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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...

June 25, 2014

Stronger Economy, Specialty Drug Use Seen Leading to Higher Employer Health-Care Costs

The five-year anomaly of tempering health-care costs in the U.S. will end in 2015, PricewaterhouseCoopers LLP (PwC) said in a report on health-care market trends released June 24. In recent years...

June 24, 2014

CMS Gets Serious About Plan C and Plan D Oversight

CMS is not pulling any punches when it comes to oversight and enforcement over Medicare Part D and Part C plan sponsors, and the agency has the tools to make any violations hurt, a CMS official said at a recent conference I listened in on via a webcast.

June 23, 2014

Burwell Gives Legal Justification For Risk Corridor Payments

Congressional Republicans as well as the nonpartisan Government Accountability Office and Congressional Research Service have questioned whether the Obama administration has legal authority to make...

June 20, 2014

Kaiser Says 57 Percent of ACA Enrollees Previously Uninsured

Among the many important data points in dispute concerning the Affordable Care Act is how many of the enrollees in the ACA marketplaces were previously uninsured. Covering the uninsured, after all,...

June 19, 2014

Insurers Expect $1 Billion in Risk Corridor Payments, Committee Finds

The Affordable Care Act includes several provisions to keep premiums stable if health insurers end up with sicker-than-expected enrollees. Congressional Republicans have charged this could lead to a...

June 18, 2014

Talking Drug Diversion with the OIG

Prescription drug diversion is a growing problem for the health-care system, resulting in both financial loss and patient harm. Last week I sat down with Leslie Hollie, the OIG's assistant inspector general for investigations, to talk about common diversion schemes and the strategies the OIG is using to fight back.

June 17, 2014

Senior Citizens Responsible for $9 Million in Medicare and Medicaid Recoveries in 2013

Senior Medicare Patrols (SMPs) were responsible for $9 million in expected Medicare and Medicaid recoveries in 2013, a recent OIG report said, thanks to fraud, waste and abuse referrals passed on to CMS contractors.

June 16, 2014

Choice of Hospital Networks Expanded Under ACA

One of the controversial elements of the coverage provided under the Affordable Care Act is that medical provider networks for which enrollees receive full coverage under the health plans are...

June 16, 2014

MACPAC Recommends Congress Extend CHIP Funding for Two More Years

The Medicaid and CHIP Payment and Access Commission June 13 recommended Congress extend federal funding for the Children's Health Insurance Program for an additional two years.   In its June...

June 16, 2014

The High Cost of Avoidable Readmissions

Lawmakers are beginning to take notice of hospital concerns over the Medicare Hospital Readmissions Reduction program.

June 13, 2014

Narrow Health Care Provider Networks To Become More Prevalent

The controversial "narrow networks" featured in many of the Affordable Care Act marketplace health plans are likely to become more prevalent in the commercial market and in Medicare Advantage plans,...

June 12, 2014

Stark Law Exception Back in Play, Thanks to CMS Notice

My favorite Stark law exception, the in-office ancillary services exception (IOASE) is back in the news, thanks to a recent notice from CMS asking for comments on any burdens associated with the IOASE's disclosure requirement. Self-referring physicians offering imaging services are required to give patients a notice disclosing ownership interests in imaging equipment, and are also required to provide a list of five alternate imaging providers operating within a 25-mile radius.

June 10, 2014

Up to $60 Million Available for Marketplace Navigators, CMS Says

The Centers for Medicare & Medicaid Services is making up to $60 million available for the next round of grants to support health-care navigators for certain states under the Affordable Care...

June 9, 2014

Does Self-Referral Really Drive Up Patient Visits?

Conventional wisdom has it that self-referring providers are always going to refer more patients for services, but is this actually the case? Yes, according to a recent GAO report, but with a caveat or two. 

June 6, 2014

Congressional Budget Office Lowers Affordable Care Act Penalty Projections

The Congressional Budget Office (CBO), on which Congress relies for estimating the costs of legislation, June 5 reduced its estimate of the number of people who will end up paying penalties under...

June 6, 2014

Meaningful Use Program Payments Approach $24 Billion; Enrollment Still Lags Behind 2013

As of April, the federal government has paid more than $23.7 billion in incentive payments to health-care providers and hospitals through the meaningful use program, which pays Medicare and...

June 4, 2014

Are OIG Hospital Compliance Reviews Too Burdensome?

Continuing its assault on what it consider burdensome audit activities by the federal government, the American Hospital Association has asked the Health and Human Services Department to block future hospital compliance audits conducted by the HHS Office of Inspector General. A recent letter from the AHA to the HHS and the Centers for Medicare & Medicaid Services said the OIG reviews often overlap with Recovery Audit Contractor (RAC) reviews, presenting hospitals with an onslaught of contractors all asking to review the same records.

