 |
 |
|
|
|
HEADLINES
What's New in Medicare and Medicaid
Answers Now
Monday, August 23, 2010
Click on a headline below for the full story.
Decisions and Developments
CCH® Reimbursement Integrated Library
The Reimbursement Integrated Library delivers the key performance indicators for maximizing reimbursement. The Library includes three invaluable titles:
- Dennis Barry's Reimbursement Advisor - This monthly newsletter provides all the facts about reimbursement strategies to minimize the adverse effects of DRGs, RBRVs, APCs and capitation to optimize hospital reimbursement.
- Receivables Report - This monthly newsletter includes actual profit-improvement examples from facilities nationwide, secrets for successfully challenging denials, tips for using automation to increase cash flow, and strategies your colleagues are using now to prepare for health care reform.
- Hospital Accounts Receivable Analysis - This quarterly journal is a synopsis of statistical data related to hospital receivables.
For more details, contact your sales rep.
|
Reimbursement Integrated Library
Dennis Barry’s Reimbursement Advisor
July 2010, Vol. 25, No. 11
In the July 2010 issue of Dennis Barry’s Reimbursement Advisor, authors examine the ongoing controversy revolving around the disproportionate share hospital statute, recommendations in the final wage index report and the interim final rule that codifies and clarifies ordering physician enrollment requirements.
Read this month's Advisor on IRN. Subscribers only
Read this month's Advisor on IntelliConnect. Subscribers only
Not a subscriber? Subscribe today.
|
Receivables Report
July 2010, Volume 25, No. 7
Avoid Eligibility Denials
Health care providers commonly face a variety of claim denials based on patient eligibility. This month, we look at some of those common denials and how best to avoid them. For example, if a payer has a preferred plan that is processed in, say, Virginia specifically for the exempt staff of an employer, the claim may be denied if the claim is submitted to the local third-party administrator who processes the claims for the hourly workers. Learn more about these problems so you can prevent them in your office by reading the July Receivables Report.
Read IRN » (ip access user) » Read IntelliConnect »
Read this month's Advisor on IRN. Subscribers only
Read this month's Advisor on IntelliConnect. Subscribers only
Not a subscriber? Subscribe today. |
Hospital Accounts Receivable Analysis
1st Quarter 2010,
vol. 24, no. 1
- Write-offs Rise Again.
US hospitals wrote off more gross revenue as uncollectible in first quarter 2010 than in the final quarter of 2009, with an increase in charity write-offs driving up the percentage. Hospitals reported 5.60 percent of total first quarter 2010 gross revenue was written off as charity or bad debt, up from 5.29 percent of gross revenue written off as uncollectible in the final quarterly financial reporting period of 2009. Get all the details in the HARA Report on First Quarter 2010.
Read IRN » (ip access user) » Read IntelliConnect »
Read this month's Advisor on IntelliConnect. Subscribers only
Not a subscriber? Subscribe today.
|
|
Headlines
from Medicare and Medicaid Guide
Medicaid EHR incentive program implementation requirements
To qualify for receipt
of 90 percent in their expenditures for implementation of the electronic
health records (EHR) incentive program, states must meet requirements
in three areas: (1) administration of the EHR incentive payment program;
(2) oversight of providers’ eligibility for and use of the incentive
payments, including reporting mechanisms and routine tracking of providers’
attestations; and (3) pursuit of initiatives that encourage adoption
of EHR and the exchange health information through the EHR technology.
CMS will determine the expenses that will be matched at 90 percent
by applying certain guiding principles. The expenditures must: (1)
directly accelerate the adoption, implementation or meaningful use
of EHR technology; (2) not be reimbursable as Medicaid Management
Information Systems expenditures; (3) be consistent with the plan
and priorities outlined by the office of the National Coordinator
for Health Information Technology; (4) not duplicate efforts directed
to similar populations; (5) be allocated appropriately among all parties
who will benefit from them; (6) meet the requirements of the regulations;
and (7) be short-term projects that will be integrated into the Medicaid
program and have sustainable outcomes within a reasonable period of
time. States’ oversight activities must include audits to verify
the eligibility of professionals seeking incentive payments, specifically,
that the professionals are not hospital-based, have not been sanctioned,
and are properly credentialed in the required professions. Professionals’
attestations concerning the population served must be checked against
other available data such as claims. They also must develop a system
to verify that the professional adopts, implements or upgrades a certified
EHR technology, checking professionals’ attestations against
the list of certified technologies and combinations of technologies.
