Healthcare stakeholders should be educated on the policy proposals contained in the Graham-Cassidy Healthcare Bill proposal.  This updated chart provides a comparative analysis of the Graham-Cassidy Bill, the Better Care Reconciliation Act (BCRA), the American Health Care Act (AHCA) and the ACA.

The chart highlights each bill’s treatment of a number of core issues, including:
•    Insurance subsidies
•    Individual mandate
•    Employer mandate
•    Young adults
•    Essential health benefits
•    Prohibition on annual and lifetime limits
•    Age-rated limit
•    Health status premium underwriting
•    Preexisting condition coverage
•    Relief for high-risk individuals
•    Medicaid expansion
•    Traditional Medicaid
•    Health Savings Accounts (HSAs)
•    Tax provisions

Healthcare_Comparison_Chart_9-18-2017

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Healthcare providers, if you serve Medicare, Medicaid and Children’s Health Insurance Program (CHIP) patients in the counties and geographical areas impacted by Hurricane Irma and Hurricane Harvey, or see patients who have been displaced from their homes in these areas who are in need of care, you need to know how government payers are responding to the crises, as well as the compliance implications of their actions for your facilities.

“Hurricane Irma has proven to be highly destructive and poses a significant threat to the health and safety of all Americans in its path,” said Health and Human Services (HHS) Secretary Tom Price, MD.  “HHS has pre-positioned assets and personnel who can rapidly deploy to assist local responses in Florida to Hurricane Irma, and this declaration will help ensure that access to care is maintained for those with Medicare and Medicaid.”  Secretary Price also authorized emergency efforts in Texas in the aftermath of Hurricane Harvey.

Beyond deployment of emergency resources, Secretary Price has declared a public health emergency in Florida, Georgia, South Carolina, Puerto Rico and the U.S. Virgin Islands in response to Hurricane Irma and in Texas and Louisiana in response to Hurricane Harvey.

The public health emergencies have enabled the Centers for Medicare and Medicaid Services (CMS) to issue several blanket programmatic waivers of certain requirements for providers who care for Medicare, Medicaid and CHIP beneficiaries, based on Section 1135 of the Social Security Act.  The blanket waivers are designed to offer beneficiaries—including those who are evacuated, transferred or dislocated as a result of the hurricanes—access to medical care during the emergency.  The waivers give hospitals, skilled nursing facilities (SNFs), other healthcare facilities and clinicians more flexibility to deliver emergency and other healthcare services in the wake of the disasters.

The flexible temporary policies regarding specified requirements are designed to bolster the effectiveness of the emergency response by, for example, allowing hospitals to share medical records without the usual restrictions and permitting doctors accredited by other states’ Medicaid programs to provide emergency treatment.  Individual facilities in the impacted areas or those treating patients evacuated from the impacted areas need not apply for these blanket waivers.

Following is a summary of the blanket waivers for both Hurricane Irma and Hurricane Harvey, under Sections 1135 or 1812(f) of the Social Security Act (for the impacted areas in the U.S. Virgin Islands, Puerto Rico, Florida, Georgia, South Carolina, Texas and Louisiana).

  • 1812(f):  Waives the requirement for a three-day prior hospitalization to obtain coverage of a stay in a SNF providing temporary emergency coverage of SNF services without a qualifying hospital stay for individuals evacuated, transferred or otherwise dislocated in 2017.  For certain beneficiaries who have exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period.
  • 483.20:  Provides relief to all impacted SNFs on the timeframe requirements for Minimum Data Set (MDS) assessments and transmission.
  • 484.20(c)(1):  Provides relief to all impacted home health agencies on the timeframes related to OASIS transmission.
  • Waives the requirement for Critical Access Hospitals to limit the number of beds to 25 and limit the length of stay to 96 hours.  This is a blanket waiver for all impacted hospitals.
  • Waives the requirement for Inpatient Prospective Payment System (IPPS) hospitals to house acute care patients in distinct units, where the distinct part unit’s beds are appropriate for acute care inpatients.  The IPPS hospital should bill for the care and indicate in the patient’s medical record that the patient is an acute care inpatient being housed in the excluded unit due to capacity issues related to the hurricane.  This is a blanket waiver for all IPPS hospitals located in the affected areas that need to use distinct part beds for acute care patients as a result of the hurricane.
  • Waives the requirement for a face-to-face visit with a physician, a new physician’s order and new medical necessity documentation for suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) when DMEPOS are lost, destroyed, irreparably damaged or rendered unusable.  Under this waiver, suppliers must continue to provide a narrative description on the claim explaining the reason why the equipment must be replaced.  They are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable as a result of the hurricane.
  • Allows coverage for replacement prescription fills for a quantity up to the amount originally dispensed of covered Part B drugs in instances in which the dispensed medication was lost or rendered unusable by damage due to the hurricane.

For providers in the states of Texas and Louisiana, CMS has extended the September 1, 2017 deadlines to October 2, 2017 for the following:

  • Applications for sole community hospital (SCH) status
  • Written requests for low-volume hospital status in order to receive the low-volume hospital payment adjustment for discharges in fiscal year (FY) 2018
  • Applications for reclassification to the Medicare Geographic Classification Review Board (MGCRB)
  • Extensions for IPPS Wage Index revisions

Please note that, according to CMS, these temporary emergency policies apply to timeframes specified in the waiver(s) issued under Section 1135 of the Social Security Act.  More information is available on the CMS website here.

