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CMS wants more power to review MA provider networks

The CMS wants more review power over  Medicare Advantage (MA) provider networks to ensure that they “provide adequate access to covered services to meet the needs of the population served.” Next month, it will formally request that the Office of Management and Budget (OMB) approve the plan.

Currently, CMS only reviews MA plans’ networks when there is a triggering event – e.g., when an insurer starts in a Medicare Advantage plan, when it expands its MA coverage or after a complaint about network issues. Translation: If an MA payer doesn’t expand its offerings or the CMS doesn’t receive any complaints, an MA plan’s provider directory might never get reviewed after first entering the market.

Assuming that the OMB approves the proposal, the CMS could act against MA payers that have incorrect information, including fining the insurers or freezing their enrollments.

Healthcare Dive notes that the Government Accounting Office (GAO)  has expressed concerns “about the size of MA provider networks and incorrect online provider directories, including having providers listed as accepting new patients who had left the network, moved or even died. GAO suggested the CMS have more oversight over MA provider networks. ‘’

“In January, the CMS found that 45% of MA provider directories had incorrect information, including which providers were taking new patients, wrong phone numbers and wrong addresses.’’

 

 


Despite CMS delays, bundled payments seen here to stay

 

Despite another delay  in CMS-led bundled-payment programs, bundled payments are likely to continue as providers’ favorite  value-based reimbursement model.

As Healthcare Dive notes: “Bundled payments serve as an entry to value-based care because of the relatively low risk providers take on. And while these programs aren’t yet proven to be successful, there is enough positive data to excite those who champion paying for healthcare based on value.”

S0, “although CMS under the current administration is less enthused for bundled payments {than the Obama administration}, the industry trend isn’t likely to stop.”

“Private payers are getting in the game, too, so hospitals should invest in EHRs that allow real-time care coordination, and should consider trying voluntary programs as an onramp to the process.”

The American Hospital Association  has spoken out against  against additional delays and thus burdens on providers. “As it exists, the {current} rule places too much risk on providers with little opportunity for reward in the form of shared savings, especially in light of the significant upfront investments required,” said AHA Executive Vice President Tom Nickels.

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Bill seeks to ease Meaningful Use demands on hospitals

 

bipartisan group has introduced a bill in the U.S. House that would apparently let the U.S. Department of Health and Human Services (HHS)  ease the burden on hospitals (apparently hospitals only) of Meaningful Use rules involving Medicare recipients.

Called an effort to “amend title XVIII of the Social Security Act to reduce the volume of future electronic health-related significant hardship requests,” the bill would  only affect  providers  still subject to the government’s electronic health record (EHR) incentive program, known as ‘Meaningful Use,”’  Robert Tennant, senior policy adviser to the Medical Group Management Association, told Medscape.

CMS no longer requires individual physicians to participate in the Meaningful Use program, which for them has been subsumed by the Quality Payment Program (QPP) of the Centers for Medicare and Medicaid Services. And, Mr. Tennant said, physicians   eligible to participate in the Medicaid portion of Meaningful Use are not penalized if they don’t participate.

He explained that the legislation might ease their Meaningful Use reporting, but any hardship exceptions would not affect them.

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CMS further lightens the MACRA load.

 

 

CMS is continuing to lighten the MACRA load after smaller and rural providers  complained that their paucity of capital and other resources make complying with the reporting requirements too difficult.

Its latest proposed move would permit  the exemption of small providers participating in the program by increasing the low-volume threshold to $90,000 or less in Medicare Part B charges or 200 or fewer Medicare patients annually. The original threshold was $30,000 in Medicare Part B charges or 100 Medicare patients. The agency believes  that the move would let about 134,000 clinicians stay out of  MIPS.

The proposal follows more than 800,000 clinicians in May being told that  they will not be evaluated under the MIPS program

MACRA will replace Medicare’s Sustainable Growth Formula with a 0.5% annual rate increase through 2019. After that, CMS says, physicians are encouraged to shift to one of two Quality Payment Programs: 1) Merit-Based Incentive Payment System (MIPS) or 2): Alternative Payment Model (APM).

Most physicians are expected to enter the MIPS.

“We’ve heard the concerns that too many quality programs, technology requirements and measures get between the doctor and the patient,” said CMS Administrator Seema Verma. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps toward alleviating burdens and improving health outcomes for all Americans that we serve.”

American Medical Association President David Barbe, M.D., praised  CMS.   “Not all physicians and their practices were ready to make the leap, and many faced daunting challenges. This flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country.”

