Tag Archives: Medicare

Appeals court overturns ruling requiring HHS to clear Medicare appeals backlog by 2021

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http://www.beckershospitalreview.com/finance/appeals-court-overturns-ruling-requiring-hhs-to-clear-medicare-appeals-backlog-by-2021.html

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The U.S. Appeals Court for the District of Columbia on Friday overturned an order requiring HHS to clear its backlog of Medicare reimbursement appeals by the end of 2020.

On Dec. 5, 2016, U.S. District Judge James Boasberg granted a motion for summary judgment filed by the American Hospital Association in AHA v. Burwell — a lawsuit that centers on the Recovery Audit Contractor Program.

He ordered HHS to incrementally reduce the backlog of 657,955 appeals pending before the agency’s Office of Medicare Hearings and Appeals over the next four years, reducing the backlog by 30 percent by the end of 2017; 60 percent by the end of 2018; 90 percent by the end of 2019; and to completely eliminate the backlog by Dec. 31, 2020.

HHS filed a motion Dec. 15, 2016, asking the judge to reconsider his decision. HHS argued it would be impossible to reduce the appeals backlog on the schedule provided by the court without improperly paying claims, regardless of merit. In January, Judge Boasberg denied HHS’ motion for reconsideration.

In late January, HHS filed an appeal in the case, seeking to avoid the district court’s order enforcing the plan to clear the appeals backlog by the end of 2020.

On Friday, the appellate court sided with HHS.

Since HHS said it was impossible to lawfully comply with the district court’s order, the appellate court ruled it was “an error of law” and “an abuse of discretion” for the district court judge to order HHS to abide by the schedule to clear the Medicare appeals backlog.

“In sum, it was an abuse of discretion to tailor the mandamus relief without tackling the Secretary’s claims that lawful compliance would be impossible,” states the appellate court’s opinion.

The appellate court held that on remand the lower court should determine if compliance with the timetable to reduce the Medicare appeals backlog is impossible.

Doctor Shortage Under Obamacare? It Didn’t Happen

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When you have a health problem, your first stop is probably to your primary care doctor. If you’ve found it harder to see your doctor in recent years, you could be tempted to blame the Affordable Care Act. As the health law sought to solve one problem, access to affordable health insurance, it risked creating another: too few primary care doctors to meet the surge in appointment requests from the newly insured.

Studies published just before the 2014 coverage expansion predicted a demand for millions more annual primary care appointments, requiring thousands of new primary care providers just to keep up. But a more recent study suggests primary care appointment availability may not have suffered as much as expected.

The study, published in April in JAMA Internal Medicine, found that across 10 states, primary care appointment availability for Medicaid enrollees increased since the Affordable Care Act’s coverage expansions went into effect. For privately insured patients, appointment availability held steady. All of the gains in access to care for Medicaid enrollees were concentrated in states that expanded Medicaid coverage. For instance, in Illinois 20 percent more primary care physicians accepted Medicaid after expansion than before it. Gains in Iowa and Pennsylvania were lower, but still substantial: 8 percent and 7 percent.

Though these findings are consistent with other research, including a study of Medicaid expansion in Michigan, they are contrary to intuition. In places where coverage gains were larger — in Medicaid expansion states — primary care appointment availability grew more.

“Given the duration of medical education, it’s not likely that thousands of new primary care practitioners entered the field in a few years to meet surging demand,” said the Penn health economist Daniel Polsky, the lead author on the study. There are other ways doctor’s offices can accommodate more patients, he added.

One way is by booking appointment requests further out, extending waiting times. The study findings bear this out. Waiting times increased for both Medicaid and privately insured patients. For example, the proportion of privately insured patients having to wait at least 30 days for an appointment grew to 10.5 percent from 7.1 percent.

The study assessed appointment availability and wait times, both before the 2014 coverage expansion and in 2016, using so-called secret shoppers. In this approach, people pretending to be patients with different characteristics — in this case with either Medicaid or private coverage — call doctor’s offices seeking appointments.

