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September 22, 2014

Is Context Key for Open Payments Program?

Context is often the key to understanding jokes, anecdotes and any other fun bits of information, and if three industry associations are to be believed, it's also key to understanding data in CMS's...

September 22, 2014

Researchers: Electronic Health Records Can Help Make Patients Safer

Adoption of an electronic health record system with advanced physician alerts and order entry assistance can significantly improve patient safety in a hospital or physician group practice,...

September 19, 2014

ACA Rate Review Provision Saved Consumers $1B in 2013, HHS Says

The Department of Health and Human Services is touting savings realized by consumers as a result of an Affordable Care Act provision requiring health insurers to justify premium increases. ...

September 19, 2014

Using Copayment Coupons for Part D Drugs? OIG Says Think Again.

A copayment coupon sounds like a great idea, giving patients the ability to pay little or no copay for their prescription drugs. Mix a copayment coupon with a drug paid for by Medicare Part D...

September 18, 2014

Unnecessary Chemo is the Worst Kind of Health-Care Fraud

Health-care fraud, in all it's various and sundry forms, is wrong, but never more so than when patient care is affected. A recent guilty plea from a Detroit-area oncologist is a case in point. Farid...

September 16, 2014

ACOs Improve Quality, Save Money, CMS Says

Accountable care organizations created under the Affordable Care Act are meeting their goals of improving patient care while saving Medicare money, the Centers for Medicare & Medicaid...

September 12, 2014

Telemedicine Debate Continues Amid New Guidance, Reports

The debate over how to improve access to telemedicine services continued this month in the wake of new model legislation from the Federation of State Medical Boards aimed at helping states...

September 12, 2014

Hackbarth To Leave MedPAC After 15 Years

Medicare Payment Advisory Commission Chairman Glenn Hackbarth, who was first appointed to the commission in 2000, will leave the panel in April 2015. He has been chairman since 2001. A resident...

September 12, 2014

WellPoint, Blue Cross and Blue Shield Plans Leading Market Share in 2014 ACA Marketplaces

Avalere Health LLC confirmed anecdotal evidence that health insurer WellPoint Inc. and various independent Blue Cross and Blue Shield plans captured the greatest percentage of customers in the...

September 12, 2014

Are Rural Health Clinics Getting More Than They Deserve from Medicare?

Rural health clinics (RHCs) are designed to serve some of the most remote parts of the country, and as such, they receive extra Medicare and Medicaid reimbursements for their services. However, a...

September 12, 2014

Did HHS Break Its Own Medicaid Waiver Rules?

A recent GAO report finds Arkansas's plan to use premium support to expand Medicaid isn't budget neutral, and faults the HHS process to approve such plans.

September 9, 2014

Louisiana Overpaid Hospitals $3M in Medicaid Meaningful Use Payments

Louisiana's Medicaid agency overpaid more than a dozen hospitals a total of $3.1 million in Medicaid meaningful use incentive payments in 2011, according to a Sept. 8 report by the Department...

September 9, 2014

Burwell Calls for Cooperation, End to Partisan Attacks on ACA

In her first major public remarks since being confirmed in June, HHS Secretary Sylvia Mathews Burwell Sept. 8 defended the Affordable Care Act and called for an end to partisan strife over...

September 8, 2014

Kaiser Study Finds Costs Dropping For Benchmark ACA Health Plans

A perpetual question about the Affordable Care Act is whether health insurance plans offered through its marketplaces will actually be affordable, or whether the law will result in premium...

September 8, 2014

Industry to CMS: Keep the CME Sunshine Reporting Exemption

It's official. The vast bulk of health-care industry stakeholders want CMS to keep the continuing medical education (CME) reporting exemption under the Open Payments program. According to the CME...

September 5, 2014

House Set to Vote on Group Insurance Plans

House Republicans promise to pass a bill allowing employees to keep non-ACA compliant group health plans.

September 5, 2014

CMS, Treasury to Team Up on Reducing Improper Payments

CMS and the Treasury Department are going into business together, with the end goal of reducing improper payments. A recent CMS notice announced an upcoming computer matching program, in which the...

September 5, 2014

ACA Tax Rule Gets Rehearing By Federal Appeals Court

The full U.S. Court of Appeals for the District of Columbia Circuit will rehear a case on Affordable Care Act tax subsidies, a move that may reduce the chances of a new Supreme Court showdown...

September 3, 2014

Meaningful Use Relief Rule Doesn't Go Far Enough, Health IT Groups Say

The final rule intended to ease EHR certification requirements for meaningful use participants this year offers only temporary relief for those struggling to meet the program's requirements, health information technology industry associations said Sept. 2.

September 3, 2014

Will We Ever Get New RAC Contracts?

Seems like it was just yesterday that CMS said new RAC contracts would be in place by February of this year. That got delayed, of course, and now it looks like we're in store for more RAC contract...

