprocessed.  Any lesser amount will require providers to contact their local contractor for direction on obtaining adjustments.  Non-participating physicians who submitted unassigned claims at the reduced nonparticipation amount also will need to request an adjustment.

Contractor websites are being updated with the new rates and these should be available shortly.

Be aware that any published MLN Matters articles affected by the new law will be revised or recinded as appropriate.

Finally, be on the alert for more information about other legislative provisions which may affect you.

Further instructions regarding other provisions of MIPPA will be forthcoming.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The House voted 383 to 41 to override the veto, while the Senate voted 70 to 26, in both cases far more than the two-thirds necessary to block the president's action.

With organized medicine and other lobbies promoting the popular measure in an election year, Republicans broke heavily from the White House. A total of 153 House Republicans voted to defy the White House, 24 more than in a June 24 vote that started the momentum toward passage of the Medicare doctors' bill yesterday. Twenty-one Senate Republicans voted for the bill this time, including four senators who had voted "nay" in the two previous Medicare votes.

The Medicare bill is the third, along with the recent farm bill and a water resources bill, to become law despite Bush's veto. Overall, Bush has vetoed 12 pieces of legislation during his presidency, including a "pocket veto" of last year's defense authorization bill.

This action applies only to the remainder of 2008. The sustainable growth rate (SGR) formula wil present this issue agin for 2009 anf yeras after unless revised by Congress.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

medicare payment UPDATE

Today the president vetoed the Medicare Improvement Act for Patients and Providers (H.R. 6331). The House of Representatives must now schedule a new vote to override the veto, followed by a similar vote in the Senate. A two-thirds majority in each chamber must support a veto override for it to succeed. 

Please use the grassroots hotline at 800.833.6354 to call Congress and urge lawmakers to immediately override the veto of H.R. 6331 to provide 18 months of positive Medicare payments to physicians and ensure that Medicare beneficiaries have access to quality care. 

Please click the links below to see how your senators and representatives previously voted on this bill.  If they voted “yea”, thank them for their support of this important legislation and urge them to vote to override the presidential veto.  If they voted “nay”, urge them to reconsider their position and vote to override the veto. 

This bill reverses the 10.6 percent cut to Medicare reimbursement that took effect July 1 and the projected 5.4 percent cut scheduled for 2009. It continues the 0.5 percent payment increase for 2008 and provides an additional 1.1 percent increase in 2009.

See how your representatives previously voted. http://clerk.house.gov/evs/2008/roll443.xml

See how your senators previously voted. http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=110&session=2&vote=00169

Click here to determine who your senators are. www.senate.gov/general/contact_information/senators_cfm.cfm

Click here to determine who your representative is. 

www.house.gov/house/MemberWWW_by_State.shtml

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The proposed 2009 Medicare Physician Fee Schedule also deals with proposed changes to the reassignment rules related to diagnostic tests, sometimes referred to as the Anti-Markup Provisions.  The discussion of the proposed rules, which occupies pages 237 through 260 of the Federal Register publication, which pages are attached at the link below, discusses the history of the Anti-Markup Rules, the proposed changes from 2008, the delay in implementation and the reasons therefore, and the litigation history of Atlantic Urological Associates v. Leavitt.

The 2009 Fee Schedule Proposals contain two alternatives. 

First, the new proposal is a far simpler proposal in which the Anti-markup Provisions would apply in all cases where the TC of the diagnostic tests is either (i) purchased from an outside supplier or (2) performed or supervised by a physician who does not share a practice with a billing physician or physician organization.  The most significant change is that the rules that specify that a physician who is employed by a contract with a single physician or physician organization shares a practice with that physician or physician organization.  CMS believes that when a physician provides his or her efforts for a single physician organization (regardless of whether those efforts are fulltime or part time), he or she has a sufficient nexus with that practice to justify not applying the Anti-markup Provisions.

Second, the alternative proposal is basically a re-proposal of the presently proposed rules with amendments to do the following:

1.        Clarify that the office of the billing physician or other supplier includes space in which the diagnostic testing is performed that is located in the same building in which the billing physician or other supplier regularly furnishes patient care;

2.        Clarify that, with respect to TCs the Anti-Markup Provision applies if the TC is either conducted or supervised outside of the office of the billing physician or other supplier;

3.        Clarify that a TC of the diagnostic test is not purchased from an outside supplier if the TC is supervised by a physician located in the office of the billing physician or another supplier;

4.        Clarify that, for the purposes of applying the payment limitation, the performing supplier with respect to the TC is the physician who supervised the TC and, with respect to the PC, the performing supplier is the physician who performed the PC;

5.        Propose an exception for diagnostic tests ordered by a physician in a physician organization; and

6.        Solicit comments on how to define net charge.

www.medlawblog.com/CMS-1403-P(2).pdf

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The AP (7/11) reports, "President Bush intends to block a bill protecting doctors from a cut in their Medicare pay, even though Congress has enough votes to override his veto, a White House spokesman indicated on Thursday." The President opposes "reduce[d] spending on private health insurers serving about nine million elderly and disabled patients through Medicare Advantage," which the bill calls for in order to "pay for rescinding [a] 10.6 rate cut" in Medicare payments to doctors. According to White House spokesman Tony Fratto, "Taking choices away from seniors in order to pay for the reimbursements for physicians is the wrong way to pass this bill and to extend the reimbursements that we want to see physicians get." The White House predicts that reduced Medicare Advantage spending -- about $13.5 billion over five years -- would slow enrollment growth," estimating "that about two million fewer people would take part in the program."

        But, "Senate Democrats say they have enough support to override [the] potential presidential veto," according to the Boston Globe (7/10, Milligan). Minutes before the vote, Sen. Edward Kennedy (D-Mass.), "under treatment for brain cancer, made a brief, triumphant return to the Senate" to vote on the measure, giving "Democrats the vote they needed to stop a Republican filibuster and pass the bill."

        In addition to concern over the pending veto, Jacob Goldstein added in the Wall Street Journal's (7/10) Health Blog that, even if the measure is instated, "the issue will return next year, just as it returned last year and the year before that." He explained that Congress passed a budget bill in 1997 "called the sustainable growth rate (SGR) for Medicare. The SGR says essentially that the amount Medicare pays doctors for an average Medicare patient can't grow faster than the economy as a whole." Meaning that "if growth in payments per beneficiary grows more than the economy as a whole, the SGR says you have to lower payments to doctors across the board to keep costs under control." Which is "fine," he stated, until "the economy slowed and healthcare spending skyrocketed early in this decade." Now, "we're stuck with continued short-term interventions until, some day, Congress come[s] up with a whole new system to start the clock running again." Modern Healthcare (7/10, Lubell) also covered the Senate's passage of the bill.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The Centers for Medicare/Medicaid Services posted the proposed 2009 Medicare Fee Schedule Rule on July 7, 2008. The link to those rules was provided in an earlier Medlaw Blog post.  

The proposals include numerous items, but I would like to highlight the following:

1.  Proposed changes to the Independent Diagnostic Testing Facility (IDTF
     enrollment requirements;

2. Significant clarification and proposed changes to the Purchased Diagnostic Testing or Anti
     markup Rules;

3.  A new Stark exemption for incentive payment and shared saving programs (gainsharing); and

4.  Proposed revisions to the Physician and Non-Physician Practitioner Enrollment Requirements.

Over the next several weeks, I will be posting articles on the Medlaw Blog regarding each of these.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Congress
Clash on Preventing Cut to Doctor Payments
Centers on How to Pay for Medicare Bill

By ANNA WILDE MATHEWS
July 7, 2008

Before Congress took the July 4th week off, a partisan standoff in the Senate blocked a bill that would prevent a cut in doctors' Medicare fees. When members return to Capitol Hill this week, the question for Democrats and Republicans will be: Who will blink to get it done?

Both parties want to avoid the 11% drop-off in physician payments. Already, lawmakers have missed the July 1 deadline for the automatic cut to go into effect, but the Bush administration said it won't process claims at the new, lower rate for the first 10 business days of July.

The clash -- and the holdup -- center mostly on how to pay for the bill. Its cost, about $20 billion over five years, reflects a package of other tweaks in addition to the doctors' money. To fund them, the bill relies largely on trimming outlays for the private insurers' version of Medicare, known as Medicare Advantage plans.

The White House has threatened to veto the bill, largely over new limits it would impose on one particular type of Medicare Advantage plan known as private fee-for-service. Such plans are offered by companies including Humana Inc., WellPoint Inc. and UnitedHealth Group Inc.

Despite the veto threat, the House passed the bill last month, 355-59. But in the week before Congress's holiday recess, it fell one vote short of the 60 needed to move forward in the Senate.

Senate Democrats have vowed to bring the bill up again this week. So the spotlight will be on a handful of Republican senators who could potentially switch votes. The American Medical Association, which backs the bill and says many of its members would be reluctant to see new Medicare patients if the cut remains in effect, ran ads last week targeting 10 Republican senators in their home states.

They include Pennsylvania Sen. Arlen Specter, New Hampshire Sen. John Sununu and Mississippi Sen. Roger Wicker. Texas Sen. John Cornyn, who, like Sens. Sununu and Wicker, is up for reelection this fall, saw the political arm of the Texas Medical Association withdraw its endorsement of him. "I think they don't understand the fury out there," said AMA President Nancy Nielsen. "It's galvanized doctors."

On the other side, America's Health Insurance Plans, the main lobbying group for the industry, ran its own ads, defending the Medicare Advantage plans. "What we'd like to see is the physician-fee issue addressed without the significant reliance all the bills propose placing on Medicare Advantage beneficiaries," said Karen Ignagni, chief executive of the group.

Even if the bill wins 60 votes in the Senate this week, it would not be enough to overcome a veto if the White House refuses to back down. That would throw the issue back to Congress with even less time left on the clock before the cuts take full effect. Democrats would then face more pressure to accept a compromise measure, likely more narrowly crafted, that does not go after the private fee-for-service plans.

Write to Anna Wilde Mathews at anna.mathews@wsj.com

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

On June 30, 2008, the Centers for Medicare and Medicaid Services (CMS) posted at the Office of Federal Register its Proposed 2009 Medicare Physician Fee Schedule rule. The rule is scheduled to be published in the July 7, 2008, edition of the Federal Register, but was placed on display at the Office of Federal Register.

As with any proposed physician fee schedule update, this proposed rule is full of interesting and significant changes to Medicare Part B payment policies, including pieces impacting the Stark Law and the purchased diagnostic test (PDT) rule. In particular, the proposed rule:

• Includes annual updates to relative value units (RVUs) used to calculate physician payment.
• Proposes to create a new series of HCPCS codes for follow-up inpatient telehealth consultations.
• Proposes changes to the methodology used to calculate the Average Sales Price (ASP) of certain covered Part B drugs effective April 1, 2008, and proposes changes to the Competitive Acquisition Program (CAP) for Part B drugs.
• Proposes changes to the IDTF enrollment requirements including: (1) proposed requirements that physician and nonphysician practitioner entities enroll and meet certain IDTF requirements; (2) proposed requirements that mobile entities furnishing diagnostic tests bill directly for the mobile diagnostic services that they furnish, regardless of where the services are performed; and (3) proposed limits regarding how long an IDTF can submit claims for services furnished prior to any effective date of IDTF revocation.
• Includes significant clarification and proposed changes to the PDT or anti-markup rule including: (1) changes that would conform aspects of this payment limitation rule to the federal physician self-referral or Stark law by modifying the current definition of "office of the billing physician" to include diagnostic services furnished in the same building (even if furnished on different floors of the building provided applicable supervision requirements can be met); (2) changes that would clarify that physician supervision—not the employment relationship of the technician—is the key factor for application of the payment rule provisions; (3) changes that would exempt diagnostic services furnished by certain multi-specialty practices in locations where only some of the ordering physicians of the physician organization work; and (4) a proposed exemption for certain non-compliant relationships where an ordering physician in a physician organization does not have any owners who have a right to receive profit distributions.
• CMS solicits numerous comments regarding these proposed changes including: (1) alternatives to the proposals it offers; (2) whether the term "net charge" should include any overhead or other costs of the billing physician when the PDT applies; and (3) whether the effective date of the PDT clarifications should be extended beyond January 1, 2009. CMS does not, however, back away from its view in the final 2008 Medicare Physician Fee Schedule that the PDT rule will apply in situations that could qualify under the "centralized building" component of the in-office ancillary services exception under the Stark law.
• Proposes a new and permanent Stark exemption for certain incentive payment and shared savings programs offered by hospitals.
• Proposes revisions to the physician and non-physician practitioner enrollment requirements.
• Proposes revisions to the appeals process rules where CMS or a contractor determines that a provider or supplier fails to meet the requirements for Medicare billing privileges.
• Proposes to change the DMEPOS supplier standards to prohibit payment to a supplier for furnishing a CPAP device to a beneficiary if the supplier also "directly or indirectly" provided the diagnostic sleep study or furnished the sleep test device used in the study.
• Proposes changes to the Physician Quality Reporting Initiative (PQRI) reporting requirements.