For instances in which there is no blanket waiver, providers can request an individual Section 1135 waiver by following the instructions available here.  According to CMS, “specific waivers granted as a result of the emergency or disaster may be retroactive to the beginning of the emergency or disaster if warranted.  CMS also has the authority to exercise certain flexibilities, which are agency policies or procedures that can be adjusted under current authority—and generally speaking, can be adjusted without reprogramming CMS’s systems.”

The effects of these natural disasters on care delivery, as well as billing and reimbursement, will not only be felt for the short term, but are likely to ripple through your organizations for at least several months and possibly more than a year.  We encourage you to check the Hurricane page on the CMS website frequently for updates.  Questions regarding claims can be directed to your Medicare Administrative Contractor on its toll-free number, which can be found here.  ICD-10 coding advice from the Centers for Disease Control and Prevention in the aftermath of the disasters is available here.

Read more updates: MiraMed eAlerts

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Hurricane Harvey wreaked havoc in southeastern Texas last week and created a public health crisis.  The tropical cyclone or what is called a category four hurricane caused unprecedented and catastrophic flooding in the southeastern part of the state.  It was the first major hurricane in the U.S. since Wilma in 2005, a category five hurricane with winds of up to 185 mph.

Harvey is the wettest storm on record in the contiguous United States and is “almost certain” to be at least the third worst storm in U.S. history when it comes to damage costs, according to Enki Research.  The firm’s current estimate ranges from $48 billion to $75 billion, with an average of $57 billion.  However, those numbers are subject to change with each passing day.  “The computer models we normally use to do estimates for hurricanes don’t work that well for this kind of a storm,” Chuck Watson, the director of research and development at Enki Research, said.

The resulting floods inundated hundreds of thousands of homes, displaced more than 30,000 people and prompted over 13,000 rescues.  Medical services and hospitals were taxed beyond capability, especially since many hospitals and medical facilities were closed and evacuated.

Though Hurricane Harvey pounded Texas with a national rainfall record for a tropical storm, crisis management coordination between the state and Texas hospitals ensured care was minimally interrupted.  The South East Texas Regional Advisory Council (SETRAC) claims that roughly 90 percent of healthcare facilities will return to full service by October, according to STAT News.

The outcome could have been much worse, considering the nature of the storm.  Houstonians pulled together and weathered the storm with great determination.  Addressing Harvey’s effects required a resourcefulness that no other catastrophe has necessitated.  The storm has challenged a comprehensive disaster plan the city and surrounding counties had prepared.  The devastation so far has been unimaginable.

The host of National Public Radio’s (NPR) show, All Things Considered, Kelly McEvers spoke with Darrell Pile, CEO of SETRAC which runs the catastrophic medical operations center which will offer a perspective of the medical challenges experienced during the storm.  This interview has been edited for length and clarity.

NPR Interview Highlights

While the storm has largely left Houston, the flooding continues.  What is the situation with the hospitals you are working with?

The flooding is devastating, and we have at least two reservoirs where water is having to be released and is, in fact, flooding neighborhoods as we speak and has placed three hospitals in harm’s way.

The three hospitals are monitoring the water coming from the two reservoirs very closely, and they could, depending on the flow of the water, find that they could become inaccessible to EMS agencies.  We are tracking that very closely.

The situation with residents in their homes—some are on the second floor of their homes—the evacuation process [for those neighborhoods] continues, and, as a result, it is unclear what the demands on the health care system may be.  However, most hospitals are up and fully functional, and we believe we can handle any new demands that happen today or tomorrow.

Has the catastrophic medical operations center ever handled anything like this?

No.  The phone lines at one point became inundated.  The amount of resources needed began to exceed what we had available.  The calls included patients needing dialysis who might be at home.  It included hospitals saying we need to evacuate.  One call was asking for 50 wheelchairs to be sent to a shelter.  We did not have 50 wheelchairs left.  Fortunately, our governor declared a disaster and the president declared a disaster and resources have been brought in from all over the state and all over the nation to help us.

How did you get those 50 wheelchairs?

I am not clear on how they ended up getting the 50 wheelchairs, but I can tell you, it can be accomplished just through one or two tweets to Houstonians.  Those with wheelchairs perhaps in their attic or stored [elsewhere] could bring an abundance of wheelchairs, perhaps more than you even need.  So there are methods to solve every problem.  It is just having enough people to make the calls or to be innovative and creative to solve the problems.  This community has come to the call.

A number of hospitals did evacuate, either prior to the storm or during. How difficult is it to evacuate a hospital?

It’s not as simple as pulling up a bus or a convoy of ambulances and moving patients from one hospital to another hospital.  My organization makes sure that the receiving hospital meets the need of every single patient they agree to receive.  As a result, the evacuation of a hospital might mean we must identify ten different hospitals to meet the unique needs of each patient.

Every day, three times per day, we have hospitals electronically advise us of beds that they have available and the type.  So a pediatric patient goes to a pediatric bed.

Moreover, we have also spent time making sure the receiving hospital is not in harm’s way so that the patient would not have to be evacuated twice.  We have worked with the [Texas] Department of State Health Services to also identify hospitals with beds available in cities such as Dallas or San Antonio or Austin or even further away so that a patient doesn’t move twice.

Some Houston hospitals added flood protections as a result of other devastating storms, including Allison in 2001. Have those worked?