The states must develop an appeals process for providers who dispute
the Medicaid agency’s determinations. State Medicaid programs
are encouraged to partner with other payers and/or federally funded
programs to share the cost of systems and equipment needed for implementation.
All costs must be allocated equitably according to the principles
outlined in 42
C.F.R. §495.358. CMS Letter to State Medicaid
Directors, No. SMDL-10-016, August 17, 2010. ¶53,582.
ESRD quality incentive program proposed
A quality incentive program (QIP) proposed
by CMS for renal dialysis facilities, as mandated by Section 153(c)
of the Medicare Improvements for Patients and Providers Act of 2008
(MIPPA) (P.L.
110-275), would reduce reimbursement starting on January 1,
2012, by up to 2.0 percent to providers that fail to meet standards
on three initial quality measures, one on hemodialysis adequacy and
two on anemia management. CMS chose these three measures because they
are already reported by facilities and they are crucial to end-stage
renal disease (ESRD) patient survival. The three measures in the initial
year of the QIP would be: (1) an achieved urea reduction ratio of
65 percent or more; (2) controlled anemia, as shown by the percentage
of patients whose hemoglobin levels were less than 10 grams per deciliter
(g/dL); and (3) controlled anemia, as shown by the percentage of patients
whose hemoglobin levels were greater than 12 g/dL. Data from calendar
year 2010 would be used to calculate each facility’s QIP scores.
Performance standards for these three measures would be the lesser
of the national performance rates for each measure, based on 2008
data, or a facility’s actual performance rate in 2007. There
would be a maximum score of 10 points for each measure, with a total
performance score of 30 possible points. For every 1.0 percentage
point an individual facility’s performance falls below the scale
of standards, CMS would subtract two points from the maximum points
for each measure. CMS would implement a sliding scale of payment reductions
for payments in 2012, when the minimum total performance score that
facilities would need to achieve to avoid a payment reduction would
be 26 points. The following scale would be used to reduce a facility’s
reimbursement: scores of 26-30 points would receive no reduction;
scores of 21-25 points would receive a 0.5 percent reduction; scores
of 16-20 points, a 1.0 percent reduction; scores of 11-15 points,
a 1.5 percent reduction; and scores of 0-10 points, a 2.0 percent
reduction. Proposed rule, 75 FR 49215, August 12,
2010, ¶220,805.
Court upholds Medicaid-planning annuity purchase
A federal court in Connecticut ordered
the state Medicaid agency to determine the eligibility of an institutionalized
applicant without regard to his wife’s purchase of a single-premium
annuity, which converted assets to income. It rejected the agency’s
attempt to treat the annuity as an asset, which would have put the
applicant over the resource limit until the couple spent down about
$180,000. The terms of the annuity provided that no interest in it
could be sold or transferred, including the right to payment of the
income. The spouse named the state agency as remainder beneficiary
up to the amount expended for her husband’s care as required
under the Deficit Reduction Act (P.L. 109-171) and state regulations.
Payment of the premium depleted the couple’s assets by about
half, and the amount remaining was close to the resource allowance
allowed to a community spouse under Soc. Sec. Act §1924.
The court found that the Medicaid agency violated federal law when
it demanded that the wife sell the annuity. Soc.
