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Sample records for medicare program payment

  1. 76 FR 68011 - Medicare Program; Advanced Payment Model

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    ... Medicare Program; Advanced Payment Model; Notice #0;#0;Federal Register / Vol. 76, No. 212 / Wednesday... Services Medicare Program; Advanced Payment Model AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the testing of the Advance Payment Model...

  2. An Analysis of Medicare's Incentive Payment Program for Physicians in Health Professional Shortage Areas

    ERIC Educational Resources Information Center

    Chan, Leighton; Hart, L. Gary; Ricketts III, Thomas C.; Beaver, Shelli K.

    2004-01-01

    Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in rural and urban areas where there is a shortage of generalist physicians. Purpose: To examine the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program. We determined the program's…

  3. 78 FR 57800 - Medicare Program; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-20

    ... security feature known as multifactor authentication to the Web portal. Multifactor authentication uses a...; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal AGENCY: Centers for... Medicare Secondary Payer (MSP) Web portal to conform to section 201 of the Medicare IVIG and...

  4. 42 CFR 419.41 - Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... amounts and national Medicare program payment amounts. 419.41 Section 419.41 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM... Calculation of national beneficiary copayment amounts and national Medicare program payment amounts. (a)...

  5. 42 CFR 419.41 - Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... amounts and national Medicare program payment amounts. 419.41 Section 419.41 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM... Calculation of national beneficiary copayment amounts and national Medicare program payment amounts. (a)...

  6. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining...

  7. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining...

  8. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining...

  9. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining...

  10. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payments for Medicare+Choice nursing and allied... NURSING FACILITIES Specific Categories of Costs § 413.87 Payments for Medicare+Choice nursing and allied... reimbursement for approved nursing and allied health education programs and the methodology for determining...

  11. Medicare Program; Medicare Clinical Diagnostic Laboratory Tests Payment System. Final rule.

    PubMed

    2016-06-23

    This final rule implements requirements of section 216 of the Protecting Access to Medicare Act of 2014 (PAMA), which significantly revises the Medicare payment system for clinical diagnostic laboratory tests. This final rule also announces an implementation date of January 1, 2018 for the private payor rate-based fee schedule required by PAMA. PMID:27373013

  12. The lessons of Medicare's prospective payment system show that the bundled payment program faces challenges.

    PubMed

    Altman, Stuart H

    2012-09-01

    Policy makers have been trying to replace Medicare's fee-for-service payment system for years with approaches that pay one price for an aggregation of services. The intent is to reward providers for offering needed care in the most appropriate and cost-effective manner. Medicare's first payment change designed to accomplish such a change was the hospital prospective payment system, introduced during 1983-84. But because it focused only on hospital care, its impact on total Medicare spending was limited. In 2011 Medicare began a new initiative to expand the "bundled payment" concept to link payments for multiple services that patients receive during an episode of care. The goal of Medicare's current bundled payment initiative is to provide incentives to deliver health care more efficiently while maintaining or improving quality. This article provides a detailed analysis of how Medicare implemented the hospital prospective payment system, how hospitals responded to the new incentives, and lessons learned that are applicable to the bundled payment initiative. The lessons include that any Medicare payment reform needs to continuously respond to the many different components of the health system and that payment reform should be coupled with analogous reforms in private insurance payment, so that providers receive consistent signals to alter their behavior. PMID:22949439

  13. 42 CFR 419.41 - Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... amounts and national Medicare program payment amounts. 419.41 Section 419.41 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM... § 419.41 Calculation of national beneficiary copayment amounts and national Medicare program...

  14. 42 CFR 419.41 - Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... amounts and national Medicare program payment amounts. 419.41 Section 419.41 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM... § 419.41 Calculation of national beneficiary copayment amounts and national Medicare program...

  15. 42 CFR 419.41 - Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... amounts and national Medicare program payment amounts. 419.41 Section 419.41 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM... § 419.41 Calculation of national beneficiary copayment amounts and national Medicare program...

  16. 78 FR 72155 - Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-02

    ... January 1, 2012, did function for 3 or more years (76 FR 70289). The 3-year MLR is designed to represent a...) Prospective Payment System (PPS) On August 12, 2010, we published in the Federal Register a final rule (75 FR... Register, a final rule (76 FR 70228 through 70316) titled, ``Medicare Program; End-Stage Renal...

  17. The Impact of Hospital-Acquired Conditions on Medicare Program Payments

    PubMed Central

    Kandilov, Amy M. G.; Coomer, Nicole M.; Dalton, Kathleen

    2014-01-01

    Research Objective Hospital-acquired conditions, or HACs, often result in additional Medicare payments, generated during the initial hospitalization and in subsequent health care encounters. The purpose of this article is to estimate the incremental cost to Medicare, as measured by Medicare program payments, of six HACs. Study Design The researchers used a matched case-control design to determine the incremental increase in Medicare payments attributable to each HAC. For each HAC patient, five comparison patients were matched on diagnosis group, sex, race, and age. Using the matched sample, we estimated a hospital fixed effects log-linear regression on total Medicare payments for the episode of care, further controlling for co-morbid conditions. Care episodes included the initial hospitalization and all inpatient, outpatient, physician, home health, and hospice care that occurred within 90 days of hospital discharge. Population Studied All Medicare fee-for-service patients discharged alive from a hospital between October 2008 and June 2010 with one of six HACs—severe pressure ulcer, fracture, catheter-associated urinary tract infection, vascular catheter-associated infection, surgical site infection following certain orthopedic procedures, or deep vein thrombosis/ pulmonary embolism following certain orthopedic procedures—were included in the sample and matched to five similar patients without the HACs. Principal Findings The multivariate analysis suggests that Medicare paid an additional $146 million per year across these HAC care episodes compared with what would have been paid without the HACs. Conclusions HACs create a significant financial burden for the Medicare program. We compare the incremental Medicare payments for these six HACs to the current and upcoming Medicare HAC payment penalties. PMID:25386385

  18. Medicare Program; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal. Final rule.

    PubMed

    2016-05-17

    This final rule specifies the process and timeline for expanding CMS' existing Medicare Secondary Payer (MSP) Web portal to conform to section 201 of the Medicare IVIG and Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act). The final rule specifies a timeline for developing a multifactor authentication solution to securely permit authorized users other than the beneficiary to access CMS' MSP conditional payment amounts and claims detail information via the MSP Web portal. It also requires that we add functionality to the existing MSP Web portal that permits users to: Notify us that the specified case is approaching settlement; obtain time and date stamped final conditional payment summary statements and amounts before reaching settlement; and ensure that relatedness disputes and any other discrepancies are addressed within 11 business days of receipt of dispute documentation. PMID:27192735

  19. 78 FR 50495 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-19

    ... line FQHC Federally qualified health center FR Federal Register FTE Full-time equivalent FUH Follow-up... 42 CFR Parts 412, 413, 414, et al. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care; Hospital Prospective Payment System and Fiscal...

  20. 75 FR 50041 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-16

    ..., phone 1-800-743-3951. Electronic Access This Federal Register document is also available from the... CFR Parts 412, 413, 415, et al. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System Changes and FY2011...

  1. 77 FR 53257 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-31

    ... Printing Office Web page at: http://www.gpo.gov/fdsys/browse/collection.action?collectionCode=FR . Free... 42 CFR Parts 412, 413, 424, et al. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal...

  2. 77 FR 38066 - Medicare Program; Announcement of a New Opportunity for Participation in the Advance Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-26

    ... Register (76 FR 68012), we published a notice entitled ``Medicare Program; Advance Payment Model'' that... the application process. In November 30, 2011 Federal Register (76 FR 74067), we published a second... Opportunity for Participation in the Advance Payment Model for Accountable Care Organizations (ACOs)...

  3. 75 FR 23105 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System Payment-Update for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-30

    ...This notice updates the payment rates for the Medicare prospective payment system (PPS) for inpatient psychiatric hospital services provided by inpatient psychiatric facilities (IPFs). These changes are applicable to IPF discharges occurring during the rate year beginning July 1, 2010 through June 30, 2011. We are also responding to comments on the IPF PPS teaching adjustment and the market......

  4. 76 FR 34633 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-14

    .... SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2011-9644 of May 5, 2011 (76 FR 25788), there were a number...InpatientPPS/01_overview.asp ). III. Correction of Errors In FR Doc. 2011-9644 of May 5, 2011 (76 FR 25788... Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute...

  5. 78 FR 27485 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-10

    ... schedule an appointment to view public comments, phone 1 (800) 743- 3951. Electronic Access This Federal... fiscal year FPL Federal poverty line FQHC Federally qualified health center FR Federal Register FTE Full... CFR Parts 412, 418, 482, et al. Medicare Program; Hospital Inpatient Prospective Payment Systems...

  6. 76 FR 74067 - Medicare Program; Announcement of a New Application Deadline for the Advance Payment Model

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-30

    ... Register (76 FR 68012), we published a notice announcing the Advance Payment Model. Additional information.... ACTION: Notice. SUMMARY: This notice announces a new application deadline for participation in the... portion of future shared savings could increase participation in the Medicare Shared Savings Program,...

  7. 75 FR 71799 - Medicare Program: Hospital Outpatient Prospective Payment System and CY 2011 Payment Rates...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-24

    ...The final rule with comment period in this document revises the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of......

  8. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for conditional Medicare payments. 411.165 Section 411.165 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Special...

  9. 42 CFR 411.32 - Basis for Medicare secondary payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for Medicare secondary payments. 411.32 Section 411.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance...

  10. 42 CFR 411.32 - Basis for Medicare secondary payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for Medicare secondary payments. 411.32 Section 411.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance...

  11. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for Medicare primary payments. 411.175 Section 411.175 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Special Rules:...

  12. 42 CFR 411.33 - Amount of Medicare secondary payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Amount of Medicare secondary payment. 411.33 Section 411.33 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance...

  13. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for conditional Medicare payments. 411.165 Section 411.165 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Special...

  14. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for Medicare primary payments. 411.175 Section 411.175 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Special Rules:...

  15. 42 CFR 411.32 - Basis for Medicare secondary payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for Medicare secondary payments. 411.32 Section 411.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance...

  16. 42 CFR 411.33 - Amount of Medicare secondary payment.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Amount of Medicare secondary payment. 411.33 Section 411.33 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance...

  17. 42 CFR 411.33 - Amount of Medicare secondary payment.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Amount of Medicare secondary payment. 411.33 Section 411.33 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance...

  18. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for conditional Medicare payments. 411.165 Section 411.165 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Special...

  19. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for conditional Medicare payments. 411.165 Section 411.165 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Special...

  20. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for Medicare primary payments. 411.175 Section 411.175 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Special Rules:...

  1. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for Medicare primary payments. 411.175 Section 411.175 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Special Rules:...

  2. 42 CFR 411.32 - Basis for Medicare secondary payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for Medicare secondary payments. 411.32 Section 411.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance...

  3. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for conditional Medicare payments. 411.165 Section 411.165 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Special...

  4. 42 CFR 411.32 - Basis for Medicare secondary payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for Medicare secondary payments. 411.32 Section 411.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance...

  5. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for Medicare primary payments. 411.175 Section 411.175 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Special Rules:...

  6. 77 FR 67449 - Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-09

    ...-Stage Renal Disease Bundled FDA Food and Drug Administration FI/MAC Fiscal Intermediary/Medicare..., 2010, we published in the Federal Register a final (75 FR 49030) titled, ``End-Stage Renal Disease... comment period (76 FR 18930) titled, ``Changes in the End-Stage Renal Disease Prospective Payment...

  7. 78 FR 46733 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-01

    ...This notice updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs). These changes are applicable to IPF discharges occurring during the fiscal year (FY) beginning October 1, 2013 through September 30,...

  8. 77 FR 24409 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-24

    ... INFORMATION CONTACT: Erick Chuang, (410) 786-1816. SUPPLEMENTARY INFORMATION: I. Regulatory Overview In FR Doc. 2011-26812 of November 30, 2011 (76 FR 74122) and FR Doc. 2011-33751 of January 4, 2012 (77 FR 217... for payment in the claims year but did not meet the Medicare requirements for payment (76 FR...

  9. 42 CFR 411.206 - Basis for Medicare primary payments and limits on secondary payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for Medicare primary payments and limits on secondary payments. 411.206 Section 411.206 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON...

  10. 42 CFR 411.206 - Basis for Medicare primary payments and limits on secondary payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for Medicare primary payments and limits on secondary payments. 411.206 Section 411.206 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON...

  11. 42 CFR 411.206 - Basis for Medicare primary payments and limits on secondary payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for Medicare primary payments and limits on secondary payments. 411.206 Section 411.206 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON...

  12. 42 CFR 411.206 - Basis for Medicare primary payments and limits on secondary payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for Medicare primary payments and limits on secondary payments. 411.206 Section 411.206 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON...

  13. 42 CFR 411.206 - Basis for Medicare primary payments and limits on secondary payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for Medicare primary payments and limits on secondary payments. 411.206 Section 411.206 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON...

  14. 42 CFR 414.21 - Medicare payment basis.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Medicare payment basis. 414.21 Section 414.21 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Physicians...

  15. 42 CFR 414.21 - Medicare payment basis.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Medicare payment basis. 414.21 Section 414.21 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Physicians...

  16. 42 CFR 414.21 - Medicare payment basis.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Medicare payment basis. 414.21 Section 414.21 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Physicians and...

  17. 42 CFR 414.21 - Medicare payment basis.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Medicare payment basis. 414.21 Section 414.21 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Physicians and...

  18. 42 CFR 414.21 - Medicare payment basis.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Medicare payment basis. 414.21 Section 414.21 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Physicians...

  19. Medicare program; payment change for home dialysis--HCFA. Final rule.

    PubMed

    1992-11-17

    This final rule implements section 6203(b) of the Omnibus Budget Reconciliation Act of 1989, which limits Medicare payment for home dialysis equipment, supplies, and support services. Also, in accordance with section 6203(b), we are requiring that, for Medicare payments to be made to a supplier of home dialysis supplies and equipment when the patient's self-care home dialysis is not under the direct supervision of a Medicare approved renal dialysis facility, the patient must certify that the supplier is the sole supplier of his or her dialysis supplies and equipment. In addition, the supplier must agree to receive payment on an assignment basis only and must certify that it has entered into a written agreement with an approved dialysis facility, under which the facility agrees to furnish the patient with all home dialysis services. We are also providing a one-time-only opportunity for certain home dialysis patients to immediately change their current method of payment. PMID:10122660

  20. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Payment § 460.180 Medicare payment to PACE organizations. (a) Principle...

  1. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Payment § 460.180 Medicare payment to PACE organizations. (a) Principle...

  2. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Payment § 460.180 Medicare payment to PACE organizations. (a) Principle...

  3. 42 CFR 424.66 - Payment to entities that provide coverage complementary to Medicare Part B.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... complementary to Medicare Part B. 424.66 Section 424.66 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT To Whom... Medicare Part B. (a) Conditions for payment. Medicare may pay an entity for Part B services furnished by...

  4. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for conditional Medicare payment in workers' compensation cases. 411.45 Section 411.45 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Limitations on Medicare...

  5. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for conditional Medicare payment in workers' compensation cases. 411.45 Section 411.45 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Limitations on Medicare...

  6. 78 FR 48995 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-12

    ...This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on November 16, 2012, entitled ``Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B......

  7. 77 FR 227 - Medicare Program; Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-04

    ... physician payment not previously identified. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2011-28597 of November 28, 2011 (76 FR 73026), the final rule with comment period entitled ``Medicare Program.... Correction of Errors 0 In FR Doc. 2011-28597 of November 28, 2011 (76 FR 73026), the final rule with...

  8. Medicare program; payment for durable medical equipment and orthotic and prosthetic devices--HCFA. Final rule.

    PubMed

    1995-07-10

    This final rule addresses comments received on an interim final rule with comment period published on December 7, 1992. The interim final rule implemented section 4062(b) of the Omnibus Budget Reconciliation Act of 1987. It specified that payment under the Medicare program for durable medical equipment (DME), prosthetics, and orthotics furnished on or after January 1, 1989 is limited to the lower of the actual charge for the equipment or the fee schedule amount established by the carrier. This final rule describes amendments to the methods for computing fee schedules covering the six classes of DME and how they are updated in subsequent years in accordance with sections 13542 through 13546 of the Omnibus Budget Reconciliation Act of 1993. PMID:10172375

  9. 78 FR 43533 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-19

    ..., phone 1-800-743-3951. Electronic Access This Federal Register document is also available from the... Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value... Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs;...

  10. 78 FR 26437 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-06

    ... viewing by the public, including any personally identifiable or confidential business information that is... FR 51476). To be consistent with these other Medicare payment systems and streamline the published... presented in last year's SNF PPS update notice for FY 2013 (77 FR 46214, August 2, 2012). Crosswalk to...

  11. 78 FR 47935 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-06

    ... Hospital Inpatient PPS (IPPS) final rule (76 FR 51476). To be consistent with these other Medicare payment... Federally qualified health center FR Federal Register FY Fiscal year GAO Government Accountability Office... rule reflect an update to the rates that we published in the SNF PPS update notice for FY 2013 (77...

  12. 76 FR 25787 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-05

    ...We are proposing to revise the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems and to implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act......

  13. 76 FR 9502 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-18

    ...: Randy Throndset, (410) 786-0131. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2010-27778 (75 FR...; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices; Correction AGENCY: Centers for Medicare & Medicaid...

  14. 78 FR 61191 - Medicare Program; FY 2014 Inpatient Prospective Payment Systems: Changes to Certain Cost...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-03

    ... August 19, 2013 Federal Register (78 FR 50496)), we made payment and policy changes under the Medicare... Periods That Span More Than One Federal Fiscal Year In the FY 2014 IPPS/LTCH PPS final rule (78 FR 50645... this final rule''. We described that process as follows (78 FR 50646): t cost report settlement,...

  15. 78 FR 31558 - Medicare Program; Second Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-24

    ... of Health and Human Services (DHHS) (the Secretary) and the Administrator of the Centers for Medicare & Medicaid Services (CMS) (the Administrator) on the clinical integrity of the Ambulatory Payment... 17, 2013. Marilyn Tavenner, Acting Administrator, Centers for Medicare & Medicaid Services....

  16. 76 FR 16788 - Medicare Program; Solicitation of Two Nominations to the Advisory Panel on Ambulatory Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-25

    ... HUMAN SERVICES Centers for Medicare and Medicaid Services Medicare Program; Solicitation of Two... Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice solicits nominations of two new members... two vacancies on the Panel as of September 30, 2011. The purpose of the Panel is to review the...

  17. Medicare Advantage update: benefits, enrollment, and payments after the ACA.

    PubMed

    Linehan, Kathryn

    2013-07-19

    In 2012, the Medicare program paid private health plans $136 billion to cover about 13 million beneficiaries who received Part A and B benefits through the Medicare Advantage (MA) program rather than traditional fee-for-service (FFS) Medicare. Private plans have been a part of the program since the 1970s. Debate about the policy goals--Should they cost less per beneficiary than FFS Medicare? Should they be available to all beneficiaries? Should they be able to offer additional benefits?--has long accompanied Medicare's private plan option.This debate is reflected in the history of Medicare payment policy,and policy decisions over the years have affected plans' willingness to participate and beneficiaries' enrollment at different periods of the program. Recently, evidence that the Medicare program was paying more per beneficiary in MA relative to what would have been spent under FFS Medicare prompted policymakers to reduce MA payments in the Patient Protection and Affordable Care Act of 2010 (ACA). So far, plans continue to participate in MA and enrollment continues to grow, but payment reductions in 2012 through 2014 have been partially offset by payments made to plans through the quality bonus payment demonstration.This brief contains recent data on plan enrollment, availability, and benefits and discusses MA plan payment policy, including changes to MA payment made in the ACA and their actual and projected effects. PMID:24049878

  18. 42 CFR 424.66 - Payment to entities that provide coverage complementary to Medicare Part B.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... complementary to Medicare Part B. 424.66 Section 424.66 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE... complementary to Medicare Part B. (a) Conditions for payment. Medicare may pay an entity for Part B...

  19. 42 CFR 424.66 - Payment to entities that provide coverage complementary to Medicare Part B.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... complementary to Medicare Part B. 424.66 Section 424.66 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE... complementary to Medicare Part B. (a) Conditions for payment. Medicare may pay an entity for Part B...

  20. Medicare program; End-Stage Renal Disease prospective payment system, quality incentive program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. Final rule.

    PubMed

    2014-11-01

    This final rule will update and make revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2015. This rule also finalizes requirements for the ESRD quality incentive program (QIP), including for payment years (PYs) 2017 and 2018. This rule will also make a technical correction to remove outdated terms and definitions. In addition, this final rule sets forth the methodology for adjusting Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule payment amounts using information from the Medicare DMEPOS Competitive Bidding Program (CBP); makes alternative payment rules for certain DME under the Medicare DMEPOS CBP; clarifies the statutory Medicare hearing aid coverage exclusion and specifies devices not subject to the hearing aid exclusion; will not update the definition of minimal self-adjustment; clarifies the Change of Ownership (CHOW) and provides for an exception to the current requirements; revises the appeal provisions for termination of a CBP contract, including the beneficiary notification requirement under the Medicare DMEPOS CBP, and makes a technical change to the regulation related to the conditions for awarding contracts for furnishing infusion drugs under the Medicare DMEPOS CBP. PMID:25376058

  1. Effect of Medicare Advantage Payments on Dually Eligible Medicare Beneficiaries

    PubMed Central

    Atherly, Adam; Dowd, Bryan E.

    2005-01-01

    This study estimates the effect of Medicare Advantage (MA) payments and State Medicaid policies on the choice by Medicaid eligible Medicare beneficiaries to either join a MA plan, remain in the fee-for-service (FFS) and enroll in Medicaid (dually enrolled), or remain in FFS Medicare without joining Medicaid. Individual plan choice was modeled using a multinomial logit. The sample includes Medicaid-eligible Medicare beneficiaries (including specified low income Medicare beneficiaries [SLMBs] and qualified Medicare beneficiaries [QMBs]) drawn from the 2000 Medicare Current Beneficiary Survey (MCBS). We find a $10 increase in monthly MA payment reduces the probability of dual enrollment by four percentage points, and FFS Medicare enrollment by 11 percentage points. PMID:17290630

  2. Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Short Inpatient Hospital Stays; Transition for Certain Medicare-Dependent, Small Rural Hospitals Under the Hospital Inpatient Prospective Payment System; Provider Administrative Appeals and Judicial Review. Final rule with comment period; final rule.

    PubMed

    2015-11-13

    This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2016 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. Further, this document includes certain finalized policies relating to the hospital inpatient prospective payment system: Changes to the 2-midnight rule under the short inpatient hospital stay policy; and a payment transition for hospitals that lost their status as a Medicare-dependent, small rural hospital (MDH) because they are no longer in a rural area due to the implementation of the new Office of Management and Budget delineations in FY 2015 and have not reclassified from urban to rural before January 1, 2016. In addition, this document contains a final rule that finalizes certain 2015 proposals, and addresses public comments received, relating to the changes in the Medicare regulations governing provider administrative appeals and judicial review relating to appropriate claims in provider cost reports. PMID:26567438

  3. Medicare program; payment for customized wheelchairs--HCFA. Interim final rule with comment period.

    PubMed

    1991-12-20

    Section 4152(c)(4)(B) of the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508) amended section 1834(a)(4) of the Social Security Act to provide that a wheelchair furnished on or after January 1, 1992 is treated as a customized item for payment purposes under part B of Medicare if it meets the definition provided in that paragraph, unless the Secretary develops specific criteria before January 1, 1992, in which case the Secretary's criteria go into effect. This interim final rule with comment period sets forth the Secretary's criteria that a wheelchair must meet to be considered a customized item. PMID:10116069

  4. 78 FR 74825 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-10

    ..., phone 1-800-743-3951. Electronic Access This Federal Register document is also available from the... noted in the correcting document published in the Federal Register on September 6, 2013 (78 FR 54842... Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital...

  5. 76 FR 59263 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-26

    ... care hospital quality measures. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2011-19719 of August 18, 2011 (76 FR 51476), the final rule entitled ``Medicare Program; Hospital Inpatient Prospective... 9A. In Table 9C.--Hospitals Redesignated as Rural Under Section 1886(d)(8)(E) of the Act--FY 2012,...

  6. 75 FR 45699 - Medicare Program: Changes to the Hospital Outpatient Prospective Payment System and CY 2010...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-03

    ... (FR) on November 20, 2009, entitled ``Medicare Program: Changes to the Hospital Outpatient Prospective..., (410) 786-0378. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. E0-26499 of November 20, 2009 (74 FR 60316) (hereinafter referred to as the CY 2010 OPPS/ASC final rule), there were several...