Comments on this proposed rule are due by August 29, 2008, with the final rule expected in November for implementation effective as of
January 1, 2009.

*We would like to thank Barry Alexander (Nelson, Mullins, Riley & Scarborough, LLP Raleigh, North Carolina) and Alex M. Hendler (Washington, DC) for providing this email alert.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

The Questions and Answers below apply to the recent decision by the Centers for Medicare & Medicare Services to hold for up to 10 business days claims paid under the Medicare physician fee schedule (MPFS) that contain July 2008 dates of service.

Q1.      Will claims containing services paid under the MPFS be held that contain both June and July dates of service?

A1.      Yes, your local contractor will hold the entire claim for 10 business days.

Q2.      Will claims be held that contain both services paid under the MPFS and services paid under a separate fee schedule?

A2.      Yes, claims that contain both services paid and not paid under the MPFS will be held. For example, a claim with a July date containing an Evaluation and Management code and a drug code would be held.

Q3.      Does the holding of claims paid under the MPFS also include anesthesia and purchased diagnostic services?

A3.      Yes, contractors will hold all claims with dates of service July 1, 2008, and after that contain services paid under the MPFS, including anesthesia and purchased diagnostic services.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

In continuing coverage from previous editions of Health and Life Sciences Law Daily, the New York Times (6/27, Pear) reports that physicians now "face a 10 percent cut in Medicare payments next week, following the Senate's failure on Thursday to take up legislation that would have averted the cuts." By a vote of 58 to 40 on Thursday, "Republican senators blocked" the bill, which "would cancel the 10 percent cut scheduled to occur on Tuesday and would increase Medicare payments to doctors by 1.1 percent in January." Dr. Nancy H. Nielsen, president of the American Medical Association, warned that "the cuts would force many doctors to 'limit the number of new Medicare patients they treat.'"

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The Medicare rules for the physician fee schedule (RB-RVS) would have mandated a 10% reduction for 2008 pursuant to the sustainable growth rate (SGR) formula. Congress postponed that for the first 6 months of 2008, but he 2nd 6 months is looming. Without actionmt he postmenement ends and the automatic 10.1% reduction kicks in automatically. The House has approved another reprieve. Quick Senate action is expected. Excerpts form the WSJ report follow.

Expect the current elected officials to enact the reprieve for the next 6 months and pass this problem on to the new administration.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Highmark Blue Cross/Blue Shield announced in the April 2008 PRN that the reduction for technical component reimbursement for multiple procedures, originally intended to be effective as of July 1, 2008, will be postponed until September 1, 2008.  A copy of that announcement is contained in the link below.

www.medlawblog.com/PRN Article.pdf

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On May 2, 2008 CMS issued a policy update regarding services provided incident to the services of a physician/non physician practitioner. The purpose of the publication was to clarify policies related to Part B Services provided incident to the services of physicians. The publication clarifies common incident to issues such as the documentation required to authorize the incident to service, the supervision requirements for incident to services and the documentation requirements regarding the professional title of the person providing the service. Additional information regarding the policy update is available at http://www.cms.hhs.gov/Transmittals/downloads/R87BP.pdf.

Paul Welk
412-594-5536
pwelk@tuckerlaw.com

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On April 21, 2008 the Centers for Medicare and Medicaid Services ("CMS") released a proposed rule regarding the Fiscal Year 2009 Inpatient Rehabilitation Facility Prospective Payment System. The proposed rule discusses changes to the 75% rule and requires a freeze on inpatient rehabilitation facility rates from April 1, 2008 through September 30, 2009. The proposed rule also discusses lowering the compliance threshold for certain cost reporting periods. Comments to CMS are being accepted through June 20, 2008. Under the Social Security Act, the final rule will be published on or before August 1. The proposed rule can be found in its entirety at http://www.cms.hhs.gov/InpatientRehabFacPPS/downloads/cms-1554-p-display.pdf

Paul J. Welk
412-594-5536
pwelk@tuckerlaw.com

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CMS has proposed new Stark regulations as part of the hospital in-patient perspective payment system rules for Fiscal Year 2009. 

On April 14, 2008, CMS proposed new IPPS rules which contain proposed Stark regulations with respect to alternative solutions for the "stand in the shoes" provisions which were first proposed in the Stark Phase III rules and solicits new comments on a proposed exception for gain sharing. 

The proposed rules have been posted on the MedLaw Blog and can also be accessed through the link below.

http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-P.pdf

We will be posting summaries of the "Stand in the Shoes" and "Gain Sharing" proposals written the next several days.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

Pittsburgh MSA Included in DMEPOS Medicare Competitive Bidding Program

Medicare will begin implementation of a Competitive Bidding Program for DMEPOS effective July 1, 2008. This program will affect patients in ten competitive bidding areas (CBAs) that align with the ten metropolitan statistical areas (MSAs) selected for the first phase of this program and includes ten product care categories of DMEPOS. 

The ten MSAs include Pittsburgh. 

Ten product categories include oxygen supplies, standard power wheelchairs and scooters, complex rehabilitative power wheelchairs, mail order diabetic supplies, enter nutrients, continuous positive airway pressure (CPAP) and respiratory assist devices, hospital beds, negative pressure wound therapy, walkers and related accessories, and support services (Group 2 mattresses). See the attached MLN Matters link from CMS for additional information. 

http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0805.pdf

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Highmark Medicare Local Coverage Determinations (LCDs)

Highmark Medicare Services has published the initial draft set of LCDs as part of its plans to fulfill CMS requirements to consolidate ICEs by July 1, 2008. Highmark's instructions for submitting comments for the proposed Local Coverage Determinations (LCDs) and the proposed LCDs are included in the attached link. The following LCDs are included:

• Approved Drugs and Biologicals
• Blepharoplasty/Blepharoptosis
• Blood Glucose Monitoring in a Skilled Nursing Facility (SNF)
• Botulinum Toxin Type A and B
• Cancer Chemotherapeutic Agents
• Cardiovascular Stress Testing
• Cataract Surgery
• Chiropractic Services
• Co-Management of Surgical Procedures
• Complex Cataract Extraction
• Computed Tomographic Angiography of the Chest
• Consultations
• Coverage of Services and Procedures in Nursing Facilities
• Routine Foot Care
• Debridement of Mycotic Nails
• Diagnostic Laryngoscopy
• Monitored Anesthesia Care (MAC)
• Electrocardiography
• End - Diagnostic Pneumatic Compression Therapy
• Erythropoiesis Stimulating Agents (ESAs)
• Evaluation and Management Services in a Nursing Facility
• Fluorescein and Indocyanine Green Angiography
• Fundus Photography
• Intraoperative Neurophysiological Testing
• Luteinizing Hormone-Releasing (LHRH) Analogs
• Magnetic Pelvic Floor Stimulation (MPFS)
• Magnetic Resonance Imaging (MRI) of the Breast
• Moh's Micrographic Surgery (MMS)
• Non-Invasive Cerebrovascular Arterial Studies
• Non-Invasive Peripheral Venous Studies
• Ophthalmic A and B scans
• Ophthalmic Biometry for Intraocular Leans (IOL) Power Calculation
• Ophthalmoscopy Extended
• Parathormone (Parathyroid Hormone)
• Paravertebral Facet Joint Nerve Block and Sacroiliac Joint Injections
• Physical Medicine and Rehabilitation Services, PT and OT
• Psychiatric Therapeutic Procedures
• Radiation Therapy Services
• Radiologic Examination of the Chest (CXR)
• Real-Time, Outpatient Cardiac Monitoring
• Removal of Benign or Premalignant Skin Lesions
• Removal of Impacted Cerumen
• Scanning Computerized Ophthalmic Diagnostic Imaging
• Sleep Disorder Testing
• Speech-Language Pathology (SLP) Services
• Surgical Treatment of Nails
• Surveillance of Implantable Cardioverter-Defibrillator (ICD), Office, Internet or Non-Internet Based
• Thermotherapies (Minimally Invasive Surgical Techniques [MISTs] for Benign Prostatic Hypertrophy (BPH))
• Transesopageal Echocardiography (TEE)
• Transthoracic Echocardiography (TTE)
• Treatment of Dysphagia (Swallowing Disorders), General; Includes VitalStim® Therapy
• Treatment of Varicose Veins of the Lower Extremities
• Trigger Point Injections
• Visual Fields
• Wound Care
• Acute Care: Inpatient, Observation, and Treatment Room Services
• Human Skin Equivalents (HSE) - Use in the Treatment of Chronic Cutaneous Ulcer Wounds

http://www.highmarkmedicareservices.com/transition/j12/lcd.html

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CMS has decided to make no change to Section 220.1 of the existing National Coverage Determination Manual titled “Computed Tomography” (PUB 100-3, 220.1). The link to the CMS announcement is:

https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=206

The summary of the decision is as follows:

Conclusions

In summary, there is uncertainty regarding any potential health benefits or patient management alterations from including coronary CTA in the diagnostic workup of patients who may have CAD. No adequately powered study has established

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Medicare recently announced that it will be increasing the frequency of its audits under the Medicare Recovery Audit Program in the near future. Under the Recovery Audit Program, Medicare contracts with auditors who review the records of health care providers to determine if Medicare was incorrectly billed for services and if so, to determine the amounts of overpayments due back to the Federal Government. In the past three years alone, the Recovery Audit Program has resulted in the return of more than $300,000,000 to the Federal Government. Medicare has indicated that they will begin monitoring 19 states in the near future, s significant increase from the contractors’ current scope which has been in just three states. An additional five states will be added in October.

In order to help reduce the risk of significant repayment obligations to the Federal Government under a Medicare Audit, it is important to establish a Medicare Compliance Program and to periodically verify that the program is in fact being complied with. Although this may not reduce the risk of being audited, it should help to reduce the risk of a significant repayment obligation. Finally, in the event a provider is subject to a Medicare audit it is important to take the steps necessary to prepare an appropriate response and to be familiar with the steps of the audit process. 

For additional information on the Medicare Recovery Audit Program, please see http://www.cms.hhs.gov/rac.

Paul J. Welk
412-594-5536
pwelk@tuckerlaw.com

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The Medicare Appeals Process: Five Levels to Protect Providers, Physicians and Other Suppliers brochure has been updated and is now available to order print copies or as a downloadable PDF file. To view the PDF file, go to http://www.cms.hhs.gov/MLNProducts/downloads/MedicareAppealsProcess.pdf or to order hard copies, please visit the MLN Product Ordering Page at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5 on the CMS website.