Improvement in Medicaid enrollees’ ability to obtain appointments may come as a surprise. Of all insurance types, Medicaid is the least likely to be accepted by physicians because it tends to pay the lowest rates. But some provisions of the Affordable Care Act may have enhanced Medicaid enrollees’ ability to obtain primary care.

The law increased Medicaid payments to primary care providers to Medicare levels in 2013 and 2014 with federal funding. Some states extended that enhanced payment level with state funding for subsequent years, but the study found higher rates of doctors’ acceptance of Medicaid even in states that didn’t do so.

The Affordable Care Act also included funding that fueled expansion of federally qualified health centers, which provide health care to patients regardless of ability to pay. Because these centers operate in low-income areas that are more likely to have greater concentrations of Medicaid enrollees, this expansion may have improved their access to care.

Other trends in medical practice might have aided in meeting growing appointment demand. “The practice and organization of medical care has been dynamic in recent years, and that could partly explain our results,” Mr. Polsky said. “For example, if patient panels are better managed by larger organizations, the trend towards consolidation could absorb some of the increased demand.”

Although the exact explanation is uncertain, what is clear is that the primary care system has not been overwhelmed by coverage expansion. Waiting times have gone up, but the ability of Medicaid patients to get appointments has improved, with no degradation in that aspect for privately insured patients.

Commentary: Why Republicans will always struggle to repeal Obamacare

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http://www.reuters.com/article/us-lemieux-healthcare-commentary-idUSKBN1AJ286

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With John McCain’s dramatic “no” vote, the Health Care Freedom Act (HFCA) died early last Friday morning and with it any hope of repealing the Affordable Care Act (ACA) for the foreseeable future. While conservatives might prefer to blame incompetent vote-whipping in the Senate, the ACA could prove resilient for the same reason Medicare and Social Security have: most voters prefer not to wonder if they will be able to eat when hungry or see a doctor when sick. Any program that gives more economic security to a broad, politically powerful group will be dangerous to meddle with, even in these polarized times.

Conservative activists and pundits who don’t want to contend with that reality may point to the president they were dealt: Donald Trump knew essentially nothingabout health care and he alternated between disengagement and crude bullying of wavering senators ahead of the vote.

Blaming Senate Majority Leader Mitch McConnell is less convincing. McConnell is a masterful legislative strategist and it took his maneuvering to bring a bill supported by less than 30 percent of the public to within one vote of passing. Indeed, McConnell may only have come even that close because he skipped the normal committee hearing process, protecting the proposal from more public and media scrutiny.

The real lesson here is that once major social programs are in place, it’s simply very hard to eliminate them.

In his 1994 book “Dismantling the Welfare State?” the political scientist Paul Pierson showed that major social welfare programs were very resilient, and conservative attempts to repeal them generally failed. This was true even in parliamentary systems with fewer choke points to stop repeal than the American system.

In the United States, the clearest example is Social Security. Before becoming president, Ronald Reagan had a desire to make it a voluntary program, but he quickly abandoned any thoughts of radically restructuring the program after taking office. Instead he oversaw a bipartisan plan to protect the program’s solvency through a combination of regressive tax increases and benefit cuts. When the Republican controlled-Senate narrowly passed a one-year freeze to seniors’ annual cost-of-living adjustment freeze during Reagan’s second term, the president abandoned the unpopular proposal, letting it die in the House of Representatives.

George W. Bush, after winning re-election in 2004, made Social Security privatization his signature domestic issue. Bush travelled the country, making the case for a system of voluntary private accounts to partially replace Social Security for young workers. But the idea was politically toxic, actually becoming less popularthe more Bush discussed it. Congressional Democrats, who had collaborated with Republicans on major domestic legislation during Bush’s first term, came out against the proposal en masse. Republicans controlled both houses of Congress but they refused to take responsibility for highly unpopular changes to a cherished program. No Social Security privatization bill came close to a vote. Republicans have not actively pursued the goal since.