Absolutely.  We had a situation where in prior storms, water came into a tunnel system that connects the Texas Medical Center hospitals.  [The tunnels] make it easier to go from one hospital to another hospital.  However, waters came in and flooded every hospital through that tunnel system.

The Texas Medical Center invested in submarine-type doorways, and when there is a risk of flooding, they now close those doorways.  So each hospital is compartmentalized.  As a result, this storm—even though flooding devastated our community, it did not devastate Texas Medical Center.  So, congratulations to the Texas Medical Center.

Do the hospitals have the staff they need right now?

I can imagine some of the hospitals have fewer employees available to staff the hospital.  Some members of their workforce have lost everything—their homes destroyed, their automobiles destroyed.

Tomorrow, we will be holding a meeting to discuss what our hospitals need.  And from there we will be identifying where we need to place nurses.  We have an abundance of nurses from throughout Texas who have offered to help.  We also have an abundance of physicians who have offered to help.  Now it’s a matter of making sure we place them in the proper facilities.

The Aftermath of Hurricane Harvey

Hurricane Harvey began with raging winds, but its legacy will be the seemingly endless stream of water that swamped parts of Houston and the surrounding area.  Harvey whipped up tons of water from the sea and hurled it down on the country’s fourth most populous city, drowning vast tracks of the landscape and battering it with almost a year’s worth of rainfall in less than a week.

Houstonians are strong and will rebound from Harvey’s devastation.  So will its hospitals and medical community.  The rebuilding process will not happen without the assistance of those within and outside the healthcare industry.  The American Hospital Association (AHA) has been supporting colleagues at the Texas Hospital Association as they work with hospitals and health systems, as well as local and federal agencies, to respond to the ongoing disaster.

Concerned citizens can help relief efforts in a number of ways:

Blood Donations: The American Association of Blood Banks (AABB) is urging eligible donors, especially those with type O-positive blood, to make donation appointments as soon as possible.  Those interested in donating may contact the following organizations to find a local blood drive and schedule an appointment:

Texas Hospital Association Assistance Fund: The Texas Hospital Association has established an assistance fund to help hospital employees who experienced significant property loss or damage.  Administrative services are being provided in kind, so 100 percent of donations can be used to assist individuals in need. AHA has contributed an initial $50,000 to get the fund started.

For more information or to make a donation, visit https://www.tha.org/Harvey/ReliefFund.  For additional details, visit www.tha.org/harvey.

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Don’t gamble on your risk adjustment HCC coding.

Learn about how to stay in compliance and maximize reimbursements

Rescheduled date – September 28, 2017 | 2:00 to 3:00 pm EDT

Register today: Webinar: HCC Coding and Auditing Strategies

Do you have risk-adjusted physician services contracts for your Medicare Advantage patients? Then read on…you may be leaving money on the table by missing proper codes and creating inaccurate HCC coding.

Don’t miss this opportunity to learn about risk-adjusted HCCs and the strategies that will keep you in compliance and make sure that you maximize the reimbursement due to you.

In this webinar, you will learn:

  • Trends affecting Medicare Advantage and the healthcare industry
  • What are risk adjustment HCCs and how are they reimbursed?
  • Why is risk adjustment important for compliance and reimbursement?
  • What are the HCC types and programs
  • How to calculating an ROI for properly identifying and coded HCCs
  • Strategies for HCC compliance and reimbursement improvement

Presenters:

Amber Broadwater – MBA, RHIA, LHRM, ICD-10 Trainer – Vice President of Client Services, Coding Division at MiraMed Global Services.

Phil C. Solomon – Vice President of Marketing Strategy and Thought Leadership at MiraMed Global Services and Publisher of Revenue Cycle News Blog.

Save Your Spot – Register today: Webinar: HCC Coding  and Auditing Strategies 

For more information, contact Phil Solomon at phil.solomon@miramedgs.com

 

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CMS Seeking Comments for Abandoning Cardiac Bundles and Limiting CJR Model

The proposed rule change posted to the Federal Register on August 10, 2017 indicates the Centers for Medicare and Medicaid Services (CMS) will rescind the regulations governing two mandatory bundled payment programs, the Advancing Care Coordination through Episode Payment Models (EPMs) and Cardiac Rehabilitation Incentive (CRI) Payment Models, which were scheduled to start in 2018.  It also proposes to revise certain aspects of the Comprehensive Care for Joint Replacement (CJR) model, including:

  • Giving certain hospitals selected for participation in the CJR model a one-time option to choose whether to continue their participation in the model;
  • Providing technical refinements and clarifications for certain payment, reconciliation and quality provisions; and
  • Increasing the pool of eligible clinicians that qualify as affiliated practitioners under the Advanced Alternative Payment Model (APM) track.

The August 14, 2017 edition of Cardiovascular Business published the article, “Cardiac Bundles to be Canceled by CMS,” that reported the same bundles have already been delayed twice since Health and Human Services Secretary Tom Price, MD, and CMS Administrator Seema Verma, MPH, took the reins at the agencies. Both have been critical of making bundled payments mandatory, with Verma saying in her confirmation hearing that new payment models should be expanded more gradually.

Price, an orthopedic surgeon, was the lead author of a letter to CMS in 2016 criticizing the mandatory cardiac bundles and the expansion of a joint replacement bundle, saying the moves would lead to providers consolidating and turning away Medicare beneficiaries. “Medicare providers and their patients are blindly forced into high-risk government-dictated reforms with unknown impacts,” he wrote. “Any true medical experiment requires patient consent. However, patients residing in an affected geographical area will have no choice about their participation.”

