http://www.beckershospitalreview.com/finance/medicare-audits-ups-936-in-last-five-years.html
Tag Archives: CMS
Failure to Improve Is Still Being Used, Wrongly, to Deny Medicare Coverage
For months, physical therapists worked with Mrs. Kirby, a retired civil servant who is now 75, trying to help her regain enough mobility to go home. Then her daughter received an email from one of the therapists saying, “Edwina has reached her highest practical level of independence.”
Translation: Mrs. Kirby wouldn’t receive Medicare coverage for further physical therapy or for the nursing home. If she wanted to stay and continue therapy, she’d have to pay the tab herself.
Medicare beneficiaries often hear such rationales for denying coverage of skilled nursing, home health care or outpatient therapy: They’re not improving. They’ve “reached a plateau.” They’re “stable and chronic,” or have achieved “maximum functional capacity.”
Deanna Kirby wasn’t buying it. “I knew they couldn’t refuse you, even if you’re not improving,” she said.
She’s right. A federal judge last month ordered the federal Centers for Medicare and Medicaid Services to do a better job of informing health care providers and Medicare adjudicators that the so-called improvement standard was no longer in effect.
Ex-executive who helped feds with Sacred Heart probe given year in prison
Will Medicare Premium Increases Be an Issue in November?
http://blogs.wsj.com/washwire/2016/06/22/will-medicare-premium-increases-be-an-issue-in-november/
Buried in the Medicare trustees report released Wednesday are a few lines that could cause political controversy. “In 2017 there may be a substantial increase in the Part B premium rate for some beneficiaries,” the actuaries write—which means seniors will find out about increases shortly before Election Day.
Higher-than-expected Medicare spending in 2014 and 2015 set the stage for a large premium adjustment in 2016. But, notably, the absence of inflation thanks to the drop in energy prices last year meant that seniors receiving Social Security benefits did not receive an annual cost-of-living adjustment.
The Medicare statute has a “hold harmless” provision that prevents Part B premiums from rising by more than the amount of a Social Security cost-of-living adjustment. For most beneficiaries, the provision meant that in 2016, they received no such adjustment—but also did not pay a higher Part B premium. However, nearly one-third of beneficiaries—new Medicare enrollees, “dual eligibles” enrolled in both Medicare and Medicaid (in places where state Medicaid programs pay the Medicare Part B premium), and wealthy seniors subject to Medicare means-testing—do not qualify for the provision.
The New York Times noted last fall that the hold-harmless provision, by protecting most beneficiaries, exposed some to higher increases: “If premiums are frozen for 70 percent of beneficiaries, premiums for the other 30 percent must be raised more to cover the expected increase in overall Medicare costs. In other words … the higher Medicare costs must be spread across a smaller group of people.”
Unintended Consequences
http://altarum.org/health-policy-blog/unintended-consequences
How does it feel knowing the clinical decisions our physicians make affect their pocketbook? MIPS, or the Merit-based Incentive Payment System, is now the law of the land. MIPS attempts to incentivize physicians based on quality measures, use of electronic health records, practice improvement approaches and cost of care. The Centers for Medicare and Medicaid (CMS), is tasked with working out the details of the program, which aims to take us from a system where physicians are incentivized to “do something” to patients to one in which “quality” is the predominate goal.
Here’s my quandary: As a Geriatrician, I have practiced a lower cost approach to care my whole career. I try to avoid acute hospitalization, medications and procedures in my frail older patients. Why? Because my experience, as well as a growing body of evidence-based literature, supports this approach. I should be wholeheartedly embracing this new approach to physician incentives. So, why do I feel sick when I think about it?
Drug and Device Makers Pay Thousands of Docs with Disciplinary Records
Physicians whose state boards have sanctioned them for harming patients, unnecessarily prescribing addictive drugs, bilking federal insurance programs, and even sexual misconduct nonetheless continue to receive payments for consulting, giving talks about products, and more.
Appeals court reopens whistleblower’s case against Medicare Advantage orgs
In a newly issued opinion, a federal appeals court gives a whistleblower another chance to make his case that major health insurers inflated Medicare Advantage risk scores to collect greater government payments.
The Centers for Medicare & Medicaid Services pays Medicare Advantage organizations based on a risk score calculated by measuring a beneficiary’s overall health, with higher payments for sicker patients.
But whistleblower James Swoben claims that UnitedHealth, Aetna, WellPoint, Health Net and physician group HealthCare Partners gamed the system by conducting biased retrospective reviews of medical records already submitted to CMS. Such reviews would violate the False Claims Act.
Seven healthcare industry trends to watch
5 reasons to take hospital ratings with a big grain of salt
It’s hospital ratings season in America, that time of year when marketing executives kick it into high gear to trumpet — and spin — the way their hospitals are graded by outside organizations.
This year, their workload has been especially heavy. In addition to annual rankings released Tuesday by U.S. News & World Report, the federal Centers for Medicare and Medicaid Services (CMS) just released its star-rating system for hospitals nationwide. While the ratings offer some valuable information to consumers, here’s why you shouldn’t put too much stock in the results.
No matter how objective the metrics, ratings are inherently subjective
The federal government and private organizations use a vast array of hospital data to break down their performance and boil it into easy-to-understand ratings for consumers. U.S. News & World report formulates its rankings by relying on a mix of physician surveys and data reported to trade groups and the federal government. CMS ratings are based solely on data hospitals are required to report to the agency.
The information itself may be objective, but which data points are used — and how they are weighted — can lead to contradictory conclusions. Consider the following:
Of US News & World Report’s’ top five hospitals, only one — Mayo Clinic — received a top, five-star rating from CMS. The rest — Cleveland Clinic, Massachusetts General Hospital, UCLA Medical Center, and Johns Hopkins — were not even in CMS’ top 100. (Johns Hopkins did not receive a rating from CMS because of incomplete data).
J.B. Silvers, a professor of health care finance at Case Western Reserve University, said the information, while boiled down into simple lists and stars, can be difficult for consumers to unpack, especially when hospitals are working behind the scenes to figure out ways to better their scores every year. “Some hospitals are better at working the numbers than others,” he said. “My guess is the safety net hospitals aren’t as good at it as richer hospitals.”
HENRY KOTULA 