Nor have Republicans had any success at attacking the Great Society’s cornerstone health policy, Medicare. Sometimes they actively go in the opposite direction. In George W. Bush’s first term, Bush worked with Republicans to pass a corporate-friendly expansion of Medicare to partially cover payments for prescription drugs. Tea Party activists consider this one of the Bush era’s major betrayals of small government conservatism. But even arch-conservatives like Rick Santorum voted for the law. The politics were irrefutable: senior citizens vote, mostly Republican, and they fill a lot of prescriptions.

In 2011, now-Speaker of the House Paul Ryan proposed a plan to convert Medicare into a system in which seniors received vouchers (whose value would decrease over time) to purchase health insurance on private markets. The proposal was extremely unpopular and created a major backlash. Ryan has never officially abandoned some form of vouchers as a goal, but he has not put any Medicare restructuring on his legislative agenda since taking the Speaker’s gavel. The Ryan budget’s threat to Medicare, however, proves a reliably spooky specter for Democrats to invoke when sending fundraising emails or appealing to older swing voters.

Social programs are often not fully appreciated by their beneficiaries until someone proposes getting rid of them. Facing an existential threat made the Affordable Care Act much more popular – as then-Speaker of the House Nancy Pelosi predicted, support for it increased once people found out what was in it. The Republican proposals to replace the ACA, conversely, are staggeringly unpopular. As recently as last year, more Americans disapproved of the ACA than supported it, but its approval ratings are now over 50 percent, while the repeal bills started out unpopular and became more so.

The majority support for the ACA wasn’t soft, either. Supporters of the ACA were far more motivated than its opponents during the repeal struggle, putting their time and sometimes their bodies on the line, such as when disabled people were ejected from the offices of members of Congress.  This helps to explain why moderate Republican Senators Susan Collins of Maine and Lisa Murkowski of Alaska (not to mention Democratic senators representing states that Trump won in landslides such as West Virginia and Montana) were unwavering in their opposition. The weekend after the HCFA was voted down, Murkowsi was repeatedly greeted by supporters, some in tears, thanking her for her no vote, while Nevada Senator Dean Heller was rewarded for his “yes” vote by seeing his approval rating plummet to 22 percent.

This doesn’t mean that supporters of the ACA should be complacent. Even when Republicans have failed to eliminate major social programs, they have been able to make them less generous in ways that caused real harm, Reagan’s Social Security adjustment included. Trump is signaling that he will damage the ACA administratively, and 19 states are still refusing the ACA’s generous Medicaid expansion.

Moreover, the failure to eliminate major welfare programs is a tendency, not an iron law. In 1996, President Bill Clinton signed a welfare “reform” bill that led to more than 6 million mothers with children losing welfare benefits.

That was possible partly because welfare, unlike Obamacare, only benefits the poor, who are politically disempowered.

Still, Republicans just came closer to passing a partial repeal of the ACA than many would have thought possible.

The battle over healthcare is far from over, but the repeated failures of the GOP efforts to repeal it prove the political durability of the social safety net.

Medicare proposed changes would cut home health reimbursement

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http://www.healthcarefinancenews.com/news/home-health-agencies-concerned-about-cuts-proposed-medicare-payments?mkt_tok=eyJpIjoiTXpOa01qUXhaVGd5TnpkaiIsInQiOiJudFozOHVLS1VVNXZZRE42Y0RmTWdIZHpkOU0yNERUSmlXU0VCMlJDMEFyMmVTUUc4aVwvcXRVc0gzXC9ndUdJVjhHT1drZkkzdDhBVFhHZ3BHVjI1NmhIVHY1RmNXSENVdWtwb3RVVnVtaFNWbXNFdnBzb0JVenRcL1ZuR1p0MW0zRyJ9

Home health agencies could see decreases of $80 million in 2017 and $950 million in 2019.

Home health providers object to the Centers for Medicare and Medicaid Services’ proposed rule that would reduce Medicare payments by 0.4 percent, or $80 million, in 2018, and up to  $950 million in 2019.

