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CMS offers plan (again) in hopes of clearing Medicare appeals backlog Print E-mail
Written by Vitale Health Law   
Friday, 18 November 2016 19:14

Hospital executives who are tired of waiting for their Medicare appeals cases to be settled are being presented with an option. The Centers for Medicare and Medicaid is offering to pay hospitals 66 percent of the net allowable for short-term inpatient stays in exchange for dropping their pending appeals of denied claims.

CMS recently announced that beginning December 1, it will make available an administrative settlement process for inpatient status claims. This process will be open to eligible hospitals willing to withdraw certain pending appeals in exchange for timely partial payment.

The move is intended to make a dent in the Medicare appeals backlog, which according to the Department of Health and Human Services, grew to nearly 900,000 at the end of last year.

CMS made a similar offer in 2014, at which time it completed settlements with 2,022 hospitals, representing approximately 346,000 claims. CMS paid approximately $1.47 billion to providers that agreed to the settlement process. However, it also paid out 68 percent of hospital claims.

CMS has indicated four main reasons for the backlog... 

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Final Medicare Fee Schedule Sweetens Primary Care Pay Print E-mail
Written by Robert Lowes | Medscape Medical News   
Monday, 07 November 2016 00:00

The Center for Medicare and Medicaid Services (CMS) today <11/2/16> released a final version of its Medicare fee schedule for 2017 that makes good on earlier proposals to pay primary care physicians more for work that was previously uncompensated or undercompensated... Medicare will begin to pay more in 2017 for treating patients with chronic illnesses and those with cognitive and behavioral problems.

Read more in the current issue of Week in Review>>

Last Updated on Monday, 07 November 2016 17:27
Brace yourself: Changes to MIPS are coming Print E-mail
Written by Accountable Care Options, LLC   
Thursday, 27 October 2016 07:06

For physicians trying to keep pace with all the health care changes and practice transformations, planned modifications to the Merit-Based Incentive Payment System (MIPS) could make life a little easier next year.

MIPS takes parts of the Physician Quality Reporting System (PQRS), the Value Modifier and the Medicare Electronic Health Record (EHR) incentive program and puts them into a single new program. Rather than rush physicians into new rules, the Centers for Medicare and Medicaid Services (CMS) has proposed a phase-in option. The details are still fuzzy, but if a physician practice reports some form of quality data electronically in 2017, it will avoid a penalty and later have an opportunity for incentives on Medicare Part B payments.

MIPS looks at four areas: quality; advancing care information; clinical practice improvement activities; and cost. Under the new plan, a practice won’t initially have to show that it was meeting those measures in 2017, just show that for a certain portion of the year it was submitting data.

In phase one, a practice will report meaningful use using an EHR that's certified at 2014 standards and will provide PQRS attestation. In phases two and three, the practice will submit those elements again and add resource use.

The move to MIPS is part of CMS’ efforts to incentivize practices to move along the same path as everybody else and become more efficient. The agency is seeking ways to reduce unnecessary health care spending on patient populations by finding high-quality and efficient partners.

Under the program, a practice with cost measures such as per-patient per-month or per-patient per-year spending that are far above those of its peers in a particular specialty will see a negative effect on its Medicare payments. If the measures are below average, the practice can be eligible in 2019 for incentives based on performance in 2017. The rules change in 2018.

CMS is also looking for meaningful reductions in costs, meaning not only expenses are going down, they’re moving below those of a practice’s peers. The agency makes the determination based on data it collects and publishes online in CMS quality and resource use reports.

Separately, practices submit data on how they are transforming or improving themselves using criteria such as being flexible in appointments and offering same-day, evening and weekend access. Physicians are evaluated on how well individualized care plans maintain or improve patient health.

The results will determine the size of the payment adjustment in phases two and three. It will be mild and modest at the beginning, CMS says. That figure, which would increase or decrease payments, could be around 4 percent in 2019, rising to 5 percent the next year and to 9 percent in 2022.
Final MACRA Regs Bump More Than Half of Clinicians Out of MIPS Print E-mail
Written by FHI's Week in Review   
Tuesday, 18 October 2016 18:58

Robert Lowes, reporting for Medscape Medical News (Login/Complimentary Registration required) on October 14, 2016:

The federal government today issued final regulations for the Medicare Accountability and CHIP Reauthorization Act (MACRA), which now exclude or exempt between 53% and 57% of physicians and other clinicians from a possible 2019 penalty in the new reimbursement system.

The Centers for Medicare & Medicaid Services (CMS) gave roughly 200,000 more clinicians this break mostly by redefining practices that would not have to participate in the new system because their involvement with Medicare is minimal. In its proposed MACRA regulations, CMS defined such low-volume providers as having less than $10,000 in Medicare-allowable charges and fewer than 100 Medicare patients. By raising the dollar threshold to $30,000 in the final regulations, the agency bumped up the number of low-volume providers from 226,000 to 384,000.

Read more in the current issue of Week in Review>>

Last Updated on Tuesday, 18 October 2016 19:03
The end to ICD-10 code flexibility: How are you handling it? Print E-mail
Written by The Health Law Offices of Anthony C. Vitale   
Tuesday, 11 October 2016 18:09

It may be hard to believe, but ICD-10 recently celebrated its first birthday.

The change from ICD-9 to ICD-10 meant the addition of thousands of more very specific, and in some cases, very unusual diagnostic codes. Examples include: being pecked by a chicken, bitten by a cow and struck by a macaw. You can read more about that in this Medical Economics article.
The switch to ICD-10 also meant that the Centers for Medicare and Medicaid Services (CMS) was expecting a lot of confusion. That's why providers were given a year grace period to get it right.
However, effective Oct. 1, that grace period came to an end. That means CMS no longer is accepting unspecified codes on Medicare fee-for-service claims. CMS review contractors will use coding specificity as the reason for an audit for a denial of a reviewed claim. And, the agency says it will "notify providers of coding issues they identify during review and of steps needed to correct those issues."

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Last Updated on Tuesday, 11 October 2016 18:15
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