Archive for: Auditing and assessment
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CMS releases 2010 OPPS proposed rule
Changes for separately payable drugs, physician supervision
Outpatient facilities and pharmacies hoping to see an increase in reimbursement for separately payable drugs in CMS’ 2010 OPPS proposed rule didn’t get their wish, but they did see additional proposed guidance on physician supervision rules.
CMS also proposes to allow hospitals to bill Medicare for pulmonary and intensive cardiac rehabilitation services.
“My sense when I first looked at the proposed rule this year was that it seemed much shorter,” says Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC. One reason for that, Shah says, might be because CMS chose not to add any additional composite APCs or additional outpatient quality indicators.
That doesn’t mean CMS is abandoning its commitment to “value-based” purchasing principles, Shah says, but it does seem like CMS is taking some time to assess the impact of its current composite APCs before adding additional ones.
Reimbursement for separately payable drugs Providers and various stakeholders have repeatedly weighed in to CMS over the past four years that charge compression has a huge negative impact on how it computes payment rates for separately payable drugs. CMS acknowledges this as an issue, and in its discussion on how it calculated payment rates for 2010, CMS referred to the pharmacy stakeholders’ proposal.
Although CMS analyzed the pharmacy stakeholders’ proposal, the agency elected not to use that methodology nor did it follow the APC Advisory Panel’s recommendations. Instead, CMS introduced a new calculation method: the result is that CMS’ proposed payment for 2010 for all separately payable drugs of average sales price (ASP) plus 4% came as a total surprise, says Shah.
“The fact that the 2010 proposed payment rates for separately payable drugs remains the same as what we have today, despite the CMS’ new calculation methodology is truly disheartening,” says Shah.
CMS’ new methodology does shift some packaged drug costs to separately payable drugs, but falls quite short of covering what providers would consider their drug acquisition costs and pharmacy overhead/handling costs, says Shah.
Shah cautions that an in-depth reading of the information is required to analyze how CMS arrived at the payment rate.
“To the end user – hospitals paid under OPPS - if the proposed payment rate of ASP plus 4% is made final for 2010, then nothing will look different,” Shah says. She is hopeful that hospitals will weigh in on this and other CMS proposed changes.
“CMS’ proposal is far from what providers have been telling CMS they need for separately payable drug reimbursement to cover both acquisition and pharmacy overhead/handling costs,” Shah says.
Some estimates provided to CMS indicate that adequate coverage of drug acquisition costs and pharmacy overhead would result CMS paying closer to ASP plus 13% for separately payable drugs, Shah says. Alternatively, CMS could reimburse hospitals at ASP plus 6% and provide a separate add-on payment for pharmacy handling/overhead costs similar to what the pharmacy stakeholders group proposed and APC Advisory Panel supported.
“Unfortunately, CMS’ proposal for 2010 is far from what providers have been telling CMS they need for separately payable drug reimbursement to cover both acquisition and pharmacy overhead/handling costs,” Shah says.
Physician supervision and incident to
CMS proposes to allow physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, and clinical psychologists to provide supervision of hospital outpatient therapeutic services when their license allows them to do so.
“The fact that they are going to be able to do the supervision is a huge benefit to hospitals,” says Kimberly Anderwood Hoy, Esq., CPC, director of Medicare and compliance at HCPro, Inc., in Marblehead, MA. Under last year’s clarification, hospitals were not be able to bill for services supervised by a nurse practitioner unless a physician was present.
“This really expands the number of people who can provide supervision, and that is really important in rural areas,” Hoy says.
However, Hoy cautions that the change, if finalized, would not go into effect until 2010, so hospitals must still follow the current rules for 2009.
“The fact that we see so much discussion in the 2010 OPPS proposed rule on this topic is a testament to providers and other industry organizations for a raising tough questions with CMS on its physician supervision and incident-to language over the past 12-16 months”, says Shah.
CMS added a discussion of its expectation that the supervising physician or nonphysician practitioner to be able step in and assume providing the service. In addition, the supervising practitioner can’t be occupied with any other procedure he or she can’t leave.
“That begs the question about whether the emergency physician is always appropriate to use to provide supervision,” Hoy says.
CMS did clarify its definition of what “in the hospital” means, which will be very helpful, Hoy says. Under the proposed change, “in the hospital” would mean areas in the main building(s) of the hospital that are under the ownership, financial, and administrative control of the hospital; are operated as part of the hospital; and for which the hospital bills the services furnished under the hospital’s CMS Certification Number.
“There are some very provider-friendly things . . . but those don’t go into effect until 2010,” Hoy says.
Hoy also recommended facilities carefully read the physician supervision requirements for cardiac and pulmonary rehabilitation services.
“There’s a nice opportunity for hospitals to expand those programs because it’s going to be a little easier to operate,” Hoy says.
Additional proposed changes
CMS proposes to evaluate surgically implantable biologicals that are not receiving pass-through payment before January 1, 2010, for pass-through status using the device category pass-through process. CMS has also proposed to increase the separately payable drug packaging threshold to $65 (it is currently $60) and to package 5HT3 antiemetics.
CMS is also considering paying rural providers for kidney disease education services furnished on or after January 1, 2010, to Medicare beneficiaries diagnosed with Stage IV chronic kidney disease.
CMS will accept comments on the proposed rule until August 31, and will respond to comments in a final rule to be issued by November 1.
Hospital’s ’what if’ scenario becomes reality
The patient access team at Skagit Valley Hospital has many goals as it works through this economic recession: Sustain morale, maintain trust, minimize criticism, and acknowledge success.
