Science.gov

Sample records for medicare program payment

  1. 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

    ..., Medicaid, and Children's Health Insurance Program beneficiaries. One potential mechanism for achieving... partnerships through complementary efforts, including the Medicare Shared Savings Program and initiatives... Register (76 FR 68012), we published a notice entitled ``Medicare Program; 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

    ...; 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 Strengthening... MSP Web portal. It also requires that we add functionality to the existing MSP Web portal that...

  4. 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)...

  5. 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...

  6. 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...

  7. 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...

  8. 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...

  9. 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...

  10. 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

  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.

  12. 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...

  13. 77 FR 4908 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-01

    ... INFORMATION: I. Background In FR Doc. 2011-19719 of August 18, 2011 (76 FR 51476), the final rule entitled... Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2012 Rates; Corrections AGENCY: Centers...

  14. 77 FR 27869 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-11

    ... Web page at: http://www.gpo.gov/fdsys/browse/collection.action?collectionCode=FR . Free public access... 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 Year...

  15. 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...

  16. 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.

  17. 76 FR 68011 - Medicare Program; Advanced Payment Model

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    ... the initiative and the application process is available on the Innovation Center Web site at http... begin in 2012, and provides information about the model and application process. DATES: Application Submission Deadline: Applicants must submit both the application for the Medicare Shared Savings Program...

  18. 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...-AR53 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

  19. 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...

  20. 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... effective date requirements. ] IV. Correction of Errors In FR Doc. 2012-19079 of August 31, 2012 (77 FR...-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

  1. Medicare program; end-stage renal disease prospective payment system, quality incentive program, and bad debt reductions for all Medicare providers. Final rule.

    PubMed

    2012-11-01

    This final rule updates and makes revisions to the end-stage renal disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2013. This rule also sets forth requirements for the ESRD quality incentive program (QIP), including for payment year (PY) 2015 and beyond. In addition, this rule implements changes to bad debt reimbursement for all Medicare providers, suppliers, and other entities eligible to receive Medicare payment for bad debt and removes the cap on bad debt reimbursement to ESRD facilities. (See the Table of Contents for a listing of the specific issues addressed in this final rule.)

  2. 77 FR 43329 - Medicaid Program; State Allotments for Payment of Medicare Part B Premiums for Qualifying...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-24

    ... for Payment of Medicare Part B Premiums for Qualifying Individuals (QIs) for FY 2012 AGENCY: Centers... States' final allotments available to pay the Medicare Part B premiums for Qualifying Individuals (QIs.... DATES: The final QI allotments for payment of Medicare Part B premiums for FY 2011 are effective...

  3. 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...

  4. 42 CFR 411.33 - Amount of Medicare secondary payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 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...

  5. 78 FR 43533 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-19

    ...This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2014 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this proposed rule, we describe the proposed changes to the amounts and factors used to determine......

  6. Medicare Payment Systems: A Look Back and a Look Forward.

    PubMed

    Schaum, Kathleen Dianne

    2013-12-01

    Medicare is the major payer for patients with chronic wounds. Over the past 50 years, the Medicare payment systems have undergone numerous changes. At the beginning of the Medicare program, providers were paid based on fee-for-service. In 1997, many of the Medicare payment systems were converted to prospective payment systems (PPSs). Currently, Medicare is conducting many demonstration payment programs to provide the best quality outcomes, at the lowest total cost of care (not necessarily the lowest cost product or procedure), and with patient satisfaction. While the demonstration payment programs are being tested, providers may receive parallel Medicare payments: payment through current PPS and through the demonstration payment program. Wound care providers and manufacturers need to prepare now for the future payment systems. PMID:24761334

  7. Medicare Payment Systems: A Look Back and a Look Forward

    PubMed Central

    Schaum, Kathleen Dianne

    2013-01-01

    Medicare is the major payer for patients with chronic wounds. Over the past 50 years, the Medicare payment systems have undergone numerous changes. At the beginning of the Medicare program, providers were paid based on fee-for-service. In 1997, many of the Medicare payment systems were converted to prospective payment systems (PPSs). Currently, Medicare is conducting many demonstration payment programs to provide the best quality outcomes, at the lowest total cost of care (not necessarily the lowest cost product or procedure), and with patient satisfaction. While the demonstration payment programs are being tested, providers may receive parallel Medicare payments: payment through current PPS and through the demonstration payment program. Wound care providers and manufacturers need to prepare now for the future payment systems. PMID:24761334

  8. 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

    ...; Center for Medicare Management, Hospital & Ambulatory Policy Group, Division of Outpatient Care; 7500... components of the Medicare hospital Outpatient Prospective Payment System (OPPS). The Charter requires that... consist of a chair and up to 15 members who are full- time employees of hospitals, hospital systems,...

  9. 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

    ...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. In addition, in the Addendum to this proposed rule, we describe the proposed changes to the amounts and factors used to determine the rates for Medicare acute......

  10. 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...

  11. 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

    ... Physician Order and Certification for Payment of Hospital Inpatient Services under Medicare Part A Issues. Susanne Seagrave, (410) 786-0044, Physician Order and Certification for Payment of Inpatient... line FQHC Federally qualified health center FR Federal Register FTE Full-time equivalent FUH...

  12. 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...

  13. Medicare program; coverage and payment of ambulance services; inflation update for CY 2004. Final rule with comment period.

    PubMed

    2003-12-01

    This final rule provides the sunset date for the interim bonus payment for rural ambulance mileage of 18 through 50 miles as required by the Medicare, Medicaid and State Child Health Insurance Program Benefits Improvement and Protection Act of 2000 (BIPA) and provides notice of the annual Ambulance Inflation Factor (AIF) for ambulance services for calendar year (CY) 2004. The statute requires that this inflation factor be applied in determining the fee schedule amounts and payment limits for ambulance services.

  14. 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...

  15. 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...

  16. 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...

  17. 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...

  18. 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

    ... Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on... Medicare Program; Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work Relative... public, including any personally identifiable or confidential business information that is included in...

  19. Medicare Program; FY 2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

    PubMed

    2016-08-01

    This final rule will update the hospice wage index, payment rates, and cap amount for fiscal year (FY) 2017. In addition, this rule changes the hospice quality reporting program, including adopting new quality measures. Finally, this final rule includes information regarding the Medicare Care Choices Model (MCCM).

  20. Medicare Program; FY 2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

    PubMed

    2016-08-01

    This final rule will update the hospice wage index, payment rates, and cap amount for fiscal year (FY) 2017. In addition, this rule changes the hospice quality reporting program, including adopting new quality measures. Finally, this final rule includes information regarding the Medicare Care Choices Model (MCCM). PMID:27529902

  1. 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...