Sec. Act §1902(a)(10)(C)(i) requires that the agency’s
methodology for determining financial eligibility for Medicaid for
institutional care be no more restrictive than the methodology used
for the Supplemental Security Income (SSI) program. The SSI program
treats annuities with similar terms as income, not an asset that the
spouse could be required to sell. The applicant and spouse were granted
judgment as a matter of law. Lopes v. Starkowski,
D. Conn., August 10, 2010, ¶303,518.
Expanded options for Medicaid HCBS begin in October
CMS has issued guidance to assist
state Medicaid agencies in expanding the optional home- and community-based
services (HCBS) benefits using the flexibility offered under the Patient
Protection and Affordable Care Act (PPACA) (P.L. 111-148). The Deficit
Reduction Act of 2005 (DRA) (P.L. 109-171) allowed states to offer
HCBS as an optional benefit under the state plan. The benefits were
limited to individuals with income up to 150 percent of the federal
poverty level (FPL). States were permitted to cap enrollment and to
maintain waiting lists, and they were not required to offer benefits
statewide. PPACA amended Soc. Sec. Act §1915(i) to
allow state Medicaid programs to target HCBS to specific populations
and tailor the benefit to their needs. However, states exercising
the new options may not limit the number of eligible individuals who
may receive the benefit, nor may they create waiting lists. All benefits
must be offered statewide, and members of a targeted population must
have access to the services regardless of their location. States may
seek approval of plans to add the optional benefits for five years
at a time. During the first five-year period, they may phase in the
new benefit, if they do, the phase-in must be complete, and the benefit
available statewide, by the end of the period. States must report
on the projected enrollment each year, and if the actual enrollment
exceeds projections, the agency may tighten its needs-based criteria
for new enrollees. However, any Medicaid beneficiary who qualified
under an earlier, less restrictive standard, must remain eligible
and continue to receive benefits for as long as he or she continues
to meet those criteria and the state is authorized to offer the benefit. CMS
Letter to State Medicaid Directors, No. SMDL-10-015, August
6, 2010, ¶53,580.
Reimbursement for off-shore insurance cost
A district court was directed to reconsider reasonable cost
reimbursement for premiums that several nonprofit hospitals had paid
for malpractice, workers’ compensation, and other insurance
to an offshore insurance company established by the hospitals. The Provider
Reimbursement Manual (PRM) prohibits reimbursement for premiums
paid to an offshore insurance company if its investments in certain
equity securities exceed 10 percent of the company’s admitted
assets. The hospitals’ offshore insurance company invested 40
to 50 percent of its assets in equity securities. In light of the
insurance company’s noncompliance, the hospitals disallowed
their premium payments on the annual cost reports, and later sought
to recover those premiums by challenging the PRM’s 10 percent
requirement. Contrary to the Secretary’s argument, HHS was required
to act through notice-and-comment rulemaking pursuant to the Administrative
Procedure Act prior to imposing the 10 percent requirement. When an
agency imposes numerical limits that are not derived from a statute
or regulation, the agency is legislating and must act through rulemaking. Catholic
Health Initiatives v. Sebelius, D.C. Cir., August 13, 2010, ¶303,519.
CMS Actuary questions Medicare Trustee’s projections
The projected Medicare expenditures in
the 2010 Annual Report of the Board of Trustees of the Federal Hospital
Insurance and Federal Supplemental Medical Insurance Trust Funds do
not represent the best estimate of actual future Medicare expenditures.
For example, the Report includes savings from Medicare payment rates
for physician services as determined by the Sustainable Growth Rate
(SGR) system that are scheduled to be reduced by approximately 30
percent over the next three years. In addition, the recently enacted
Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148),
as amended by the Health Care Education and Reconciliation Act (HCERA)
(P.L. 111-152),
calls for a reduction in payment rate updates equal to the increase
in economy-wide multifactor productivity for most of the other categories
of Medicare providers. In the view of the Office of the Actuary, and
that of the independent outside experts they have consulted, neither
of these update reductions is sustainable in the long range, and Congress
is very likely to override or otherwise modify these reductions in
the future. CMS Office of the Actuary, August 5,
2010, ¶60,155.
Interest rate unchanged
The
current interest rate of 11 percent will remain in effect until the
Secretary of the Treasury notifies HHS of any changes in the annual
interest rate. The Secretary of the Treasury may change the annual
interest rate on a quarterly basis after considering private consumer
rates of interest, and the rate must be equal to or higher than the
rate determined from the “Schedule of Certified Interest Rates
with Range of Maturities” or the Department of Treasury’s
current value of funds rate. Notice, 75 FR 48690,
August 11, 2010, ¶262,890.
