This final rule, effective June 16, 2016, specifies the process and timeline for expanding CMS' existing Medicare Secondary Payer (MSP) Web portal to conform to section 201 of the Medicare IVIG and Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act).
Showing posts sorted by date for query CMS. Sort by relevance Show all posts
Showing posts sorted by date for query CMS. Sort by relevance Show all posts
Tuesday, May 17, 2016
Wednesday, February 17, 2016
The State of Medical Care in California’s Workers’ Compensation System
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| Katherine Roe |
Todays' guest post is authored by Katie Roe* of the California Bar and was originally published at rivercityattorneys.com/blog (Fraulob & Brown).
When you’re injured at work, you expect that your employer’s insurance carrier will dutifully provide you with proper medical treatment for your injury. After all, future medical care is one of the “benefits” injured workers are entitled to in California. Denial of medical treatment is the number one frustration we hear from our clients on a daily basis.
What injured workers quickly discover is that their medical treatment is strictly controlled by the insurance carrier and their medical fate is in the hands of a doctor who has never treated them and may not even have their complete medical records. This process is called Utilization Review (UR). Under UR an outside physician gets to decide whether or not the insurance company should authorize the medical treatment prescribed by your primary treating physician. This doctor doesn’t even have to be licensed in California.
If the medical treatment prescribed by your physician is denied, your only recourse is to appeal the decision to an Independent Medical Reviewed (IMR). In California, MAXIMUS is the company contracted to conduct IMR reviews. Like UR doctors, the IMR doctor deciding your fate, has never met you or treated you and does not need to be licensed in California. In fact, their identity is protected. If your medical treatment is denied by UR, your chances of IMR overturning the decision are not good. California Workers’ Compensation Institute, an insurance research group, found that 91% of IMR decisions uphold the UR denial. If the treatment is denied by IMR, absent a change in circumstances, the denial will be in effect for one year.
While an injured worker has the right to appeal an IMR determination to the Workers’ Compensation Appeals Board, the only legal bases on which to appeal are fraud, conflict of interest, or mistake of fact. However, even if your appeal is successful the WCAB still cannot overturn the IMR doctor’s decision. If an appeal is granted, the remedy is referral to a different IMR for another review. Yes, you read that right, your award is to go through the IMR process again!
Many injured workers end up seeking treatment for their work related injuries through private insurance, Medicare or Medi-Cal. A study by J. Paul Leigh, a health economist at the University of California, Davis, estimated that only 1/3 of necessary medical treatment and lost wages is being paid for by workers’ compensation insurers.
The lack of adequate medical care for injured workers today is the result of Senate Bill 863, which was passed on August 1, 2012 and signed into law by Governor Brown on September 18, 2012. This law was the result of lobbying by big businesses and insurance companies, who have influence over the State Legislature and the Governor of California. We remind our clients that you also have a political voice. We recommend you go to Voters Injured at Work (www.viaw.org) for information on how to become involved with fixing this broken system.
To read more about the dismal state of medical treatment for injured workers all over America I encourage you to read Insult to Injury by Michael Grabell athttps://www.propublica.org/article/the-demolition-of-workers-compensation.
*Katherine Roe is originally from the San Francisco Bay Area. She attended University of St. Thomas, Saint Paul Minnesota for her undergraduate degree in Sociology with a minor in Criminal Justice. She earned her Master in Public Administration from University of Notre Dame de Namur, Belmont, CA. Katie graduated from University of the Pacific McGeorge School of Law in Sacramento where she received the Witkin Award for Health Law and Elder Law Clinic. She is a practicing attorney in the areas of Workers’ Compensation Law, Social Security Disability and Elder Law, including estate planning with wills, trusts, deeds, powers of attorney and health care directives.
While in college, Katie tutored grade school and high school students in low-income neighborhoods in Saint Paul and Minneapolis, MN and interned with the Oakdale, MN Police Department.
During law school, Katie interned with Legal Aid Society of San Mateo County, Human Rights Fair Housing Commission and the California Department of Insurance. While at McGeorge, she worked in the Elder and Health Law Clinic where she handled Medicare appeals, elder abuse cases, restraining orders, wills, trusts, consumer protection, special needs trusts, and powers of attorney.
While the Clinical Fellow at McGeorge she received the Cohn Sisters’ Scholarship for Patient Advocacy.
While in college, Katie tutored grade school and high school students in low-income neighborhoods in Saint Paul and Minneapolis, MN and interned with the Oakdale, MN Police Department.
During law school, Katie interned with Legal Aid Society of San Mateo County, Human Rights Fair Housing Commission and the California Department of Insurance. While at McGeorge, she worked in the Elder and Health Law Clinic where she handled Medicare appeals, elder abuse cases, restraining orders, wills, trusts, consumer protection, special needs trusts, and powers of attorney.
While the Clinical Fellow at McGeorge she received the Cohn Sisters’ Scholarship for Patient Advocacy.