Some of Price’s concerns have been countered by research. An August 2016 analysis by Avalere Health, a leading Washington DC-based healthcare consulting firm, said that 85 percent of the hospitals required to participate in the cardiac bundles would not experience gains or losses greater than $500,000 per year. Institutions with spending already far above the regional average would face the heaviest losses.

The elimination of the cardiac bundles would remove a path for practices to qualify for the 5 percent bonus in 2019 under the APM track introduced by the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA).

On August 16, 2017, Becker’s Hospital CFO Report outlined eight things that are key components of the proposed rule change in their article, “CMS Cancels Cardiac Bundles, Scales Back CJR Model: 8 Things to Know.”

  1. CMS sent a proposed rule to the Office of Management and Budget last week. The title of the rule indicated CMS would cancel mandatory bundled payment initiatives for heart attacks, bypass surgery, and hip and femur fractures. Details on the changes were revealed on August 15, 2017 when the proposed rule was made public.
  2. The proposed rule would cancel the mandatory bundled payment program for heart attacks and bypass surgeries as well as the cardiac rehabilitation payment model, which is intended to test whether a payment incentive can increase the utilization of cardiac rehabilitative services.
  3. The proposed rule would eliminate mandatory bundling for hip and femur fracture treatment under the Comprehensive Care for Joint Replacement program.
  4. The cardiac bundled payment models and expansion of the CJR program are slated to begin Jan. 1, 2018.
  5. The proposed rule would scale back the existing CJR model. Under the proposed rule, the CJR program would be mandatory for hospitals in 34 of the 67 geographic areas chosen for the program. The CJR model would continue on a voluntary basis in the other 33 geographic areas. The proposed rule would also make participating in the CJR model voluntary for all low volume and rural hospitals in the 67 areas.
  6. “Changing the scope of these models allows CMS to test and evaluate improvements in care processes that will improve quality, reduce costs, and ease burdens on hospitals,” said CMS Administrator Seema Verma. “Stakeholders have asked for more input on the design of these models. These changes make this possible and give CMS maximum flexibility to test other episode-based models that will bring about innovation and provide better care for Medicare beneficiaries.”
  7. Ashley Thompson, the American Hospital Association’s senior vice president for public policy analysis and development, said the AHA is concerned cancellation of the bundled payment models could cause problems for provider organizations that have spent valuable resources to implement these programs.
  8. CMS will accept comments on the proposed rule until October 16, 2017.

Chris Garcia, CEO of Remedy Partners, said his organization had forecasted similar hurdles due to the bundles’ mandatory nature, as well as how complex cardiac care can be.

“We were not surprised that the mandatory models were running into trouble. Cardiac care is very complicated. So many specialists will touch a patient during a cardiac episode. We had heard from our cardiology partners and they said, ‘What are they talking about? This is crazy.’ The amount of effort CMS has put into the models so far was really the only surprising aspect to the proposed cancellation,” Garcia said.

The models were originally slated to begin in July 2017, but provisions of the final rule—including the start date—were delayed multiple times over the past year to give the new administration a chance to review them.

Those who are interested in commenting on the proposed rule that cancels the EPMs and CRI incentive payment model and to rescind the regulations governing these models must respond by 5:00 pm EDT on or before October 16, 2017.

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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The Centers for Medicare & Medicaid Services (CMS) is pursuing changes that would cut 340B payment rates to hospitals and may impair safety-net hospitals’ ability to treat low-income patients.

The 340B program requires drug manufacturers to provide outpatient drugs to eligible healthcare organizations and covered entities at considerably reduced prices.  The long-standing Medicare policy allows CMS to pay up to six percent more than the average sales price in the 340B program.

The proposed Outpatient Prospective Payment System (OPPS) rule, posted recently on Federal Register, would reduce 340B Drug Discount Program payment rates, drastically cutting Medicare payments for drugs that are acquired under the 340B drug pricing program.  CMS has proposed updating the OPPS rates by 1.75 percent, which would pay hospitals 22.5 percent less than the average sales price for some drugs purchased under the 340B program.

Industry Groups Unhappy with OPPS Proposal

Industry groups immediately made their feelings known about the proposal and they weren’t happy.  “For 25 years, the 340B Drug Pricing program—which enjoys broad, bipartisan support—has been critical in expanding access to life-saving prescription drugs to low-income patients in communities across the country,” said American Hospital Association (AHA) Executive Vice President Tom Nickels.  “The patients who benefit from the much-needed 340B program are the ones who will have their access to care threatened.  Cutting Medicare payments for hospital services in the 340B program is not based on sound policy.  Additionally, this proposed rule punishes hospitals for a policy outside of CMS’ jurisdiction.  It is unclear why the administration would choose to punitively target 340B safety-net hospitals serving vulnerable patients, including those in rural areas, rather than addressing the real issue: the skyrocketing cost of pharmaceuticals,” Nichols said.

The AHA is not the only industry group angry with the proposal. The association 340B Health, a group with more than 1,300 hospitals that supports involvement in the 340B program, said most of its members would likely withdraw from the program if CMS cuts payments that would take away most, if not all, of their savings on Part B drugs.  “With the uninsured rate rising again and so much uncertainty about the healthcare marketplace, this is no time to cut reimbursement to hospitals that serve patients in need,” 340B Health CEO Ted Slafsky said in a statement.

