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Medicaid pay bump linked to more new-patient appointments
Primary care physicians accepted significantly more Medicaid patients after the Affordable Care Act’s mandated Medicaid pay bump, a 10-state study showed.
Researchers at the University of Pennsylvania in Philadelphia and the Urban Institute in Washington, D.C., found that appointment availability for new Medicaid patients increased from 59% before the pay increase to 66% after, according to the study published Jan. 21 in the New England Journal of Medicine. Appointment availability for privately insured patients showed no major change in the same time period (doi:10.1056/NEJMsa1413299).
The Medicaid pay bump had a dramatic effect on physicians’ willingness to take on more Medicaid patients, according to the study’s lead investigator, Daniel Polsky, Ph.D., of the University of Pennsylvania.
“A lot of people were saying that doctors are not going to change how they see patients just for a policy that’s going to be in place for 2 years,” Dr. Polsky said in an interview. “When we started the study, a lot of people were predicting we weren’t going to find anything. When we got the data back … we were quite surprised at the magnitude of what we found.”
To assess the impact of the Medicaid pay bump, field staff sought new-patient primary care appointments, presenting themselves as either covered by Medicaid or by private health insurance. Callers contacted primary care practices in Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas during two periods: November 2012 through March 2013 and from May 2014 through July 2014. Practices were chosen randomly and callers were assigned to a script requesting a new-patient appointment for routine care or an urgent health care concern. A total of 7,753 calls were placed during the first period and 4,225 during the second.
States with the largest increases in Medicaid appointment availability also tended to be those with the largest increase in Medicaid payments. An exception was Montana, which had the smallest change in Medicaid reimbursements of the 10 states but still had an increase of 6.8 percentage points in Medicaid appointment availability. Although new appointments became more available, waiting times changed little over time and did not correspond to the changes in payments, Dr. Polsky and his colleagues found.
Providing higher Medicaid payments appears to be an effective strategy for ensuring access to enrollees among already-participating primary care physicians, Dr. Polsky said. Although Congress declined to extend funding for the payment increases past 2014, the investigators noted that 15 states are maintaining the higher rates. In states that are not extending the pay increase, Medicaid payments to primary care physicians are expected to fall between 43% and 47% in 2015, the investigators said.
“Evidence has an influence on policy,” Dr. Polsky said. The results of this study “suggest that if you spent a little bit more paying providers when they saw Medicaid patients, that money wouldn’t go to waste.”
On Twitter @legal_med
Primary care physicians accepted significantly more Medicaid patients after the Affordable Care Act’s mandated Medicaid pay bump, a 10-state study showed.
Researchers at the University of Pennsylvania in Philadelphia and the Urban Institute in Washington, D.C., found that appointment availability for new Medicaid patients increased from 59% before the pay increase to 66% after, according to the study published Jan. 21 in the New England Journal of Medicine. Appointment availability for privately insured patients showed no major change in the same time period (doi:10.1056/NEJMsa1413299).
The Medicaid pay bump had a dramatic effect on physicians’ willingness to take on more Medicaid patients, according to the study’s lead investigator, Daniel Polsky, Ph.D., of the University of Pennsylvania.
“A lot of people were saying that doctors are not going to change how they see patients just for a policy that’s going to be in place for 2 years,” Dr. Polsky said in an interview. “When we started the study, a lot of people were predicting we weren’t going to find anything. When we got the data back … we were quite surprised at the magnitude of what we found.”
To assess the impact of the Medicaid pay bump, field staff sought new-patient primary care appointments, presenting themselves as either covered by Medicaid or by private health insurance. Callers contacted primary care practices in Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas during two periods: November 2012 through March 2013 and from May 2014 through July 2014. Practices were chosen randomly and callers were assigned to a script requesting a new-patient appointment for routine care or an urgent health care concern. A total of 7,753 calls were placed during the first period and 4,225 during the second.
States with the largest increases in Medicaid appointment availability also tended to be those with the largest increase in Medicaid payments. An exception was Montana, which had the smallest change in Medicaid reimbursements of the 10 states but still had an increase of 6.8 percentage points in Medicaid appointment availability. Although new appointments became more available, waiting times changed little over time and did not correspond to the changes in payments, Dr. Polsky and his colleagues found.
Providing higher Medicaid payments appears to be an effective strategy for ensuring access to enrollees among already-participating primary care physicians, Dr. Polsky said. Although Congress declined to extend funding for the payment increases past 2014, the investigators noted that 15 states are maintaining the higher rates. In states that are not extending the pay increase, Medicaid payments to primary care physicians are expected to fall between 43% and 47% in 2015, the investigators said.
“Evidence has an influence on policy,” Dr. Polsky said. The results of this study “suggest that if you spent a little bit more paying providers when they saw Medicaid patients, that money wouldn’t go to waste.”
On Twitter @legal_med
Primary care physicians accepted significantly more Medicaid patients after the Affordable Care Act’s mandated Medicaid pay bump, a 10-state study showed.
Researchers at the University of Pennsylvania in Philadelphia and the Urban Institute in Washington, D.C., found that appointment availability for new Medicaid patients increased from 59% before the pay increase to 66% after, according to the study published Jan. 21 in the New England Journal of Medicine. Appointment availability for privately insured patients showed no major change in the same time period (doi:10.1056/NEJMsa1413299).
The Medicaid pay bump had a dramatic effect on physicians’ willingness to take on more Medicaid patients, according to the study’s lead investigator, Daniel Polsky, Ph.D., of the University of Pennsylvania.
“A lot of people were saying that doctors are not going to change how they see patients just for a policy that’s going to be in place for 2 years,” Dr. Polsky said in an interview. “When we started the study, a lot of people were predicting we weren’t going to find anything. When we got the data back … we were quite surprised at the magnitude of what we found.”
To assess the impact of the Medicaid pay bump, field staff sought new-patient primary care appointments, presenting themselves as either covered by Medicaid or by private health insurance. Callers contacted primary care practices in Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas during two periods: November 2012 through March 2013 and from May 2014 through July 2014. Practices were chosen randomly and callers were assigned to a script requesting a new-patient appointment for routine care or an urgent health care concern. A total of 7,753 calls were placed during the first period and 4,225 during the second.
States with the largest increases in Medicaid appointment availability also tended to be those with the largest increase in Medicaid payments. An exception was Montana, which had the smallest change in Medicaid reimbursements of the 10 states but still had an increase of 6.8 percentage points in Medicaid appointment availability. Although new appointments became more available, waiting times changed little over time and did not correspond to the changes in payments, Dr. Polsky and his colleagues found.
Providing higher Medicaid payments appears to be an effective strategy for ensuring access to enrollees among already-participating primary care physicians, Dr. Polsky said. Although Congress declined to extend funding for the payment increases past 2014, the investigators noted that 15 states are maintaining the higher rates. In states that are not extending the pay increase, Medicaid payments to primary care physicians are expected to fall between 43% and 47% in 2015, the investigators said.
“Evidence has an influence on policy,” Dr. Polsky said. The results of this study “suggest that if you spent a little bit more paying providers when they saw Medicaid patients, that money wouldn’t go to waste.”
On Twitter @legal_med
Key clinical point: Primary care physicians saw more Medicaid patients during the 2-year period when Medicaid payments were higher under the Affordable Care Act.
Major finding: Overall appointment availability for Medicaid callers increased from 59% before the ACA to 66% during the pay increase.
Data source: A study of primary care offices in 10 states from November 2012 through March 2013 and from May 2014 through July 2014.
Disclosures: The study was funded by the Robert Wood Johnson Foundation. The investigators reported no relevant conflicts of interest.
State of the Union: Obama announces Precision Medicine Initiative
President Obama has announced a new initiative that aims to improve medical treatments for many diseases by tailoring treatments to a patient’s unique genetic makeup.
During his Jan. 20 State of the Union address, the president unveiled the Precision Medicine Initiative, a plan to increase physicians’ ability to take a patient’s individual genetic makeup and molecular subtypes of diseases into account to improve the chances of successful treatment.
“I want the country that eliminated polio and mapped the human genome to lead a new era of medicine – one that delivers the right treatment at the right time,” President Obama said in his speech. “In some patients with cystic fibrosis, this approach has reversed a disease once thought unstoppable. Tonight, I’m launching a new Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes – and to give all of us access to the personalized information we need to keep ourselves and our families healthier.”
“Physicians have been at the forefront of accelerating genomic discoveries and rapidly driving these innovations into daily clinical practice,” said Dr. Robert M. Wah, president of the American Medical Association. “We believe that all of the Administration’s policies should advance and build on the incredible progress that physicians are making to apply genetic and genomic breakthroughs into clinical decision-making and health promotion that can ease substantial disease burden and cost in this country.”
American College of Cardiology President Patrick T. O’Gara called the announcement an important step for continuing medical progress.
“Incredible advances have already been made in cardiovascular research, and I hope initiatives like this will lead to even more important discoveries, treatments, and cures that can be directed to patients more quickly,” Dr. O’Gara said in a statement. “The promise of precision medicine is within our grasp.”
Few details on the initiative were released during the State of the Union address; however, research into precision medicine, also known as personalized medicine, is already underway. In August 2014, the National Institutes of Health launched the Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trials, or ALCHEMIST, a 3-part clinical trial to identify early-stage lung cancer patients with tumors that harbor certain uncommon genetic changes. The research will evaluate whether drug treatments targeted against those changes can lead to improved survival. The project adds to research by the Cancer Genome Atlas, a collaboration between the National Cancer Institute and the National Human Genome Research Institute, both divisions of NIH.
Additionally, in 2013, the American Heart Association set aside a 5-year, $30 million research fund to dig deeper into two large national studies in hopes of finding more clues to personalized treatment and prevention of cardiovascular disease. The AHA and its two main collaborators, the University of Mississippi and Boston University, said their goal is to expand population studies by adding more research subjects and more genetic analysis.
Although much of the president’s address focused on nonmedical issues, he did take the opportunity to let legislators in the Republican-led Congress know that he would veto any bill that seeks to undo progress gained under the Affordable Care Act.
“We can’t put the security of families at risk by taking away their health insurance, or unraveling the new rules on Wall Street, or refighting past battles on immigration when we’ve got a system to fix,” President Obama said. “And if a bill comes to my desk that tries to do any of these things, it will earn my veto.”
The president also urged Congress to pass the Healthy Families Act, a bill that would require businesses to provide employees up to 7 paid sick days per year. His administration also plans to help more states adopt sick leave laws of their own, he said.
“Since paid sick leave won where it was on the ballot last November, let’s put it to a vote right here in Washington. Send me a bill that gives every worker in America the opportunity to earn 7 days of paid sick leave,” he said.
On Twitter @legal_med
President Obama has announced a new initiative that aims to improve medical treatments for many diseases by tailoring treatments to a patient’s unique genetic makeup.
During his Jan. 20 State of the Union address, the president unveiled the Precision Medicine Initiative, a plan to increase physicians’ ability to take a patient’s individual genetic makeup and molecular subtypes of diseases into account to improve the chances of successful treatment.