  2. 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

    ...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 and to implement certain provisions of the Affordable Care Act and other legislation. In addition, we describe the changes to the amounts and factors used to determine......

  3. 78 FR 26437 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-06

    ... 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 FY... center FR Federal Register FY Fiscal year GAO Government Accountability Office HCPCS Healthcare...

  4. 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...

  5. 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,...

  6. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2015.

    PubMed

    2014-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2015 as required by the statute. This final rule finalizes a policy to collect data on the amount and mode (that is, Individual, Concurrent, Group, and Co-Treatment) of therapy provided in the IRF setting according to therapy discipline, revises the list of diagnosis and impairment group codes that presumptively meet the "60 percent rule'' compliance criteria, provides a way for IRFs to indicate on the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) form whether the prior treatment and severity requirements have been met for arthritis cases to presumptively meet the "60 percent rule'' compliance criteria, and revises and updates quality measures and reporting requirements under the IRF quality reporting program (QRP). This rule also delays the effective date for the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the "60 percent rule'' that were finalized in FY 2014 IRF PPS final rule and adopts the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the "60 percent rule'' that are finalized in this rule. This final rule also addresses the implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), for the IRF prospective payment system (PPS), which will be effective when ICD-10-CM becomes the required medical data code set for use on Medicare claims and IRF-PAI submissions.

  7. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2015.

    PubMed

    2014-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2015 as required by the statute. This final rule finalizes a policy to collect data on the amount and mode (that is, Individual, Concurrent, Group, and Co-Treatment) of therapy provided in the IRF setting according to therapy discipline, revises the list of diagnosis and impairment group codes that presumptively meet the "60 percent rule'' compliance criteria, provides a way for IRFs to indicate on the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) form whether the prior treatment and severity requirements have been met for arthritis cases to presumptively meet the "60 percent rule'' compliance criteria, and revises and updates quality measures and reporting requirements under the IRF quality reporting program (QRP). This rule also delays the effective date for the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the "60 percent rule'' that were finalized in FY 2014 IRF PPS final rule and adopts the revisions to the list of diagnosis codes that are used to determine presumptive compliance under the "60 percent rule'' that are finalized in this rule. This final rule also addresses the implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), for the IRF prospective payment system (PPS), which will be effective when ICD-10-CM becomes the required medical data code set for use on Medicare claims and IRF-PAI submissions. PMID:25122947

  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.

  9. 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.

  10. New Directions for Medicare Payment Systems

    PubMed Central

    Goody, Brigid; Friedman, Maria A.; Sobaski, William

    1994-01-01

    This overview discusses articles published in this issue of the Health Care Financing Review, entitled “Medicare Payment Systems: Moving Toward the Future.” These articles focus on the onjoing development of Medicare payment methodologies, their adoption by non-Medicare payers, and issues to be addressed in the development of all-payer systems based on these methodologies. PMID:10142366

  11. 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.

  12. 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.

  13. 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

    ... FR 60315) included several corrections to figures and data for the Hospital Readmissions Reduction... 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...

  14. 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..., 485, and 489 RIN 0938-AP80; RIN 0938-AP33 Medicare Program; Hospital Inpatient Prospective...

  15. 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... requirements. IV. Correction of Errors In FR Doc. 2011-19719 of August 18, 2011 (76 FR 51476), make...

  16. 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...

  17. 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

  18. 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.

  19. 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

  20. 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).

  1. Medicare Interim Payment System's Impact on Medicare Home Health Utilization

    PubMed Central

    Liu, Korbin; Long, Sharon K.; Dowling, Krista

    2003-01-01

    The Medicare home health interim payment system (IPS) implemented in fiscal year 1998 provided very strong incentives for home health agencies (HHAs) to reduce the number of visits provided to each Medicare user and to avoid those beneficiaries whose Medicare plan of care was likely to exceed the average beneficiary cost limit. We analyzed multiple years of data from the Medicare Current Beneficiary Survey (MCBS) to examine how the IPS affected subgroups of the Medicare population by health and socioeconomic characteristics. We found that the IPS strongly reduced overall utilization, but that few subgroups were disproportionately affected. PMID:14997695

  2. 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...

  3. Medicare and Medicaid programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; electronic reporting pilot; Inpatient Rehabilitation Facilities Quality Reporting Program; revision to Quality Improvement Organization regulations. Final rule with comment period.

    PubMed

    2012-11-15

    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 2013 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, the ASC Quality Reporting (ASCQR) Program, and the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program. We are continuing the electronic reporting pilot for the Electronic Health Record (EHR) Incentive Program, and revising the various regulations governing Quality Improvement Organizations (QIOs), including the secure transmittal of electronic medical information, beneficiary complaint resolution and notification processes, and technical changes. The technical changes to the QIO regulations reflect CMS' commitment to the general principles of the President's Executive Order on Regulatory Reform, Executive Order 13563 (January 18, 2011).

  4. 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

    ... Year 2011 for New Clinical Laboratory Tests Payment Determinations AGENCY: Centers for Medicare... following years. We refer readers to Sec. 414.508(b). For each new clinical laboratory test code, a... public on the appropriate basis for establishing payment amounts for a specified list of new...

  5. 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

  6. 75 FR 49029 - Medicare Program; End-Stage Renal Disease Prospective Payment System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-12

    ... Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 410, 413 and 414 Medicare... HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 410, 413 and 414 RIN 0938... AV Arteriovenous BIPA Medicare, Medicaid, and SCHIP (State Children's Health Insurance...

  7. 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

    ... for requesting and obtaining the low-volume hospital payment adjustment for FY 2011 (75 FR 50240). For... hospital status for FYs 2011 and 2012 in the FY 2011 IPPS/LTCH PPS final rule (75 FR 20574 through 20575... total payments to IPPS hospitals relative to FY 2012. In the FY 2013 IPPS/LTCH PPS final rule (77...

  8. 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

    ... (71 FR 69683 and 69684), we revised our update methodology by applying the growth update to the per... Add-On to the Composite Rate Portion of the ESRD Blended Payment Rate i. Estimating Growth in Expenditures for Drugs and Biologicals in CY 2013 ii. Estimating per Patient Growth iii. Applying the...

  9. 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,...

  10. 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).

