CMS Healthcare Payment Strategies Decrease the Hospital Readmissions

The Health Care Innovation Awards project has brought benefits to sufferers as well as new ideas for healthcare payment strategies to CMS.

The Centers for Medicare & Medicaid Services (CMS) Innovation Center was created in case to develop more revolutionary healthcare payment strategies that could reduce the cost of Medicare, Medicaid, and the CHIP programs. One of its initiatives, the Health Care Innovation Awards, was recently profiled in a CMS Blog.

The Health Care Innovation Awards project has brought benefits to sufferers as well as new ideas for healthcare payment strategies to CMS. For example, Innovative Oncology Business Solutions, Inc. adopted a medical home approach that improved access to care by extending same-day appointments and weekend hours as well as improved patient engagement through disease management guidance.

There was greater sufferer satisfaction found for the increased office hours on the weekends. The results also show that all of this led to fewer emergency room visits and hospital readmissions for more than 2,100 patients.

Medicaid EHR Incentive Program Changes in the Stage 2 Rule: What Medicaid Providers Need to Know

Find out How the Stage 2 Rule Affects Medicaid EHR Incentive Program Participants

On August 23, 2012, the Centers for Medicare & Medicaid Services (CMS) published the final rule for Stage 2 of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The rule provides new criteria that eligible professionals (EPs) and eligible hospitals must meet in order to successfully participate in the EHR Incentive Programs.

Included in the Stage 2 final rule are important changes to the Medicaid EHR Incentive Program, including the determination of patient volume calculations. Importantly, the changes to Medicaid patient volume calculations are applicable to eligible providers regardless of which stage of the EHR Incentive Program they are participating in. It is important for Medicaid providers that they understand these changes and how they affect their participation in the program.

 

Click on the links below for information about:

 

Medicaid changes to patient volume calculations 

Q: The Stage 1 Rule stated that, in order for a Medicaid encounter to count towards the patient volume of an eligible provider, Medicaid had to either pay for all or part of the service, or pay all or part of the premium, deductible or coinsurance for that encounter. The Stage 2 Rule now states that the Medicaid encounter can be counted towards patient volume if the patient is enrolled in the state's Medicaid program (either through the state's fee-for-service programs or the state's Medicaid managed care programs) at the time of service without the requirement of Medicaid payment liability. How will this change affect patient volume calculations for Medicaid eligible providers?

 

A: Billable services provided by an eligible provider to a patient enrolled in Medicaid would count toward meeting the minimum Medicaid patient volume threshold, regardless of Medicaid's payment liability for the services, and irrespective of whether the provider is in Stage 1 or Stage 2 of the incentive program.  Read the rest of the answer here.  

 

CHIP patients eligible to be included in Medicaid patient volume totals

Q: The Stage 2 Rule describes changes to how a state considers CHIP patients in the Medicaid patient volume total when determining provider eligibility. Patients in which kinds of CHIP programs are now appropriate to be considered in the Medicaid patient volume total?

 

A: States that have offered CHIP as part of a Medicaid expansion under Title 19 or Title 21 can include those patients in their provider's Medicaid patient volume calculation as there is cost liability to the Medicaid program in either case (in Stage 1, only CHIP programs created under a Medicaid expansion via Title 19 were eligible). This change to the patient volume calculation is applicable to all eligible providers, regardless of the stage of the incentive program they are participating in. Read the rest of the answer here.  

 

Changes to the base year of the Medicaid EHR Incentive Program for hospital incentive payment calculation 

Q: Are there any changes to the base year for the Medicaid EHR Incentive Program hospital incentive payment calculation?

 

A: Yes, but depending on when a hospital starts participating in the incentive program. Under the Stage 1 Rule, all Medicaid eligible hospitals calculated the base year using a 12-month period ending in the Federal fiscal year before the hospital's fiscal year that serves as the first payment year. But as described in the Stage 2 rule, hospitals that begin participating in the incentive program in program year 2013 or later will use the most recent continuous 12‑month period for which data are available prior to the payment year.  Read the rest of the answer here.

 

To find out more information about the Stage 2 final rule, visit the Stage 2 section of the EHR website.

 

Want more information about the EHR Incentive Programs?

Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Health care fraud prevention and enforcement efforts recover record $4 billion; new Affordable Care Act tools will help fight fraud

Joint DOJ & HHS  efforts result in largest sum ever recovered in single year; new rules under the Affordable Care Act will keep fraudulent providers and suppliers out of Medicare, Medicaid, CHIP and avoid payments of fraudulent claims

U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius and U.S. Associate Attorney General Thomas J. Perrelli today announced a new report showing that the government’s health care fraud prevention and enforcement efforts recovered more than $4 billion in taxpayer dollars in Fiscal Year (FY) 2010.  This is the highest annual amount ever recovered from people who attempted to defraud seniors and taxpayers.  In addition, HHS today announced new rules authorized by the Affordable Care Act that will help the department work proactively to prevent and fight fraud, waste and abuse in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).

These findings, released today, in the annual Health Care Fraud and Abuse Control Program (HCFAC) report, are a result of President Obama making the elimination of fraud, waste, and abuse a top priority in his administration.  The success of this joint Department of Justice (DOJ) and HHS effort would not have been possible without the Health Care Fraud Prevention & Enforcement Action Team (HEAT), created in 2009 to prevent waste, fraud and abuse in the Medicare and Medicaid programs and to crack down on the fraud perpetrators who are abusing the system and costing American taxpayers billions of dollars.  These efforts to reduce fraud will continue to improve with the new tools and resources provided by the Affordable Care Act, including the new rules announced today.

“President Obama has made it very clear that fraud and abuse of taxpayers’ dollars are unacceptable.  And for too long, our fraud prevention efforts have focused on chasing after taxpayer dollars after they have already been paid out,” said Sebelius.  “Thanks to the President’s leadership and the new tools provided by the Affordable Care Act, we can focus on stopping fraud before it happens.”

“Our aggressive pursuit of health care fraud has resulted in the largest recovery of taxpayer dollars in the history of the Justice Department,” said Perrelli. “These actions are in large part because of the great work being led by the Health Care Fraud Prevention and Enforcement Action Team. Through this initiative, we are working in partnership with government, law enforcement and industry leaders, and the public to protect taxpayer dollars, control health care costs, and ensure the strength and integrity of our most essential health care programs.”

Health Care Fraud and Abuse Control Program Report

More than $4 billion stolen from federal health care programs was recovered and returned to the Medicare Health Insurance Trust Fund, the Treasury, and others in FY 2010.  This is an unprecedented achievement for the Health Care Fraud and Abuse Control Program (HCFAC), a joint effort of the two departments to coordinate federal, state, and local law enforcement activities to fight health care fraud and abuse.

The Affordable Care Act provides additional tools and resources to help fight fraud that will help boost these efforts, including an additional $350 million for HCFAC activities.  The administration is already using tools authorized by the Affordable Care Act, including enhanced screenings and enrollment requirements, increased data sharing across government, expanded overpayment recovery efforts, and greater oversight of private insurance abuses.

HHS and DOJ have enhanced their coordination through HEAT and have expanded Medicare Fraud Strike Force teams since 2009. HHS and DOJ hosted a series of regional fraud prevention summits around the country, and sent letters to state attorneys general urging them to work with HHS and federal, state and local law enforcement officials to mount a substantial outreach campaign to educate seniors and other Medicare beneficiaries about how to prevent scams and fraud.  During FY 2010, HEAT and the Medicare Fraud Strike Force expanded local partnerships and helped educate Medicare beneficiaries about how to protect themselves against fraud.

In FY 2010, the total number of cities with Strike Force prosecution teams was increased to seven, all of which have teams of investigators and prosecutors dedicated to fighting fraud.  The Strike Force teams use advanced data analysis techniques to identify high-billing levels in health care fraud hot spots so that interagency teams can target emerging or migrating schemes along with chronic fraud by criminals masquerading as health care providers or suppliers.  Strike Force enforcement accomplishments in all seven cities during FY 2010 include:

• 140 indictments involving charges filed against 284 defendants who collectively billed the Medicare program more than $590 million;


• 217 guilty pleas negotiated and 19 jury trials litigated, winning guilty verdicts against 23 defendants; and


• Imprisonment for 146 defendants sentenced during the fiscal year, averaging more than 40 months of incarceration.