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CMS PUBLISHES CORRECTED 2008
AMBULATORYSURGERYCENTER FEE SCHEDULE

On February 22, 2008, CMS published corrections to the 2008 payment rates for ambulatory surgery centers. Following is the link to the corrected final rule.

http://a257.g.akamaitech.net/7/257/2422/01jan20081800/edocket.access.gpo.gov/2008/pdf/08-671.pdf

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SIMPLE CMS EXPLANATION OF MEDICARE PHYSICIAN FEE SCHEDULE

CMS issued a relatively simple explanation of the Medicare Physician Fee Schedule on February 19, 2008. The release is entitled The Revised Medicare Physician Fee Schedule Fact Sheet for January 2008. It explains the following:

1.     the work, practice expense, and malpractice expense components of the RVU formula;

2.     the conversion factor process, the six month reprieve of the SGR reductions so that the conversion factor for the first six months of 2008 will be $38.0870;

3.     the fact that the conversion factor will revert back to $34.0682 as of July 1, 2008.

http://www.cms.hhs.gov/MLNProducts/downloads/MedcrePhysFeeSchedfctsht.pdf

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On January 25, 2008 CMS published a proposed rule which clarifies and expands the current enrollment requirements that durable medical equipment and prosthetics, orthotics and supplies ("DMEPOS") suppliers must meet to establish and continue to have billing privileges in the Medicare Program. These provisions may affect the ability of physical therapists to provide DMEPOS to their patients. The proposed rule is available at: http://a257.g.akamaitech.net/7/257/2422/25jan20081800/edocket.access.gpo.gov/2008/pdf/E8-1346.pdf and comments can be submitted until March 25, 2008. 

Paul Welk
412-594-5536
pwelk@tuckerlaw.com

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CORF SERVICES

I.          INTRODUCTION

CORF Services may consist of physician services, physical and occupational therapy services, speech pathology services, respiratory services, prosthetic or orthotic devices and related services, social and psychological services, drugs and biologicals, vaccines and supplies, appliances and equipment. Any of these services may be provided provided a physician first certifies the medical necessity of skilled rehabilitation services and establishes a plan of treatment in accordance with 42 CFR §410.105. The 2008 Regulations are intended to do the following:

1.          Distinguish the types of physician services which are comprehensive outpatient rehabilitation facility (CORF) services provided by a physician and, therefore, included within the CORF reimbursement, from physician services which are separate medical or surgical physician services and therefore not included within CORF reimbursement but are separately billable;

2.          Coordinate the regulations with the existing fee schedule reimbursement structure;

3.          Revise the conditions for coverage; and

4.          Clarify the coverage of nursing services, drugs and biologicals, and vaccines.

 II.         PHYSICIAN SERVICES

1.          Statute: The distinction is based upon the statutory language of 42 USC §1395x(cc)(1)(2), which defines CORF services and CORF. The definition of services includes physician services but is not intended to cover typical outpatient or inpatient physician services.

2.         Regulations: The 2008 Regulations distinguish between types of services. 42 CFR §414.100(a) specifically provides that CORF physician services are administrative in nature and that diagnostic and therapeutic physician services are not CORF services, but (if otherwise covered) would be separately reimbursable under part 414.

a.         Physician Services are defined in 42 USC §1395x(q) as surgical and medical or consultative services. 

b.         CORF services are defined in 42 USC §1395x(cc) to exclude any services which would not be covered if provided to an inpatient at a hospital facility.

c.         42 USC §1395x(b)(4) defines hospital inpatient services and specifically excludes medical or surgical services provided by physicians (including residents or interns) certified nurse midwives, certified registered nurse anesthetists, and psychologists.

III.         REIMBURSEMENT

42 CFR §414.1105 defines the payment mechanism for CORF services, which has been in effect since 1999 when CORF reimbursement was changed from cost-based reimbursement to physician fee schedule reimbursement. 

1.         Section 414.1105(b) specifically states that there will be no separate payment for physician services that are CORF services (physician/administration services).

2.         All other services are paid pursuant to the physician fee schedule pursuant to Section 414.1105(a) which states, that CORF services will be paid at the lesser of 80% of the following:

            a.         The actual charge for the item or services; or

b.         The non-facility amount determined under the physician fee schedule established under Section 1848(b) of the act for the item or service.

That reference is to Section 1848 of the Social Security Act, i.e., 42 USC

§1395w-4, which established the Medicare RB-RVS physician fee schedule in 1992.

3.          Supplies and durable medical equipment that are CORF services under 42 CFR §410.100(f), orthotic devices that are CORF services under 42 CFR §410.100(g), and drugs and biologicals that are CORF services at the lesser of eighty percent (80%) of either (1) actual charge or (2) the DMEPOS fee schedule.

a.         Prosthetic devices are devices that replace all or part of an organ or body member but exclude dental and renal dialysis machines.

b.         Orthotic devices include orthopedic devices and services reasonably necessary to effectuate their use.

c.         Drugs and biologicals are those prescribed by a physician and not otherwise excluded from Part B coverage.

IV.        COVERAGE REQUIREMENTS.   

CMS has revised the coverage requirements of 42 CFR §410.105 to clarify that all services provided must be necessary for the rehabilitation of the patient, allows certain home services, and extends the review period to 90 days instead of 60 days, except for respiratory services. 42 CFR §410.105(c)(1)(ii) now requires that treatment plan to:

1.        Indicate the diagnosis and rehabilitation goals;

2.        Prescribe the type, amount, frequency and duration of the skilled rehabilitation services, including PT, OT, speech and respiratory therapy; and

3.        Indicate the other CORF services to be furnished that relate directly to such rehabilitation goals. 

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REPORTING OF CARDIAC REHABILITATION SERVICES

Cardiac rehab services were being reported as CPT 93797 (physician services for outpatient cardiac rehabilitation without continuous ECG monitoring) and CPT 93798 (physician services for outpatient cardiac rehabilitation with continuing ECG monitoring). CMS proposed to establish two new HCPCs codes to report cardiac rehab services, i.e., GXXX 1 (physician services for outpatient cardiac rehabilitation without continuous ECG monitoring per hour) and GXXX 2 (physician services for outpatient cardiac rehabilitation with continuous ECG monitoring per hour).

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On November 1, 2007, the Centers for Medicare and Medicaid Services ("CMS") released its final Medicare Physician Fee Schedule Rule for calendar year 2008. In addition to announcing CMS' payment rates for 2008, the final rule includes a new definition of physical therapist assistant and sets forth certain personnel standards for the provision of physical therapy services. 

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

In continuing coverage from yesterday's briefing, Bloomberg (12/20, Goldstein, Johnston) reports that a "scheduled cut in Medicare payments to doctors will be postponed," and the State Children's Health Insurance Program (SCHIP) "will be extended at its current enrollment under legislation the U.S. House sent to the President" on Wednesday. By a vote of 411 to 3, the House passed the bill, which the Senate approved unanimously on Tuesday. According to press secretary Dana Perino, "President George W. Bush is expected to sign the compromise legislation." Under this bill, physicians who treat Medicare patients will "get a 0.5 percent increase through June 30, rather than a 10.1 percent cut on Jan. 1."

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

Conrgress is working on an unusual solution to the yearly Medicare update. The SGR formula mandates a fee decresase, projected to be about 10%. In past years, Congress has overidden the fee reduction with a modest increase. Of course, since the sustainable growth reate formula is never changed, the chasm gorws every year. This year, instead of an override, Congress is merely proposing a 6 month delay in the decrease. Below id the report from the Kaiser Daily Health Policy Report. 

Chair Max Baucus (D-Mont.) and ranking member Chuck Grassley (R-Iowa) on Monday agreed on a Medicare package that would delay for six months a scheduled 10% reduction in Medicare physician fees, a Republican committee aide said, CQ Today reports. The fee cut is scheduled to take effect on Jan. 1, 2008. The lawmakers previously called for a one- or two-year fix of the physician fee cut, but "difficulty in finding ways to pay for the legislation, along with Senate Republican leadership's demand that the package be able to pass by unanimous consent, forced them to scale back their ambitions," according to CQ Today (Armstrong, CQ Today, 12/17).

The package would cost about $6 billion, but lawmakers, looking to attract Republican support and avoid a presidential veto, will not propose "anything close to the billions of dollars in cuts in payments to Medicare Advantage insurers that many Democrats have backed," the Wall Street Journal reports (Lueck, Wall Street Journal, 12/18).

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A.        Refinement of Work Relative Value Units.

            Since the physician fee schedule is first established in 1992, it has been composed of three categories of relative value units, i.e., work, malpractice expense, and overhead. Each of these units is assigned a value and the sum of those units is multiplied by the dollar conversion factor to establish the Medicare reimbursement for each particular CPT code. The system includes a process for refining the work relative value units, i.e., a re-evaluation of the value of the work units assigned to each CPT code. CMS uses a standard five year review cycle based upon input by the AMA/Specialty Society Relative Scale Update Committee (RUC). For 2008, CMS has revised the work units for comprehensive hearing tests (92557), visual audiometry (92579), doppler color flow (93325), and 14 home visit codes (99336 through 99350). The values, which are contained in Table 14 of the proposed physician fee schedule, is attached below at the link entitled Table 14: Work RVU Revisions.

www.medlawblog.com/Table 14 Work RVU Revisions(1).pdf

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The 2008 Medicare Physician Fee Schedule also includes revised performance standards for Independent Diagnostic Testing Facilities (IDTFs). The revisions are promulgated via 42 CFR § 410.33. The link below is the text of the regulations with the new provisions "boxed" for easy identification. Following is a description of these new IDTF performance standards beginning January 1, 2008:  

| Posted By Michael Cassidy In Medicare & Reimbursement | 3 Comments | Permalink

The Medicare Anti-Markup provisions for diagnostic tests, which will be effective as of January 1, 2008, are intended to prevent physicians or other medical suppliers from purchasing either the professional component (PC) or technical component (TC) of any diagnostic test (excluding clinical laboratory tests subject to separate restrictions) and profiting or marking up the acquisition cost by billing globally in accordance with the fee schedule.

| Posted By Michael Cassidy In Medicare & Reimbursement | 4 Comments | Permalink

HIGHMARK  ANNOUNCES AMBULATORY SURGERY  CENTER

ACCREDITATION REQUIREMENTS

In the October 2007 PRN, Highmark announced that, as of January 2008, it will require freestanding ambulatory surgery centers (ASC) to be accredited by one of three accrediting bodies, i.e., the Joint Commission, the Accreditation Association for Ambulatory Healthcare ("AAAHC"), or the American Association for Accreditation of Ambulatory Surgery Facilities ("AAASF"). The text of the PRN article appears below. Note that newly formed ASCs, i.e., those practicing for less than a year, may apply for network participation and have 18 months to complete Highmark accreditation requirements. Existing ASCs which already participate in Highmark's network have an 18-month compliance window. However, ASCs have been in existence for more than a year, but which do not currently participate in Highmark's network, must receive accreditation before they are eligible to apply for network participation.

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MEDICARE PUBLISHES PART B SPECIALTY GUIDES

Highmark Medicare Services has developed specialty guides to explain and provide hot links to source material for the following specialties or issues:

·        Ambulance

·        Ambulatory surgery centers

·        Anesthesia

·        Clinical laboratories

·        Podiatry

·        Physical therapy

The link below lead you to the Medicare Part B Specialty Guides website at Highmark Medicare Services:

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ASC PAYMENT REGS RELEASED

The Medicare Ambulatory Surgical Center (ASC) payment system final rule was published in the Federal Register by HHS on August 2, 2007. The link below is to the text of the regulations. The new payment rates will be effective for Medicare 2008, although the first impact will not be fully phased in until 2011, as follows:

                                    2008   -   25%

                                    2009   -   50%

                                    2010   -   75%

                                    2011   - 100%

The new system will increase the number of covered procedures from 2,571 5o 3,300. ASC groups expect payment reduction to a schedule that pays about 65% of hospital outpatient department payment rates.