  11. 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

  12. Medicare. Indirect Medical Education Payments Are Too High. GAO Report to Congressional Committees.

    ERIC Educational Resources Information Center

    Zimmerman, Michael; And Others

    A report to the Congressional Committees examines the variation in Medicare costs and payments among teaching and nonteaching hospitals and identifies factors explaining the variation. Three chapters are as follows: (1) introduction (i.e., the Medicare Program, Medicare payments for inpatient hospital services, objectives, scope, and methodology);…

  13. Medicare Payments: How Much Do Chronic Conditions Matter?

    PubMed Central

    Erdem, Erkan; Prada, Sergio I.; Haffer, Samuel C.

    2013-01-01

    Objective Analyze differences in Medicare Fee-for-Service utilization (i.e., program payments) by beneficiary characteristics, such as gender, age, and prevalence of chronic conditions. Methods Using the 2008 and 2010 Chronic Conditions Public Use Files, we conduct a descriptive analysis of enrollment and program payments by gender, age categories, and eleven chronic conditions. Results We find that the effect of chronic conditions on Medicare payments is dramatic. Average Medicare payments increase significantly with the number of chronic conditions. Finally, we quantify the effect of individual conditions and find that “Stroke / Transient Ischemic Attack” and “Chronic Kidney Disease” are the costliest chronic conditions for Part A, and “Cancer” and “Chronic Kidney Disease” are the costliest for Part B. PMID:24753967

  14. New York's Medicare Marketplace: examining new York's Medicare advantage plan landscape in light of payment reform.

    PubMed

    Goggin-Callahaan, Doug; Baker, Joe; Bennett, Rachel; Clerk, Michell; Hersey, Eric; Riccardi, Fred; Torbattejad, May; Xu, Denise

    2013-01-01

    The Patient Protection and Affordable Care Act (ACA) provided for cost savings in the Medicare program, in part to underwrite coverage expansion to Medicare beneficiaries, to finance new coverage for those not eligible for Medicare, and to strengthen Medicare's financial outlook. One cost-saving measure, a reformulation and reduction in payments to private health insurance plans that provide Medicare benefits through the Medicare Advantage (MA) program, had a sound policy basis but was criticized, particularly by opponents o fthe ACA, as a measure that would lead to increased costs, reductions in benefits, and diminished plan choices to Medicare beneficiaries enrolled in MA plans. Despite dire predictions to this effect, a review of a sample of MA plan offerings in New York State in 2012 shows that Medicare beneficiaries enrolled in such plans did not experience significant benefit reductions or increased costs. While the number of plan offerings decreased, the reduction was mostly caused by the elimination of duplicative plan choices in 2011. Although the MA plan executives we interviewed indicated that further reductions in plan reimbursement in future years-tempered by potential bonus payments for meeting quality and performance metrics-could impact plan costs and benefits, they believed plans will employ a number of strategies to remain in the market and maintain benefciary benefits and cost structures. However, government regulators and consumer advocates will need to examine MA plan offerings in the coming years to determine the efect ofplan reaction to the ACA payments on beneficiaries'costs for coverage and access

  15. 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...

  16. 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

    ... clinical diagnostic laboratory tests under Part B of title XVIII of the Social Security Act (the Act) that..., 2001 notice (66 FR 58743) to implement section 531(b) of BIPA. Section 942(b) of the Medicare... payment amount for each such code, an explanation of the reasons for each determination, the data on...

  17. Rural Medicare Advantage Plan Payment in 2015.

    PubMed

    Kemper, Leah; Barker, Abigail R; McBride, Timothy D; Mueller, Keith

    2015-12-01

    Payment to Medicare Advantage (MA) plans was fundamentally altered in the Patient Protection and Affordable Care Act of 2010 (ACA). MA plans now operate under a new formula for county-level payment area benchmarks, and in 2012 began receiving quality-based bonus payments. The Medicare Advantage Quality Bonus Payment Demonstration expanded the bonus payments to most MA plans through 2014; however, with the end of the demonstration bonus payments has been reduced for intermediate quality MA plans. This brief examines the impact that these changes in MA baseline payment are having on MA plans and beneficiaries in rural and urban areas. Key Data Findings. (1) Payments to plans in rural areas were 3.9 percent smaller under ACA payment policies in 2015 than they would have been in the absence of the ACA. For plans in urban areas, the payments were 8.8 percent smaller than they would have been. These figures were determined using hypothetical pre-ACA and actual ACA-mandated benchmarks for 2015. (2) MA plans in rural areas received an average annual bonus payment of $326.77 per enrollee in 2014, but only $63.76 per enrollee in 2015, with the conclusion of the demonstration. (3) In 2014, 92 percent of rural MA beneficiaries were in a plan that received quality-based bonus payments under the demonstration, while in March 2015, 56 percent of rural MA beneficiaries were in a plan that was eligible for quality-based bonus payments.

  18. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2014. Final rule.

    PubMed

    2013-08-01

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2014 (for discharges occurring on or after October 1, 2013 and on or before September 30, 2014) as required by the statute. This final rule also revised the list of diagnosis codes that may be counted toward an IRF's "60 percent rule'' compliance calculation to determine "presumptive compliance,'' update the IRF facility-level adjustment factors using an enhanced estimation methodology, revise sections of the Inpatient Rehabilitation Facility-Patient Assessment Instrument, revise requirements for acute care hospitals that have IRF units, clarify the IRF regulation text regarding limitation of review, update references to previously changed sections in the regulations text, and revise and update quality measures and reporting requirements under the IRF quality reporting program.

  19. Medicare program; payment to health maintenance organizations and competitive medical plans--HCFA. Proposed rule.

    PubMed

    1984-05-25

    These proposed regulations would implement section 114 of the Tax Equity and Fiscal Responsibility Act of 1982. This provision of the law amended section 1876 of the Social Security Act, which authorizes Medicare reimbursement to eligible organizations on a prospective basis for those organizations that have a risk contract or on a reasonable cost basis for those that have a cost contract. The definition of an eligible organization includes both health maintenance organizations (HMOs) that meet the definition of a qualified HMO under the Public Health Service Act and competitive medical plans (CMPs). The purpose of this proposal is to set forth the requirements that an entity must meet in order to be (1) eligible to enter into a Medicare contract (either risk or reasonable cost) as an eligible organization and (2) reimbursed by Medicare on a capacitation basis (either prospectively or retrospectively) for items and services furnished to Medicare enrollees. PMID:10299521

  20. 78 FR 29139 - Medicare Program; Bundled Payments for Care Improvement Model 1 Open Period

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-17

    ... participation in Model 1 of the Bundled Payments for Care Improvement initiative. DATES: Model 1 of the Bundled... for participation in Model 1 of the Bundled Payments for Care Improvement initiative. Interested... authority under section 1115A of the Social Security Act (the Act), as added by section 3021 of...