Including Strike Force matters, federal prosecutors opened 1,116 criminal health care fraud investigations as of the end of FY 2010, and filed criminal charges in 488 cases involving 931 defendants.  A total of 726 defendants were convicted for health care fraud-related crimes during the year.

In addition to these criminal enforcement successes, 2010 was a record year for recoveries obtained in civil health care matters brought under the False Claims Act—more than $2.5 billion, which is the largest in the history of the Department of Justice.

The HCFAC annual report can be found here, oig.hhs.gov/publications/hcfac.asp.  For more information on the joint DOJ-HHS Strike Force activities, visit: http://www.StopMedicareFraud.gov/.

New Affordable Care Act Rules to Fight Fraud
Today, HHS also announced new rules authorized by the Affordable Care Act which will help stop health care fraud.  The provisions of the Affordable Care Act implemented through this final rule include new provider screening and enforcement measures to help keep bad actors out of Medicare, Medicaid and CHIP.  The final rule also contains important authority to suspend payments when a credible allegation of fraud is being investigated.
“Thanks to the new law, CMS now has additional resources to help detect fraud and stop criminals from getting into the system in the first place," CMS Administrator Donald Berwick, M.D. said.  “The Affordable Care Act’s new authorities allow us to develop sophisticated, new systems of monitoring and oversight to not only help us crack down on fraudulent activity scamming these programs, but also help us to prevent the loss of taxpayer dollars across the board for millions of American health care consumers.”

Specifically, the final rule:

• Creates a rigorous screening process for providers and suppliers enrolling Medicare, Medicaid and CHIP to keep fraudulent providers out of those programs.  Types of providers and suppliers that have been identified in the past as posing a higher risk of fraud, for example durable medical equipment suppliers, will be subject to a more thorough screening process.


• Requires new enrollment process for Medicaid and CHIP providers.  Under the Affordable Care Act, States will have to screen providers who order and refer to Medicaid beneficiaries to determine if they have a history of defrauding government.  Providers that have been kicked out of Medicare or another State’s Medicaid or CHIP will be barred from all Medicaid and CHIP programs.


• Temporarily stops enrollment of new providers and suppliers.  Medicare and state agencies will be on the look out for trends that may indicate health care fraud – including using advanced predictive modeling software, such as that used to detect credit card fraud.  If a trend is identified in a category of providers or geographic area, the program can temporarily stop enrollment as long as that will not impact access to care for patients.


• Temporarily stops payments to providers and suppliers in cases of suspected fraud.  Under the new rules, if there has been a credible fraud allegation, payments can be suspended while an action or investigation is underway.

A copy of the regulation is on display today at the Federal Register and may be downloaded from the following link: www.ofr.gov/inspection.aspx. Several days after the regulation is published, the preceding link will be deactivated and the published version of the regulation will be available on the National Archives website at www.archives.gov/federal-register/news.html.  CMS will continue to take public comments on limited areas of this final rule for 60 days.

More information can be found at www.HealthCare.gov, a web portal made available by the U.S. Department of Health and Human Services.  A fact sheet on the new rules is available at www.HealthCare.gov/news/factsheets.

Source: Human and Health Services

Program for Children Has Uncertain Future

January 3, 2010, 9:25 pm

Program for Children Has Uncertain Future

By DAVID M. HERSZENHORN

WASHINGTON — As Democratic Congressional leaders work to merge the House and Senate versions of major health care legislation, a big question is what they will do about the Children’s Health Insurance Program, which now provides coverage to more than nine million children and pregnant women and is expected to cover more than 14 million by 2013.

The Senate bill would preserve the program, known as CHIP, and would extend federal financing through 2015, two years past its expiration date under current law. Two Democrats, Senators John D. Rockefeller IV of West Virginia and Bob Casey of Pennsylvania, fought hard to protect CHIP in the bill.

The House bill, by contrast, would end CHIP and redirect the millions of children either to Medicaid, the federal-state insurance program for the poor, or to new health insurance exchanges where moderate-income Americans would be able to buy private coverage using new federal subsidies to help offset the cost.

Unlike many of the issues facing Senate and House negotiators, the question of what to do with CHIP is not just a cerebral policy point. In recent years, states have made huge strides in covering children, particularly those in low- and moderate-income families, and experts say those gains could be put at risk.