The Partnership for Quality Home Healthcare is especially concerned about a groupings model proposal starting in 2019 that  would change the unit of payment from 60-day episodes of care to 30-day periods of care and places patients in payment groups based on how they fit in six clinical categories.

“CMS is proposing a major reform to home health reimbursement without having worked collaboratively with industry partners like the Partnership and we expect to be included in payment reform development going forward,” said Partnership Chairman Keith Myers. “We question whether CMS has the unilateral authority to make such a proposed change without action by Congress.”

CMS said the six clinical groups used to categorize 30-day periods of care are based on the patient’s primary reason for home healthcare.

The new model could result in a $950 million Medicare payment cuts for home health providers in 2019 if it is implemented in a non-budget neutral manner, according to Home Health Care News. If implemented in a partially-budget-neutral manner, it could reduce payments by $480 million, the report said.

CMS is not proposing a revision to the split percentage payment approach in the change to a 30-day period. However, the agency said it is proposing to phase-out of the split percentage payment approach in the future and is soliciting feedback now.

For 2018, Medicare payments to home health agencies would be reduced by 0.4 percent, or $80 million, based on the proposed policies, CMS projects.

The $80 million decrease reflects the effects of a $190 million increase from a 1 percent home health payment update, a $170 million decrease from a -0.97 percent adjustment to the 60-day episode payment rate to account for nominal case-mix growth, and a $100 million decrease due to the sunset of the rural add-on provision.

The Medicare Access and CHIP Reauthorization Act, or MACRA extended until Jan. 1, 2018 the rural add-on, which increased by 3 percent the payment amount otherwise made for home health services in a rural area.

Additionally, the proposed rule for 2018 refines the home health value-based purchasing model. It revises the applicable measure for receiving performance scores for any of the home health consumer assessment of healthcare providers and systems, or HHCAHPS.

The Partnership for Quality Home Health Care said it plans to release an analysis of the proposed payment model and its impacts on home health delivery.

The coalition is concerned that Affordable Care Act directives for high-risk beneficiaries to receive access to home health services would result in disproportionate cuts to provide the care if the payments are implemented as drafted.

Tuesday’s home health rule is among several proposals that reflect a broader strategy by CMS to relieve regulatory burdens for providers, support the patient-doctor relationship in healthcare and promote transparency, flexibility, and innovation in the delivery of care, CMS said.

“CMS is committed to helping patients and their doctors make better decisions about their healthcare choices,” said CMS Administrator Seema Verma. “We’re redesigning the payment system to be more responsive to patients’ needs and to improve outcomes. The new payment system aims to encourage innovation and collaboration and to incentivize home health providers to meet or exceed industry quality standards.”

ACOs are leaving $886M in net payments on the table, analysis finds

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http://www.beckershospitalreview.com/accountable-care-organizations/acos-are-leaving-886m-in-net-payments-on-the-table-analysis-finds.html

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ACOs in Track 1 of the Medicare Shared Savings Program are losing out on millions of dollars in additional net payments from CMS by not taking on more risk and missing out on the Quality Payment Program’s 5 percent lump sum bonus payment for ACOs in Track 2 and 3, according to an analysis from Avalere.

The analysis simulates how much Track 1 ACOs would earn if they were enrolled in Track 2 — based on 2015 performance — and the QPP was in place. Track 1 ACOs do not bear downside financial risk, and therefore share in a smaller portion of savings than their Track 2 and 3 counterparts. However, if these ACOs had taken on more risk in 2015, they would have earned $178 million more in shared savings, according to the analysis. And if the Track 1 ACOs took on downside risk, they would qualify as an Advanced Alternative Payment Model under the Medicare Access and CHIP Reauthorization Act’s QPP. These models have the opportunity to earn a bonus up to 5 percent on Medicare Part B expenditures — and based on 2015 performance, those ACOs would be leaving $1.1 billion in AAPM bonus payments on the table by not bearing the downside risk necessary to qualify, according to the report.