  1. 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

    ... Payment Model: Applications for the performance period beginning on April ] 1, 2012 will be accepted from... announces a new deadline for applications to the Advance Payment Model for the performance period beginning... February 1, 2012. The period during which applications will be accepted for the performance...

  2. 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

    ... or confidential business information that is included in a comment. We post all comments received... Clinical Studies--Revisions of Medicare Coverage Requirements B. Ultrasound Screening for Abdominal Aortic... FFS Fee-for-service FOBT Fecal occult blood test FQHC Federally qualified health center FR...

  3. 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 73417... Center RIA Regulatory Impact Analysis RHC Rural Health Clinic SNF Skilled Nursing Facility UDS...

  4. 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

    ... Inpatient Services under Medicare Part A. Ann Marshall, (410) 786-3059, Requirement for Physician Order for... fiscal year FPL Federal poverty line FQHC Federally qualified health center FR Federal Register FTE Full... Provider-Specific File PS&R Provider Statistical and Reimbursement PQRS Physician Quality Reporting...

  5. 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...

  6. Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2005. Final rule with comment period.

    PubMed

    2004-11-15

    This final rule refines the resource-based practice expense relative value units (RVUs) and makes other changes to Medicare Part B payment policy. These policy changes concern: supplemental survey data for practice expense; updated geographic practice cost indices for physician work and practice expense; updated malpractice RVUs; revised requirements for supervision of therapy assistants; revised payment rules for low osmolar contrast media; changes to payment policies for physicians and practitioners managing dialysis patients; clarification of care plan oversight requirements; revised requirements for supervision of diagnostic psychological testing services; clarifications to the policies affecting therapy services; revised requirements for assignment of Medicare claims; addition to the list of telehealth services; and, several coding issues. We are making these changes to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. This final rule also addresses the following provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-17) (MMA): coverage of an initial preventive physical examination; coverage of cardiovascular (CV) screening blood tests; coverage of diabetes screening tests; incentive payment improvements for physicians in shortage areas; payment for covered outpatient drugs and biologicals; payment for renal dialysis services; coverage of routine costs associated with certain clinical trials of category A devices as defined by the Food and Drug Administration; hospice consultation service; indexing the Part B deductible to inflation; extension of coverage of intravenous immune globulin (IVIG) for the treatment in the home of primary immune deficiency diseases; revisions to reassignment provisions; and, payment for diagnostic mammograms, physicians' services associated with drug administration services and coverage of religious nonmedical health

  7. Medicare and Medicaid Programs; CY 2016 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

    PubMed

    2015-11-01

    This final rule will update 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, 2016. As required by the Affordable Care Act, this rule implements the 3rd year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates. This rule updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking and provides a clarification regarding the use of the "initial encounter'' seventh character applicable to certain ICD-10-CM code categories. This final rule will also finalize reductions to the national, standardized 60-day episode payment rate in CY 2016, CY 2017, and CY 2018 of 0.97 percent in each year to account for estimated case-mix growth unrelated to increases in patient acuity (nominal case-mix growth) between CY 2012 and CY 2014. In addition, this rule implements a HH value-based purchasing (HHVBP) model, beginning January 1, 2016, in which all Medicare-certified HHAs in selected states will be required to participate. Finally, this rule finalizes minor changes to the home health quality reporting program and minor technical regulations text changes.

  8. 75 FR 34611 - Medicare Program; Supplemental Proposed Changes to the Hospital Inpatient Prospective Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-17

    ... CONTACT: Tzvi Hefter, (410) 786-4487. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2010-12567 of... Errors In FR Doc. 2010-12567 of June 2, 2010, make the following corrections: A. Corrections to the...; Supplemental Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care...

  9. 75 FR 30917 - Medicare Program; Supplemental Proposed Changes to the Hospital Inpatient Prospective Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-02

    ... final rule (69 FR 49099 through 49102), a 25 percent low-volume adjustment to all qualifying hospitals... 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...

  10. 76 FR 19365 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    ... payments published in the FY 2011 IPPS final rule (75 FR 50042). Overall, all hospitals will experience an... exceptions policy (see the FY 2005 IPPS final rule, 69 FR 49105). ** This hospital has been assigned a wage... 2011 IPPS/LTCHPPS final rule) appeared in the August 16, 2010 Federal Register (75 FR 50042) and...

  11. 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

    ...-visit rates, the nonroutine medical supply (NRS) conversion factors, and the low utilization payment... correcting amendment corrects a technical error identified in the November 17, 2010 final rule. DATES...: Randy Throndset, (410) 786-0131. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2010-27778 (75...

  12. 76 FR 40987 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-12

    .... Updates to the HH PPS II. Provisions of the Proposed Rule A. Case-Mix Measurement 1. Independent Review of... deferred finalizing a payment reduction for CY 2012 until a further study of the case-mix data was completed. Independent review of the case-mix model has been conducted and the results are discussed...

  13. 76 FR 68525 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-04

    .... However, we deferred finalizing a payment reduction for CY 2012 until a further study of the case-mix data was completed. Independent review of the case-mix model has been conducted and the results were... nominal case-mix growth. In the CY 2012 HH PPS proposed rule (76 FR 40991), we also stated that...

  14. 75 FR 42835 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-22

    ... FR Federal Register FTE Full-time Equivalent FY Federal Fiscal Year HCFA Health Care Financing... Assessment Instrument PPS Prospective Payment System QIC Qualified Independent Contractors RAC Recovery Audit... 2002 IRF PPS final rule (66 FR 41316) and the FY 2006 IRF PPS final rule (70 FR 47880), we...

  15. 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...

  16. 75 FR 42885 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-22

    ... occurred in a final rule (74 FR 40288, August 11, 2009) that set forth updates to the SNF PPS payment rates... certain SNF level of care determinations. In the July 30, 1999 final rule (64 FR 41670), we indicated that... in the SNF PPS final rule for FY 2001 (65 FR 46770, July 31, 2000). In particular, section 101(a)...

  17. 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...

  18. 75 FR 34614 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-17

    ... Hefter, (410) 786-4487. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2010-12563 of June 2, 2010... correction notice. III. Correction of Errors In FR Doc. 2010-12563 of June 2, 2010, make the following... care hospital prospective payment system (FY 2010 IPPS/RY 2010 LTCH PPS) notice), there were...

  19. 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...