“Attention must be paid to the possibility that some children who lose CHIP coverage could fall through the cracks and become uninsured,” Genevieve M. Kenney and Allison Cook wrote last month in a brief prepared for the Urban Institute, the Washington research group.

Some House Democrats, including Representative Henry A. Waxman of California, the chairman of the Energy and Commerce Committee and a lead author of the health care legislation, have said it is difficult to defend a stand-alone government insurance program for children once subsidies are available for entire families.

In Transition, Risks
But many children’s health advocates cite numerous risks. Simply shifting children from one program to another could result in some losing coverage, even on a temporary basis. And there is a chance that parents, even with new subsidies, will find coverage unaffordable and choose not to buy it for themselves or their children, despite a new mandate in both bills that nearly everyone obtain coverage.

Then there are more complicated situations, like those of children whose parents have mixed immigrant status. Under both the Senate and House bills, illegal immigrants would not be eligible for the insurance subsidies.

Some experts project that as many as 14 percent of children with health care through government programs come from such families. And while the bills would provide for the creation of child-only insurance policies, it is unclear how those policies would work and whether children would face difficulties obtaining coverage that way.

The bills also seek to push people with access to employer-sponsored health insurance to buy it, allowing exemptions only for families for whom such coverage would be extremely expensive. Many low-income workers already choose to enroll their children in CHIP because private coverage is too costly.

“The country has made remarkable progress in covering kids in recent years because of the success of CHIP and its companion program, Medicaid,” said Jocelyn A. Guyer, co-executive director of the Center for Children and Families at Georgetown University. “It would be a major problem if health reform undercut these gains by shutting CHIP down too abruptly or by moving kids into coverage that isn’t as affordable and as well-designed to get them the care they need to develop and grow.”

In an effort to tilt the debate in favor of maintaining CHIP as a standalone program, Mr. Rockefeller and Mr. Casey prevailed upon the Senate majority leader, Harry Reid of Nevada, to include two more years of federal financing — through 2015 — which would serve as a bridge beyond the creation of insurance exchanges, where people would be able to buy subsidized private coverage.

Under the Senate bill, state-based exchanges would begin in 2014. The House bill calls for a national insurance exchange to begin in 2013.

Factoring in Medicaid
Tied directly to the question of CHIP’s future is the proposed expansion of Medicaid to include many more low-income Americans, particularly childless adults.

Medicaid would grow under both measures, with eligibility expanded to individuals and families earning up to 133 percent of the federal poverty level (currently about $29,327) under the Senate bill, and up to 150 percent of the poverty level ($33,075) under the House bill.

States have generally expressed apprehension about the proposed Medicaid expansion, because they would eventually share in the cost of covering new enrollees. Medicaid generally provides more comprehensive coverage than CHIP, but potentially offers fewer choices of doctors and other health providers because of Medicaid’s low payment rates. States currently must provide Medicaid coverage to all children through age 5, from families earning up to 133 percent of the poverty level, and to children ages 6 to 18 with family income up to 100 percent of the poverty level.

The House bill, in addition to more broadly expanding Medicaid eligibility, would also increase payment rates for primary care physicians — a step that many health advocates say is needed to improve access to providers for children and adults. The Senate bill does not increase Medicaid payment rates.

In a statement after the Senate adopted its health care bill on Dec. 24, Dr. Irwin Redlener, president of the Children’s Health Fund, a New York-based advocacy group, praised the preservation of CHIP, but criticized the Senate bill for not lifting Medicaid payment rates. “Unfortunately, the Senate bill fails to improve reimbursement rates for Medicaid providers and omits a provision to automatically enroll otherwise uninsured infants, both of which were in the House bill,” Dr. Redlener said.

The Fight Ahead
Mr. Rockefeller, in an interview just before the Senate adopted its bill, said that he was prepared to battle against his colleagues in the House to preserve CHIP in the final health care legislation. “I am not going to drop kids,” he said.

But Mr. Rockefeller also said he was optimistic that House Democratic leaders, however reluctant, would make the adjustments needed to get the final legislation through the Senate, where Democrats cannot afford to lose a single vote.

“The House doesn’t like the Senate, anyway,” he said. “I don’t blame them.”