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CMS rule would force more transparency by private hospital accreditors

 

The Centers for Medicare & Medicaid Services (CMS) has published a draft rule meant to   increase transparency and address critical patient-safety issues at hospitals. The proposed rule would require private hospital accreditation organizations to publicly release details about problems found in hospital inspections. The problems and the steps that the facilities would need to take to address them would have to be posted within 90 days of a report to the facility.

Rita E. Numerof, Ph.D.,  president of Numerof & Associates, a  healthcare sector consultancy writes:  “Healthcare consumers have a right to this information. Almost 90% of hospitals are overseen by private accreditors—not directly by government regulators. And medical errors remain a leading cause of death and injuries in U.S. hospitals, with estimates starting at nearly 100,000 people a year dying due to such mistakes.”

She adds:

“Each year, CMS does its own inspection of healthcare facilities to validate the work of the private accreditation organizations. The agency has reported that state inspectors frequently found ‘serious deficiencies’ that were not reported by private reviewers. In the agency’s language: ‘This continued trend of high disparity rates from FY 2012 to FY 2015 raises serious concerns regarding the [accrediting organizations’] ability to appropriately identify and cite health and safety deficiencies during the survey process.’

“For more than a decade, industry executives from leading facilities have acknowledged behind closed doors that they know their organizations are unsafe. But they have not taken the actions required to fix the issues—largely because they haven’t felt pressure from CMS or the market to do so. This kind of transparency is likely to change that.”

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5 building blocks for successful bundling

“Baby at Play,” by Thomas Eakins (1876).

Win Whitcomb, M.D., writing in Hospitals & Health Networks, presents what he calls five “building blocks of success” in bundled payments. He is chief medical officer at Remedy Partners, in Darien, Conn.; an assistant professor of medicine at the University of Massachusetts Medical School,  and a founder and a past president of the Society of Hospital Medicine.

Here are his building blocks, in abbreviated form:

1. Data

“For the first time, we are able to view cost data over the entire span of an episode, including acute care and the post-acute recovery period… Administrators and clinicians can identify variation in costs or quality, analyze processes underlying the variation and then implement new processes designed to mitigate such variation.”

“In addition, information systems are emerging that provide access to a patient’s location and clinical status over the entire course of an episode (something most electronic health records cannot do).”

2. Incentives

“Bundled payments disrupt the fee-for-service incentive to increase utilization. Medicare’s Bundled Payments for Care Improvement program enables hospitals, physician groups, post-acute facilities and home health agencies to bear first-dollar risk for an episode. The risk-bearing entity’s monetary reward for lowering costs can be invested in human resources (e.g., patient navigators) and technological resources (e.g., performance reporting and patient tracking software) that help the program succeed.”

“Gainsharing, most often offered to physicians, but also possible with hospitals, nursing facilities and other providers, can ensure that the risk-bearing entity and physicians or other providers have the same goal. Gainsharing in these programs can reward either internal cost savings (derived from, for example, bulk purchasing of implantable devices) or the net payment reconciliation amount (derived from, for example, lower post-acute facility utilization or fewer readmissions).”

3. Post-acute performance networks

“Successful risk-bearing entities build networks of post-acute facilities and home health agencies to ensure efficient and high-quality care for patients after an episode. Inclusion in such a network can be based on costs, readmissions or quality — such as star ratings, the availability of on-site providers and disease specialty programs. ”

4. Care redesign

“CMS promotes care redesign, or improving quality while cutting costs, as the defining feature of bundled payments. Successful organizations have redesigned care for specific bundles like joint replacement; others have redesigned care in an across-the-board fashion agnostic to bundle type.”

“Examples of across-the-board care redesign include deploying an early mobility program, using a decision-support tool to determine an optimal post-discharge location, applying rules to identify candidates for palliative care, having a structured goals-of-care conversation or using protocols to avoid unnecessary acute care transfers of skilled nursing patients. ”

5. Pooling knowledge

“BPCI  supports the role of a ‘convener,’ working with ‘episode initiators’ (providers) to deploy the program. Conveners can provide crucial support for healthcare organizations that aren’t able to go it alone because of a shortage of resources or expertise in data analytics, information technology, care redesign and, in some cases, the assumption of a portion of financial risk.”

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Feds: UnitedHealth overcharged Medicare by $1 billion

By FRED SCHULTE

For Kaiser Health News

The Justice Department on Tuesday accused giant insurer UnitedHealth Group of overcharging the federal government by more than $1 billion through its Medicare Advantage plans.