“The CMS’ new value-based payment incentives really tip the scales for doctors to assume greater financial risk,” Josh Seidman, PhD, senior vice president at Avalere, said in a statement. “For those physicians who were dipping their toes in the water with low-risk ACO models, the incentives now make it advantageous for a majority of them to move more aggressively into greater accountability for population health.”

Of course, some of the ACOs would have also generated net losses. The analysis indicates some of the ACOs in the simulation would have had to pay back CMS for spending above the benchmark. These shared losses would have totaled $437 million. Benefits and losses taken together, if all Track 1 ACOs joined Track 2 of the MSSP and performed as well as they did in 2015, they would earn additional net payments of $886 million, according to the analysis.

However, the majority of ACOs would still benefit by joining Track 2. Avalere found 79 percent, or 307 of the Track 1 ACOs, would have financially benefitted, compared to 21 percent, or 82, that would not.

This year 486 ACOs are participating in Track 1, accounting for most of the MSSP program. Track 2 counts just six participants and Track 3 has 36 ACOs.

How GOP Will Still Carve Up Medicare

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https://www.forbes.com/sites/johnwasik/2017/07/19/how-gop-will-still-carve-up-medicare/#48a9aa5943f1

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Now that the GOP’s plan for repealing and replacing Obamacare seems to be in a coma, the party has turned its attention to the 2018 federal budget.

Although specific spending details in the House committee mark-ups are still being hammered out, the GOP is back to its old script.

The GOP has a working blueprint to cut billions out of federal programs and balance the budget without tax increases. And, among other items, it still wants to privatize Medicare.

Speaker of the House Paul Ryan (R-WI). (Photo by Win McNamee/Getty Images)

Medicare covers more than 55 million Americans. Most of them are 65 or older and millions are permanently disabled. It’s the nation’s second-largest government-managed single-payer plan after Medicaid, which covers some 70 million.

 

While Medicare provides coverage for doctors and hospitals, it also covers prescription drugs if you pay an additional premium. You also have the option to buy into private policies through Medicare Advantage — if you don’t want the fee-for-service part of basic Medicare.

The rehashed House GOP budget blueprint wants to reshape Medicare into more of a Medicare Advantage model, which now covers some 19 million Americans.

What does that mean? Funding for the guaranteed part of Medicare would be shifted into the privatized scheme. You’d receive a fixed stipend or “premium support” to buy a private policy on an exchange.

Buying private plans on an exchange? Where have we heard that before? Oh yes, that was the model for the Affordable Care Act, or Obamacare, which the GOP has spent the last seven yearstrying to repeal. It’s been a staple of House Speaker Paul Ryan’s policy platform for years.

According to the House Budget Committee blueprint:

“The Medicare improvements envisioned in this budget resolution would adopt the popular simplified coverage structure of Medicare Advantage, and allow seniors greater plan choices while reducing costs.

It would resemble the private insurance market, in which the majority of Americans select a single health care plan to cover all their medical needs.”

In theory, having private insurers compete with the government to provide more coverage at a lower cost sounds like a good idea. But is it possible, given the government’s massive economies of scale?

Without generous subsidies, the prospect of insurers offering a better Medicare deal is like the corner grocer trying to compete with Wal-Mart. Moreover, using Medicare Advantage as a model is a horrible idea.

Medicare Advantage insurers have been embroiled in numerous billing scams, according to the non-partisan Center for Public Integrity. The Center, an independent watchdog, has published more than two dozen pieces on this ongoing morass. Here’s a summary of their findings:

“Congress created private Medicare Advantage health plans 11 years ago to help control health care spending on the elderly. But a Center for Public Integrity investigation found that billions of tax dollars are wasted every year through manipulation of a Medicare payment tool called a “risk score.”

The formula is supposed to pay health plans more for sicker patients and less for healthy people, but often it pays too much. The government has for years missed opportunities to corral tens of billions of dollars in overcharges and other billing errors tied to abuse of risk scores.