  20. 75 FR 46169 - Medicare Program; Proposed Changes to the Hospital Outpatient Prospective Payment System and CY...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-03

    ... April 7, 2000, we published in the Federal Register a final rule with comment period (65 FR 18434) to... Register (74 FR 60316). In that final rule with comment period, we revised the OPPS to update the payment... November 18, 2008 final rule with comment period (73 FR 68502) pertaining to the APC assignment of...

  1. 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),...

  2. 78 FR 47859 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-06

    ... FY 2013 IRF PPS notice (77 FR 44618) to update the federal prospective payment rates for FY 2014... the IRF PPS provisions appears in the original FY 2002 IRF PPS final rule (66 FR 41316) and the FY 2006 IRF PPS final rule (70 FR 47880), we are providing below a general description of the IRF PPS...

  3. 78 FR 46733 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-01

    ... Register (69 FR 66922). In developing the IPF PPS, in order to ensure that the IPF PPS is able to account... intention to 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...

  4. 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...

  5. 76 FR 51475 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-18

    ... March 14, 2011, at 76 FR 13515, is confirmed as final without change. Applicability dates: The update to... of the Payment Window Policy to Services Furnished at Physicians' Practices P. Changes to MS-DRGs... LTCH PPS in the same documents that update the IPPS (73 FR 26797 through 26798). 4. Critical...

  6. An outlier pool for Medicare HMO payments

    PubMed Central

    Beebe, James C.

    1992-01-01

    Medicare pays “at-risk” health maintenance organizations a prospective capitation amount that is established by the adjusted average per capita cost (AAPCC) formula for estimating the amount enrollees would have cost had they remained in the fee-for-service sector. Because the AAPCC accounts for a very small percentage of the variation in beneficiary costs, considerable research has been devoted to improving the formula. A way to improve the explained variance is to remove the most expensive beneficiaries from the AAPCC payment system and pay for them separately. This article examines one approach to a payment system that combines the AAPCC with an outlier payment mechanism. PMID:10124439

  7. Kaiser-Permanente's Medicare Plus Project: A Successful Medicare Prospective Payment Demonstration

    PubMed Central

    Greenlick, Merwyn R.; Lamb, Sara J.; Carpenter, Theodore M.; Fischer, Thomas S.; Marks, Sylvia D.; Cooper, William J.

    1983-01-01

    The Medicare Plus project of the Oregon Region Kaiser-Permanente Medical Care Program was designed as a model for prospective payment to Increase Health Maintenance Organization (HMO) participation in the Medicare program. The project demonstrated that it is possible to design a prospective payment system that costs the Medicare program less than services purchased in the community from fee-for-service providers; would provide appropriate payment to the HMO; and in addition, creates a “savings” to return to beneficiaries in the form of comprehensive benefits to motivate them to enroll in the HMO. Medicare Plus was highly successful in recruiting 5,500 new and 1,800 conversion members into the demonstration, through use of a media campaign, a recruitment brochure, and a telephone information center. Members recruited were a representative age and geographic cross section of the senior citizen population in the Portland, Oregon metropolitan area. Utilization of inpatient services by Medicare Plus members in the first full year (1981) was 1679 days per thousand members and decreased to 1607 in the second full year (1982). New members made an average of eight visits per year to ambulatory care facilities. PMID:10310002

  8. Diagnosis-Based Risk Adjustment for Medicare Prescription Drug Plan Payments

    PubMed Central

    Robst, John; Levy, Jesse M.; Ingber, Melvin J.

    2007-01-01

    The 2003 Medicare Prescription Drug, Improvement, and Modernization Act (MMA) created Medicare Part D, a voluntary prescription drug benefit program. The benefit is a government subsidized prescription drug benefit within Medicare. This article focuses on the development of the prescription drug risk-adjustment model used to adjust payments to reflect the health status of plan enrollees. PMID:17722748

  9. 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...

  10. 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...

  11. 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,...

  12. 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

  13. 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

  14. 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.

  15. 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...

  16. 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.

  17. 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

  18. 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...

  19. 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.../HospitalOutpatientPPS/HORD . In addition, the CY 2012 Statewide Average CCRs displayed in Table 11 (76...

  20. 75 FR 21329 - Medicaid Program; State Allotments for Payment of Medicare Part B Premiums for Qualifying...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-23

    ... Abstinence Programs Extension and Hurricane Katrina Unemployment Relief Act of 2005 (Pub. L. 109-91) was... million in FY 2002. On March 29, 1999, we published a notice in the Federal Register (64 FR 14931) to.... Therefore, on August 26, 2005, we published in the Federal Register an interim final rule (70 FR...

  1. 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... 3 of the ``Emergency Aid to American Survivors of the Haiti Earthquake Act'' enacted on January 27, 2010 (Haiti Earthquake Act, Pub. L. 111-127) amended section 1933(g)(2)(M) of the Social Security...

  2. MEDICARE PAYMENTS AND SYSTEM-LEVEL HEALTH-CARE USE

    PubMed Central

    ROBBINS, JACOB A.

    2015-01-01

    The rapid growth of Medicare managed care over the past decade has the potential to increase the efficiency of health-care delivery. Improvements in care management for some may improve efficiency system-wide, with implications for optimal payment policy in public insurance programs. These system-level effects may depend on local health-care market structure and vary based on patient characteristics. We use exogenous variation in the Medicare payment schedule to isolate the effects of market-level managed care enrollment on the quantity and quality of care delivered. We find that in areas with greater enrollment of Medicare beneficiaries in managed care, the non–managed care beneficiaries have fewer days in the hospital but more outpatient visits, consistent with a substitution of less expensive outpatient care for more expensive inpatient care, particularly at high levels of managed care. We find no evidence that care is of lower quality. Optimal payment policies for Medicare managed care enrollees that account for system-level spillovers may thus be higher than those that do not. PMID:27042687

  3. 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.

  4. 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

  5. Medicare and Medicaid programs: hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs; Hospital Value-Based Purchasing Program; organ procurement organizations; quality improvement organizations; Electronic Health Records (EHR) Incentive Program; provider reimbursement determinations and appeals. Final rule with comment period and final rules.

    PubMed

    2013-12-10

    : 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 2014 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, the ASC Quality Reporting (ASCQR) Program, and the Hospital Value-Based Purchasing (VBP) Program. In the final rules in this document, we are finalizing changes to the conditions for coverage (CfCs) for organ procurement organizations (OPOs); revisions to the Quality Improvement Organization (QIO) regulations; changes to the Medicare fee-for-service Electronic Health Record (EHR) Incentive Program; and changes relating to provider reimbursement determinations and appeals.

