The Centers for Medicare & Medicaid Services (CMS) issued, Sept. 17, a proposed rule for revising several compliance requirements that have been identified as unnecessary, obsolete, or excessively burdensome on healthcare providers and suppliers of durable medical equipment. The proposed changes are in accordance with President Trump’s Jan. 30, 2017, Executive Order “Reducing Regulation and Controlling Regulatory Costs” and also take […]
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Tag Archives: proposes
Medicare Proposes Big E/M Changes
Be aware of three proposals that would make coding these services easier, but also may negatively affect physician reimbursement. The Centers for Medicare & Medicaid Services (CMS) has proposed radical changes that, if finalized, would ease the documentation requirements for new and established outpatient visits, while also creating a uniform payment for evaluation and management […]
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CMS Proposes Add-on Codes
CMS includes in the proposed rule some new Part B specific add-on codes that are to be used specifically with E/M codes which create the single rate of $ 93 for established patients 99212-99215 and a single rate for new patients 99202-99205 of $ 135. The add-on codes are designed to provide for an additional payment to primary […]
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CMS Proposes a Single E/M Payment, Streamlined Doc Requirements
The Federal Register scheduled for publication on July 27, 2018 will include a proposal for a single E/M payment for new outpatient services, and a different single E/M payment for established outpatient E/M services, regardless of the E/M level submitted. This is one of several Centers for Medicare & Medicaid Services’ (CMS) proposals to streamline E/M documentation requirements, […]
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CMS proposes aligning packaging logic
CMS proposes aligning its conditional packaging logic with how it applies packaging to labs, while also proposing to delete the much-maligned modifier -L1 for separately payable laboratory tests in 2017.
CMS proposes Medicare Advantage and Part D payment and policy updates
CMS proposes rolling back 2-midnight rule
CMS proposes rolling back 2-midnight rule
The controversial 2-midnight rule may be no more following CMS’ release of its latest proposed rule for the hospital inpatient prospective payment system (IPPS). When it was first put in place for fiscal year 2014, the 2-midnight rule established a benchmark for inpatient admissions where a Medicare Part A payment would be considered reasonable and necessary for patient stays that lasted at least two midnights. Stays that didn’t reach that benchmark would be billed as outpatient services, which are covered by Medicare Part B and tend to result in lower hospital reimbursements.
Under the new proposed rule, CMS would no longer impose a 0.2% payment cut for inpatient stays under the 2-midnight rule. Hospitals would also receive a one-time 0.6% payment in fiscal year 2017 to offset the reduction in inpatient payments over the previous three years.
In the proposed rule, CMS wrote, "We still believe the assumptions underlying the 0.2[%] reduction to the rates put in place beginning in FY 2014 were reasonable at the time we made them in 2013. Nevertheless … in the context of this case, we believe it would be appropriate to use our authority … to prospectively remove, beginning in FY 2017, the 0.2[%] reduction to the rates put in place beginning in FY 2014."
The proposed rule, which would affect about 3,330 acute care hospitals and 430 long-term care hospitals, would apply to patient discharges from October 1, 2016 and later.
Under the proposed rule, acute care hospitals that are meaningful use electronic health record (EHR) users and that successfully participate in the Hospital Inpatient Quality Reporting Program would receive a 0.9% payment increase.
Overall, CMS estimates that the elimination of the payment cut and proposed payment increases will result in an additional $ 539 million in payments in fiscal year 2017.
CMS held a comment period for the proposed rule, which ended in June. A final rule will be issued August 1.
The proposed rule comes as welcome news to some. Following the announcement of the proposed rule, the American Hospital Association (AHA) released a statement from President and CEO Rick Pollack that said, "[The] rule includes a very important outcome because it reverses the inappropriate and unfair 0.2[%] payment reduction for inpatient services that was implemented as part of the original ‘two-midnight’ policy. The AHA successfully challenged [CMS’] interpretation through the courts to convince them to restore the resources that hospitals are lawfully due."
Background
Two years ago, CMS enacted the payment cuts for inpatient stays to offset an anticipated increase in inpatient admissions as a result of the 2014 IPPS 2-midnight rule. The increase in admissions was predicted to cost $ 220 million.
Following the rule’s introduction, there was vocal opposition to the rule from hospitals that argued it arbitrarily complicated care for Medicare beneficiaries, and legal challenges were subsequently launched over the 0.2% cut.
In the case Shands Jacksonville Medical Center v. Burwell, several hospitals and hospital associations, including the AHA, questioned whether Sylvia Burwell, secretary of the Department of Health and Human Services (HHS), had the authority to make the proposed across-the-board reductions, and whether her prediction of the $ 220 million increase was valid.
In September, the U.S. District Court for the District of Columbia found that HHS did have the authority to reduce the reimbursement rates, but that the justification for the 0.2% cut was lacking.
In his ruling, District Judge Randolph Moss wrote, "The Court is unable to evaluate whether the [s]ecretary’s decision was reasonable because her omission prevented the public from offering meaningful comments. The [p]laintiffs never had the opportunity to explain where, in their view, she went wrong, and, thus, the [s]ecretary never had to provide a reasoned justification of her position."