Monday, December 21, 2015
CMS Implements SMART Act Functionality for Repayment
The Workers' Compensation community of stakeholders lobbied strenuously through 2012 for revision of the conditional payment process utilized by the Centers for Medicare and Medicaid (CMS). The SMART Act of 2012 codifies the process to comply with the Medicare Secondary Payer Act. CMS has now implemented an on-line process to facilitate reimbursement:
Thursday, December 17, 2015
Insurance Carrier Subject to Lawsuit for Failing to Reimburse CMS
Workers' Compensation insurance carriers have a duty to reimburse the Centers of Medicare and Medicaid Services for conditional medical payments. Failure to do so may result in a private cause of action by the injured worker or his representative for double damages. Once the lawsuit is filed the workers' compensation insurance company cannot mitigate the double recovery penalty by making payment.
A private cause of action was permitted to go forward seeking double damages by an estate against a workers' compensation insurance carrier for failing to reimburse CMS for conditional medical payments. The District Court, Charles R. Simpson, III , Senior District Judge, held that an issue of fact as to whether insurer did nothing to reimburse Medicare prior to estate's commencement of private action precluded summary judgment.
The Court held that a genuine issue of material fact existed as to whether workers' compensation insurer did nothing to appropriately reimburse Medicare for medical expenses that Medicare had paid for a work-related injury until estate of deceased employee brought private action under the Medicare Secondary Payer Act (MSPA), precluding summary judgment on whether estate was entitled to double recovery under the MSPA. 42 U.S.C.A. § 1395y(b)(3)(A).
A private cause of action was permitted to go forward seeking double damages by an estate against a workers' compensation insurance carrier for failing to reimburse CMS for conditional medical payments. The District Court, Charles R. Simpson, III , Senior District Judge, held that an issue of fact as to whether insurer did nothing to reimburse Medicare prior to estate's commencement of private action precluded summary judgment.
The Court held that a genuine issue of material fact existed as to whether workers' compensation insurer did nothing to appropriately reimburse Medicare for medical expenses that Medicare had paid for a work-related injury until estate of deceased employee brought private action under the Medicare Secondary Payer Act (MSPA), precluding summary judgment on whether estate was entitled to double recovery under the MSPA. 42 U.S.C.A. § 1395y(b)(3)(A).
"The private cause of action provision allows for damages “in an amount double the amount otherwise provided” – the purpose being to encourage beneficiaries to bring claims even if Medicare has already paid the beneficiaries' expenses. Once a private cause of action claim has been lodged against a defendant, a defendant cannot escape the double damages provided for in that provision by paying single damages to Medicare."
Estate of McDonald v. Indemnity Insurance Company of..., --- F.Supp.3d ---- (2015), CIVIL ACTION NO. 3:12CV–577–CRS, 2015 WL 6997440, Filed April 14, 2015.
Estate of McDonald v. Indemnity Insurance Company of..., --- F.Supp.3d ---- (2015), CIVIL ACTION NO. 3:12CV–577–CRS, 2015 WL 6997440, Filed April 14, 2015.
Monday, November 16, 2015
CMS MSP FInal Conditional Payments Portal To Open
Upcoming Updates to the Medicare Secondary Payer Recovery Portal (MSPRP) Modification for Inclusion of Final Conditional Payment (CP) Process Functionality
As part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP will be modified to include Final CP process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.
When the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute. Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP. Once calculated, this amount will remain the Final Conditional Payment Amount as long as:
- The case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and
- Settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.
Monday, November 9, 2015
CMS Has a New Play Book for Conditional Payments - The Time Factor
The Centers for Medicare and Medicare Services (CMS) has invoked the element of time to encourage workers' compensation settlements to be finalized. After almost 15 years has lapsed from the Patel Memo of July 11, 2001, CMS is encouraging compensation claims to be resolved in a timely fashion when conditional payments are at issue.
Recently enacted Federal debt collection legislation has set the tone to encourage repayment of conditional payments in a timely fashion.
Adding the element of a time deadline in any negotiation results in an acceleration or resolution. CMS announced today:
"...Upcoming Updates to the Medicare Secondary Payer Recovery Portal (MSPRP) Modification for Inclusion of Final Conditional Payment (CP) Process Functionality"
"As part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP will be modified to include Final CP process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.
"When the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute. Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP.
"...Upcoming Updates to the Medicare Secondary Payer Recovery Portal (MSPRP) Modification for Inclusion of Final Conditional Payment (CP) Process Functionality"
"As part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP will be modified to include Final CP process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.
"When the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute. Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP.
"Once calculated, this amount will remain the Final Conditional Payment Amount as long as:
- The case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and
- Settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.
Monday, October 5, 2015
And they didn't see it coming........
Rafael Gonzalez authored a very helpful, and spot on, post today that summarizes the new approach of The Centers for Medicare and Medicaid Services (CMS) to recoup benefits under Medicare Secondary Payer law (42 U.S.C. § 1395y(b)) (MSP) before a final determination is made in the underlying workers' compensation claim.
Additionally, the cottage industries (lawyers, insurance carriers & employers, ie. MARC) who lobbied for The Strengthening Medicare and Repaying Taxpayers (SMART) Act of 2011, never saw the forest from the trees as they tried to stake out their territory.
