Thursday, February 9, 2017

CMS to Clear Medicare Appeals Backlog

6 things to know

In an effort to help clear the backlog of Medicare appeals, CMS has offered to pay hospitals 66 percent of the net allowable amount for short-term inpatient stays in exchange for hospitals dropping their pending appeals of denied claims.
Here are six things to know about CMS' offer.
1. Acute care hospitals and critical access hospitals are the only types of providers permitted to take part in the settlement process with CMS.
2. The settlement does not apply to any short-term hospital admissions that occurred after Oct. 1, 2013.
3. Claims subject to pending appeals before an administrative law judge or the Medicare appeals board are eligible for the settlement.
4. CMS will make the settlement process available Dec. 1. The deadline for hospitals to submit an Expression of Interest is Jan. 31, 2017.
5. CMS will host a call Nov. 16 to offer more details on the settlement process.
6. CMS made a similar offer to help clear the Medicare appeals backlog in September 2014. That settlement offer resulted in CMS paying nearly $1.5 billion to 2,022 hospitals across the nation.

100 Things to Know About Medicare Reimbursement in 2017


Since its launch in 1965, Medicare has been one of the most influential programs for hospitals, health systems and other providers. Medicare has played a prominent part in various reform movements, including the shift from fee-for-service to value-based payment models, and the program's policies and reimbursement rates have acted as a catalyst for change nationwide.
The following list sheds some light on several facets of Medicare reimbursement, covering everything from the latest update to the Inpatient Prospective Payment System to mandatory bundled payment models.
Inpatient hospital reimbursement1. Hospitals that fall under CMS' Inpatient Prospective Payment System agree to pre-determined rates to serve Medicare beneficiaries. More than 3,300 acute care hospitals and 430 long-term care hospitals receive payments under the IPPS.
2. Hospitals generally receive IPPS payments on a per-discharge or per-case basis for Medicare beneficiary inpatient stays. Discharges are assigned to diagnosis-related groups, which sort them by similar clinical conditions and procedures administered by the hospital during the stay.
3. CMS updates the IPPS each fiscal year. CMS released the FY 2017 final rule in early August.
4. Under the FY 2017 final rule, acute care hospitals that report quality data and that are meaningful users of EHRs will receive a 0.95 percent increase in Medicare operating rates.
5. That overall 0.95 percent payment increase reflects a positive 2.7 percent market basket update, a negative 0.3 percentage point update for a productivity adjustment, a negative 0.75 percentage point update for cuts under the ACA, a negative 1.5 percentage point documentation and coding adjustment as part of the American Taxpayer Relief Act of 2012 and an increase of about 0.8 percentage points to remove the adjustment to offset the estimated costs of the two-midnight rule.
6. Hospitals that do not submit quality data lose a fourth of the market basket update (2.7 percent), and hospitals that are not meaningful users of EHRs will be subject to a three-fourths reduction of the market basket update in FY 2017.
7. Under the two-midnight rule, which was introduced in the 2014 IPPS rule, CMS expected a decline in the number of long observation stays and an increase in the number of inpatient admissions. CMS proposed offsetting the cost through a 0.2 percent reduction in inpatient payments. The payment reduction was strongly opposed by hospitals and sparked lawsuits challenging the payment cut.
8. CMS removed this adjustment for FY 2017 and also its effects in FYs 2014 through 2016. "CMS believes the assumptions underlying the -0.2 percent adjustment were reasonable at the time they were made," wrote CMS in the final rule. However, in light of the unique circumstances surrounding this adjustment, the agency decided to remove it.
9. As part of the ACA, Medicare disproportionate share hospital payments will be reduced by 75 percent, or $49.9 billion, by 2019. CMS said in the FY 2017 final IPPS rule it will distribute nearly $6 billion in DSH payments in FY 2017, about $400 million less than in FY 2016.
10. In the FY 2017 final rule, CMS added four new claims-based measures (three clinical episode-based payment measures and one communication and coordination of care measure) for the FY 2019 Inpatient Quality Reporting Program and subsequent years.
11. CMS removed 15 claims-based measures for the FY 2019 payment determination and subsequent years in the final rule.
12. CMS made changes to the Hospital Value-Based Purchasing Program, which was established under the ACA, in the final FY 2017 rule. The agency added two condition-specific payment measures (one for acute myocardial infarction and one for heart failure) beginning in FY 2021 and a 30-day mortality measure following coronary artery bypass graft surgery beginning in FY 2022. CMS said the condition-specific payment measures capture payments for all care, including readmissions and subsequent cardiac events, across multiple care settings, services and supplies during the 30-day episode of care.
13. CMS made several changes to existing Hospital Acquired Conditions Reduction Program policies in the FY 2017 final rule, including changing the program scoring methodology from current decile-based scoring to a continuous scoring methodology.
For outpatient reimbursement & other CMS issues CLICK HERE.