“I want the country that eliminated polio and mapped the human genome to lead a new era of medicine – one that delivers the right treatment at the right time,” President Obama said in his speech. “In some patients with cystic fibrosis, this approach has reversed a disease once thought unstoppable. Tonight, I’m launching a new Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes – and to give all of us access to the personalized information we need to keep ourselves and our families healthier.”
“Physicians have been at the forefront of accelerating genomic discoveries and rapidly driving these innovations into daily clinical practice,” said Dr. Robert M. Wah, president of the American Medical Association. “We believe that all of the Administration’s policies should advance and build on the incredible progress that physicians are making to apply genetic and genomic breakthroughs into clinical decision-making and health promotion that can ease substantial disease burden and cost in this country.”
American College of Cardiology President Patrick T. O’Gara called the announcement an important step for continuing medical progress.
“Incredible advances have already been made in cardiovascular research, and I hope initiatives like this will lead to even more important discoveries, treatments, and cures that can be directed to patients more quickly,” Dr. O’Gara said in a statement. “The promise of precision medicine is within our grasp.”
Few details on the initiative were released during the State of the Union address; however, research into precision medicine, also known as personalized medicine, is already underway. In August 2014, the National Institutes of Health launched the Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trials, or ALCHEMIST, a 3-part clinical trial to identify early-stage lung cancer patients with tumors that harbor certain uncommon genetic changes. The research will evaluate whether drug treatments targeted against those changes can lead to improved survival. The project adds to research by the Cancer Genome Atlas, a collaboration between the National Cancer Institute and the National Human Genome Research Institute, both divisions of NIH.
Additionally, in 2013, the American Heart Association set aside a 5-year, $30 million research fund to dig deeper into two large national studies in hopes of finding more clues to personalized treatment and prevention of cardiovascular disease. The AHA and its two main collaborators, the University of Mississippi and Boston University, said their goal is to expand population studies by adding more research subjects and more genetic analysis.
Although much of the president’s address focused on nonmedical issues, he did take the opportunity to let legislators in the Republican-led Congress know that he would veto any bill that seeks to undo progress gained under the Affordable Care Act.
“We can’t put the security of families at risk by taking away their health insurance, or unraveling the new rules on Wall Street, or refighting past battles on immigration when we’ve got a system to fix,” President Obama said. “And if a bill comes to my desk that tries to do any of these things, it will earn my veto.”
The president also urged Congress to pass the Healthy Families Act, a bill that would require businesses to provide employees up to 7 paid sick days per year. His administration also plans to help more states adopt sick leave laws of their own, he said.
“Since paid sick leave won where it was on the ballot last November, let’s put it to a vote right here in Washington. Send me a bill that gives every worker in America the opportunity to earn 7 days of paid sick leave,” he said.
On Twitter @legal_med
President Obama has announced a new initiative that aims to improve medical treatments for many diseases by tailoring treatments to a patient’s unique genetic makeup.
During his Jan. 20 State of the Union address, the president unveiled the Precision Medicine Initiative, a plan to increase physicians’ ability to take a patient’s individual genetic makeup and molecular subtypes of diseases into account to improve the chances of successful treatment.
“I want the country that eliminated polio and mapped the human genome to lead a new era of medicine – one that delivers the right treatment at the right time,” President Obama said in his speech. “In some patients with cystic fibrosis, this approach has reversed a disease once thought unstoppable. Tonight, I’m launching a new Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes – and to give all of us access to the personalized information we need to keep ourselves and our families healthier.”
“Physicians have been at the forefront of accelerating genomic discoveries and rapidly driving these innovations into daily clinical practice,” said Dr. Robert M. Wah, president of the American Medical Association. “We believe that all of the Administration’s policies should advance and build on the incredible progress that physicians are making to apply genetic and genomic breakthroughs into clinical decision-making and health promotion that can ease substantial disease burden and cost in this country.”
American College of Cardiology President Patrick T. O’Gara called the announcement an important step for continuing medical progress.
“Incredible advances have already been made in cardiovascular research, and I hope initiatives like this will lead to even more important discoveries, treatments, and cures that can be directed to patients more quickly,” Dr. O’Gara said in a statement. “The promise of precision medicine is within our grasp.”
Few details on the initiative were released during the State of the Union address; however, research into precision medicine, also known as personalized medicine, is already underway. In August 2014, the National Institutes of Health launched the Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trials, or ALCHEMIST, a 3-part clinical trial to identify early-stage lung cancer patients with tumors that harbor certain uncommon genetic changes. The research will evaluate whether drug treatments targeted against those changes can lead to improved survival. The project adds to research by the Cancer Genome Atlas, a collaboration between the National Cancer Institute and the National Human Genome Research Institute, both divisions of NIH.
Additionally, in 2013, the American Heart Association set aside a 5-year, $30 million research fund to dig deeper into two large national studies in hopes of finding more clues to personalized treatment and prevention of cardiovascular disease. The AHA and its two main collaborators, the University of Mississippi and Boston University, said their goal is to expand population studies by adding more research subjects and more genetic analysis.
Although much of the president’s address focused on nonmedical issues, he did take the opportunity to let legislators in the Republican-led Congress know that he would veto any bill that seeks to undo progress gained under the Affordable Care Act.
“We can’t put the security of families at risk by taking away their health insurance, or unraveling the new rules on Wall Street, or refighting past battles on immigration when we’ve got a system to fix,” President Obama said. “And if a bill comes to my desk that tries to do any of these things, it will earn my veto.”
The president also urged Congress to pass the Healthy Families Act, a bill that would require businesses to provide employees up to 7 paid sick days per year. His administration also plans to help more states adopt sick leave laws of their own, he said.
“Since paid sick leave won where it was on the ballot last November, let’s put it to a vote right here in Washington. Send me a bill that gives every worker in America the opportunity to earn 7 days of paid sick leave,” he said.
On Twitter @legal_med
Justices grill attorneys on right to sue states over Medicaid payments
Some Supreme Court justices appear skeptical about whether physicians and other health providers have the right to sue states over low Medicaid reimbursement.
During oral arguments Jan. 20 in Armstrong v. Exceptional Child Center Inc., Chief Justice John G. Roberts Jr. questioned whether letting providers challenge state-set payment rates would lead to a wave of litigation and force federal judges to make state budgetary decisions.
“There are dozens of different types of providers under the [Social Security] Act,” Justice Roberts said during oral arguments. “Now, what do you do if each of those providers bring a lawsuit similar to yours? The effect, it seems to me, will be putting the setting of budget priorities in the hands of dozens of different federal judges, and I just don’t know what the practical significance of that’s going to be.”
In Armstrong v. Exceptional Child Center Inc., the high court justices are weighing whether the U.S. Constitution’s Supremacy Clause – which establishes the Constitution and federal law as the law of the land – gives health care providers under Medicaid a private “right of action” to enforce Medicaid funding conditions against states. The case originates from a 2009 lawsuit by Exceptional Child Center Inc., of Twin Falls, Idaho, and four other residential habilitation centers against Richard Armstrong, director of the Idaho Department of Health and Welfare.
The centers claimed the state was violating Medicaid’s equal access provision by refusing to raise its payment rates. Under the equal access provision, states that accept federal Medicaid funding are required to set reimbursement rates at levels sufficient to retain enough providers and make sure patients have proper access to care. The Idaho Department of Health and Welfare and its Medicaid division conducted yearly cost studies between 2006 and 2009, developed a new rate-setting methodology, and recommended substantial increases in reimbursement rates for supported living services, according to court documents. However, the new methodology and rate increases were not enacted for budgetary reasons.
A district court ruled in favor of the centers, and the 9th U.S. Circuit Court of Appeals affirmed the ruling. The state petitioned the Supreme Court to resolve the issue.
During arguments, Idaho deputy attorney general Carl J. Withroe argued the courtroom is an incorrect avenue for Medicaid providers to dispute pay rates. If displeased, physicians and other health providers should issue an administrative challenge to the Centers for Medicare & Medicaid Services over its approval of the state’s Medicaid plan. He noted that such state plans – known as waivers – must be approved by the CMS every 5 years.
But Justice Sonia Sotomayor called this pathway an ineffective remedy.
“Let’s assume inflation is going up constantly. What happens 2 years into the plan when providers can’t work for what the state is giving or the state is imposing a tremendous hardship on them, which is happening to a lot of providers who are being underpaid. Where do they go? ... What do they do?”
Other panelists, such as Justice Ruth Bader Ginsberg, expressed doubt that the centers’ case against the state has merit, namely that Idaho is violating Medicaid’s equal access provision.
“According to the district court, all eligible recipients received the services that they needed,” Justice Ginsberg said. “So again, there was no waiting list; nobody’s being kept waiting. These providers, while they say they’re not getting enough, are still providing the service. So where is the [equal access] violation?”
Attorney James M. Piotrowski, who represented the centers, countered that the equal access provision imposes both procedural and substantive requirements. The substantive requirement mandates there must be enough providers to allow access and generate quality care, Mr. Piotrowski said. The procedural requirement entails that the rates be set based upon factors that Congress considers important.
“The violation of [the equal access provision] here was that the state gave no consideration whatsoever to the federal factors,” he said. “They relied only on their own factors.”
The Armstrong case is being closely watched by states, physicians, and patient advocates alike. Twenty-seven states have reached out to the high court in support of Idaho. The states saidthey have been subject to numerous, unwarranted lawsuits because of misguided interpretations of the Supremacy Clause. A number of physician and patient advocacy associations joined a friend-of-the-court brief in support of the centers, including the American Academy of Family Physicians and the American Medical Association. The AMA and other organizations said ongoing violations of Medicaid’s equal access provision by states continue to drive doctors from the program and harm access to care.
A decision by the high court is expected by June.
On Twitter @legal_med
Some Supreme Court justices appear skeptical about whether physicians and other health providers have the right to sue states over low Medicaid reimbursement.
During oral arguments Jan. 20 in Armstrong v. Exceptional Child Center Inc., Chief Justice John G. Roberts Jr. questioned whether letting providers challenge state-set payment rates would lead to a wave of litigation and force federal judges to make state budgetary decisions.
“There are dozens of different types of providers under the [Social Security] Act,” Justice Roberts said during oral arguments. “Now, what do you do if each of those providers bring a lawsuit similar to yours? The effect, it seems to me, will be putting the setting of budget priorities in the hands of dozens of different federal judges, and I just don’t know what the practical significance of that’s going to be.”
In Armstrong v. Exceptional Child Center Inc., the high court justices are weighing whether the U.S. Constitution’s Supremacy Clause – which establishes the Constitution and federal law as the law of the land – gives health care providers under Medicaid a private “right of action” to enforce Medicaid funding conditions against states. The case originates from a 2009 lawsuit by Exceptional Child Center Inc., of Twin Falls, Idaho, and four other residential habilitation centers against Richard Armstrong, director of the Idaho Department of Health and Welfare.
The centers claimed the state was violating Medicaid’s equal access provision by refusing to raise its payment rates. Under the equal access provision, states that accept federal Medicaid funding are required to set reimbursement rates at levels sufficient to retain enough providers and make sure patients have proper access to care. The Idaho Department of Health and Welfare and its Medicaid division conducted yearly cost studies between 2006 and 2009, developed a new rate-setting methodology, and recommended substantial increases in reimbursement rates for supported living services, according to court documents. However, the new methodology and rate increases were not enacted for budgetary reasons.
