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CMS cancels earlier edits to Medicare billing for partial hospitalizations

Aug 2017 – CMS revoked Medicare reimbursement changes to its medical billing requirements and process for partial hospitalization services over concerns that the proposed edits would substantially increase the administrative burden on providers. The earlier ruling mandated providers to furnish a minimum of 20 hours per week of therapeutic services and to submit bills weekly. Click here to read more.

CMS seeks more oversight over Medicare Advantage provider networks

July 2017 – The CMS wants the plans to upload their networks to a central federal database for review if they haven’t undergone an entire CMS network review in the previous three years. According to CMS this would provide “timely compliance monitoring.” The CMS would review provider information annually to make sure the payers are complying. Click here to read more.

CMS’ map shows 47 counties without an insurer in the exchange market

June 2017 – A federal map of payer participation in the health insurance exchanges shows 47 counties nationwide are projected to have no insurers for 2018. Currently, at least 35,000 active exchange participants live in the counties projected to be without coverage in 2018, and roughly 2.4 million are projected to have one issuer, CMS said. Click here to read more.

GAO Report: Medicare High Risk Issue

n 2016, Medicare was projected to cover approximately 57 million people with estimated expenditures of about $696 billion. The Centers for Medicare & Medicaid Services (CMS), which administers Medicare, faces many challenges related to implementing payment methods that encourage efficient service delivery including implementing changes to payment models outlined in the Patient Protection and Affordable Care Act and the Medicare Access and CHIP Reauthorization Act of 2015, managing the program to serve beneficiaries well, and safeguarding the program from loss due to fraud, waste, and abuse.

The three Key approach to this issue will be:

  • Reforming and refining payment methods to encourage efficient service delivery
  • Improving program management for efficiency and better service to beneficiaries
  • Enhancing program integrity to safeguard Medicare from loss

For details check out the report written by the US Government Accountability Office

CMS published 2016 Program Audit Enforcement Report based on 2016 audit findings

CMS published the 2016 Program audit enforcement report

Key points of interest:

  • Analysis of change in overall audit scores and specific audit scores by program area. Scores fell markedly both overall and in each individual program area audited in 2016.
  • The average number of conditions cited per sponsor has fallen from 38 in 2012 to just under 18 in 2016.
  • There was a marked decrease in the number of ICARs issued per audit in CDAG and ODAG between the two years
  • CMPs imposed totaled $7.5 million, with an average of $357,756 per CMP. The highest CMP imposed was $2,498,850 and the lowest CMP imposed was $3,325.
  • Of the 37 organizations audited during 2016, 17 (46%) received an enforcement action.
  • 17 CMPs were imposed based on 2016 program audits where as in 12 CMPs were imposed for 2015 program audits.

Read the full report here 2016_Program_Audit_Enforcement_Report


CMS Releases 2017 Audit Protocol for Part C and Part D

HHS proposes significant changes to the Medicare appeals process

The U.S. Department of Health and Human Services (HHS) issued a Notice of Proposed Rulemaking (NPRM) on changes to the Medicare claims appeal process. The NPRM is part of the Administration’s efforts to address the unprecedented and sustained increase in the number of appeals and to eliminate the backlog of appeals currently pending at the Office of Medicare Hearings and Appeals (OMHA) and the Departmental Appeals Board (DAB).

For more read the HHS blog post.

Click here for the Federal Register publication.

Refer here for the Primer on the Medicare Appeals process.

CMS launches largest-ever multi-payer initiative to improve primary care

The Centers for Medicare & Medicaid Services (CMS) announced its largest-ever initiative to transform and improve how primary care is delivered and paid for in America. The effort, the Comprehensive Primary Care Plus (CPC+) model, will be implemented in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve. The initiative is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care. Read more >>

CMS Releases Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries

The Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH), released a new Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries.

The Guide was developed in collaboration with the Disparities Solutions Center at Massachusetts General Hospital and the National Opinion Research Center (NORC) at the University of Chicago as part of the CMS Equity Plan for Improving Quality in Medicare, and is designed to assist hospital leaders and stakeholders focused on quality, safety, and care redesign in identifying root causes and solutions for preventing avoidable readmissions among racially and ethnically diverse Medicare beneficiaries.