  6. 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

  7. 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

  8. Medicare payment changes and physicians' incomes.

    PubMed

    Weeks, William B; Wallace, Amy E

    2002-01-01

    An effort to control the physician portion of Medicare expenditures and to narrow the income gap between primary care and procedure-based physicians was effected through t he enactment of the Medicare Fee Schedule (MFS). To determine whether academic and private sector physicians' incomes had demonstrated changes consistent with payment changes, we collected income information from surveys of private sector physicians and academic physicians in six specialties: (1) family practice; (2) general internal medicine; (3) psychiatry; (4) general surgery; (5) radiology; and (6) anesthesiology. With the exception of general internal medicine, the anticipated changes in Medicare revenue were not closely associated with income changes in either the academic or private sector group. Academic physicians were underpaid, relative to their private sector counterparts, but modestly less so at the end of the period examined. Our findings suggest that using changes in payment schedules to change incomes in order to influence the attractiveness of different specialties, even with a very large payer, may be ineffective. Should academic incomes remain uncompetitive with private sector incomes, it may be increasingly difficult to persuade physicians to enter academic careers. PMID:12462656

  9. Risk Adjustment for Medicare Total Knee Arthroplasty Bundled Payments.

    PubMed

    Clement, R Carter; Derman, Peter B; Kheir, Michael M; Soo, Adrianne E; Flynn, David N; Levin, L Scott; Fleisher, Lee

    2016-09-01

    The use of bundled payments is growing because of their potential to align providers and hospitals on the goal of cost reduction. However, such gain sharing could incentivize providers to "cherry-pick" more profitable patients. Risk adjustment can prevent this unintended consequence, yet most bundling programs include minimal adjustment techniques. This study was conducted to determine how bundled payments for total knee arthroplasty (TKA) should be adjusted for risk. The authors collected financial data for all Medicare patients (age≥65 years) undergoing primary unilateral TKA at an academic center over a period of 2 years (n=941). Multivariate regression was performed to assess the effect of patient factors on the costs of acute inpatient care, including unplanned 30-day readmissions. This analysis mirrors a bundling model used in the Medicare Bundled Payments for Care Improvement initiative. Increased age, American Society of Anesthesiologists (ASA) class, and the presence of a Medicare Major Complications/Comorbid Conditions (MCC) modifier (typically representing major complications) were associated with increased costs (regression coefficients, $57 per year; $729 per ASA class beyond I; and $3122 for patients meeting MCC criteria; P=.003, P=.001, and P<.001, respectively). Differences in costs were not associated with body mass index, sex, or race. If the results are generalizable, Medicare bundled payments for TKA encompassing acute inpatient care should be adjusted upward by the stated amounts for older patients, those with elevated ASA class, and patients meeting MCC criteria. This is likely an underestimate for many bundling models, including the Comprehensive Care for Joint Replacement program, incorporating varying degrees of postacute care. Failure to adjust for factors that affect costs may create adverse incentives, creating barriers to care for certain patient populations. [Orthopedics. 2016; 39(5):e911-e916.]. PMID:27359282

  10. 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

  11. 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.

  12. 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...

  13. 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...

  14. 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...

  15. Medicare program; Medicare prescription drug benefit. Final rule.

    PubMed

    2005-01-28

    fallback PDPs may also offer supplemental benefits through enhanced alternative coverage for an additional premium. All organizations offering drug plans will have flexibility in the design of the prescription drug benefit. Consistent with the MMA, this final rule also provides for subsidy payments to sponsors of qualified retiree prescription drug plans to encourage retention of employer-sponsored benefits. We are implementing the drug benefit in a way that permits and encourages a range of options for Medicare beneficiaries to augment the standard Medicare coverage. These options include facilitating additional coverage through employer plans, MA-PD plans and high-option PDPs, and through charity organizations and State pharmaceutical assistance programs. See sections II.C, II.J, and II.P, and II.R of this preamble for further details on these issues. The proposed rule identified options and alternatives to the provisions we proposed and we strongly encouraged comments and ideas on our approach and on alternatives to help us design the Medicare Prescription Drug Benefit Program to operate as effectively and efficiently as possible in meeting the needs of Medicare beneficiaries. PMID:15678603

  16. 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...

  17. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Denial of enrollment in the Medicare program. 424.530 Section 424.530 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Requirements...

  18. 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...

  19. 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...

  20. 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...

  1. 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...

  2. 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...

  3. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Final rule.

    PubMed

    2015-11-24

    This final rule implements a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. We believe this model will further our goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures. PMID:26606762

  4. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Final rule.

    PubMed

    2015-11-24

    This final rule implements a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. We believe this model will further our goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures.

  5. 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

  6. 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

  7. 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.

  8. 78 FR 41013 - Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-09

    ...-15766, published on Wednesday, July 3, 2013 (78 FR 40272), there was an error that is identified and... was ``-$18.6 Million'' instead of ``$18.6 Million.'' IV. Correction of Errors In FR Doc. 2013-15766... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 431 RIN 0938-AR52 Medicare...

  9. Medicare program; FY 2014 hospice wage index and payment rate update; hospice quality reporting requirements; and updates on payment reform. final rule.

    PubMed

    2013-08-01

    This final rule updates the hospice payment rates and the wage index for fiscal year (FY) 2014, and continues the phase out of the wage index budget neutrality adjustment factor (BNAF). Including the FY 2014 15 percent BNAF reduction, the total 5 year cumulative BNAF reduction in FY 2014 will be 70 percent. The BNAF phase-out will continue with successive 15 percent reductions in FY 2015 and FY 2016. This final rule also clarifies how hospices are to report diagnoses on hospice claims, and provides updates to the public on hospice payment reform. Additionally, this final rule changes the requirements for the hospice quality reporting program by discontinuing currently reported measures and implementing a Hospice Item Set with seven National Quality Forum (NFQ) endorsed measures beginning July 1, 2014, as proposed. Finally, this final rule will implement the hospice Experience of Care Survey on January 1, 2015, as proposed. PMID:23977715

  10. Medicare program; inpatient psychiatric facilities prospective payment system--update for rate year beginning July 1, 2011 (RY 2012). Final rule.

    PubMed

    2011-05-01

    This final rule updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs) for discharges occurring during the rate year (RY) beginning July 1, 2011 through September 30, 2012. The final rule also changes the IPF prospective payment system (PPS) payment rate update period to a RY that coincides with a fiscal year (FY). In addition, the rule implements policy changes affecting the IPF PPS teaching adjustment. It also rebases and revises the Rehabilitation, Psychiatric, and Long-Term Care (RPL) market basket, and makes some clarifications and corrections to terminology and regulations text. PMID:21548399

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

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... other way. (v) There was failure to file a proper claim for any reason other than physical or mental... 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...