A district court ruled in favor of the centers, and the 9th U.S. Circuit Court of Appeals affirmed the ruling. The state petitioned the Supreme Court to resolve the issue.
During arguments, Idaho deputy attorney general Carl J. Withroe argued the courtroom is an incorrect avenue for Medicaid providers to dispute pay rates. If displeased, physicians and other health providers should issue an administrative challenge to the Centers for Medicare & Medicaid Services over its approval of the state’s Medicaid plan. He noted that such state plans – known as waivers – must be approved by the CMS every 5 years.
But Justice Sonia Sotomayor called this pathway an ineffective remedy.
“Let’s assume inflation is going up constantly. What happens 2 years into the plan when providers can’t work for what the state is giving or the state is imposing a tremendous hardship on them, which is happening to a lot of providers who are being underpaid. Where do they go? ... What do they do?”
Other panelists, such as Justice Ruth Bader Ginsberg, expressed doubt that the centers’ case against the state has merit, namely that Idaho is violating Medicaid’s equal access provision.
“According to the district court, all eligible recipients received the services that they needed,” Justice Ginsberg said. “So again, there was no waiting list; nobody’s being kept waiting. These providers, while they say they’re not getting enough, are still providing the service. So where is the [equal access] violation?”
Attorney James M. Piotrowski, who represented the centers, countered that the equal access provision imposes both procedural and substantive requirements. The substantive requirement mandates there must be enough providers to allow access and generate quality care, Mr. Piotrowski said. The procedural requirement entails that the rates be set based upon factors that Congress considers important.
“The violation of [the equal access provision] here was that the state gave no consideration whatsoever to the federal factors,” he said. “They relied only on their own factors.”
The Armstrong case is being closely watched by states, physicians, and patient advocates alike. Twenty-seven states have reached out to the high court in support of Idaho. The states saidthey have been subject to numerous, unwarranted lawsuits because of misguided interpretations of the Supremacy Clause. A number of physician and patient advocacy associations joined a friend-of-the-court brief in support of the centers, including the American Academy of Family Physicians and the American Medical Association. The AMA and other organizations said ongoing violations of Medicaid’s equal access provision by states continue to drive doctors from the program and harm access to care.
A decision by the high court is expected by June.
On Twitter @legal_med
Some Supreme Court justices appear skeptical about whether physicians and other health providers have the right to sue states over low Medicaid reimbursement.
During oral arguments Jan. 20 in Armstrong v. Exceptional Child Center Inc., Chief Justice John G. Roberts Jr. questioned whether letting providers challenge state-set payment rates would lead to a wave of litigation and force federal judges to make state budgetary decisions.
“There are dozens of different types of providers under the [Social Security] Act,” Justice Roberts said during oral arguments. “Now, what do you do if each of those providers bring a lawsuit similar to yours? The effect, it seems to me, will be putting the setting of budget priorities in the hands of dozens of different federal judges, and I just don’t know what the practical significance of that’s going to be.”
In Armstrong v. Exceptional Child Center Inc., the high court justices are weighing whether the U.S. Constitution’s Supremacy Clause – which establishes the Constitution and federal law as the law of the land – gives health care providers under Medicaid a private “right of action” to enforce Medicaid funding conditions against states. The case originates from a 2009 lawsuit by Exceptional Child Center Inc., of Twin Falls, Idaho, and four other residential habilitation centers against Richard Armstrong, director of the Idaho Department of Health and Welfare.
The centers claimed the state was violating Medicaid’s equal access provision by refusing to raise its payment rates. Under the equal access provision, states that accept federal Medicaid funding are required to set reimbursement rates at levels sufficient to retain enough providers and make sure patients have proper access to care. The Idaho Department of Health and Welfare and its Medicaid division conducted yearly cost studies between 2006 and 2009, developed a new rate-setting methodology, and recommended substantial increases in reimbursement rates for supported living services, according to court documents. However, the new methodology and rate increases were not enacted for budgetary reasons.
A district court ruled in favor of the centers, and the 9th U.S. Circuit Court of Appeals affirmed the ruling. The state petitioned the Supreme Court to resolve the issue.
During arguments, Idaho deputy attorney general Carl J. Withroe argued the courtroom is an incorrect avenue for Medicaid providers to dispute pay rates. If displeased, physicians and other health providers should issue an administrative challenge to the Centers for Medicare & Medicaid Services over its approval of the state’s Medicaid plan. He noted that such state plans – known as waivers – must be approved by the CMS every 5 years.
But Justice Sonia Sotomayor called this pathway an ineffective remedy.
“Let’s assume inflation is going up constantly. What happens 2 years into the plan when providers can’t work for what the state is giving or the state is imposing a tremendous hardship on them, which is happening to a lot of providers who are being underpaid. Where do they go? ... What do they do?”
Other panelists, such as Justice Ruth Bader Ginsberg, expressed doubt that the centers’ case against the state has merit, namely that Idaho is violating Medicaid’s equal access provision.
“According to the district court, all eligible recipients received the services that they needed,” Justice Ginsberg said. “So again, there was no waiting list; nobody’s being kept waiting. These providers, while they say they’re not getting enough, are still providing the service. So where is the [equal access] violation?”
Attorney James M. Piotrowski, who represented the centers, countered that the equal access provision imposes both procedural and substantive requirements. The substantive requirement mandates there must be enough providers to allow access and generate quality care, Mr. Piotrowski said. The procedural requirement entails that the rates be set based upon factors that Congress considers important.
“The violation of [the equal access provision] here was that the state gave no consideration whatsoever to the federal factors,” he said. “They relied only on their own factors.”
The Armstrong case is being closely watched by states, physicians, and patient advocates alike. Twenty-seven states have reached out to the high court in support of Idaho. The states saidthey have been subject to numerous, unwarranted lawsuits because of misguided interpretations of the Supremacy Clause. A number of physician and patient advocacy associations joined a friend-of-the-court brief in support of the centers, including the American Academy of Family Physicians and the American Medical Association. The AMA and other organizations said ongoing violations of Medicaid’s equal access provision by states continue to drive doctors from the program and harm access to care.
A decision by the high court is expected by June.
On Twitter @legal_med
Supreme Court to decide whether doctors can sue over low Medicaid payments
Physicians are closely watching a U.S. Supreme Court case that could affect their ability to fight low Medicaid payments.
On Jan. 20, the justices will hear arguments in Armstrong v. Exceptional Child Center Inc., a legal dispute that centers on whether physicians and other health care providers have the right to sue states to compel them to raise Medicaid payment rates.
Allowing providers to seek legal action over low Medicaid payments helps to ensure that payment is adequate and that states are held accountable, according to Dr. Reid B. Blackwelder, board chair of the American Academy of Family Physicians. Under the equal access provision of the Medicaid Act, states that accept federal Medicaid funding are required to set reimbursement rates at levels sufficient to retain enough providers and make sure patients have proper access to care.
“States really have the freedom and the will to make [payment] decisions based on their budgets,” Dr. Blackwelder said in an interview. “We feel the only way to create a remedy to the state’s noncompliance [to the equal access provision] is the individual’s right to sue.”
The case stems from a 2009 lawsuit by Exceptional Child Center Inc. of Twin Falls, Idaho, and four other residential habilitation centers against Richard Armstrong, director for the Idaho Department of Health and Welfare. The centers claimed the state should have raised its Medicaid payment rates after studies determined rate increases were necessary. The Idaho Department of Health and Welfare and its Medicaid division had conducted yearly cost studies between 2006 and 2009, developed a new rate-setting methodology, and recommended substantial increases in reimbursement rates for supported living services, according to court documents. However, the new methodology and rate increases were not enacted for budgetary reasons.
A district court ruled in favor of the centers, and the 9th U.S. Circuit Court of Appeals affirmed the ruling. The state petitioned the Supreme Court to resolve the issue. Idaho noted a split among the lower courts as to whether the Constitution’s Supremacy Clause – which establishes the Constitution and federal law as the law of the land – supplies a private right of action to enforce Medicaid funding conditions against states. In a court brief, Idaho Attorney General Lawrence G. Wasden said the Supremacy Clause does not do so and that only Congress has the authority to enforce federal statutes.
Mr. Wasden added that the Centers for Medicare & Medicaid Services had not found issue with Idaho’s payment rates nor had initiated any disciplinary actions against the state.
“If CMS believes a state has failed to correct a deficiency, CMS may initiate a process to withhold federal funds, either entirely or limited to the fund associated with the noncompliant service,” Mr. Wasden said in court documents. “At no time relevant to this case has CMS ever initiated any compliance action or otherwise complained about the state’s rates.”
Twenty-seven states reached out to the high court in support of Idaho. The states said they have been subject to numerous, unwarranted lawsuits because of misguided interpretations of the Supremacy Clause.
A number of physician and patient advocacy associations joined a friend-of-the-court brief in support of the centers, including the AAFP and the American Medical Association. The physicians’ court brief noted that 32 states reduced and/or froze Medicaid rates in 2012, and 23 did the same in 2013. As a result, Medicaid payment rates have often fallen below the average cost to deliver care and make it untenable for physicians to take on Medicaid patients.
“Noncompliance with Medicaid’s equal-access mandate will continue unless private enforcement is allowed to challenge states that adopt Medicaid payment rates based on arbitrary or politically expedient budgetary decisions,” AMA President Dr. Robert M. Wah said in a statement.
The Supreme Court’s decision will have a significant impact on whether physicians and other providers continue to participate in Medicaid and whether patients can find necessary care, added Jane Perkins, legal director of the National Health Law Program, a nonprofit that advocates the rights of low-income patients. The National Health Law Program issued its own friend-of-the-court brief in support of the centers.
“There are a tremendous number of potential ‘bigger picture’ impacts” to the court’s decision, Ms. Perkins said in an interview. “Researchers have found time and again that while many things go into a provider’s decision whether or not to participate in Medicaid, one of the main things is the payment rate. If [Idaho wins], I really fear the already problematic state of provider participation in many places is only going to get worse."
OnTwitter @legal_med
Physicians are closely watching a U.S. Supreme Court case that could affect their ability to fight low Medicaid payments.
On Jan. 20, the justices will hear arguments in Armstrong v. Exceptional Child Center Inc., a legal dispute that centers on whether physicians and other health care providers have the right to sue states to compel them to raise Medicaid payment rates.
Allowing providers to seek legal action over low Medicaid payments helps to ensure that payment is adequate and that states are held accountable, according to Dr. Reid B. Blackwelder, board chair of the American Academy of Family Physicians. Under the equal access provision of the Medicaid Act, states that accept federal Medicaid funding are required to set reimbursement rates at levels sufficient to retain enough providers and make sure patients have proper access to care.
“States really have the freedom and the will to make [payment] decisions based on their budgets,” Dr. Blackwelder said in an interview. “We feel the only way to create a remedy to the state’s noncompliance [to the equal access provision] is the individual’s right to sue.”
