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Government News
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July 19, 2010
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1. HHS on July 12 made it easier for hospitals and physicians to qualify for billions of dollars in incentives for implementing and using electronic health records (EHRs). While the incentives are tied to the Medicare and Medicaid programs, commercial carriers could see improved efficiencies if the incentives boost adoption rates among network providers.
“We support anything the government does to encourage the use of EHRs because it will have a positive effect on our members,” says Joel Slackman, a managing director at the Blue Cross and Blue Shield Association. Once a physician has an EHR, even if it was purchased solely for the Medicare program, the physician isn’t going to “limit its use to just Medicare patients.…It will be used for all of their patients,” he tells HPW.
The final version of the so-called “meaningful use” rules are less stringent than the regs proposed in January. That version, which prompted about 2,000 comments, called for physicians to meet 25 objectives and hospitals to meet 23. Noncompliance with just one objective might have been enough to negate the incentive. Physician groups, hospitals and health insurers worried that the earlier version would discourage adoption of EHRs.
The 846-page final version splits goals into two sets. Providers must meet a core set of 15 objectives, and can choose five additional items from a menu of 10 objectives. The regulation, which goes into effect on Jan. 1, 2011, covers the first phase of a three-phase incentive program.
For health insurers, the improved flexibility is likely to translate to an increase in the number of network providers who use EHRs and e-prescribing. But physicians who have a small percentage of Medicaid aren’t eligible to participate, and those with a small percentage of Medicare might decide the incentives aren’t worth the effort. Providers need 30% of their encounters to be Medicaid, for example. “Well, that leaves a lot of [network] doctors out,” says Bruce Taffel, M.D., chief medical officer at SharedHealth, an electronic health information technology subsidiary launched by BlueCross BlueShield of Tennessee in 2005.
“The concern is that more and more doctors are getting out of Medicaid and reducing their Medicare encounters, so they might not be eligible” for the federal incentives.
Slackman says the flexibility included in the final rule is an improvement over the previous version and appears to strike a balance between setting reasonable goals without overloading physicians. “We were concerned about the all-or-nothing approach of the proposed rule,” he says. “We see it as very positive that CMS moved away from that approach and introduced some flexibility into how the program works.” That flexibility, he adds, jibes with incentive programs that are used by some commercial carriers, which allow physicians to earn some incentives for meeting only some of the goals.
The program, called for by the American Recovery and Reinvestment Act of 2009, authorizes up to $27 billion to be used for incentives over 10 years. That translates to as much as $44,000 (through Medicare) and $63,750 (through Medicaid) per clinician. The incentives, however, aren’t paid in advance, which means providers will need to invest some money upfront before being reimbursed by CMS. Some health plans, such as UnitedHealth Group, offer interest-free loans to providers, which allows them to eliminate out-of-pocket costs.
Increased use of EHRs will enable greater integration and sharing of health plan and provider data to support clinical decisions, treatment opportunities and overall care management, which will help improve the health and well being of the population, says Eric Demers, senior vice president of health and life sciences at MEDecision.
At a July 13 press conference announcing the new rules, HHS Sec. Kathleen Sebelius asserted that the data contained in the EHRs would be secure. Robert Shelton, CEO of Private Access, Inc., a software company, says that without such assurances, adoption of EHRs would be stifled. “None of these new technologies will accomplish much if patients are afraid to permit their confidential information to be included in them, or if the consumer controls are too difficult for everyone to use them effectively,” he says.
Although many commercial carriers have included EHR requirements in pay-for-performance programs, they should be evaluated to ensure the requirements and deadlines mesh with the new federal rules and don’t impose a different set of incentives and deadlines on their network providers, suggests Jordan Battani, principal researcher in Computer Sciences Corporation’s (CRC) Global Health Care Group. “That would just fragment everyone’s attention and ensure at least some level of failure,” Battani asserts.
But for health insurers that don’t have such a program in place, now might not be the time to launch one. “I don’t think this is a great time for them to be thinking about how to spend more money when they are struggling to understand the impact of the reform law,” says Taffel.
Although Medicare Advantage carriers aren’t included in the incentive program, Battani predicts CMS will eventually require MA plan sponsors to demonstrate that their provider networks are meeting the meaningful-use criteria. Beginning in 2012, MA plans, under the health reform law, will be eligible for bonuses of up to 5% of total payments for achieving certain quality targets. She says it’s not hard to imagine that the meaningful use of health IT by MA network providers will become a part of the definition.
“It will be another lever CMS can use to ensure that the provider sector is on board with EHRs. So MA plans had better get pretty savvy pretty quick about the meaningful-use rule and what is required,” she warns.
The trade group America’s Health Insurance Plans (AHIP) supports the new rule, but says administrative simplification requirements included in the proposed version should not have been stripped out. “To get the full benefits of health information technology, it needs to be used for quality as well as for administrative simplification,” says spokesperson Robert Zirkelbach. “Health plans have taken a number of steps to make it easier for physicians to file claims and get payment electronically, but if [providers] continue to file paper claims, we are not going to get the full benefits of health IT.”