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| Rafael Gonzalez |
With multiple reporting trigger points CMS is new able to capture data quickly and with the implementation of the expedited US Treasury debt collection procedures, the Digital Accountability and Transparency Act (DATA Act). the process will now ignore the sluggish/delayed workers' compensation program/adjudication.
CMS has now operationalized a new procedure, "As part of the continuing efforts to improve the Coordination of Benefits & Recovery (COB&R) program and claims payment accuracy in Medicare Secondary Payer (MSP) situations, the Centers for Medicare & Medicaid Services (CMS) will be transitioning a portion of the Non-Group Health Plan (NGHP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its CommercialRepayment Center (CRC)."
Ironically, this process cuts through the red tape and cottage industry's interests of the State programs and moves the claims to the goal of Federalization of the entire system based also on a uniformity of processing, coding and determinations at the Federal administrative level. See also, D. Torrey, The Federalization Standards Issue, A Short History Before and After NFIB v. Sebelius (2012), ABA, 2013. "These views speak loudly to the expectation of educated observers that state-based workers’ compensation will endure and that federalization is unlikely."
CMS has now operationalized a new procedure, "As part of the continuing efforts to improve the Coordination of Benefits & Recovery (COB&R) program and claims payment accuracy in Medicare Secondary Payer (MSP) situations, the Centers for Medicare & Medicaid Services (CMS) will be transitioning a portion of the Non-Group Health Plan (NGHP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its CommercialRepayment Center (CRC)."
Ironically, this process cuts through the red tape and cottage industry's interests of the State programs and moves the claims to the goal of Federalization of the entire system based also on a uniformity of processing, coding and determinations at the Federal administrative level. See also, D. Torrey, The Federalization Standards Issue, A Short History Before and After NFIB v. Sebelius (2012), ABA, 2013. "These views speak loudly to the expectation of educated observers that state-based workers’ compensation will endure and that federalization is unlikely."
Perhaps, the very next step may be an effort to follow the liability program models, wherein pre-disposition, alternate resolution, is possible early in the process, ie. the mass tort specialized programs for resolution.
Of course, workers' compensation (WC) insurers and employers would then need to really expedite WC claims. But then, wasn't that the intent of the now antiquated 1911 system anyway?
Click below to read the post on LinkedIn:
New Process for Primary Payers Resolving Medicare Conditional Payments Begins Today
Click below to read the post on LinkedIn:
New Process for Primary Payers Resolving Medicare Conditional Payments Begins Today
Wednesday, August 5, 2015
CMS to Speed-Up MSP Collection Practices
The Centers for Medicare and Medicaid Services (CMS) has announced that it intends to speed up its collections practices enforcing the Medicare Secondary Payer Act (MSP). CMS stated that such procedures are mandatory under the Digital Accountability and Transparency Act of 2014 or the DATA Act Public Law No: 113-101 (05/09/2014).
Thursday, July 16, 2015
CMS - ICD10 Codes in Effect for Reporting Requirements Oct 1, 2015
Medicare Secondary Payer Act - CMS Reporting Requirements ICD10 Codes to be required as of October 1, 2015.
Reporting Reminder: Effective October 1, 2015, Responsible Reporting Entities and their agents will be required to report ICD-10-CM diagnosis codes on claim reports with a CMS Date of Incident (DOI) on or after October 1, 2015. This timeline and reporting requirements have not changed. For more information on ICD diagnosis code reporting, please refer to the MMSEA Section 111 NGHP User Guide Technical Information Chapter IV (Section 6.2.5 – ICD-9 and ICD-10 Codes). The NGHP User Guide can be downloaded from the NGHP User Guide page available at the following link: http://go.cms.gov/MIRNGHPUserGuide.
Reporting Reminder: Effective October 1, 2015, Responsible Reporting Entities and their agents will be required to report ICD-10-CM diagnosis codes on claim reports with a CMS Date of Incident (DOI) on or after October 1, 2015. This timeline and reporting requirements have not changed. For more information on ICD diagnosis code reporting, please refer to the MMSEA Section 111 NGHP User Guide Technical Information Chapter IV (Section 6.2.5 – ICD-9 and ICD-10 Codes). The NGHP User Guide can be downloaded from the NGHP User Guide page available at the following link: http://go.cms.gov/MIRNGHPUserGuide.
Monday, July 13, 2015
CMS Moved the Coordination of Benefits Secure Website (COBSW)
The Centers for Medicare and Medicaid Services has formally moved:
The URL for accessing the Section 111 Coordination of Benefits Secure Website (COBSW) has been changed to: https://www.cob.cms.hhs.gov/Section111//.
July 13, 2015 - Updated MMSEA Section 111 NGHP User Guide Version 4.7 - Chapters I-V Now Available
The URL for accessing the Section 111 Coordination of Benefits Secure Website (COBSW) has been changed to: https://www.cob.cms.hhs.gov/Section111//.
July 13, 2015 - Updated MMSEA Section 111 NGHP User Guide Version 4.7 - Chapters I-V Now Available
The updated MMSEA Section 111 NGHP User Guide dated July 13, 2015 has been posted to the NGHP User Guide page. Refer to Chapter 1-1 of each chapter for a summary of Version 4.7 updates.