June 3, 2014

Growth in Individual Health Insurance Market

Much data remains to be revealed about the Affordable Care Act, and a key issue is whether it is resulting in greater health insurance coverage.  The Kaiser Family Foundation (KFF) took a stab at...

June 3, 2014

HHS Announces Up to $300 Million for Community Health Centers

The Department of Health and Human Services said June 3 it is making up to $300 million available to community health centers to improve the care they offer. The funding, included in the...

June 3, 2014

Do RACs Really Add to Hospital Burdens?

RACs have been operating nationally for several years now, but a question that's often asked is whether they're merely adding to the administrative burden facing hospitals rather than accomplishing their original mission by identifying and recovering overpayments. An answer to that question was included in the recent RACTrac survey from the American Hospital Association, which said said that 48 percent of hospitals reported spending over $25,000 to manage their RAC process during the first quarter of 2014, while 11 percent reported spending over $100,000.

May 30, 2014

White House Advisors Call for Ending Fee-for-Service

The latest in a string of criticisms of the way the nation pays for health care services came May 29 from a top technical advisory panel to President Obama. The President’s Council of Advisors...

May 30, 2014

Federal Advisory Group to Help Design Proposed Health IT Safety Center

A federal advisory group in July will offer recommendations to federal regulators on the governance and structure of the proposed Health Information Technology Safety Center, a central hub for...

May 29, 2014

HHS Should Close Loophole On Malpractice Reporting, Group Says

Physicians and other health-care providers should be required to report medical malpractice payments to the federal government's National Practitioner Data Bank (NPDB), the advocacy group Public...

May 29, 2014

Are Insurance Exchange Subsidies Going to the Right People?

Cost-sharing subsidies and tax credits associated with the health-insurance exchanges are key to reducing costs for people signing up for insurance under the ACA, but there's a chance they might not be going to the right people. Three Republican Senators recently sent a letter to the OIG calling for further review of the procedures and safeguards surrounding exchange subsidies.

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Medicare Administrative Contractors

Part D

Health and Human Services

health plan identifier

HIPAA

electronic fund transfers

HealthCare.gov

consumers

polls

surveys

Health Insurance

Exchanges

email

survey

Accenture

Sebelius

chief risk officer

doc fix

Senate Finance Committee

House Ways and Means Committtee

doctors

Caremark

CVS

Ramadoss

settlement

Affordable Care Act health insurance marketplace HealthCare.gov health insurance enrollment files rate of errors Daniel Durham America's Health Insurance Plans Arent Fox LLP Georgetown University McCourt School of Public Policy White House Chief of Staff Denis McDonough Oct. 1

Centers for Medicare and Medicaid Services

information exchange

IRS

Treasury Department

Orlando

NHCAA

HFPP

ZPIC

zone program integrity contractor

Georgetown University Center for Children and Familes

Insurance exchanges

healthcare.gov

ehealth

ehealthinsurance

outlier payments

actuaries

Janssen

Scios

Johnson & Johnson

Risperdal

Invega

Natrecor

SAMHSA

Information Security

Medicare eligibility age

physician payment fix

PODs

physician-owned distributorship

FCA

Taxpayers Against Fraud Education Fund

Social Security

death master file

compliance review

Social Security numbers

Medicare identification cards

fraud and abuse

identity theft

sleep studies

sleep apnea

polysomnography

First Amendment

Reliance Medical Systems

Affordable Care Act health insurance marketplaces navigators in-person assisters Kentucky Health Benefit Exchange Medicaid subsidies Families USA Enroll America Barbara Jordan Virginia Michigan

University of Miami Hospital

Part A

redetermination

health exchanges

Joseph Hudzik

Overpayments

self-disclosure

Margaret Hutchinson

Arkansas

Part C

ACLR

SNFs

skilled nursing facility

Kris Mastrangelo

Harmony Healthcare International

medications

PhRma

Marketplaces

navigators

House Oversight

health insurance marketplaces exchanges Affordable Care Act Department of Health and Human Services states state-based marketplaces state parntership marketplaces federally-facilitated marketplaces

Ponemon

medical identity theft

out-of-pocket costs

rebate

Part B

Affordable Care Act health information technology contractors federally-faciliated marketplaces House Energy and Commerce Health Subcommittee CGI Federal Inc. Serco Inc. Quality Software Services Inc. Equifax Workforce Solutions Brett Graham Leavitt Partners LLC state-based marketplaces Utah Small Business Health Options Program

Peter Budetti

Affordable Care Act health insurance marketplaces Department of the Treasury Internal Revenue Service Department of Health and Human Services individual mandate shared responsibility payment minimum essential coverage exemptions Medicaid financial integrity standards appeals eligibility

Office of Management and Budget

Health Care Fraud and Abuse Control