Modern Healthcare reports in its July 23, 2007 issue that "ACS's Can't Drive at 65". The final rule established only policies and formulas for CMS to use in calculating payment rates, and the 65% is an estimate.

http://www.cms.hhs.gov/snfpps/downloads/CMS-1545-F-display.pdf

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PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

24.       The authority citation for part 414 is revised to read as follows:

Authority:       Secs. 1102, 1871, and 1881(b)(1) of the Social Security Act (42 U.S.C. 1302, 1395hh, and 1395rr(b)(1)).

Subpart B--Physicians and Other Practitioners

25.       Section 414.50 is revised to read as follows:

§414.50 Physician billing for purchased diagnostic tests.

(a)        General rule.  (1) For services covered under section 1861(s)(3) of the Act and paid for under part 414 of this chapter (other than clinical diagnostic laboratory tests paid under section 1833(a)(2)(D) of the Act, which are subject to the special rules set forth in section 1833(h)(5)(A) of the Act), if a physician or medical group bills for the technical or professional component of a diagnostic test that was performed by an outside supplier, the payment to the physician or the medical group (less the applicable deductibles and coinsurance) for the technical or professional component of the test may not exceed the lowest of the following amounts:

(i)         The supplier's net charge to the physician or medical group.

(ii)        The physician's or medical group's actual charge.

(iii)       The fee schedule amount for the test that would be allowed if the supplier billed directly.

(2)        This provision applies regardless of whether the test or its interpretation was purchased by the physician or medical group billing for the test or the interpretation, or whether the right to bill for the test or its interpretation was reassigned to the physician or medical group billing for the test or the interpretation.

(3)        For purposes of paragraph (a) of this section--

(i)         The physician's or other supplier's net charge must be determined without regard to any charge that is intended to reflect the cost of equipment or space leased to the outside supplier by or through the billing physician or medical group.

(ii)        An outside supplier is someone other than a full-time employee of the billing physician or medical group.

(b)        Restriction on payment. (1)  The physician or medical group must identify the supplier and indicate the supplier's net charge for the test. If the physician or medical group fails to provide this information, CMS makes no payment to the physician or medical group and the

physician or medical group may not bill the beneficiary.

(2)        Physicians and medical groups that accept Medicare assignment may bill beneficiaries for only the applicable deductibles and co-insurance.

(3)        Physicians and medical groups that do not accept Medicare assignment may not bill the beneficiary more than the payment amount described in paragraph (a) of this section.

26.       Section 414.65 is amended by revising paragraph (a)(1) to read as follows:

§414.65 Payment for telehealth services.

(a) *   *   *

(1)        The Medicare payment amount for office or other outpatient visits, consultation, individual psychotherapy, psychiatric diagnostic interview examination, pharmacologic management, end stage renal disease related services included in the monthly capitation payment (except for one visit per month to examine the access site), individual medical nutrition therapy, and neurobehavioral status exam furnished via an interactive telecommunications system is equal to the current fee schedule amount applicable for the service of the physician or practitioner.

            *          *          *          *          *

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The text of both of the discussions of the Independent Diagnostic Testing Facility (IDTF) regulations and of the specific regulations themselves are posted below in full. The fundamental changes from the earlier proposals are as follows:

1.      IDTF must maintain comprehensive general professional liability insurance in the amount of $300,000 per location.

2.      There will no longer be retroactive enrollment. The enrollment date will be the later of the completion of the application or the date the IDTF actually begins services, and enrollments will be processed through an online application.

3.      The IDTF will be required to provide updated information regarding any changes contained in the enrollment application regarding ownership, location, general supervision or adverse legal actions within 30 days of occurrence.

4.      The IDTF must have a documented complaint process. 

5.      The physician responsible for general supervision will not be ultimately responsible for the operations of the IDTF. The regulations will clarify that these responsibilities remain the responsibilities of the owners/shareholders.

6.      A physician may be responsible for only three IDTF sites, whether they be fixed or mobile. The responsibility clarification will not change the existing requirements for direct or personal supervision of tests.

7.      The sharing of facilities at fixed sites will be prohibited.

The specific requirements regarding these changes are listed in the proposed regulations and discussed in the comments below.

 Download file

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2008 MEDICARE CHANGES:

PHYSICIAN BILLING FOR PURCHASED DIAGNOSTIC TESTS

CMS is proposing to revise the rules on prohibited mark-ups for purchased diagnostic tests. Revised proposed Section 414.50 will state that “if the physician or medical group bills for the technical or professional component of a diagnostic test that was performed by an outside supplier, the payment to the physician or the medical group (less the applicable deductible and coinsurance) for the technical or professional component of the test may not exceed the lowest of the following amounts:

            (i)         The supplier’s net charge to the physician or medical group.

(ii)        The physician’s or medical group’s actual charge.

(iii)       The fee schedule amount for the test that would be allowed if the supplier billed directly.

This provision applies regardless of whether the test or its interpretation was purchased by the physician or medical group billing for the test or the interpretation, or the right to bill for the test or its interpretation was reassigned to the physician or medical group billing for the test or the interpretation.

For purposes of this provision, the physicians’ or other suppliers’ net charge must be determined without regard to any charge that is intended to reflect the cost of equipment or space leased to the outside supplier, buyer or through the billing physician or medical group, and an outside supplier is somewhat other than the full-time employee of the billing physician or medical group.

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CMS PROPOSES MEDICARE CHANGES FOR 2008

The Centers for Medicare and Medicaid Services (CMS) has issued its proposed rules to revise the Medicare Physician Fee Schedule (MPFS) for 2008. Links to both the CMS press release announcing the proposed rules and to the proposed rules themselves are contained below:

·        Press Release:

http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2239&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

·        Medicare Proposed Rule:

http://www.cms.hhs.gov/physicianfeesched/downloads/CMS-1385-P.pdf?agree=yes&next=Accept

The proposed rule implements the update procedure required by the sustainable growth rate (SGR) methodology, which result in a negative 9.9% update, i.e., a decrease, in Medicare payments. CMS notes that Congress has intervened to eliminate the negative update or decrease for each of the last five years.

Med Law Blog will post an article on what we believe to be the items of most interest to physicians over the next several weeks regarding the following items: proposals to close the perceived Stark loopholes, revisions in the enrollment process for independent diagnostic testing facilities (IDTF), and establishment of mark-up prohibitions for both the technical and professional component of diagnostic tests. Following is a description of the provisions in the proposed rule by CMS:

·        Updating the Geographic Practice Cost Indices (GPCI) to reflect more recent data.

·        Revising certain physician payment localities according to one of three proposed options

·        Using the Physician Assistance and Quality Initiative Fund (PAQI), created by TRHCA that provides $1.35 billion for physician payment and quality improvement initiatives, to extend voluntary quality reporting bonus payments into 2008.

·        Requiring that persons furnishing physical and occupational therapy services to people with Medicare meet licensing, registration, or certification requirements in the state in which they practice, and that they complete an approved educational program for the services they are furnishing. The proposed rule would also change the time frames for certifying a plan of care.

·        Updating regulations governing payment of certain services furnished in Comprehensive Outpatient Rehabilitation Facilities (CORF's), to reflect payment under the MPFS. This conforms to a statutory mandate.

·        Adding neurobehavioral status exams to the list of telemedicine services eligible for Medicare payment.

·        Adding certain ophthalmologic imaging procedures to the list of procedures that would be subject to the Deficit Reduction Act of 2005 (DRA) provision that caps payment for the technical component of imaging procedures at the payment amount under the hospital outpatient prospective payment system.

·        Modifying the requirements under the competitive acquisition program (CAP) for Part B drugs for verifying that a drug ordered by a physician has been administered.

·        Requiring the reporting of hemoglobin or hematocrit data on claims for drugs used to treat anemia secondary to anticancer treatment.

·        Modifying a number of physician self-referral provisions to close loopholes that have made the Medicare program vulnerable to abuse.

·        Modifying enrollment standards for Independent Diagnostic Testing Facilities (IDTFs).

·        Eliminating the exemption for computer-generated faxes from the e-prescribing standards.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Following is the text of a post from Alan Goldberg  identifying the CMS hospital report card. My thanks to Alan.

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| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

KEY FACTS: PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI)

PQRI is a precursor to Medicare pay for performance (P4P) or quality incentives established by the Tax Relief and Healthcare Act of 2006 (TRHCA). The first quality reporting period will be July 1, 2007 through December 31, 2007.

Payment Amount: Congress budgeted $1.35 billion but the payment amount per provider is;

(1)        Subject to the number of participating/reporting physicians;

(2)        Limited to no more than 1.5% of the total allowed charges for covered services provided during the reporting period, i.e., 7/1/07 - 12/31/07;

(3)        Will be paid in a single consolidated payment in “mid 2008.”

Eligible Providers: Doctors, Dentists, Chiropractors, Podiatrists, Optometrists, PT, OT, PA, CRNA, CNS, NM, Psychologist, Dietician.  

Eligible Services: CMS has identified 74 measures for 2007 PQRI; eligible services for 2008 are being developed.

Procedure and Reporting Thresholds: Providers should select services applicable to their patient panels. In order to “successfully report” and receive the bonus payments, certain reporting thresholds must be met:

(1)        When 3 or fewer measures are selected, providers must report in at least 80% of the potential cases.

(2)        When more than 3 measures are selected, the 80% threshold must be satisfied for at least 3 measures.

Sample instructions for 4 measures follows:

2007 Physician Quality Reporting Initiative (PQRI)Measure Specifications

DESCRIPTION:

Percentage of patients aged 18 through 75 years with diabetes (type 1 or type 2) who had most recent hemoglobin Al c greater than 9.0%

INSTRUCTIONS:

This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The performance period for this measure is 12 months. The most recent quality code submitted will be used for performance calculation. It is anticipated that clinicians who provide services for the primary management of diabetes mellitus will submit this measure.

This measure can be reported using CPT Category II codes:

ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender, etc..) are used to identify patients who are included in the measure's denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable performance exclusions for this measure.

NUMERATOR:

Patients with most recent hemoglobin Alc level > 9.0%

Numerator Instructions: This is a poor control measure. A lower rate indicates better performance (e.g., low rates of poor control indicate better care)

Numerator Coding:

Most Recent Hemoglobin Al c Performed

CPT II 3046F: Most recent hemoglobin Alc level > 9.0% OR

CPT II 3044F: Most recent hemoglobin Alc level < 7.0% OR

CPT II 3045F: Most recent hemoglobin Alc level 7.0% to 9.0%

OR

Hemoglobin Al c not Performed, Reason Not Specified

Append a reporting modifier (8P) to CPT Category II code 3046F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

• 8P: Hemoglobin Alc level was not performed during the performance period (12 months), reason not otherwise specified

DENOMINATOR:

Patients aged 18-75 years with the diagnosis of diabetes

Denominator Coding:

An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required to identify patients for denominator inclusion.

ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00, 648.01, 648.02, 648.03, 648.04

AND

CPT ERA service codes or G-codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211,99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99343, 99324, 99344, 99325, 99345, 99326, 99347, 99327, 99348, 99328, 99349, 99334, 99350, 99335, G0270, 99336, G0271, 99337, 99341, 99342,

RATIONALE:

Intensive therapy of glycosylated hemoglobin (Al c) reduces the risk of microvascular complications.

CLINICAL RECOMMENDATION STATEMENTS:

A glycosylated hemoglobin should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than three-month intervals. (AACE/ACE)

The Al c should be universally adopted as the primary method of assessment of glycemic control. On the basis of data from multiple interventional trials, the target for attainment of glycemic control should be Al c values 6.5%. (AACE/ACE)

Obtain a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care. In the absence of well-controlled studies that suggest a definite testing protocol, expert opinion recommends glycosylated hemoglobin be obtained at least twice a year in patients who are meeting treatment goals and who have stable glycemic control and more frequently (quarterly assessment) in patients whose therapy was changed or who are not meeting glycemic goals. (Level of evidence: E) (ADA)

Because different assays can give varying glycated hemoglobin values, the ADA recommends that laboratories only use assay methods that are certified as traceable to the Diabetes Control and Complications Trial Al c reference method. The ADA's goal for glycemic control is Al c <7%. (Level of evidence: B) (ADA)

Monitor and treat hyperglycemia, with a target Al C of 7%, but less stringent goals for therapy may be appropriate once patient preferences, diabetes severity, life expectancy and functional status have been considered. (AGS)

DESCRIPTION:

Percentage of patients aged 18 through 75 years with diabetes (type 1 or type 2) who had most recent LDL-C level in control (less than 100 mg/dl)

INSTRUCTIONS:

This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The performance period for this measure is 12 months. The most recent quality code submitted will be used for performance calculation. It is anticipated that clinicians who provide services for the primary management of diabetes mellitus will submit this measure.

