Earlier this month, CMS proposed changes to the Medicare Physician Fee Schedule and Quality Payment Program with the goal of “modernizing Medicare and restoring the doctor-patient relationship.” The proposed changes achieve this goal by streamlining the billing process and reducing the amount of paperwork providers face, empowering providers to maximize use of electronic health record systems, and ultimately, enabling providers to spend more time with their patients.

There is a lot contained in the proposed rules. My colleague, Ellen Janos, highlighted how the proposed rules promote access to virtual care. Then, my colleagues Matt Mora and Ellyn Sternfield dove into how the proposal would reduce payments for new drugs under the Part B program. And now, here is a quick rundown of the other major changes contained in the proposed rules:

Continue Reading CMS Focuses on a Modern Medicare

The government is focusing on opioids.  Whether it be program policies, enforcement, or legislation, combating the opioid epidemic continues to be a major focus for government officials.  It is also a major piece of the health care legislation moving in both the House and the Senate.

In the Senate, the Judiciary Committee advanced five bills relating to the opioid crisis, and the HELP Committee advanced the “Opioid Crisis Response Act of 2018,” which has over 40 measures relating to opioids. Most recently (6/12), the Senate Finance Committee unanimously approved the Helping To End Addiction And Lessen (HEAL) Substance Use Disorders Act Of 2018.  That Act includes the expansion of the Physician Payment Sunshine Act to include payments to mid-level providers, as we previously blogged about here.  Click here for a summary of all Senate bills.

On the House side, over the last two weeks, the House passed over 50 bills to combat the opioid crisis and have received bipartisan support. Additional opioid related bills have been introduced and passed out of committee. On June 20, the House voted and passed three additional opioid bills (HR 5925, HR 9797, and HR 6082). Two of these bills were considered controversial. H.R. 5797, The IMD CARE Act, repeals the Medicaid IMD exclusion for individuals with opioid use disorders. H.R. 6082, The Overdose Prevention and Patient Safety Act, amends 42 CFR Part 2 confidentiality protections pertaining to substance use disorder patient records.  Continue Reading Opioids Have Our Attention

HHS’s Office of Medicare Hearings and Appeals (OMHA) has long faced a backlog in Medicare appeals to Administrative Law Judges (ALJs). In an effort to address this backlog, OMHA established a Settlement Conference Facilitation (SCF) process. OMHA describes SCF as an alternative dispute resolution process that gives certain providers and suppliers the opportunity to resolve all eligible Part A and Part B appeals at once.

The SCF pilot began in June 2014 focusing on Medicare Part B appeals and has gradually been expanded, due in part to its success. Last week, OHMA announced a new plan to expand the SCF program even further and offer providers a quicker option to resolve eligible payment disputes: SCF Express.

Continue Reading HHS Announces a “Settlement Express” Option for Medicare Appeals

Americans today are facing an opioid epidemic that stems in part from the misuse of prescription drugs. CMS takes aim at this crisis in its CY 2019 Medicare Advantage and Part D  Proposed Rule (Proposed Rules) by setting out a framework for Part D plans to monitor and reduce the potential misuse of frequently abused prescription drugs. (Those interested in a high-level overview of the Proposed Rules should see our post from last month). Continue Reading Proposed Medicare Advantage and Part D Regulations for CY 2019 – CMS Takes on the Opioid Epidemic

Last week, the Centers for Medicare & Medicaid Services (“CMS”) released its 2018 Notice of Benefit and Payment setting out payment parameters for the Health Insurance Marketplace for upcoming years.  With several insurers withdrawing from the Marketplace and others still threatening their departure, CMS is releasing this proposed Notice nearly two months early with significant proposals seeking to strengthen the program.

At the core of CMS’s proposals to strengthen the Marketplace are updates to the HHS risk adjustment model and methodology.  Specifically, CMS is proposing: (1) an adjustment for members who are only enrolled for part of the year; (2) the inclusion of select prescription drug utilization data in the risk adjustment model; and (3) modifications to establish transfers for costs associated with high-cost enrollees so a portion of the costs exceeding $2 million for an individual would be shared among all issuers. Continue Reading 2018 Notice of Benefits and Payment: Proposed Updates to the HHS Risk Adjustment Model

image1_133753922Last month, the U.S. Government Accountability Office (GAO) released a report in which it found that manufacturer drug coupon programs for privately insured patients could potentially cause the Medicare Part B program to overspend on certain high-cost Part B drugs. The pricing for most drugs reimbursed by the Medicare Part B program is based on each drug’s average sales price (ASP), which is defined as the amount that physicians and other purchasers pay manufacturers for the drug. Currently, the ASP does not take into account drug coupons offered to privately insured patients. Continue Reading GAO Report Suggests Discount Coupons Impact Medicare Spending for Part B Drugs