Other healthcare executives agree. Bruce Siegel, CEO of America’s Essential Hospitals, said the proposal threatens hospitals’ ability to maintain critical services to patients and communities.  From the reactions of industry insiders, if they have their way, this proposal will not see the light of day and CMS will never institute the proposed OPPS policy changes.

Eight Keys to the OPPS Proposed Rule

In the proposed rule, CMS suggests changing how Medicare pays hospitals for drugs that are acquired under the 340B Drug Discount Program.  There are several important keys tied to the proposal that are highlighted in Becker’s Hospital CFO Report titled, “CMS releases OPPS proposed rule for 2018: Nine things to know.”  The following are some salient points of the proposed rule.

Payment Update

  1. CMS proposed updating the OPPS rates by 1.75 percent in 2018.  The agency arrived at its proposed rate increase through the following updates: a positive 2.9 percent market basket update, a negative 0.4 percentage point update for a productivity adjustment and a negative 0.75 percentage point adjustment for cuts under the ACA.
  2. After considering all other policy changes included in the proposed rule, except for the provisions related to 340B drug payments, CMS estimates hospital OPPS payments would increase by two percent next year.

Proposed 340B Program Changes

  1. CMS proposed paying hospitals 22.5 percent less than the average sales price for drugs purchased through the 340B program.  That is compared to the current payment rate of average sales price plus six percent.  Under the proposed rule, the current payment would continue for vaccines.
  2. Regarding the proposed 340B program changes, CMS said it “seeks comment on implementing this proposal in a manner that will bring down out-of-pocket drug costs for Medicare patients and allows providers to best meet their patients’ needs.”

Proposed Update to Inpatient-only List

  1. The Medicare inpatient-only list includes procedures that are only paid for under the hospital Inpatient Prospective Payment System.  Each year, CMS reviews the list to determine whether any procedures should be taken off of the list.  For 2018, CMS proposed removing total knee arthroplasty from the IPO list.  The proposed rule also seeks comment on whether partial and total hip arthroplasty should be removed from the list.

Hospital Outpatient Quality Reporting Program Changes

  1. For 2018, CMS is proposing removing six measures from the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years.  The measures CMS is proposing to remove are:
    OP-1: Median time to fibrinolysis
    • OP-4: Aspirin at arrival
    • OP-20: Door to diagnostic evaluation by a qualified medical professional
    • OP-21: Median time to pain management for long bone fracture
    • OP-25: Safe surgery checklist use
    • OP-26: Hospital outpatient volume data on selected outpatient surgical procedures

Possible Revisions to Laboratory Date of Service Policy

  1. CMS said it is considering potential modifications to the laboratory date of service policy.  The changes would allow labs to bill Medicare directly for molecular pathology tests and advanced diagnostic laboratory tests excluded from the OPPS packaging policy and ordered less than two weeks following the date of a patient’s discharge from the hospital.  Under the current policy, if a test is ordered less than two weeks after a patient’s discharge date, the hospital must bill Medicare for the test and then pay the lab that performed the test.

Comment Period

  1. CMS will accept comments on the proposed rule until September 11, 2017.

Summary

On July 13, 2017, CMS released its proposed OPPS rule changes in a request for information (CMS-1678-P) for public review.  In doing so, CMS believes that enacting the OPPS rule change is the first step in an effort to start a national conversation about improving the healthcare delivery system, how Medicare can contribute to making the delivery system less bureaucratic and complex, and how CMS can reduce burdens for clinicians, providers and patients in a way that increases quality of care and decreases costs.  All of this with the intention of making the healthcare system more effective, simple and accessible while maintaining program integrity and preventing fraud.

CMS will respond to comments in a final rule on or about November 1, 2017.

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Do you have risk-adjusted physician services contracts for your Medicare Advantage patients? Then read on…you may be leaving money on the table by missing proper codes and creating inaccurate HCC coding.

Don’t miss this opportunity to learn about risk adjusted HCCs and the strategies that will keep you in compliance and ensure that you maximize the reimbursement due to you.

Register today: Webinar: The In’s and Out’s of HCC Coding for Better Reimbursement 

You will learn:

  • Trends affecting the healthcare industry
  • What is risk adjustment HCCs and how are they reimbursed?
  • Why is risk adjustment important for compliance and reimbursement?
  • HCC types and programs
  • Calculating the financial ROI for properly identifying and coded HCCs
  • Strategies for HCC compliance and reimbursement improvement

Presenters:

Amber Broadwater – MBA, RHIA, LHRM, ICD-10 Trainer – Vice President of Client Services, Coding Division at MiraMed Global Services.

Phil C. Solomon – Vice President of Marketing Strategy and Thought Leadership at MiraMed Global Services

Save Your Spot – Register today: Webinar: The In’s and Out’s of HCC Coding for Better Reimbursement 

For more information, contact Phil Solomon at phil.solomon@miramedgs.com

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Optimizing your revenue cycle management process is a key component for addressing a multitude of industry trends such as changes in regulations, consumerism and new reimbursement structures.

Today’s patient centric revenue cycle requires the right systems to drive performance; however, employing systems based solely on their robustness does not guarantee success.  Optimal financial performance is only achieved with a careful balance of people, processes and technologies.