Read more here;

CMS Finalizes ACA Rule to Save Taxpayers Billions

In order to effectively implement provisions of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) finalized a rule today detailing reforms to the rebate and reimbursement systems for Medicaid prescription drugs, which will save federal and state governments an estimated $2.7 billion over five years.

Read more here;

Inovaare Among Top 100 Silicon Valley Start-ups

There is no doubt that the Indian diaspora has been a great contributor towards the technology evolution in the U.S. Out of nearly 20,000 Silicon Valley start-ups, 25 percent are r*n by Indians. This also shows that the compelling rise in the technological evolution is being greatly received and addressed by the young Indian entrepreneurs. Be it IoT, or the all pervasive cloud technology, or the accelerating pace of Big Data adoption which is a great promise to solving some of the world’s most complex issues, it is greatly encouraging to see all these falling within the purview of the Indian entrepreneurial diaspora.

Click here to know more about the Top 100 Silicon Valley start-ups.

GAO Report: Medicare Advantage – Actions Needed to Enhance CMS Oversight of Provider Network Adequacy

On September 28, 2015, the Government Accountability Office (GAO) released a report. In this GAO Recommends,
the Administrator of CMS should augment oversight of MA networks to address provider availability, verify provider information submitted by MAOs, conduct more periodic reviews of MAO network information, and set minimum information requirements for MAO enrollee notification letters.

The GAO Report is available here.

CMS awards $110 mn in Affordable Care Act funding

CMS awards $110 million in Affordable Care Act funding to continue improvements in patient safety

Centers for Medicare & Medicaid Services (CMS) awarded $110 million in Affordable Care Act funding to 17 national, regional, or state hospital associations and health system organizations to continue efforts in reducing preventable hospital-acquired conditions and re-admissions. Through the Partnership for Patients initiative – a nationwide public-private collaboration that began in 2011 to reduce preventable hospital-acquired conditions by 40 percent and 30-day re-admissions by 20 percent – the second round of the Hospital Engagement Networks will continue to work to improve patient care in the hospital setting.

Click here to read more

CMS releases 2014-24 Projections of National Health Expenditures Data

CMS released 2014-24 Projections of National Health Expenditures Data

In 2014, health spending in the United States is projected to have reached $3.1 trillion, or $9,695 per person, and to have increased by 5.5 percent from the previous year as millions gained health insurance coverage and as new expensive specialty drugs hit the market. Prescription drug spending alone increased 12.6 percent in 2014, the highest growth since 2002. While more people are getting coverage, annual growth in per-enrollee expenditures in 2014 for private health insurance (5.4 percent), Medicare (2.7 percent) and Medicaid (-0.8 percent) remained slow in historical terms.

For full details read:

CMS saves $820 mn in inappropriate Medicare payments

Date 2015-07-14

CMS cutting-edge technology identifies & prevents $820 million in inappropriate Medicare payments in first three years

After three years of operations, the Centers for Medicare & Medicaid Services (CMS) today reported that the agency’s advanced analytics system, called the Fraud Prevention System, identified or prevented $820 million in inappropriate Medicare payments in the program’s first three years. The Fraud Prevention System uses predictive analytics to identify troublesome billing patterns and outlier claims for action, similar to systems used by credit card companies. The Fraud Prevention System identified or prevented $454 million in Calendar Year 2014 alone, a 10 to 1 return on investment.

Read more:

Affordable Care Act payment model saves more than $25 million

Affordable Care Act payment model saves more than $25 million in first performance year

Read the CMS Press release here

CMS Open Payments posts full year of 2014 financial data

The Centers for Medicare & Medicaid Services (CMS) today published 2014 CMS Open Payments data about transfers of value by drug and medical device makers to health care providers. The data includes information about 11.4 million financial transactions attributed to over 600,000 physicians and more than 1,100 teaching hospitals, totaling $6.49 billion.

Click here for more details.