Meanwhile, the growing power of the Medicare Advantage industry has muzzled many critics in Congress, and turned others into cheerleaders for the program.”

Back to the main story: What House Speaker Paul Ryan and GOP congressional leaders are proposing is to tear down and remold basic Medicare into the troubled Medicare Advantage program, which would be like throwing kerosene on a house fire.

There’s even more of a muddle on how the GOP would calculate how much to give seniors for their yearly stipend to cover private premiums. What if policy costs go up double digits and the stipend doesn’t keep pace with the private market?

Would private insurers offer lower rates to healthier seniors and price less-healthy Americans out of the market? Although basic Medicare would still be available, wouldn’t the money diverted to premium support undermine funding for the traditional Medicare Hospital Trust Fund, which may be insolvent by 2029?

I think there’s a reason why there’s a billboard in Kenosha, Wisconsin — in the heart of Ryan’s Congressional District — that shows Ryan in a robber’s mask. There’s an attempted theft in progress, but older Americans and the disabled will be the victims.

AHCA savings, $487 billion in Medicare cuts remain in House budget proposal

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http://www.modernhealthcare.com/article/20170719/NEWS/170719888/ahca-savings-487-billion-in-medicare-cuts-remain-in-house-budget

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The House Budget Committee on Wednesday agreed to bake in hundreds of billions in Medicaid cuts from its ACA repeal bill to the budget resolution, plus an additional $114 billion in cuts over 10 years.

The committee’s Republicans’ unanimously approved the decision with no Democrats on board. The budget resolution, which is the foundation for passing tax reform in the Senate without Democratic votes, also assumes Medicare will reduce spending by $487 million from 2018 to 2027.

Some of the additional savings would come from imposing a work requirement on Medicaid adult beneficiaries who are younger than 65 and are not on Social Security disability as a condition of eligibility.

The Medicare savings are built on an idea long-favored by Republicans — using vouchers to buy insurance, though Republicans say future beneficiaries will have the option to buy traditional Medicare too. Democrats during Wednesday’s hearing complained that traditional Medicare would cost 25% more than it does now if vouchers come into play.

The Republicans also included savings that would stem from raising the Medicare eligibility age for future beneficiaries who are 51 or younger. Under the proposal, those individuals would not become eligible for full Social Security benefits or Medicare until the age of 67. The Congressional Budget Office has estimated that would reduce Medicare spending by 2% once everyone in the program is covered by the later eligibility age.

The proposal includes a requirement that affluent seniors pay higher premiums, and that people with incomes of $1 million or more pay the full cost of Medicare premiums without any federal subsidy.

Rep. Matt Gaetz, R-Fla., said during the hearing that the proposed changes are based on math rather than Tea Party politics, as some have alleged.

The Republican spending outline also assumes the government will do better at recouping or avoiding improper payments. The proposal said that there was $59.7 billion in improper Medicare payments in in the last fiscal year, and $36.3 billion in improper Medicaid payments. The outline assumes future improper payments will be 50% lower than today’s levels.

Rep. Debbie Wasserman-Schultz, D-Fla., introduced an amendment that would have changed the resolution so that it no longer assumed American Health Care Act changes would be future law, citing the Senate bill’s collapse this week.

But every Republican present on the committee voted against the amendment. “This is the official position of the House on repeal and reform efforts,” said Rep. Bill Johnson, R-Ohio.

The budget resolution also includes a reduction in health spending of $43.9 billion over 10 years, the CBO estimate of how much the malpractice reform bill that passed the House would save.

Ranking Member John Yarmuth, D-Ky., called the budget disgraceful and others called the cuts to Medicare, Medicaid and food stamps draconian, several Republicans worried what it envisions might not come to pass.

“We might fail to achieve savings in mandatory spending,” which includes Medicaid and Medicare, Johnson said, noting that the budget resolution might make it harder to pass tax reform in the Senate.

The first hurdle, however, is for the resolution to pass the entire House of Representatives.