Michele Hill, CHAM, patient access manager at the Mount Vernon, WA, facility, knows it's not easy considering what the hospital faces:
- Federal and state budget cuts
- Change in payer mix
- Increased charity care requests
- RAC audits
"Our facility, like many others, is facing significant challenges during this time of economic downturn," Hill says.
Read the full story.
Virtual patient advocate could reduce readmissions
The spotlight’s shining on readmission rates. A Commonwealth Fund–supported study published in the April New England Journal of Medicine found that one-fifth of Medicare beneficiaries return to the hospital within 30 days of discharge and one-third return within 90 days. The study stated that unplanned readmissions cost Medicare $17.4 billion in 2004.
Developed by Timothy Bickmore, PhD, assistant professor of computer and information science at Northeastern University in Boston, the virtual patient advocate is on clinical trial at Boston Medical Center to increase patient understanding of postdischarge self-care regimens. Bickmore and his team of researchers hope the system can decrease patient readmissions within 30 days of hospital discharge.
“Nationally, it’s been shown that about 20% of patients get readmitted within 30 days,” says Bickmore, who adds that one-third of those readmissions are preventable. “There is a lot of information patients need to know before they go home. The typical discharge in the [United States] lasts about eight minutes and it’s like, ‘Here are your prescriptions and a pat on the back.’ ”
Check out the July 2009 issue of Case Management Monthly to read the full article.
Use a change-of-status form to ensure compliance when reporting condition code 44
A change-of-status form will help ensure that a hospital meets all of the criteria for reporting condition code 44, says Judith Kares, JD, CPC, regulatory specialist at HCPro, Inc., in Marblehead, MA. The form should include the following:
- A statement about the hospital’s decision to change the patient’s status from inpatient to outpatient, including appropriate rationale
- Information about how this decision will affect the patient medically and financially
- Documentation that the hospital informed the patient’s physician of the status change and asked him or her to offer input
- A place for two required signatures, one from a utilization review (UR) committee member and the other from the patient’s attending physician or an additional UR committee member
Keep the original form in the patient’s medical record and provide copies to the patient and his or her physician, Kares says. Keep a third copy in the UR committee records.
Editor’s note: This article was adapted from the June issue of Briefings on Coding Compliance Strategies.
June 15-22 Issuances: CMS issues HITECH fact sheet, OIG audits oxaliplatin billing
CMS issues fact sheet on HITECH Act
On June 16, CMS issued a fact sheet containing information and frequently asked questions about the Health Information Technology for Economic and Clinical Health (HITECH) Act.
OIG reviews oxaliplatin billing
Last week, the OIG issued two reports on oxaliplatin billing. The OIG found that University Medical Center of Southern Nevada and Louisiana State University Health Sciences Center both billed for an incorrect number of units for this drug and, as a result, received overpayments.
View the OIG report on University Medical Center.
View the OIG report on Louisiana State University Health Sciences Center.
Never Events - CMS issues surgical error NCDs and related guidance
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc
In 2002, the National Quality Forum (NQF) published a list of 27 events identified as “serious, largely preventable and of concern to both the public and health care providers.” These events have become more popularly known as “never events”—events that should never occur in a well-run health care facility with appropriate quality controls.
Go to the MedicareMentor blog to read the rest of this week's note.
Double-billing settlement highlights whistleblower concerns
Earlier this week, the University of Medicine and Dentistry of New Jersey agreed to pay the federal government $2 million to settle a whistleblower lawsuit alleging that it bilked Medicaid in a double-billing scheme that started in 1993 and ended in 2003, according to the Department of Justice (DOJ).
The settlement marks the second time UMDNJ paid the government for the double-billing scheme. The first was in 2005 when the hospital paid $4.9 million to the state of New Jersey to settle criminal charges.
In the end, UMDNJ ended up paying nearly $7 million total for the scheme, but, according to Marcella Auerbach, managing partner at Nolan & Auerbach, the hospital could have avoided the lengthy and costly litigation and saved millions, if it had acted differently.
According to Auerbach, a former federal prosecutor who now exclusively represents whistleblowers in healthcare fraud cases, UMDNJ’s in-house attorney discovered the hospital and its physicians were billing for the same services back in 2001—before any whistle was blown. The lawyer brought the issue to the hospital’s attention, but the management looked the other way, and continued to double-bill for the three years following the warning, he says.
The fact that UMDNJ knew about the double-billing, knew it was illegal, and continued to do it, is what makes the case so interesting. The hospital could have saved millions if it ceased double-billing and came clean to the government through a self-disclosure, Auerbach says.
“It’s a bet,” Auerbach says. “They are betting on the fact they won’t get caught.”
However, UMDNJ hit one too many times and ended up going bust. Steven Simring, MD, the man who filed the whistleblower lawsuit will collect $801,000 for his efforts.
Based on the details of the case, Auerbach was not surprised to see a doctor blow the whistle on the hospital. Evidence shows that there were many discussions about the double-billing in which doctors expressed concern. Auerbach says it comes as no surprise that Simring would come forward and blow the whistle rather than risk prosecution.
Auerbach says the gambler’s mind-set is common in whistleblower cases. Rather than play by the rules and fess up, many facilities try to sweep problems under the rug and pretend they never happened. Some even go one step further. Auerbach says many times concerned employees will raise compliance concern only to be handed a pink slip for their trouble, which raises another legal problem.
“These people are fired for bringing points up,” Auerbach says, “Then they come to us and they have two claims.”
Auerbach says this case can be seen as a message to healthcare leaders. The DOJ is saying take any compliance concerns presented by employees or legal council very seriously and, when appropriate, self-disclose. The alternative is a lengthy, expensive, public whistleblower case.