The case stems from a 2009 lawsuit by Exceptional Child Center Inc. of Twin Falls, Idaho, and four other residential habilitation centers against Richard Armstrong, director for the Idaho Department of Health and Welfare. The centers claimed the state should have raised its Medicaid payment rates after studies determined rate increases were necessary. The Idaho Department of Health and Welfare and its Medicaid division had conducted yearly cost studies between 2006 and 2009, developed a new rate-setting methodology, and recommended substantial increases in reimbursement rates for supported living services, according to court documents. However, the new methodology and rate increases were not enacted for budgetary reasons.
A district court ruled in favor of the centers, and the 9th U.S. Circuit Court of Appeals affirmed the ruling. The state petitioned the Supreme Court to resolve the issue. Idaho noted a split among the lower courts as to whether the Constitution’s Supremacy Clause – which establishes the Constitution and federal law as the law of the land – supplies a private right of action to enforce Medicaid funding conditions against states. In a court brief, Idaho Attorney General Lawrence G. Wasden said the Supremacy Clause does not do so and that only Congress has the authority to enforce federal statutes.
Mr. Wasden added that the Centers for Medicare & Medicaid Services had not found issue with Idaho’s payment rates nor had initiated any disciplinary actions against the state.
“If CMS believes a state has failed to correct a deficiency, CMS may initiate a process to withhold federal funds, either entirely or limited to the fund associated with the noncompliant service,” Mr. Wasden said in court documents. “At no time relevant to this case has CMS ever initiated any compliance action or otherwise complained about the state’s rates.”
Twenty-seven states reached out to the high court in support of Idaho. The states said they have been subject to numerous, unwarranted lawsuits because of misguided interpretations of the Supremacy Clause.
A number of physician and patient advocacy associations joined a friend-of-the-court brief in support of the centers, including the AAFP and the American Medical Association. The physicians’ court brief noted that 32 states reduced and/or froze Medicaid rates in 2012, and 23 did the same in 2013. As a result, Medicaid payment rates have often fallen below the average cost to deliver care and make it untenable for physicians to take on Medicaid patients.
“Noncompliance with Medicaid’s equal-access mandate will continue unless private enforcement is allowed to challenge states that adopt Medicaid payment rates based on arbitrary or politically expedient budgetary decisions,” AMA President Dr. Robert M. Wah said in a statement.
The Supreme Court’s decision will have a significant impact on whether physicians and other providers continue to participate in Medicaid and whether patients can find necessary care, added Jane Perkins, legal director of the National Health Law Program, a nonprofit that advocates the rights of low-income patients. The National Health Law Program issued its own friend-of-the-court brief in support of the centers.
“There are a tremendous number of potential ‘bigger picture’ impacts” to the court’s decision, Ms. Perkins said in an interview. “Researchers have found time and again that while many things go into a provider’s decision whether or not to participate in Medicaid, one of the main things is the payment rate. If [Idaho wins], I really fear the already problematic state of provider participation in many places is only going to get worse."
OnTwitter @legal_med
Physicians are closely watching a U.S. Supreme Court case that could affect their ability to fight low Medicaid payments.
On Jan. 20, the justices will hear arguments in Armstrong v. Exceptional Child Center Inc., a legal dispute that centers on whether physicians and other health care providers have the right to sue states to compel them to raise Medicaid payment rates.
Allowing providers to seek legal action over low Medicaid payments helps to ensure that payment is adequate and that states are held accountable, according to Dr. Reid B. Blackwelder, board chair of the American Academy of Family Physicians. Under the equal access provision of the Medicaid Act, states that accept federal Medicaid funding are required to set reimbursement rates at levels sufficient to retain enough providers and make sure patients have proper access to care.
“States really have the freedom and the will to make [payment] decisions based on their budgets,” Dr. Blackwelder said in an interview. “We feel the only way to create a remedy to the state’s noncompliance [to the equal access provision] is the individual’s right to sue.”
The case stems from a 2009 lawsuit by Exceptional Child Center Inc. of Twin Falls, Idaho, and four other residential habilitation centers against Richard Armstrong, director for the Idaho Department of Health and Welfare. The centers claimed the state should have raised its Medicaid payment rates after studies determined rate increases were necessary. The Idaho Department of Health and Welfare and its Medicaid division had conducted yearly cost studies between 2006 and 2009, developed a new rate-setting methodology, and recommended substantial increases in reimbursement rates for supported living services, according to court documents. However, the new methodology and rate increases were not enacted for budgetary reasons.
A district court ruled in favor of the centers, and the 9th U.S. Circuit Court of Appeals affirmed the ruling. The state petitioned the Supreme Court to resolve the issue. Idaho noted a split among the lower courts as to whether the Constitution’s Supremacy Clause – which establishes the Constitution and federal law as the law of the land – supplies a private right of action to enforce Medicaid funding conditions against states. In a court brief, Idaho Attorney General Lawrence G. Wasden said the Supremacy Clause does not do so and that only Congress has the authority to enforce federal statutes.
Mr. Wasden added that the Centers for Medicare & Medicaid Services had not found issue with Idaho’s payment rates nor had initiated any disciplinary actions against the state.
“If CMS believes a state has failed to correct a deficiency, CMS may initiate a process to withhold federal funds, either entirely or limited to the fund associated with the noncompliant service,” Mr. Wasden said in court documents. “At no time relevant to this case has CMS ever initiated any compliance action or otherwise complained about the state’s rates.”
Twenty-seven states reached out to the high court in support of Idaho. The states said they have been subject to numerous, unwarranted lawsuits because of misguided interpretations of the Supremacy Clause.
A number of physician and patient advocacy associations joined a friend-of-the-court brief in support of the centers, including the AAFP and the American Medical Association. The physicians’ court brief noted that 32 states reduced and/or froze Medicaid rates in 2012, and 23 did the same in 2013. As a result, Medicaid payment rates have often fallen below the average cost to deliver care and make it untenable for physicians to take on Medicaid patients.
“Noncompliance with Medicaid’s equal-access mandate will continue unless private enforcement is allowed to challenge states that adopt Medicaid payment rates based on arbitrary or politically expedient budgetary decisions,” AMA President Dr. Robert M. Wah said in a statement.
The Supreme Court’s decision will have a significant impact on whether physicians and other providers continue to participate in Medicaid and whether patients can find necessary care, added Jane Perkins, legal director of the National Health Law Program, a nonprofit that advocates the rights of low-income patients. The National Health Law Program issued its own friend-of-the-court brief in support of the centers.
“There are a tremendous number of potential ‘bigger picture’ impacts” to the court’s decision, Ms. Perkins said in an interview. “Researchers have found time and again that while many things go into a provider’s decision whether or not to participate in Medicaid, one of the main things is the payment rate. If [Idaho wins], I really fear the already problematic state of provider participation in many places is only going to get worse."
OnTwitter @legal_med
CDC: Hospital-acquired infections decreasing
Hospitals reduced significantly the number of surgical site and central-line associated bloodstream infections in 2013, according to a national analysis by the Centers for Disease Control and Prevention.
A review of data submitted by 14,500 health facilities found that central line–associated bloodstream infections (CLABSIs) fell by 46% between 2008 and 2013, and surgical site infections (SSIs) dropped by 19% over the same period. SSI data were derived from 10 select procedures, including hip arthroplasty, knee arthroplasty, colon surgery, rectal surgery, abdominal hysterectomy, vaginal hysterectomy, coronary artery bypass graft, other cardiac surgery, peripheral vascular bypass surgery, and abdominal aortic aneurysm repair.
Increased reporting by health care providers and quality measures imposed by the Centers for Medicare and Medicaid Services are likely contributors to the report’s findings, said Dr. Henry Pitt, chief quality officer for Temple University Health System, Philadelphia.
“Because of all the reporting that is being done, and the potential financial burdens that exist through CMS’s value-based purchasing program, and the work people are doing to improve these things, it’s not surprising that the data are looking better,” Dr. Pitt said in an interview.
The CDC’s annual National and State Healthcare-associated Infection Progress report summarizes data submitted to the CDC’s National Healthcare Safety Network (NHSN), a nationwide infection tracking system used by all 50 states, Washington, and Puerto Rico. In addition to SSIs and CLABSIs, findings of the report show also that methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections decreased by 8% from 2011 to 2013 and that Clostridium difficile infections dropped by 10% between 2011 and 2013. However, catheter-associated urinary tract infections have risen by 6% since 2009.
In a state-by-state comparison, 26 states performed better than the nation on at least two of the six infection types tracked by state. Sixteen states performed better than the nation on three or more infections and 19 states performed worse than the nation on two infections. Not all states reported or had enough data to calculate valid infection information on every infection in the report. Among the 2,543 U.S. hospitals with enough data to calculate a standardized infection ratio (SIR), 9% had an SIR significantly worse than the national SIR of 0.81.
Despite the progress, the report calls for more action to eliminate hospital infections and recommends its report be used by health departments, hospital associations, professional societies, health care systems and facilities, and quality improvement groups to identify infections that need additional prevention efforts.
Dr. Pitt added that CMS programs that use infection control and reduction as quality metrics will no doubt continue to impact infection reporting and outcomes. The three CMS programs associated with infection control and hospital payments include its hospital value-based purchasing, hospital readmissions reduction, and hospital-acquired condition reduction programs.
“Again, people are paying more attention, in addition to it’s the right thing to do, because more money is at risk,” Dr. Pitt said.
Data in the CDC report are from acute hospitals only.
On Twitter @legal_med
Hospitals reduced significantly the number of surgical site and central-line associated bloodstream infections in 2013, according to a national analysis by the Centers for Disease Control and Prevention.
A review of data submitted by 14,500 health facilities found that central line–associated bloodstream infections (CLABSIs) fell by 46% between 2008 and 2013, and surgical site infections (SSIs) dropped by 19% over the same period. SSI data were derived from 10 select procedures, including hip arthroplasty, knee arthroplasty, colon surgery, rectal surgery, abdominal hysterectomy, vaginal hysterectomy, coronary artery bypass graft, other cardiac surgery, peripheral vascular bypass surgery, and abdominal aortic aneurysm repair.
Increased reporting by health care providers and quality measures imposed by the Centers for Medicare and Medicaid Services are likely contributors to the report’s findings, said Dr. Henry Pitt, chief quality officer for Temple University Health System, Philadelphia.
“Because of all the reporting that is being done, and the potential financial burdens that exist through CMS’s value-based purchasing program, and the work people are doing to improve these things, it’s not surprising that the data are looking better,” Dr. Pitt said in an interview.
The CDC’s annual National and State Healthcare-associated Infection Progress report summarizes data submitted to the CDC’s National Healthcare Safety Network (NHSN), a nationwide infection tracking system used by all 50 states, Washington, and Puerto Rico. In addition to SSIs and CLABSIs, findings of the report show also that methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections decreased by 8% from 2011 to 2013 and that Clostridium difficile infections dropped by 10% between 2011 and 2013. However, catheter-associated urinary tract infections have risen by 6% since 2009.