Revenue cycle performance in healthcare is particularly challenging due to the complex nature of services to be billed, the large number of employees contributing to the process, the array of systems and tools used to process billing, the evolving interactions with patients and their growing payment liabilities due to an increased responsibility for the costs of care.

Performance Metrics and Sustainability

The revenue cycle can be broken down into two main areas: pre-service or what is considered financial clearance and post-service, typically referred to as financial settlement.  These functions include registration, bill estimation, case management, discharge billing, post-service billing reconciliation and collections.

Revenue cycle performance in these domains is only sustainable with unremitting efforts to maintain accuracy and measure performance.  Identifying and measuring overall outcomes offers general benchmarking information but is not actionable.  Adjusting revenue cycle activities for optimal outcomes are required with the specific actions that should be pursued.  The foundation for best practice revenue cycle management begins with selecting metrics based on existing best practices.  These best practices should present guidelines for the most efficient or prudent course of action and reflect the preferences and financial priorities of the organization.

Revenue cycle metrics can be broken down into two types: operational and strategic.  Operational performance metrics require consistent monitoring and should provide ample information to drive operational improvement and quality, and validate sufficient progress toward workflow goals.  Strategic metrics comprise financial, operational, customer service and quality measures that give executives a high level overview and track trends by month or current fiscal year.

High-performing healthcare organizations that operate best practice revenue cycles use the revenue cycle to continually enhance their day-to-day operations and improve patient experiences and financial recoveries.  These best practices give organizations looking to make positive changes in revenue cycle management numerous areas in the revenue cycle on which to focus their attention.

25 Keys to Patient-Centric Revenue Cycle Performance

Today’s healthcare environment of increased regulations, growing patient payment liability, and risk-based pay-for-performance models and diminishing reimbursements necessitates revenue cycle strategies that meet industry standards.  From pre-schedule to accounts receivable payment and cash posting, revenue cycle processes must be aligned in order to secure proper reimbursement from payers and patients.  The following are 25 Keys to a Patient-Centric Revenue Cycle which, when implemented, will drive positive financial results and improve the patient’s overall experience.

  1. Implement an all-encompassing strategy that measures collection goals, workflow benchmarks, policy adherence and key performance indicator milestone attainment.
  2. Post and communicate to patients the hospital’s financial assistance, discount and prompt payment policies.
  3. Remind patients of their payment obligation and attempt to collect the patient portion when performing appointment scheduling confirmation calls.
  4. Educate patients to be prepared to pay for services upon arrival at the hospital or clinic.
  5. Utilize integrated scheduling and registration tools to handle patient visits and accurately move patients through the billing process.
  6. Use a registration quality and scoring technology to accurately classify self-pay patients at point of service to improve collections.
  7. Employ real-time technologies that notify registration staff of Red Flags Rule irregularities and fraud alerts.
  8. Help patients understand what they will owe at pre-registration, registration and patient check out with an effective bill estimator.
  9. Partner with a vendor who offers a cost-effective, unlimited-use real-time insurance eligibility verifying program to check eligibility of patient accounts at any point throughout the revenue cycle collection process.
  10. Introduce a comprehensive program to help patients apply and qualify for various state and federal financial assistance programs.
  11. Install a web-based patient intelligence platform to analyze real-time workflow performance.
  12. Leverage call center technology to manage call volumes, improve customer service, improve time efficiencies and increase first call resolutions.
  13. Post patient financial services staff in the emergency department to collect co-pays, deductibles and self-pay balances.
  14. Collect a pre-determined deposit from emergency room patients during quick registration and reconcile total estimated payment due through a bill pay estimator.
  15. Preauthorize credit cards and checks at the time of scheduling, registration or any other collection checkpoint.
  16. Apply a self-pay point of service collection strategy for collecting previous and current balances.
  17. Use a self-pay collection scoring technology that creates workflows through algorithms that estimate the ability and propensity of payment.
  18. Implement a self-pay charity scoring workflow that estimates charity and financial discount write-offs before bad debt placement.
  19. Use an integrated scanning technology to maintain accuracy while improving the identification and proper storage of patient records.
  20. Implement an advanced technology to collect credit card, debit card and Automated Clearing House (ACH) payments.
  21. Offer a web-based payment portal for patient bill pay.
  22. Implement e-cashiering to give patients additional options to pay.
  23. Utilize a predictive dialer that blends inbound and outbound calls, closely monitors right-time calling analytics and sends out-patient friendly statements.
  24. Provide ongoing face-to-face and web-based collection and customer service training with the goal of ensuring that all self-pay patients are treated with respect, dignity and professionalism.
  25. Offer continuous training programs to educate staff on their responsibilities.

An important part of any well-balanced and productive revenue cycle is ensuring that there is a clear understanding of how to serve the patient and meet their wants and needs so that their healthcare encounters are less stressful and more clinically productive.  Closing the revenue cycle loop with patient satisfaction surveys gives healthcare stakeholders the feedback required to build and operate an efficient and patient-friendly revenue cycle.

Summary

To maximize revenue cycle efforts, healthcare organizations need suitable technology, adequate internal work processes, experienced people and appropriate metrics.  Without these pillars, organizations will struggle to operate efficiently.  Focusing inward on revenue cycle best practices is crucial for maintaining operational excellence without losing sight of the impact of a positive patient experience on revenue cycle performance.

