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OIG Calls for CMS to Reform Payment for Skilled Nursing Facility Services Print E-mail
Written by MWE.com   
Wednesday, 07 October 2015 15:55

The Office of Inspector General of the U.S. Department of Health and Human Services (OIG) issued a report on September 30, 2015, that calls for the Centers for Medicare and Medicaid Services (CMS) to reform payment for skilled nursing facility (SNF) services. The OIG focused on billing for therapy (e.g., speech, occupational, physical) as a driver increasing SNF revenue and noted that SNFs' margin on Medicare reimbursement for therapy was 29 percent. 

Medicare pays SNFs a daily rate for therapy that is primarily based on the level of therapy provided to the beneficiary. The OIG's review of therapy billings indicated that a disproportionate number of beneficiaries received 720 minutes of therapy during the relevant seven-day assessment period-exactly the number of minutes required for "ultra-high" categorization, which results in a higher level of resource utilization group, which in turn results in higher reimbursement.

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CMS to Test Value-Based Insurance Design in Medicare Advantage Print E-mail
Written by MWE.com   
Friday, 18 September 2015 16:33

On September 1, 2015, the Centers for Medicare & Medicaid Services (CMS) announced the Medicare Advantage Value-Based Insurance Design Model (Model). Medicare Advantage (MA) Organizations operating in Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania and Tennessee may apply to use reduced cost-sharing and/or supplemental benefits to encourage enrollees with one or more of seven targeted chronic conditions to consume higher value health care services. Specifically, CMS will allow participating MA Organizations to propose specific interventions for enrollees in one or more CMS-identified chronic disease categories that involve (i) reduced cost sharing for high value services, (ii) reduced cost sharing for high value providers, (iii) reduced cost sharing for enrollees participating in disease management or related programs or (iv) coverage of additional supplemental benefits (collectively,VBID Interventions). While CMS attempts to provide a pathway forward through the MA regulations, the Model presents certain legal risks about which MA Organizations should be aware.

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Last Updated on Friday, 02 October 2015 12:02
 
Shifting Hospice Reimbursement - Moving in the Direction of Aligning Payment with Resource Concentration Print E-mail
Written by MWE.com   
Friday, 11 September 2015 14:55

The Centers for Medicare and Medicaid Services (CMS) published its update to the home health prospective payment system for fiscal year 2016 in the August 6, 2015, Federal Register (the Final Rule). The Final Rule announces an overall 1.1 percent increase in hospice payments for FY 2016, but also makes significant changes to the structure of hospice payments for certain patients to reflect the higher costs borne by providers at different stages of the hospice benefit. These changes address some, but not all, of the challenges associated with applying a per diem rate to a benefit with highly variable costs over time, given the unique circumstances of each beneficiary's end-of of-life needs. Implementation of these new payment structures will have a financial and operational impact on hospice providers, with potential implications for referral patterns, billing systems, staffing models and clinical care guidelines. This significant change to one of the first bundled payment systems implemented by CMS may also set a precedent for service bundling in other areas of health care.

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Last Updated on Friday, 18 September 2015 16:47
 
Medicare ACOs saved $411M in 2014, but few earned bonuses Print E-mail
Written by Ilene MacDonald | Fierce Healthcare   
Friday, 28 August 2015 17:18

Medicare accountable care organizations generated $411 million in total savings in 2014, but few of the Pioneer and Medicare Shared Savings Program (MSSP) ACOs qualified for bonuses in the second year of the program, according to the latest data from the Centers for Medicare & Medicaid Services (CMS).

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Medicare ICD-10 Coding Flexibility - How it Works Print E-mail
Written by Seth Flam, DO   
Wednesday, 05 August 2015 00:00
 
Early in July, at the urging of the AMA and other physician organizations, CMS agreed to offer flexibility with regard to ICD-10 coding during the first year of implementation: October 1, 2015 - September 30, 2016. In our July 6 blog post, we outlined the new rule - and a key component of that rule centers on claim denial "flexibility:"

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