In a state-by-state comparison, 26 states performed better than the nation on at least two of the six infection types tracked by state. Sixteen states performed better than the nation on three or more infections and 19 states performed worse than the nation on two infections. Not all states reported or had enough data to calculate valid infection information on every infection in the report. Among the 2,543 U.S. hospitals with enough data to calculate a standardized infection ratio (SIR), 9% had an SIR significantly worse than the national SIR of 0.81.
Despite the progress, the report calls for more action to eliminate hospital infections and recommends its report be used by health departments, hospital associations, professional societies, health care systems and facilities, and quality improvement groups to identify infections that need additional prevention efforts.
Dr. Pitt added that CMS programs that use infection control and reduction as quality metrics will no doubt continue to impact infection reporting and outcomes. The three CMS programs associated with infection control and hospital payments include its hospital value-based purchasing, hospital readmissions reduction, and hospital-acquired condition reduction programs.
“Again, people are paying more attention, in addition to it’s the right thing to do, because more money is at risk,” Dr. Pitt said.
Data in the CDC report are from acute hospitals only.
On Twitter @legal_med
Hospitals reduced significantly the number of surgical site and central-line associated bloodstream infections in 2013, according to a national analysis by the Centers for Disease Control and Prevention.
A review of data submitted by 14,500 health facilities found that central line–associated bloodstream infections (CLABSIs) fell by 46% between 2008 and 2013, and surgical site infections (SSIs) dropped by 19% over the same period. SSI data were derived from 10 select procedures, including hip arthroplasty, knee arthroplasty, colon surgery, rectal surgery, abdominal hysterectomy, vaginal hysterectomy, coronary artery bypass graft, other cardiac surgery, peripheral vascular bypass surgery, and abdominal aortic aneurysm repair.
Increased reporting by health care providers and quality measures imposed by the Centers for Medicare and Medicaid Services are likely contributors to the report’s findings, said Dr. Henry Pitt, chief quality officer for Temple University Health System, Philadelphia.
“Because of all the reporting that is being done, and the potential financial burdens that exist through CMS’s value-based purchasing program, and the work people are doing to improve these things, it’s not surprising that the data are looking better,” Dr. Pitt said in an interview.
The CDC’s annual National and State Healthcare-associated Infection Progress report summarizes data submitted to the CDC’s National Healthcare Safety Network (NHSN), a nationwide infection tracking system used by all 50 states, Washington, and Puerto Rico. In addition to SSIs and CLABSIs, findings of the report show also that methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections decreased by 8% from 2011 to 2013 and that Clostridium difficile infections dropped by 10% between 2011 and 2013. However, catheter-associated urinary tract infections have risen by 6% since 2009.
In a state-by-state comparison, 26 states performed better than the nation on at least two of the six infection types tracked by state. Sixteen states performed better than the nation on three or more infections and 19 states performed worse than the nation on two infections. Not all states reported or had enough data to calculate valid infection information on every infection in the report. Among the 2,543 U.S. hospitals with enough data to calculate a standardized infection ratio (SIR), 9% had an SIR significantly worse than the national SIR of 0.81.
Despite the progress, the report calls for more action to eliminate hospital infections and recommends its report be used by health departments, hospital associations, professional societies, health care systems and facilities, and quality improvement groups to identify infections that need additional prevention efforts.
Dr. Pitt added that CMS programs that use infection control and reduction as quality metrics will no doubt continue to impact infection reporting and outcomes. The three CMS programs associated with infection control and hospital payments include its hospital value-based purchasing, hospital readmissions reduction, and hospital-acquired condition reduction programs.
“Again, people are paying more attention, in addition to it’s the right thing to do, because more money is at risk,” Dr. Pitt said.
Data in the CDC report are from acute hospitals only.
On Twitter @legal_med
Proposal would enable medical decision making by same-sex spouses
Under a new federal proposal, physicians could more easily provide sensitive medical information about patients to same-sex spouses and follow the treatment wishes of same-sex partners when a patient is incapacitated.
The proposal from the Centers for Medicare & Medicaid Services is aimed at making program requirements more consistent with the U.S. Supreme Court’s decision in United States v. Windsor and would apply to mental health, hospital, laboratory, hospice, long-term care, and ambulatory surgical center services.
The proposed rules allow for smoother communication among physicians, patients, and same-sex spouses and reduce frustration for all parties when it comes to medical decision making, said Dr. Harvey J. Makadon, director of the National LGBT Health Education Center at the Fenway Institute, Boston, and a professor of medicine at Harvard Medical School.
“The proposed rules essentially recognize the reality that same-sex individuals can now get married and that their spouses need to be treated in the same way that all spouses are treated in terms of being involved in health care decision making,” Dr. Makadon said in an interview. “Rules like this make life easier for clinicians, who are in a better position not only to respect [same-sex relationships], but to feel like the CMS supports their ability to involve the appropriate loved ones in a patient’s care.”
In Windsor, the Supreme Court in 2013 held that Section 3 of the Defense of Marriage Act (DOMA) was unconstitutional because it violated the Fifth Amendment. DOMA had stated that, within government programs, the word “marriage” meant only a legal union between one man and one woman and the word “spouse” could refer only to a husband or wife of the opposite sex. Since the decision, the government has started approving some Medicare enrollments for same-sex spouses, including care under Medicare Part A and skilled nursing services under Medicare Advantage.
The CMS proposal, announced Dec. 11, would revise language within the Medicare and Medicare programs to recognize marriages between individuals of the same sex who were lawfully married under state law, regardless of where the couple now resides or the jurisdiction in which a health provider is located. The regulations would mandate that same-sex partners be afforded treatment equal to that afforded to opposite-sex spouses if the marriage is valid in the jurisdiction in which it was celebrated.
Specifically, CMS wants program language to reflect that hospitals, ambulatory surgical centers, and community mental health centers must inform recognized same-sex spouses of a patient’s rights in advance of care decisions when necessary. Current language requires health providers in such care environments to inform patients or, when appropriate, legal representatives, of a patient’s rights in advance of furnishing or discontinuing care. Additionally, the agency suggests adding same-sex spouses to the definition of “representative” for purposes of authorizing or terminating medical care or revoking hospice care on behalf of a terminally ill patient.
Same-sex spouses also would more easily access laboratory test results in certain circumstances. Current CMS language requires that legal representatives be notified about blood screenings and infectious disease results if patients are deemed incompetent. In such instances, recognized same-sex spouses now would be included in the definition of legal representative, according to the proposal.
The proposed rules are a significant step in the federal government’s efforts to ensure that programs treat married same-sex couples equal to their opposite-sex counterparts, as mandated by Windsor, said Hector Vargas, executive director of GLMA: Health Professionals Advancing LGBT Equality (formally known as the Gay and Lesbian Medical Association).
“While facilities and providers should already treat all married couples equally, the regulation removes any doubt about this for Medicare- and Medicaid-participating facilities and providers,” Mr. Vargas said in an interview.
The proposed rules were published Dec. 12 in the Federal Register. Comments on the latest proposal can be submitted to www.regulations.gov until Feb. 10, 2015.
On Twitter @legal_med
Under a new federal proposal, physicians could more easily provide sensitive medical information about patients to same-sex spouses and follow the treatment wishes of same-sex partners when a patient is incapacitated.
The proposal from the Centers for Medicare & Medicaid Services is aimed at making program requirements more consistent with the U.S. Supreme Court’s decision in United States v. Windsor and would apply to mental health, hospital, laboratory, hospice, long-term care, and ambulatory surgical center services.
The proposed rules allow for smoother communication among physicians, patients, and same-sex spouses and reduce frustration for all parties when it comes to medical decision making, said Dr. Harvey J. Makadon, director of the National LGBT Health Education Center at the Fenway Institute, Boston, and a professor of medicine at Harvard Medical School.
“The proposed rules essentially recognize the reality that same-sex individuals can now get married and that their spouses need to be treated in the same way that all spouses are treated in terms of being involved in health care decision making,” Dr. Makadon said in an interview. “Rules like this make life easier for clinicians, who are in a better position not only to respect [same-sex relationships], but to feel like the CMS supports their ability to involve the appropriate loved ones in a patient’s care.”
In Windsor, the Supreme Court in 2013 held that Section 3 of the Defense of Marriage Act (DOMA) was unconstitutional because it violated the Fifth Amendment. DOMA had stated that, within government programs, the word “marriage” meant only a legal union between one man and one woman and the word “spouse” could refer only to a husband or wife of the opposite sex. Since the decision, the government has started approving some Medicare enrollments for same-sex spouses, including care under Medicare Part A and skilled nursing services under Medicare Advantage.
The CMS proposal, announced Dec. 11, would revise language within the Medicare and Medicare programs to recognize marriages between individuals of the same sex who were lawfully married under state law, regardless of where the couple now resides or the jurisdiction in which a health provider is located. The regulations would mandate that same-sex partners be afforded treatment equal to that afforded to opposite-sex spouses if the marriage is valid in the jurisdiction in which it was celebrated.
Specifically, CMS wants program language to reflect that hospitals, ambulatory surgical centers, and community mental health centers must inform recognized same-sex spouses of a patient’s rights in advance of care decisions when necessary. Current language requires health providers in such care environments to inform patients or, when appropriate, legal representatives, of a patient’s rights in advance of furnishing or discontinuing care. Additionally, the agency suggests adding same-sex spouses to the definition of “representative” for purposes of authorizing or terminating medical care or revoking hospice care on behalf of a terminally ill patient.
Same-sex spouses also would more easily access laboratory test results in certain circumstances. Current CMS language requires that legal representatives be notified about blood screenings and infectious disease results if patients are deemed incompetent. In such instances, recognized same-sex spouses now would be included in the definition of legal representative, according to the proposal.
The proposed rules are a significant step in the federal government’s efforts to ensure that programs treat married same-sex couples equal to their opposite-sex counterparts, as mandated by Windsor, said Hector Vargas, executive director of GLMA: Health Professionals Advancing LGBT Equality (formally known as the Gay and Lesbian Medical Association).
“While facilities and providers should already treat all married couples equally, the regulation removes any doubt about this for Medicare- and Medicaid-participating facilities and providers,” Mr. Vargas said in an interview.
The proposed rules were published Dec. 12 in the Federal Register. Comments on the latest proposal can be submitted to www.regulations.gov until Feb. 10, 2015.
On Twitter @legal_med
Under a new federal proposal, physicians could more easily provide sensitive medical information about patients to same-sex spouses and follow the treatment wishes of same-sex partners when a patient is incapacitated.
The proposal from the Centers for Medicare & Medicaid Services is aimed at making program requirements more consistent with the U.S. Supreme Court’s decision in United States v. Windsor and would apply to mental health, hospital, laboratory, hospice, long-term care, and ambulatory surgical center services.
The proposed rules allow for smoother communication among physicians, patients, and same-sex spouses and reduce frustration for all parties when it comes to medical decision making, said Dr. Harvey J. Makadon, director of the National LGBT Health Education Center at the Fenway Institute, Boston, and a professor of medicine at Harvard Medical School.