Moss ordered Burwell to provide additional justification for the reimbursement cut and allow a public comment period. CMS issued a request for comments in December.
The following month, 55 additional hospitals filed a similar lawsuit over the 2-midnight rule’s 0.2% inpatient payment cut and the estimated increase in inpatient admissions the cut was based on.
CMS pauses reviews of short-stay claims
On a related note, in May, CMS put a temporary pause on reviews performed by Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO) to determine if payments under Medicare Part A are appropriate for claims for inpatient stays that span less than two midnights.
In a message posted June 6, CMS explained it "became aware of inconsistencies in the BFCC-QIOs’ application of the two-midnight policy for short hospital stay reviews, and … we temporarily paused short stay patient status reviews to give us time to improve standardization in the BFCC-QIOs’ review process."
BFCC-QIOs will use the temporary pause to complete retraining on the two-midnight policy and to review all claims that were denied since last October. BFCC-QIOs began conducting the short-stay claim reviews in October, which were previously conducted by Medicare Administrative Contractors.
CMS believes audit activities will resume in 60?90 days, according to the update it posted in June. In the meantime, hospitals that previously had a claim denied should check with their BFCC-QIO to see if the claim has been denied before filing an appeal. Hospitals that have already filed appeals will have the findings of the re-review performed by the BFCC-QIO shared with the appeals adjudicators.
Interstate Medical Licensure Compact Commission proposes licensure process
The medical licensing tool aimed at expediting the process through which physicians can obtain licenses to practice in multiple states is one step closer to becoming a reality as more details of the process come into focus. Once it’s up and running, the Interstate Medical Licensure Compact will allow physicians licensed in one participating state to gain licensure in other participating states without having to repeat the entire licensing process in each state.
The Interstate Medical Licensure Compact Commission, which is responsible for the compact’s governing rules and administration, recently released a proposed process for expedited licensure through the compact and opened the period for public comments. The commission will consider the proposed rule at its meeting in early October.
The expedited licensure process
The basic process is the same as the one outlined in model legislation released two years ago, says Ian Marquand, chair of the Interstate Medical Licensure Compact Commission. Under the newly proposed process, a physician applies for expedited licensure via the compact through the state where he or she claims principal licensure. The state of principal licensure is where the physician resides, practices, is employed, or files a federal tax return.
"The physician will have to provide some information so that we can make sure that state is legitimately the state of principal license. A physician can’t willy-nilly pick a state in the compact," Marquand says. The applying physician will also have to pay the commission a service fee and submit to a criminal background check through a law enforcement agency, including providing fingerprints or other biometric data.
"There are no heavy applications at this point. The point of this is to make it much easier for a physician to get licensed in additional states and for much less time and energy expended," he says.
The principal licensure state would then review the applicant’s qualifications to determine if he or she is eligible for expedited licensure, perform a criminal background check, and issue a letter to the applicant and the compact commission verifying or denying the physician’s eligibility. Once the applicant receives that letter, he or she can then select from which member states to request expedited licensure and pay those states’ licensure fees. The relevant member boards would then issue full and unrestricted licenses to the applicant. Those licenses would be valid for as long as any other full and unrestricted license normally issued by that state board.
Application turnaround time
There is not a set amount of time to process the application for licensure through the compact due to several variables, Marquand says. These variables include how quickly the physician goes to a law enforcement agency to get fingerprinted, the amount of time necessary to complete the criminal background check and deliver the results to the medical board at the state of principal licensure, and how long it takes that state of principal licensure to review the criminal background check and the applicant’s other details (e.g., board certification and medical education).
A few test runs of the process have been performed in Marquand’s home state of Montana. "We find that it only really takes a matter of hours but it’s not the only thing our people have to do. So where it falls in the queue depends on how long it’s going to take for our people to actually get to do the work. That’s a variable. The communication between a state of principal license to compact commission and then compact commission to receiving state, I don’t think those should take very long at all."
In contrast, the applicant’s responsiveness will be a factor in the turnaround time. Marquand provides a hypothetical scenario to illustrate this point: Dr. Smith, whose state of principal licensure is Montana, applies for licensure in three additional states through the commission. He is prompt about providing his fingerprints and submitting to the criminal background check, which allows the staff in Montana to process his application fairly quickly. In a matter of days Dr. Smith is certified by the commission but then puts off paying the licensure fees.
"We can’t do anything until the fees have been paid. So if the physician is slow about paying fees, that’s on them, not on us," Marquand says. "But once the fees are paid and delivered to the receiving states, we don’t expect [the states] to take very long in issuing the license."
To help motivate physicians to stay on track with their applications, the proposed rule sets a 60-day limit for the applicant to submit all requested materials.
"With every application in the professional licensing world, there’s an expiration date on the application. It doesn’t sit there forever waiting for you to finish. If you don’t get it done, it expires. Putting a 60-day limit on that seems pretty reasonable to me," he says.
Returning to the example of Dr. Smith, Marquand says if the physician applies through the compact commission, pays the initial processing fee but then doesn’t have his fingerprints taken and is unresponsive to the commission’s requests for information for more than 60 days, the application is withdrawn.