This measure can be reported using CPT Category II codes:

ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender, etc.) are used to identify patients who are included in the measure's denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable performance exclusions for this measure.

NUMERATOR:

Patients with most recent LDL-C < 100 mg/dL

Numerator Coding:

Most Recent LDL-C Performed

CPT II 3048F: Most recent LDL-C < 100 mg/dL

OR

CPT II 3049F: Most recent LDL-C 100-129 mg/dL

OR

CPT II 3050F: Most recent LDL-C 130 mg/dL

OR

LDL-C Level not Performed, Reason Not Specified

Append a reporting modifier (8P) to CPT Category II code 3048F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

• 8P: LDL-C was not performed during the performance period (12 months), reason not otherwise specified

DENOMINATOR:

Patients aged 18-75 years with the diagnosis of diabetes

Denominator Coding:

An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required to identify patients for denominator inclusion.

ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00, 648.01, 648.02, 648.03, 648.04

AND

CPT EIM service codes or G-codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99343, 99324, 99344, 99325, 99345, 99326, 99347, 99327, 99348, 99328, 99349, 99334, 99350, 99335, G0270, 99336, G0271, 99337, 99341, 99342

RATIONALE:

Persons with diabetes are at increased risk for coronary heart disease (CHD). Lowering serum cholesterol levels can reduce the risk for CHD events.

CLINICAL RECOMMENDATION STATEMENTS:

A fasting lipid profile should be obtained during an initial assessment, each follow-up assessment, and annually as part of the cardiac-cerebrovascular-peripheral vascular module. (AACE/ACE)

A fasting lipid profile should be obtained as part of an initial assessment. Adult patients with diabetes should be tested annually for lipid disorders with fasting serum cholesterol, triglycerides, HDL cholesterol, and calculated LDL cholesterol measurements. If values fall in lower-risk levels, assessments may be repeated every two years. (Level of evidence: E) (ADA)

Patients who do not achieve lipid goals with lifestyle modifications require pharmacological therapy. Lowering LDL cholesterol with a statin is associated with a reduction in cardiovascular events. (Level of evidence: A)

Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients with known coronary artery disease and type 2 diabetes. (ACP)

Statins should be used for primary prevention against macrovascular complications in patients with type 2 diabetes and other cardiovascular risk factors.

Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin.

Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction, therefore monitor and treat hypertension and dyslipidemias. (AGS)

DESCRIPTION:

Percentage of patients aged 18 through 75 years with diabetes (type 1 or type 2) who had most recent blood pressure in control (less than 140/80 mm Hg)

INSTRUCTIONS:

This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The performance period for this measure is 12 months. The most recent quality code submitted will be used for performance calculation. It is anticipated that clinicians who provide services for the primary management of diabetes mellitus will submit this measure.

This measure can be reported using either CPT Category II codes:

ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender, etc.) are used to identify patients who are included in the measure's denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or G-codes, and the appropriate CPT Category II codes OR the CPT Category II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable performance exclusions for this measure.

NUMERATOR:

Patients whose most recent blood pressure < 140/80 mm Hg

Numerator Instructions: To describe both systolic and diastolic values, two codes must be reported for this measure. For the systolic blood pressure value, report one of the systolic codes; for the diastolic blood pressure value, report one of the diastolic codes. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure.

Numerator Coding:

Most Recent Blood Pressure Measurement Performed

Systolic codes

CPT II 3074F: Most recent systolic blood pressure < 130 mm Hg

OR

CPT II 3075F: Most recent systolic blood pressure 130 to 139 mm Hg

OR

CPT II 3077F: Most recent systolic blood pressure > 140 mm Hg

AND

Diastolic codes

CPT II 3078F: Most recent diastolic blood pressure < 80 mm Hg OR

CPT II 3079F: Most recent diastolic blood pressure 80-89 mm Hg

OR

CPT II 3080F: Most recent diastolic blood pressure > 90 mm Hg

OR

Blood Pressure Measurement not Performed, Reason Not Specified

Append a reporting modifier (8P) to CPT Category II code 2000F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

• 8P: No documentation of blood pressure measurement, reason not otherwise specified

DENOMINATOR:

Patients aged 18-75 years with the diagnosis of diabetes

Denominator Coding:

An ICD-9 diagnosis code for diabetes and a CPT E/M service code are required to identify patients for denominator inclusion.

ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00, 648.01, 648.02, 648.03, 648.04

AND

CPT UM service codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99344, 99325, 99345, 99326, 99347, 99327, 99348, 99328, 99349, 99334, 99350, 99335, G0270, 99336, G0271, 99337, 99341, 99342, 99343

RATIONALE:

Intensive control of blood pressure in patients with diabetes reduces diabetes complications, diabetes-related deaths, strokes, heart failure, and microvascular complications.

CLINICAL RECOMMENDATION STATEMENTS:

Recommends that a blood pressure determination during the initial evaluation, including orthostatic evaluation, be included in the initial and every interim physical examination. (AACE/ACE)

Blood pressure control must be a priority in the management of persons with hypertension and type 2 diabetes. (ACP)

Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic blood pressure >130 mmHg or diastolic >80 mmHg should have blood pressure confirmed on a separate day. Orthostatic measurement of blood pressure should be performed to assess for the presence of autonomic neuropathy. (Level of Evidence: E) (ADA)

Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction, therefore monitor and treat hypertension and dyslipidemias. (AGS)

Measurement of blood pressure in the standing position is indicated periodically, especially in those at risk for postural hypotension. At least two measurements should be made and the average

recorded. After BP is at goal and stable, follow-up visits can usually be at 3- to 6-month intervals. Comorbidities such as heart failure, associated diseases such as diabetes, and the need for laboratory tests influence the frequency of visits. (JNC)

All individuals should be evaluated during health encounters to determine whether they are at increased risk of having or of developing chronic kidney disease. This evaluation of risk factors should include blood pressure measurement. (NKF)

Additional information is available as follows:

(1)        CMS PQRI Link: http://www.cms.hhs.gov/PQRI/

(2)        Three National Provider teleconferences; see:

parta-education@highmarkmedicarservices.com

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

View David Harlow's HealthBlawg for an update onn CMS PQRI.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The General Accounting Office (GAO) has issued a report recommending physician profiling, which they define as identifying efficient physicians. The entire report, i.e., GAO-07-307, is available at the following link: http://www.gao.gov/new.items/d07307.pdf

Following are key findings:

GAO estimates that physician account for 20% of the total health care expenditures, but influence 90% of total expenditures through referrals, admissions, etc.

Physician profiling activities occur in Medicare today, but they focus largely on improper billing practices rather than on efficient care delivery.

The report (1) estimates the prevalence in Medicare physicians who are likely to practice medicine inefficiently, (2) examines physician-focused strategies used by public and private sector health care purchasers to encourage efficient medical care, and (3) examines the potential for CMS to profile physicians in traditional Fee For Service (FFS) Medicare for efficiency and use the results in ways that are similar to other purchasers that encourage efficiency.

Overly expensive beneficiaries account for nearly one-half of total Medicare expenditures even though they represent only 20% of beneficiaries in the sample. 

Pittsburgh was included in the 12 metropolitan areas in which Medicare claims were examined. Pittsburgh’s percentage of outlier physicians was 3.8%, which was tenth on the list, with the lowest being Albuquerque, New Mexico, at 2.0%, and the highest being Miami, Florida, at 20.9%.

GAO recommends that CMS develop a profiling system which includes the following elements:

§      total Medicare expenditures as the basis for measuring efficiency, adjustments for differences in patients' health status,

§      empirically based standards that set the parameters of efficiency,

§      a physician education program that explains to physicians how the profiling system works and how their efficiency measures compare with those of their peers,

§      financial or other incentives for individual physicians to improve the efficiency of the care they provide, and

§      methods for measuring the impact of physician profiling on program spending and physician behavior.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

TEN TOP PHYSICIAN BILLING ERRORS

Highmark Medicare Services recently presented a teleconference on the ten top reasons for rejections and most common billing errors. The list is as follows:

1.         No performing PIN

2.         No verification HIC/entitlement

3.         Invalid procedure code

4.         Incomplete physical exam information for chiropractic services

5.         Missing or incomplete modifiers

6.         Missing CLIA information

7.         Missing facility address

8.         No referring UPIN

9.         NOC Code without description

10.       Incomplete address elements for patients, insured patient representative or service/supplier

For complete information about this program, go to the following link:

http://www.highmarkmedicareservices.com/calendar/partb/teleconferences.html

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

TEN TOP PHYSICIAN BILLING ERRORS

Highmark Medicare Services recently presented a teleconference on the ten top reasons for rejections and most common billing errors. The list is as follows:

1.         No performing PIN

2.         No verification HIC/entitlement

3.         Invalid procedure code

4.         Incomplete physical exam information for chiropractic services

5.         Missing or incomplete modifiers

6.         Missing CLIA information

7.         Missing facility address

8.         No referring UPIN

9.         NOC Code without description

10.       Incomplete address elements for patients, insured patient representative or service/supplier

For complete information about this program, go to the following link:

http://www.highmarkmedicareservices.com/calendar/partb/teleconferences.html

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Highmark Blue Shield has expanded its list of procedures requiring pre-authorization. The full list of procedures is available on the Highmark Resource Center website:

https://www.highmarkblueshield.com/pdf_file/rc-hbs-auth-code-update-april-2007.pdf

It includes a significant number of home health and DME services, prosthetic devices and other services. 

Highmark has also removed two procedures from the list, i.e., pharmacologic management (90862) and the new technology intraocular lens Category 3 (Q1003).

These changes will be effective April 1, 2007 and will apply to members enrolled in Select Blue, Direct Blue and Freedom Blue.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

2007 Physician Quality Reporting Initiative (PQRI)

National Provider Conference Call with Question & Answer Session

The Centers for Medicare & Medicaid Services’ (CMS) Provider Communications Group will host the first in a series of national provider conference calls on the 2007 Physician Quality Reporting Initiative (PQRI). This toll-free call will take place from 3:00 p.m. – 5:00 p.m., EST, on Tuesday, March 27, 2007.

On December 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA).  TRHCA section 101 authorizes a financial incentive for eligible professionals to participate in a voluntary quality reporting program.  Eligible professionals, who chose to participate and successfully report on a designated set of quality measures for services paid under the Medicare Physician Fee Schedule and provided between July 1 and December 31, 2007, may earn a bonus payment of 1.5% of their charges during that period, subject to a cap.   To review the list of eligible professionals, visit http://www.cms.hhs.gov/PQRI/10_EligibleProfessionals.asp#TopOfPage on the CMS website. All Medicare-enrolled professionals in these categories are eligible to participate in the 2007 PQRI, regardless of whether the professional has signed a Medicare participation agreement to accept assignment on all claims.

An overview of the 2007 PQRI will be presented that will include discussion about eligible professionals, reporting, measures and codes, and analysis and payment.   A PowerPoint slide presentation will be posted to the PQRI webpage at http://www.cms.hhs.gov/PQRI/30_EducationalResources.asp#TopOfPage on the CMS website for you to download prior to the call so that you can follow along with the presenter, Susan Nedza, M.D.