Withdrawal of laboratory accreditation
COLA formerly known as the Commission on Office Laboratory Accreditation
announced its voluntary withdrawal from the accreditation of the Pathology
specialty for laboratories. COLA is an accreditation organization
for clinical laboratories under the Clinical Laboratory Improvement
Amendments (CLIA) program. In a letter dated June 15, 2010, COLA provided
official notice of its intent to voluntarily withdraw from doing
laboratory accreditation in the specialty of Pathology effective June
30, 2010. All laboratories accredited by COLA in the specialty of
Pathology, which includes Histopathology, Oral Pathology or Cytology,
will have 60 days from the date of this Federal Register Notice
to seek either CLIA inspection by the state agency where the laboratory
is located or accreditation with another accrediting organization
that is currently CMS approved for the specialty of Pathology. Notice,
75 FR 48698, August 11, 2010, ¶262,889.
Prohibited Medicaid collection activities
A collection agency that repeatedly contacted a Medicaid beneficiary
demanding payment of a bill for physician services must respond to
the beneficiary’s lawsuit claiming violation of the Fair Debt
Collection Practices Act (FDCPA). The beneficiary’s allegations
that demands for payment continued after both he and the state Medicaid
agency informed the collector that the beneficiary was not legally
responsible for the bill were sufficient to state a claim against
the collection agency. The FDCPA prohibits false representations of
the character, legal status or amount of any debt. Demands for payment
constitute representations that the debtor is legally obligated to
pay the debt. Illinois regulations state that a provider accepts a
Medicaid patient by billing the Medicaid agency for services furnished
or by failing to make other payment arrangements upon presentation
of a patient’s Medicaid card. Because the complaint alleged
that the physician billed Medicaid for the services, it states facts
sufficient to find that he accepted the beneficiary as a Medicaid
patient, which would establish that the beneficiary had no liability
for the debt. Weathers v. Gem City Account Service, Inc.,
C.D. Ill., August 13, 2010, ¶303,520.
HIT certification applications sought
The Office of the National Coordinator for Health Information
Technology (ONC) is seeking comments on application, reporting and
records requirements for the temporary program for testing and certifying
health information technology (HIT) (see Final rule, 75 FR 36158,
June 24, 2010). The temporary certification program requires: (1)
applicants that wish to become ONC-Authorized Testing and Certification
Bodies (ONC-ATCBs) to respond to and submit an application; (2) collection
and reporting requirements for ONC-ATCBs; and (3) requirements for
ONC-ATCBs to retain records of tests and certifications, and disclose
the final results of all completed tests and certifications to ONC
at the conclusion of testing and certification activities. Notice,
75 FR 49934, August 16, 2010, ¶262,893.
Decisions and Developments
CMS Manuals
Health Insurance Portability and Accountability
(HIPAA) 5010/D.0 fixes
One-Time Notification
Manual, Pub. 100-20, Transmittal No. 749, August 6, 2010, ¶159,209.
Health Insurance Portability and Accountability
Act (HIPAA) 005010 837 institutional (837I) edits and 005010 837 professional
(837P) edits - January 2011 version
One-Time
Notification Manual, Pub. 100-20, Transmittal No. 750, August
10, 2010, ¶159,210.
Inpatient Rehabilitation Facility (IRF) annual
update: Prospective Payment System (PPS) Pricer changes for FY 2011
Medicare Claims Processing Manual, Pub. 100-04,
Transmittal No. 2026, August 13, 2010, ¶159,211.
5010 Implementation--Processing additional
International Classification of Diseases, 9th Revision-Clinical Modification
(ICD-9-CM) diagnosis and procedure codes in Pricer, Grouper, and the
Medicare Code Editor (MCE)
Medicare Claims
Processing Manual, Pub. 100-04, Transmittal No. 2028, August
13, 2010, ¶159,212.
Extract file format requirements to fully
implement change request 6312 (Fiscal Intermediary Standard System
(FISS) to deactivate billing numbers for non-frequent billers)
One-Time Notification Manual, Pub. 100-20,
Transmittal No. 751, August 13, 2010, ¶159,213.