  7. 78 FR 15882 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-13

    ... August 31, 2012 Federal Register (77 FR 53258), we published a final rule entitled ``Medicare Program... the October 3, 2012 Federal Register (77 FR 60315); October 17, 2012 Federal Register (77 FR 63751); and the October 29, 2012 Federal Register (77 FR 65495). The October 3, 2012 correcting document...

  8. Medicare Payment Reform: Aligning Incentives for Better Care.

    PubMed

    Anderson, Gerard F; Davis, Karen; Guterman, Stuart

    2015-06-01

    The Affordable Care Act (ACA) has provided the Medicare program with an array of tools to improve the quality of care that beneficiaries receive and to increase the efficiency with which that care is provided. Notably, the ACA has created the Center for Medicare and Medicaid Innovation, which is developing and testing promising new models to improve the quality of care provided to Medicare beneficiaries while reducing spending. These new models are part of an effort by the U.S. Department of Health and Human Services to increase the proportion of traditional Medicare payments tied to quality or value to 85 percent by 2016 and 90 percent by 2018. This issue brief, one in a series on Medicare's past, present, and future, explores the evolution of Medicare payment policy, the potential of value-based payment to improve care for beneficiaries and achieve savings, and strategies for accelerating its adoption. PMID:26151988

  9. Medicare program; payment for durable medical equipment and orthotic, and prosthetic devices--HCFA. Interim final rule with comment period.

    PubMed

    1992-12-01

    This interim final rule implements section 4062(b) of the Omnibus Budget Reconciliation Act of 1987 which specifies that payment under the Medicare program for durable medical equipment, orthotics, and prosthetics furnished on or after January 1, 1989 is limited to the lower of the actual charge for the equipment or the fee schedule established by the carrier. We are setting forth the methods for computing fee schedules for six classes of these items. We are also describing how the fee schedules are updated in subsequent years. PMID:10171317

  10. 42 CFR 411.52 - Basis for conditional Medicare payment in liability cases.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for conditional Medicare payment in liability cases. 411.52 Section 411.52 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE...

  11. 42 CFR 411.52 - Basis for conditional Medicare payment in liability cases.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for conditional Medicare payment in liability cases. 411.52 Section 411.52 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE...

  12. 42 CFR 411.52 - Basis for conditional Medicare payment in liability cases.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for conditional Medicare payment in liability cases. 411.52 Section 411.52 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE...

  13. 42 CFR 411.52 - Basis for conditional Medicare payment in liability cases.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for conditional Medicare payment in liability cases. 411.52 Section 411.52 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE...

  14. 42 CFR 411.52 - Basis for conditional Medicare payment in liability cases.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for conditional Medicare payment in liability cases. 411.52 Section 411.52 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE...

  15. 77 FR 44721 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-30

    ...This major proposed rule addresses changes to the physician fee schedule, payments for Part B drugs, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. It would also implement provisions of the Affordable Care Act by establishing a face-to-face encounter as a condition of payment......

  16. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2017. Final rule.

    PubMed

    2016-08-01

    This final rule will update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2017 as required by the statute. As required by section 1886(j)(5) of the Act, this rule includes the classification and weighting factors for the IRF prospective payment system's (IRF PPS's) case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2017. This final rule also revises and updates quality measures and reporting requirements under the IRF quality reporting program (QRP). PMID:27529901

  17. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... payment. Under a PACE program agreement, CMS makes a prospective monthly payment to the PACE organization... Medicare Advantage organization. (b) Determination of rate. (1) The PACE program agreement specifies the methodology used to calculate the monthly capitation amount applicable to a PACE organization. (2) Except...

  18. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... payment. Under a PACE program agreement, CMS makes a prospective monthly payment to the PACE organization... Medicare Advantage organization. (b) Determination of rate. (1) The PACE program agreement specifies the methodology used to calculate the monthly capitation amount applicable to a PACE organization. (2) Except...

  19. 76 FR 73025 - Medicare Program; Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-28

    ...This final rule with comment period addresses changes to the physician fee schedule and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. It also addresses, implements or discusses certain statutory provisions including provisions of the Patient Protection and Affordable Care Act, as......

  20. 75 FR 51465 - Medicare Program; Announcement of Five New Members to the Advisory Panel on Ambulatory Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-20

    ... Members to the Advisory Panel on Ambulatory Payment Classification Groups AGENCY: Centers for Medicare... serve on the Advisory Panel on Ambulatory Payment Classification (APC) Groups (the Panel). The purpose... system (OPPS). FOR FURTHER INFORMATION CONTACT: For inquiries about the Panel, contact the...

  1. 78 FR 31560 - Medicare Program; Public Meeting in Calendar Year 2013 for New Clinical Laboratory Test Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-24

    ...This notice announces a public meeting to receive comments and recommendations (including accompanying data on which recommendations are based) from the public on the appropriate basis for establishing payment amounts for new or substantially revised Healthcare Common Procedure Coding System (HCPCS) codes being considered for Medicare payment under the clinical laboratory fee schedule (CLFS)......

  2. Medicare Program; FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

    PubMed

    2015-08-01

    This final rule will update the hospice payment rates and the wage index for fiscal year (FY) 2016 (October 1, 2015 through September 30, 2016), including implementing the last year of the phase-out of the wage index budget neutrality adjustment factor (BNAF). Effective on January 1, 2016, this rule also finalizes our proposals to differentiate payments for routine home care (RHC) based on the beneficiary's length of stay and implement a service intensity add-on (SIA) payment for services provided in the last 7 days of a beneficiary's life, if certain criteria are met. In addition, this rule will implement changes to the aggregate cap calculation mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), align the cap accounting year for both the inpatient cap and the hospice aggregate cap with the federal fiscal year starting in FY 2017, make changes to the hospice quality reporting program, clarify a requirement for diagnosis reporting on the hospice claim, and discuss recent hospice payment reform research and analyses. PMID:26248391

  3. 42 CFR 412.110 - Total Medicare payment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Total Medicare payment. 412.110 Section 412.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE... Prospective Payment Systems § 412.110 Total Medicare payment. Under the prospective payment systems,...

  4. 42 CFR 412.110 - Total Medicare payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Total Medicare payment. 412.110 Section 412.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE... Prospective Payment Systems § 412.110 Total Medicare payment. Under the prospective payment systems,...

  5. 42 CFR 412.110 - Total Medicare payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Total Medicare payment. 412.110 Section 412.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE... Prospective Payment Systems § 412.110 Total Medicare payment. Under the prospective payment systems,...

  6. 42 CFR 412.110 - Total Medicare payment.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Total Medicare payment. 412.110 Section 412.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE... Prospective Payment Systems § 412.110 Total Medicare payment. Under the prospective payment systems,...

  7. 42 CFR 412.110 - Total Medicare payment.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Total Medicare payment. 412.110 Section 412.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE... Prospective Payment Systems § 412.110 Total Medicare payment. Under the prospective payment systems,...

  8. Medicare program; Medicare Shared Savings Program: Accountable Care Organizations. Final rule.

    PubMed

    2015-06-01

    This final rule addresses changes to the Medicare Shared Savings Program including provisions relating to the payment of Accountable Care Organizations participating in the Medicare Shared Savings Program. Under the Medicare Shared Savings Program, providers of services and suppliers that participate in an Accountable Care Organizations continue to receive traditional Medicare fee-for-service payments under Parts A and B, but the Accountable Care Organizations may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. PMID:26065102

  9. 77 FR 40951 - Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-11

    ... rule (75 FR 49030 through 49214) titled, ``End-Stage Renal Disease Prospective Payment System... November 10, 2011, we published in the Federal Register, a final rule (76 FR 70228 through 70316) titled... the CY 2012 ESRD PPS final rule (76 FR 70228), we clarified the following: For the low-volume...

  10. 78 FR 14689 - Medicare Program; Extension of the Payment Adjustment for Low-volume Hospitals and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-07

    ...) of the Act, we refer readers to the FY 2013 IPPS/LTCH PPS final rule (77 FR 53406 through 53408... Affordable Care Act in the FY 2011 IPPS/LTCH PPS final rule (75 FR 50238 through 50275 and 50414). In... for requesting and obtaining the low-volume hospital payment adjustment for FY 2011 (75 FR 50240)....

  11. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... HEALTH CARE PREPAYMENT PLANS Medicare Payment: Cost Basis § 417.550 Special Medicare program requirements... 42 Public Health 3 2010-10-01 2010-10-01 false Special Medicare program requirements. 417.550 Section 417.550 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND...

  12. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... HEALTH CARE PREPAYMENT PLANS Medicare Payment: Cost Basis § 417.550 Special Medicare program requirements... 42 Public Health 3 2011-10-01 2011-10-01 false Special Medicare program requirements. 417.550 Section 417.550 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND...

  13. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2016. Final rule.

    PubMed

    2015-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2016 as required by the statute. As required by section 1886(j)(5) of the Act, this rule includes the classification and weighting factors for the IRF PPS's case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2016. This final rule also finalizes policy changes, including the adoption of an IRF-specific market basket that reflects the cost structures of only IRF providers, a 1-year phase-in of the revised wage index changes, a 3-year phase-out of the rural adjustment for certain IRFs, and revisions and updates to the quality reporting program (QRP). PMID:26248390

  14. 77 FR 68891 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-16

    ... prescribing FFS Fee-for-service FR Federal Register GAF Geographic adjustment factor GAO Government... comment period (76 FR 72452). Several types of providers are projected to see decreases in Medicare PFS... on November 25, 1991 (56 FR 59502) set forth the fee schedule for payment for physicians'...

  15. 78 FR 58385 - Medicare Program; Prospective Payment System for Federally Qualified Health Centers; Changes to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-23

    ... period (57 FR 24961) and the April 3, 1996 final rule (61 FR 14640). Regulations pertaining to FQHCs are... provided on or after January 1, 2011. Accordingly, in the CY 2011 Medicare PFS final rule (75 FR...

  16. 76 FR 72708 - Medicare Program; Renaming and Other Changes to the Advisory Panel on Hospital Outpatient Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-25

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Renaming and Other Changes to.... Background The Secretary of the Department of Health and Human Services (the Secretary) is required by..., that the Panel is diverse in all respects of the following: Geography, rural or urban practice,...

  17. 78 FR 2407 - Medicare Payment Advisory Commission Nomination Letters

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-11

    ... From the Federal Register Online via the Government Publishing Office GOVERNMENT ACCOUNTABILITY OFFICE Medicare Payment Advisory Commission Nomination Letters AGENCY: Government Accountability Office... the Medicare Payment Advisory Commission (MedPAC) and gave the Comptroller General responsibility...

  18. 77 FR 42735 - Appointments to the Medicare Payment Advisory Commission

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-20

    ... From the Federal Register Online via the Government Publishing Office GOVERNMENT ACCOUNTABILITY OFFICE Appointments to the Medicare Payment Advisory Commission AGENCY: Government Accountability Office... Medicare Payment Advisory Commission (MedPAC) and gave the Comptroller General responsibility...

  19. 76 FR 81503 - Medicare Payment Advisory Commission Nomination Letters

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-28

    ... From the Federal Register Online via the Government Publishing Office GOVERNMENT ACCOUNTABILITY OFFICE Medicare Payment Advisory Commission Nomination Letters AGENCY: Government Accountability Office... the Medicare Payment Advisory Commission (MedPAC) and gave the Comptroller General responsibility...

  20. 76 FR 5591 - Medicare Payment Advisory Commission Nomination Letters

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-01

    ... From the Federal Register Online via the Government Publishing Office GOVERNMENT ACCOUNTABILITY OFFICE Medicare Payment Advisory Commission Nomination Letters AGENCY: Government Accountability Office... the Medicare Payment Advisory Commission (MedPAC) and gave the Comptroller General responsibility...

  1. Medicare program; self-implementing coverage and payments provisions: 1990 legislation--HCFA. Final rule with comment period.

    PubMed

    1992-08-12

    This rule updates Medicare regulations to add or conform them to certain self-implementing provisions on coverage of services and payment requirements under the Omnibus Budget Reconciliation Act of 1990 (OBRA '90). OBRA '90 was enacted November 5, 1990 and the cited changes to the statute are already in effect. Certain related self-implementing provisions of the Omnibus Budget Reconciliation Act of 1989 (OBRA '89), and the Medicare Catastrophic Coverage Act (MCCA) of 1988, are included as necessary for consistency and clarity of the OBRA '90 provisions. PMID:10121189

  2. Medicare program; revision of ambulatory surgical center payment rate methodology--HCFA. Final notice of payment rates.

    PubMed

    1990-02-01

    This final notice sets forth the revised payment rates for ambulatory surgical center services. We are refining the methodology used to determine the payment rates and have based the rates on the most recent survey data collected from participating ambulatory surgical centers. In addition, we have computed the payment rates using the HCFA hospital wage index. We are also incorporating the payment for intraocular lens inserted during cataract surgery into the facility rate as required by section 4063(b) of the Omnibus Budget Reconciliation Act of 1987. Finally, we are changing the payment policy for surgical procedures that are terminated due to medical complications that increase the surgical risk to the patient. As a result of the refinements to our ratesetting methodology, this final notice establishes eight payment groups rather than the six proposed groups. Of these eight groups, two groups (Group 6 and Group 8) contain only cataract procedures. PMID:10170503

  3. 75 FR 14606 - Medicare Program; Request for Nominations to the Advisory Panel on Ambulatory Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-03-26

    ... of the following: Geography; rural or urban practice; race, ethnicity, sex, and disability; medical... enable them to participate fully in the Panel's work. Such expertise encompasses hospital payment...

  4. 75 FR 23851 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-05-04

    ... public comments, phone 1-800-743-3951. Electronic Access This Federal Register document is also available...; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Fiscal Year 2011 Rates; Effective...

  5. 42 CFR 493.1828 - Suspension of all Medicare payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 5 2013-10-01 2013-10-01 false Suspension of all Medicare payments. 493.1828 Section 493.1828 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Suspension of all Medicare payments. (a) Application. (1) CMS may suspend payment for all...

  6. 42 CFR 493.1828 - Suspension of all Medicare payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 5 2011-10-01 2011-10-01 false Suspension of all Medicare payments. 493.1828 Section 493.1828 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Suspension of all Medicare payments. (a) Application. (1) CMS may suspend payment for all...

  7. 42 CFR 493.1828 - Suspension of all Medicare payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 5 2014-10-01 2014-10-01 false Suspension of all Medicare payments. 493.1828 Section 493.1828 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Suspension of all Medicare payments. (a) Application. (1) CMS may suspend payment for all...

  8. 42 CFR 493.1828 - Suspension of all Medicare payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 5 2012-10-01 2012-10-01 false Suspension of all Medicare payments. 493.1828 Section 493.1828 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Suspension of all Medicare payments. (a) Application. (1) CMS may suspend payment for all...

  9. 42 CFR 493.1828 - Suspension of all Medicare payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Suspension of all Medicare payments. 493.1828 Section 493.1828 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Suspension of all Medicare payments. (a) Application. (1) CMS may suspend payment for all...

  10. 78 FR 29139 - Medicare Program; Bundled Payments for Care Improvement Model 1 Open Period

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-17

    ... committed to achieving better health, better care, and lower costs through continuous improvement for... costs through continuous improvement. Create a cycle that leads to continually decreasing the cost of an... Improvement Model 1 Open Period AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION:...

  11. 76 FR 32085 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Rate...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-03

    ...This document corrects two technical errors that appeared in the final rule published in the Federal Register on May 6, 2011 entitled, ``Inpatient Psychiatric Facilities Prospective Payment System--Update for Rate Year Beginning July 1, 2011 (RY...

  12. 42 CFR 418.405 - Effect of coinsurance liability on Medicare payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Effect of coinsurance liability on Medicare payment. 418.405 Section 418.405 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Coinsurance § 418.405 Effect...

  13. 42 CFR 418.405 - Effect of coinsurance liability on Medicare payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Effect of coinsurance liability on Medicare payment. 418.405 Section 418.405 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Coinsurance § 418.405 Effect...

  14. 42 CFR 418.405 - Effect of coinsurance liability on Medicare payment.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Effect of coinsurance liability on Medicare payment. 418.405 Section 418.405 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Coinsurance § 418.405...

  15. 42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED...

  16. 42 CFR 417.528 - Payment when Medicare is not primary payer.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Payment when Medicare is not primary payer. 417.528 Section 417.528 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  17. 42 CFR 418.405 - Effect of coinsurance liability on Medicare payment.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Effect of coinsurance liability on Medicare payment. 418.405 Section 418.405 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Coinsurance § 418.405...

  18. 42 CFR 417.528 - Payment when Medicare is not primary payer.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Payment when Medicare is not primary payer. 417.528 Section 417.528 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  19. 42 CFR 417.528 - Payment when Medicare is not primary payer.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payment when Medicare is not primary payer. 417.528 Section 417.528 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS,...

  20. 42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED...

  1. 42 CFR 417.528 - Payment when Medicare is not primary payer.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Payment when Medicare is not primary payer. 417.528 Section 417.528 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  2. 42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED...

  3. 42 CFR 417.528 - Payment when Medicare is not primary payer.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Payment when Medicare is not primary payer. 417.528 Section 417.528 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS,...

  4. 42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED...

  5. 42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED...

  6. 42 CFR 418.405 - Effect of coinsurance liability on Medicare payment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Effect of coinsurance liability on Medicare payment. 418.405 Section 418.405 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Coinsurance § 418.405...

  7. 75 FR 30917 - Medicare Program; Supplemental Proposed Changes to the Hospital Inpatient Prospective Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-02

    ... Federal Register (75 FR 23852). Therefore, the proposed policies and payment rates in that proposed rule... 1, 2009 (74 FR 43838). In implementing section 3137(c) of Public Law 111-148, we requested the... Adjustment for the Rural and Imputed Floors In the FY 2009 IPPS final rule (73 FR 48574 through 48575),...

  8. 76 FR 70227 - Medicare Program; End-Stage Renal Disease Prospective Payment System and Quality Incentive...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-10

    ...This final rule updates and makes certain revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2012. We are also finalizing the interim final rule with comment period published on April 6, 2011, regarding the transition budget-neutrality adjustment under the ESRD PPS,. This final rule also sets forth requirements for the ESRD quality incentive......

  9. 78 FR 54842 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-06

    ... 2014 Changes for the Hospital Outpatient Prospective Payments System (78 FR 43692) and the correlating preamble language (78 FR 43689). As noted previously, because the OPPS is a budget neutral system, and... within the system. The corrections to this impact table (78 FR 43692) relative to the impact...

  10. 78 FR 74229 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-10

    ... FFS Fee-for-service FOBT Fecal occult blood test FQHC Federally qualified health center FR Federal... November 25, 1991 (56 FR 59502) set forth the first fee schedule used for payment for physicians' services... rule, published November 2, 1998 (63 FR 58814), effective for services furnished in CY 1999. Based...

  11. 75 FR 49029 - Medicare Program; End-Stage Renal Disease Prospective Payment System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-12

    ... Federal Register a proposed rule entitled ``End-Stage Renal Disease Prospective Payment System'' (74 FR... separately billable services into a single base rate of $198.64 developed from CY 2007 claims data (74 FR... FR 49949). The case-mix adjusters would include variables for age, body surface area (BSA), low...

  12. 77 FR 47223 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-07

    ...) in a final rule that appeared in the November 15, 2004 Federal Register (69 FR 66922). In developing... publish a notice in the Federal Register each spring to update the IPF PPS (71 FR 27041). In the May 6, 2011 IPF PPS final rule (76 FR 26432), we changed the payment rate update period to a rate year...

  13. 75 FR 42885 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-22

    ... Unfunded Mandates Reform Act, Public Law 104-4 I. Background Annual updates to the prospective payment... period described in section 1888(e)(2)(E) of the Act. In the final rule for FY 2002 (66 FR 39562, July 31... Act. DATES: Effective Date: The rate updates in this notice with comment period are effective...

  14. 76 FR 26363 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-06

    ... Health Center FR Federal Register FY Fiscal Year GAO Government Accountability Office HAC Hospital... notice with comment period (75 FR 42886, July 22, 2010) that set forth updates to the SNF PPS payment rates for fiscal year (FY) 2011. We subsequently published a correction notice (75 FR 55801,...

  15. 76 FR 59265 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-26

    ... Nursing Facility (SNF) Prospective Payment System (PPS) final rule (76 FR 48486, 48540) inadvertently... FURTHER INFORMATION CONTACT: John Kane, (410) 786-0557. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2011-19544 of August 8, 2011 (76 FR 48486), there were three technical errors that are identified...

  16. 75 FR 81138 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-27

    ... Hospices'' final rule (75 FR 70372). DATES: Effective Date: This correction is effective January 1, 2011.... Background In FR Doc. 2010-27778 of November 17, 2010 (75 FR 70372), there was a technical error that this... calculation of the NRS payment amounts for services provided in rural areas. III. Correction of Errors In...

  17. 78 FR 26879 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-08

    ... IRF PPS notice (77 FR 44618) to update the Federal prospective payment rates for FY 2014 using updated... 2002 IRF PPS final rule (66 FR 41316) and the FY 2006 IRF PPS final rule (70 FR 47880), we are... PPS from FY 2002 through FY 2005, as described in the FY 2002 IRF PPS final rule (66 FR 41316),...

  18. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Policy Changes and Fiscal Year 2016 Rates; Revisions of Quality Reporting Requirements for Specific Providers, Including Changes Related to the Electronic Health Record Incentive Program; Extensions of the Medicare-Dependent, Small Rural Hospital Program and the Low-Volume Payment Adjustment for Hospitals. Final rule; interim final rule with comment period.

    PubMed

    2015-08-17

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2016. Some of these changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act), the Pathway for Sustainable Growth Reform(SGR) Act of 2013, the Protecting Access to Medicare Act of 2014, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, and other legislation. We also are addressing the update of the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2016.As an interim final rule with comment period, we are implementing the statutory extensions of the Medicare dependent,small rural hospital (MDH)Program and changes to the payment adjustment for low-volume hospitals under the IPPS.We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2016 and implementing certain statutory changes to the LTCH PPS under the Affordable Care Act and the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of 2014.In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific providers (acute care hospitals,PPS-exempt cancer hospitals, and LTCHs) that are participating in Medicare, including related provisions for eligible hospitals and critical access hospitals participating in the Medicare Electronic Health Record (EHR)Incentive Program. We also are updating policies relating to the

  19. 75 FR 32858 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-10

    ...-AP77 Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...; Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit... entitled ``Medicare Program; Policy and Technical Changes to the Medicare Advantage and the...

  20. Cost of schizophrenia in the Medicare program.

    PubMed

    Feldman, Rachel; Bailey, Robert A; Muller, James; Le, Jennifer; Dirani, Riad

    2014-06-01

    Medicare beneficiaries diagnosed with non-schizoaffective schizophrenia (MBS) in a 5% national Medicare fee-for-service sample from 2003-2007 were followed for 1-6 years. Medicare population and cost estimates also were made from 2001-2009. Service utilization and Medicare (and beneficiary share) payments for all services except prescription drugs were analyzed. Although adults with schizophrenia make up approximately 1% of the US adult population, they represent about 1.5% of Medicare beneficiaries. MBSs are disproportionately male and minority compared to national data describing the overall schizophrenia population. They also are younger than the general Medicare population (GMB): males are 9 years younger than females on average, and most enter Medicare long before age 65 through eligibility for social security disability, remaining in the program until death. The cost of care for MBSs in 2009 was, on average, 80% higher than for the average GMB per patient year (2010 dollars), and more than 50% of these costs are attributable to a combination of psychiatric and medical hospitalizations, concentrated in about 30% of MBSs with 1 or more hospitalizations per year. From 2004-2009, total estimated Medicare fee-for-service payments for MBSs increased from $9.4 billion to $11.5 billion, excluding Part D prescription drugs and payments for services to MBSs in Medicare for less than 1 year. Study results characterize utilization and costs for other services and suggest opportunities for further study to inform policy to improve access and continuity of care and decrease costs to the Medicare program associated with this population. PMID:24156665

  1. Valuing neurosurgery services: part II. The interdependence of Current Procedural Terminology and federal Medicare payment policy.

    PubMed

    Bean, James R

    2002-04-15

    Current Procedural Terminology (CPT) policies for coding of medical procedures and services are adopted by the American Medical Association CPT editorial panel. Since institution of the Medicare Fee Schedule in 1992, the Medicare budget neutrality rule has strongly influenced CPT policies for the coding of additions or modifications. The Centers for Medicare and Medicaid Services Medicare program policies, particularly payment limits, influence code modification strategies and CPT editorial panel processes. PMID:16212303

  2. 42 CFR 413.82 - Direct GME payments: Special rules for States that formerly had a waiver from Medicare...

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... formerly had a waiver from Medicare reimbursement principles. 413.82 Section 413.82 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES... Direct GME payments: Special rules for States that formerly had a waiver from Medicare...