Thursday, July 9, 2015
CMS Announces Changes to Physician Fee Schedules: End of Life Care Discussion Payments Proposed
Under a new proposal announced by the Centers for Medicare and Medicaid Services, physicians will be paid to discuss "end of life care" with patients.
“CMS is building on the important work of Congress to shift the Medicare program toward a system that rewards physicians for providing high quality care,” said Andy Slavitt, Administrator of CMS. “Thanks to the recent landmark Medicare and children’s health insurance program legislation, CMS and Congress are working together to achieve a better Medicare payment system for physicians and the American people.”
In the proposed CY 2016 Physician Fee Schedule rule, CMS is also seeking comment from the public on implementation of certain provisions of the MACRA, including the new Merit-based Incentive payment system (MIPS). This is part of a broader effort at the Department to move the Medicare program to a health care system focused on the delivery of quality care and value.
The proposed rule includes updates to payment policies, proposals to implement statutory adjustments to physician payments based on misvalued codes, updates to the Physician Quality Reporting System, which measures the quality performance of physicians participating in Medicare, and updates to the Physician Value-Based Payment Modifier, which ties a portion of physician payments to performance on measures of quality and cost. CMS is also seeking comment on the potential expansion of the Comprehensive Primary Care Initiative, a CMS Innovation Center initiative designed to improve the coordination of care for Medicare beneficiaries.
The proposed rule also seeks comment on a proposal that supports patient- and family-centered care for seniors and other Medicare beneficiaries by enabling them to discuss advance care planning with their providers. The proposal follows the American Medical Association’s recommendation to make advance care planning services a separately payable service under Medicare.
The release of the rule triggers a 60-day comment period, during which time CMS welcomes the input of stakeholders and the public. A final rule will be published this fall. For a fact sheet on the proposed rule, Proposed policy, payment, and quality provisions changes to the Medicare Physician Fee Schedule for Calendar Year 2016, please see here. For further information, please see the rule on display here.
Monday, June 1, 2015
GAO calls for better Medicare fee setting data and more transparency
Many state workers' compensation medical fee schedules are based upon Medicare rates. A new study from US Government Accounting Office reports that the underlying rate making scheme is biased and the GAO recommends increased transparency of the process.
The American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) has a process in place to regularly review Medicare physicians' services' work relative values (which reflect the time and intensity needed to perform a service). Its recommendations to the Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that administers Medicare, though, may not be accurate due to process and data-related weaknesses.
First, the RUC's process for developing relative value recommendations relies on the input of physicians who may have potential conflicts of interest with respect to the outcomes of CMS's process. While the RUC has taken steps to mitigate the impact of physicians' potential conflicts of interest, a member of the RUC told GAO that specialty societies' work relative value recommendations may still be inflated.
RUC staff indicated that the RUC may recommend a work relative value to CMS that is less than the specialty societies' median survey result if the value seems accurate based on the RUC members' clinical expertise or by comparing the value to those of related services.
Second, GAO found weaknesses with the RUC's survey data, including that some of the RUC's survey data had low response rates, low total number of responses, and large ranges in responses, all of which may undermine the accuracy of the RUC's recommendations. For example, while GAO found that the median number of responses to surveys for payment year 2015 was 52, the median response rate was only 2.2 percent, and 23 of the 231 surveys had under 30 respondents.
CMS's process for establishing relative values embodies several elements that cast doubt on whether it can ensure accurate Medicare payment rates and a transparent process.
First, although CMS officials stated that CMS complies with the statutory requirement to review all Medicare services every 5 years, the agency does not maintain a database to track when a service was last valued or have a documented standardized process for prioritizing its reviews.
Second, CMS's process is not fully transparent because the agency does not publish the potentially misvalued services identified by the RUC in its rulemaking or otherwise, and thus stakeholders are unaware that these services will be reviewed and payment rates for these services may change.
Third, CMS provides some information about its process in its rulemaking, but does not document the methods used to review specific RUC recommendations. For example, CMS does not document what resources were considered during its review of the RUC's recommendations for specific services.
Finally, the evidence suggests—and CMS officials acknowledge—that the agency relies heavily on RUC recommendations when establishing relative values. For example, GAO found that, in the majority of cases, CMS accepts the RUC's recommendations and participation by other stakeholders is limited. Given the process and data-related weaknesses associated with the RUC's recommendations, such heavy reliance on the RUC could result in inaccurate Medicare payment rates.
CMS has begun to research ways to develop an approach for validating RUC recommendations, but does not yet have a specific plan for doing so. In addition, CMS does not yet have a plan for how it will use funds Congress appropriated for the collection and use of data on physicians' services or address the other data challenges GAO identified.
Why GAO Did This Study
Payments for Medicare physicians' services totaled about $70 billion in 2013. CMS sets payment rates for about 7,000 physicians' services primarily on the basis of the relative values assigned to each service. Relative values largely reflect estimates of the physician work and practice expenses needed to provide one service relative to other services.