In a 79-page lawsuit filed in Los Angeles, the Justice Department alleged that the insurer made patients appear sicker than they were in order to collect higher Medicare payments than it deserved. The government said it had “conservatively estimated” that the company “knowingly and improperly avoided repaying Medicare” for more than a billion dollars over the course of the decade-long scheme.

“To ensure that the program remains viable for all beneficiaries, the Justice Department remains tireless in its pursuit of Medicare fraud perpetrated by healthcare providers and insurers,” said acting U.S. Attorney Sandra R. Brown for the Central District of California, in a statement announcing the suit. “The primary goal of publicly funded healthcare programs like Medicare is to provide high-quality medical services to those in need — not to line the pockets of participants willing to abuse the system.”

Tuesday’s filing is the second time that the Justice Department has intervened to support a whistleblower suing UnitedHealth under the federal False Claims Act. Earlier this month, the government joined a similar case brought by California whistleblower James Swoben in 2009. Swoben, a medical data consultant, also alleges that UnitedHealth overbilled Medicare.

The case joined on Tuesday was first filed in 2011 by Benjamin Poehling, a former finance director for the UnitedHealth division that oversees Medicare Advantage Plans. Under the False Claims Act, private parties can sue on behalf of the federal government and receive a share of any money recovered.

UnitedHealth is the nation’s biggest Medicare Advantage operator, covering about 3.6 million patients in 2016, when Medicare paid the company $56 billion, according to the complaint.

Medicare Advantage plans are private insurance plans offered as an alternative to traditional fee-for-service option.

Medicare pays the health plans using a complex formula called a risk score, which is supposed to pay higher rates for sicker patients than for people in good health. But waste and overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity concluded that improper payments linked to jacked-up risk scores have cost taxpayers tens of billions of dollars.

Tuesday’s court filing argues that UnitedHealth repeatedly ignored findings from its own auditors that risk scores were often inflated — and warnings by officials from the Centers for Medicare & Medicaid Services (CMS) — that it was responsible for ensuring the billings it submitted were accurate.

UnitedHealth denied wrongdoing and said it would contest the case.

“We are confident our company and our employees complied with the government’s Medicare Advantage program rules, and we have been transparent with CMS about our approach under its unclear policies,” UnitedHealth spokesman Matt Burns said in a statement.

Burns went on to say that the Justice Department “fundamentally misunderstands or is deliberately ignoring how the Medicare Advantage program works. We reject these claims and will contest them vigorously.”

A spokesman for CMS, which has recently faced congressional criticism for lax oversight of the program, declined comment.

Central to the government’s case is UnitedHealth’s aggressive effort, starting in 2005, to review millions of patient records to look for missed revenue. These reviews often uncovered payment errors, sometimes too much and sometimes too little. The Justice Department contends that UnitedHealth typically notified Medicare only when it was owed money.

UnitedHealth “turned a blind eye to the negative results of those reviews showing hundreds of thousands of unsupported diagnoses that it had previously submitted to Medicare, according to the suit.

Justice lawyers also argue that UnitedHealth executives knew as far back as 2007 that they could not produce medical records to validate about 1 in 3 medical conditions Medicare paid UnitedHealth’s California plans to cover. In 2009, federal auditors found about half the diagnoses were invalid at one of its plans.

The lawsuit cites more than a dozen examples of undocumented medical conditions, from chronic hepatitis to spinal cord injuries. At one medical group, auditors reviewed records of 126 patients diagnosed with spinal injuries. Only two were verified, according to the complaint.

The Justice Department contends that invalid diagnoses can cause huge losses to Medicare. For instance, UnitedHealth allegedly failed to notify the government of at least 100,000 diagnoses it knew were unsupported based on reviews in 2011 and 2012. Those cases alone generated $190 million in overpayments, according to the suit.

While Medicare Advantage has grown in popularity and now treats nearly 1 in 3 elderly and disabled Medicare patients, its inner workings have remained largely opaque.

CMS officials for years have refused to make public financial audits of Medicare Advantage insurers, even as they have released similar reviews of payments made to doctors, hospitals and other medical suppliers participating in traditional Medicare.

But Medicare Advantage audits obtained by the Center for Public Integrity through a court order in a Freedom of Information Act lawsuit show that payment errors — typically overpayments — are common.

All but two of 37 Medicare Advantage plans examined in a 2007 audit were overpaid — often by thousands of dollars per patient. Overall, just 60 percent of the medical conditions health plans were paid to cover could be verified. The 2007 audits are the only ones that have been made public.