  3. 42 CFR 417.448 - Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Medicare enrollees of risk HMOs or CMPs. 417.448 Section 417.448 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH..., and Disenrollment under Medicare Contract § 417.448 Restriction on payments for services received...

  4. 42 CFR 417.448 - Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... Medicare enrollees of risk HMOs or CMPs. 417.448 Section 417.448 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH..., and Disenrollment under Medicare Contract § 417.448 Restriction on payments for services received...

  5. 42 CFR 417.448 - Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... Medicare enrollees of risk HMOs or CMPs. 417.448 Section 417.448 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH..., and Disenrollment under Medicare Contract § 417.448 Restriction on payments for services received...

  6. 42 CFR 417.448 - Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Medicare enrollees of risk HMOs or CMPs. 417.448 Section 417.448 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE... Disenrollment under Medicare Contract § 417.448 Restriction on payments for services received by...

  7. 42 CFR 413.82 - Direct GME payments: Special rules for States that formerly had a waiver from Medicare...

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... formerly had a waiver from Medicare reimbursement principles. 413.82 Section 413.82 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES... Direct GME payments: Special rules for States that formerly had a waiver from Medicare...

  8. 42 CFR 417.448 - Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Medicare enrollees of risk HMOs or CMPs. 417.448 Section 417.448 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE... Disenrollment under Medicare Contract § 417.448 Restriction on payments for services received by...

  9. 76 FR 18930 - Medicare Programs: Changes to the End-Stage Renal Disease Prospective Payment System Transition...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-06

    ... published a final rule (75 FR 49030 through 49214) in the Federal Register, entitled ``Medicare Program; End... the transition budget-neutrality adjustment. As described in the CY 2011 ESRD PPS final rule (75 FR... FR 49082), we explained that section 1881(b)(14)(E)(iii) of the Act requires that we make...

  10. For Medicare's New Approach To Physician Payment, Big Questions Remain.

    PubMed

    Wynne, Billy

    2016-09-01

    The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established a new framework for Medicare physician payment. Designed to stabilize uncertain payment rates for Medicare's fee-for-service (FFS) system and incentivize physicians to move into new alternative payment systems, MACRA contains several uncertainties of its own. In a textbook illustration of why it's important to be careful what you wish for, it's increasingly easy to predict that implementation of MACRA will be delayed as a result of both regulatory and legislative breaches of its statutory timeline. This article traces the contemporary history of the Medicare physician payment system and efforts to implement additional changes. PMID:27605645

  11. 78 FR 38679 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-27

    ... Program. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2013-10234 of May 10, 2013 (78 FR 27486... errors. ] III. Correction of Errors In FR Doc. 2013-10234 of May 10, 2013 (78 FR 27486), make the... Hours--Continuous. Stimulation target Cortical; varies according to Deep brain nuclei... Ascending...

  12. 77 FR 60315 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-03

    .... SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2012-19079 of August 31, 2012 (77 FR 53258), there were a... grammatical error in our discussion of the Agency for Healthcare Research and Quality (AHRQ) indicators. On... regarding the final performance standards for the FY 2015 Hospital Value-Base Purchasing (HVBP) Program,...

  13. 75 FR 60640 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-10-01

    .... Background In FR Doc. 2010-19092 of August 16, 2010 (75 FR 50042), there were a number of technical errors... FR Doc. 2010-19092 of August 16, 2010, make the following corrections: A. Corrections to the Preamble... Rehabilitation and Respiratory Care Services; Medicaid Program: Accreditation for Providers of...

  14. 77 FR 217 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-04

    ..., Hospital Value-Based Purchasing (VBP) Program Issues. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2011-28612 of November 30, 2011 (76 FR 74122), (hereinafter referred to as the CY 2012 OPPS/ASC final... they had been included in the CY 2012 OPPS/ASC final rule with comment period (76 FR 74122)...

  15. 76 FR 15316 - Medicaid Program; State Allotments for Payment of Medicare Part B Premiums for Qualifying...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-21

    ... November 24, 2008 (73 FR 70893), and reflecting funding for the QI program made available under the legislation discussed above. II. Charts The final QI allotments for FY 2010 and the preliminary QI allotments.... SUMMARY: This notice contains charts providing the States' final allotments available to pay the...

  16. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals. Final rule.

    PubMed

    2016-08-22

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2017. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and

  17. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection. Final Rule.

    PubMed

    2015-08-01

    This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2016. In addition, it specifies a SNF all-cause all-condition hospital readmission measure, as well as adopts that measure for a new SNF Value-Based Purchasing (VBP) Program, and includes a discussion of SNF VBP Program policies we are considering for future rulemaking to promote higher quality and more efficient health care for Medicare beneficiaries. Additionally, this final rule will implement a new quality reporting program for SNFs as specified in the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). It also amends the requirements that a long-term care (LTC) facility must meet to qualify to participate as a skilled nursing facility (SNF) in the Medicare program, or a nursing facility (NF) in the Medicaid program, by establishing requirements that implement the provision in the Affordable Care Act regarding the submission of staffing information based on payroll data. PMID:26242002

  18. Medicare's prospective payment system: A critical appraisal

    PubMed Central

    Coulam, Robert F.; Gaumer, Gary L.

    1992-01-01

    Implementation of the Medicare prospective payment system (PPS) for hospital payment has produced major changes in the hospital industry and in the way hospital services are used by physicians and their patients. The substantial published literature that examines these changes is reviewed in this article. This literature suggests that most of the intended effects of PPS on costs and intensity of care have been realized. But the literature fails to answer fundamental questions about the effectiveness and equity of administered pricing as a policy tool for cost containment. The literature offers some hope that the worst fears about the effects of PPS on quality of care and the health of the hospital industry have not materialized. But because of data lags, the studies done to date seem to tell us more about the effects of the early, more generous period of PPS than about the opportunity costs of reducing hospital cost inflation. PMID:25372306

  19. 76 FR 60378 - Exclusions From Medicare and Limitations on Medicare Payment

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-29

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare and Medicaid 42 CFR Part 411 Exclusions From Medicare and Limitations on Medicare Payment CFR Correction In Title 42 of the Code of Federal Regulations, Parts 400...

  20. 75 FR 56015 - Exclusions from Medicare and Limitations on Medicare Payment

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-15

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 411 Exclusions from Medicare and Limitations on Medicare Payment CFR Correction In Title 42 of the Code of Federal Regulations, Parts 400...

  1. Prospective payment for hospital capital by Medicare: issues and options.

    PubMed

    Sloan, F A; Valvona, J

    1986-01-01

    After this year, Medicare will no longer reimburse capital-related expenses. Instead, a new approach may be implemented. Should the new capital payment scheme be prospective? Should Medicare continue to recognize return on equity? What will be the relationship between Medicare payment and health care planning? These and other questions should be asked since the answers will directly affect the health care setting. PMID:3519530

  2. 77 FR 32407 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-01

    ... Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for...; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year...-9364. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2012-8071 of April 12, 2012 (77 FR...

  3. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... similar hospital services under 42 CFR part 412. Payment for outpatient hospital services shall be made based on a PPS used in the Medicare program to pay for similar hospital services under 42 CFR part 419... to pay for similar SNF services under 42 CFR part 413. (2) For Medicare participating hospitals...

  4. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... similar hospital services under 42 CFR part 412. Payment for outpatient hospital services shall be made based on a PPS used in the Medicare program to pay for similar hospital services under 42 CFR part 419... to pay for similar SNF services under 42 CFR part 413. (2) For Medicare participating hospitals...

  5. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... similar hospital services under 42 CFR part 412. Payment for outpatient hospital services shall be made based on a PPS used in the Medicare program to pay for similar hospital services under 42 CFR part 419... to pay for similar SNF services under 42 CFR part 413. (2) For Medicare participating hospitals...

  6. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... similar hospital services under 42 CFR part 412. Payment for outpatient hospital services shall be made based on a PPS used in the Medicare program to pay for similar hospital services under 42 CFR part 419... to pay for similar SNF services under 42 CFR part 413. (2) For Medicare participating hospitals...

  7. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... similar hospital services under 42 CFR part 412. Payment for outpatient hospital services shall be made based on a PPS used in the Medicare program to pay for similar hospital services under 42 CFR part 419... to pay for similar SNF services under 42 CFR part 413. (2) For Medicare participating hospitals...

  8. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Requirements for enrolling in the Medicare program. 424.510 Section 424.510 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  9. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Requirements for enrolling in the Medicare program. 424.510 Section 424.510 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  10. 75 FR 71064 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-22

    ... Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit... Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2012 and Other... CONTACT: Sabrina Ahmed, (410) 786-7499. SUPPLEMENTARY INFORMATION: I. Background In FR Doc....

  11. 42 CFR 411.53 - Basis for conditional Medicare payment in no-fault cases.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for conditional Medicare payment in no-fault... Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.53 Basis for conditional Medicare payment in no-fault cases. (a) A conditional Medicare payment may be made in...

  12. 42 CFR 411.53 - Basis for conditional Medicare payment in no-fault cases.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for conditional Medicare payment in no-fault... Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.53 Basis for conditional Medicare payment in no-fault cases. (a) A conditional Medicare payment may be made in...

  13. 42 CFR 411.53 - Basis for conditional Medicare payment in no-fault cases.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for conditional Medicare payment in no-fault... Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.53 Basis for conditional Medicare payment in no-fault cases. (a) A conditional Medicare payment may be made in...

  14. 42 CFR 411.53 - Basis for conditional Medicare payment in no-fault cases.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for conditional Medicare payment in no-fault... Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.53 Basis for conditional Medicare payment in no-fault cases. (a) A conditional Medicare payment may be made in...

  15. 42 CFR 411.53 - Basis for conditional Medicare payment in no-fault cases.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for conditional Medicare payment in no-fault... Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.53 Basis for conditional Medicare payment in no-fault cases. (a) A conditional Medicare payment may be made in...

  16. Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2006 and certain provisions related to the Competitive Acquisitions Program of outpatient drugs and biologicals under Part B. Final rule with comment.

    PubMed

    2005-11-21

    This rule addresses Medicare Part B payment policy, including the physician fee schedule that are applicable for calendar year (CY) 2006; and finalizes certain provisions of the interim final rule to implement the Competitive Acquisition Program (CAP) for Part B Drugs. It also revises Medicare Part B payment and related policies regarding: Physician work; practice expense (PE) and malpractice relative value units (RVUs); Medicare telehealth services; multiple diagnostic imaging procedures; covered outpatient drugs and biologicals; supplemental payments to Federally Qualified Health Centers (FQHCs); renal dialysis services; coverage for glaucoma screening services; National Coverage Decision (NCD) timeframes; and physician referrals for nuclear medicine services and supplies to health care entities with which they have financial relationships. In addition, the rule finalizes the interim RVUs for CY 2005 and issues interim RVUs for new and revised procedure codes for CY 2006. This rule also updates the codes subject to the physician self-referral prohibition and discusses payment policies relating to teaching anesthesia services, therapy caps, private contracts and opt-out, and chiropractic and oncology demonstrations. As required by the statute, it also announces that the physician fee schedule update for CY 2006 is -4.4 percent, the initial estimate for the sustainable growth rate for CY 2006 is 1.7 percent and the conversion factor for CY 2006 is $36.1770. PMID:16299947

  17. 42 CFR 405.371 - Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services. 405.371 Section 405.371 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE...

  18. 42 CFR 405.371 - Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services. 405.371 Section 405.371 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE...

  19. 42 CFR 405.371 - Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services. 405.371 Section 405.371 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE...

  20. 42 CFR 405.371 - Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services. 405.371 Section 405.371 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE...

  1. Medicare payments to the neurology workforce in 2012

    PubMed Central

    Skolarus, Lesli E.; Burke, James F.; Callaghan, Brian C.; Becker, Amanda

    2015-01-01

    Objective: Little is known about how neurology payments vary by service type (i.e., evaluation and management [E/M] vs tests/treatments) and compare to other specialties, yet this information is necessary to help neurology define its position on proposed payment reform. Methods: Medicare Provider Utilization and Payment Data from 2012 were used. These data included all direct payments to providers who care for fee-for-service Medicare recipients. Total payment was determined by medical specialty and for various services (e.g., E/M, EEG, electromyography/nerve conduction studies, polysomnography) within neurology. Payment and proportion of services were then calculated across neurologists' payment categories. Results: Neurologists comprised 1.5% (12,317) of individual providers who received Medicare payments and were paid $1.15 billion by Medicare in 2012. Sixty percent ($686 million) of the Medicare payment to neurologists was for E/M, which was a lower proportion than primary providers (approximately 85%) and higher than surgical subspecialties (range 9%–51%). The median neurologist received nearly 75% of their payments from E/M. Two-thirds of neurologists received 60% or more of their payment from E/M services and over 20% received all of their payment from E/M services. Neurologists in the highest payment category performed more services, of which a lower proportion were E/M, and performed at a facility, compared to neurologists in lower payment categories. Conclusion: E/M is the dominant source of payment to the majority of neurologists and should be prioritized by neurology in payment restructuring efforts. PMID:25832665

  2. Medicare and Medicaid programs; Home Health Prospective Payment System rate update for CY 2014, home health quality reporting requirements, and cost allocation of home health survey expenses. Final rule.

    PubMed

    2013-12-01

    This final rule will update the Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, the low-utilization payment adjustment (LUPA) add-on, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective January 1, 2014. As required by the Affordable Care Act, this rule establishes rebasing adjustments, with a 4-year phase-in, to the national, standardized 60-day episode payment rates; the national per-visit rates; and the NRS conversion factor. In addition, this final rule will remove 170 diagnosis codes from assignment to diagnosis groups within the HH PPS Grouper, effective January 1, 2014. Finally, this rule will establish home health quality reporting requirements for CY 2014 payment and subsequent years and will clarify that a state Medicaid program must provide that, in certifying HHAs, the state's designated survey agency carry out certain other responsibilities that already apply to surveys of nursing facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID), including sharing in the cost of HHA surveys. For that portion of costs attributable to Medicare and Medicaid, we will assign 50 percent to Medicare and 50 percent to Medicaid, the standard method that CMS and states use in the allocation of expenses related to surveys of nursing homes. PMID:24294635

  3. 77 FR 70447 - Medicare Program; Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment (HOP...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-26

    ... Department of Health and Human Services (DHHS) (the Secretary) and the Administrator of the Centers for Medicare & Medicaid Services (CMS) (the Administrator) on the clinical integrity of the APC groups and...: November 14, 2012. Marilyn Tavenner, Acting Administrator, Centers for Medicare & Medicaid...

  4. 77 FR 31366 - Medicare Program; Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment (HOP...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-25

    ... Department of Health and Human Services (DHHS) (the Secretary) and the Administrator of the Centers for Medicare & Medicaid Services (CMS) (the Administrator) on the clinical integrity of the APC groups and... Administrator, Centers for Medicare & Medicaid Services. BILLING CODE 4120-01-P...

  5. The continuing cost of privatization: extra payments to Medicare Advantage plans jump to $11.4 billion in 2009.

    PubMed

    Biles, Brian; Pozen, Jonah; Guterman, Stuart

    2009-05-01

    The Medicare Modernization Act of 2003 explicitly increased Medicare payments to private Medicare Advantage (MA) plans. As a result, MA plans have, for the past six years, been paid more for their enrollees than they would be expected to cost in traditional fee-for-service Medicare. Payments to MA plans in 2009 are projected to be 13 percent greater than the corresponding costs in traditional Medicare--an average of $1,138 per MA plan enrollee, for a total of $11.4 billion. Although the extra payments are used to provide enrollees additional benefits, those benefits are not available to all beneficiaries-- but they are financed by general program funds. If payments to MA plans were instead equal to the spending level under traditional Medicare, the more than $150 billion in savings over 10 years could be used to finance improved benefits for the low-income elderly and disabled, or for expanding health-insurance coverage. PMID:19449498

  6. 75 FR 38533 - Medicare Program; Second Semi-Annual Meeting of the Advisory Panel on Ambulatory Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-02

    ... the Advisory Panel on Ambulatory Payment Classification Groups--August 23 & 24, 2010 AGENCY: Centers...: This notice announces the second semi-annual meeting of the Advisory Panel on Ambulatory Payment.../FACA/05_AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp#TopOfPage to obtain the...

  7. 78 FR 43820 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-22

    ... Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug...; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug Benefit... In FR Doc. 2013-12156 of May 23, 2013 (78 FR 31284), there were a number of technical,...

  8. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and Fiscal Year 2014 rates; quality reporting requirements for specific providers; hospital conditions of participation; payment policies related to patient status. Final rules.

    PubMed

    2013-08-19

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems. Some of the changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act) and other legislation. These changes will be applicable to discharges occurring on or after October 1, 2013, unless otherwise specified in this final rule. We also are updating the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits will be effective for cost reporting periods beginning on or after October 1, 2013. We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and implementing certain statutory changes that were applied to the LTCH PPS by the Affordable Care Act. Generally, these updates and statutory changes will be applicable to discharges occurring on or after October 1, 2013, unless otherwise specified in this final rule. In addition, we are making a number of changes relating to direct graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or have revised requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities (IPFs)) that are participating in Medicare. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program. In addition, we are revising the conditions of participation (CoPs) for hospitals relating to the

  9. 78 FR 7434 - Medicare Program: Notice of Two Membership Appointments to the Advisory Panel on Hospital...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-01

    ... Program; Solicitation of Two Nominations to the Advisory Panel on Hospital Outpatient Payment'' (77 FR... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program: Notice of Two Membership... announces two new membership appointments to the Advisory Panel on Hospital Outpatient Payment (HOP,...

  10. 76 FR 40497 - Medicare Program; Changes to the End-Stage Renal Disease Prospective Payment System for CY 2012...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-08

    ... Disease Bundled FDA Food and Drug Administration FI/MAC Fiscal Intermediary Medicare Administrative... August 12, 2010, we published in the Federal Register, a final rule (75 FR 49030 through 49214), entitled... 1886(b)(3)(B)(xi)(II) of the Act. In the CY 2011 ESRD PPS final rule (75 FR 49030), the Centers...

  11. Variation in Medicare Payments for Colorectal Cancer Surgery

    PubMed Central

    Abdelsattar, Zaid M.; Birkmeyer, John D.; Wong, Sandra L.

    2015-01-01

    Purpose: Colorectal cancer (CRC) is the second most expensive cancer in the United States. Episode-based bundled payments may be a strategy to decrease costs. However, it is unknown how payments are distributed across hospitals and different perioperative services. Methods: We extracted actual Medicare payments for patients in the fee-for-service Medicare population who underwent CRC surgery between January 2004 and Decembe 2006 (N = 105,016 patients). Payments included all service types from the date of hospitalization up to 1 year later. Hospitals were ranked from least to most expensive and grouped into quintiles. Results were case-mix adjusted and price standardized using empirical Bayes methods. We assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variation in payment. Results: There is wide variation in total payments for CRC care within the first year after CRC surgery. Actual Medicare payments were $51,345 per patient in the highest quintile and $26,441 per patient in the lowest quintile, representing a difference of Δ = $24,902. Differences were persistent after price standardization (Δ = $17,184 per patient) and case-mix adjustment (Δ = $4,790 per patient). Payments for the index surgical hospitalization accounted for the largest share (65%) of payments but only minimally varied (11.6%) across quintiles. However, readmissions and postacute care services accounted for substantial variations in total payments. Conclusion: Medicare spending in the first year after CRC surgery varies across hospitals even after case-mix adjustment and price standardization. Variation is largely driven by postacute care and not the index surgical hospitalization. This has significant implications for policy decisions on how to bundle payments and define episodes of surgical CRC care. PMID:26130817

  12. 76 FR 37121 - Medicare Program; Second Semi-Annual Meeting of the Advisory Panel on Ambulatory Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-24

    ... the Advisory Panel on Ambulatory Payment Classification Groups--August 10, 2011 Through August 12...: Notice. SUMMARY: This notice announces the second semi-annual meeting of the Advisory Panel on Ambulatory... at:...

  13. Alternative geographic configurations for Medicare payments to health maintenance organizations.

    PubMed

    Porell, F W; Tompkins, C P; Turner, W M

    1990-01-01

    Under prevailing legislation, Medicare payments to health maintenance organizations (HMOs) are based upon projected fee-for-service reimbursement levels for enrollees' county of residence. These rates have been criticized in light of substantial variations in rates among neighboring counties and large fluctuations in rates over time. In this study, the use of nine alternative configurations and the county itself were evaluated on the basis of payment-area homogeneity, payment rate stability, and policy criteria, including the fiscal impacts of reconfiguration on HMOs. The results revealed rather modest differences among most alternative configurations and do not lend strong support for payment area reconfiguration at this time. PMID:10113270

  14. Impact of Medicare payment reductions on access to surgical services.

    PubMed Central

    Mitchell, J B; Cromwell, J

    1995-01-01

    OBJECTIVE. This study evaluates the impact of surgical fee reductions under Medicare on the utilization of surgical services. DATA SOURCES. Medicare physician claims data were obtained from 11 states for a five-year time period (1985-1989). STUDY DESIGN. Under OBRA-87, Medicare reduced payments for 11 surgical procedures. A fixed effects regression method was used to determine the impact of these payment reductions on access to care for potentially vulnerable Medicare beneficiaries: joint Medicaid-eligibles, blacks, and the very old. DATA COLLECTION/EXTRACTION METHODS. Medicare claims and enrollment data were used to construct a cross-section time-series of population-based surgical rates from 1985 through 1989. PRINCIPAL FINDINGS. Reductions in surgical fees led to small but significant increases in use for three procedures, small decreases in use for two procedures, and no impact on the remaining six procedures. There was little evidence that access to surgery was impaired for potentially vulnerable enrollees; in fact, declining fees often led to greater rates of increases for some subgroups. CONCLUSIONS. Our results suggest that volume responses by surgeons to payment changes under the Medicare Fee Schedule may be smaller than HCFA's original estimates. Nevertheless, both access and quality of care should continue to be closely monitored. PMID:8537224

  15. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Limitations on Medicare Payment for Services Covered Under Workers' Compensation § 411.45 Basis for conditional Medicare payment in workers' compensation cases. (a) A conditional Medicare payment may be made...' compensation benefits, but the intermediary or carrier determines that the workers' compensation carrier...

  16. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Limitations on Medicare Payment for Services Covered Under Workers' Compensation § 411.45 Basis for conditional Medicare payment in workers' compensation cases. (a) A conditional Medicare payment may be made...' compensation benefits, but the intermediary or carrier determines that the workers' compensation carrier...

  17. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... Limitations on Medicare Payment for Services Covered Under Workers' Compensation § 411.45 Basis for conditional Medicare payment in workers' compensation cases. (a) A conditional Medicare payment may be made...' compensation benefits, but the intermediary or carrier determines that the workers' compensation carrier...

  18. 76 FR 42771 - Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-19

    ...--Federally Qualified Health Center FR--Federal Register FTE--full time equivalent GAF--Geographic adjustment... rule, published on November 25, 1991 (56 FR 59502), set forth the fee schedule for payment for... service in a final rule, published November 2, 1998 (63 FR 58814), effective for services furnished...

  19. 75 FR 40039 - Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-13

    ... renal disease FAX Facsimile FDA Food and Drug Administration (HHS) FFS Fee-for-service FR Federal... rule, published on November 25, 1991 (56 FR 59502), set forth the fee schedule for payment for...' service in a final rule, published November 2, 1998 (63 FR 58814), effective for services furnished...

  20. 77 FR 31620 - Medicare Program; Public Meeting in Calendar Year 2012 for New Clinical Laboratory Tests Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-29

    ... published in the Federal Register on November 23, 2001 (66 FR 58743), to implement section 531(b) of BIPA... in Sec. 414.509. (See the November 27, 2007 final rule (72 FR 66275 through 66280).) IV. Registration... Year 2012 for New Clinical Laboratory Tests Payment Determinations AGENCY: Centers for...

  1. 75 FR 30041 - Medicare Program; Public Meeting in Calendar Year 2010 for New Clinical Laboratory Tests Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-05-28

    ... on November 23, 2001 in the Federal Register (66 FR 58743) to implement section 531(b) of BIPA... set forth in 42 CFR 414.509. We also refer readers to the November 27, 2007 final rule (72 FR 66275... Year 2010 for New Clinical Laboratory Tests Payment Determinations AGENCY: Centers for...

  2. 76 FR 10600 - Medicare Program; Public Meeting in Calendar Year 2011 for New Clinical Laboratory Tests Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-25

    ... with the procedures published on November 23, 2001 in the Federal Register (66 FR 58743) to implement... forth in Sec. 414.509. We also refer readers to the November 27, 2007 final rule (72 FR 66275 through... Year 2011 for New Clinical Laboratory Tests Payment Determinations AGENCY: Centers for...