ACA Round-Up: Medicare Trustees Report Does Not Trigger IPAB, And More

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http://healthaffairs.org/blog/2017/07/14/aca-round-up-medicare-trustees-report-does-not-trigger-ipab-and-more/

Click to access TR2017.pdf

All eyes yesterday were focused on the Senate, which released significant new amendments to the Better Care Reconciliation Act. But the Senate was not the only game in town.

On July 13 the Medicare Trustees released their 2017 Medicare Trust Fund report. One of the most controversial creations of the ACA was the Independent Payment Advisory Board (IPAB). The ACA established specific target growth rates for Medicare and charged the IPAB with ensuring that Medicare expenditures stayed within these limits.

Each year the CMS Chief Actuary must make a determination as to whether the projected average Medicare growth rate for the 5-year period ending 2 years later will exceed the target growth rate. For each year since the provision went into effect in 2013, the CMS Chief Actuary has determined that the projected growth rates will not exceed these limits. It was thought that this year might be different, but for 2017 the Chief Actuary again concluded that the growth rate will not be exceeded, and said so in a letter to CMS.

The IPAB was supposed to be a 15-member board of experts that would, for years when Medicare growth rates were projected to exceed the threshold, make recommendations for cutting costs. These would be implemented unless Congress enacted an alternate approach that would achieve the same savings or waived the requirement to cut costs by a three-fifths majority. The IPAB has never been created, but under the ACA, in the absence of an IPAB its power to make program cuts devolves to the HHS Secretary.

The IPAB is deeply disliked in Congress and proposals to abolish it have wide support. But the IPAB statute seems to say that the IPAB can only be abolished by a joint resolution of Congress which must be introduced into Congress by February 1, 2017 and be enacted, following very specific procedures, by August 15, 2017.  In fact, one bill to abolish the IPAB was introduced into the Senate by February 1 with 36 Republican co-sponsors, and another with 12 Democratic co-sponsors, while a House bill was introduced on February 3 with 233 Democratic and Republican cosponsors. But August 15 is coming up quickly and Congress seems to have its hands full with other issues. Moreover, the CBO would likely view elimination of the IPAB as coming with a high price tag.

It may not matter much. The IPAB provision recognizes that Congress can always change its mind.  It could presumably change its rules to allow it to abolish the IPAB whenever it chose to do so. In fact, the rules that the House adopted for the 115th session provide that any IPAB submittals are not to be considered during the 2017-2018 session. But if Congress chose to proceed according to the ACA’s provisions, the IPAB would find few defenders.

Federal Exchange Eligibility Redeterminations And Re-Enrollment

CMS released on July 13 a guidance describing how it intends to handle eligibility redeterminations and re-enrollment for federal exchange enrollees for 2018. Basically, CMS intends to use the same procedures it used for redeterminations and reenrollment for 2017, which in turn were similar to those used for 2016.  The exchange will continue to auto-reenroll enrollees who fail to select a plan, and to terminate enrollees who have been auto-reenrolled more than once without contact with the exchange.

There is one change for 2018: CMS will discontinue advance premium tax credits (APTC) and cost-sharing reduction (CSR) payments not just for enrollees who received APTC or CSRs and did not file a tax return in a prior year in which they received ATPC or CSRs, as CMS did in 2016, but additionally for enrollees who failed to file form 8962 to reconcile the APTC they received and the premium tax credits to which they were entitled, and failed to contact the exchange and obtain an updated eligibility determination for 2018. Filing a tax return and reconciling APTC with premium tax credits is an eligibility requirement for receiving APTC and CSRs in subsequent years, but federal regulations prohibit termination of coverage for this reason unless direct notice is sent to the enrollee that coverage will be terminated for failure to file. Until now, CMS has not been able to provide the required notice for those who fail to reconcile.