In addition, MLN Matters article MM5558, posted on the Medicare Learning Network, can be referenced prior to the call.  The article provides a program overview of the 2007 PQRI.  MM5558 is available at the following link:     http://www.cms.hhs.gov/mlnmattersarticles/downloads/mm5558.pdf.

Following the presentation, callers will have an opportunity to ask questions of CMS subject matter experts.

Conference call details:                                                

                                                Date:  Tuesday, March 27, 2007                                                                                                          Conference Title:  2007 Physician Quality Reporting Initiative

                                                Time:  3:00 p.m. – 5:00 p.m. EST

In order to receive the call-in information, you must register for the call via the internet by following the instructions below.

If you are planning to sit in with a group, only one person needs to register to receive the call-in data.  This registration is solely to reserve a phone line, not to allow participation.

1.         To register for the call participants need to go to:

https://ww4.premconf.com/webrsvp/register?conf_id=549030

2.         Click ”Continue” to be taken to the registration screen.

3.         Fill in all required data.

4.         Click ”Submit”.

5.         You will be taken to the confirmation screen where the call-in number will

be given.

6.         The pass code for the call is 549030.

7.         To view the time the call will start, registrants will need to select their

time zone in the drop down box under ”Time” on the confirmation screen.

8.         Click "Confirm Registration" to receive a confirmation email.

Online Evaluation Form

CMS has developed an online evaluation form that can be quickly completed and submitted. Participants are asked to complete this online evaluation form to help CMS make informed decisions on improving training activities. The online evaluation form titled “Training Evaluation Form” can be found on the registration page, http://www.cms.hhs.gov/medlearn/cont_eval_form.asp.  CMS looks forward to hearing your comments.

If you have questions, or require special accommodations, please contact Geanelle E. Griffith at geanelle.griffith@cms.hhs.gov or at (410) 786-4466.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

MEDICAL PAYMENT ADVISORY COMMISSION (MEDPAC) REPORTS

DEAL WITH PRACTICE EXPENSE METHODOLOGY, SGR AND P4P: 

MedPac reported to Congress on a variety of issues in March of 2007. MedPac predicted that the new practice expense methodology will produce a 7% E&M increase, but an 8-9% decrease for major imaging procedures by 2010. MedPac concluded that Sustainable Growth Rate (SGR) methodology is flawed and will continue to produce Medicare reimbursement declines unless revised.

While recommending a payment update (i.e., increase) for 2008, despite SGR projected decreases, and implementation of quality payment initiatives, MedPac nevertheless concluded that the prime indicators of Medicare physician reimbursement adequacy, i.e., participating physician members and beneficiary service volume, are stable, and concluded that any Medicare reimbursement update should be offset by expected gains in physician productivity of 1.7%, stating “Physicians, like other providers, taxpayers and firms that fund Medicare, should be expected to increase their productivity each year.”  

Access to the complete report is available at the MedPac website: http://www.medpac.gov/.,

which is also accessible through the Blog links.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

PRESCRIPTION FOR PENNSYLVANIA - GOVERNOR RENDELL’S PROPOSAL

FOR PENNSYLVANIA HEALTH CARE REFORM

Representatives of Governor Rendell’s administration reported at the Pennsylvania Bar Institute Annual Health Law Institute that Governor Rendell’s “Prescription for Pennsylvania,” the comprehensive state health care reform program, is expected to be presented to the Pennsylvania Legislature before the end of the month. Prescription for Pennsylvania is intended to increase access, affordability and quality throughout Pennsylvania.

Although the legislation has not yet been officially  proposed, so we cannot yet provide any specific analysis, it is expected that some of the significant components will be as follows:

§      Expanded required health insurance coverage for small employers (along with tax-based financial incentives), expansion of basic health insurance coverage for uninsured, and required health insurance coverage for college students;

§      Expansion of the scope of practice for nurse practitioners, physician assistants, certified registered nurse anesthetists and nurse midwifes, including such items as expanded prescription authority, expanded independent practice, and required credentialing by networks and health care providers;

§      Expansion of medical facility sites to improve access for Pennsylvanians by allowing nurse managed care centers, expansion of federally qualified health centers, allowing pharmacists to manage drug therapies in hospitals and other institutions, and supporting nurse practitioner practice in pharmacies;

§      Re-establishing of a process similar to Certificate of Need which will require regional approval based on resource budgets for new facilities such as imaging facilities and ambulatory surgery centers in Pennsylvania; and

§      Comprehensive Pay for Performance programs which will be uniform across third party payor programs to provide united incentives for performance improvement.

All of this is, of course, subject to specific proposals yet to be presented. Information can be obtained from the following websites:

http://www.gohcr.state.pa.us/prescription-for-pennsylvania/Rx-for-Pennsylvania.pdf

http://www.gohcr.state.pa.us/prescription-for-pennsylvania/Rx-for-Affordability.pdf

http://www.gohcr.state.pa.us/prescription-for-pennsylvania/Rx-for-Access.pdf

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

The Centers for Medicare and Medicaid Services (CMS) has quietly reversed itself on the new standards for Independent Diagnostic Testing Facilities (IDTFs). Transmittal 187, which established new standards for IDTFs and was scheduled to be effective as of February 26, 2007,  was rescinded without explanation. Therefore, some of the more significant changes, such as:

§      Limiting the number of sites a physician can supervise to three and expanding the supervising physician’s responsibilities to include overall operation and administration;

§      Prohibiting the sharing of facilities without a Medicare supplier; and

§      Establishing 14 specific operating standards;

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that the 2007 Physician Quality Reporting Initiative (PQRI) webpage is now available.

On December 20, 2006 the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the 2007 Physician Quality Reporting Initiative.

PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services.

This newly established webpage will be updated regularly, so check it often for timely and reliable information from CMS.

For more information on 2007 PQRI, visit http://www.cms.hhs.gov/PQRI/01_Overview.asp#TopOfPage on the CMS website.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The Centers for Medicare and Medicaid Services (CMS) announced significant changes to the regulatory requirements for operating independent diagnostic testing facilities (IDTFs) on January 26, 2007, which new rules will become affective February 26, 2007. These new requirements affect the:

§      Performance standards for operation.

§      The requirements for both interpreting and supervising physicians.

§      Licensing requirements for technicians.

Rather than try to summarize all of the changes for you, I am including links to both explanatory and direct source materials:

A.        Summary of Independent Diagnostic Testing Facility Performance Standards from the CMS Website. www.cms.hhs.gov/MedicareProviderSupEnroll/downloads/Independentdiagnostictestingfacility.pdf

B.         CMS Manual System Pub 100-08 regarding the implementation of new compliance standards for Independent Diagnostic Testing Facilities,  found courtesy of “Health Blawg”,  which is David Harlow’s Healthcare Law Blog. healthblawg.typepad.com/healthblawg/2007/02/idtf_requiremen.html

C.        Section 42 CFR § 410.33, which are the formal federal regulations defining the requirements for Independent Diagnostic Testing Facilities.  ecfr.gpoaccess.gov/cgi/t/text/text-idx 

D.        Highmark Medicare Services Independent Diagnostic Testing Facility Billing Guide. www.highmarkmedicareservices.com/partb/bguides/idtf.html

I hope the information is helpful.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Medicare will cover intracranial percutaneous angioplasty (PTA) with stenting effective February 5, 2007. MLN Matters #MM5432 released on January 5, 2007 explains the changes in Medicare policy regarding reimbursement for PTA. Coverage will be effective as of November 6, 2006 for a PTA and stenting of intracranial arteries for the treatment of cerebral artery stenosis greater than equal to 50% in patients with intracranial atherosclerotic disease when furnished in accordance with FDA-approved protocols. The key points announced in the MLN Matters article are as follows:

§      Providers billing FIs and A/B MACs should note this coverage applies to claims with:

·        A discharge date on or after November 6, 2006;

·        ICD-9-CM procedure codes of 00.62 and 00.65 both being present;

·        ICD-9-CM diagnosis code 437.0 present; and

·        The IDE number present on a 0624 revenue code line.

§      Non-institutional providers billing Medicare carriers or A/B MACs should note this coverage applies to claims with:

·        CPT code 37799 (Unlisted procedure, Vascular surgery);

·        A QA modifier to denote Category B IDE clinical trial; and

·        The appropriate IDE number.

For full information on the transmittals can be obtained from the CMS website at the following two link:

http://www.cms.hhs.gov/Transmittals/downloads/R1147CP.pdf

http://www.cms.hhs.gov/Transmittals/downloads/R64NCD.pdf.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Highmark Blue Cross Blue Shield plans to follow the Medicare reductions for the technical component of multiple diagnostic imaging services beginning in the spring of 2007. Following is a quote from the announcement in the December 2006 PRN:

“Highmark Blue Cross Blue Shield plans to reduce payment for certain diagnostic imaging services when more than one service is performed for the same patient, during the same session, on the same service date.

Blue Cross Blue Shield’s payment reduction will be similar to the policy implemented by the Centers for Medicare & Medicaid Services in January 2006.

Blue Cross Blue Shield’s payment reduction will affect only the technical component of the diagnostic imaging services. Implementation of the payment reduction is planned for spring of 2007.”

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

Assuming siganture by the President of the "Medicare Improvments and Extension Act of  2006"  , the following will be the major Medicare changes for the coming year. The complete text of the changes and Committee reports are avaialble on the link in the article posted here yesterday.

1.        2007 PHYSICIAN FEE SCHEDULE: The conversion factor for the Medicare Physician Fee was revised for 2007 only to eliminate the 5% reduction which would have been mandatory under Medicare’s sustainable growth rate formula.

2.         QUALITY REPORTING INCENTIVES OF 1.5% FOR 2007: The Act establishes a mechanism for enhancing the quality of reporting system first established by the Medicare Improvement Act of 2003 by adopting the quality measure specified in the physician voluntary reporting program, previously established by the Centers for Medicare and Medicaid Services, and establishing deadlines for adoption new quality measures. The Act provides transitional bonus incentive payments for quality reporting in 2007 equal to 1.5% of the Secretary’s estimate of allowed charges under the federal supplementary medical insurance trust fund for the covered professional services furnished during the reporting period, and provides future funding to promote physician payment stability and quality initiatives of $60 million to be transferred from the fund in 2007, 2008 and 2009.

3.         MEDICARE GEOGRAPHIC ADJUSTMENT: Extends floor established in Section 1848 (e) (1) (E) of the Social Security Act by MMA 2003 is extended through 2007 to protect physician work component payments in rural areas.

4.         2007 END STAGE RENAL DIALYSIS (ESRD) UPDATE: The composite rate component of the basic case -mix prospective payment is increased by 1.6% for 2007.

5.         RURAL CLINICAL DIAGNOSTIC LABORATORY TESTS: Reasonable cost payments for certain clinical diagnostic laboratory tests furnished to hospital patients in rural areas is extended until 2008.

6.         COMPETITIVE ACQUISITION PROGRAM (CAP): An audit process is established for reviewing drug and biological payments in the CAP program.

7.         QUALITY REPORTING PENALTIES: The Act extends the 2% penalty for the failure to observe the quality reporting programs for hospitals and applies it to ambulatory surgery centers.

8.         MEDICARE THERAPY EXCEPTION PROCESS: The exception process for appealing additional physical therapy payments is extended through 2007.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

All health care providers covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) must begin using the standard unique identifiers for healthcare providers and health plans mandated by HIPAA no later than May 23, 2007. According to the Centers for Medicare and Medicaid Services release on November 17, 2006, “every covered health care provide must obtain a new NPI … even providers that do not conduct electronic transactions and are not covered by HIPAA may be required by health plans or employers to obtain one.” CMS states that health care providers can apply for NPIs in one of three ways:

§      For the most efficient application processing in the fastest receipt of NPIs, use the web-based application process. Simply log onto the National Plan and Provider Enumeration System (NPPES) and apply on line.

§      Health care providers can agree to have an Electronic File Interchange (EFI) organization (EFIO) submit application data on their behalf if an EFIO requests their permission to do so.