  3. 75 FR 78246 - Medicare Program; Re-Chartering of the Advisory Panel on Ambulatory Payment Classification (APC...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-15

    ... Charter effective through November 21, 2012. FOR FURTHER INFORMATION CONTACT: Shirl Ackerman-Ross, (410... new technology APCs to clinical APCs). Evaluating APC group weights. Reviewing packaging the cost of... methodology for packaging and the impact of packaging on APC group structure and payment. Removing...

  4. Medicare's New Bundled Payment For Joint Replacement May Penalize Hospitals That Treat Medically Complex Patients.

    PubMed

    Ellimoottil, Chandy; Ryan, Andrew M; Hou, Hechuan; Dupree, James; Hallstrom, Brian; Miller, David C

    2016-09-01

    In an effort to reduce episode payment variation for joint replacement at US hospitals, the Centers for Medicare and Medicaid Services (CMS) recently implemented the Comprehensive Care for Joint Replacement bundled payment program. Some stakeholders are concerned that the program may unintentionally penalize hospitals because it lacks a mechanism (such as risk adjustment) to sufficiently account for patients' medical complexity. Using Medicare claims for patients in Michigan who underwent lower extremity joint replacement in the period 2011-13, we applied payment methods analogous to those CMS intends to use in determining annual bonuses or penalties (reconciliation payments) to hospitals. We calculated the net difference in reconciliation payments with and without risk adjustment. We found that reconciliation payments were reduced by $827 per episode for each standard-deviation increase in a hospital's patient complexity. Moreover, we found that risk adjustment could increase reconciliation payments to some hospitals by as much as $114,184 annually. Our findings suggest that CMS should include risk adjustment in the Comprehensive Care for Joint Replacement program and in future bundled payment programs. PMID:27605647

  5. 42 CFR 422.322 - Source of payment and effect of MA plan election on payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to Medicare Advantage Organizations § 422.322 Source of payment and effect of MA plan election on payment. (a) Source...

  6. Medicare program; payment policies under the physician fee schedule, five-year review of work relative value units, clinical laboratory fee schedule: signature on requisition, and other revisions to part B for CY 2012. Final rule with comment period.

    PubMed

    2011-11-28

    This final rule with comment period addresses changes to the physician fee schedule and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. It also addresses, implements or discusses certain statutory provisions including provisions of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act) and the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. In addition, this final rule with comment period discusses payments for Part B drugs; Clinical Laboratory Fee Schedule: Signature on Requisition; Physician Quality Reporting System; the Electronic Prescribing (eRx) Incentive Program; the Physician Resource-Use Feedback Program and the value modifier; productivity adjustment for ambulatory surgical center payment system and the ambulance, clinical laboratory, and durable medical equipment prosthetics orthotics and supplies (DMEPOS) fee schedules; and other Part B related issues. PMID:22145186

  7. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2017, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and SNF Payment Models Research. Final rule.

    PubMed

    2016-08-01

    This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2017. In addition, it specifies a potentially preventable readmission measure for the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP), and implements requirements for that program, including performance standards, a scoring methodology, and a review and correction process for performance information to be made public, aimed at implementing value-based purchasing for SNFs. Additionally, this final rule includes additional polices and measures in the Skilled Nursing Facility Quality Reporting Program (SNF QRP). This final rule also responds to comments on the SNF Payment Models Research (PMR) project. PMID:27529900

  8. 76 FR 19527 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    ...This proposed rule would implement section 3022 of the Affordable Care Act which contains provisions relating to Medicare payments to providers of services and suppliers participating in Accountable Care Organizations (ACOs). Under these provisions, providers of services and suppliers can continue to receive traditional Medicare fee-for-service payments under Parts A and B, and be eligible for......

  9. 78 FR 16614 - Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-18

    ..., appeals of Part A claim denials that were remanded from the ALJ level to the QIC level will be returned to the ALJ level for adjudication of the Part A claim appeal consistent with the scope of review... Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part...

  10. Medicare and Medicaid programs; CY 2015 Home Health Prospective Payment System rate update; Home Health Quality Reporting Requirements; and survey and enforcement requirements for home health agencies. Final rule.

    PubMed

    2014-11-01

    This final rule updates Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective for episodes ending on or after January 1, 2015. As required by the Affordable Care Act, this rule implements the second year of the four-year phase-in of the rebasing adjustments to the HH PPS payment rates. This rule provides information on our efforts to monitor the potential impacts of the rebasing adjustments and the Affordable Care Act mandated face-to-face encounter requirement. This rule also implements: Changes to simplify the face-to-face encounter regulatory requirements; changes to the HH PPS case-mix weights; changes to the home health quality reporting program requirements; changes to simplify the therapy reassessment timeframes; a revision to the Speech-Language Pathology (SLP) personnel qualifications; minor technical regulations text changes; and limitations on the reviewability of the civil monetary penalty provisions. Finally, this rule also discusses Medicare coverage of insulin injections under the HH PPS, the delay in the implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), and a HH value-based purchasing (HH VBP) model. PMID:25376056

  11. Medicare

    MedlinePlus

    ... receiving health services. . . . . . . . . 15 If you have other health insurance. . . . . . . . . . . 15 Contacting Social Security Visit our website At ... 2048 What is Medicare? Medicare is our country’s health insurance program for people age 65 or older. People ...

  12. Medicare

    MedlinePlus

    Medicare is the U.S. government's health insurance program for people age 65 or older. Some people under age 65 can qualify for Medicare, too. They include those with disabilities, permanent kidney ...

  13. Medicare

    Cancer.gov

    The Centers for Medicare & Medicaid Services administers Medicare, a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease.

  14. 42 CFR 422.520 - Prompt payment by MA organization.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Application Procedures and Contracts for Medicare Advantage Organizations § 422.520 Prompt payment by MA organization. (a) Contract between CMS...

  15. Rethinking Medicare Payment Adjustments for Quality

    PubMed Central

    Averill, Richard F.; McCullough, Elizabeth C.; Hughes, John S.

    2016-01-01

    Payment reforms aimed at linking payment and quality have largely been based on the adherence to process measures. As a result, the attempt to pay for value is getting lost in an overly complex attempt to measure value. The “Incentivizing Health Care Quality Outcomes Act of 2014” (HR 5823) proposes to replace the existing patchwork of process and outcomes quality measures with a uniform, coordinated, and comprehensive outcomes-based quality measurement system. The Outcomes Act represents a shift in payment policy toward getting value instead of an increasingly complex attempt to measure value. PMID:26945288

  16. Private Carriers' Physician Payment Rates Compared With Medicare and Medicaid.

    PubMed

    Krause, Trudy Millard; Ukhanova, Maria; Revere, Frances Lee

    2016-01-01

    This research evaluated the 2013 published physician reimbursement rates for Medicare and Medicaid in Texas and compared the rates with the mean fees from private carriers. Physician claims data were extracted from the Truven MarketScan Commercial Claims Databases. The average allowed amounts per unit per procedure code were compiled. The 2013 Medicare physician fee schedule was obtained and filtered to Texas. The 2013 Texas Medicaid physician fee schedule was obtained. The mean commercial allowed amounts were compared with those of Medicare and Medicaid on a per-unit rate. Comparison ratios were derived for each code. The CPT© procedure codes were then grouped into the categories assigned by the American Medical Association. The ratios of private/Medicare and private/Medicaid varied greatly by procedure type and locality, with the Texas Medicaid fees well below both private and Medicare fees. The discrepancy in payment amounts demonstrates the variation in payment rates among payer sources. The practical implications demonstrate the provider challenges in managing patient mix to maintain a viable practice. PMID:27295293

  17. Medicare payment for selected adverse events: building the business case for investing in patient safety.

    PubMed

    Zhan, Chunliu; Friedman, Bernard; Mosso, Andrew; Pronovost, Peter

    2006-01-01

    This study estimates that Medicare extra payments under the hospital prospective payment system (PPS) range from about $700 per case of decubitus ulcer to $9,000 per case of postoperative sepsis in the five types of adverse events identifiable in Medicare claims. Medicare extra payment for the five types of events totals more than $300 million per year, accounting for 0.27 percent of annual Medicare hospital spending. But these extra payments cover less than a third of the extra costs incurred by hospitals in treating these adverse events. We conclude that both Medicare and hospitals gain financially by improving patient safety. PMID:16966737

  18. 42 CFR 447.31 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 447.31 Section 447.31 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Provisions § 447.31 Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and...

  19. 42 CFR 493.1826 - Suspension of part of Medicare payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 5 2012-10-01 2012-10-01 false Suspension of part of Medicare payments. 493.1826 Section 493.1826 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Suspension of part of Medicare payments. (a) Application. (1) CMS may impose this sanction if a...

  20. 42 CFR 447.31 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 447.31 Section 447.31 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Provisions § 447.31 Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and...

  1. 42 CFR 493.1826 - Suspension of part of Medicare payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Suspension of part of Medicare payments. 493.1826 Section 493.1826 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Suspension of part of Medicare payments. (a) Application. (1) CMS may impose this sanction if a...

  2. 42 CFR 493.1826 - Suspension of part of Medicare payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 5 2014-10-01 2014-10-01 false Suspension of part of Medicare payments. 493.1826 Section 493.1826 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Suspension of part of Medicare payments. (a) Application. (1) CMS may impose this sanction if a...

  3. 42 CFR 493.1826 - Suspension of part of Medicare payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 5 2011-10-01 2011-10-01 false Suspension of part of Medicare payments. 493.1826 Section 493.1826 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Suspension of part of Medicare payments. (a) Application. (1) CMS may impose this sanction if a...

  4. 42 CFR 447.31 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 447.31 Section 447.31 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Provisions § 447.31 Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and...

  5. 42 CFR 447.31 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 4 2011-10-01 2011-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 447.31 Section 447.31 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Provisions § 447.31 Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and...

  6. 42 CFR 493.1826 - Suspension of part of Medicare payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 5 2013-10-01 2013-10-01 false Suspension of part of Medicare payments. 493.1826 Section 493.1826 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Suspension of part of Medicare payments. (a) Application. (1) CMS may impose this sanction if a...

  7. Rebasing the Medicare payment for dialysis: rationale, challenges, and opportunities.

    PubMed

    Wish, Diane; Johnson, Doug; Wish, Jay

    2014-12-01

    After Medicare's implementation of the bundled payment for dialysis in 2011, there has been a predictable decrease in the use of intravenous drugs included in the bundle. The change in use of erythropoiesis-stimulating agents, which decreased by 37% between 2007, when its allowance in the bundle was calculated, and 2012, was because of both changes in the Food and Drug Administration labeling for erythropoiesis-stimulating agents in 2011 and cost-containment efforts at the facility level. Legislation in 2012 required Medicare to decrease (rebase) the bundled payment for dialysis in 2014 to reflect this decrease in intravenous drug use, which amounted to a cut of 12% or $30 per treatment. Medicare subsequently decided to phase in this decrease in payment over several years to offset the increase in dialysis payment that would otherwise have occurred with inflation. A 3% reduction from the rebasing would offset an approximately 3% increase in the market basket that determines a facility's costs for 2014 and 2015. Legislation in March of 2014 provides that the rebasing will result in a 1.25% decrease in the market basket adjustment in 2016 and 2017 and a 1% decrease in the market basket adjustment in 2018 for an aggregate rebasing of 9.5% spread over 5 years. Adjusting to this payment decrease in inflation-adjusted dollars will be challenging for many dialysis providers in an industry that operates at an average 3%-4% margin. Closure of facilities, decreases in services, and increased consolidation of the industry are possible scenarios. Newer models of reimbursement, such as ESRD seamless care organizations, offer dialysis providers the opportunity to align incentives between themselves, nephrologists, hospitals, and other health care providers, potentially improving outcomes and saving money, which will be shared between Medicare and the participating providers. PMID:25189926

  8. 75 FR 73169 - Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-29

    ... for Mileage 3. Analysis of and Responses to Public Comments a. Basis for Reconsideration of the... Quality Reporting System Measures (3) Summary of Comments and Responses i. The Final 2011 Physician... Initiative (PQRI) 3. Electronic Prescribing (eRx) Incentive Program X. Response to Comments XI....

  9. Prospective payment for Medicare hospital capital: Implications of the research

    PubMed Central

    Cotterill, Philip G.

    1992-01-01

    The special characteristics of capital have an important effect on the cross-section variation in hospitals' capital costs. Variables reflecting capital age and financing differences perform as expected and add substantial explanatory power to capital cost models. However, even with the inclusion of these variables, the capital-cost models perform poorly compared with total-cost models. The empirical findings of this article support using the total-cost models to develop a common set of adjustment factors for capital and operating payment amounts in the Medicare prospective payment system. PMID:25372157

  10. 42 CFR 414.906 - Competitive acquisition program as the basis for payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Competitive acquisition program as the basis for payment. 414.906 Section 414.906 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals...

  11. Medicare physician payment rules for 2011: a primer for the neurointerventionalist.

    PubMed

    Manchikanti, Laxmaiah; Hirsch, Joshua A

    2011-12-01

    Physicians generally have been affected by significant changes in the patterns of medical practice evolving over the past several decades. The Patient Protection and Affordable Care Act of 2010, also called ACA for short, impacts physician professional practice dramatically. Physicians are paid in the USA for their personal services. The payment system is highly variable in the private insurance market; however, governmental systems have a formula based payment, mostly based on the Medicare payment system. Physician services are billed under part B. The Neurointerventional practice is typically performed in a hospital setting. The VA system is a frequently cited successful implementation of a government supported health care program. Availability of neurointerventional services at many VA medical centers is limited. Since the inception of the Medicare program in 1965, several methods have been used to determine the amounts paid to physicians for each covered service. Initially, the payment systems compensated physicians on the basis of their charges. In 1975, just over 10 years after the inception of the Medicare program, payments changed so as not to exceed the increase in medical economic index. The involvement of medical economic index failed to curb increases in costs, leading to the determination of a yearly change in fees by legislation from 1984 to 1991. In 1992, the fee schedule essentially replaced the prior payment system that was based on the physician's charges, which also failed to curb the growth in spending. Thus, in 1998, the sustainable growth rate system was introduced. In 2009, multiple unsuccessful attempts were made by Congress to repeal the formula. The mechanism of the sustainable growth rate includes three components that are incorporated into a statutory formula: expenditure targets, growth rate period and annual adjustments of payment rates for physician services. PMID:21990479

  12. Medicare physician payment rules for 2011: a primer for the neurointerventionalist.

    PubMed

    Manchikanti, L; Hirsch, J A

    2011-01-01

    Physicians generally have been affected by significant changes in the patterns of medical practice evolving over the past several decades. The Patient Protection and Affordable Care Act of 2010, also called ACA for short, impacts physician professional practice dramatically. Physicians are paid in the USA for their personal services. The payment system is highly variable in the private insurance market; however, governmental systems have a formula based payment, mostly based on the Medicare payment system. Physician services are billed under part B. The Neurointerventional practice is typically performed in a hospital setting. The VA system is a frequently cited successful implementation of a government supported health care program. Availability of neurointerventional services at many VA medical centers is limited. Since the inception of the Medicare program in 1965, several methods have been used to determine the amounts paid to physicians for each covered service. Initially, the payment systems compensated physicians on the basis of their charges. In 1975, just over 10 years after the inception of the Medicare program, payments changed so as not to exceed the increase in medical economic index. The involvement of medical economic index failed to curb increases in costs, leading to the determination of a yearly change in fees by legislation from 1984 to 1991. In 1992, the fee schedule essentially replaced the prior payment system that was based on the physician's charges, which also failed to curb the growth in spending. Thus, in 1998, the sustainable growth rate system was introduced. In 2009, multiple unsuccessful attempts were made by Congress to repeal the formula. The mechanism of the sustainable growth rate includes three components that are incorporated into a statutory formula: expenditure targets, growth rate period and annual adjustments of payment rates for physician services. PMID:21670102

  13. Quality in Medicare: From Measurement to Payment and Provider to Patient

    PubMed Central

    Milgate, Karen; Hackbarth, Glenn

    2005-01-01

    Establishing the Medicare Program in 1965 led to greater access to care for millions of Americans. Yet, until the mid-1980s Medicare spent minimal efforts measuring or improving quality. Since that time, the Health Care Financing Administration (HCFA), later called CMS, has led many efforts to measure, publicly report, and work with providers to improve care. In 2005, policymakers seek to build incentives for improved quality into the payment system. This policy is critical for encouraging improvement and rewarding investment. Future efforts need to look beyond individual provider settings to encouraging improvement for patients receiving care in multiple settings, and at home. PMID:17290640

  14. Rebasing the Medicare Payment for Dialysis: Rationale, Challenges, and Opportunities

    PubMed Central

    Johnson, Doug

    2014-01-01

    After Medicare’s implementation of the bundled payment for dialysis in 2011, there has been a predictable decrease in the use of intravenous drugs included in the bundle. The change in use of erythropoiesis-stimulating agents, which decreased by 37% between 2007, when its allowance in the bundle was calculated, and 2012, was because of both changes in the Food and Drug Administration labeling for erythropoiesis-stimulating agents in 2011 and cost-containment efforts at the facility level. Legislation in 2012 required Medicare to decrease (rebase) the bundled payment for dialysis in 2014 to reflect this decrease in intravenous drug use, which amounted to a cut of 12% or $30 per treatment. Medicare subsequently decided to phase in this decrease in payment over several years to offset the increase in dialysis payment that would otherwise have occurred with inflation. A 3% reduction from the rebasing would offset an approximately 3% increase in the market basket that determines a facility’s costs for 2014 and 2015. Legislation in March of 2014 provides that the rebasing will result in a 1.25% decrease in the market basket adjustment in 2016 and 2017 and a 1% decrease in the market basket adjustment in 2018 for an aggregate rebasing of 9.5% spread over 5 years. Adjusting to this payment decrease in inflation-adjusted dollars will be challenging for many dialysis providers in an industry that operates at an average 3%–4% margin. Closure of facilities, decreases in services, and increased consolidation of the industry are possible scenarios. Newer models of reimbursement, such as ESRD seamless care organizations, offer dialysis providers the opportunity to align incentives between themselves, nephrologists, hospitals, and other health care providers, potentially improving outcomes and saving money, which will be shared between Medicare and the participating providers. PMID:25189926

  15. 42 CFR 422.308 - Adjustments to capitation rates, benchmarks, bids, and payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to Medicare Advantage Organizations § 422.308 Adjustments to capitation rates, benchmarks, bids, and...

  16. Medicare Program; Reporting and Returning of Overpayments. Final rule.

    PubMed

    2016-02-12

    This final rule requires providers and suppliers receiving funds under the Medicare program to report and return overpayments by the later of the date that is 60 days after the date on which the overpayment was identified; or the date any corresponding cost report is due, if applicable. The requirements in this rule are meant to ensure compliance with applicable statutes, promote the furnishing of high quality care, and to protect the Medicare Trust Funds against fraud and improper payments. This rule provides needed clarity and consistency in the reporting and returning of self-identified overpayments. PMID:26878741

  17. 76 FR 59138 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-23

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2012 AGENCY: Centers for Medicare... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be...

  18. 42 CFR 421.304 - Medicare integrity program contractor functions.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Medicare integrity program contractor functions... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medicare Integrity Program Contractors § 421.304 Medicare integrity program contractor functions. The contract between CMS and a...

  19. 77 FR 51542 - Medicare Program; Solicitation of Two Nominations to the Advisory Panel on Hospital Outpatient...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-24

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Solicitation of Two... Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice solicits nominations for two new members to the Advisory Panel on Hospital Outpatient Payment (HOP, the Panel). There will be two vacancies on the...

  20. Medicare and Medicaid programs; fraud and abuse OIG anti-kickback provisions--HHS. Proposed rule.

    PubMed

    1989-01-23

    These proposed regulations are designed to implement section 14 of Pub. L. 100-93, the Medicare and Medicaid Patient and Program Protection Act of 1987, by specifying various payment practices which, although potentially capable of inducing referrals of business under Medicare, would not be considered kickbacks for purposes of criminal prosecution or civil remedies. PMID:10304257

  1. Pharmaceutical "charge compression" under the Medicare outpatient prospective payment system.

    PubMed

    Braid, Mary Jo; Forbes, Kevin F; Moran, Donald W

    2004-01-01

    Analysis of the actual acquisition costs of a sample of pharmaceuticals demonstrates that payment rates for pharmaceutical therapies under the Medicare hospital outpatient prospective payment system (OPPS) are systematically biased against fully reimbursing high cost pharmaceutical therapies. Under the Centers for Medicare and Medicaid Services' (CMS') methodology, which assumes a constant markup, a bias in the cost estimate occurs when hospitals apply below average markups in establishing their charges for pharmaceutical products with above average costs. We developed a model of the relationship between product costs and charge markups. The logarithmic model shows that an increase in the acquisition cost per episode can be expected to lead to a reduction in the charge markup multiple. When markups for pharmaceuticals decline as acquisition cost increases, a rate-setting methodology that assumes a constant markup results in reimbursement for higher cost products that can be far below acquisition cost. The incentives in the payment system could affect site of care choices and beneficiary access. PMID:15151194

  2. After the "Doc Fix": Implications of Medicare Physician Payment Reform for Academic Medicine.

    PubMed

    Rich, Eugene C; Reschovsky, James D

    2016-07-01

    The Medicare Access and CHIP Reauthorization Act (MACRA) introduces incentives for clinicians serving Medicare patients to move away from traditional "fee-for-service" and into alternative payment models (APMs) such as accountable care organizations and bundled payment arrangements. Thus, MACRA creates strong reasons for various teaching clinical services to participate in APMs, not only for Medicare patients but for other public and private payers as well. Unfortunately, different APMs may be more or less applicable to the diverse teaching physician roles, academic clinical programs, and patient populations served by medical schools and teaching hospitals. Therefore, this time of transition will complicate the work of academic clinical program leaders endeavoring to sustain the tripartite mission of patient care, health professional education, and research. Nonetheless, payment reforms promoted by MACRA can reward efforts to reinvent medical education to better incorporate value into medical decision making, as well as to give clinical learners the tools and insights needed to recognize their personal financial (and other) conflicts and navigate these to meet their patients' needs. This post-MACRA environment may intensify the need for researchers in academic medicine to stay independent of the short-term financial interests of affiliated clinical institutions. Health sciences scholars must be able to study effectively and speak forcefully regarding the actual benefits, risks, and costs of health care services so that educators and clinicians can identify high-value care and deliver it to their patients. PMID:27224297

  3. Medicare program; Medicare prescription drug discount card. Interim final rule with comment period.

    PubMed

    2003-12-15

    Section 101, subpart 4 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, codified in section 1860D-31 of the Social Security Act, provides for a voluntary prescription drug discount card program for Medicare beneficiaries entitled to benefits, or enrolled, under Part A or enrolled under Part B, excluding beneficiaries entitled to medical assistance for outpatient prescription drugs under Medicaid, including section 1115 waiver demonstrations. Eligible beneficiaries may access negotiated prices on prescription drugs by enrolling in drug discount card programs offered by Medicare-endorsed sponsors. Eligible beneficiaries may enroll in the Medicare drug discount card program beginning no later than 6 months after the date of enactment of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and ending December 31, 2005. After December 31, 2005, beneficiaries enrolled in the program may continue to use their drug discount card during a short transition period beginning January 1, 2006 and ending upon the effective date of a beneficiary's outpatient drug coverage under Medicare Part D, but no later than the last day of the initial open enrollment period under Part D. Beneficiaries with incomes no more than 135 percent of the poverty line applicable to their family size who do not have outpatient prescription drug coverage under certain programs--Medicaid, certain health insurance coverage or group health insurance (such as retiree coverage), TRICARE, and Federal employees Health Benefits Program (FEHBP)--also are eligible for transitional assistance, or payment of $600 in 2004 and up to $600 in 2005 of the cost of covered discount card drugs obtained under the program. In most cases, any transitional assistance remaining available to a beneficiary on December 31, 2004 may be rolled over to 2005 and applied toward the cost of covered discount card drugs obtained under the program during 2005. Similarly, in most cases, any

  4. Medicare Physician Fee Schedule Ends at Age 26: Succeeding in an Era of Payment Reform.

    PubMed

    Allison, Adele

    2016-01-01

    The Medicare Access and CHIP Reauthorization Act of 2015 solidifies healthcare payment reform by signaling the death of traditional fee-for-service reimbursement for providers. Effective 2019, Medicare payments will rely heavily on data, risk-sharing, and transparency to advance value over volume. Other payers will follow. PMID:27039638

  5. 42 CFR 421.304 - Medicare integrity program contractor functions.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Medicare integrity program contractor functions. 421.304 Section 421.304 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING Medicare...

  6. 42 CFR 421.304 - Medicare integrity program contractor functions.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Medicare integrity program contractor functions. 421.304 Section 421.304 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING Medicare...

  7. 42 CFR 421.304 - Medicare integrity program contractor functions.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Medicare integrity program contractor functions. 421.304 Section 421.304 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medicare Integrity...

