News From February 2012

From: NY Times – 2/29/12

Article Excerpts:

The plot involved 10 doctors, 9 separate clinics in New York City and 105 different corporations, all in service of a health care fraud ring that federal authorities say conspired to steal more than a quarter of a billion dollars from insurance companies. And when the details were announced on Wednesday, they cast an unflattering spotlight on how immigrants from the former Soviet Union have often dominated such schemes in the city.

…The ring, according to the indictment, created and ran the nine clinics in the Bronx, Brooklyn and Queens, which provided unnecessary and excessive medical treatments, including physical therapy, acupuncture, pain management, psychological services, X-rays, M.R.I.’s and other services. Its members are charged with conspiring to steal $279 million, although the total loss to the private insurance companies was listed at $113 million.

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From: Associated Press – 2/29/12

Article Excerpts:

The Texas doctor accused of “selling his signature” to process almost $375 million in false Medicare and Medicaid claims went unnoticed for half a decade by a fraud detection system that some critics say is broken.

Authorities say Jacques Roy and six others indicted for health care fraud certified 11,000 Medicare beneficiaries through more than 500 home health providers over five years. Those numbers would have made Roy’s Medicare practice the busiest in the country. But an investigation into Roy and his business practices didn’t begin until about a year ago, officials said.

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Value Based Purchasing – CMS FAQ Responses

From: CMS Website – 2/28/12

CMS has developed a frequently asked questions response for the soon to be implemented (FFY 2013)  Medicare Value Based Purchasing program.  There is some very useful information provided to help explain this very complicated program.

CMS Presentation – Hospital Value-Based Purchasing

From: CMS National Call -2/28/12

I have included the link above to a CMS prepared slide show covering the Hospital VBP program that will be implemented on October 1, 2012 (FFY 2013).  This slide show provides a fairly comprehensive explanation of this very complicated program.  If you desire to understand this program, this presentation is an excellent starting point.

From: Kaiser Daily Health Policy Report – 2/28/12

Excerpt:

Both hospital and consumer groups are reacting positively to new federal rules meant to improve the effective use of the technology, and new electronic health records certification rules are released.

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Medicare GME – Final Section 5506 Cap Increase List Released

From: CMS Inpatient Acute Website – 2/28/12

CMS posted the GME/IME redistribution listing on their website earlier this week.  There is a download file that contains the hospitals by provider receiving increases in the GME/IME FTE caps.  A summary of the winning States and total redistributed FTEs is presented below:

From: The HILL’s Healthcare Blog – 1/26/12

Article Excerpt

The federal government could save billions of dollars a year by halting overpayments to privately run Medicare Advantage plans, House Democrats said Thursday.

Democrats released a new report, which they had requested from the Government Accountability Office, that concludes MA plans routinely classify their customers as being sicker than if they were on traditional Medicare, triggering higher reimbursement rates. 

The GAO found that MA plans were overpaid by $1.2 billion to $3.1 billion in 2010, with excess payments likely growing since then. The insurance industry however points out that the GAO report doesn’t say MA plans anything wrong but rather that they offer “diagnostic coding that is more comprehensive,” leaving open the possibility that they do a better job identifying conditions patients actually have.

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From: DHCS Website – 2/23/12

Memo Excerpt:

 Assembly Bill 102, signed by Governor Brown on June 28, 2011, directs the Department of Health Care Services (DHCS) and the Department of Mental Health (DMH) to create a transition plan to guide the transfer of Medi-Cal related specialty mental health services to DHCS, effective July 1, 2012. The bill also requires the departments to convene a series of meetings and forums with stakeholders (clients, providers, counties, and representatives of the Legislature) to inform the creation of the transition plan. DHCS and DMH held stakeholder meetings in July and August of 2011. These meetings informed the development of the draft transition plan and to receive input on the draft plan prior to submission to the Legislature on October 1, 2011.

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Health Reform Law Provides Coverage for Nearly 50K Americans with Pre-Existing Conditions

From: HHS News Release – 2/23/12

News Release Excerpt:

Health and Human Services Secretary Kathleen Sebelius today announced that the new health care law’s Pre-Existing Condition Insurance Plan (PCIP) program is providing insurance to nearly 50,000 people with high-risk pre-existing conditions nationwide. The Department released a new report demonstrating how PCIP is helping to fill a void in the insurance market for consumers with pre-existing conditions who are denied insurance coverage and are ineligible for Medicare or Medicaid coverage.

“For too long, Americans with pre-existing conditions were locked out of the health care system and their health suffered,” said HHS Secretary Kathleen Sebelius. “Thanks to health reform, our most vulnerable Americans across the country have the care they need.”

Under the Affordable Care Act, in 2014, insurers will be prohibited from denying coverage to any American with a pre-existing condition. Until then, the PCIP program will continue to provide enrollees with affordable insurance coverage.

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Medicare & Medicaid EHR Incentive Program – Stage 2

Proposed Rules CMS-0044-P; Filed 2/23/12; FR Publication 3/7/12

CMS Summary:

This proposed rule would specify the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments. In addition, it would specify payment adjustments under Medicare for covered professional services and hospital services provided by EPs, eligible hospitals, and CAHs failing to demonstrate meaningful use of certified EHR technology and other program participation requirements. This proposed rule would also revise certain Stage 1 criteria, as well as criteria that apply regardless of Stage, as finalized in the final rule titled Medicare and Medicaid Programs; Electronic Health Record Incentive Program published on July 28, 2010 in the Federal Register. The provisions included in the

Medicaid section of this proposed rule (which relate to calculations of patient volume and hospital eligibility) would take effect shortly after finalization of this rule, not subject to the proposed 1 year delay for Stage 2 of meaningful use of certified EHR technology.

CMS-0044-P 2 Changes to Stage 1 of meaningful use would take effect for 2013, but most would be optional until 2014.