Last week, the OIG issued a favorable opinion to a hospice provider seeking to make supplemental payments to skilled nursing facilities.  Under the proposed arrangement, the hospice provider would make a supplemental payment to the nursing facility for dual-eligible individuals electing the hospice benefit that would be in addition to and separate from what the managed care organization (“MCO”) pays the nursing facility.

This supplemental payment by the hospice provider is different than the traditional payments that hospice providers make to nursing facilities for dual-eligible individuals.  Traditionally, when a dual-eligible individual residing in a nursing facility elects the hospice benefit, Medicare pays the hospice provider a per diem rate that does not include room and board.  Medicaid is responsible for paying the individual’s room and board.  Medicaid pays room and board to the hospice provider and the hospice provider pays the nursing facility the negotiated rate.  In a 1998 Special Fraud Alert on nursing home arrangements with hospices, the OIG specifically stated that this payment arrangement, in which the hospice provider pays the nursing facility only after receiving payment from Medicaid, is acceptable. Continue Reading OIG Gives Green Light to Hospice Provider’s Payment to Nursing Facilities

Last month, Jonathan Woodson, M.D., the Assistant Secretary of Defense for Health Affairs for the U.S. Department of Defense, issued a memorandum that effectively changes the Military Health System (“MHS”) policy on telemedicine. The new policy enables the MHS to treat patients via telemedicine when the patients are located in their homes or other locations “deemed appropriate by the treating provider.” Previously, similar to the originating site restrictions found in the current Medicare reimbursement laws, MHS providers could only treat patients via telemedicine if the patients were physically present at a military treatment facility or other designated facility, which did not include the patient’s home.

The memorandum notes that one of MHS’s major focus areas over the past year has been promoting additional options for accessing care. And the Assistant Secretary has been an outspoken advocate for expanding telemedicine services in the MHS. For example, during the keynote speech at the American Telemedicine Association’s 2014 conference, he noted that as care standards continue to evolve, it’s imperative that the MHS embrace telehealth. Continue Reading U.S. Department of Defense Expands Telemedicine Access for Military Members

Last week, the Centers for Medicare & Medicaid Services (CMS) released its 2017 Advance Rate Notice and draft Call Letter (“2017 Draft Call Letter”) for the Medicare Advantage (“MA”) and Part D programs.  With the final 2017 Call Letter to be released April 4, 2015, CMS is providing interested stakeholders until this Friday, March 4th to provide comments.

The 2017 Call Letter proposes a variety of updates to the program, many that are designed to improve the accuracy of payments to plans serving beneficiaries dually eligible for Medicare and Medicaid (“dual eligibles”).  Of note, CMS proposes updates to the risk adjustment model used to calculate payments to MA plans and to the Star Rating system used to evaluate plan performance.  CMS stated that these proposed changes reflect the public comments received when it shared research findings on the accuracy of the CMS-HCC model for paying dual eligible beneficiaries and the impact of socioeconomic factors on the Star Ratings and solicited input.  A few of the interesting 2017 proposals include: Continue Reading CMS Releases 2017 Advance Notice and Draft Call Letter

For too long, health industry stakeholders have bandied about massive amounts of information that could not be used in a comparative sense.  Both public and private payers had their own proprietary reporting metrics, providers banged their heads against the wall chasing all those different metrics, and consumers had no actionable information, leaving them to seek care from providers they “like.”

Last week, the Core Quality Measures Collaborative, led by America’s Health Insurance Plans (AHIP) and its member plans’ Chief Medical Officers, leaders from CMS and the National Quality Forum (NQF), as well as national physician organizations, employers and consumers, released seven sets of clinical quality measures.  The measures signal, for the first time, multi-payer alignment on core measures for a provider quality program.

The Collaborative recognized a need for information about health care quality that could be used to inform the decisions of consumers, employers, physicians and other clinicians, and policymakers.  With this agreement, there is a real opportunity for all stakeholders to have truly comparable information.  The new core measure sets focus on the following areas:

Continue Reading Groundbreaking Multi-Payer Alignment on Core Measures for Quality-Based Payments