  8. 42 CFR 421.304 - Medicare integrity program contractor functions.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Medicare integrity program contractor functions. 421.304 Section 421.304 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING Medicare...

  9. 42 CFR 420.410 - Establishment of a program to collect suggestions for improving Medicare program efficiency and...

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Section 420.410 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... monetary savings to the Medicare program. (b) General rule. CMS may make payment for adopted suggestions.... (g) Basis for reward payment—(1) General rule. If CMS determines that it is appropriate to make...

  10. 75 FR 19677 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-15

    ...This final rule makes revisions to the regulations governing the Medicare Advantage (MA) program (Part C) and prescription drug benefit program (Part D) based on our continued experience in the administration of the Part C and D programs. The revisions strengthen various program participation and exit requirements; strengthen beneficiary protections; ensure that plan offerings to beneficiaries......

  11. 77 FR 22071 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-12

    ...This final rule with comment period revises the Medicare Advantage (MA) program (Part C) regulations and prescription drug benefit program (Part D) regulations to implement new statutory requirements; strengthen beneficiary protections; exclude plan participants that perform poorly; improve program efficiencies; and clarify program requirements. It also responds to public comments regarding......

  12. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates; quality reporting requirements for specific providers; reasonable compensation equivalents for physician services in excluded hospitals and certain teaching hospitals; provider administrative appeals and judicial review; enforcement provisions for organ transplant centers; and electronic health record (EHR) incentive program. Final rule.

    PubMed

    2014-08-22

    are participating in Medicare. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program. In addition, we are making technical corrections to the regulations governing provider administrative appeals and judicial review; updating the reasonable compensation equivalent (RCE) limits, and revising the methodology for determining such limits, for services furnished by physicians to certain teaching hospitals and hospitals excluded from the IPPS; making regulatory revisions to broaden the specified uses of Medicare Advantage (MA) risk adjustment data and to specify the conditions for release of such risk adjustment data to entities outside of CMS; and making changes to the enforcement procedures for organ transplant centers. We are aligning the reporting and submission timelines for clinical quality measures for the Medicare HER Incentive Program for eligible hospitals and critical access hospitals (CAHs) with the reporting and submission timelines for the Hospital IQR Program. In addition, we provide guidance and clarification of certain policies for eligible hospitals and CAHs such as our policy for reporting zero denominators on clinical quality measures and our policy for case threshold exemptions. In this document, we are finalizing two interim final rules with comment period relating to criteria for disproportionate share hospital uncompensated care payments and extensions of temporary changes to the payment adjustment for low-volume hospitals and of the Medicare-Dependent, Small Rural Hospital (MDH) Program. PMID:25167590

  13. 76 FR 65909 - Medicare and Medicaid Program; Regulatory Provisions To Promote Program Efficiency, Transparency...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-24

    ... August 5, 1982 (47 FR 34082). Most of the revisions since then have been payment related with the exception of a final rule published on November 18, 2008 (73 FR 68502) that revised four existing health and... published a final rule in the Federal Register (73 FR 36448) entitled ``Medicare Program; Appeals of CMS...

  14. Medicare program; Medicare integrity program, intermediary and carrier functions, and conflict of interest requirements--HCFA. Proposed rule.

    PubMed

    1998-03-20

    This proposed rule would implement section 1893 of the Social Security Act (the Act) by establishing the Medicare integrity program (MIP) to carry out Medicare program integrity activities that are funded from the Medicare Trust Funds. Section 1893 expands our contracting authority to allow us to contract with "eligible entities" to perform Medicare program integrity activities. These activities include review of provider and supplier activities, including medical, fraud, and utilization review: cost report audits; Medicare secondary payer determinations; education of providers, suppliers, beneficiaries, and other persons regarding payment integrity and benefit quality assurance issues; and developing and updating a list of durable medical equipment items that are subject to prior authorization. This proposed rule would set forth the definition of eligible entities, services to be procured, competitive requirements based on Federal acquisition regulations and exceptions (guidelines for automatic renewal), procedures for identification, evaluation, and resolution of conflicts of interest, and limitations on contractor liability. In addition, this proposed rule would bring certain sections of the Medicare regulations concerning fiscal intermediaries and carriers into conformity with the Act. The rule would distinguish between those functions that the statute requires be included in agreements with intermediaries and those that may be included in the agreements. It would also provide that some or all of the listed functions may be included in carrier contracts. Currently all these functions are mandatory for carrier contracts. These changes would give us the flexibility to transfer functions from one intermediary or carrier to another or to otherwise limit the functions an intermediary or carrier performs if we determine that to do so would result in more effective and efficient program administration. PMID:10177750

  15. Medicare incentive payments for meaningful use of electronic health records: accounting and reporting developments.

    PubMed

    2012-02-01

    The Healthcare Financial Management Association through its Principles and Practices (P&P) Board publishes issue analyses to provide short-term practical assistance on emerging issues in healthcare financial management. In a new issue analysis excerpted in this article, HFMA's P&P Board provides some clarity to the healthcare industry on certain accounting and reporting issues resulting from incentive payments under the Medicare program for the meaningful use of electronic health record (EHR) technology. Consultation on these matters with independent auditors is highly recommended. PMID:22372298

  16. 42 CFR 422.304 - Monthly payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Monthly payments. 422.304 Section 422.304 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Payments to Medicare Advantage Organizations § 422.304 Monthly payments. (a) General...

  17. 75 FR 71189 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-22

    ... Federal Register on January 28, 2005 (70 FR 4588 through 4741 and 70 FR 4194 through 4585, respectively... Medicare Part D prescription drug plan sponsors (72 FR 68700). In April 2008, we published a final rule to address policy and technical changes to the Part D program (73 FR 20486). In September 2008 and...

  18. Medicare physician payment systems: impact of 2011 schedule on interventional pain management.

    PubMed

    Manchikanti, Laxmaiah; Singh, Vijay; Caraway, David L; Benyamin, Ramsin M; Hirsch, Joshua A

    2011-01-01

    Physicians in the United States have been affected by significant changes in the patterns of medical practice evolving over the last several decades. The recently passed affordable health care law, termed the Patient Protection and Affordable Care Act of 2010 (the ACA, for short) affects physicians more than any other law. Physician services are an integral part of health care. Physicians are paid in the United States for their personal services. This payment also includes the overhead expenses for maintaining an office and providing services. The payment system is highly variable in the private insurance market; however, governmental systems have a formula-based payment, mostly based on the Medicare payment system. Physician services are billed under Part B. Since the inception of the Medicare program in 1965, several methods have been used to determine the amounts paid to physicians for each covered service. Initially, the payment systems compensated physicians on the basis of their charges. In 1975, just over 10 years after the inception of the Medicare program, payments changed so as not to exceed the increase in the Medical Economic Index (MEI). Nevertheless, the policy failed to curb increases in costs, leading to the determination of a yearly change in fees by legislation from 1984 to 1991. In 1992, the fee schedule essentially replaced the prior payment system that was based on the physician's charges, which also failed to live up to expectations for operational success. Then, in 1998, the sustainable growth rate (SGR) system was introduced. In 2009, multiple attempts were made by Congress to repeal the formula - rather unsuccessfully. Consequently, the SGR formula continues to hamper physician payments. The mechanism of the SGR includes 3 components that are incorporated into a statutory formula: expenditure targets, growth rate period, and annual adjustments of payment rates for physician services. Further, the relative value of a physician fee schedule

  19. Geographic variations in hospital charges and Medicare payments for major joint arthroplasty.

    PubMed

    Thakore, Rachel V; Greenberg, Sarah E; Bulka, Catherine M; Ehrenfeld, Jesse M; Obremskey, William T; Sethi, Manish K

    2015-05-01

    National data on hospital-level charges and Medicare payments have shown that joint arthroplasty is the most common surgical procedure among the elderly. Yet, no study has investigated micro and macro level geographic variations in hospital charges and payment. We used the Medicare Provider Charge Data to investigate Medicare payments and charges for 2750 hospitals accounting for 427,207 patients who underwent major joint arthroplasty and 932 hospitals for 18,714 patients who had a complication/comorbidity. We found a significant difference in hospital charges and payments based on geographic region (P<0.001). We concluded that hospital charges demonstrate a high variability even when using areas to control for differences in hospital wages and high variation in reimbursements in some areas remains unexplained by Medicare's current method of calculating reimbursement. PMID:25556041

  20. Long-Term Impact of Medicare Payment Reductions on Patient Outcomes

    PubMed Central

    Wu, Vivian Y; Shen, Yu-Chu

    2014-01-01

    Objective To examine the long-term impact of Medicare payment reductions on patient outcomes for Medicare acute myocardial infarction (AMI) patients. Data Sources Analysis of secondary data compiled from 100 percent Medicare Provider Analysis and Review between 1995 and 2005, Medicare hospital cost reports, Inpatient Prospective Payment System Payment Impact Files, American Hospital Association annual surveys, InterStudy, Area Resource Files, and County Business Patterns. Study Design We used a natural experiment—the Balanced Budget Act (BBA) of 1997—as an instrument to predict cumulative Medicare revenue loss due solely to the BBA, and basing on the predicted loss categorized hospitals into small, moderate, or large payment-cut groups and followed Medicare AMI patient outcomes in these hospitals over an 11-year panel between 1995 and 2005. Principal Findings We found that while Medicare AMI mortality trends remained similar across hospitals between pre-BBA and initial-BBA periods, hospitals facing large payment cuts saw smaller improvement in mortality rates relative to that of hospitals facing small cuts in the post-BBA period. Part of the relatively higher AMI mortalities among large-cut hospitals might be related to reductions in staffing levels and operating costs, and a small part might be due to patient selection. Conclusions We found evidence that hospitals facing large Medicare payment cuts as a result of BBA of 1997 were associated with deteriorating patient outcomes in the long run. Medicare payment reductions may have an unintended consequence of widening the gap in quality across hospitals. PMID:24845773

  1. Sugar daddy. Most Americans know Medicare as the health insurance program for the elderly, but to providers, it's a jobs program, a capital financier and a safety net.

    PubMed

    Hallam, K; Gardner, J

    1999-11-01

    Most Americans know Medicare as the health insurance program that covers the elderly. But to providers it's much more that. The program pays for medical education, finances capital projects and subsidizes care for the indigent. Should Medicare continue making those add-on payments? Is that the program's mission? The debate is intensifying. PMID:10623271

  2. Statistical Uncertainty in the Medicare Shared Savings Program

    PubMed Central

    DeLia, Derek; Hoover, Donald; Cantor, Joel C.

    2012-01-01

    Objective Analyze statistical risks facing CMS and Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program (MSSP). Methods We calculate the probability that shared savings formulas lead to inappropriate payment, payment denial, and/or financial penalties, assuming that ACOs generate real savings in Medicare spending ranging from 0–10%. We also calculate expected payments from CMS to ACOs under these scenarios. Results The probability of an incorrect outcome is heavily dependent on ACO enrollment size. For example, in the MSSP two-sided model, an ACO with 5,000 enrollees that keeps spending constant faces a 0.24 probability of being inappropriately rewarded for savings and a 0.26 probability of paying an undeserved penalty for increased spending. For an ACO with 50,000 enrollees, both of these probabilities of incorrect outcomes are equal to 0.02. The probability of inappropriate payment denial declines as real ACO savings increase. Still, for ACOs with 5,000 patients, the probability of denial is at least 0.15 even when true savings are 5–7%. Depending on ACO size and the real ACO savings rate, expected ACO payments vary from $115,000 to $35.3 million. Discussion Our analysis indicates there may be greater statistical uncertainty in the MSSP than previously recognized. CMS and ACOs will have to consider this uncertainty in their financial, administrative, and care management planning. We also suggest analytic strategies that can be used to refine ACO payment formulas in the longer term to ensure that the MSSP (and other ACO initiatives that will be influenced by it) work as efficiently as possible. PMID:24800155

  3. 42 CFR 422.316 - Special rules for payments to Federally qualified health centers.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to Medicare Advantage Organizations § 422.316 Special rules for payments to Federally qualified health...

  4. 42 CFR 424.515 - Requirements for reporting changes and updates to, and the periodic revalidation of Medicare...

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ..., and the periodic revalidation of Medicare enrollment information. 424.515 Section 424.515 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and...

  5. 42 CFR 424.515 - Requirements for reporting changes and updates to, and the periodic revalidation of Medicare...

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ..., and the periodic revalidation of Medicare enrollment information. 424.515 Section 424.515 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and...

  6. Rural Implications of Medicare's Post-Acute-Care Transfer Payment Policy

    ERIC Educational Resources Information Center

    Schoenman, Julie A.; Mueller, Curt D.

    2005-01-01

    Under the Medicare post-acute-care (PAC) transfer policy, acute-care hospitals are reimbursed under a per-diem formula whenever beneficiaries are discharged from selected diagnosis-related groups (DRGs) to a skilled nursing facility, home health care, or a prospective payment system (PPS)-excluded facility. Total per-diem payments are below the…

  7. Medicare program; FY 2015 hospice wage index and payment rate update; hospice quality reporting requirements and process and appeals for Part D payment for drugs for beneficiaries enrolled in hospice. Final rule.

    PubMed

    2014-08-22

    This final rule will update the hospice payment rates and the wage index for fiscal year (FY) 2015 and continue the phase-out of the wage index budget neutrality adjustment factor (BNAF). This rule provides an update on hospice payment reform analyses, potential definitions of "terminal illness'' and "related conditions,'' and information on potential processes and appeals for Part D payment for drugs while beneficiaries are under a hospice election. This rule will specify timeframes for filing the notice of election and the notice of termination/revocation; add the attending physician to the hospice election form, and require hospices to document changes to the attending physician; require hospices to complete their hospice aggregate cap determinations within 5 months after the cap year ends, and remit any overpayments; and update the hospice quality reporting program. In addition, this rule will provide guidance on determining hospice eligibility; information on the delay in the implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM); and will further clarify how hospices are to report diagnoses on hospice claims. Finally, the rule will make a technical regulations text change. PMID:25167592

  8. Assessing Medicare's hospital pay-for-performance programs and whether they are achieving their goals.

    PubMed

    Kahn, Charles N; Ault, Thomas; Potetz, Lisa; Walke, Thomas; Chambers, Jayne Hart; Burch, Samantha

    2015-08-01

    Three separate pay-for-performance programs affect the amount of Medicare payment for inpatient services to about 3,400 US hospitals. These payments are based on hospital performance on specified measures of quality of care. A growing share of Medicare hospital payments (6 percent by 2017) are dependent upon how hospitals perform under the Hospital Readmissions Reduction Program, the Value-Based Purchasing Program, and the Hospital-Acquired Condition Reduction Program. In 2015 four of five hospitals subject to these programs will be penalized under one or more of them, and more than one in three major teaching hospitals will be penalized under all three. Interactions among these programs should be considered going forward, including overlap among measures and differences in scoring performance. PMID:26240240

  9. Medicare program; appeals of CMS or CMS contractor determinations when a provider or supplier fails to meet the requirements for Medicare billing privileges. Final rule.

    PubMed

    2008-06-27

    This final rule implements a number of regulatory provisions that are applicable to all providers and suppliers, including durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. This final rule establishes appeals processes for all providers and suppliers whose enrollment, reenrollment or revalidation application for Medicare billing privileges is denied and whose Medicare billing privileges are revoked. It also establishes timeframes for deciding enrollment appeals by an Administrative Law Judge (ALJ) within the Department of Health and Human Services (DHHS) or the Departmental Appeals Board (DAB), or Board, within the DHHS; and processing timeframes for CMS' Medicare fee-for-service (FFS) contractors. In addition, this final rule allows Medicare FFS contractors to revoke Medicare billing privileges when a provider or supplier submits a claim or claims for services that could not have been furnished to a beneficiary. This final rule also specifies that a Medicare contractor may establish a Medicare enrollment bar for any provider or supplier whose billing privileges have been revoked. Lastly, the final rule requires that all providers and suppliers receive Medicare payments by electronic funds transfer (EFT) if the provider or supplier, is submitting an initial enrollment application to Medicare, changing their enrollment information, revalidating or re-enrolling in the Medicare program. PMID:18677828

  10. No payments, copayments and faux payments: are medical practitioners adequately equipped to manage Medicare claiming and compliance?

    PubMed

    Faux, M A; Wardle, J L; Adams, J

    2015-02-01

    The complexity of Medicare claiming means it is often beyond the comprehension of many, including medical practitioners who are required to interpret and apply Medicare every day. A single Medicare service can be the subject of 30 different payment rates, multiple claiming methods and a myriad of rules, with severe penalties for non-compliance, yet the administrative infrastructure and specialised human resourcing of Medicare may have decreased over time. As a result, medical practitioners experience difficulties accessing reliable information and support concerning their claiming and compliance obligations. Some commentators overlook the complexity of Medicare and suggest that deliberate misuse of the system by medical practitioners is a significant contributor to rising healthcare costs, although there is currently no empirical evidence to support this view. Quantifying the precise amount of leakage caused by inappropriate claiming has proven an impossible task, although current estimates are $1-3 billion annually. The current government's proposed copayment plan may cause increases in non-compliance and incorrect Medicare claiming, and a causal link has been demonstrated between medical practitioner access to Medicare education and significant costs savings. Medicare claiming is a component of almost every medical interaction in Australia, yet most education in this area currently occurs on an ad hoc basis. Research examining medical practitioner experiences and understanding regarding Medicare claiming and compliance is urgently required to adapt medicine responsibly to our rapidly changing healthcare environment. PMID:25650538

  11. 76 FR 79193 - Medicare Program; Independence at Home Demonstration Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-21

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Independence at Home... incentive and service delivery system that utilizes physician and nurse practitioner directed home-based... establishing the Independence at Home (IAH) Demonstration. The IAH Demonstration will test a service...

  12. Medicare home health payment reform may jeopardize access for clinically complex and socially vulnerable patients.

    PubMed

    Rosati, Robert J; Russell, David; Peng, Timothy; Brickner, Carlin; Kurowski, Daniel; Christopher, Mary Ann; Sheehan, Kathleen M

    2014-06-01

    The Affordable Care Act directed Medicare to update its home health prospective payment system to reflect more recent data on costs and use of services-an exercise known as rebasing. As a result, the Centers for Medicare and Medicaid Services will reduce home health payments 3.5 percent per year in the period 2014-17. To determine the impact that these reductions could have on beneficiaries using home health care, we examined the Medicare reimbursement margins and the use of services in a national sample of 96,621 episodes of care provided by twenty-six not-for-profit home health agencies in 2011. We found that patients with clinically complex conditions and social vulnerability factors, such as living alone, had substantially higher service delivery costs than other home health patients. Thus, the socially vulnerable patients with complex conditions represent less profit-lower-to-negative Medicare margins-for home health agencies. This financial disincentive could reduce such patients' access to care as Medicare payments decline. Policy makers should consider the unique characteristics of these patients and ensure their continued access to Medicare's home health services when planning rebasing and future adjustments to the prospective payment system. PMID:24889943

  13. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Special Medicare program requirements. 417.550 Section 417.550 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  14. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Special Medicare program requirements. 417.550 Section 417.550 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  15. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Special Medicare program requirements. 417.550 Section 417.550 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  16. 76 FR 61103 - Medicare Program; Comprehensive Primary Care Initiative

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-03

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Comprehensive Primary Care... announces a solicitation for health care payer organizations to participate in the Comprehensive Primary Care initiative (CPC), a multipayer model designed to improve primary care. DATES: Letter of...

  17. Medicare

    MedlinePlus

    ... functionalities on this website may not be available. Medicare.gov Is my test, item, or service covered? ... added to Hospital Compare Learn more Address change/Medicare card issue? Lost or incorrect Medicare card? Select ...

  18. 75 FR 70165 - Medicare Program; Request for Information Regarding Accountable Care Organizations and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-17

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Chapter IV Medicare Program; Request for Information Regarding Accountable Care Organizations and the Medicare Shared Saving Program AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Request for information. SUMMARY: This...

  19. 42 CFR 405.371 - Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR... CMS or a Medicare contractor if CMS or the Medicare contractor possesses reliable information that...

  20. 77 FR 53967 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-04

    ...This final rule specifies the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments. In addition, it specifies payment adjustments under Medicare for covered professional services and hospital services provided by EPs, eligible......

  1. 42 CFR 411.33 - Amount of Medicare secondary payment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... deductible obligation. (3) An ESRD beneficiary received 8 dialysis treatments for which a facility charged... met. The primary payer paid $1,024 for Medicare-covered services. The composite rate per...

  2. 42 CFR 411.33 - Amount of Medicare secondary payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... deductible obligation. (3) An ESRD beneficiary received 8 dialysis treatments for which a facility charged... met. The primary payer paid $1,024 for Medicare-covered services. The composite rate per...

  3. Medicare and State health care programs: fraud and abuse; OIG anti-kickback provisions--HHS. Final rule.

    PubMed

    1991-07-29

    This final rule implements section 14 of Public Law 100-93, the Medicare and Medicaid Patient and Program Protection Act of 1987, by specifying various payment practices which, although potentially capable of inducing referrals of business under Medicare or a State health care program, will be protected from criminal prosecution or civil sanctions under the anti-kickback provisions of the statute. PMID:10112868

  4. Medicare program; changes to the criteria for determination of reasonable charges--HCFA. Final rule.

    PubMed

    1987-03-01

    This rule revises the Medicare regulations governing reasonable charges for payment for the purchase of used durable medical equipment. This revision is intended to encourage the sale of used equipment to Medicare beneficiaries. In addition, to correct a program inequity and to simplify program administration, we are extending, for services furnished on or after January 1, 1987, one of the provisions of section 9304 of the Consolidated Omnibus Budget Reconciliation Act of 1985. The provision we are extending deals with determining customary charges for physicians who have terminated their compensation agreements with a hospital. PMID:10301337

  5. Risk adjustment of Medicare capitation payments using the CMS-HCC model.

    PubMed

    Pope, Gregory C; Kautter, John; Ellis, Randall P; Ash, Arlene S; Ayanian, John Z; Lezzoni, Lisa I; Ingber, Melvin J; Levy, Jesse M; Robst, John

    2004-01-01

    This article describes the CMS hierarchical condition categories (HCC) model implemented in 2004 to adjust Medicare capitation payments to private health care plans for the health expenditure risk of their enrollees. We explain the model's principles, elements, organization, calibration, and performance. Modifications to reduce plan data reporting burden and adaptations for disabled, institutionalized, newly enrolled, and secondary payer subpopulations are discussed. PMID:15493448

  6. 76 FR 52955 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-24

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports... nature and will focus on the actuarial and economic assumptions and methods by which Trustees might...

  7. 76 FR 58514 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-21

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports... spending in the long run. The Panel's discussion is expected to be very technical in nature and will...

  8. 76 FR 28196 - Medicare and Medicaid Programs; Opportunities for Alignment Under Medicaid and Medicare

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-16

    ... health care, and long-term care supports and services. \\10\\ See Exec. Order No. 13563, 76 FR 14 (Jan. 18... discussion of this first step. \\11\\ See Memorandum for the Heads of Executive Departments and Agencies, 74 FR... care under the Medicare and Medicaid programs for individuals with both Medicare and Medicaid...

  9. The ephemeral accountable care organization-an unintended consequence of the Medicare shared savings program.

    PubMed

    Harvey, H Benjamin; Gowda, Vrushab; Gazelle, G Scott; Pandharipande, Pari V

    2014-02-01

    A fundamental element of health care payment reform under the Affordable Care Act is the development of Accountable Care Organizations (ACOs). The ACO model employs shared-risk contracts to better align the interests of health care providers and payers with the intent of driving efficiency and quality in care. The Medicare Shared Savings Program is the most popular of the Medicare ACO programs, with over 200 health systems across the nation participating at this time. However, a pitfall in the way that the Medicare Shared Savings Program is structured, specifically the benchmarking and rebasing method, could make it difficult for even top-performing ACOs to achieve sustained success, thereby threatening the long-term viability of the program. In this paper, we present this pitfall to the radiology community as well as potential solutions that can be considered by CMS moving forward. PMID:24360903

  10. Physician Payments from Industry Are Associated with Greater Medicare Part D Prescribing Costs

    PubMed Central

    Perlis, Roy H.; Perlis, Clifford S.