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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The Centers for Medicare and Medicaid Services has estimated that the House-passed American Health Care Act (AHCA) would reduce insurance coverage by 13 million people by 2026—10 million less than the Congressional Budget Office’s (CBO’s) prediction.

The actuary estimated that average net premiums paid by consumers in the individual insurance market in 2026 would be about five percent higher than under current law, and that average cost-sharing amounts would be about 61 percent higher.  These approximations represent a marked difference from the CBO’s estimates.

The CMS report estimated the AHCA would reduce federal Medicaid spending by $383.2 billion from 2017 through 2026.  The cost reductions would come mainly from repealing the Affordable Care Act’s (ACA’s) Medicaid expansion to low-income adults.  That is far less than the $834 billion in Medicaid cuts projected by the CBO.

Which organization’s estimate (the CMS or the CBO) will be the closest to the correct number when the analysis period is completed?  It is hard to tell.  Neither organization’s analysis on other projections has proven to be infallible.  In fact, both organizations’ estimates have historically been incorrect.  Performing forward flow financial analysis estimates is extremely difficult, even with granular data.  Market dynamics and changing conditions can have a material impact on the assumptions made in all projections making accurate budgetary estimates for legislations virtually impossible.

What is the CBO?

The CBO, established in 1974 is a nonpartisan government agency that reports economic and budgetary data to Congress.  The CBO was formed and signed into law by President Richard M. Nixon.  The goal of the CBO is to provide timely, accurate reports delivered in a nonpartisan and objective manner about proposed legislation and current law that concerns federal programs funded by U.S. taxpayers.  They also guide the Joint Committee on Taxation and the Department of Treasury regarding the fiscal considerations of legislation, as well as the national debt.

The CBO employs more than 230 professionals and maintains a departmental budget of approximately $47 million.  All positions within CBO, including the directorship, are hired without regard to an individual’s political affiliation, and all employees are expected to remain expressly nonpartisan.

The CBO director is a joint appointment from the Speaker of the House of Representatives and the President Pro Tempore of the Senate.  The director is appointed to a four-year term.

CBO’s Projections for the AHCA

The CBO reported on the cost and coverage impact of the House Republicans’ bill to repeal and replace the ACA.  The following are 15 key projections compared to the current law:

  1. Reduce the cumulative deficit by $119 billion by 2026; the prior version of the AHCA would have cut the deficit by $150 billion.
  2. Increase the number of uninsured by 14 million in 2018, growing to 23 million by 2026; the previous bill would have raised the number of uninsured by 24 million in 2026.
  3. Result in a total of 51 million uninsured in 2026, compared with 28 million under current law.
  4. Significantly increase the number of uninsured among people ages 50 to 64 with income under 200 percent of poverty.
  5. Lower federal Medicaid spending by $834 billion over ten years.
  6. Reduce the number of people on Medicaid by 14 million in 2026, a 17 percent decrease.
  7. Save $290 billion over ten years by replacing the ACA’s premium and cost-sharing subsidies with less generous age-based premium tax credits, reducing spending from $665 billion to $375 billion.
  8. Increase Medicare disproportionate-share payments to hospitals by $43 billion over ten years due to a jump in uninsured patients.
  9. Prompt states where half the U.S. population lives to seek waivers from the ACA’s individual insurance market rules on minimum essential health benefits, use of pre-existing conditions for setting premiums and guaranteed issue.
  10. Reduce individual-market premiums in states that did not seek waivers by about four percent in 2026, mainly because younger, healthier people and fewer older, sicker people would buy coverage.
  11. Create individual-market instability in states seeking fuller waivers where one-sixth of the U.S. population lives; premiums for people seeking to buy comprehensive plans would become unaffordable.
  12. Reduce individual-market premiums overall while sharply increasing premiums for older, low-income people.
  13. Substantially increase out-of-pocket costs for people in states that waived ACA requirements on essential health benefits, particularly for maternity, mental health and substance abuse services.
  14. Prompt a few million people to use premium tax credits to buy plans that don’t cover major medical costs.
  15. Result in four million more people in employer-based health plans by 2026, mainly because employers would see the individual market as a less desirable option for their workers.

What is the CMS Office of the Actuary?

The CMS Office of the Actuary (OACT) annually produces projections of healthcare spending for categories within the National Health Expenditure Accounts.  These projections track health spending by source of funds (for example, private health insurance, Medicare, Medicaid), by type of service (hospital, physician, prescription drugs, etc.), and by the sponsor (businesses, households, governments).  The latest projections begin after the latest historical year (2015) and go through 2025.

The OACT is led by Chief Actuary Paul Spitalnic.  He is responsible for meeting the functional responsibilities of the OACT.  Those responsibilities include:

  • Conducting and directing the actuarial program for CMS and directing the development of and methodologies for macroeconomic analysis of healthcare financing issues.
  • Performing actuarial, economic and demographic studies to estimate CMS program expenditures under current law and proposed modifications to current law.
  • Providing program estimates for use in the President’s budget and reports required by Congress.
  • Studying questions concerned with financing present and future health programs, evaluating operations of the Federal Hospital Insurance Trust Fund and Supplementary Medical Insurance Trust Fund and performing microanalyses for the purpose of assessing the impact of various healthcare financing factors upon the costs of federal programs.
  • Estimating the financial effects of proposals to create national health insurance systems or other national or incremental health insurance reform.
  • Developing and conducting studies to estimate and project national and area health expenditures.
  • Developing, maintaining and updating provider market basket input price indexes and the Medicare Economic Index.
  • Analyzing data on physicians’ costs and charges to develop payment indices and monitor the expansion of service and inflation of costs in the healthcare sector.
  • Performing actuarial reviews and audits of employee benefit expenses charged to Medicare by fiscal intermediaries and carriers.
  • Publishing cost projections and economic analyses, and providing actuarial, technical advice and consultation to CMS components, governmental components, Congress and outside organizations.