September 3, 2014

Measuring Individual Docs for Quality May Not Be Worth Effort, MedPAC Says

Congress's Medicare advisers are urging the Centers for Medicare & Medicaid Services not to focus on the performance of individual physicians in the agency's quality measurement programs...

September 3, 2014

CMS Final Rule Allows Consumers to Automatically Re-Enroll for 2015 on HealthCare.gov

With the second open enrollment period of the Affordable Care Act scheduled to start Nov. 15 for the 2015 plan year, the Department of Health and Human Services’ Centers for Medicare &...

August 29, 2014

The Doc Fix is Still Cheap, Medicare Spending Will Slow, and Other CBO Predictions

CBO predicts Medicare spending will slow over the next decade. In the short-term, Medicaid spending will rise considerably because of states expanding coverage under the Affordable Care Act.

August 25, 2014

Healthcare Efficiency Index Highlights Savings From Administrative Simplification

Increased adoption of information technologies to process health-care claims electronically could save providers and payers $8 billion next year, according to a report by the Council for...

August 21, 2014

Study: 7 Million Could Get Affordable Care Act Coverage Outside of Open Enrollment

While the Obama administration has been proud of getting more than 8 million people to sign up for health coverage during the first open enrollment period of the Affordable Care Act, millions more...

August 20, 2014

Affordable Care Act Risk Sharing Rules May Give Taxpayers Unlimited Exposure, Report Says

Among the many hot-button issues involving the Affordable Care Act are risk sharing rules designed to protect health insurers from ending up with higher-than-average numbers of enrollees who have...

August 19, 2014

350,000 Who May Drop Coverage Would Buy Lower-Value Plans

Health insurers have suggested that the Affordable Care Act be amended to allow for more affordable plans that cover the same list of services but a lower share of claims. Aug. 18 the Council for...

August 19, 2014

Are Nursing Homes Doing Enough to Report Abuse Allegations?

Federal regulations require nursing homes to report any abuse and neglect allegations to the proper authorities, but it looks like barely half of nursing homes are actually doing this correctly. A...

August 18, 2014

Open Payments Is Back Online

Last Friday was a banner day for CMS, as it was finally able to put the Open Payments system back online. The database had been offline for 12 days (since Aug. 3) due to an investigation into a...

August 13, 2014

Health Data Exchange Stymied By ‘Lack of a Business Case,' Policy Group Says

The primary barrier to electronic health information exchange is “the lack of a business case” for doing so, according to a policy brief published Aug. 11 by Health Affairs.   Despite evidence...

August 13, 2014

Is the Sunshine Act on the Cusp of a Delay?

Last week CMS announced it was temporarily taking the Open Payments system offline, due to potential issues involving the review and dispute process for physicians. According to CMS, the review and dispute process, which was supposed to be finished by Aug. 27, will be adjusted for every day the Open Payments system is offline.

August 8, 2014

Proposed 2015 Health Insurance Premiums Up 7.5 Percent on Average

Average proposed health insurance premiums for 2015 are 7.5 percent higher than 2014, beating predictions from experts that they’d increase at a faster rate, PricewaterhouseCoopers LLP (PwC) reports....

August 8, 2014

Kitchen Sink Draft Bill Covers a lot of Anti-Fraud Territory

In an effort to add more teeth to Medicare fraud fighting, a Republican congressman has released a discussion draft bill packed with a kitchen's sink worth of provisions, including removing Social Security numbers from Medicare cards and mandating MACs to create provider outreach and education programs focused on lowering improper payments.

August 7, 2014

Are We Going to Have to Wait Six More Months for the Sunshine Report?

September is around the corner, bringing with it a new school year, football and the eagerly anticipated public report from the CMS Open Payments program. However, that deadline is being aggressively questioned by the American Medical Association and over 110 state medical groups and industry associations, which have called on CMS to push the report back to March 31, 2015. 

August 7, 2014

Balance Called For With Narrow ACA Networks

One of the hot topics about the Affordable Care Act is that it has led to more limited provider networks in the health plans sold through the ACA marketplaces. But a panel that briefed reporters on...

August 6, 2014

RACs Are Back, Albeit on a Limited Basis

Providers, it's time to get ready, because RAC audits are back. RACs have been on hiatus since a February suspension of the ability to request documents associated with claims reviews, but a recent CMS notification announced a limited restart of the program that could continue until new RAC contracts are awarded.

August 5, 2014

Medicare Won't Go Bankrupt Until 2030

The medicare part A Trust Fund won't go bankrupt until 2030 under new projections, but the entire Medicare system is still in dire need of reform.

August 5, 2014

Second Bundled Payment Experiment Fails, RAND Reports

The Affordable Care Act authorizes a wide variety of health care payment reforms intended to reduce cost and improve the efficiency and quality of the American health care system. One of the leading...