§      Health care providers may wish to obtain a copy of the paper NPI Application/Update Form (CMS-10114) and mail the completed, signed application to the NPI Enumerator located in Fargo, North Dakota.

NPI information can be obtained at the CMS website at:

http://www.cms.hhs.gov/NationalProvIdentStand/03_apply.asp.

Information can be obtained from the NPI Enumerator at Phone: 1-800-465-3203 or Email:

customerservice@npienumerator.com.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The Office of Inspector General (OIG) issued Advisory Opinion 06-22, which is another in a series of similar approving gainsharing arrangements, i.e., 01-01 and 05-01 through 05-06. Under the current proposed arrangement, a hospital would pay a cardiac surgery group 50 percent of the hospital’s first year cost savings directly attributable to specific changes in the surgical group’s operating room practices, which changes would involve (1) limiting the use of certain surgical supplies, (2) substituting less costly items for items currently being used by the surgeons, and (3) product standardization of certain cardiac devices. As with its earlier gainsharing opinions, the OIG concluded that the proposed arrangement would implicate the civil monetary penalty (CMP) provisions, and would potentially implicate the anti-kickback law, but that the OIG would not impose sanctions under these authorities against the requestors, given the following safeguards:

Civil Money Penalties

(1) The practices and savings would be “clearly and separately identified” allowing “for public scrutiny and individual physician accountability for any adverse effects.”

(2) There was “credible medical support” for that position that the arrangement would “not adversely affect patient care.”

(3) The payments would be based on all surgeries regardless of payor.

(4) The arrangement would protect against “inappropriate reductions in services” by utilizing “objective historical and clinical measures.”

(5) The physicians would nevertheless have the same selection of surgical devices available, regardless of standardization.

(6) Full disclosure of the program would be provided to patients.

(7) The financial incentives under the proposed arrangement would be “reasonably limited in duration and amount.

(8) The surgical group’s profits would be distributed on a per capita basis and, as such, “any incentive for an individual surgeon to generate disproportionate cost savings” would be “mitigated.

Anti-Kickback Law. 

(1) The arrangement would have a one-year term, participation would be limited to surgeons already on the Hospital’s medical staff, and the potential savings derived from procedures for Federal healthcare program beneficiaries would be capped (based on the prior year’s admissions of such beneficiaries).

(2) Because the surgeon group would be composed only of cardiac surgeons, the proposed arrangement could not be used to reward cardiologists or other physicians in a position to make referrals to the surgical group.

(3) Because the cost saving recommendations carry “some increased liability risk for the physicians,” it is “not unreasonable for the surgeon to receive compensation,” particularly where it would be limited in amount, duration, and scope.

Stark Law. 

Finally, as in its earlier gainsharing opinions, the OIG declined to provide any guidance regarding the Stark Law because it is outside the scope of the advisory opinion process.  

The full opinion is available on the OIG website at http://oig.hhs.gov/.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

In accordance with § 626 of the Medicare Modernization Act of 2003, which commissioned a study by the GAO to evaluate a payment system using groups of covered services under the outpatient prospective payment system, the Centers for Medicare and Medicaid Services (CMS) proposed a new reimbursement system for Ambulatory Surgery Centers (ASC) on August 23, 2006 in the Federal Register. The full text of the proposal is available at www.cms.hhs.gov/ASCPayment/06_CMS1506P.asp#TopOfPage. Key changes include:

1.         A new ASC Fee Schedule protocol which will link the ASC procedure payment rate to approximately 62% of the reimbursement rate for the procedures as done in hospital outpatient departments, which rates will be phased in beginning January 1, 2008 and will become fully operational as of January 1, 2009;

2.         The addition of 14 procedures to the lists in 2007;

3.         The addition of 750 new procedures to the lists for 2008, which procedures will primarily be office-based procedures but for which the reimbursement will be capped at the lower of the non-facility expense for that procedure as provided in the Medicare Physician Fee Schedule or the new ASC rates; and

4.         The bundling of most surgical implants into the new ASC rates.

The goal of the new ASC reimbursement protocol is to coordinate ASC payments with hospital outpatient department payments at a rate which is intended to maintain neutrality between site of service choices. The proposed uniform conversion rate is intended to implement such neutrality. However, given the significant relative discrepancies between certain groups of ASC reimbursement at current rates, with some categories increasing and some categories decreasing, the new payment rate may change the economics of current ASC structures. The proposals fail to maintain relative neutrality between site of service by failing to have uniform inflation adjustments or update factors and failing to provide the same set of professional services for ambulatory surgery centers.

| Posted By Michael Cassidy In Medicare & Reimbursement | 2 Comments | Permalink

The Centers for Medicare and Medicaid Services (CMS) issued the final rule for the 2007 Physician Schedule on November 1, 2006, which will soon be published in the Federal Register.

§      The final rule provides a 5% reduction in the 2007 Fee Schedule, which is just a slight change from the proposed 5.1% reduction proposed in August of 2006. 

§      The work component RVU for the intermediate office visit E & M Code will increase by 37%.

§      There will be a 25% reduction in the technical component for multiple imaging services rather than the original proposed 50% reduction.

§      Nuclear imaging services will be included as a Stark designated health service.

A link to the Physician Fee Schedule will be published as soon as it is posted.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

CMS Gainsharing Demonstration

            The Centers for Medicare and Medicaid Services (CMS) announced its Physician-Hospital Collaboration Demonstration (PHCD) Project. This is a three year demonstration program designed to examine whether allowing hospitals to provide financial incentives for physicians to support better care can improve patient outcomes without increasing costs. The CMS Press Release is available in the CMS website in the CMS Press Release Archives at http://www.cms.hhs.gov/apps/media/ questionmedia=pressr.

Congressional Advisory Board Analyzes Physician Payment System Options

            The Supplemental Medical Insurance program (Part B of Medicare), which will cost about $158 billion in 2006, pays for physicians' services, outpatient hospital services, durable medical equipment, physical therapy, and certain other outpatient services. About 38 percent of those expenditures are payments for services provided by physicians, which are based on a schedule of fees that specifies the amount to be paid for each type of service. Most of Medicare's payment rates are simply adjusted each year for inflation -- but not those for physician's services. Those rates are governed by a complex formula -- the Sustainable Growth Rate (SGR) mechanism -- that, unless overridden by legislation, will reduce fees by about 4 percent or 5 percent annually for at least the next several years.

            Legislation has overridden the formula's results in each of the past four years, and the prospect of future, year-after-year rate reductions raised the question of whether the SGR formula is a viable mechanism -- and if not, what alternatives might be appropriate. This brief describes the SGR mechanism and presents the potential budgetary effects of several other approaches. Many of the possible alternatives would be costly. For example, overriding the formula with a 1 percent rate increase in 2007 would raise outlays by $6 billion over the next 10 years. Replacing the formula with an inflation index would cost more than $200 billion over the coming decade.

            The full report is available at http://www.cbo.gov/ftpdocs/75xx/doc7542/09-07-SGR-brief.pdf.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

In the Proposed Rules, the link for which was provided in the August 29, 2006 MedLaw Blog post, CMS announced proposed changes to the reassignment exceptions for purposes of Medicare billing and to the definition of “centralized building” for purposes of the ancillary services exception of Stark II.

REASSIGNMENT

CMS is basically proposing to treat purchased technical components of diagnostic tests and the purchased professional component (i.e., interpretations) of tests similarly. Section 1861 (s)(3) of the Social Security Act already prohibits the purchase and mark-up of diagnostic tests, i.e., the technical component. CMS is concerned that the reassignment changes enacted by § 952 of the Medicare Modernization Act of 2004 (MMA), which amends Social Security Act § 1842 (b)(6)(A)(i) to allow Prescription Drug, Improvement, and "where the service was provided under a contractual arrangement between such physician or other person and entity" would be misunderstood to allow the purchase of the professional component of a test for less than the Medicare Fee Schedule and an resulting mark-up through the reassignment provisions. Prior to MMA, reassignment was basically allowed only among employers/employees and when services were performed on the premises of designated healthcare facilities (i.e., hospitals and physician directed clinics). CMS commented that the reassignment rules were basically intended to accommodate hospital emergency department staffing companies that employed physicians on a contract basis.

By permitting reassignment for “contractual arrangements”, CMS is concerned that this reassignment exception can be used in conjunction with the “physician services” exception for purposes of the Stark Act to justify arrangements in which physicians are enrolled in multiple assignment accounts under contractual arrangements to provide services on a basis that would permit the mark-up of those services by the billing physician group. CMS stated that its concerns in this area are best illustrated by the “pod laboratory” concept, the legality of which was questioned in Advisory Opinions 04-18 and 04-17, in which an entity would lease space in a medical building, sub-divide the space into separate areas or cubicles for different physician groups, and enroll the pathologists in the assignment accounts of each of the physician groups in order to allow those physician groups to bill directly for those services. 

In order to restrict or prevent these arrangements, CMS is proposing two amendments and is considering a third, as follows:

1.         CMS is proposing that the amount billed to Medicare by the billing entity may not exceed the lowest of the following amounts:

a.         The physician or other supplier's net charge to the billing physician or medical group,

b.         The billing physician's or medical group's actual charge, or

c.         the fee schedule amount for the service that would be allowed if the physician or other supplier billed directly.

2.         CMS is proposing that, in order to bill for the technical component, the billing entity would be required to perform the interpretation.

3.         CMS is considering further amendments that would impose conditions on when a physician or medical group may bill for reassigned professional components of diagnostic tests such as requiring that the test must be ordered by a physician that is financially independent of the person or entity performing the test and also of the physician or medical group performing the interpretation, requiring that the physician or medical performing the interpretation does not actually see the patient, and requiring the physician or medical group billing for the interpretation to have performed the technical component of the test.

Frankly, these requirements existing would not appear to restrict enrollment in multiple assignment accounts any more than group practice requirements. Perhaps, that is why the amendment of these “centralized building” definition is key to these provisions.

CENTRALIZED BUILDING

The pod concept concerns CMS because it theoretically allows the establishment of multiple centralized buildings at a single location for the performance of ancillary services in situations where none of the individual spaces is actually independently capable of performing the professional services. Therefore, CMS is proposing to revise the definition of “centralized building” to add the following language:

“A centralized building does not include space that is owned or leased by a group practice if that space is less than 350 square feet. This limitation does not apply to space owned or rented in a building where no more than three group practices own or lease space in the ‘same building’ (as defined in this section) and share the same ‘physician in the group practice’ (as defined in this section). A centralized building does not include space owned or leased by a group practice if equipment needed to perform substantially all (at least 90% of the designated health services furnished in that space in any given calendar year) is not permanently located in that space. That is, equipment needed to perform more than 10% of the designated health services furnished in that space in a calendar year cannot be temporarily moved into that space from another space in the ‘same building’ or from outside ‘the same building'."