CMS Estimates for the AHCA

The OACT has estimated the financial and coverage effects through 2026 of selected provisions of the AHCA (H.R. 1628), which was passed by the House on May 4,2017.  Here are ten key estimates listed in the OACT estimated impact report.

  1. CMS estimated there would be eight million fewer people covered by Medicaid in 2026 compared with current law.  The CBO projected a Medicaid coverage decline of 14 million by 2026.
  2. The CMS actuary said the AHCA would reduce federal spending by $328 billion over ten years, mainly due to lower Medicaid expenditures.  The CBO projected that the bill would reduce federal deficits by $119 billion.
  3. CMS estimates there will be fewer insurance coverage losses than those projected by the CBO. However, those losses could be in the millions.
  4. By 2026, the CBO says 43 million people would be uninsured, compared with 31 million estimated by the CMS.
  5. The CMS actuary predicted that 25 percent of states would seek waivers under the AHCA from Obamacare’s requirements that all insurers offer essential health benefits and not consider applicants’ pre-existing conditions in setting premiums.
  6. The OACT said it is possible that such waivers “could result in a deteriorating or possibly failing market depending on how a state chose to implement the waiver.”
  7. That is consistent with the CBO’s prediction that waivers could create instability in the individual insurance market, make premiums unaffordable for people seeking to buy comprehensive health plans, and substantially hike out-of-pocket costs for people seeking maternity, mental health and substance abuse services.
  8. The AHCA’s per capita cap on total federal Medicaid spending would lead to a 0.5 percent cut per year in federal payments to the states, according to the actuary.
  9. The reduction from the per capita cap would total $64.9 billion over ten years, while the decrease from the repeal of Medicaid expansion funding would total $274.8 billion.
  10. Also, the AHCA would cause the Medicare Hospital Insurance Trust Fund for inpatient care to become insolvent in 2026, two years earlier than under current law.  That is because the AHCA would repeal the ACA’s additional Medicare payroll tax on wealthy Americans and increase Medicare disproportionate-share payments to hospitals for serving more uninsured patients.

Summary

The House Republicans and the White House are now waiting on the Senate Republican leadership to work out their differences on the latest release of a draft of its long-awaited healthcare bill.  The legislation—called the Better Care Reconciliation Act of 2017—would roll back much of the ACA, the healthcare law better known as Obamacare, including various tax provisions.

The Senate legislation contains key differences from the AHCA, the House GOP’s legislation to repeal Obamacare.  The differences could be sticking points if the two chambers have to compromise on the bill, which they would have to do before it could reach President Donald Trump’s desk.

The legislation faces an uncertain future as the Senate deliberates, and the House, the President and the people, wait impatiently to view the final results of the AHCA or Better Care Reconciliation Act.  Will the Senate gain enough votes to pass their legislation?  Only time will tell.

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Announcing New Webinar: HCC Reimbursement Strategies

Do you have risk-adjusted physician services contracts for your Medicare Advantage patient? Then read on…you may be leaving money on the table by missing proper and inaccurate HCC coding.

Don’t miss this opportunity to learn about risk adjusted HCCs and the strategies that will keep you in compliance and make sure that you maximize the reimbursement due to you.

Register today: HCC Reimbursement Strategies Webinar

You will learn:

  • Trends affecting the healthcare industry
  • What is risk adjustment HCCs and how are they reimbursed?
  • Why is risk adjustment important for compliance and reimbursement?
  • HCC types and programs
  • Calculating the financial ROI for properly identifying and coded HCCs
  • Strategies for HCC compliance and reimbursement improvement

Presenters:

Amber Broadwater – MBA, RHIA, LHRM, ICD-10 Trainer – Vice President of Client Services, Coding Division at MiraMed Global Services.

Phil C. Solomon – Vice President of Marketing Strategy and Thought Leadership at MiraMed Global Services

Save Your Spot – Register today: HCC Reimbursement Strategies Webinar

For more information, contact Phil Solomon at phil.solomon@miramedgs.com

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The Key Roles Medical Billers and Coders Play in Health Care

by Phil C. Solomon June 12, 2017

Medical billers and coders typically don’t make headlines but they are imperative to the success of any medical facility. Carrington College has submitted the following infographic which describes how the coding process translates from an encounter to billing of a claim. Translating Care into ICD-10 Codes There are over 140,000 codes used to denote different types of examinations, […]

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New Webinar: Improve HCC Reimbursement with Risk Adjustment Coding Strategies

by Phil C. Solomon June 6, 2017

Join us for our upcoming free webinar: Improve HCC Reimbursement with Risk Adjustment Coding Strategies June 22, 2017 | 2 pm – 3 pm EDT Register Now: Improve Reimbursement with Risk Adjustment HCC Coding Strategies https://attendee.gotowebinar.com/register/4600147017512814083?source=sm-1 Medicare Advantage makes up 31 percent of total Medicare spending, serves over 17 million enrollees and it is expected […]

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