The Protecting Access to Medicare Act of 2014 included a provision for GAO to study the RUC's process for developing relative value recommendations for CMS. GAO evaluated (1) the RUC's process for recommending relative values for CMS to consider when setting Medicare payment rates; and (2) CMS's process for establishing relative values, including how it uses RUC recommendations. GAO reviewed RUC and CMS documents and applicable statutes and internal control standards, analyzed RUC and CMS data for payment years 2011 through 2015, and interviewed RUC staff and CMS officials.
What GAO Recommends
CMS should better document its process for establishing relative values and develop a process to inform the public of potentially misvalued services identified by the RUC. CMS should also develop a plan for using funds appropriated for the collection and use of information on physicians' services in the determination of relative values. HHS agreed with two of GAO's recommendations, but disagreed with using rulemaking to inform the public of RUC-identified services. GAO clarified that the recommendation is not limited to rulemaking.
Click here to read the full report.
Better Data and Greater Transparency Could Improve Accuracy
GAO-15-434: Published: May 21, 2015. Publicly Released: May 21, 2015.
The American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) has a process in place to regularly review Medicare physicians' services' work relative values (which reflect the time and intensity needed to perform a service). Its recommendations to the Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that administers Medicare, though, may not be accurate due to process and data-related weaknesses.
First, the RUC's process for developing relative value recommendations relies on the input of physicians who may have potential conflicts of interest with respect to the outcomes of CMS's process. While the RUC has taken steps to mitigate the impact of physicians' potential conflicts of interest, a member of the RUC told GAO that specialty societies' work relative value recommendations may still be inflated.
RUC staff indicated that the RUC may recommend a work relative value to CMS that is less than the specialty societies' median survey result if the value seems accurate based on the RUC members' clinical expertise or by comparing the value to those of related services.
Second, GAO found weaknesses with the RUC's survey data, including that some of the RUC's survey data had low response rates, low total number of responses, and large ranges in responses, all of which may undermine the accuracy of the RUC's recommendations. For example, while GAO found that the median number of responses to surveys for payment year 2015 was 52, the median response rate was only 2.2 percent, and 23 of the 231 surveys had under 30 respondents.
CMS's process for establishing relative values embodies several elements that cast doubt on whether it can ensure accurate Medicare payment rates and a transparent process.
First, although CMS officials stated that CMS complies with the statutory requirement to review all Medicare services every 5 years, the agency does not maintain a database to track when a service was last valued or have a documented standardized process for prioritizing its reviews.
Second, CMS's process is not fully transparent because the agency does not publish the potentially misvalued services identified by the RUC in its rulemaking or otherwise, and thus stakeholders are unaware that these services will be reviewed and payment rates for these services may change.
Third, CMS provides some information about its process in its rulemaking, but does not document the methods used to review specific RUC recommendations. For example, CMS does not document what resources were considered during its review of the RUC's recommendations for specific services.
Finally, the evidence suggests—and CMS officials acknowledge—that the agency relies heavily on RUC recommendations when establishing relative values. For example, GAO found that, in the majority of cases, CMS accepts the RUC's recommendations and participation by other stakeholders is limited. Given the process and data-related weaknesses associated with the RUC's recommendations, such heavy reliance on the RUC could result in inaccurate Medicare payment rates.
CMS has begun to research ways to develop an approach for validating RUC recommendations, but does not yet have a specific plan for doing so. In addition, CMS does not yet have a plan for how it will use funds Congress appropriated for the collection and use of data on physicians' services or address the other data challenges GAO identified.
Why GAO Did This Study
Payments for Medicare physicians' services totaled about $70 billion in 2013. CMS sets payment rates for about 7,000 physicians' services primarily on the basis of the relative values assigned to each service. Relative values largely reflect estimates of the physician work and practice expenses needed to provide one service relative to other services.
The Protecting Access to Medicare Act of 2014 included a provision for GAO to study the RUC's process for developing relative value recommendations for CMS. GAO evaluated (1) the RUC's process for recommending relative values for CMS to consider when setting Medicare payment rates; and (2) CMS's process for establishing relative values, including how it uses RUC recommendations. GAO reviewed RUC and CMS documents and applicable statutes and internal control standards, analyzed RUC and CMS data for payment years 2011 through 2015, and interviewed RUC staff and CMS officials.
What GAO Recommends
CMS should better document its process for establishing relative values and develop a process to inform the public of potentially misvalued services identified by the RUC. CMS should also develop a plan for using funds appropriated for the collection and use of information on physicians' services in the determination of relative values. HHS agreed with two of GAO's recommendations, but disagreed with using rulemaking to inform the public of RUC-identified services. GAO clarified that the recommendation is not limited to rulemaking.
Click here to read the full report.
Better Data and Greater Transparency Could Improve Accuracy
GAO-15-434: Published: May 21, 2015. Publicly Released: May 21, 2015.
Thursday, May 28, 2015
In the name of privacy...
After the massive US IRS data breach announcement this week, CMS has posted that it is establishing a more secure system for access to Medicare Secondary Payer Information. This is pretty consistent with President Obama's announcement to take Social Security Numbers off of Medicare Cards.
The real issue is that while workers' compensation records are supposedly confidential in State systems, the Federal government has consistently neglected to insure that privacy whether be: medical records under HIPPA; by integration of state's motor vehicle or workers' compensation records utilizing Social Security Numbers, or by Medicare Secondary Payer Act electronic data systems.