While Slackman agrees that adoption of such administrative transactions by physicians would improve the overall system, he says CMS hasn’t abandoned the idea, which is likely to be included in the second stage of the rule. The Blues association had suggested that CMS provide a safe harbor for providers who didn’t use an EHR, but did submit claims or check eligibility electronically through a clearinghouse, multi-payer Web portal or practice-management system.
Battani agrees and says that some providers will naturally increase their use of electronic claims filing and eligibility checks. “There is enough cost-reduction value in doing it that many providers will do it anyway. And much of the compliance work will be done by clearinghouses and other vendors.”
But Zirkelbach maintains that such requirements would have gone a long way toward making the system more efficient.
To see an overview of the final rules, visit http://healthcarereform.nejm.org/?p=3732&query=home.
Reprinted from the July 19, 2010, issue of HEALTH PLAN WEEK
2. Federal officials say they have broken up a kickback scheme in Texas involving several dental practices. A total of five dentists in the McAllen, Texas, area have been indicted for allegedly illegally referring Medicaid patients to an oral and maxillofacial surgeon in exchange for payment, the U.S. Attorney’s Office for the Southern District of Texas said June 22 and 23. The dentists referred Medicaid patients in exchange for 15% of the total payments from the program, the feds say. They face a maximum of five years in prison and a $25,000 fine per count if convicted. In addition, the surgeon and two of his employees have been indicted for soliciting and receiving kickbacks, the feds said June 22. The surgeon is charged with submitting claims to Medicaid for services not performed, examinations not performed by him personally, and services not performed by qualified personnel (including administration of anesthesia). The surgeon faces up to 10 years in prison and a $250,000 fine if convicted.
Reprinted from the July 2010 issue of The HCCA-AIS MEDICAID COMPLIANCE NEWS
3. WellPoint, Inc. notified 470,000 customers that their personal records may have been exposed during an upgrade to the company’s website, the Associated Press reported June 30. AP says that last October an outside vendor upgraded the insurer’s online program that allows customers to track their applications for coverage. The vendor “told the insurer all security measures were back in place. But a California customer discovered that she could call up confidential information of other customers by manipulating Web addresses used in the program.” That customer filed a lawsuit against the company in March. Wellpoint tells AIS, “The vast majority of such manipulation and the resulting unauthorized access occurred at the hands of certain attorneys (representing an applicant). We believe that this manipulation was conducted to support a class action against Anthem, or its parent company WellPoint — over the very breach being committed.…We are currently weighing our legal options with respect to the data, the impact — if any — on our members, and the remediation costs incurred as a result of these actions.” The breach affected 230,000 Anthem Blue Cross members in California, as well as members of Blue Cross and Blue Shield plans in 14 other states.
Reprinted
from the July 2010 issue of REPORT ON PATIENT PRIVACY
4. In a win for pharmacy benefit managers, but a setback for states seeking more transparency, a federal appeals court recently struck down provisions of a District of Columbia law that would have designated PBMs as “fiduciaries” of employer-sponsored health plans.
The U.S. Court of Appeals for the District of Columbia on July 9 found that key portions of the 2004 DC AccessRx Act — which would have required disclosure of conflicts of interest and pass-through of rebate savings and would have limited drug-switching activities — were unconstitutional. The court determined that since PBMs engage in claims administration for their clients and are regulated exclusively by the federal Employee Retirement Income Security Act, states and municipalities cannot impose such requirements.
Cheering the decision, Pharmaceutical Care Management Association (PCMA) President and CEO Mark Merritt says it is a “major victory for consumers and payers.” PBMs can now “continue to work aggressively to reduce the costs and improve the quality of prescription drug benefits,” he adds.Sharon Treat, executive director of the National Legislative Association on Prescription Drug Prices, contends that the decision is a “blow to consumer protections and states’ rights to regulate transparency and prevent kickbacks and other purchasing
practices that drive up the cost of prescription drugs.”
Laws providing for greater PBM regulation and transparency have been popping up in growing numbers across several states. According to the National Conference of State Legislatures, at least 14 states plus the District of Columbia have enacted some type of direct state PBM regulation, while another 10 states have imposed requirements under restricted circumstances.In Maryland and Vermont, similar PBM laws have gone unchallenged by the PBM industry.
View the ruling at freepdfhosting.com/f8e43bfe6f.pdf.
Reprinted
from the July 16, 2010, issue of DRUG BENEFIT NEWS
Reprinted from the July 2010 issue of The HCCA-AIS MEDICAID COMPLIANCE NEWS
6. Maine’s Superintendent of Insurance Mila Kofman asked HHS to temporarily exempt the state from the health reform law’s minimum medical loss ratio requirement for individual plans until 2014. In a letter dated July 1, Kofman said she’s worried that the 80% minimum MLR requirement may disrupt the state’s individual health insurance market. For example, she cited a Securities and Exchange Commission filing by one of the two insurers warning that it would be forced to pull out of the state if Maine does not receive the waiver. Kofman added that Maine already requires an MLR of 65%, and that all premium rates in the state are subject to prior approval by her office. Under the health reform law, HHS has the authority to grant exemptions if the requirement would “destabilize the market.”