“The proposed rules essentially recognize the reality that same-sex individuals can now get married and that their spouses need to be treated in the same way that all spouses are treated in terms of being involved in health care decision making,” Dr. Makadon said in an interview. “Rules like this make life easier for clinicians, who are in a better position not only to respect [same-sex relationships], but to feel like the CMS supports their ability to involve the appropriate loved ones in a patient’s care.”
In Windsor, the Supreme Court in 2013 held that Section 3 of the Defense of Marriage Act (DOMA) was unconstitutional because it violated the Fifth Amendment. DOMA had stated that, within government programs, the word “marriage” meant only a legal union between one man and one woman and the word “spouse” could refer only to a husband or wife of the opposite sex. Since the decision, the government has started approving some Medicare enrollments for same-sex spouses, including care under Medicare Part A and skilled nursing services under Medicare Advantage.
The CMS proposal, announced Dec. 11, would revise language within the Medicare and Medicare programs to recognize marriages between individuals of the same sex who were lawfully married under state law, regardless of where the couple now resides or the jurisdiction in which a health provider is located. The regulations would mandate that same-sex partners be afforded treatment equal to that afforded to opposite-sex spouses if the marriage is valid in the jurisdiction in which it was celebrated.
Specifically, CMS wants program language to reflect that hospitals, ambulatory surgical centers, and community mental health centers must inform recognized same-sex spouses of a patient’s rights in advance of care decisions when necessary. Current language requires health providers in such care environments to inform patients or, when appropriate, legal representatives, of a patient’s rights in advance of furnishing or discontinuing care. Additionally, the agency suggests adding same-sex spouses to the definition of “representative” for purposes of authorizing or terminating medical care or revoking hospice care on behalf of a terminally ill patient.
Same-sex spouses also would more easily access laboratory test results in certain circumstances. Current CMS language requires that legal representatives be notified about blood screenings and infectious disease results if patients are deemed incompetent. In such instances, recognized same-sex spouses now would be included in the definition of legal representative, according to the proposal.
The proposed rules are a significant step in the federal government’s efforts to ensure that programs treat married same-sex couples equal to their opposite-sex counterparts, as mandated by Windsor, said Hector Vargas, executive director of GLMA: Health Professionals Advancing LGBT Equality (formally known as the Gay and Lesbian Medical Association).
“While facilities and providers should already treat all married couples equally, the regulation removes any doubt about this for Medicare- and Medicaid-participating facilities and providers,” Mr. Vargas said in an interview.
The proposed rules were published Dec. 12 in the Federal Register. Comments on the latest proposal can be submitted to www.regulations.gov until Feb. 10, 2015.
On Twitter @legal_med
Feds expect to recover nearly $5 billion of wrongful Medicare and Medicaid payments
The U.S. Department of Health and Human Services Office of Inspector General expects to recover $4.9 billion in improper Medicaid and Medicare payments in 2014, down from $5.8 billion recoveries in 2013.
Of the expected recoveries, $4.1 billion stem from investigative work by the government and about $830 million result from program audits, according to a December announcement by the OIG.
While recoveries were slightly down from last year, exclusions from federal programs rose, according to the report to Congress. In 2014, the OIG excluded 4,017 health providers from participating in federal health care programs, up from 3,214 in 2013. The OIG also took 971 criminal actions against individuals or health care entities that allegedly engaged in crimes against programs such as Medicare and Medicaid. Courts weighed in on 533 civil and administrative cases in 2014, including false claims and unjust-enrichment lawsuits. Administrative cases included both OIG-initiated actions and provider self-disclosure cases. In comparison, the OIG took 960 criminal actions and 472 civil actions against health care providers in 2013.
Significant overpayment cases in 2014 included a six-state seizure by the Medicare Fraud Strike Force in May 2014 that resulted in charges against 90 health care providers, including physicians, for their alleged participation in Medicare fraud schemes totaling $260 million. The OIG also accepted an $85 million settlement from Daytona Beach, Fla.–based Halifax Hospital Medical Center to resolve allegations that Halifax entered into prohibited contracts with oncologists and neurosurgeons in violation of the Stark Law, resulting in the submission of false claims.
On Twitter @legal_med
The U.S. Department of Health and Human Services Office of Inspector General expects to recover $4.9 billion in improper Medicaid and Medicare payments in 2014, down from $5.8 billion recoveries in 2013.
Of the expected recoveries, $4.1 billion stem from investigative work by the government and about $830 million result from program audits, according to a December announcement by the OIG.
While recoveries were slightly down from last year, exclusions from federal programs rose, according to the report to Congress. In 2014, the OIG excluded 4,017 health providers from participating in federal health care programs, up from 3,214 in 2013. The OIG also took 971 criminal actions against individuals or health care entities that allegedly engaged in crimes against programs such as Medicare and Medicaid. Courts weighed in on 533 civil and administrative cases in 2014, including false claims and unjust-enrichment lawsuits. Administrative cases included both OIG-initiated actions and provider self-disclosure cases. In comparison, the OIG took 960 criminal actions and 472 civil actions against health care providers in 2013.
Significant overpayment cases in 2014 included a six-state seizure by the Medicare Fraud Strike Force in May 2014 that resulted in charges against 90 health care providers, including physicians, for their alleged participation in Medicare fraud schemes totaling $260 million. The OIG also accepted an $85 million settlement from Daytona Beach, Fla.–based Halifax Hospital Medical Center to resolve allegations that Halifax entered into prohibited contracts with oncologists and neurosurgeons in violation of the Stark Law, resulting in the submission of false claims.
On Twitter @legal_med
The U.S. Department of Health and Human Services Office of Inspector General expects to recover $4.9 billion in improper Medicaid and Medicare payments in 2014, down from $5.8 billion recoveries in 2013.
Of the expected recoveries, $4.1 billion stem from investigative work by the government and about $830 million result from program audits, according to a December announcement by the OIG.
While recoveries were slightly down from last year, exclusions from federal programs rose, according to the report to Congress. In 2014, the OIG excluded 4,017 health providers from participating in federal health care programs, up from 3,214 in 2013. The OIG also took 971 criminal actions against individuals or health care entities that allegedly engaged in crimes against programs such as Medicare and Medicaid. Courts weighed in on 533 civil and administrative cases in 2014, including false claims and unjust-enrichment lawsuits. Administrative cases included both OIG-initiated actions and provider self-disclosure cases. In comparison, the OIG took 960 criminal actions and 472 civil actions against health care providers in 2013.
Significant overpayment cases in 2014 included a six-state seizure by the Medicare Fraud Strike Force in May 2014 that resulted in charges against 90 health care providers, including physicians, for their alleged participation in Medicare fraud schemes totaling $260 million. The OIG also accepted an $85 million settlement from Daytona Beach, Fla.–based Halifax Hospital Medical Center to resolve allegations that Halifax entered into prohibited contracts with oncologists and neurosurgeons in violation of the Stark Law, resulting in the submission of false claims.
On Twitter @legal_med
Court: State cannot withhold Medicaid payments for program violations
State administrators cannot withhold Medicaid payments from physicians suspected of program violations without evidence of fraud, a Texas appeals court has ruled.
Appellate judges also struck down a rule that enabled the Texas Health and Human Services Commission (THHSC) to retain seized payments after a hold is terminated to offset a possible overpayment.
Although the original plaintiffs in the case were dentists, the decision will apply to all physicians and health providers in Texas, said Donald P. “Rocky” Wilcox, vice president and general counsel for the Texas Medical Association.
“This is a really good decision,” Mr. Wilcox said in an interview. “We saw physicians, dentists, and others having a [payment] hold stay in place even after the agency said there was no more suspicion or allegation of fraud, just a dispute over whether the coding was proper.”
The case originated from a Medicaid payment hold placed on Harlingen Family Dentistry PC during a fraud investigation by the THHSC, according to Harlingen’s attorney, Jason Ray of Austin. An administrative law judge (ALJ) ruled that there was no evidence of fraud but that the dental practice may have potentially committed program violations. The ALJ allowed the payment hold to stand. Harlingen did not appeal and instead filed a separate lawsuit with another dental group that challenged the state’s authority to withhold payments in such circumstances.
A trial court ruled in favor of the state and the decision was appealed to the Texas Court of Appeals, Third District, at Austin, which overturned the decision Nov. 25. The judges said that withholding payments from health providers for alleged program violations, no matter how minor, is inconsistent with the intent of state law, which is to permit holds under instances involving Medicaid fraud or abuse.
“The fact that the challenged rules lack the due-process notice and hearing requirements that are the hallmark of legislation expressly authorizing the imposition of pre-notice payment holds bolsters our conclusion,” the judges said in their opinion.
Additionally, the appeals court revoked another rule that had allowed the state to retain Medicaid payments even after a provider had been cleared of fraud and a hold terminated. The THHSC’s right to possess funds pursuant to a payment hold for fraud depends solely on the existence of credible evidence of such fraud, the appeals court said. Once the statutory basis for imposing the hold ceases to exist, the THHSC no longer has the authority to keep the money.
In a court brief, Ann Hartley, an attorney for the Texas Attorney General’s office, argued that the state has the authority to impose a temporary payment hold when a Medicaid provider commits a program violation, whether or not fraud is alleged. The hold continues until a final determination is made as to whether, and how much, the provider has been overpaid, in which case the seized money is applied to offset or recoup overpayment or pay restitution or penalties imposed, the brief said.
Mr. Ray said that he believes the ruling will have a significant impact on health providers across the state. He oted that many medical practices and professionals have suffered because of the state’s excessive Medicaid payment holds. In a number of cases, he said, the holds resulted from accidental overbilling or paperwork errors.
“It’s a good message to government,” Mr. Ray said in an interview. “Nobody likes fraud, but they need to redirect their efforts to finding providers that are really engaged in fraud and not spend their time and effort driving good providers out of business.”
When asked to comment on this case, the THHSC did not respond to this news organization.
On Twitter @legal_med
State administrators cannot withhold Medicaid payments from physicians suspected of program violations without evidence of fraud, a Texas appeals court has ruled.
Appellate judges also struck down a rule that enabled the Texas Health and Human Services Commission (THHSC) to retain seized payments after a hold is terminated to offset a possible overpayment.
Although the original plaintiffs in the case were dentists, the decision will apply to all physicians and health providers in Texas, said Donald P. “Rocky” Wilcox, vice president and general counsel for the Texas Medical Association.
“This is a really good decision,” Mr. Wilcox said in an interview. “We saw physicians, dentists, and others having a [payment] hold stay in place even after the agency said there was no more suspicion or allegation of fraud, just a dispute over whether the coding was proper.”
The case originated from a Medicaid payment hold placed on Harlingen Family Dentistry PC during a fraud investigation by the THHSC, according to Harlingen’s attorney, Jason Ray of Austin. An administrative law judge (ALJ) ruled that there was no evidence of fraud but that the dental practice may have potentially committed program violations. The ALJ allowed the payment hold to stand. Harlingen did not appeal and instead filed a separate lawsuit with another dental group that challenged the state’s authority to withhold payments in such circumstances.