Additionally, the Federal government will probably be mandating the reporting workers' compensation payment information, in Federal Income Returns shortly. The batting record of the IRS this week on privacy has been dismal.
Time will only tell whether workers' compensation data can actually be shielded from intruders.
CMS announced today:
"As part of the Strengthening Medicare and Repaying Taxpayers (SMART) Act, the Centers for Medicare & Medicaid Services (CMS) will be implementing optional MFA services on the MSPRP. MFA is the use of two or more different authentication factors to verify the identity of an end user. Verified users will have access to view unmasked claim data on the Portal.
"Non debtors will still need to have a Verified Proof of Representation or Consent to Release authorization to perform actions on cases. Please note that MFA and the associated identity proofing process will be optional to portal users. Portal users may continue to use the portal without going through the MFA process but will not have the benefit of viewing un-masked data.
"MFA is scheduled to be available beginning on July 13, 2015. Updated user guides and training materials will be available on CMS.gov and within the portal upon implementation.
The real issue is that while workers' compensation records are supposedly confidential in State systems, the Federal government has consistently neglected to insure that privacy whether be: medical records under HIPPA; by integration of state's motor vehicle or workers' compensation records utilizing Social Security Numbers, or by Medicare Secondary Payer Act electronic data systems.
Additionally, the Federal government will probably be mandating the reporting workers' compensation payment information, in Federal Income Returns shortly. The batting record of the IRS this week on privacy has been dismal.
Time will only tell whether workers' compensation data can actually be shielded from intruders.
CMS announced today:
"As part of the Strengthening Medicare and Repaying Taxpayers (SMART) Act, the Centers for Medicare & Medicaid Services (CMS) will be implementing optional MFA services on the MSPRP. MFA is the use of two or more different authentication factors to verify the identity of an end user. Verified users will have access to view unmasked claim data on the Portal.
"Non debtors will still need to have a Verified Proof of Representation or Consent to Release authorization to perform actions on cases. Please note that MFA and the associated identity proofing process will be optional to portal users. Portal users may continue to use the portal without going through the MFA process but will not have the benefit of viewing un-masked data.
"MFA is scheduled to be available beginning on July 13, 2015. Updated user guides and training materials will be available on CMS.gov and within the portal upon implementation.
Tuesday, May 5, 2015
Look Who Is Prescribing What
“This transparency will give patients, researchers, and providers access to information that will help shape the future of our nation’s health for the better,” said acting CMS Administrator Andy Slavitt. “Beneficiaries’ personal information is not available; however, it’s important for consumers, their providers, researchers, and other stakeholders to know how many prescription drugs are prescribed and how much they cost the health care system, so that they can better understand how the Medicare Part D program delivers care.”
The new data set contains information from over one million distinct health care providers who collectively prescribed approximately $103 billion in prescription drugs and supplies paid under the Part D program. The data characterizes the individual prescribing patterns of health providers that participate in Medicare Part D for over 3,000 distinct drug products. For each prescriber and drug, the dataset includes the total number of prescriptions that were dispensed, which include original prescriptions and any refills, and the total drug cost paid by beneficiaries, Part D plans, and other sources.
CMS created the new data set using drug claim information submitted by Medicare Advantage Prescription Drug plans and stand-alone Prescription Drug Plans. With this data, it will be possible to conduct a wide array of prescription drug analyses that compare drug use and costs for specific providers, brand versus generic drug prescribing rates, and to make geographic comparisons at the state level.
The Administration has set measurable goals and a timeline to move Medicare toward paying providers based on the quality, rather than the quantity, of care they give patients. This is part of a wide set of initiatives to achieve better care, smarter spending and healthier people through our health care system. Open sharing of data securely, timely and more broadly supports insight and innovation in health care delivery.
Today’s Part D prescriber data availability adds to the unprecedented information previously released on services and procedures provided to Medicare beneficiaries, including hospital charge data on common impatient and outpatient services as well as utilization and payment information for physicians and other healthcare professionals. In addition, under the Qualified Entity (QE) program, CMS releases Medicare data to approved entities for the purposes of producing public performance reports on physicians, hospitals, and other providers. To date, CMS has certified 11 regional QEs and one national QE.
To view a fact sheet on the Medicare Part D prescriber data, visit: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Part-D-Prescriber.html
Updated: May 15, 2015
Related articles
How Proposed Part D Changes Are Playing On Capitol Hill (workers-compensation.blogspot.com)
The new data set contains information from over one million distinct health care providers who collectively prescribed approximately $103 billion in prescription drugs and supplies paid under the Part D program. The data characterizes the individual prescribing patterns of health providers that participate in Medicare Part D for over 3,000 distinct drug products. For each prescriber and drug, the dataset includes the total number of prescriptions that were dispensed, which include original prescriptions and any refills, and the total drug cost paid by beneficiaries, Part D plans, and other sources.
CMS created the new data set using drug claim information submitted by Medicare Advantage Prescription Drug plans and stand-alone Prescription Drug Plans. With this data, it will be possible to conduct a wide array of prescription drug analyses that compare drug use and costs for specific providers, brand versus generic drug prescribing rates, and to make geographic comparisons at the state level.