The purpose of this amendment is obviously to make it impossible to establish centralized buildings for multiple physician practices, but to still recognize the fact that many physicians legitimately practice in relatively small physical facilities for purposes of providing ancillary services.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

CMS and the OIG are concerned with the potential for erroneous payments for either unjustified or medically unnecessary services in the independent diagnostic testing facilities (IDTF), which concern is initially based upon an audit performed for fiscal year 2001 by the OIG (A-03-03-00002). Therefore, in the August 22, 2006 Proposed Regulations, a link to which was posted here in yesterday's MedLAw Blog post,  the Department of Health and Human Services (HHS) is proposing to subject IDTFs to standards similar to Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) as promulgated at 42 CFR 424.57 on October 11, 2000. IDTF would be required to meet the following standards as of January 1, 2007 and any new or re-enrolling IDTF would be required to certify compliance with those standards at the time of application, which standards are as follows:

1.         Operate its business and compliance with all applicable federal, state and local licensure and regulatory requirements with regard to the health and safety of patients;

2.         Provide complete and accurate information on Medicare participation enrollment applications;

3.         Maintain a physical facility with space and equipment appropriate for the services designated on the enrollment application;

4.         Have all applicable testing equipment available at the physical site, excluding portable equipment;

5.         Maintain a primary business telephone, listed under the name of the business and located at the physical site which numbers must be available through directory assistance;

6.         Maintain comprehensive liability insurance of at least $300,000 or 20% of its average annual Medicare billings, whichever is greater, obtain from an insurance company not owned by a relative;

7.         Agree not to directly solicit patients, which would include but not be limited to solicitation through telephone, computer or in-person contacts and agree not to accept patients unless referred for diagnostic testing by an attending physician (or non-physician practitioners in accordance with § 410.32 (a)(3);

8.         Answer beneficiary questions and respond to complaints with appropriate documentation;

9.         Openly post the standards for review by the public and by patients;

10.       Disclose to the government any person having ownership, financial or control interest or any other legal interest in the supplier at the time of enrollment or within 30 days of any change;

11.       Have its testing equipment calibrated per equipment instructions in compliance with applicable national standards;

12.       Have technical staff on duty with the appropriate credentials to perform designated testing along with maintain appropriate licensure or documentation for such individuals;

13.       Have proper medical storage along with retrieval of medical records upon request from CMS or designated contractors; and

14.       Permit CMS, and any agents or contractors, to conduct unannounced on-time inspections to confirm compliance with each standard.

In addition to the compliance standards, the physician supervision standard of  42 CFR § 410.33 (b)(1) would be revised to limit physicians who provide supervision to no more than three IDTF sites.

The discussion of these revisions are contained on pages 49060 through 49062 of the Proposed Rules and the proposed regulation is 42 CFR § 410.33 contained on page 49080 of the August 22, 2006 Proposed Rules.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services issued the 2007 Proposed Physician Fee Schedule in the August 22, 2006 Federal Register: http://www.cms.hhs.gov/quarterlyproviderUpdates/downloads/cms1321p.pdf.  In addition to the fee schedule reductions arising out of the proposed revisions to the work relative value units (RVUs) as proposed in the Federal Register on June 29, 2006, as reported in the Med Law Blog at that time, the new proposed physician fee schedule also incorporates the 5.1% reduction which would be mandated by the Sustainable Growth Rate (SGR) parameters currently in place. Congress has legislatively overridden the mandatory reductions for the past several years, and there are proposals not only to do so again this year but to reform the Medicare payment system using Pay For Performing (P4P) or quality incentives.

The combined impact of the SGR reductions and the work RVU reductions by specialty are projected in Table 7 of the Proposed Rules, August 22, 2006 Federal Register at page 49070.

In addition to the reimbursement changes, the Proposed Rules also make significant revisions to the participation requirements for Independent Diagnostic Testing Facilities, and proposed changes to the Stark II definition of “centralized billing” and clarifications of the Reassignment Rules, both of which will be the subject of separate MedLaw Blog posts in the next few days. 

| Posted By Michael Cassidy In Medicare & Reimbursement | 2 Comments | Permalink

Following is the text from the payment delay reminder issued by HGSAdministrators (now Highmark Medicare Services):

A brief hold will be placed on Medicare payments for all claims during the last 9 days of the Federal fiscal year (September 22 through September 30, 2006).   These payment delays are mandated by Section 5203 of the Deficit Reduction Act of 2005. No interest will be accrued and no late penalties will be paid to an entity or individual by reason of this one-time hold on payments. All claims held during this time will be paid on October 2, 2006.

This policy only applies to claims subject to payment. It does not apply to full denials, no-pay claims, and other non-claim payments such as periodic interim payments, home health requests for anticipated payments, and cost report settlements.

Please note that payments will not be staggered and no advance payments will be allowed during this 9-day hold.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Physician Care Plan Oversight (CPO) is paid under the Medicare Physician Fee Schedule (MPFS), and due to a provision in the Medicare Claims Processing Manual (Publication 100-04, Chapter 12, Section 180), Non-Physician Practitioners (NPPs) have been prohibited from billing for this service in a home health setting.

The current manual section (Section 180) provides that the physician who signs the plan of care for home health services must be the same person that bills for physician CPO. Since only a physician can sign the plan of care for home health services, NPPs have been unable to bill for physician home health CPO.

Under the Final Physician Fee Schedule Rule, published in the Federal Register on November 15, 2004, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs), practicing within the scope of state law, may bill for CPO.

The intention of the Centers for Medicare & Medicaid Services (CMS), as outlined in later portions of the Medicare Claims Processing Manual, was to allow NPPs to bill for physician CPO within their state scope of practice. The current inconsistency in Section 180 will not allow NPPs to be paid for this service.

CR4374 revises the policy that states that the same provider that signs the plan of care does not have to be the same provider that bills for physician CPO effective October 2, 2006.

See Med Learn Matters MM4374 at the hgsa website, www.hgsa.com, which is now Highmark Medicare Services.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

On June 22, 2006, CMS announced proposed changes for the Medicare Physician Fee Schedule. The proposed changes will appear in the June 29, 2006 Federal Register. The proposed changes include a comprehensive review of the RVU work component for Evaluation and Management Codes, which is projected to increase Medicare expenditures by $4 billion, and a reevaluation of practice expense RVUs. The changes are intended to be phased in over 4 years. Additional details and links are available at the Veritus Web site. The Med Law Blog will provide greater analysis after the proposed is published.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

FOR HIGH VOLUME PROCEDURES

In an effort to facilitate consumer directed healthcare, CMS has begun posting the payments that Medicare will make for certain high volume procedures. At this point, the approved Medicare Payments are included in the segment of the CMS website constructed to provide consumer information. Although informative, reports of the action express reservations regarding the usefulness for consumers because the information:

*Provides ranges for payments in large geographic locations;

*It does not provide hospital specific information; and

*It does not provide relative information regarding payments by private insurance carriers.

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

PROGRAM (CAP)
FOR PART B DRUGS ENROLLMENT DEADLINE IS JUNE 2, 2006

This is just a reminder that the Competitive Acquisition Program for Part B drugs for Medicare physicians will be open for enrollment only until June 2, 2006. Participating physicians will be given the opportunity to obtain and bill for Medicare Part B covered drugs through either the CAP program or through the average sales price (ASP) system. More information is available at CMS/CAP.

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FOR CARDIAC REHABILITATION PROGRAMS

Effective for services performed on or after March 22, 2006, the Centers for Medicare and Medicaid Services (CMS) is updating Section 20.10 of the Medicare National Coverage Determinations Manual (NCD Manual) to include additional clinical indications for which cardiac rehabilitation services are covered. The NCD Manual now includes a comprehensive description of the services that must be provided as part of a comprehensive cardiac rehabilitation program, extends the window of time during which the services must be provided, and restructures the language in an effort to improve clarity. The new revision can be viewed at Cardiac Rehabilitation Programs NCD Manual.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

CMS PUBLISHES FINAL ENROLLMENT REQUIREMENTS FOR MEDICARE PARTICIPATION

The Centers for Medicare and Medicaid Services (CMS) have published the final rule establishing the enrollment requirements for participation in Medicare. The proposed rule was published on April 25, 2003. There are no significant surprises in the final rule, which does the following:

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The Medicare Modernization Act of 2003 required the Secretary of Health and Human Services to make the national coverage determination (NCD) process a public and transparent process, with the intent of making the NCD process one that would be better serve Medicare providers and beneficiaries. On April 11, 2006, CMS issued two documents related to "Guidance for The Public, Industry and CMS Staff," i.e.:

| Posted By Michael Cassidy In Medicare & Reimbursement | 1 Comments | Permalink

The Highmark Blue Shield Prior Authorization requirement for enumerated diagnostic imaging procedures will become effective April 1, 2006. The Prior Authorization Guide (Guide) is available on the Highmark Provider Resource Center Web site.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

HIPAA requires all healthcare providers to use the National Provider Identifier (NPI) for electronic transactions as of May 23, 2007. Providers can obtain and use NPI now according to the following timetable:

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The Blue Cross Association posted some reactions from organized medicine to the recent agrement by the AMA to develop performance measures. See http://bcbshealthissues.com.

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The American Medical Association has signed pact with Congress "agreeing" as follows:

*The parties will develop a total of 140 quality measures covering 34 clinical areas.

*Doctors will voluntarily report on at least 3 to 5 quality measures per physician by 2007.

*Doctors should receive additional reimbursement to cover administrative costs.

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DEFICIT REDUCTION ACT OF 2005:
SUMMARY OF MEDICARE REIMBURSEMENT CHANGES

President Bush signed the Deficit Reduction Act of 2005 (DRA 2005) on February 8, 2006. DRA 2005 contained numerous budget cutting provisions impacting Medicare and Medicaid reimbursement programs. Following is a description of the most significant.

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AMBULATORY SURGERY CENTER, GAIN SHARING DEMONSTRATION PROJECTS, THERAPY SERVICE, AND SPECIALTY HOSPITAL REFERRAL PROHIBITIONS

As reported last week, the House of Representatives has passed the Deficit Reduction Act of 2005 (DRA 2005), which is expected to be signed by President Bush in the very near future. When ultimately passed, we will provide a more detailed explanation of the critical issues, but the following are additional reimbursement issues impacted by DRA 2005:

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

Physicians had hoped for budget neutrality in the Deficit Reduction Act of 2005, i.e., the "zero update," expecting the 4.4% decrease implemented by the current Medicare Sustainable Growth Rate rules to be eliminated. The general reimbursement reduction mandated for 2006 was eliminated by DRA 2005, but DRA 2005 requires that the cost of the physician reimbursement increases be offset by future reductions, meaning that DRA 2005 is simply postponing these reimbursement decreases until future years.

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On December 23, 2005, CMS implemented a streamlined PVRP by reducing the number of quality indicators to be reported using G-Code indicators from the original 36 to a "core set" of 16 special quality indicators. The revision was described in a new MedLearn Matters Release (MM 4183) and was implemented as of January 3, 2006.

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AUTOMATIC 4.4% MEDICARE REDUCTION EFFECTIVE JANUARY 1, 2006; CMS ADVISES DELAYED SUBMISSION TO EXPEDITE PLANNED "ZERO UPDATE"

CMS officials suggested that physicians intentionally delay submitting claims to await passage of the "zero update" feature of the proposed Deficit Reduction Act of 2005.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

The centers for Medicaid and Medicaid Services (CMS) reported today that quality of care has improved significantly in hospitals participating in the premier hospital quality incentive demonstration project, a groundbreaking Medicare pay for performance demonstration project. The press release was posted on the CMS website on
November 14, 2005.

See CMS Press Release.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

P4P is the newest healthcare reform theory. Many believe the theory developed wide-spread acceptance following the landmark report, To Err is Human, published by the Institute of Medicine (IOM) in 2000, followed by the IOM report, Crossing the Quality Chasm: A New Health System For the Twenty-First Century, issued in 2001. There is almost unanimous agreement that P4P, if implemented correctly, has great potential to improve patient care. The basic premise is to (1) define quality by some measurable standard, (2) provide reimbursement incentives which compensate improved quality and (3) assess performance and pay accordingly.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

In the December 2004 PRN, Highmark stated that concierge medical practices are "not compatible" with its network requirements. Highmark stated that Blue Cross Blue Shield will initiate termination of impacted provider contracts or a without cause basis upon learning of conversion to concierge practice models.

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink

As of Monday, July 25, Medicare will only pay for physical therapy services provided in physician offices "incident to" the physician's services if the physical therapy services are provided by "qualified personnel" as defined in a June 24 transmittal to Medicare contractors.

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Highmark will pay for care by more than one physician for treatment of hospital or skilled nursing facility in patients when the physicians are treating two or more separate conditions or the severity of the single condition requires the services of two or more physicians. The medical records should:

- Document the primary physician's request for the consult(s)
- Document the seriousness of the medical condition

| Posted By Michael Cassidy In Medicare & Reimbursement | 0 Comments | Permalink