Processing claims spanning more than ten years
with unlimited occurrence span codes (OSCs)
One-Time
Notification Manual, Pub. 100-20, Transmittal No. 752, August
13, 2010, ¶159,214.
January 2011 common edits and enhancements
module (CEM) updates
One-Time Notification
Manual, Pub. 100-20, Transmittal No. 753, August 13, 2010, ¶159,215.
National Council for Prescription Drug Programs
(NCPDP) code set updates
One-Time Notification
Manual, Pub. 100-20, Transmittal No. 755, August 13, 2010, ¶159,216.
5010 implementation--changes to present on
admission (POA) indicator "1" and the K3 segment
One-Time Notification Manual, Pub. 100-20,
Transmittal No. 756, August 13, 2010, ¶159,217.
DAB Decisions
Necessary respiratory care
A
long-term care facility was properly issued a civil money penalty
of $350 per day when it failed to substantially comply with 42 C.F.R. §483.25 by
not providing a resident with the necessary respiratory care to maintain
his highest practicable physical well-being. The CMS surveyor, who
discovered the resident in distress during two of the episodes, contended
that the facility was obliged to measure the resident’s oxygen
saturation levels at least once per eight-hour shift through a pulse
oximeter, but records revealed the facility had only done so on three
occasions over a six-day period. Although the facility argued that
the surveyor’s testimony did not adequately establish the applicable
duty of care, the administrative law judge reasonably relied upon
the surveyor as an experienced and informed medical professional who
directly observed the situation. The facility mischaracterized testimony
from its director of nursing that there were alternative methods for
measuring the resident’s oxygen saturation levels that were
acceptably employed because the physician’s order did not specify
the method to be used. However, both the director and the surveyor
represented that pulse oximetry was the only method of obtaining the
percentage measurement called for by the physician’s plan of
care. Embassy Health Care Center, HHS Departmental
Appeals Board, Appellate Division, Doc. No. A-10-65, Dec. No. 2327,
August 5, 2010, ¶122,248.
Medicaid administrative costs
CMS
properly disallowed the full amount of $2,513,951 for the period October
1, 2001 through September 30, 2007, for costs claimed by the New Jersey
Department of Human Services (NJ DHS) related to the administration
of the Office of the Ombudsman for the Institutionalized Elderly (OOIE)
because the NJ DHS did not show the costs were necessary for the proper
and efficient administration of its state Medicaid plan. NJ DHS admitted
that its approved cost allocation plan did not include any methodology
for allocating OOIE costs to Medicaid. A 1991 agreement between OOIE
and NJ DHS’ Division of Medical Assistance and Health Services
did not comply with the requirement under 45 C.F.R. §95.507(b)(6)
to purchase services whose costs are allocated and to specify which
services will be purchased. In addition, the methodology NJ DHS used
to allocate OOIE costs to Medicaid were inconsistent with the requirements
of Office of Management and Budget Circular OMB A-87, and NJ DHS did
not provide the type of supporting documentation for its claims that
was required by the applicable regulations. Accordingly, CMS disallowance
of the NJ DHS’ use of Medicaid funds was affirmed. New
Jersey Department of Human Services v. CMS, HHS Departmental
Appeals Board, Appellate Division, Doc. No. A-10-4, Dec. No. 2328,
August 5, 2010, ¶122,249.
|
|
|
|
|
|
|
Subscribe to NetNews
|
|
|
Receive the NetNews newsletters via e-mail and to stay up-to-date on all the latest developments.
|
|
About
This Newsletter
|
|
|
To access the IntelliConnect™ full text documents you must be a subscriber to
the Medicare
and Medicaid Guide and the Reimbursement
Integrated Library IntelliConnect product
(depending on the link).*
Links within news stories display full text documents including legislation, regulations, court decisions, rulings and government reports.
The first time you click on a link you will be
taken to the IntelliConnect login
page, where you will need to enter your ID and
password. Subsequent links will take you directly to
the desired document. |
|
Want to Subscribe?
|
|
|
If you aren't a subscriber to the Medicare and Medicaid Guide or the
Reimbursement Integrated Library, call 800-449-9525 or let
us contact you to receieve a free trial to allow you to click on
the links within the news stories and see the full text documents. |
|