"It put some onus on the physician to take some action. But will it take 60 days for processing? No, that’s just the time we give the physician to get any information that we need. But I can’t imagine that happening very often, if at all." Marquand says.
Once a physician is certified through the commission, that certification is valid for one year. This means that if Dr. Smith initially selects one compact state for licensure, such as Wyoming, and then decides six months later that he wants a license for Idaho as well, he will not have to reapply, Marquand says. Dr. Smith will simply need to inform his state of principal licensure?Montana?that he’d like to practice Idaho. The board in Montana will notify the commission and then Idaho will issue the license fairly quickly.
"The only thing that would preclude that would be if Dr. Smith gets in trouble with either the Montana or the Wyoming board and his license is suspended. Then his compact eligibility goes out the window," he says.
When a physician’s license is suspended, it is the responsibility of the member state in which the disciplinary action occurred to notify the commission, which in turn, would notify all the states in the compact. At that point, it would be up to each individual state to decide what to do.
"It’s presumed that reciprocal discipline will happen very quickly. So if Dr. Smith gets in trouble in Wyoming, Wyoming reports him to the commission and Montana would probably take very swift action to suspend his license there, Marquand says. "And if he’s licensed anywhere else in the compact, those states would have the option of doing the same. We want to at least make it possible for very swift action in all the states.
He adds that there are circumstances where reciprocal discipline is automatic, such as when a license from a state of principal licensure is revoked, suspended, or surrendered. In such cases, states can change that automatic action to something else, if they choose. So while states would have some discretion, it may come after an initial action.
Physicians who retain clean records and maintain their qualifications would be able to obtain licenses in as many compact states as they want within a year of achieving certification from the commission, as long as they’re willing to pay the fees.
Work to be done
Some details of this process have yet to be finalized. For example, the amount of the commission’s processing fee has yet to be determined. The commission will likely take up this issue by the end of the year.
"Each individual state within the compact also needs to have its own discussion of whether it wants to charge an application fee to cover the cost of reviewing the physician’s qualifications," Marquand says. In Montana there is a proposal put forth for a $ 100 fee. That proposal still needs to go through a public comment period and receive final approval from the state medical board.
After considering the provisions of the proposed rule, the commission will have several options: Adopt the rule as-is, adopt it with amendments, send it back to the committee for more work, or scrap it completely.
"I’m certainly optimistic that the commission will adopt these. And whether there are any changes suggested to them through comments, we’ll deal with them. I think the commission is anxious to get these rules in place and move on to the next topic," Marquand says.
If the commission decides that the proposal requires significant changes, the rule could be brought back to the commission as early as December.
Work on the application portal for expedited licensure is also underway but an open date has not been announced, Marquand says. However, the commission has set January 2017 as the target date for the first licenses to be issued by a member state using the compact process.
To assist with all the work that remains to be done, the U.S. Health Resources and Services Administration (HRSA) recently announced a $ 250,000 annual grant for three years to help the commission get up and running. The grant, which was requested by the Federation of State Medical Board, underwrites the cost of the commission.
"That takes a huge load off on us as commissioners. We know that through that grant there will be money available to cover technical costs, meeting costs, and maybe even staff costs for the next three years," Marquand says. He forecasts that after the three years, the commission should be able to stand on its own financially and operate on the service fees it collects.
Telemedicine
Often the Interstate Medical Licensure Compact is discussed in the same breath as telemedicine but Marquand emphasizes the distinction between the two. The compact relates exclusively to licensing and therefore does not provide any rules, regulations, or even any guidelines on the use of telemedicine. Although physicians or health organizations may want to use it to allow their own practice or corporate practice to expand into more states, they will still need to follow the regulations of those states once licensed.
"I understand that there may be benefits of the compact for physicians who want to do telemedicine in more places, but that’s not specifically why the compact exists. The compact exists for licensed physicians to get licenses in other states quickly and efficiently, regardless of what kind of practice they want to do," Marquand says.
He recalls this topic came up at a press event in Washington, D.C., designed to promote the compact to members of Congress and major healthcare organizations. When the question was posed of who would be the major user of the compact?large healthcare organizations that want to use telemedicine, or individual physicians who want to expand a practice across state lines either in person or by telemedicine?the answer that came back was it would likely be both.
"Here’s how I look at this: Think of two parallel highways. On one, there are physicians using telemedicine. The compact is on the other, with ramps between them," he explains. "The folks on the telemedicine highway may take a ramp over to the compact highway to get additional licensure, but then they’ll get back on the telemedicine highway."
Moving forward
As this issue of CPRLI went to print, 17 states have enacted compact legislation and nine others have introduced it. Marquand is optimistic more will adopt legislation.
"There are a couple that haven’t quite got to the finish line and we understand there are going to be states that are on the sidelines, waiting to see what the commission does and see how the compact really works," he says.
That’s why Marquand says the work the commission is doing to get the compact up and running is so important. The successful operation of the compact will be the commission’s biggest promotional tool for convincing additional states to participate. The hope is to bolster the case for joining once the commission has concrete figures on time frames and the number of licenses issued.