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May 18, 2004
Vol. 1, No. 13
Weekly news and analysis
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| MEDICARE MURMURS |
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Oxford Health Plans Inc. last week said it will increase its Medicare coverage area to include counties in northern and central New Jersey and the lower Hudson Valley in New York.
Recent Medicare reform "created more predictable and stable pricing in many parts of New Jersey and New York by requiring that the county reimbursement to health plans be at least equivalent to the actual Medicare healthcare costs in the county," said Charles G. Berg, president and chief executive officer of Oxford. "This will encourage health plans to increase their participation in the Medicare Advantage program, therefore bringing much-needed stability to the program overall."
The company will begin offering Oxford Medicare Advantage for July 1 enrollment, pending approval from the Centers for Medicare & Medicaid Services.
Compiled from staff reports
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| LETTERS TO THE EDITOR |
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Send letters to bcote@hcpro.com. Include tips, ideas, questions, and problems related to Medicare reform. The editors reserve the right to edit letters for clarity. |
| DATEBOOK |
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December 2004-Expect the Office of Inspector General to report to Congress by December on existing End Stage Renal Drug billing codes and their use.
July 1-Hospitals failing to comply with bloodborne pathogen standards are subject to civil money penalities from OSHA. Hospitals must be in compliance this summer. |
© 2004 HCPro, Inc. |
Medicare Reform Advisor publishes 48 weekly issues. Four weeks during the year, we do not publish and take time to research. This is one of them.
However, as a thank you, we are including a few short items this week just to keep things rolling. Remember, if you're a new subscriber in the last few weeks, your subscription allows you to search all of the previous issues dating back to February. Contact the editor with any questions.
| Exec Corner: CMS proposal outlines quality payments |
Hospitals reporting quality data to CMS would receive almost a 5% pay increase for each Medicare case in fiscal 2005, according to a rule CMS proposed May 11. The proposal comes as part of CMS' inpatient prospective payment system rules and many come from the Medicare-reform law. Hospitals that don't report the quality data stand to lose hundreds of thousands, says a senior reimbursement analyst with the University of Connecticut Health Center in Farmington, CT. A final rule is due out this summer. To receive the payment update, hospitals must report quality data for 10 measures (covering heart attack, heart failure, and pneumonia patients). According to CMS, data should comply with the following:
- Data should reflect patient discharges during the most recent quarter available
- Data should include all patients, not simply Medicare beneficiaries
- The number of cases submitted by a hospital must conform to Hospital Voluntary Reporting Initiative requirements, namely, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) specifications for accredited hospitals and CMS specifications for non-accredited hospitals.
CMS will make hospital-level measures calculated from the hospital-submitted data available to the public after removing patient and physician identifiers and eliminating measures based on insufficient data. CMS will also verify that data is properly formatted.
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No limit to Part D reimbursement rates
Under Medicare's Part B outpatient program, two reimbursement rates are possible for any given drug, but once Part D begins in 2006, "the number is technically infinity, and could easily be more than five or 10," according to 60% of attendees at a recent pharmaceutical and biotech seminar in Washington, DC. Here are four other changes under Part D. Use them as part of employee training:
- Provides coverage for an initial physical exam (but not related lab work), only for people who first enroll in Part B after January 1, 2005. Current Medicare beneficiaries enrolled in Part B and those who become entitled to Part A after that date but never enroll in Part B do not receive this benefit.
- Allows each drug plan to decide independently which drugs to cover under its formulary.
- Requires people to remain in the drug plan they choose for a year, but allows drug plans to change the drugs they cover during the year.
- Imposes a late penalty on people who don't enroll in a drug plan when they are first eligible, unless they have "creditable coverage." Creditable coverage includes coverage that is comparable to the new Medicare Part D prescription drug benefit, such as coverage provided under Medicaid or an employer-sponsored health plan. The Act says that drug coverage obtained under a Medigap policy is not considered "comparable coverage." Drug coverage obtained under a Medigap H, I, or J policy may not be considered comparable coverage; someone with a Medigap H, I, or J policy who delays enrollment in a Medicare drug plan may have to pay the late penalty.
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SNF operator to pay $232,000 for false claims
Robert C. Bristol and his company Regency Health Services agreed May 6 to pay $232,000 to the federal government for submitting false claims to CMS, according to the U.S. attorney's office in the northern district of Maryland. Regency Health Services operates Regency Nursing and Rehabilitation Center, a skilled nursing facility in Forestville. Bristol submitted Medicare cost reports to the fiscal intermediary that administers the Medicare program on behalf of CMS. Bristol sent its Medicaid cost reports to the Department of Health and Mental Hygiene for the state. The cost reports included reimbursement for full-time salaries for Bristol and his wife, though he worked part-time only at Regency; his wife did not work there at all. The reports also included salaries and expenses of a management company Bristol owned; personal travel and meals and entertainment expenses; premiums for whole life insurance policies in Bristol's name (he borrowed against them for personal use); and a 1997 condominium rental which he and his wife used. In addition to the financial settlement, the government will exclude Bristol and Regency Health Services from Medicare, Medicaid, and all other federal health programs for five years.
Editor's note: CMS will increase its scrutiny of Medicare cost reports. There are several measures in the reform law related to cost report preparation we will cover in the months ahead.
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Updates on five studies
The following are some updates on Medicare-reform related studies:
- A study will conclude in 2005 on the ability of practices in hematology, oncology, and medical oncology to obtain drugs and biologicals for cancer treatment at 106% of the average sales price for these drugs and biologicals.
- Sole Community Hospitals only need to supply at least one cost report from an applicable period, if they're missing one. This is in effect, as of January. CMS, however, will further study issues and abuses with cost reports. Expect the Office of Inspector General to do more audits.
- The Department of Health and Human Services (HHS) will start to look at accreditation and quality standards for durable medical equipment suppliers. Effective: one-year from the date HHS announces them.
- A report is due to Congress on the state of evaluation and management guidelines and how to update them. This is due by October.
- The GAO will report to Congress by next year on patient access to physician services under Medicare. The agency will look at claims submitted by physicians under Medicare part B, changes in use of physician services over time, and the extent to which physicians accept new Medicare patients.
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McClellan Uncut
Comments from Medicare Administrator Mark McClellan on 'preventable errors'
From the National Institute of Managed Health Care's 10th anniversary meeting in Washington, DC, on Capitol Hill, April 26.
On Bush introducing a new set of IT initiatives:
"He is announcing a set of steps that he wants the administration to take to move us into an era when electronic health records are not something that people keep talking about as maybe being available some day down the road, but an actual integral part of delivering care, making sure that each patient gets the right treatment at the right time as efficiently as possible. One reason that health care costs are so high in this country is that...we're spending a lot of money on preventable medical errors and what I would consider, potentially preventable adverse events. Many medicines that get used today have side effects and complications that we just can't predict very well because we don't understand exactly who's going to benefit and who might be harmed by many of the treatments that are on the market today.
"At [the] FDA, we think it's a big success for a cholesterol medicine or a new heart medicine to have an impact on 20% of the people who take it. Why, because if you have an impact on people's lives or quality of lives, that's worth an awful lot. But it would be worth an awful lot more if we could target much more effectively these treatments-to that 20% of people rather than having to deliver care, much less accurately and much less precisely. And health information technology, I think, can help with that and that's why I'm a big supporter as you might have guessed of the President's new initiatives."
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Bryan Cote
Executive Editor
E-mail address: bcote@hcpro.com |