A trial court ruled in favor of the state and the decision was appealed to the Texas Court of Appeals, Third District, at Austin, which overturned the decision Nov. 25. The judges said that withholding payments from health providers for alleged program violations, no matter how minor, is inconsistent with the intent of state law, which is to permit holds under instances involving Medicaid fraud or abuse.
“The fact that the challenged rules lack the due-process notice and hearing requirements that are the hallmark of legislation expressly authorizing the imposition of pre-notice payment holds bolsters our conclusion,” the judges said in their opinion.
Additionally, the appeals court revoked another rule that had allowed the state to retain Medicaid payments even after a provider had been cleared of fraud and a hold terminated. The THHSC’s right to possess funds pursuant to a payment hold for fraud depends solely on the existence of credible evidence of such fraud, the appeals court said. Once the statutory basis for imposing the hold ceases to exist, the THHSC no longer has the authority to keep the money.
In a court brief, Ann Hartley, an attorney for the Texas Attorney General’s office, argued that the state has the authority to impose a temporary payment hold when a Medicaid provider commits a program violation, whether or not fraud is alleged. The hold continues until a final determination is made as to whether, and how much, the provider has been overpaid, in which case the seized money is applied to offset or recoup overpayment or pay restitution or penalties imposed, the brief said.
Mr. Ray said that he believes the ruling will have a significant impact on health providers across the state. He oted that many medical practices and professionals have suffered because of the state’s excessive Medicaid payment holds. In a number of cases, he said, the holds resulted from accidental overbilling or paperwork errors.
“It’s a good message to government,” Mr. Ray said in an interview. “Nobody likes fraud, but they need to redirect their efforts to finding providers that are really engaged in fraud and not spend their time and effort driving good providers out of business.”
When asked to comment on this case, the THHSC did not respond to this news organization.
On Twitter @legal_med
State administrators cannot withhold Medicaid payments from physicians suspected of program violations without evidence of fraud, a Texas appeals court has ruled.
Appellate judges also struck down a rule that enabled the Texas Health and Human Services Commission (THHSC) to retain seized payments after a hold is terminated to offset a possible overpayment.
Although the original plaintiffs in the case were dentists, the decision will apply to all physicians and health providers in Texas, said Donald P. “Rocky” Wilcox, vice president and general counsel for the Texas Medical Association.
“This is a really good decision,” Mr. Wilcox said in an interview. “We saw physicians, dentists, and others having a [payment] hold stay in place even after the agency said there was no more suspicion or allegation of fraud, just a dispute over whether the coding was proper.”
The case originated from a Medicaid payment hold placed on Harlingen Family Dentistry PC during a fraud investigation by the THHSC, according to Harlingen’s attorney, Jason Ray of Austin. An administrative law judge (ALJ) ruled that there was no evidence of fraud but that the dental practice may have potentially committed program violations. The ALJ allowed the payment hold to stand. Harlingen did not appeal and instead filed a separate lawsuit with another dental group that challenged the state’s authority to withhold payments in such circumstances.
A trial court ruled in favor of the state and the decision was appealed to the Texas Court of Appeals, Third District, at Austin, which overturned the decision Nov. 25. The judges said that withholding payments from health providers for alleged program violations, no matter how minor, is inconsistent with the intent of state law, which is to permit holds under instances involving Medicaid fraud or abuse.
“The fact that the challenged rules lack the due-process notice and hearing requirements that are the hallmark of legislation expressly authorizing the imposition of pre-notice payment holds bolsters our conclusion,” the judges said in their opinion.
Additionally, the appeals court revoked another rule that had allowed the state to retain Medicaid payments even after a provider had been cleared of fraud and a hold terminated. The THHSC’s right to possess funds pursuant to a payment hold for fraud depends solely on the existence of credible evidence of such fraud, the appeals court said. Once the statutory basis for imposing the hold ceases to exist, the THHSC no longer has the authority to keep the money.
In a court brief, Ann Hartley, an attorney for the Texas Attorney General’s office, argued that the state has the authority to impose a temporary payment hold when a Medicaid provider commits a program violation, whether or not fraud is alleged. The hold continues until a final determination is made as to whether, and how much, the provider has been overpaid, in which case the seized money is applied to offset or recoup overpayment or pay restitution or penalties imposed, the brief said.
Mr. Ray said that he believes the ruling will have a significant impact on health providers across the state. He oted that many medical practices and professionals have suffered because of the state’s excessive Medicaid payment holds. In a number of cases, he said, the holds resulted from accidental overbilling or paperwork errors.
“It’s a good message to government,” Mr. Ray said in an interview. “Nobody likes fraud, but they need to redirect their efforts to finding providers that are really engaged in fraud and not spend their time and effort driving good providers out of business.”
When asked to comment on this case, the THHSC did not respond to this news organization.
On Twitter @legal_med
CMS expands ability to deny provider enrollments
The Centers for Medicare & Medicaid Services is tightening scrutiny of providers enrolling in Medicare in an effort to curb fraudulent billing and keep providers with unpaid Medicare debt from reentering the program.
New rules announced Dec. 3 by the CMS strengthen the agency’s ability to deny or revoke the enrollment of entities and individuals believed to pose a program integrity risk to Medicare. The regulations come after the February 2011 revision of CMS’s enrollment policy, a revamp aimed at increasing the integrity of Medicare. Under the Dec. 3 enrollment provisions, the CMS can now:
• Deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt (existing overpayment or another form of financial obligation).
• Deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felonies (murder, rape, assault, extortion, embezzlement, income tax evasion).
• Revoke the billing privileges of providers and suppliers who have a pattern or practice of billing for services that do not meet Medicare requirements.
The new rules will prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program, and then reenroll as a new business to avoid repayment of the outstanding Medicare debt, according to the agency.
Physicians and other prospective enrollees who owe Medicare money can avoid being denied by agreeing to a CMS-approved extended repayment schedule for the entire outstanding Medicare debt or by repaying it in full.
In its final rule, the CMS acknowledged that the majority of Medicare provider enrollees submit valid claims that meet the CMS guidelines.
“A small percentage of providers and suppliers are engaging in fraudulent, wasteful, inappropriate, or abusive activities,” the agency wrote in the Federal Register. “Our provider enrollment revisions are directed at such providers and suppliers, and we believe that removing them, as necessary, from the Medicare program will only serve to benefit Medicare beneficiaries, the trust funds, the taxpayers, and the hundreds of thousands of legitimate Medicare providers and suppliers that have proven to be reliable partners of the program.”
The final rules will be published in the Federal Register Dec. 5. A preliminary version of the regulations is available on the Federal Register website.
On Twitter @legal_med
The Centers for Medicare & Medicaid Services is tightening scrutiny of providers enrolling in Medicare in an effort to curb fraudulent billing and keep providers with unpaid Medicare debt from reentering the program.
New rules announced Dec. 3 by the CMS strengthen the agency’s ability to deny or revoke the enrollment of entities and individuals believed to pose a program integrity risk to Medicare. The regulations come after the February 2011 revision of CMS’s enrollment policy, a revamp aimed at increasing the integrity of Medicare. Under the Dec. 3 enrollment provisions, the CMS can now:
• Deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt (existing overpayment or another form of financial obligation).
• Deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felonies (murder, rape, assault, extortion, embezzlement, income tax evasion).
• Revoke the billing privileges of providers and suppliers who have a pattern or practice of billing for services that do not meet Medicare requirements.
The new rules will prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program, and then reenroll as a new business to avoid repayment of the outstanding Medicare debt, according to the agency.
Physicians and other prospective enrollees who owe Medicare money can avoid being denied by agreeing to a CMS-approved extended repayment schedule for the entire outstanding Medicare debt or by repaying it in full.
In its final rule, the CMS acknowledged that the majority of Medicare provider enrollees submit valid claims that meet the CMS guidelines.
“A small percentage of providers and suppliers are engaging in fraudulent, wasteful, inappropriate, or abusive activities,” the agency wrote in the Federal Register. “Our provider enrollment revisions are directed at such providers and suppliers, and we believe that removing them, as necessary, from the Medicare program will only serve to benefit Medicare beneficiaries, the trust funds, the taxpayers, and the hundreds of thousands of legitimate Medicare providers and suppliers that have proven to be reliable partners of the program.”
The final rules will be published in the Federal Register Dec. 5. A preliminary version of the regulations is available on the Federal Register website.
On Twitter @legal_med
The Centers for Medicare & Medicaid Services is tightening scrutiny of providers enrolling in Medicare in an effort to curb fraudulent billing and keep providers with unpaid Medicare debt from reentering the program.
New rules announced Dec. 3 by the CMS strengthen the agency’s ability to deny or revoke the enrollment of entities and individuals believed to pose a program integrity risk to Medicare. The regulations come after the February 2011 revision of CMS’s enrollment policy, a revamp aimed at increasing the integrity of Medicare. Under the Dec. 3 enrollment provisions, the CMS can now:
• Deny the enrollment of providers, suppliers, and owners affiliated with an entity that has unpaid Medicare debt (existing overpayment or another form of financial obligation).
• Deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felonies (murder, rape, assault, extortion, embezzlement, income tax evasion).
• Revoke the billing privileges of providers and suppliers who have a pattern or practice of billing for services that do not meet Medicare requirements.
The new rules will prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program, and then reenroll as a new business to avoid repayment of the outstanding Medicare debt, according to the agency.
Physicians and other prospective enrollees who owe Medicare money can avoid being denied by agreeing to a CMS-approved extended repayment schedule for the entire outstanding Medicare debt or by repaying it in full.
In its final rule, the CMS acknowledged that the majority of Medicare provider enrollees submit valid claims that meet the CMS guidelines.
“A small percentage of providers and suppliers are engaging in fraudulent, wasteful, inappropriate, or abusive activities,” the agency wrote in the Federal Register. “Our provider enrollment revisions are directed at such providers and suppliers, and we believe that removing them, as necessary, from the Medicare program will only serve to benefit Medicare beneficiaries, the trust funds, the taxpayers, and the hundreds of thousands of legitimate Medicare providers and suppliers that have proven to be reliable partners of the program.”
The final rules will be published in the Federal Register Dec. 5. A preliminary version of the regulations is available on the Federal Register website.
On Twitter @legal_med
Proposed ACO rules allow time to grow before penalties
A federal proposal to extend the period before an accountable care organization can be penalized for poor performance may keep many ACOs from disbanding and encourage more to form, said Clif Gaus, president and CEO of the National Association of ACOs.
Under the proposal, announced Dec. 1 by the Centers for Medicare & Medicaid Services, new and existing ACOs in the Medicare Shared Savings Program (MSSP) could take an additional 3 years before facing punishment for subpar performance. Currently, ACOs can choose to receive a smaller share of any savings for 3 years before becoming subject to any penalties.
“We’re pleased they’ve extended the one-sided track to additional 3 year contract terms,” Mr. Gaus said in an interview. “That was a major concern of ours. Our surveys have shown more than two-thirds of ACOs were going to drop out if they didn’t have the option to stay in the one-sided track.”
Although the change would give ACOs a total of 6 years before incurring possible punishment, the shift would come with a catch. Three-year-old ACOs that decide to avoid penalties for another 3 years could retain only 40% of the money they save Medicare, compared to the 50% maximum they can keep during their first 3 years.