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

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... other way. (v) There was failure to file a proper claim for any reason other than physical or mental... 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...

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

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... other way. (v) There was failure to file a proper claim for any reason other than physical or mental... 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...

  14. 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.

  15. 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

  16. 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

  17. 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

    ... Advisory Panel on Hospital Outpatient Payment (HOP Panel)--March 11 and 12, 2013 AGENCY: Centers for...-annual meeting of the Advisory Panel on Hospital Outpatient Payment (HOP, the Panel), (the Ambulatory... their associated weights, and hospital outpatient therapeutic supervision issues. DATES: Meeting...

  18. 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

    ... the cost report, pass-through payments, correct coding, new technology applications (including...: Representatives must contact our Public Affairs Office at (202) 690-6145. Advisory Committees' Information Lines... compression, revisions to the cost report, pass-through payments, correct coding, new technology...

  19. Vulnerability of Rural Hospitals to Medicare Outpatient Payment Reform

    PubMed Central

    Mohr, Penny E.; Franco, Sheila J.; Blanchfield, Bonnie B.; Cheng, C. Michael; Evans, William N.

    1999-01-01

    Because the Balanced Budget Act (BBA) of 1997 requires implementation of a Medicare prospective payment system (PPS) for hospital outpatient services, the authors evaluated the potential impact of outpatient PPS on rural hospitals. Areas examined include: (1) How dependent are rural hospitals on outpatient revenue? (2) Are they more likely than urban hospitals to be vulnerable to payment reform? (3) What types of rural hospitals will be most vulnerable to reform? Using Medicare cost report data, the authors found that small size and government ownership are more common among rural than urban hospitals and are the most important determinants of vulnerability to payment reform. PMID:11481724

  20. 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

  1. Medicare program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs. Final rule.

    PubMed

    2014-05-23

    The final rule will revise the Medicare Advantage (MA) program (Part C) regulations and prescription drug benefit program (Part D) regulations to implement statutory requirements; improve program efficiencies; and clarify program requirements. The final rule also includes several provisions designed to improve payment accuracy.

  2. 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

    ... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR... overpayment or fraud or willful misrepresentation exists or that the payments to be made may not be...

  3. Medicare program; clarification of Medicare's accrual basis of accounting policy--HCFA. Final rule.

    PubMed

    1995-06-27

    This final rule revises the Medicare regulations to clarify the concept of "accrual basis of accounting" to indicate that expenses must be incurred by a provider of health care services before Medicare will pay its share of those expenses. This rule does not signify a change in policy but, rather, incorporates into the regulations Medicare's longstanding policy regarding the circumstances under which we recognize, for the purposes of program payment, a provider's claim for costs for which it has not actually expended funds during the current cost reporting period. PMID:10143395

  4. Proposed Medicare Physician Payment Schedule for 2017: Impact on Interventional Pain Management Practices.

    PubMed

    Manchikanti, Laxmaiah; Kaye, Alan D; Hirsch, Joshua A

    2016-01-01

    The Centers for Medicare and Medicaid Services (CMS) released the proposed 2017 Medicare physician fee schedule on July 7, 2016, addressing Medicare payments for physicians providing services either in an office or facility setting, which also includes payments for office expenses and quality provisions for physicians. This proposed rule occurs in the context of numerous policy changes, most notably related to the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) and its Merit-Based Incentive Payment System (MIPS). The proposed rule affects interventional pain management specialists in reimbursement for evaluation and management services, as well as procedures performed in a facility or in-office setting.Changes in the proposed fee schedule impacting interventional pain management practices include adjustments to the meaningful use (MU) program, care management in patient-centered services, identification and review of potentially misvalued services, evaluation of moderate sedation services, Medicare telehealth services, updated geographic practice cost index, data collection on resources used in furnishing global services, reporting of modifier 25 for zero day global services, Medicare Advantage Part C provider and supplier enrollment, appropriate use criteria (AUC) for advanced imaging services, and Medicare shared savings programs. The proposed schedule has provided rates for new epidural codes with or without imaging (fluoroscopy or computed tomography [CT]) and a fee schedule for a new code covering endoscopic spinal decompression. Review of payment rates show major discrepancies in payment schedules with high payments for hospitals, 2,156% higher than in-office procedures. Some procedures which were converted from in-office settings to ambulatory surgery centers (ASCs) are being reimbursed at 1,366% higher than ASCs. The Medicare Payment Advisory Commission (MedPAC) recommendation on avoiding the discrepancies and site-of-service differentials in in

  5. Proposed Medicare Physician Payment Schedule for 2017: Impact on Interventional Pain Management Practices.

    PubMed

    Manchikanti, Laxmaiah; Kaye, Alan D; Hirsch, Joshua A

    2016-01-01

    The Centers for Medicare and Medicaid Services (CMS) released the proposed 2017 Medicare physician fee schedule on July 7, 2016, addressing Medicare payments for physicians providing services either in an office or facility setting, which also includes payments for office expenses and quality provisions for physicians. This proposed rule occurs in the context of numerous policy changes, most notably related to the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) and its Merit-Based Incentive Payment System (MIPS). The proposed rule affects interventional pain management specialists in reimbursement for evaluation and management services, as well as procedures performed in a facility or in-office setting.Changes in the proposed fee schedule impacting interventional pain management practices include adjustments to the meaningful use (MU) program, care management in patient-centered services, identification and review of potentially misvalued services, evaluation of moderate sedation services, Medicare telehealth services, updated geographic practice cost index, data collection on resources used in furnishing global services, reporting of modifier 25 for zero day global services, Medicare Advantage Part C provider and supplier enrollment, appropriate use criteria (AUC) for advanced imaging services, and Medicare shared savings programs. The proposed schedule has provided rates for new epidural codes with or without imaging (fluoroscopy or computed tomography [CT]) and a fee schedule for a new code covering endoscopic spinal decompression. Review of payment rates show major discrepancies in payment schedules with high payments for hospitals, 2,156% higher than in-office procedures. Some procedures which were converted from in-office settings to ambulatory surgery centers (ASCs) are being reimbursed at 1,366% higher than ASCs. The Medicare Payment Advisory Commission (MedPAC) recommendation on avoiding the discrepancies and site-of-service differentials in in

  6. Growth and payment adequacy of medicare postacute care rehabilitation.

    PubMed

    Kaplan, Sally J

    2007-11-01

    In the early 1990s, Medicare experienced rapid growth in the number of providers furnishing postacute care (PAC). Spending grew at an even faster pace than the supply of providers. By the late 1990s, the U.S. Congress required the Centers for Medicare & Medicaid (formerly the Health Care Financing Administration) to design and implement prospective payment systems (PPSs) for the 4 PAC settings. Congress intended that the new payment systems moderate growth in spending for PAC. Instead, prospective payment generally has accelerated growth in spending and generated high profits among providers. This article presents growth trends in providers and Medicare spending. It discusses the Medicare Payment Advisory Commission's (MedPAC) assessment of payment adequacy for 2006 and 2007 for the 4 postacute sectors and problems with the PPSs that result in misaligned payments and costs. This article also reviews MedPAC's studies to compare patient-assessment instruments for 3 of the 4 settings and to compare outcomes across settings for joint-replacement patients.