The Administration has set measurable goals and a timeline to move Medicare toward paying providers based on the quality, rather than the quantity, of care they give patients. This is part of a wide set of initiatives to achieve better care, smarter spending and healthier people through our health care system. Open sharing of data securely, timely and more broadly supports insight and innovation in health care delivery.
Today’s Part D prescriber data availability adds to the unprecedented information previously released on services and procedures provided to Medicare beneficiaries, including hospital charge data on common impatient and outpatient services as well as utilization and payment information for physicians and other healthcare professionals. In addition, under the Qualified Entity (QE) program, CMS releases Medicare data to approved entities for the purposes of producing public performance reports on physicians, hospitals, and other providers. To date, CMS has certified 11 regional QEs and one national QE.
To view a fact sheet on the Medicare Part D prescriber data, visit: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Part-D-Prescriber.html
Updated: May 15, 2015
Related articles
How Proposed Part D Changes Are Playing On Capitol Hill (workers-compensation.blogspot.com)
CMS Defines Further Defines Policy Implementation on Part D Coverage of Benzodiazepines and Barbiturates (workers-compensation.blogspot.com)
Study: Cancer costs 'skyrocketed' despite drug cuts (workers-compensation.blogspot.com)
Big Pharma: More corruption reported in the architecture of evidence based medicine (workers-compensation.blogspot.com)
Public Comment Sought on Draft Document for Workplace Tobacco Policies (workers-compensation.blogspot.com)
Friday, April 24, 2015
CMS Posts Sample Notice To Beneficiaries Regarding Appeal Rights
CMS has posted the following notice regarding MSP Appeal Rights under the SMART Act. Under the process the the Social Security Beneficiary is only a party of notice and the the direct parties become the Insurance Carrier or Workers' Compensation Entity who initiates the appeal. The process has yet to unfold when an injured workers moves for standing to appear and participate in the process.
On February 27, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a final rule implementing certain provisions of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART ACT). This final rule establishes a formal appeals process for applicable plans (liability insurance (including self-insurance), no-fault insurance, and workers’ compensation laws or plans) in situations where the Secretary seeks Medicare Secondary Payer (MSP) recovery directly from an applicable plan. The rule is effective April 28, 2015, and applies to demand letters issued on or after April 28, 2015.
Beneficiaries will be notified in writing if an item or service they received is the subject of an appeal by the insurer or workers’ compensation entity.
A new document titled Appeals Process for Insurers and Workers’ Compensation Entities and Required Notice to Medicare Beneficiaries has been loaded to the downloads section of the What’s New page on the Beneficiary Services section of CMS.gov. The following link can be used to access the main page http://go.cms.gov/beneficiary. Once on the main page click the “What’s New” link in the left side menu and scroll to the bottom of the page.
Wednesday, April 22, 2015
Single Payer: State v Federal
Does the demise of the Vermont Single Payer system signal that change is on the horizon on a national level for a more sweeping program? The medical costs of state workers' compensation programs have become so profitable for cottage industries that are directly and ancillary connected to the delivery of work related medical care that the system is our of balance. One has to look seriously at the comments by John E. McDonough in the NEJM.
"At some point, perhaps 5 to 15 years from now, as the size and scope of Medicare, Medicaid, and the ACA subsidy structure balloon far beyond today's larger-than-life levels, our political leaders may discover the inanity of running multiple complex systems to insure different classes of Americans. If advanced by the right leaders at the right time, the logic of consolidation may become glaringly evident and launch us on a new path. If such consolidation is to occur, like it or not, I believe it will happen federally and not in the states — and no time soon."
The Demise of Vermont's Single-Payer Plan
John E. McDonough, Dr.P.H., M.P.A.
N Engl J Med 2015; 372:1584-1585 April 23, 2015 DOI: 10.1056/NEJMp1501050
"At some point, perhaps 5 to 15 years from now, as the size and scope of Medicare, Medicaid, and the ACA subsidy structure balloon far beyond today's larger-than-life levels, our political leaders may discover the inanity of running multiple complex systems to insure different classes of Americans. If advanced by the right leaders at the right time, the logic of consolidation may become glaringly evident and launch us on a new path. If such consolidation is to occur, like it or not, I believe it will happen federally and not in the states — and no time soon."
The Demise of Vermont's Single-Payer Plan
John E. McDonough, Dr.P.H., M.P.A.
N Engl J Med 2015; 372:1584-1585 April 23, 2015 DOI: 10.1056/NEJMp1501050
Tuesday, April 21, 2015
CMS will be presenting a webinar on “Applicable Plan” Appeals
“Applicable Plan” Appeals Webinar – April 28, 2015
CMS will be presenting a webinar on “Applicable Plan” Appeals.
The term “applicable plan” means liability insurance (including self-insurance), no-fault insurance and workers’ compensation laws or plans. Effective for recovery demand letters issued directly to applicable plans as the identified debtor on or after April 28, 2015, applicable plans have formal appeal rights.