The exception is a bum deal, said Julian D. “Bo” Bobbitt Jr., an ACO expert and health law attorney in Raleigh, N.C.
“They call them incentive payments for a reason,” he said in an interview. “You need to incentivize. Physicians already need to wait about 18 months for calculations to determine if there are any savings, and then to ratchet it down – that’s an unnecessary disincentive.”
The proposed changes come in response to criticism by ACOs that the shared savings program does not allow enough time to build infrastructure and enhance quality before financial risk is incurred.
More than 330 ACOs in 47 states currently participate in the MSSP. In their first year, ACOs held spending below their benchmarks by $705 million and earned shared savings payments of more than $315 million, according to the CMS. Another 60 ACOs had expenditures below their benchmark, but not by an amount sufficient to earn shared savings.
Also under the proposal is a new ACO option with even greater rewards for those willing to take greater risks. This third track would allow ACOs to retain up to 75% of money they save, but also be responsible for up to 75% of all losses, depending on the quality performance of the ACO. Bonuses for the tier would be capped at 20% of an ACO’s updated benchmark and losses at 15% of its updated benchmark in each year of the organization’s agreement period.
Third-track ACOs would have a list of patients at the start of the year whose treatment and costs they must manage. Currently, the CMS identifies beneficiaries as included in an ACO at the end of the year based on how much care they received from network providers. Stakeholders have requested that the CMS identify the patients at the beginning of the year to allow for more targeted improvement efforts.
The proposed rules smooth out some of the problems with administration of the shared savings program, but do not address all physician concerns with the program, Mr. Bobbitt said. For instance, the proposals do not provide a solution for physicians employed by large health systems who wish to participate in an ACO in a smaller group. Right now, no subset of an entity can set up or join an ACO under one tax identification number.
“A health system employer of physicians not only can block a group of physicians from participating in any ACO, but even if they consented, the only way CMS would allow it would be if the entire mass of physicians participated,” Mr. Bobbitt said. “This is particularly difficult for primary care physicians who can be very successful in a small primary care–centric ACO. The hospital system pool of employed physicians may be in the thousands and not have the right ratio of subspecialties for ACO success. I had hoped that this would have been addressed in the regs.”
Mr. Gaus agreed the proposals are a good start, but noted that more improvements to the shared savings program are needed. His association plans to take advantage of continuing the dialogue with the CMS on making changes to the program. The proposed rules are open to a 60-day comment period.
Among other questions, the government is asking for feedback on alternative ways of determining whether an ACO has saved the government money. The CMS now estimates the amount ACO participants have spent in the past and uses that as a benchmark. Under one scenario, ACO spending would be compared to the average amount spent by doctors and health providers in the same geographical area.
“CMS has opened the door for discussion on a lot of the important issues around benchmarking and benchmarking trending, for example,” Mr. Gaus said. “They sound like they want to make improvements to the benchmark process, and we’re going to comment extensively about that. We think the benchmark process can be more fairly done.”
Comments can be submitted to www.regulations.gov until Feb. 7, 2015.
On Twitter @legal_med
A federal proposal to extend the period before an accountable care organization can be penalized for poor performance may keep many ACOs from disbanding and encourage more to form, said Clif Gaus, president and CEO of the National Association of ACOs.
Under the proposal, announced Dec. 1 by the Centers for Medicare & Medicaid Services, new and existing ACOs in the Medicare Shared Savings Program (MSSP) could take an additional 3 years before facing punishment for subpar performance. Currently, ACOs can choose to receive a smaller share of any savings for 3 years before becoming subject to any penalties.
“We’re pleased they’ve extended the one-sided track to additional 3 year contract terms,” Mr. Gaus said in an interview. “That was a major concern of ours. Our surveys have shown more than two-thirds of ACOs were going to drop out if they didn’t have the option to stay in the one-sided track.”
Although the change would give ACOs a total of 6 years before incurring possible punishment, the shift would come with a catch. Three-year-old ACOs that decide to avoid penalties for another 3 years could retain only 40% of the money they save Medicare, compared to the 50% maximum they can keep during their first 3 years.
The exception is a bum deal, said Julian D. “Bo” Bobbitt Jr., an ACO expert and health law attorney in Raleigh, N.C.
“They call them incentive payments for a reason,” he said in an interview. “You need to incentivize. Physicians already need to wait about 18 months for calculations to determine if there are any savings, and then to ratchet it down – that’s an unnecessary disincentive.”
The proposed changes come in response to criticism by ACOs that the shared savings program does not allow enough time to build infrastructure and enhance quality before financial risk is incurred.
More than 330 ACOs in 47 states currently participate in the MSSP. In their first year, ACOs held spending below their benchmarks by $705 million and earned shared savings payments of more than $315 million, according to the CMS. Another 60 ACOs had expenditures below their benchmark, but not by an amount sufficient to earn shared savings.
Also under the proposal is a new ACO option with even greater rewards for those willing to take greater risks. This third track would allow ACOs to retain up to 75% of money they save, but also be responsible for up to 75% of all losses, depending on the quality performance of the ACO. Bonuses for the tier would be capped at 20% of an ACO’s updated benchmark and losses at 15% of its updated benchmark in each year of the organization’s agreement period.
Third-track ACOs would have a list of patients at the start of the year whose treatment and costs they must manage. Currently, the CMS identifies beneficiaries as included in an ACO at the end of the year based on how much care they received from network providers. Stakeholders have requested that the CMS identify the patients at the beginning of the year to allow for more targeted improvement efforts.
The proposed rules smooth out some of the problems with administration of the shared savings program, but do not address all physician concerns with the program, Mr. Bobbitt said. For instance, the proposals do not provide a solution for physicians employed by large health systems who wish to participate in an ACO in a smaller group. Right now, no subset of an entity can set up or join an ACO under one tax identification number.
“A health system employer of physicians not only can block a group of physicians from participating in any ACO, but even if they consented, the only way CMS would allow it would be if the entire mass of physicians participated,” Mr. Bobbitt said. “This is particularly difficult for primary care physicians who can be very successful in a small primary care–centric ACO. The hospital system pool of employed physicians may be in the thousands and not have the right ratio of subspecialties for ACO success. I had hoped that this would have been addressed in the regs.”
Mr. Gaus agreed the proposals are a good start, but noted that more improvements to the shared savings program are needed. His association plans to take advantage of continuing the dialogue with the CMS on making changes to the program. The proposed rules are open to a 60-day comment period.
Among other questions, the government is asking for feedback on alternative ways of determining whether an ACO has saved the government money. The CMS now estimates the amount ACO participants have spent in the past and uses that as a benchmark. Under one scenario, ACO spending would be compared to the average amount spent by doctors and health providers in the same geographical area.
“CMS has opened the door for discussion on a lot of the important issues around benchmarking and benchmarking trending, for example,” Mr. Gaus said. “They sound like they want to make improvements to the benchmark process, and we’re going to comment extensively about that. We think the benchmark process can be more fairly done.”
Comments can be submitted to www.regulations.gov until Feb. 7, 2015.
On Twitter @legal_med
A federal proposal to extend the period before an accountable care organization can be penalized for poor performance may keep many ACOs from disbanding and encourage more to form, said Clif Gaus, president and CEO of the National Association of ACOs.
Under the proposal, announced Dec. 1 by the Centers for Medicare & Medicaid Services, new and existing ACOs in the Medicare Shared Savings Program (MSSP) could take an additional 3 years before facing punishment for subpar performance. Currently, ACOs can choose to receive a smaller share of any savings for 3 years before becoming subject to any penalties.
“We’re pleased they’ve extended the one-sided track to additional 3 year contract terms,” Mr. Gaus said in an interview. “That was a major concern of ours. Our surveys have shown more than two-thirds of ACOs were going to drop out if they didn’t have the option to stay in the one-sided track.”
Although the change would give ACOs a total of 6 years before incurring possible punishment, the shift would come with a catch. Three-year-old ACOs that decide to avoid penalties for another 3 years could retain only 40% of the money they save Medicare, compared to the 50% maximum they can keep during their first 3 years.
The exception is a bum deal, said Julian D. “Bo” Bobbitt Jr., an ACO expert and health law attorney in Raleigh, N.C.
“They call them incentive payments for a reason,” he said in an interview. “You need to incentivize. Physicians already need to wait about 18 months for calculations to determine if there are any savings, and then to ratchet it down – that’s an unnecessary disincentive.”
The proposed changes come in response to criticism by ACOs that the shared savings program does not allow enough time to build infrastructure and enhance quality before financial risk is incurred.
More than 330 ACOs in 47 states currently participate in the MSSP. In their first year, ACOs held spending below their benchmarks by $705 million and earned shared savings payments of more than $315 million, according to the CMS. Another 60 ACOs had expenditures below their benchmark, but not by an amount sufficient to earn shared savings.
Also under the proposal is a new ACO option with even greater rewards for those willing to take greater risks. This third track would allow ACOs to retain up to 75% of money they save, but also be responsible for up to 75% of all losses, depending on the quality performance of the ACO. Bonuses for the tier would be capped at 20% of an ACO’s updated benchmark and losses at 15% of its updated benchmark in each year of the organization’s agreement period.
Third-track ACOs would have a list of patients at the start of the year whose treatment and costs they must manage. Currently, the CMS identifies beneficiaries as included in an ACO at the end of the year based on how much care they received from network providers. Stakeholders have requested that the CMS identify the patients at the beginning of the year to allow for more targeted improvement efforts.
The proposed rules smooth out some of the problems with administration of the shared savings program, but do not address all physician concerns with the program, Mr. Bobbitt said. For instance, the proposals do not provide a solution for physicians employed by large health systems who wish to participate in an ACO in a smaller group. Right now, no subset of an entity can set up or join an ACO under one tax identification number.
“A health system employer of physicians not only can block a group of physicians from participating in any ACO, but even if they consented, the only way CMS would allow it would be if the entire mass of physicians participated,” Mr. Bobbitt said. “This is particularly difficult for primary care physicians who can be very successful in a small primary care–centric ACO. The hospital system pool of employed physicians may be in the thousands and not have the right ratio of subspecialties for ACO success. I had hoped that this would have been addressed in the regs.”
Mr. Gaus agreed the proposals are a good start, but noted that more improvements to the shared savings program are needed. His association plans to take advantage of continuing the dialogue with the CMS on making changes to the program. The proposed rules are open to a 60-day comment period.
Among other questions, the government is asking for feedback on alternative ways of determining whether an ACO has saved the government money. The CMS now estimates the amount ACO participants have spent in the past and uses that as a benchmark. Under one scenario, ACO spending would be compared to the average amount spent by doctors and health providers in the same geographical area.
“CMS has opened the door for discussion on a lot of the important issues around benchmarking and benchmarking trending, for example,” Mr. Gaus said. “They sound like they want to make improvements to the benchmark process, and we’re going to comment extensively about that. We think the benchmark process can be more fairly done.”
Comments can be submitted to www.regulations.gov until Feb. 7, 2015.
On Twitter @legal_med