Reprinted from the July 19, 2010, issue of HEALTH PLAN WEEK
7. An assortment of recommended preventive services, such as cancer screenings and immunizations, will soon be covered without cost to health insurance policyholders. Under the health reform law, if an individual enrolls in a new health plan on or after Sept. 23, the insurer must cover recommended preventive services without cost sharing such as copayments or deductibles. Depending on a member’s health plan and other factors such as age, some of the covered services are blood pressure, diabetes and cholesterol tests; cancer screenings; smoking cessation services; vaccines; mammograms for women over 40 years of age; and colon cancer screenings for adults over the age of 50. This requirement does not apply to grandfathered plans, HHS added. To see what services will be included, visit www.healthcare.gov/center/regulations/
prevention/recommendations.html
Reprinted from the July 19, 2010, issue of HEALTH PLAN WEEK
8. The House on July 14 passed HR 5712, which corrected and clarified several Medicare and Medicaid policies established by the health reform law. If passed by the Senate and signed by the president, The Veterans’, Seniors’, and Children’s Health Technical Corrections Act of 2010 provides $95 million for CMS to retroactively reprocess claims for services that were affected by the reform law. According to CQHealthBeat, the bill would also clarify Medicare enrollment rules for those eligible for the military’s TRICARE health plan, implement a new payment system for skilled nursing facilities, allow certain children’s hospitals to continue receiving discounts for “orphan drugs,” extend through fiscal 2011 a law that permits hospitals to be reclassified in a higher-wage-index area for Medicare reimbursements, and guarantee that medical residency spots shared by affiliated hospitals would not be reallocated to other hospitals.
Reprinted from the July 19, 2010, issue of AIS's HEALTH REFORM WEEK
9. The state of California should repay $136,000 to the federal government for Medicaid payments made for services billed after the date of the beneficiary’s death, the HHS Office of Inspector General (OIG) says in an audit report (A-09-09-00110) posted June 29. Medical services cannot be provided after a beneficiary has died, so the government considers services billed after the date of death to be unallowable, OIG explains. State agencies should be using the Social Security Administration’s data file of deceased individuals to make sure that providers are not billing for services after patients have died, the report notes. California’s Department of Public Health uses the state’s Office of Vital Records to check Medicaid claims. OIG reviewed fee-for-service claims dated Jan. 1, 2007, through June 20, 2008, and found that the state paid a total of $273,457 for 1,205 claims submitted for 35 deceased patients. Auditors verified the findings by checking beneficiaries’ death certificates. OIG says California should return $136,729 that is the federal share of the payments and strengthen its process for finding payments for deceased beneficiaries. The state generally agreed with the findings. It commented that there could be potential delays in obtaining and updating the data in its Medicaid eligibility files. To read the report, visit AIS’s Government Resources, and click on “OIG Audit Reports.”
Reprinted from the July 2010 issue of The HCCA-AIS MEDICAID COMPLIANCE NEWS
10. The U.S. House of Representatives on July 2 approved legislation that would put an end to anticompetitive “pay-for-delay” drug patent settlements. Economists with the Federal Trade Commission estimate that collusive deals between brand and generic drug companies cost consumers about $3.5 billion a year by delaying their access to the lower-cost medications. “Congress has taken a critical step towards ending a practice that is dramatically increasing the cost of prescription drugs,” FTC Chairman Jon Leibowitz says in a statement. The bill, Sen. Herb Kohl’s (D-Wis.) Preserve Access to Affordable Generics Act, was included in a supplemental war appropriations bill. It is now awaiting a Senate vote.
Additional
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| Hot Products |
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• Managed Medicare and Medicaid Factbook: 2010 • Special Needs Plans: Regulatory Challenges and Market Strategies • Health Reform’s Impact on Commercial and Medicare Health Plans *Not affiliated with the Blue Cross Blue Shield Association or its member companies. Best
Sellers • Report on Patient Privacy and AIS's HIPAA Compliance Center • 2000-2009 Survey Results: Pharmacy Benefit Trends & Data • Guide to Managing Never Events and HACs See full
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| Hot Products |
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New
• Managed Medicare and Medicaid Factbook: 2010 • Special Needs Plans: Regulatory Challenges and Market Strategies • Health Reform’s Impact on Commercial and Medicare Health Plans *Not affiliated with the Blue Cross Blue Shield Association or its member companies. Best
Sellers • Report on Patient Privacy and AIS's HIPAA Compliance Center • 2000-2009 Survey Results: Pharmacy Benefit Trends & Data • Guide to Managing Never Events and HACs See full
listing |
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