    2016-01-01

    Background The U.S. Physician Payments Sunshine Act mandates the reporting of payments or items of value received by physicians from drug, medical device, and biological agent manufacturers. The impact of these payments on physician prescribing has not been examined at large scale. Methods We linked public Medicare Part D prescribing data and Sunshine Act data for 2013. Physician payments were examined descriptively within specialties, and then for association with prescribing costs and patterns using regression models. Models were adjusted for potential physician-level confounding features, including sex, geographic region, and practice size. Results Among 725,169 individuals with Medicare prescribing data, 341,644 had documented payments in the OPP data (47.1%). Among all physicians receiving funds, mean payment was $1750 (SD $28336); median was $138 (IQR $48-$394). Across the 12 specialties examined, a dose-response relationship was observed in which greater payments were associated with greater prescribing costs per patient. In adjusted regression models, being in the top quintile of payment receipt was associated with incremental prescribing cost per patient ranging from $27 (general surgery) to $2931 (neurology). Similar associations were observed with proportion of branded prescriptions written. Conclusions While distribution and amount of payments differed widely across medical specialties, for each of the 12 specialties examined the receipt of payments was associated with greater prescribing costs per patient, and greater proportion of branded medication prescribing. We cannot infer a causal relationship, but interventions aimed at those physicians receiving the most payments may present an opportunity to address prescribing costs in the US. PMID:27183221

  11. Medicare's Bundled Payment initiative: most hospitals are focused on a few high-volume conditions.

    PubMed

    Tsai, Thomas C; Joynt, Karen E; Wild, Robert C; Orav, E John; Jha, Ashish K

    2015-03-01

    The Bundled Payments for Care Improvement initiative is a federally funded innovation model mandated by the Affordable Care Act. It is designed to help transition Medicare away from fee-for-service payments and toward bundling a single payment for an episode of acute care in a hospital and related postacute care in an appropriate setting. While results from the initiative will not be available for several years, current data can help provide critical early insights. However, little is known about the participating organizations and how they are focusing their efforts. We identified participating hospitals and used national Medicare claims data to assess their characteristics and previous spending patterns. These hospitals are mostly large, nonprofit, teaching hospitals in the Northeast, and they have selectively enrolled in the bundled payment initiative covering patient conditions with high clinical volumes. We found no significant differences in episode-based spending between participating and nonparticipating hospitals. Postacute care explains the largest variation in overall episode-based spending, signaling an opportunity to align incentives across providers. However, the focus on a few selected clinical conditions and the high degree of integration that already exists between enrolled hospitals and postacute care providers may limit the generalizability of bundled payment across the Medicare system. PMID:25732486

  12. 42 CFR 421.214 - Advance payments to suppliers furnishing items or services under Part B.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING... Standards for tracking each advance payment and its recoupment. (g) Requirements for CMS. (1) In...

  13. 42 CFR 421.214 - Advance payments to suppliers furnishing items or services under Part B.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING... Standards for tracking each advance payment and its recoupment. (g) Requirements for CMS. (1) In...

  14. 42 CFR 421.214 - Advance payments to suppliers furnishing items or services under Part B.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING... Standards for tracking each advance payment and its recoupment. (g) Requirements for CMS. (1) In...

  15. 42 CFR 421.316 - Limitation on Medicare integrity program contractor liability.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Limitation on Medicare integrity program contractor... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medicare Integrity Program Contractors § 421.316 Limitation on Medicare integrity program contractor liability. (a) A MIP contractor,...

  16. Making sense of the Medicare physician payment data release: uses, limitations, and potential.

    PubMed

    Patel, Kavita; Masi, Domitilla; Brandt, Caitlin

    2014-11-01

    In April 2014, the Centers for Medicare and Medicaid Services released a data file containing information on Medicare payments made to physicians and other providers. Though an important achievement in promoting greater health system transparency, limitations in the data have hindered key users, including consumers, payers, and providers, from discerning meaningful information from the file. This brief outlines the significance of the data release, the limitations of the dataset, the current uses of the information, and proposals for rendering the file more meaningful for public use. PMID:25470832

  17. Collect data, monitor claims receipts to ensure prompt Medicare, Medicaid payment.

    PubMed

    1999-10-01

    What to do when your Medicare or Medicaid plan pays claims late. Doctors in New Mexico say they're going broke because health plans don't pay for months. But managed care plans with commercial lives aren't the only plans that pay claims late. Plans with Medicare and Medicaid lives also can have payment problems. Find out how the physicians in New Mexico are tackling the problem, and see what you can do to prevent it from happening to you. PMID:10662124

  18. Lessons Learned from the National Medicare & You Education Program

    PubMed Central

    Goldstein, Elizabeth; Teichman, Lori; Crawley, Barbara; Gaumer, Gary; Joseph, Catherine; Reardon, Leo

    2001-01-01

    In fall 1998 CMS implemented the National Medicare Education Program (NMEP) to educate beneficiaries about their Medicare program benefits; health plan choices; supplemental health insurance; beneficiary rights, responsibilities, and protections; and health behaviors. CMS has been monitoring the implementation of the NMEP in six case study sites as well as monitoring each of the information channels for communicating with beneficiaries. This article describes select findings from the case studies, and highlights from assessment activities related to the Medicare & You handbook, the toll-free 1-800-MEDICARE Helpline, Internet, and Regional Education About Choices in Health (REACH). PMID:12500359

  19. Medicare's drug discount card program: beneficiaries' experience with choice.

    PubMed

    Hassol, Andrea; Wrobel, Marian V; Doksum, Teresa

    2007-01-01

    This article describes Medicare beneficiaries' experience with the choice among Medicare drug discount cards and is based primarily on surveys and focus groups with beneficiaries as well as interviews with other stakeholders. Although competition and choice have the potential to reduce cost and enhance quality in the Medicare Program, our findings highlight some of the challenges involved in making choice work in practice. Despite the unique and temporary nature of the drug discount card program, these findings have considerable relevance to the Part D drug benefit and to other Medicare initiatives that rely on choice. PMID:17722747

  20. Centers for Medicare & Medicaid Services Transition From Payments for Volume to Value: Implications for North Carolina Physicians, Providers, and Patients.

    PubMed

    Teferi, Sabrina; Jackson, Ronald; Wild, Richard E

    2016-01-01

    The US Department of Health and Human Services and the Centers for Medicare & Medicaid Services have announced goals and timelines to transition from payments based on volume to payments based on value, quality, and efficient delivery of care. These value-based payments and alternative payment models will impact all health care professionals and provider organizations by encouraging better care, healthier people, and spending health care dollars wisely and efficiently. PMID:27422958

  1. Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations--Revised Benchmark Rebasing Methodology, Facilitating Transition to Performance-Based Risk, and Administrative Finality of Financial Calculations. Final rule.

    PubMed

    2016-06-10

    Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. This final rule addresses changes to the Shared Savings Program, including: Modifications to the program's benchmarking methodology, when resetting (rebasing) the ACO's benchmark for a second or subsequent agreement period, to encourage ACOs' continued investment in care coordination and quality improvement; an alternative participation option to encourage ACOs to enter performance-based risk arrangements earlier in their participation under the program; and policies for reopening of payment determinations to make corrections after financial calculations have been performed and ACO shared savings and shared losses for a performance year have been determined. PMID:27295736

  2. Medicare bundled payment: what is it worth to you?

    PubMed

    Harris, John; Elizondo, Idette; Isdaner, Andrew

    2014-01-01

    Hospital leaders who are contemplating participation in a bundled payment initiative should first assess current circumstances to determine the extent of the opportunity for their organizations. Those who have decided conditions are favorable for such an initiative should next perform a financial assessment that includes modeling direct contract results, assessing the financial impact of reduced utilization and of improved clinical care and operations, and evaluating the net financial impact. Hospital executives also should understand the competitive and strategic benefits that bundled payment offers. PMID:24511781

  3. 42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Medicare benefits secondary to LGHP benefits. 411.204 Section 411.204 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT...

  4. 42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Medicare benefits secondary to LGHP benefits. 411.204 Section 411.204 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT...

  5. 42 CFR 424.507 - Ordering and referring covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... for Medicare beneficiaries. 424.507 Section 424.507 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and Maintaining Medicare Billing Privileges § 424.507 Ordering...

  6. 42 CFR 411.108 - Taking into account entitlement to Medicare.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Taking into account entitlement to Medicare. 411.108 Section 411.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT...

  7. 42 CFR 411.108 - Taking into account entitlement to Medicare.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Taking into account entitlement to Medicare. 411.108 Section 411.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT...

  8. 42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Medicare benefits secondary to LGHP benefits. 411.204 Section 411.204 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT...

  9. 42 CFR 424.525 - Rejection of a provider or supplier's enrollment application for Medicare enrollment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... application for Medicare enrollment. 424.525 Section 424.525 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and Maintaining Medicare Billing Privileges § 424.525 Rejection of...

  10. 42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Medicare benefits secondary to LGHP benefits. 411.204 Section 411.204 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT...

  11. 42 CFR 424.507 - Ordering and referring covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... for Medicare beneficiaries. 424.507 Section 424.507 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and Maintaining Medicare Billing Privileges § 424.507 Ordering...

  12. 42 CFR 411.108 - Taking into account entitlement to Medicare.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Taking into account entitlement to Medicare. 411.108 Section 411.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT...

  13. 42 CFR 424.525 - Rejection of a provider or supplier's enrollment application for Medicare enrollment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... application for Medicare enrollment. 424.525 Section 424.525 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and Maintaining Medicare Billing Privileges §...

  14. 42 CFR 411.108 - Taking into account entitlement to Medicare.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Taking into account entitlement to Medicare. 411.108 Section 411.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT...

  15. 42 CFR 411.108 - Taking into account entitlement to Medicare.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Taking into account entitlement to Medicare. 411.108 Section 411.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT...

  16. 42 CFR 424.525 - Rejection of a provider or supplier's enrollment application for Medicare enrollment.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... application for Medicare enrollment. 424.525 Section 424.525 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and Maintaining Medicare Billing Privileges §...

  17. 42 CFR 421.302 - Eligibility requirements for Medicare integrity program contractors.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... the Medicare program. (3) Complies with conflict of interest provisions in 48 CFR chapters 1 and 3... 42 Public Health 3 2010-10-01 2010-10-01 false Eligibility requirements for Medicare integrity..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medicare...

  18. 42 CFR 421.316 - Limitation on Medicare integrity program contractor liability.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Limitation on Medicare integrity program contractor liability. 421.316 Section 421.316 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medicare Integrity...

  19. Medicare

    MedlinePlus

    ... for people age 65 or older. Some people under age 65 can qualify for Medicare, too. They include those with disabilities, permanent kidney failure, or amyotrophic lateral sclerosis. Medicare helps with the cost of health care. It does not cover all ...

  20. 42 CFR 424.540 - Deactivation of Medicare billing privileges.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Deactivation of Medicare billing privileges. 424.540 Section 424.540 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements...

  1. 42 CFR 424.540 - Deactivation of Medicare billing privileges.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Deactivation of Medicare billing privileges. 424.540 Section 424.540 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  2. 42 CFR 424.540 - Deactivation of Medicare billing privileges.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Deactivation of Medicare billing privileges. 424.540 Section 424.540 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements...

  3. 42 CFR 424.540 - Deactivation of Medicare billing privileges.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Deactivation of Medicare billing privileges. 424.540 Section 424.540 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  4. 42 CFR 424.540 - Deactivation of Medicare billing privileges.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Deactivation of Medicare billing privileges. 424.540 Section 424.540 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements...

  5. Medicare program; reasonable charge limitations--HCFA. Final rule with comment period.

    PubMed

    1986-08-11

    This final rule implements section 9304(a) of the Consolidated Omnibus Budget Reconciliation Act of 1985 which enacted section 1842(b)(8) of the Social Security Act (Act). In accordance with section 1842(b)(8) of the Act, we specify the circumstances under which HCFA or its Medicare Part B carriers will consider establishing special reasonable charge payment limits for services (including supplies and equipment) reimbursed under Part B of the Medicare program. The rule describes the factors HCFA or a carrier will consider and the procedures it will follow in establishing them. The limits would be either an upper limit to correct a grossly excessive charge or a lower limit to correct a grossly deficient charge. In either case, the limit would be either a specific dollar amount, or a special method used in determining reasonable charges to be allowed for a particular service or category of service. The purpose of this rule is to establish a stronger framework for setting special reasonable charge limits for services when the standard reimbursement methodology results in payments that are grossly excessive or deficient. A related purpose is to protect the Medicare program from excessive outlays and to prevent any adverse effects on both Medicare beneficiaries and consumers in general that we believe would result from a lack of such limits. The rule also will protect suppliers from reimbursement that is grossly deficient. PMID:10300984

  6. Medicare program; establishment of the Medicare Advantage Program; interpretation. Final rule; interpretation.

    PubMed

    2005-03-21

    This final rule clarifies our interpretation of the meaning of "entity" in the final rule titled "Medicare Program; Establishment of the Medicare Advantage Program" published in the Federal Register on January 28, 2005 (70 FR 4588). Subsequent to the publication of the Medicare Advantage (MA) final rule on January 28, 2005, we have received inquiries from parties interested in offering an MA Regional Plan concerning whether they could jointly enter into a contract with us to offer a single MA Regional Plan in a multistate region. The participating health plans wish to contract with each other to create a single "joint enterprise." They have asked us whether such a joint enterprise could be considered an "entity" under sections 1859(a)(1)and 1855(a)(1) of the Social Security Act, for purposes of offering an MA Regional Plan. The MA final rule is scheduled to take effect on March 22, 2005. Our interpretation of the word "entity" that follows in the "Supplementary Information" section of this final rule is deemed to be included in that final rule. PMID:15786589

  7. Medicare program; Medicare depreciation, useful life guidelines--HCFA. Final rule.

    PubMed

    1983-08-18

    These final rules amend Medicare regulations to clarify which useful life guidelines may be used by providers of health care services to determine the useful life of a depreciable asset for Medicare reimbursement purposes. Current regulations state that providers must utilize the Departmental useful life guidelines or, if none have been published by the Department, either the American Hospital Association (AHA) useful life guidelines of 1973 of IRS guidelines. We are eliminating the reference to IRS guidelines because these are now outdated for Medicare purposes since they have been rendered obsolete either by the IRS or by statutory change. We are also deleting the specific reference to the 1973 AHA guidelines since these guidelines are updated by the AHA periodically. In addition, we are clarifying that certain tax legislation on accelerated depreciation, passed by Congress, does not apply to the Medicare program. PMID:10299127

  8. 42 CFR 423.2315 - Medicare Coverage Gap Discount Program Agreement.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Medicare Coverage Gap Discount Program Agreement... BENEFIT Medicare Coverage Gap Discount Program § 423.2315 Medicare Coverage Gap Discount Program Agreement. (a) General rule. The Medicare Coverage Gap Discount Program Agreement (or Discount Program...

  9. 42 CFR 423.2315 - Medicare Coverage Gap Discount Program Agreement.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Medicare Coverage Gap Discount Program Agreement... BENEFIT Medicare Coverage Gap Discount Program § 423.2315 Medicare Coverage Gap Discount Program Agreement. (a) General rule. The Medicare Coverage Gap Discount Program Agreement (or Discount Program...

  10. 42 CFR 423.2315 - Medicare Coverage Gap Discount Program Agreement.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Medicare Coverage Gap Discount Program Agreement... BENEFIT Medicare Coverage Gap Discount Program § 423.2315 Medicare Coverage Gap Discount Program Agreement. (a) General rule. The Medicare Coverage Gap Discount Program Agreement (or Discount Program...

  11. 76 FR 63017 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-11

    ... January 28, 2005 Federal Register (70 FR 4588 through 4741 and 70 FR 4194 through 4585, respectively.... For instance, in September 2008 and January 2009, we issued Part C and D regulations (73 FR 54226 and 74 FR 1494, respectively) to implement provisions in the Medicare Improvement for Patients...

  12. 77 FR 27778 - Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel-May 21, 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-11

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel--May 21, 2012 Correction In notice document 2012-10702 appearing...

  13. Bundled payment initiatives for Medicare and non-Medicare total joint arthroplasty patients at a community hospital: bundles in the real world.

    PubMed

    Doran, James P; Zabinski, Stephen J

    2015-03-01

    In the setting of current United States healthcare reform, bundled payment initiatives and episode of care payment models for total joint arthroplasty (TJA) have become increasingly common. The following is a review of our results and experience in a community hospital with bundled payment initiatives for both non-Medicare and Medicare TJA patients since 2011. We have successfully decreased the cost of the TJA episode of care in comparison to our historical averages prior to 2011. This cost-reduction has primarily been achieved through decreased length of inpatient stay, increased discharge to home rather than to skilled nursing or inpatient rehabilitation facilities, reduction in implant cost, improvement in readmission rate and migration of cases to lower cost sites of service. PMID:25680450

  14. 42 CFR 422.324 - Payments to MA organizations for graduate medical education costs.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payments to MA organizations for graduate medical education costs. 422.324 Section 422.324 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to Medicare Advantage Organizations §...

  15. Ostomy Home Skills Program

    MedlinePlus Videos and Cool Tools

    ... DEA, FDA, and Medicare Part B Drugs Accountable Care Organizations Physician Payment Sunshine Act Stark Law and ... Overview of Medicare Quality Programs Phases of Surgical Care Physician Quality Reporting System Value-Based Payment Modifier ...

  16. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Requirements for enrolling in the Medicare program. 424.510 Section 424.510 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE...

  17. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Requirements for enrolling in the Medicare program. 424.510 Section 424.510 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE...

  18. 42 CFR 421.316 - Limitation on Medicare integrity program contractor liability.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Limitation on Medicare integrity program contractor liability. 421.316 Section 421.316 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING...

  19. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Requirements for enrolling in the Medicare program. 424.510 Section 424.510 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE...

  20. 42 CFR 421.316 - Limitation on Medicare integrity program contractor liability.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Limitation on Medicare integrity program contractor liability. 421.316 Section 421.316 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING...

  1. 42 CFR 421.316 - Limitation on Medicare integrity program contractor liability.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Limitation on Medicare integrity program contractor liability. 421.316 Section 421.316 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE CONTRACTING...

  2. An Economic History of Medicare Part C

    PubMed Central

    Mcguire, Thomas G; Newhouse, Joseph P; Sinaiko, Anna D

    2011-01-01

    Context: Twenty-five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee-for-service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector. Methods: In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program's structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer-sponsored health insurance with managed care over the same time period. Findings: Beneficiaries' access to private plans has been inconsistent over the program's history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years. Conclusions: Major changes in Medicare Advantage's payment rules are needed in order to simultaneously encourage the participation of private plans, the provision of high-quality care, and to save Medicare money. PMID:21676024

  3. Taking Risk: Early Results From Teaching Hospitals' Participation in the Center for Medicare and Medicaid Innovation Bundled Payments for Care Improvement Initiative.

    PubMed

    Kivlahan, Coleen; Orlowski, Janis M; Pearce, Jonathan; Walradt, Jessica; Baker, Matthew; Kirch, Darrell G

    2016-07-01

    The authors describe observations from the 27 teaching hospitals constituting the Association of American Medical Colleges (AAMC) cohort in the Center for Medicare and Medicaid Innovation (CMMI) Bundled Payments for Care Improvement (BPCI) initiative. CMMI introduced BPCI in August 2011 and selected the first set of participants in January 2013. BPCI participants enter into Medicare payment arrangements for episodes of care for which they take financial risk. The first round of participants entered risk agreements on October 1, 2013 and January 1, 2014. In April 2014, CMMI selected additional participants who started taking financial risk in 2015. Selected episodes include congestive heart failure (CHF), major joint replacement (MJR), and cardiac valve surgery. The AAMC cohort of participating hospitals selected clinical conditions on the basis of patient volume, opportunity to impact savings and quality, organizational and clinical team readiness, and prior process improvement experience. Early financial results suggest that focused attention to postacute care utilization and outcomes, rapid changes in care processes, program pricing rules, and team composition drove savings and losses. The first cohort of participants generated savings in MJR, CHF, and cardiac valve episodes; losses were experienced in stroke, percutaneous coronary intervention, and spine surgery. Although about one-quarter of U.S. teaching hospitals are participating in BPCI, the proliferation of existing and new payment models, as well as the 2015 announcement to increasingly pay providers according to value, mandates close scrutiny of program outcomes. The authors conclude by proposing additional opportunities for research related to alternative payment models. PMID:26886810

  4. 42 CFR 414.707 - Basis of payment.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Basis of payment. 414.707 Section 414.707 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals § 414.707 Basis of payment....

  5. Use of Medicare services before and after introduction of the prospective payment system.

    PubMed Central

    Manton, K G; Woodbury, M A; Vertrees, J C; Stallard, E

    1993-01-01

    OBJECTIVE. The case mix-adjusted pattern of use of health care services, especially posthospital care, is compared before and after the introduction of Medicare's Prospective Payment System (PPS). DATA SOURCES. The 1982 and 1984 National Long Term Care Surveys (NLTCS) linked to Medicare administrative records 1982-1986 provide health and health service use data for 12-month periods before and after the introduction of PPS. STUDY DESIGN. Case-mix differences between pre- and post-periods are controlled by using the Grade of Membership model to identify health groups from the NLTCS data. Differences in timing (e.g., hospital length of stay) were controlled using life table models estimated for each health group, that is, service use patterns pre- and post-PPS are compared within groups. PRINCIPAL FINDINGS. Hospital LOS and admission rates declined post-PPS. Changes in the timing and location of death occurred but, overall, mortality did not increase. Changes in post-acute care service use by elderly, chronically disabled Medicare beneficiaries were observed: home health service use increased overall and among the unmarried disabled population. CONCLUSIONS. PPS did not adversely affect quality of care as reflected in mortality or in hospital readmissions. Moreover, the differential use of post-acute care, and changes in hospital LOS by health group, indicate that the system responded, specific to marital status and age, to the severity of needs of chronically disabled persons. PMID:8344820

  6. Medicare Program: Expanding Uses of Medicare Data by Qualified Entities. Final rule.

    PubMed

    2016-07-01

    This final rule implements requirements under Section 105 of the Medicare Access and CHIP Reauthorization Act of 2015 that expand how qualified entities may use and disclose data under the qualified entity program to the extent consistent with applicable program requirements and other applicable laws, including information, privacy, security and disclosure laws. This rule also explains how qualified entities may create non-public analyses and provide or sell such analyses to authorized users, as well as how qualified entities may provide or sell combined data, or provide Medicare claims data alone at no cost, to certain authorized users. In addition, this rule implements certain privacy and security requirements, and imposes assessments on qualified entities if the qualified entity or the authorized user violates the terms of a data use agreement required by the qualified entity program. PMID:27400462

  7. 76 FR 78741 - Medicare, Medicaid, Children's Health Insurance Programs; Transparency Reports and Reporting of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-19

    ... 42 CFR Parts 402 and 403 Medicare, Medicaid, Children's Health Insurance Programs; Transparency..., Children's Health Insurance Programs; Transparency Reports and Reporting of Physician Ownership or... medical supplies covered by Medicare, Medicaid or the Children's Health Insurance Program (CHIP) to...

  8. 76 FR 67743 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    ... Medicare or Medicaid programs or Children's Health Insurance Program (CHIP); revalidating their Medicare... enrollment issues. SUPPLEMENTARY INFORMATION: I. Background In the February 2, 2011 Federal Register (76 FR... Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary...

  9. Medicare program; standards for reuse of hemodialyzer filters and other dialysis supplies--HCFA. Final rule.

    PubMed

    1987-10-01

    This final rule contains standards and conditions for safe and effective hemodialyzer reuse and reprocessing, enforceable as Medicare conditions for coverage. It incorporates by reference voluntary guidelines and standards adopted by the Association for the Advancement of Medical Instrumentation in July 1986 (i.e., "Recommended Practice for Reuse of Hemodialyzers"). In addition, the rule provides standards for reuse of dialyzer caps and prohibits reuse of transducer filters in ESRD facilities. As provided in section 9335(k) of Pub. L. 99-509, the Omnibus Budget reconciliation Act of 1986, failure of facilities to comply with these conditions could result in suspension of payment or removal of the facility from coverage under the Medicare program. PMID:10301900

  10. Medicare program; competitive acquisition of outpatient drugs and biologicals under Part B. Interim final rule with comment period.

    PubMed

    2005-07-01

    This interim final rule with comment period implements provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 that require the implementation of a competitive acquisition program for certain Medicare Part B drugs not paid on a cost or prospective payment system basis. Beginning January 1, 2006, physicians will generally be given a choice between obtaining these drugs from vendors selected through a competitive bidding process or directly purchasing these drugs and being paid under the average sales price system. PMID:15999432

  11. 42 CFR 412.432 - Method of payment under the inpatient psychiatric facility prospective payment system.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... the requirements of § 413.64(h) of this chapter. (c) Interim payments for Medicare bad debts and for... Medicare bad debts and for costs of an approved education program and other costs paid outside...

  12. 42 CFR 412.432 - Method of payment under the inpatient psychiatric facility prospective payment system.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... the requirements of § 413.64(h) of this chapter. (c) Interim payments for Medicare bad debts and for... Medicare bad debts and for costs of an approved education program and other costs paid outside...

  13. Measuring Beneficiary Knowledge of the Medicare Program: A Psychometric Analysis

    PubMed Central

    Bann, Carla M.; Terrell, Sherry A.; McCormack, Lauren A.; Berkman, Nancy D.