August 5, 2014

CMS Projects Inpatient Hospital Payments Will Decrease by $756 Million in FY 2015

Hospitals say the disproportionate share program cuts in the final Medicare payment rule issued by the Centers for Medicare & Medicaid Services Aug. 4 will hurt their ability to provide...

August 4, 2014

CMS Proposed Rule Would Result in Lower Subsidies, Milliman Finds

A proposed rule by the Centers for Medicare & Medicaid Services aimed at simplifying re-enrollment for the 8 million people who signed up for health insurance in the Affordable Care Act...

August 1, 2014

Is Change Afoot for the False Claims Act?

The winds of change may soon be blowing over the False Claims Act, courtesy of a proposal that would seek to increase the amount of self-reported FCA violations. I attended a Congressional hearing this past week that featured testimony from an attorney who said incentives should be added to the FCA to encourage companies to create certified compliance programs.

August 1, 2014

CMS Releases Three Medicare Payment Rules

The Centers for Medicare & Medicaid Services July 31 released three Medicare final payment rules for fiscal 2015 affecting nursing homes, inpatient rehabilitation facilities, and inpatient...

July 31, 2014

Group Health Plans That Don’t Comply With Affordable Care Act Could Be Continued Under Bill

With two votes from Democrats, the House Energy and Commerce Committee July 30 approved legislation that would allow health insurers to offer group plans that were in effect in 2013, including old...

July 31, 2014

Temporary Moratoria Are Back- At Least for Six More Months

If you're a home health agency or ambulance supplier looking to enroll in Medicare in the Houston area, you're out of luck, at least for the next six months. CMS recently announced it was extending temporary enrollment moratoria for HHAs and ambulance suppliers operating in several metropolitan areas.

July 29, 2014

Telehealth Advocates Hopeful About Future Policy Changes

The likelihood Congress will move on any bills this year—particularly health care legislation—is slim. But, telehealth advocates are encouraged by what they see as growing bipartisan support for...

July 25, 2014

OIG Turns Up the Heat on Medicare Overpayments

In a story that seems to repeat itself over and over, the OIG has uncovered more improper Medicare payments, this time associated with Medicare administrative contractors (MACs).

July 24, 2014

Workforce Survey Finds ‘Strong' Growth for Health IT

More than 80 percent of health-care organizations hired at least one health information technology expert in 2013, an increase over previous years, according to a survey released July 22 by...

July 24, 2014

Providers Want More Clarity in Final EHR Flexibility Rule

Health care providers want assurances that a proposal intended to give them flexibility in the federal government’s electronic health record incentive program won’t come back to bite them in...

July 23, 2014

If Your Sunshine Act Submissions Aren't Accurate, You Could Be in Big Trouble

We're less than two months out from the public release of Sunshine Act data, and while the initial data submissions have already been made, it's an ongoing process and the penalties for inaccuracy can be steep.

July 22, 2014

Courts Issue Dueling Rulings in ACA Subsidies Cases

C ompeting federal court decisions July 22 left up in the air whether federal subsidies provided individuals enrolling in health insurance coverage under the Affordable Care Act are legal....

July 21, 2014

HHS Issues Interpretation of 340B Program Discounts

Despite an adverse court decision, the federal government is maintaining its position on how safety-net providers can receive discounts on drugs that may have “orphan” uses. The HHS July 21...

July 18, 2014

CMS Exempts U.S. Territories From Major ACA Requirements

The five U.S. territories have been forced to become an experiment in what happens when the guaranteed availability, community rating and other reforms of the Affordable Care Act are applied without...

July 18, 2014

Federal Government Scores Another Win Against Health-Care Fraud

The Department of Justice scored another win in the on-going fight against health-care fraud with the recent announcement of a guilty plea by an executive of Alpha Diagnostics, a supplier of portable x-ray services based in Owings Mills, Md.

July 16, 2014

Industry Associations Not Happy With OIG Proposed Rule on Exclusions

It's official: Industry associations aren't happy with a recent proposal from the OIG increasing the agency's exclusion authority. Comment letters from the AMA, the AHA and PhRMA all took issue with the proposed rule, especially a provision that would abolish the current six-year statute of limitations for imposing exclusions on individuals or entities. 

July 16, 2014

Kaiser Family Foundation: 10.6 Million Got Assistance to Enroll in Affordable Care Act Health Insurance Marketplaces

After surveying 843 programs that provided assistance to people enrolling in coverage through the Affordable Care Act health insurance marketplaces during the first open enrollment period in...

July 16, 2014

Biotech Industry Optimistic But Value Remains the Issue

At the BIO 2014 International Convention in San Diego last month, there was a strong sense of optimism, along with acknowledgements of not-so-hidden dangers around, which became more apparent on...

