Policy Updates

CMS Outlines Improvements in RAC Audit Processes

In the face of complaints from hospitals about backlogs, time-consuming procedures, and lengthy appeals processes involving Medicare Recovery Audit Contractor audits, the Centers for Medicare & Medicaid Services recently outlined changes it has implemented in the RAC audit process to address these and other concerns. They are (in CMS's own words): Better Oversight of RACs We are holding RACs accountable for performance by requiring them to maintain a 95% accuracy score. RACs that fail to maintain this rate will receive a progressive reduction in the number of claims they are allowed to review. We also require RACs to maintain an [...]

iqtsupport2019-05-09T06:00:15-04:00May 9, 2019|Centers for Medicare & Medicaid Services, Medicare|

Are Savings Baked Into Medicare Advantage?

Medicare Advantage plans spend less for their members’ care than traditional Medicare – even when beneficiaries switch from traditional Medicare to a Medicare Advantage plan. This spending trend, moreover, applies to all types of Medicare beneficiaries, even after risk adjustment, regardless of age, gender, or dual-eligibility. It even applies to beneficiaries with chronic medical conditions, according to a recent study. Why the difference? The study’s authors suggest “favorable self-selection.” Past studies have suggested that Medicare Advantage plans’ care management components are responsible for reduced costs but this study casts that theory in doubt. Another theory is that the provider networks [...]

iqtsupport2019-05-08T13:00:45-04:00May 8, 2019|Medicare|

New Client

DeBrunner & Associates is pleased to welcome our newest client: the University of Pittsburgh Medical Center. As Pennsylvania’s largest non-governmental employer, with more than 87,000 employees, UPMC consists of more than 30 hospitals, more than 700 doctors' offices and outpatient sites, an international division, and an enterprises division. Welcome!

iqtsupport2019-05-08T06:00:46-04:00May 8, 2019|Uncategorized|

CMS Adopts Rule to Protect Medicaid Payments

A new Medicaid provider payment reassignment regulation eliminates the ability of states to divert any portion of Medicaid payments to third parties. Such diversion was authorized, in a limited manner, in 2014, when CMS created an exception to the existing prohibition on the diversion of provider payments to third parties. That exception involved diversion of payments to selected third parties, mostly in-home personal care workers, but in this new, final regulation, the agency eliminates this exception, maintaining that it is inconsistent with the Social Security Act. Learn more about the new regulation in a CMS news release or see the [...]

iqtsupport2019-05-07T06:00:52-04:00May 7, 2019|Medicaid, Medicaid regulations|

CMS Solicits Waiver Input From Stakeholders

The Centers for Medicare & Medicaid Services is soliciting ideas from stakeholders about new approaches that might be employed in the development of state relief and empowerment waivers, also known as section 1332 waivers. Last year CMS loosened section 1332 waiver requirements and offered states four concepts for how to take advantage of both the waivers and the less stringent requirements. Section 1332 waivers permit states to seek exemption from selected requirements of the Affordable Care Act to pursue new approaches to enhancing access to quality, affordable health insurance. Through a new request for information, CMS now seeks …to build [...]

iqtsupport2019-05-06T06:00:32-04:00May 6, 2019|Affordable Care Act, Centers for Medicare & Medicaid Services, health care reform|

Senate Finance Committee Reports on Supplemental Medicaid Payments

The majority members of the Senate Finance Committee have published a report on supplemental Medicaid payments. According to the new document, This report seeks to increase educational understanding of Medicaid supplemental payments, as well as outline the reporting mechanisms for these payments to ensure adequate stewardship of taxpayer dollars. The report consists of descriptions of the different types of supplemental Medicaid payments that states make to some providers, including: Medicaid disproportionate share payments (Medicaid DSH) non-DSH payments upper-payment limit payments (UPL payments) demonstration supplemental payments medical education payments It also describes the magnitude of these payments, noting that supplemental Medicaid [...]

iqtsupport2019-05-03T06:00:54-04:00May 3, 2019|Medicaid, Medicaid disproportionate share, Medicaid DSH, Medicaid upper-payment limit|

Mandatory Payment Models Coming to Medicare?

Even as CMS rolls out new, voluntary Medicare alternative payment models, it is contemplating making participation in future models mandatory rather than voluntary, as is currently the case. Or so Centers for Medicare & Medicaid Services administrator Seema Verma told a gathering in Baltimore last week. At the heart of the idea, Verma told her audience, is that while CMS is pleased with participation in voluntary accountable care organization models, organizations are choosing to participate in ACO models they think would benefit them most while posing little or no downside financial risk. The agency may need to move away from [...]

iqtsupport2019-05-02T06:00:59-04:00May 2, 2019|Accountable Care Organization, ACO, Alternative payment models, Centers for Medicare & Medicaid Services, Medicare, Medicare reimbursement policy|

Uninsured ED and Inpatient Visits Down Since ACA

Uninsured hospital admissions and emergency department visits are down since passage of the Affordable Care Act. And Medicaid-covered admissions and ER visits are up, according to a new analysis. The report, published on the JAMA Network Open, found that ER visits by uninsured patients fell from 16 percent to eight percent between 2006 and 2016, with most of this decline after 2014, while uninsured discharges fell from six percent to four percent. The rate of uninsured ER visits declined, moreover, at a time when overall ER visits continued to rise. While the Affordable Care Act is likely the cause of [...]

iqtsupport2019-05-01T06:00:26-04:00May 1, 2019|Affordable Care Act, hospitals, Medicaid|

Bureaucratic Requirements May Be Driving Medicaid Enrollment Decline

State eligibility redetermination processes may be pushing down Medicaid enrollment nation-wide. Last year, national Medicaid enrollment fell 1.5 million, more than half of them children, and according to a new report from Families USA, much of that decline may be attributable to the challenging eligibility redetermination requirements imposed on Medicaid-eligible individuals by some states. Those requirements include a 98-page packet that Tennessee sends to individuals seeking to retain their Medicaid eligibility; Arkansas’ limit of 10 days to respond to requests for information to redetermine eligibility; and Missouri’s decision to discontinue using data from other public safety-net programs to redetermine eligibility. [...]

iqtsupport2019-04-30T06:00:02-04:00April 30, 2019|Medicaid|

Adverse Selection May Explain Rising ACO Costs

Hospital ACO costs are rising because of the sicker patients they attract, a new study suggests. According to researchers at University of Wisconsin Health, patients served by traditional Medicare or by physician-led accountable care organizations often switch to hospital-led Medicare ACOs as they encounter health problems, bringing those hospital-led ACOs sicker patients than those otherwise served by such organizations. As a result, the per patient costs of hospital-led Medicare ACOs often rise more than those of the costs of traditional Medicare and physician-led ACOs. Often, these shifts are encouraged by patients’ medical specialists. Hospital-led Medicare ACOs have been criticized for [...]

iqtsupport2019-04-29T10:11:51-04:00April 29, 2019|Accountable Care Organization, ACO, Alternative payment models, Medicare|