CMS officials are conducting more of these audits, called Risk Adjustment Data Validation, or RADV. But results are years overdue.

 


CMS gives states reprieve on new Medicaid standards

 

By PHIL GALEWITZ

Kaiser Health News

The Trump administration has given states three extra years to carry out plans for helping elderly and disabled people receive Medicaid services without being forced to go into nursing homes.

Federal standards requiring states find ways of delivering care to Medicaid enrollees in home and community-based settings will take effect in 2022 instead of 2019, the Centers for Medicare & Medicaid Services announced this week.

The standards were set by an Obama administration rule adopted in 2014 that governs where more than 3 million Medicaid enrollees get care.

Among other things, the rule requires states to provide opportunities for enrollees to engage in community life, control their own money and seek employment in competitive settings. It also ensures that enrollees in group homes and other residential settings get more privacy and housing choices that include places where non-disabled people live.

Matt Salo, executive director of the National Association of Medicaid Directors, applauded the delay.

“We have long been on record saying that the regulation was hopelessly unrealistic in its time frame,” he said. “Delaying it actually helps consumers because the underlying regulation was going to push too many changes too fast into a system that wasn’t ready.”

The Obama administration’s 2014 rule was an effort to create a federal standard to improve the quality of care that the disabled receive outside institutions.

Some states had tried — and struggled — to make changes on their own, partly due to a lack of funding and political difficulties of changing deeply entrenched relationships with providers.

Some had, for instance, forced providers to change long-standing operations at group homes and so-called sheltered workshops, such as Goodwill Industries, where disabled people often work apart from other employees, performing menial tasks for less than minimum wage.

Helping disabled people find work in places where they are not segregated costs states more money, said Gary Blumenthal, CEO of the Association of Developmental Disabilities Providers.

The delay in implementing the federal rule is “a victory for the status quo and for states reluctant to embrace the [new standards],” he said.

States spent several years fighting the new rules during the Obama administration and that slowed their planning, said Elizabeth Priaulx, senior legal specialist with the National Disability Rights Network. She noted states were under pressure from nursing homes and for-profit group homes to resist the changes.

“It is unfortunate the delay had to occur,” but many states were not ready, she said.

The new rule also directs states and providers to reconfigure existing community settings such as group homes to ensure that people will have more privacy. “Without these dollars it’s difficult to change the system,” Blumenthal said.

Funds Already Shifting

In 2014, state Medicaid programs for the first time spent more on long-term care in home and community-based settings than on nursing homes. But there was great variation: Mississippi spent about 25 percent of its long-term care dollars on home and community care while Oregon and other states spent nearly 80 percent.

Camille Dobson, deputy executive director of the National Association of States United for Aging and Disability, said the delay was important for states worried about losing federal funding if they didn’t meet the new standards.

“It was very likely that most of the states would not have been in compliance by March 2019 and so CMS would [have been] faced with taking money away from programs that help people stay in their homes rather than go to nursing facilities,” Dobson said.

The administration’s announcement of the delay came less than a week after the House passed the American Health Care Act, which would take $880 billion over 10 years out of the Medicaid program. It was expected after Health and Human Services Secretary Tom Price in March invited states to apply for waivers from federal Medicaid rules that he said were too onerous to help improve the program.

So far, Tennessee is the only state that has received final approval from CMS for its implementation plan. States still face a 2019 deadline to gain approval for their implementation plans.

Kathy Carmody, CEO of The Institute on Public Policy for People with Disabilities in Illinois, said there is concern the Trump administration may not just delay the rule’s implementation, but eventually eliminate it altogether.

“We are disappointed,” she said, noting that Illinois ranks last or near last on several measures of care for people receiving home and community-based services. That includes having about half of its disabled Medicaid enrollees in residential care settings with seven or eight other disabled people and less than 6 percent of its disabled enrollees in competitive employment, she said.

“We were really hoping the rule would be a push from the federal government to help us evolve into the 21st century and get out of the mid-1980s where we are stuck,” Carmody said.


Feds join lawsuit alleging UnitedHealth engaged in massive Medicare fraud

By FRED SCHULTE

Kaiser Health News

The Justice Department has joined a California whistleblower’s lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans.

Justice officials filed legal papers to intervene in the suit, first brought by whistleblower James Swoben in 2009, on Friday in federal court in Los Angeles. On Monday, they sought a court order to combine Swoben’s case with that of another whistleblower.

Swoben has accused the insurer of “gaming” the Medicare Advantage payment system by “making patients look sicker than they are,” said his lawyer, William K. Hanagami. Hanagami said the combined cases could prove to be among the “larger frauds” ever against Medicare, with damages that he speculates could top $1 billion.

