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CMS wants to force hospitals to reveal negotiated rates. Can it do that? Print E-mail
Written by FHInews   
Friday, 09 August 2019 16:17

Samantha Liss reports for Healthcare Dive:

The Trump administration believes it has the authority to compel hospitals to reveal secret pricing information tucked into their contracts with insurance plans, but the case isn't entirely clear-cut. A legal challenge to the proposed rule requiring the disclosure from hospitals and insurance companies is likely, and experts are split on the odds payers and providers could beat back the effort in court. Hospitals and insurers are loathe to share payer-specific negotiated prices, arguing it would harm patients in the form of higher prices or limited access to care. Payers believe it would create a floor for hospital prices, encouraging any hospital being paid less to demand higher reimbursement, while hospitals argue it will fuel anticompetitive behavior among payers and reduce access to care.

CMS’s Targeted Probe and Educate (TPE) Program: Top 5 Things to Know Print E-mail
Written by Matt Fischer   
Tuesday, 21 May 2019 10:01
In 2014, the Centers for Medicare and Medicaid Services (CMS) started a program that combined the process of reviewing a sample of claims with providing follow up education as a way to help reduce errors in the claim submission process.  This is called the Targeted Probe and Educate Program (TPE).  The goal of the program is to help providers and suppliers identify errors made and quickly make improvements.  CMS has acknowledged that since its inception the program needs improvements and that this type of review can be burdensome.  Most providers and suppliers never experience a TPE review; however, for the ones that receive notification, here are the top five things you should know before moving forward:
  • Who is selected?
Medicare Administrative Contractors (MACs) use data analysis to identify providers and suppliers with high error rates or unusual billing practices (i.e. they vary significantly from their peers).  The focus is placed on particular items or services with a high national error rate and that are a financial risk to the Medicare program.
  • What is the process?
If selected, you will first receive a notification letter.  This letter will provide the services under review in addition to a local MAC contact person.  The letter will also identify a sample of 20 to 40 claims to be reviewed.  Once the review is complete, a summary results letter will follow outlining the error rate and next steps.  This is considered one round.  Overall, the TPE process is up to three rounds.  With each round, the provider and supplier will be provided time to correct any identified issues.
  • What are the common errors?
Errors can include simple mistakes such as missing signatures or certification documents to more complex denials such as lacking medical necessity or notes failing to support all elements of eligibility.
  • Can I be subject to multiple reviews at one time?
Yes, providers and suppliers could be subject to separate probes for more than one item or service.
  • What do they mean by education?
The education will be tailored to the most recent round of review and based on the errors identified. The education will address the errors along with the specific corrections that need to be made.

Here are some other important reminders…the Medicare Targeted Probe and Educate program does not replace other automated MAC reviews such as utilization reviews; you are still required to respond to and are subject to other records requests from other contractors and agencies (e.g. CERT, QIO, UPIC, OIG); and there are no changes to the appeals process.  If notification is received, it’s important to know what to expect during this process.
ABOUT THE AUTHOR: Mr. Fischer is an attorney with the Florda Healthcare Law Firm based in Delray Beach, FL.
Last Updated on Tuesday, 21 May 2019 10:09
CBO weighs in on Medicare-for-All Print E-mail
Written by FHInews   
Monday, 06 May 2019 00:00
A report released Wednesday by the nonpartisan Congressional Budget Office outlined a veritable laundry list of options and technicalities lawmakers would need to consider if they are serious about Medicare-for-All.
Here's a PDF of the Congressional Budget Office report.

Here's a KHN analysis.
Last Updated on Tuesday, 07 May 2019 17:54
Medicare spending on healthcare for elderly dips, driven by better cardiovascular care Print E-mail
Written by Jeff Lagasse | Healthcare Finance   
Monday, 11 February 2019 00:00
Healthcare spending among the Medicare population age 65 and older has slowed dramatically since 2005, and as much as half of that reduction can be attributed to reduced spending on cardiovascular disease, a new Harvard study has found. Led by Otto Eckstein Professor of Applied Economics David Cutler, a team of researchers showed  that by 2012, those reductions saved the average person nearly $3,000 a year. Across the entire elderly population, those savings add up to an impressive $120 billion, with about half of those savings coming from Medicare. The authors say the findings show that that widespread preventative care has the potential to save money.

Last Updated on Wednesday, 13 February 2019 08:53
Holiday Gift Giving: Healthcare Providers Beware of Federal Law Print E-mail
Written by Vitale Health Law   
Tuesday, 09 October 2018 17:42
As we approach the holidays, now may be an appropriate time to point out the rules relating to gifts that providers can give to Medicare and Medicaid beneficiaries. During this  time of the year, some healthcare professionals may want to give gifts to their patients, other physicians or even referral sources. Before you do, consider this: It can land you in a heap of trouble with the federal government unless you follow the law. In December 2016, the Health and Human Services Office of the Inspector General released a policy statement regarding gifts of nominal value to Medicare and Medicaid beneficiaries. At that time, the OIG raised the nominal value of gifts allowed from having a retail value of no more than $10 per item or $50 in aggregate annually per beneficiary to $15 per item or $75 in aggregate annually per beneficiary.

Last Updated on Tuesday, 09 October 2018 17:44
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