July 15, 2014

Providers Remain Largely Unaware of Health IT-Related Safety Issues, Report Says

Health-care providers are generally unaware of the potential hazards posed by the use of health information technologies, according to a research report published by the Office of the National...

July 11, 2014

Senators Question Pricing of Gilead's Hepatitis C Drug

Senate Finance Committee Chairman Ron Wyden (D-Ore.), and senior Finance Committee member Chuck Grassley (R-Iowa), July 11 requested detailed pricing information on the Hepatitis C virus drug...

July 11, 2014

Battle Lines Drawn Between Providers and RACs

The battle is really shaping up between RACs and hospitals and physicians, as evidenced by a recent Senate staff report and roundtable meeting. I was at the Senate Special Committee on Aging roundtable, where a range of participants representing both providers and RACs sparred over the effectiveness of the RAC program, and program integrity contractors in general.

July 11, 2014

GAO Says Excluding Brokerage Commissions from ACA Medical Loss Ratio Would Have Decreased Rebates

Health insurance brokers have mounted an offensive to try to get their commissions excluded from administrative expenses that are limited under the Affordable Care Act. They have pointed to surveys...

July 10, 2014

No Evidence of Medicare Upcoding Amid Fears, Growth in EHRs, Study Says

There is no evidence suggesting hospitals are systematically using electronic health records (EHRs) to claim a sicker patient population through billing codes, or upcode, to increase Medicare...

July 8, 2014

CMS Wants to End Sunshine Reporting Exemption for CME, Or Does It?

Buried inside the 600-plus pages of the proposed 2015 Medicare physician fee schedule is a provision that on first glance looks major: CMS wants to excise an entire section of the Sunshine Act that grants reporting exemptions to manufacturers that fund continuing medical education events.

July 7, 2014

White House Ratchets Up Pressure On States to Expand Medicaid

White House says states that haven't expanded Medicaid have missed out on $88 billion in federal funding.

July 3, 2014

Milliman Finds Narrow ACA Networks Reduce Premiums

Under the Affordable Care Act health insurers have limited options for reducing premiums in the individual and small group markets, since the law prohibits them from discriminating against people with medical conditions and it requires that a standard package of benefits be covered.

July 3, 2014

More From AHLA's Annual Meeting: OIG Update

AHLA's annual meeting was so jam-packed with information that I can't resist one more blog post about it, if only to highlight what the OIG has been up to lately. Robert DeConti, the OIG's assistant inspector general for legal affairs, said medically unnecessary cardiac procedures have been on the OIG's radar screen of late

July 2, 2014

New York, New York: Notes From AHLA's Annual Meeting

I just returned from two-action packed days in New York covering the AHLA's Annual Meeting, and one of my big takeaways is that provider grumbling over the RAC program are starting to gain some some traction within Congress.

July 1, 2014

Meaningful Use-Certified EHRs Not Always Interoperable, Study Finds

Electronic health record systems certified for use in Stage 2 of the meaningful use program aren't always interoperable with other EHR systems, according to a study published June 26 in the...

July 1, 2014

Supreme Court Ruling Could Affect Other Employers

While the June 30 Supreme Court ruling that contraceptive coverage regulations implementing the Affordable Care Act's preventive services mandate for women violates the Religious Freedom...

June 30, 2014

Contraceptive Insurance Rule Narrowed by U.S. High Court

Congressional reaction to the U.S. S upreme Court’s decision in the Hobby Lobby case June 30 broke down along partisan lines, with Republicans praising the decision as a victory...

June 27, 2014

Hospital Administrators See ICD-10 as Problematic for Health IT, Survey Says

Hospital administrators expect that the anticipated conversion to the  ICD-10  (International Classification of Diseases, 10th Revision) code set will immediately make a host of health IT activities...

June 27, 2014

Adjusted Vs. Unadjusted Savings in CMS's Fraud Prevention System

I briefly touched on the recent CMS predictive modeling report in a previous blog post, but I think it merits a second post, if only to talk about the introduction of adjusted savings.

June 27, 2014

House, Senate Leaders Introduce Bill to Change Post-Acute Care System

Change may be coming to Medicare’s post-acute care system, but it may take a decade for it to arrive. Leaders of the Senate Finance and House Ways and Means committees June 26 introduced...

June 26, 2014

Do Medical Device Data Systems Pose a Risk to Patients? FDA Says No.

FDA proposes to exempt medical device data systems from regulations because they pose a low risk to patients. 

June 26, 2014

Congress Isn't Happy With CMS, Again

I headed up to the Hill yesterday for yet another Congressional hearing into Medicare fraud, waste and abuse, and as usual, the members weren't happy with the lack of progress CMS has made in protecting the program.

June 25, 2014

Lab Arrangements May Violate Anti-Kickback Law, OIG Says

The Department of Health and Human Services Office of Inspector General is warning clinical laboratories and physicians that providing remuneration to physicians to collect, process and package...