UnitedHealth spokesman Matt Burns denied any wrongdoing by the company. “We are honored to serve millions of seniors through Medicare Advantage, proud of the access to quality health care we provided, and confident we complied with program rules,” he wrote in an email.

Burns also said that “litigating against Medicare Advantage plans to create new rules through the courts will not fix widely acknowledged government policy shortcomings or help Medicare Advantage members and is wrong.”

Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and people with disabilities — about a third of those eligible for Medicare — at a cost to taxpayers of more than $150 billion a year.

Although the plans generally enjoy strong support in Congress, they have been the target of at least a half-dozen whistleblower lawsuits alleging patterns of overbilling and fraud. In most of the prior cases, Justice Department officials have decided not to intervene, which often limits the financial recovery by the government and also by whistleblowers, who can be awarded a portion of recovered funds. A decision to intervene means that the Justice Department is taking over investigating the case, greatly raising the stakes.

“This is a very big development and sends a strong signal that the Trump administration is very serious when it comes to fighting fraud in the health care arena,” said Patrick Burns, associate director of Taxpayers Against Fraud, based in Washington, a nonprofit supported by whistleblowers and their lawyers. Burns said the “winners here are going to be American taxpayers.”

Burns also contends that the cases against UnitedHealth could potentially exceed $1 billion in damages, which would place them among the top two or three whistleblower-prompted cases on record.

“This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope,” Burns said.

On Monday, the government said it wants to consolidate the Swoben case with another whistleblower action filed in 2011 by former UnitedHealth executive Benjamin Poehling and unsealed in March by a federal judge. Poehling also has alleged that the insurer generated hundreds of millions of dollars or more in overpayments.

When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score.

But overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity found that these improper payments have cost taxpayers tens of billions of dollars.

“If the goal of fraud is to artificially increase risk scores and you do that wholesale, that results in some rather significant dollars,” Hanagami said.

David Lipschutz, senior policy attorney for the Center for Medicare Advocacy, a nonprofit offering legal assistance and other resources for those eligible for Medicare, said his group is “deeply concerned by ongoing improper payments” to Medicare Advantage health plans.

These overpayments “undermine the finances of the overall Medicare program,” he said in an emailed statement. He said his group supports “more rigorous oversight” of payments made to the health plans.

The two whistleblower complaints allege that UnitedHealth has had a practice of asking the government to reimburse it for underpayments, but did not report claims for which it had received too much money, despite knowing some these claims had inflated risk scores.

The federal Centers for Medicare & Medicaid Services said in draft regulations issued in January 2014 that it would begin requiring that Medicare Advantage plans report any improper payment — either too much or too little.

These reviews “cannot be designed only to identify diagnoses that would trigger additional payments,” the proposal stated.

But CMS backed off the regulation’s reporting requirements in the face of opposition from the insurance industry. The agency didn’t say why it did so.

The Justice Department said in an April 2016 amicus brief in the Swoben case that the CMS decision not to move ahead with the reporting regulation “does not relieve defendants of the broad obligation to exercise due diligence in ensuring the accuracy” of claims submitted for payment.

The Justice Department concluded in the brief that the insurers “chose not to connect the dots,” even though they knew of both overpayments and underpayments. Instead, the insurers “acted in a deliberately ignorant or reckless manner in falsely certifying the accuracy, completeness and truthfulness of submitted data,” the 2016 brief states.

The Justice Department has said it also is investigating risk-score payments to other Medicare Advantage insurers, but has not said whether it plans to take action against any of them.


Trump’s CMS pushes back against bundled payments

knee

The CMS has delayed the expansion of a major bundled- payment pilot, Comprehensive Care for Joint Replacement, and implementation of its bundled-payment initiatives for cardiac care to Oct. 1, 2017, from July 1, according to an interim final rule posted to the Federal Register. It also again delayed the effective date of a final rule detailing the  implementation process  for CJR and other bundled-payment programs, to May 20, 2017 from March 21.

The agency is considering delaying  implementation of all bundled-payment initiatives even further, until 2018.

Modern Healthcare speculated that the Trump administration’s “move to delay these initiatives raises questions about the future of government initiatives to usher healthcare out of fee-for-service operations and into a new age of value-based payment.”

The new secretary of health and human services is Tom Price, M.D., who had a very lucrative career as an orthopedic surgeon and has been a major investor in some medical companies. CMS ultimately reports to him and President Trump.

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