GAO Finds Tax Credit Verification Procedures Wanting

Finally, on July 13, 2017, the Government Accountability Office released a report on Improvements Needed in CMS and IRS Controls over Health Insurance Premium Tax Credits. The report is long and detailed and reviews comprehensively the controls that CMS and the IRS have in place—or, more often, do not have in place—for ensuring that improper premium tax credits are not made.

The GAO scored both agencies for failing to provide accurate assessments of improper payments. It also criticized each agency for failing to have procedures in place for verifying most eligibility requirements for premium tax credits and for identifying and correcting errors in premium tax credit reporting and collecting overpayments. The agencies responded that they are working on improving verification and processing procedures, but that that they have limited resources and verification is not always possible.

In the end, a tax-based system for paying for health insurance that depends on accurate reporting and verification of citizenship or lawful alien status, incarceration status, income, residence, health insurance premiums, household composition, availability of alternative forms of coverage, and tax filing status of applicants and enrollees—and requires coordination of two independent federal agencies—is very difficult to administer. If the Senate’s BCRA is adopted, administration of the program will only become more complicated, as all of these factors remain relevant and to them will be added age and the possibility of new forms of coverage that do not qualify for premium tax credits, but can be paid for using tax-subsidized health savings accounts. The GAO has its future work cut out for it in any event.

Healthcare companies overbilling Medicare targeted by nonprofit whistleblowers group

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http://www.healthcarefinancenews.com/news/healthcare-companies-overbilling-medicare-targeted-nonprofit-whistleblowers-group?mkt_tok=eyJpIjoiTlRJM01qYzNNekUzWkRNeCIsInQiOiJpNmdaaVhQY1hiamFJbVwvWFNjSGxPMXVYZ015RmRRUEVDVW9yaHRCNjhkRDBPamIxcTlhaGZvSUN2WTNoOTY4ZXhWZ0hxNVVmWFdWQTg0ejR2eDZCT0Z6UCtjVEw2UytxTGJYMUNiWnpnT0tiUUZzY0RWVjFmZW1cL1dFM2hLUzhGIn0%3D

The outreach was prompted by a Justice Department announcement in June that Genesis Healthcare would pay the federal government more than $53.6M.

The nonprofit Corporate Whistleblower Center is urging a medical doctor in any state to call them if they possess proof a healthcare company is substantially overbilling Medicare for hospice services for people who are not dying. The organization is also interested in hearing about skilled nursing or nursing homes facilities that are billing Medicare as if they are fully staffed when in fact they’re not.

The outreach was prompted by a Justice Department announcement in June that Genesis Healthcare would pay the federal government more than $53.6 million to settle lawsuits and investigations alleging that companies it acquired violated the False Claims Act — submitting false claims to government healthcare programs for medically unnecessary therapy and hospice services, and grossly substandard nursing care.

Allegedly the companies were also billing for hospice services for patients who weren’t terminally ill and were thus ineligible for the Medicare hospice benefit. The companies also allegedly billed inappropriately for certain physician evaluation management services.

Additionally, the settlement resolves allegations that Genesis and its affiliates violated certain essential requirements that nursing homes have to meet to participate in and receive reimbursements from government healthcare programs, and failed to provide sufficient nurse staffing to meet residents’ needs. The whistleblowers will receive a combined $9.67 million as their share of the recovery in this case.

The Corporate Whistleblower Center suspects that similar scenarios have the potential to occur in every state, whether it be a hospital admitting Medicare patients who should not have been admitted, a nursing home billing Medicare as if their Medicare patients are receiving the proper care when they’re not, or a hospice company signing up patients who are not dying.

The group advised potential whistleblowers not to approach the government first, or the news media. It offers help finding law firms to handle the information.

Potential whistleblowers can contact the Corporate Whistleblower Center at 866-714-6466 or at corporatewhistleblower.com.

 

Healthcare Triage News: The Senate’s BCRA Bill – High Premiums, Huge Deductibles, AND Massive Medicaid Cuts

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Healthcare Triage News: The Senate’s BCRA Bill – High Premiums, Huge Deductibles, AND Massive Medicaid Cuts

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