The presentation will include:
-an introduction to the appeals process (as the process is new to applicable plans), information on the appeals process specific to applicable plans, and
-tips/suggestions to applicable plans regarding the recovery process, including appeals.
Date: April 28, 2015 Start time: 1:00 PM Eastern time.
URL: https://webinar.cms.hhs.gov/r2g9kffqc46/
Please begin logging in approximately 15 minutes before the start time, due to the large number of participants
CMS will be presenting a webinar on “Applicable Plan” Appeals.
The term “applicable plan” means liability insurance (including self-insurance), no-fault insurance and workers’ compensation laws or plans. Effective for recovery demand letters issued directly to applicable plans as the identified debtor on or after April 28, 2015, applicable plans have formal appeal rights.
The presentation will include:
-an introduction to the appeals process (as the process is new to applicable plans), information on the appeals process specific to applicable plans, and
-tips/suggestions to applicable plans regarding the recovery process, including appeals.
Date: April 28, 2015 Start time: 1:00 PM Eastern time.
URL: https://webinar.cms.hhs.gov/r2g9kffqc46/
Please begin logging in approximately 15 minutes before the start time, due to the large number of participants
Monday, March 9, 2015
Is The Reserve Offset Heading for Extinction?
The Obama Administration is proposing stricter collection of workers' compensation payments data of Social Security beneficiaries.
Social Security-Budget Estimates and Related Information
Budget Overview, February 2015
"10. Establish Workers’ Compensation Information Reporting. Current law requires SSA to reduce an individual’s Disability Insurance (DI) benefit if he or she receives workers’ compensation (WC) or public disability benefits (PDB). SSA currently relies upon beneficiaries to report when they receive these benefits. This proposal would improve program integrity by requiring states, local governments, and private insurers that 23 administer WC and PDB to provide this information to SSA. Furthermore, this proposal would provide for the development and implementation of a system to collect such information from states, local governments, and insurers."
FY 2016 BUDGET OVERVIEW, p. 22
http://www.ssa.gov/budget/FY16Files/2016BO.pdf
With that information, the SSA can determine if the Federal Government is accurately calculating the Federal SSA/Workers' Compensation setoff.
The obvious inequity, cost shifting, exists in those states where a reverse offset is taken. In those states, ie. NJ, the workers' compensation insurance company takes the offset credit, and NOT the Federal Government (SSA).
The collection and publication of this data will verify the inequity between States and the cost shifting to the Federal government in some states and not others. A demand for the elimination of this inequity may result in the extinction of the Reverse Offset.
See: The Gift That Keeps Giving: The SSA Reverse Offset
Social Security-Budget Estimates and Related Information
Budget Overview, February 2015
"10. Establish Workers’ Compensation Information Reporting. Current law requires SSA to reduce an individual’s Disability Insurance (DI) benefit if he or she receives workers’ compensation (WC) or public disability benefits (PDB). SSA currently relies upon beneficiaries to report when they receive these benefits. This proposal would improve program integrity by requiring states, local governments, and private insurers that 23 administer WC and PDB to provide this information to SSA. Furthermore, this proposal would provide for the development and implementation of a system to collect such information from states, local governments, and insurers."
FY 2016 BUDGET OVERVIEW, p. 22
http://www.ssa.gov/budget/FY16Files/2016BO.pdf
With that information, the SSA can determine if the Federal Government is accurately calculating the Federal SSA/Workers' Compensation setoff.
The obvious inequity, cost shifting, exists in those states where a reverse offset is taken. In those states, ie. NJ, the workers' compensation insurance company takes the offset credit, and NOT the Federal Government (SSA).
The collection and publication of this data will verify the inequity between States and the cost shifting to the Federal government in some states and not others. A demand for the elimination of this inequity may result in the extinction of the Reverse Offset.
See: The Gift That Keeps Giving: The SSA Reverse Offset
Friday, February 27, 2015
Saturday, February 7, 2015
Medical Debt Still a Problem Under Health Law — Despite Protections
Elizabeth and Britt Harmon struggled for years to have a child, and were thrilled when their son Orin was born in February 2013. But they were unprepared for the medical problems that then upended the Brooksville, Maine couple’s lives.
Orin was born with pulmonary stenosis, a heart condition, and severe asthma. He required constant care, including frequent trips to the hospital and medications that cost hundreds of dollars. The Harmons had insurance through Britt’s job at a plumbing company, but it covered “maybe half” of their child’s medical expenses, Elizabeth said.
Elizabeth Harmon with son, Orin, who is just a few days old in this picture.
They are resting at home between medical appointments. (Photo by Britt Harmon
Then, Britt’s employer dropped insurance as a benefit at the end of 2013; he lost his job in June. The family scrambled to find coverage but went three months without any before qualifying in July for MaineCare, Maine’s Medicaid program for low-income people. By then, the Harmons had accumulated thousands of dollars in medical debt, Elizabeth said. They’re still working — with the help of a local non-profit organization — to pay it off.
“I’ve sold furniture out of my own house to try to pay off some of the bills,” she said. “There were so many bills, it was impossible to keep track of everything.”
The federal health law was intended to keep a surprise illness or...
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