    2003-01-01

    Reliable measures of Medicare beneficiaries' program knowledge are necessary for credible program monitoring, evaluation, and public accountability. This study developed and evaluated the psychometric properties of two possible measures of beneficiary knowledge. One measure was based on self-reported knowledge, the other was a true/false quiz which requires beneficiaries to demonstrate their knowledge. We used data from the 1998 and 1999 Medicare Current Beneficiary Survey (MCBS) to evaluate the reliability and construct validity of the indices. Overall, based on both content considerations and the psychometric analyses, the true/false quiz proved to be the more accurate and useful measure of beneficiaries' knowledge. PMID:14628404

  14. 42 CFR 424.520 - Effective date of Medicare billing privileges.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Effective date of Medicare billing privileges. 424.520 Section 424.520 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements...

  15. 42 CFR 424.520 - Effective date of Medicare billing privileges.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Effective date of Medicare billing privileges. 424.520 Section 424.520 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  16. 42 CFR 424.520 - Effective date of Medicare billing privileges.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Effective date of Medicare billing privileges. 424.520 Section 424.520 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  17. 42 CFR 424.520 - Effective date of Medicare billing privileges.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Effective date of Medicare billing privileges. 424.520 Section 424.520 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements...

  18. 42 CFR 424.570 - Moratoria on newly enrolling Medicare providers and suppliers.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Moratoria on newly enrolling Medicare providers and suppliers. 424.570 Section 424.570 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  19. 42 CFR 424.520 - Effective date of Medicare billing privileges.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Effective date of Medicare billing privileges. 424.520 Section 424.520 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements...

  20. 42 CFR 424.518 - Screening levels for Medicare providers and suppliers.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Screening levels for Medicare providers and suppliers. 424.518 Section 424.518 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and...

  1. Making Medicare Advantage a Middle-Class Program

    PubMed Central

    Glazer, Jacob; McGuire, Thomas

    2013-01-01

    This paper studies the role of Medicare's premium policy in sorting beneficiaries between traditional Medicare (TM) and managed care plans in the Medicare Advantage (MA) program. Beneficiaries vary in their demand for care. TM fully accommodates demand but creates a moral hazard inefficiency. MA rations care but disregards some elements of the demand. We describe an efficient assignment of beneficiaries to these two options, and argue that efficiency requires an MA program oriented to serve the large middle part of the distribution of demand: the “middle class.” Current Medicare policy of a “single premium” for MA plans cannot achieve efficient sorting. We characterize the demand-based premium policy that can implement the efficient assignment of enrollees to plans. If only a single premium is feasible, the second-best policy involves too many of the low-demand individuals in MA and a too low level of services relative to the first best. We identify approaches to using premium policy to revitalize MA and improve the efficiency of Medicare. PMID:23454916

  2. Making Medicare advantage a middle-class program.

    PubMed

    Glazer, Jacob; McGuire, Thomas G

    2013-03-01

    This paper studies the role of Medicare's premium policy in sorting beneficiaries between traditional Medicare (TM) and managed care plans in the Medicare advantage (MA) program. Beneficiaries vary in their demand for care. TM fully accommodates demand but creates a moral hazard inefficiency. MA rations care but disregards some elements of the demand. We describe an efficient assignment of beneficiaries to these two options, and argue that efficiency requires an MA program oriented to serve the large middle part of the distribution of demand: the "middle class." Current Medicare policy of a "single premium" for MA plans cannot achieve efficient sorting. We characterize the demand-based premium policy that can implement the efficient assignment of enrollees to plans. If only a single premium is feasible, the second-best policy involves too many of the low-demand individuals in MA and a too low level of services relative to the first best. We identify approaches to using premium policy to revitalize MA and improve the efficiency of Medicare. PMID:23454916

  3. Disclosure of Industry Payments to Physicians: An Epidemiologic Analysis of Early Data From the Open Payments Program.

    PubMed

    Marshall, Deborah C; Jackson, Madeleine E; Hattangadi-Gluth, Jona A

    2016-01-01

    The Centers for Medicare and Medicaid Services' Open Payments program implements Section 6002 of the Affordable Care Act requiring medical product manufacturers to report payments made to physicians or teaching hospitals as well as ownership or investment interests held by physicians in the manufacturer. To determine the characteristics and distribution of these industry payments by specialty, we analyzed physician payments made between August 1, 2013, and December 31, 2013, that were publicly disclosed by Open Payments. We compared payments between specialty types (medical, surgical, and other) and across specialties within each type using the Pearson χ(2) test and the Kruskal-Wallis test. The number of physicians receiving payments was compared with the total number of active physicians in each specialty in 2012. We also analyzed physician ownership interests. Allopathic and osteopathic physicians received 2.43 million payments totaling $475 million. General payments represented 90% of payments by total value ($430 million) (per-physician median, $100; interquartile range [IQR], $31-$273; mean ± SD, $1407±$23,766), with the remaining 10% ($45 million) as research payments (median, $2365; IQR, $592-$8550; mean ± SD, $12,880±$66,743). Physicians most likely to receive general payments were cardiovascular specialists (78%) and neurosurgeons (77%); those least likely were pathologists (9%). Reports of ownership interest in reporting entities included $310 million in dollar amount invested and $447 million in value of interest held by 2093 physicians. In conclusion, the distribution and characteristics of industry payments to physicians varied widely by specialty during the first half-year of Open Payments reporting. PMID:26763512

  4. Medicare program; requirements for the Medicare incentive reward program and provider enrollment. Final rule.

    PubMed

    2014-12-01

    This final rule implements various provider enrollment requirements. These include: Expanding the instances in which a felony conviction can serve as a basis for denial or revocation of a provider or supplier's enrollment; if certain criteria are met, enabling us to deny enrollment if the enrolling provider, supplier, or owner thereof had an ownership relationship with a previously enrolled provider or supplier that had a Medicare debt; enabling us to revoke Medicare billing privileges if we determine that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements; and limiting the ability of ambulance suppliers to "backbill" for services performed prior to enrollment. PMID:25509061

  5. Medicare Pays for Chronic Care Management.

    PubMed

    Sorrel, Amy Lynn

    2015-09-01

    As of January, the Centers for Medicare & Medicaid Services began paying for chronic care management of patients with two or more conditions under its Chronic Care Management program. The payment applies to patients in traditional fee-for-service and noncapitated Medicare Advantage plan arrangements. Texas Medical Association leaders caution the program has some hefty requirements. PMID:26360339

  6. 42 CFR 413.76 - Direct GME payments: Calculation of payments for GME costs.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Direct GME payments: Calculation of payments for GME costs. 413.76 Section 413.76 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES;...

  7. 78 FR 45233 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2013

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-26

    ... Listing of Program Issuances--April Through June 2013 AGENCY: Centers for Medicare & Medicaid Services... through June 2013, relating to the Medicare and Medicaid programs and other programs administered by...

  8. 77 FR 49799 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-17

    ... Listing of Program Issuances--April Through June 2012 AGENCY: Centers for Medicare & Medicaid Services... through June 2012, relating to the Medicare and Medicaid programs and other programs administered by...

  9. 42 CFR 495.208 - Avoiding duplicate payment.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... PROGRAM Requirements Specific to Medicare Advantage (MA) Organizations § 495.208 Avoiding duplicate payment. (a) Unless a qualifying MA EP is entitled to a maximum payment for a year under the Medicare FFS EHR incentive program, payment for such an individual is only made under the MA EHR incentive...

  10. 42 CFR 495.208 - Avoiding duplicate payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... PROGRAM Requirements Specific to Medicare Advantage (MA) Organizations § 495.208 Avoiding duplicate payment. (a) Unless a qualifying MA EP is entitled to a maximum payment for a year under the Medicare FFS EHR incentive program, payment for such an individual is only made under the MA EHR incentive...

  11. 78 FR 31283 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-23

    ... enrolling new members, and ultimately contract termination. In the February 22, 2013 Federal Register (78 FR... pertaining to the MA and Prescription Drug program provisions were published on April 12, 2012 (77 FR 22072) and a correction was published June 1, 2012 (77 FR 32407). This final rule implements section 1103...

  12. Service mix in the hospital outpatient department: implications for Medicare payment reform.

    PubMed Central

    Miller, M E; Sulvetta, M B; Englert, E

    1995-01-01

    OBJECTIVE. To determine if implementation of a PPS for Medicare hospital outpatient department (HOPD) services will have distributional consequences across hospital types and regions, this analysis assesses variation in service mix and the provision of high-technology services in the HOPD. DATA. HCFA's 1990 claims file for a 5 percent random sample of Medicare beneficiaries using the HOPD was merged, by hospital provider number, with various HCFA hospital characteristic files. STUDY DESIGN. Hospital characteristics examined are urban/rural location, teaching status, disproportionate-share status, and bed size. Two analyses of HOPD services are presented: mix of services provided and the provision of high-technology services. The mix of services is measured by the percentage of services in each of 14 type-of-service categories (e.g., medical visits, advanced imaging services, diagnostic testing services). Technology provision is measured by the percentage of hospitals providing selected high-technology services. FINDINGS/CONCLUSIONS. The findings suggest that the role hospital types play in providing HOPD services warrants consideration in establishing a PPS. HOPDs in major teaching hospitals and hospitals serving a disproportionate share of the poor play an important role in providing routine visits. HOPDs in both major and minor teaching hospitals are important providers of high-technology services. Other findings have implications for the structure of an HOPD PPS as well. First, over half of the services provided in the HOPD are laboratory tests and HOPDs may have limited control over these services since they are often for patients referred from local physician offices. Second, service mix and technology provision vary markedly among regions, suggesting the need for a transition to prospective payment. Third, the organization of service supply in a region may affect service provision in the HOPD suggesting that an HOPD PPS needs to be coordinated with payment

  13. 77 FR 64344 - Medicare and Medicaid Programs; Approval of the Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-19

    ...This notice announces our decision to approve the Community Health Accreditation Program (CHAP) for continued recognition as a national accrediting organization for hospices that wish to participate in the Medicare or Medicaid programs. A hospice that participates in Medicaid must also meet the Medicare conditions of participation (CoPs) as referenced in our...

  14. 75 FR 67751 - Medicare Program: Community-Based Care Transitions Program (CCTP) Meeting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-03

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program: Community-Based Care... about the upcoming Community-based Care Transitions Program. The meeting is open to the public, but... will be posted on the CMS Care Transitions Web site at...

  15. 42 CFR 423.329 - Determination of payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Determination of payments. 423.329 Section 423.329 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Payments to Part D Plan Sponsors For Qualified Prescription...

  16. Better Patient Care At High-Quality Hospitals May Save Medicare Money And Bolster Episode-Based Payment Models.

    PubMed

    Tsai, Thomas C; Greaves, Felix; Zheng, Jie; Orav, E John; Zinner, Michael J; Jha, Ashish K

    2016-09-01

    US policy makers are making efforts to simultaneously improve the quality of and reduce spending on health care through alternative payment models such as bundled payment. Bundled payment models are predicated on the theory that aligning financial incentives for all providers across an episode of care will lower health care spending while improving quality. Whether this is true remains unknown. Using national Medicare fee-for-service claims for the period 2011-12 and data on hospital quality, we evaluated how thirty- and ninety-day episode-based spending were related to two validated measures of surgical quality-patient satisfaction and surgical mortality. We found that patients who had major surgery at high-quality hospitals cost Medicare less than those who had surgery at low-quality institutions, for both thirty- and ninety-day periods. The difference in Medicare spending between low- and high-quality hospitals was driven primarily by postacute care, which accounted for 59.5 percent of the difference in thirty-day episode spending, and readmissions, which accounted for 19.9 percent. These findings suggest that efforts to achieve value through bundled payment should focus on improving care at low-quality hospitals and reducing unnecessary use of postacute care. PMID:27605651

  17. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Reinstatement in other Medicare and Medicaid programs. 460.168 Section 460.168 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Reinstatement in other Medicare and Medicaid programs. To facilitate a participant's reinstatement in...

  18. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 4 2011-10-01 2011-10-01 false Reinstatement in other Medicare and Medicaid programs. 460.168 Section 460.168 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Reinstatement in other Medicare and Medicaid programs. To facilitate a participant's reinstatement in...

  19. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false Reinstatement in other Medicare and Medicaid programs. 460.168 Section 460.168 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Reinstatement in other Medicare and Medicaid programs. To facilitate a participant's reinstatement in...

  20. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Reinstatement in other Medicare and Medicaid programs. 460.168 Section 460.168 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Reinstatement in other Medicare and Medicaid programs. To facilitate a participant's reinstatement in...

  1. 42 CFR 421.302 - Eligibility requirements for Medicare integrity program contractors.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... the Medicare program. (3) Complies with conflict of interest provisions in 48 CFR chapters 1 and 3... 42 Public Health 3 2011-10-01 2011-10-01 false Eligibility requirements for Medicare integrity program contractors. 421.302 Section 421.302 Public Health CENTERS FOR MEDICARE & MEDICAID...

  2. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Reinstatement in other Medicare and Medicaid programs. 460.168 Section 460.168 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Reinstatement in other Medicare and Medicaid programs. To facilitate a participant's reinstatement in...

  3. 42 CFR 424.16 - Timing of certification for individual admitted to a hospital before entitlement to Medicare...

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... a hospital before entitlement to Medicare benefits. 424.16 Section 424.16 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Certification and Plan Requirements § 424.16 Timing...

  4. 42 CFR 424.16 - Timing of certification for individual admitted to a hospital before entitlement to Medicare...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... a hospital before entitlement to Medicare benefits. 424.16 Section 424.16 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Certification and Plan Requirements § 424.16 Timing of certification...

  5. 42 CFR 424.16 - Timing of certification for individual admitted to a hospital before entitlement to Medicare...

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... a hospital before entitlement to Medicare benefits. 424.16 Section 424.16 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Certification and Plan Requirements § 424.16 Timing...

  6. 42 CFR 424.16 - Timing of certification for individual admitted to a hospital before entitlement to Medicare...

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... a hospital before entitlement to Medicare benefits. 424.16 Section 424.16 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE PAYMENT Certification and Plan Requirements § 424.16 Timing...

  7. Practice patterns, case mix, Medicare payment policy, and dialysis facility costs.

    PubMed Central

    Hirth, R A; Held, P J; Orzol, S M; Dor, A

    1999-01-01

    OBJECTIVE: To evaluate the effects of case mix, practice patterns, features of the payment system, and facility characteristics on the cost of dialysis. DATA SOURCES/STUDY SETTING: The nationally representative sample of dialysis units in the 1991 U.S. Renal Data System's Case Mix Adequacy (CMA) Study. The CMA data were merged with data from Medicare Cost Reports, HCFA facility surveys, and HCFA's end-stage renal disease patient registry. STUDY DESIGN: We estimated a statistical cost function to examine the determinants of costs at the dialysis unit level. PRINCIPAL FINDINGS: The relationship between case mix and costs was generally weak. However, dialysis practices (type of dialysis membrane, membrane reuse policy, and treatment duration) did have a significant effect on costs. Further, facilities whose payment was constrained by HCFA's ceiling on the adjustment for area wage rates incurred higher costs than unconstrained facilities. The costs of hospital-based units were considerably higher than those of freestanding units. Among chain units, only members of one of the largest national chains exhibited significant cost savings relative to independent facilities. CONCLUSIONS: Little evidence showed that adjusting dialysis payment to account for differences in case mix across facilities would be necessary to ensure access to care for high-cost patients or to reimburse facilities equitably for their costs. However, current efforts to increase dose of dialysis may require higher payments. Longer treatments appear to be the most economical method of increasing the dose of dialysis. Switching to more expensive types of dialysis membranes was a more costly means of increasing dose and hence must be justified by benefits beyond those of higher dose. Reusing membranes saved money, but the savings were insufficient to offset the costs associated with using more expensive membranes. Most, but not all, of the higher costs observed in hospital-based units appear to reflect

  8. 77 FR 17072 - Medicare and Medicaid Programs; Approval of the Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-23

    ...This notice announces our decision to approve the Community Health Accreditation Program (CHAP) for recognition as a national accreditation program for home health agencies (HHAs) seeking to participate in the Medicare or Medicaid...

  9. 75 FR 76471 - Medicare Program; Renewal of the Medicare Evidence Development & Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-08

    ... FR 68780) announcing the establishment of the Medicare Coverage Advisory Committee (MCAC). The... Evidence Development & Coverage Advisory Committee (MEDCAC) AGENCY: Centers for Medicare & Medicaid... Development & Coverage Advisory Committee (MEDCAC). ADDRESSES: Copies of the Charter: To obtain a copy of...

  10. 78 FR 25013 - Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-29

    ... mistakes'' or unintentional billing errors. In the June 8, 1998 Federal Register (63 FR 31123), we.... Provider Enrollment In the April 21, 2006 Federal Register (71 FR 20754), we published a final rule titled... pattern or practice of submitting claims for services that fail to meet Medicare requirements;...

  11. 42 CFR 414.408 - Payment rules.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ...) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) § 414.408 Payment rules... bidding program for that CBA; or (B) Supplier with a valid Medicare billing number, if the...

  12. 42 CFR 414.408 - Payment rules.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ...) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) § 414.408 Payment rules... bidding program for that CBA; or (B) Supplier with a valid Medicare billing number, if the...

  13. 42 CFR 414.408 - Payment rules.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ...) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) § 414.408 Payment rules. (a... bidding program for that CBA; or (B) Supplier with a valid Medicare billing number, if the...

  14. 42 CFR 414.408 - Payment rules.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ...) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) § 414.408 Payment rules... bidding program for that CBA; or (B) Supplier with a valid Medicare billing number, if the...

  15. 75 FR 43178 - Medicare Program; Solicitation for Proposals for the Medicare Imaging Demonstration

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-23

    ... defined in Sec. 1834(e)(1)(B) of the Social Security Act (the Act): Diagnostic magnetic resonance imaging... the Medicare Imaging Demonstration AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION... an opportunity to apply to participate in the Medicare Imaging Demonstration (MID) that...

  16. 42 CFR 420.410 - Establishment of a program to collect suggestions for improving Medicare program efficiency and...

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Establishment of a program to collect suggestions for improving Medicare program efficiency and to reward suggesters for monetary savings. 420.410 Section 420.410 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM...

  17. 42 CFR 419.2 - Basis of payment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Basis of payment. 419.2 Section 419.2 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES General Provisions § 419.2 Basis of payment. (a)...

  18. 42 CFR 414.65 - Payment for telehealth services.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Payment for telehealth services. 414.65 Section 414.65 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Physicians and Other Practitioners § 414.65 Payment...

  19. 42 CFR 414.610 - Basis of payment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ...) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedule for... Medicare beneficiary. No direct payment will be made under this subpart if billing for the ambulance service is required to be consolidated with billing for another benefit for which payment may be...

  20. 42 CFR 408.84 - Billing and payment procedures.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Billing and payment procedures. 408.84 Section 408.84 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PREMIUMS FOR SUPPLEMENTARY MEDICAL INSURANCE Direct Remittance: Group Payment § 408.84 Billing and payment procedures. (a)...

  1. 42 CFR 412.604 - Conditions for payment under the prospective payment system for inpatient rehabilitation facilities.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Conditions for payment under the prospective... MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment for Inpatient Rehabilitation Hospitals...

  2. 42 CFR 412.541 - Method of payment under the long-term care hospital prospective payment system.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Method of payment under the long-term care hospital prospective payment system. 412.541 Section 412.541 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective...

  3. 76 FR 67567 - Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-01

    ...This notice announces the inpatient hospital deductible and the hospital and extended care services coinsurance amounts for services furnished in calendar year (CY) 2012 under Medicare's Hospital Insurance Program (Medicare Part A). The Medicare statute specifies the formulae used to determine these amounts. For CY 2012, the inpatient hospital deductible will be $1,156. The daily coinsurance......

  4. Understanding the Impacts of the Medicare Modernization Act: Concerns of Congressional Staff

    ERIC Educational Resources Information Center

    Mueller, Keith J.; Coburn, Andrew F.; MacKinney, Clinton; McBride, Timothy D.; Slifkin, Rebecca T.; Wakefield, Mary K.

    2005-01-01

    Sweeping changes to the Medicare program embodied in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), including a new prescription drug benefit, changes in payment policies, and reform of the Medicare managed-care program, have major implications for rural health care. The most efficient mechanism for research to…

  5. Managed care and Medicare reform.

    PubMed

    Oberlander, J B

    1997-04-01

    A primary goal of many Medicare reform proposals is to move program beneficiaries into managed care plans operated by private insurance companies. Advocates contend that managed care plans, especially health maintenance organizations (HMOs), can save substantial money for the federal government, while also improving the quality of medical care and scope of covered benefits for Medicare enrollees. Should Medicare follow the private sector by adopting managed care-based reforms? This article summarized the claims that are made for and against incorporating managed care into Medicare, and reviews evidence from the program's experience with HMOs on financial savings, benefits coverage, and quality of care. This evidence raises concerns regarding the ability of HMOs to provide adequate care for chronically ill Medicare patients. Moreover, there is considerable uncertainty about the future performance of managed care plans. I therefore conclude that policy makers should move cautiously in embracing managed care and that Medicare should not adopt financial incentives, such as vouchers, that are intended to push beneficiaries into HMOs. However, Medicare beneficiary enrollment in managed care plans is likely to increase substantially in coming years regardless of public policy. It is therefore critical for Medicare to pursue policies that protect the quality of care for elderly and disabled patients in managed care plans; curtail excessive payments to HMOs that result from favorable selection of healthier enrollees; and preserve the current fee-for-service Medicare program. PMID:9159717

  6. Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships--HCFA. Proposed rule.

    PubMed

    1998-01-01

    This proposed rule would incorporate into regulations the provisions of sections 1877 and 1903(s) of the Social Security Act. Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services under the Medicare program, unless certain exceptions apply. The following services are designated health services: Clinical laboratory services. Physical therapy services. Occupational therapy services. Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services. Radiation therapy services and supplies. Durable medical equipment and supplies. Parenteral and enteral nutrients, equipment, and supplies. Prosthetics, orthotics, and prosthetic devices and supplies. Home health services. Outpatient prescription drugs. Inpatient and outpatient hospital services. In addition, section 1877 provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for designated health services furnished under a prohibited referral, nor may the Secretary make payment for a designated health service furnished under a prohibited referral. Section 1903(s) of the Social Security Act extended aspects of the referral prohibition to the Medicaid program. It denies payment under the Medicaid program to a State for certain expenditures for designated health services. Payment would be denied if the services are furnished to an individual on the basis of a physician referral that would result in the denial of payment for the services under Medicare if Medicare covered the services to the same extent and under the same terms and conditions as under the State plan. This proposed rule incorporates these statutory provisions into the Medicare and Medicaid regulations and interprets certain aspects of the

  7. 42 CFR 412.348 - Exception payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... Capital Costs Determination of Transition Period Payment Rates for Capital-Related Costs § 412.348... hospital will equal a fixed percentage of the hospital's capital-related costs. The minimum payment...

  8. 42 CFR 424.122 - Conditions for payment for emergency inpatient hospital services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Conditions for payment for emergency inpatient hospital services. 424.122 Section 424.122 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT...

  9. 77 FR 53204 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-31

    ... Register (63 FR 68780). This notice announces the Wednesday, November 14, 2012, public meeting of the... Evidence Development and Coverage Advisory Committee--November 14, 2012 AGENCY: Centers for Medicare... meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'')...

  10. 77 FR 15372 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-15

    ... Register (63 FR 68780). This notice announces the Wednesday, May 16, 2012, public meeting of the Committee... Evidence Development and Coverage Advisory Committee--May 16, 2012 AGENCY: Centers for Medicare & Medicaid... Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'') will be held...

  11. 76 FR 33565 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-08

    ...This rule proposes to implement new statutory requirements regarding the release and use of standardized extracts of Medicare claims data to measure the performance of providers and suppliers in ways that protect patient privacy. This rule explains how entities can become qualified by CMS to receive standardized extracts of claims data under Medicare Parts A, B, and D for the purpose of......

  12. 76 FR 76541 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-07

    ...This final rule implements Section 10332 of the Affordable Care Act regarding the release and use of standardized extracts of Medicare claims data for qualified entities to measure the performance of providers of services (referred to as providers) and suppliers. This rule explains how entities can become qualified by CMS to receive standardized extracts of claims data under Medicare Parts A,......

  13. 78 FR 13059 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-26

    ...This notice announces that a public meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'') will be held on Wednesday, May 1, 2013. The Committee generally provides advice and recommendations concerning the adequacy of scientific evidence needed to determine whether certain medical items and services can be covered under the Medicare statute. This......

  14. 78 FR 75304 - Medicare Program; Medicare Secondary Payer and Certain Civil Money Penalties

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-11

    ... either the Office of Inspector General (OIG) or CMS (See the October 20, 1994 (58 FR 52967) notice titled...; Medicare Secondary Payer and Certain Civil Money Penalties AGENCY: Centers for Medicare & Medicaid Services... rulemaking (ANPRM) solicits public comment on specific practices for which civil money penalties (CMPs)...

  15. 75 FR 58405 - Medicare Program; Meeting of the Advisory Panel on Medicare Education, October 13, 2010

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-24

    .... 217a). The Secretary signed the charter establishing this Panel on January 21, 1999 (64 FR 7899, February 17, 1999) and approved the renewal of the charter on January 21, 2009 (74 FR 13442, March 27, 2009... on Medicare Education, October 13, 2010 AGENCY: Centers for Medicare & Medicaid Services (CMS),...

  16. Medicare program: changes to the Medicare claims appeal procedures. Interim final rule with comment period.

    PubMed

    2005-03-01

    Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services, can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B under sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. This interim final rule responds to comments on the November 15, 2002 proposed rule regarding changes to these appeal procedures, establishes the implementing regulations, and explains how the new procedures will be implemented. It also sets forth provisions that are needed to implement the new statutory requirements enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). PMID:15754467

  17. 42 CFR 419.31 - Ambulatory payment classification (APC) system and payment weights.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Ambulatory payment classification (APC) system and... Outpatient Services § 419.31 Ambulatory payment classification (APC) system and payment weights. (a) APC... OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEM FOR...

  18. 42 CFR 421.214 - Advance payments to suppliers furnishing items or services under Part B.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Carriers § 421.214... Standards for tracking each advance payment and its recoupment. (g) Requirements for CMS. (1) In...

  19. 42 CFR 421.214 - Advance payments to suppliers furnishing items or services under Part B.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Carriers § 421.214... Standards for tracking each advance payment and its recoupment. (g) Requirements for CMS. (1) In...

  20. 77 FR 31361 - Medicare and Medicaid Programs; Application by American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-25

    ...-Approval of its Ambulatory Surgery Center (ASC) Accreditation Program AGENCY: Centers for Medicare and... Program (AOA/HFAP) for continued recognition as a national accrediting organization for ambulatory surgery...--Ambulatory surgery center Insurance Program; and No. 93.774, Medicare--Supplementary Medical...

  1. Medicare program; protocol for the reuse of dialysis bloodlines--HCFA. Proposed rule.

    PubMed

    1988-07-27

    This proposed rule would establish standards for reuse of bloodlines during hemodialysis as a Medicare condition of coverage for suppliers of end-stage renal disease (ESRD) services. The rule would require that if a facility reuses bloodlines it must reuse only a bloodline for which the Food and Drug Administration (FDA) has accepted the manufacturer's protocol for reuse for that particular bloodline, and that the facility reuse the bloodlines only in accordance with that protocol. Effective July 1, 1988, bloodlines labeled "for single use only or its equivalent" may not be reused but items labeled, for example, "sterility guaranteed for first use only" could be reused if the facility follows a manufacturer's protocol for reprocessing accepted by the FDA. Section 1881(f)(7)(C) of the Social Security Act, added by section 9335(k) of the Omnibus Budget Reconciliation Act of 1986, provides that failure of a facility to comply with these standards would be cause for us to terminate the facility from participation in the Medicare program and to deny payment for the dialysis treatment affected. PMID:10302616

  2. 77 FR 35917 - Medicare Program; Medicare Secondary Payer and “Future Medicals”

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-15

    ... interest with respect to Medicare Secondary Payer (MSP) claims involving automobile and liability insurance...' compensation law or plan, automobile and liability insurance (including self-insurance), or no- fault...

  3. How Successful Is Medicare Advantage?

    PubMed Central

    Newhouse, Joseph P; McGuire, Thomas G

    2014-01-01

    Context Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture. Methods This article summarizes findings from our group's work evaluating MA's recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy. Findings Beneficiaries make “mistakes” in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of “zero-premium” plans signals inefficiency in plan design and in the market's functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower-cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM's performance. Conclusions Medicare policies regarding lock-in provisions and risk adjustment that were adopted in the mid-2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan

  4. 42 CFR 414.904 - Average sales price as the basis for payment.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Average sales price as the basis for payment. 414.904 Section 414.904 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals...

  5. 42 CFR 412.82 - Payment for extended length-of-stay cases (day outliers).

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Payment for extended length-of-stay cases (day outliers). 412.82 Section 412.82 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments for Outlier Cases, Special...

  6. 42 CFR 412.84 - Payment for extraordinarily high-cost cases (cost outliers).

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Payment for extraordinarily high-cost cases (cost outliers). 412.84 Section 412.84 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments for Outlier Cases, Special...

  7. 42 CFR 412.312 - Payment based on the Federal rate.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Payment based on the Federal rate. 412.312 Section 412.312 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs...

  8. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Payment based on the hospital-specific rate. 412.332 Section 412.332 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital...

  9. 75 FR 32480 - Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-08

    ... HUMAN SERVICES Administration on Aging Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program Funding for Title VI Native American Programs Purpose of Notice: Availability of funding opportunity announcement. Funding Opportunity Title/Program Name: Affordable Care...

  10. 78 FR 72089 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-02

    ... or Medicaid program or the Children's Health Insurance Program (CHIP); revalidating their Medicare... enrollment issues. SUPPLEMENTARY INFORMATION: I. Background In the February 2, 2011 Federal Register (76 FR... Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary...

  11. 77 FR 71423 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-30

    ... Register (76 FR 16422), we published a notice entitled ``Medicare, Medicaid, and Children's Health... or Medicaid program or the Children's Health Insurance Program (CHIP); revalidating their Medicare... enrollment issues. SUPPLEMENTARY INFORMATION: ] I. Background In the February 2, 2011 Federal Register (76...

  12. Medicare+Choice: doubling or disappearing?

    PubMed

    Berenson, Robert A

    2001-01-01

    Although the changes in the program created by the Balanced Budget Act are often viewed as the reason for the current instability in the Medicare+Choice (M+C) program, in fact, health plans are having difficulties in all of their markets, not just in Medicare. It may be time to reconsider the purpose of the program and to fundamentally redesign how payments are made to managed care organizations contracting with Medicare. Two alternative approaches are suggested: treating M+C like another provider type by severing the payment linkage to spending under traditional Medicare, and overhauling the program by creating a value-based purchasing orientation rewarding plans that provide higher-quality care to beneficiaries with chronic diseases. PMID:11911326

  13. Medicare program: changes to the Medicare claims appeal procedures. Final rule.

    PubMed

    2009-12-01

    Under the procedures in this final rule, Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B pursuant to sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. After publication of a proposed rule implementing the section 521 changes, additional new statutory requirements for the appeals process were enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). In March 2005, we published an interim final rule with comment period to implement these statutory changes. This final rule responds to comments on the interim final rule regarding changes to these appeal procedures, makes revisions where warranted, establishes the final implementing regulations, and explains how the new procedures will be put into practice. PMID:20169676

  14. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs Determination of Transition Period Payment Rates for Capital-Related Costs § 412.332 Payment based on the hospital-specific rate. The payment amount for...

  15. 42 CFR 447.55 - Standard co-payment.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Standard co-payment. 447.55 Section 447.55 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PAYMENTS FOR SERVICES Payments: General Provisions Deductible, Coinsurance, Co-Payment Or Similar Cost-Sharing Charge...

  16. 75 FR 65360 - Medicare and Medicaid Programs; Application by the Joint Commission for Deeming Authority for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-10-22

    ... the Joint Commission for Deeming Authority for Psychiatric Hospitals AGENCY: Centers for Medicare... organization for psychiatric hospitals that wish to participate in the Medicare or Medicaid programs. Section... from a psychiatric hospital provided certain requirements are met. Section 1861(f) of the...

  17. 76 FR 65891 - Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-24

    ...This proposed rule would revise the requirements that hospitals and critical access hospitals (CAHs) must meet to participate in the Medicare and Medicaid programs. These proposed changes are an integral part of our efforts to reduce procedural burdens on providers. This proposed rule reflects the Centers for Medicare and Medicaid Services' (CMS') commitment to the general principles of the......

  18. 77 FR 11130 - Medicare Program; Application by the American Association of Diabetes Educators (AADE) for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-24

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Application by the American... identifying the national accreditation body making the request, describing the nature of the request, and..., Department of Health and Human Services, Attention: CMS-3259-PN, P.O. Box 8016, Baltimore, MD...

  19. 75 FR 21207 - Medicare Program; Ambulatory Surgical Centers, Conditions for Coverage

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-23

    ... August 31, 2007, we published a proposed rule (72 FR 50470) in the Federal Register entitled, ``Medicare... November 18, 2008, we published a final rule (73 FR 68502), entitled ``Medicare Program; Changes to the... information before they arrived at the ASC for the procedure (see 73 FR 68718). Therefore, in response...

  20. 42 CFR 421.302 - Eligibility requirements for Medicare integrity program contractors.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... CFR chapters 1 and 3, and is not excluded under the conflict of interest provision at § 421.310. (4... 42 Public Health 3 2013-10-01 2013-10-01 false Eligibility requirements for Medicare integrity program contractors. 421.302 Section 421.302 Public Health CENTERS FOR MEDICARE & MEDICAID...

  1. 42 CFR 421.302 - Eligibility requirements for Medicare integrity program contractors.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... CFR chapters 1 and 3, and is not excluded under the conflict of interest provision at § 421.310. (4... 42 Public Health 3 2014-10-01 2014-10-01 false Eligibility requirements for Medicare integrity program contractors. 421.302 Section 421.302 Public Health CENTERS FOR MEDICARE & MEDICAID...

  2. 42 CFR 421.302 - Eligibility requirements for Medicare integrity program contractors.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... CFR chapters 1 and 3, and is not excluded under the conflict of interest provision at § 421.310. (4... 42 Public Health 3 2012-10-01 2012-10-01 false Eligibility requirements for Medicare integrity program contractors. 421.302 Section 421.302 Public Health CENTERS FOR MEDICARE & MEDICAID...

  3. 76 FR 29249 - Medicare Program; Pioneer Accountable Care Organization Model: Request for Applications

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-20

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Pioneer Accountable Care... participate in the Pioneer Accountable Care Organization Model for a period beginning in 2011 and ending...://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/pioneer-aco . Application...

  4. 77 FR 46439 - Medicare Program; Prior Authorization for Power Mobility Device (PMD) Demonstration

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-03

    ... in 60-day and 30-day Federal Register notices that published on February 7, 2012 (77 FR 6124) and May 29, 2012 (77 FR 31616), respectively. The information collection requirements are approved under OMB... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Prior Authorization for...

  5. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Establishing and Maintaining Medicare Billing Privileges § 424.530 Denial of enrollment in the Medicare program..., supplier, an owner, managing employee, an authorized or delegated official, medical director, supervising..., debt, felony) of an owner, managing employee, an authorized or delegated official, medical...

  6. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... requirement found in 42 CFR 489.28(a). (9) Application fee/hardship exception. An institutional provider's or... Establishing and Maintaining Medicare Billing Privileges § 424.530 Denial of enrollment in the Medicare program..., supplier, an owner, managing employee, an authorized or delegated official, medical director,...

  7. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... requirement found in 42 CFR 489.28(a). (9) Application fee/hardship exception. An institutional provider's or... Establishing and Maintaining Medicare Billing Privileges § 424.530 Denial of enrollment in the Medicare program..., supplier, an owner, managing employee, an authorized or delegated official, medical director,...

  8. 42 CFR 424.535 - Revocation of enrollment and billing privileges in the Medicare program.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) CONDITIONS FOR MEDICARE... accordance with the FASA implementing regulations and the Department of Health and Human Services nonprocurement common rule at 45 CFR part 76. (3) Felonies. The provider, supplier, or any owner of the...

  9. 78 FR 79081 - Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-27

    ...This proposed rule would establish national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to ensure that they adequately plan for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It would also ensure that these providers and suppliers are adequately......

  10. 78 FR 59702 - Medicare Program; Medicare Appeals: Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-27

    ...This notice announces the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective for requests for ALJ hearings and judicial review filed on or after January 1, 2014. The calendar year 2014 AIC threshold amounts are......

  11. 75 FR 58407 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-24

    ... for requests for ALJ hearings and judicial review filed on or after January 1, 2011. The 2011 AIC threshold amounts are $130 for ALJ hearings and $1,300 for judicial review. DATES: Effective Date: This... and judicial review at $100 and $1,000, respectively, for Medicare Part A and Part B appeals....

  12. 75 FR 8982 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-26

    ... in the Federal Register (63 FR 68780) announcing establishment of the Medicare Coverage Advisory... November 24, 1998. On January 26, 2007 the Secretary published a notice in the Federal Register (72 FR 3853... professions such as epidemiology and biostatistics, and methodology of trial design. The MEDCAC functions on...

  13. 75 FR 78705 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-16

    ... in the Federal Register (63 FR 68780) announcing establishment of the Medicare Coverage Advisory... November 24, 1998. On January 26, 2007 the Secretary published a notice in the Federal Register (72 FR 3853... methodology of trial design. The MEDCAC functions on a committee basis. The committee reviews and...

  14. 42 CFR 423.906 - General payment provisions.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false General payment provisions. 423.906 Section 423.906 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Special Rules for States-Eligibility Determinations for...

  15. 42 CFR 417.536 - Cost payment principles.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Cost payment principles. 417.536 Section 417.536 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Medicare...

  16. 42 CFR 414.102 - General payment rules.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false General payment rules. 414.102 Section 414.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for Parenteral and Enteral Nutrition...

  17. 42 CFR 405.372 - Proceeding for suspension of payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Proceeding for suspension of payment. 405.372 Section 405.372 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Suspension of Payment, Recovery of Overpayments, and Repayment...

  18. 42 CFR 414.102 - General payment rules.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false General payment rules. 414.102 Section 414.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Fee Schedules for Parenteral and Enteral Nutrition...

  19. 76 FR 67801 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    .... In the April 7, 2011 Federal Register (76 FR 19528), we published the Shared Savings Program proposed...-based purchasing initiatives, please refer to section I.A. of the proposed rule (76 FR 19530). B... within section 3022 of the Affordable Care Act is in section I.B. of the proposed rule (see 76 FR...

  20. 75 FR 44313 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-28

    ... rule (75 FR 1844), entitled ``Medicare and Medicaid Programs; Electronic Health Record Incentive... technology are coordinated. In the interim final rule published on January 13, 2010 (75 FR 2014) entitled... related proposed rule published on March 10, 2010, (75 FR 11328) entitled ``Proposed Establishment...

  1. 75 FR 81885 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Correcting Amendment

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-29

    .... Background In FR Doc. 2010-17207 (75 FR 44314) the final rule entitled ``Medicare and Medicaid Programs... rule (75 FR 16236) on the electronic prescribing of controlled substances. We are aligning our... the Preamble In FR Doc. 2010-17207 of July 28, 2010, we make the following corrections: ] 1. On...

  2. Individualizing Medicare.

    PubMed

    Chollet, D J

    1999-05-01

    Despite the enactment of significant changes to the Medicare program in 1997, Medicare's Hospital Insurance trust fund is projected to be exhausted just as the baby boom enters retirement. To address Medicare's financial difficulties, a number of reform proposals have been offered, including several to individualize Medicare financing and benefits. These proposals would attempt to increase Medicare revenues and reduce Medicare expenditures by having individuals bear risk--investment market risk before retirement and insurance market risk after retirement. Many fundamental aspects of these proposals have yet to be worked out, including how to guarantee a baseline level of saving for health insurance after retirement, how retirees might finance unanticipated health insurance price increases after retirement, the potential implications for Medicaid of inadequate individual saving, and whether the administrative cost of making the system fair and adequate ultimately would eliminate any rate-of-return advantages from allowing workers to invest their Medicare contributions in corporate stocks and bonds. PMID:10915458

  3. Public financing of the Medicare program will make its uniform structure increasingly costly to sustain.

    PubMed

    Baicker, Katherine; Shepard, Mark; Skinner, Jonathan

    2013-05-01

    The US Medicare program consumes an ever-rising share of the federal budget. Although this public spending can produce health and social benefits, raising taxes to finance it comes at the cost of slower economic growth. In this article we describe a model incorporating the benefits of public programs and the cost of tax financing. The model implies that the "one-size-fits-all" Medicare program, with everyone covered by the same insurance policy, will be increasingly difficult to sustain. We show that a Medicare program with guaranteed basic benefits and the option to purchase additional coverage could lead to more unequal health spending but slower growth in taxation, greater overall well-being, and more rapid growth of gross domestic product. Our framework highlights the key trade-offs between Medicare spending and economic prosperity. PMID:23650321

  4. 77 FR 44255 - Medicare Program; Application by the American Association of Diabetes Educators (AADE) for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-27

    ...This final notice announces the approval of an application from the American Association of Diabetes Educators for continued recognition as a national accreditation program for accrediting entities that wish to furnish outpatient diabetes self-management training to Medicare...

  5. 77 FR 37678 - Medicare and Medicaid Programs; Application From American Association for Accreditation of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-22

    ... American Association for Accreditation of Ambulatory Surgery Facilities for Continued Approval of Its Ambulatory Surgery Facilities Accreditation Program AGENCY: Centers for Medicare and Medicaid Services, HHS... application from the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)...

  6. Public Financing Of The Medicare Program Will Make Its Uniform Structure Increasingly Costly To Sustain

    PubMed Central

    Baicker, Katherine; Shepard, Mark; Skinner, Jonathan

    2013-01-01

    The US Medicare program consumes an ever-rising share of the federal budget. Although this public spending can produce health and social benefits, raising taxes to finance it comes at the cost of slower economic growth. In this article we describe a model incorporating the benefits of public programs and the cost of tax financing. The model implies that the “one-size-fits-all” Medicare program, with everyone covered by the same insurance policy, will be increasingly difficult to sustain. We show that a Medicare program with guaranteed basic benefits and the option to purchase additional coverage could lead to more unequal health spending but slower growth in taxation, greater overall well-being, and more rapid growth of gross domestic product. Our framework highlights the key trade-offs between Medicare spending and economic prosperity. PMID:23650321

  7. 42 CFR 422.308 - Adjustments to capitation rates, benchmarks, bids, and payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to... years before 2004. (c) Risk adjustment—(1) General rule. CMS will adjust the payment amounts under § 422...) General rule. For 2011 and subsequent years, for purposes of the adjustment under paragraph (c)(1) of...

  8. 75 FR 58789 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2010

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-24

    ...This notice lists CMS manual instructions, substantive and interpretive regulations, and other Federal Register notices that were published from April through June 2010, relating to the Medicare and Medicaid programs. This notice provides information on national coverage determinations (NCDs) affecting specific medical and health care services under Medicare. Additionally, this notice......

  9. 75 FR 14905 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-October Through December 2009

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-03-26

    ...This notice lists CMS manual instructions, substantive and interpretive regulations, and other Federal Register notices that were published from October 2009 through December 2009, relating to the Medicare and Medicaid programs. This notice provides information on national coverage determinations (NCDs) affecting specific medical and health care services under Medicare. Additionally, this......

  10. 76 FR 2453 - Medicare Program; Hospital Inpatient Value-Based Purchasing Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-01-13

    ...In this proposed rule, we are proposing to implement a Hospital Value-Based Purchasing program (``Hospital VBP program'' or ``the program'') under section 1886(o) of the Social Security Act (``Act''), under which value-based incentive payments will be made in a fiscal year to hospitals that meet performance standards with respect to a performance period for the fiscal year involved. The......

  11. Fraud fighters gain muscle. As fraud cases mount, fledgling program aims to step up policing of Medicare contractors.

    PubMed

    Hallam, K; Taylor, M

    1999-08-16

    The use of fiscal intermediaries to police Medicare claims has come under the spotlight, mainly because many of those contractors have themselves settled Medicare or Medicaid fraud charges. One answer: the new Medicare Integrity Program, which will beef up federal fraud fighters. PMID:10557464

  12. 75 FR 81278 - Medicare Program: Solicitation of Comments Regarding Development of a Recovery Audit Contractor...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-27

    ... rules for the MA program (69 FR 46866) and prescription drug benefit program (69 FR 46632). The final regulations implementing both programs, published on January 28, 2005 (70 FR 4588 and 70 FR 4194, respectively... Regarding Development of a Recovery Audit Contractor Program for the Medicare Part C and D Programs...

  13. Intersection of quality metrics and Medicare policy.

    PubMed

    Nau, David P

    2011-12-01

    The federal government is increasing its push for a high-value health care system by increasing transparency and accountability related to quality. The Medicare program has begun to publicly rate the quality of Medicare plans, including prescription drug plans, and is transforming its payment policies to reward plans that deliver the highest levels of quality. These policies will have a cascade effect on pharmacies and pharmacists as the Medicare plans look for assistance in improving the quality of medication use. This commentary describes the Medicare policies directed toward improvement of quality and their effect on pharmacy payment and opportunities for pharmacists to affirm their role in a high-quality medication use system. PMID:22045907

  14. Aligning incentive payments with outcomes: lessons from a Medicaid Section 1115 waiver program.

    PubMed

    Drake, Matt; Gevorgyan, Anush; Hetterich, Charles

    2016-04-01

    By obtaining a Medicaid waiver under Section 1115 of the Social Security Act, many states have taken advantage of an opportunity to innovate and transform their Medicaid programs. The Center for Medicare and Medicaid Innovation has granted Section 1115 waivers to several states to develop Delivery System Reform Incentive Payment (DSRIP) programs, which vary in their federal funding pools, structures, and goals, but share key characteristics, such as the withholding of payment until certain milestones and metrics are met. The DSRIP project in New York--as exemplified by Finger Lakes Performing Provider System--is being closely watched across the country as CMS and state Medicaid programs contemplate similar measures to transform Medicaid and bend its cost curve. PMID:27244980

  15. Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2003 and inclusion of registered nurses in the personnel provision of the critical access hospital emergency services requirement for frontier areas and remote locations. Final rule with comment period.

    PubMed

    2002-12-31

    This final rule with comment period refines the resource-based practice expense relative value units (RVUs) and makes other changes to Medicare Part B payment policy. In addition, as required by statute, we are announcing the physician fee schedule update for CY 2003. The update to the physician fee schedule occurs as a result of a calculation methodology specified by law. That law required the Department to set annual updates based in part on estimates of several factors. Although subsequent after-the-fact data indicate that actual increases were different to some degree from earlier estimates, the law does not permit those estimates to be revised. A subsequent law required estimates to be revised for FY 2000 and beyond. Although we have exhaustively examined opportunities for a different interpretation of law that would allow us to correct the flaw in the formula administratively, current law does not permit such an interpretation. Accordingly, without Congressional action to address the current legal framework, the Department is compelled to announce herein a physician fee schedule update for CY 2003 of -4.4 percent. Because the Department would adopt a change in the formula that determines the physician update if the law permitted it, we have examined how proper adjustments to past data could result in a positive update. The Department believes that revisions of estimates used to establish the sustainable growth rates (SGR) for fiscal years (FY) 1998 and 1999 and Medicare volume performance standards (MVPS) for 1990-1996 would, under present calculations, result in a positive update. The Department intends to work closely with Congress to develop legislation that could permit a positive update, and hopes that such legislation can be passed before the negative update takes effect. Because the Department wishes to change the update promptly in the event that Congress provides the Department legal authority to do so, we are requesting comments regarding how

  16. Medicare and Medicaid programs: revisions to deeming authority survey, certification, and enforcement procedures. Final rule.

    PubMed

    2015-05-22

    This final rule revises the survey, certification, and enforcement procedures related to CMS oversight of national accrediting organizations (AOs). The revisions implement certain provisions under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). The revisions also clarify and strengthen our oversight of AOs that apply for, and are granted, recognition and approval of an accreditation program in accordance with the statute. The rule also extends some provisions, which are applicable to Medicare-participating providers, to Medicare-participating suppliers subject to certification requirements, and clarifies the definition of "immediate jeopardy." PMID:26003965

  17. 42 CFR 413.75 - Direct GME payments: General requirements.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE.... (2) The type of residency program in which the individual participates and the number of years...

  18. 42 CFR 413.75 - Direct GME payments: General requirements.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE.... (2) The type of residency program in which the individual participates and the number of years...

  19. 42 CFR 413.75 - Direct GME payments: General requirements.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE.... (2) The type of residency program in which the individual participates and the number of years...

  20. 77 FR 9179 - Medicare Program; Reporting and Returning of Overpayments

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-16

    ..., Reporting and recordkeeping requirements, Rural areas, X-rays. For the reasons set forth in the preamble... regulations related to Medicare overpayments. (See the March 25, 1998 (63 FR 14506) and January 25, 2002 (67 FR 3662) proposed rules.) On March 23, 2010, the Patient Protection and Affordable Care Act (Pub....