  7. Growth and payment adequacy of medicare postacute care rehabilitation.

    PubMed

    Kaplan, Sally J

    2007-11-01

    In the early 1990s, Medicare experienced rapid growth in the number of providers furnishing postacute care (PAC). Spending grew at an even faster pace than the supply of providers. By the late 1990s, the U.S. Congress required the Centers for Medicare & Medicaid (formerly the Health Care Financing Administration) to design and implement prospective payment systems (PPSs) for the 4 PAC settings. Congress intended that the new payment systems moderate growth in spending for PAC. Instead, prospective payment generally has accelerated growth in spending and generated high profits among providers. This article presents growth trends in providers and Medicare spending. It discusses the Medicare Payment Advisory Commission's (MedPAC) assessment of payment adequacy for 2006 and 2007 for the 4 postacute sectors and problems with the PPSs that result in misaligned payments and costs. This article also reviews MedPAC's studies to compare patient-assessment instruments for 3 of the 4 settings and to compare outcomes across settings for joint-replacement patients. PMID:17964895

  8. Medicare program; prospective payment system and consolidated billing for skilled nursing facilities for FY 2014. Final rule.

    PubMed

    2013-08-01

    This final rule updates the payment rates used under the prospective payment system for skilled nursing facilities (SNFs) for fiscal year (FY) 2014. In addition, it revises and rebases the SNF market basket, revises and updates the labor related share, and makes certain technical and conforming revisions in the regulations text. This final rule also includes a policy for reporting the SNF market basket forecast error in certain limited circumstances and adds a new item to the Minimum Data Set (MDS), Version 3.0 for reporting the number of distinct therapy days. Finally, this final rule adopts a change to the diagnosis code used to determine which residents will receive the AIDS add-on payment, effective for services provided on or after the October 1, 2014 implementation date for conversion to ICD-10-CM. PMID:23923146

  9. Effects of Medicare payment reform: evidence from the home health interim and prospective payment systems.

    PubMed

    Huckfeldt, Peter J; Sood, Neeraj; Escarce, José J; Grabowski, David C; Newhouse, Joseph P

    2014-03-01

    Medicare continues to implement payment reforms that shift reimbursement from fee-for-service toward episode-based payment, affecting average and marginal payment. We contrast the effects of two reforms for home health agencies. The home health interim payment system in 1997 lowered both types of payment; our conceptual model predicts a decline in the likelihood of use and costs, both of which we find. The home health prospective payment system in 2000 raised average but lowered marginal payment with theoretically ambiguous effects; we find a modest increase in use and costs. We find little substantive effect of either policy on readmissions or mortality.

  10. 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

    ... the Advisory Panel on Hospital Outpatient Payment (HOP Panel) August 26-27, 2013 AGENCY: Centers for...: This notice announces the second semi-annual meeting of the Advisory Panel on Hospital Outpatient... Classification (APC) groups and their associated weights, and hospital outpatient therapeutic...

  11. 75 FR 73091 - Medicare Program; Town Hall Meeting on the Fiscal Year 2012 Applications for Add-on Payments for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-29

    ... Secretary (after notice and opportunity for public comment). (See the FY 2002 proposed rule (66 FR 22693, May 4, 2001) and final rule (66 FR 46912, September 7, 2001) for a more detailed discussion.) In the September 7, 2001 final rule (66 FR 46914), we noted that we evaluate a request for special payment for...

  12. 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

    ...' Information Lines: You may also refer to the CMS Federal Advisory Committee Hotlines at 1-(877) 449-5659 (toll...; APC grouping; Current Procedural Terminology codes and Healthcare Common Procedure Coding System coding experts; the use of, and payment for, drugs and medical devices, and other services in...

  13. 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

    ...-554) requires the Secretary to establish procedures for coding and payment determinations for new... permit public consultation in a manner consistent with the procedures established for implementing coding... on November 23, 2001 in the Federal Register (66 FR 58743) to implement section 531(b) of...

  14. 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...

  15. 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

  16. Evidence-Based Imaging Guidelines and Medicare Payment Policy

    PubMed Central

    Sistrom, Christopher L; McKay, Niccie L

    2008-01-01

    Objective This study examines the relationship between evidence-based appropriateness criteria for neurologic imaging procedures and Medicare payment determinations. The primary research question is whether Medicare is more likely to pay for imaging procedures as the level of appropriateness increases. Data Sources The American College of Radiology Appropriateness Criteria (ACRAC) for neurological imaging, ICD-9-CM codes, CPT codes, and payment determinations by the Medicare Part B carrier for Florida and Connecticut. Study Design Cross-sectional study of appropriateness criteria and Medicare Part B payment policy for neurological imaging. In addition to descriptive and bivariate statistics, multivariate logistic regression on payment determination (yes or no) was performed. Data Collection Methods The American College of Radiology Appropriateness Criteria (ACRAC) documents specific to neurological imaging, ICD-9-CM codes, and CPT codes were used to create 2,510 medical condition/imaging procedure combinations, with associated appropriateness scores (coded as low/middle/high). Principal Findings As the level of appropriateness increased, more medical condition/imaging procedure combinations were payable (low = 61 percent, middle = 70 percent, and high = 74 percent). Logistic regression indicated that the odds of a medical condition/imaging procedure combination with a middle level of appropriateness being payable was 48 percent higher than for an otherwise similar combination with a low appropriateness score (95 percent CI on odds ratio=1.19–1.84). The odds ratio for being payable between high and low levels of appropriateness was 2.25 (95 percent CI: 1.66–3.04). Conclusions Medicare could improve its payment determinations by taking advantage of existing clinical guidelines, appropriateness criteria, and other authoritative resources for evidence-based practice. Such an approach would give providers a financial incentive that is aligned with best

  17. 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

  18. Medicare program; end-stage renal disease prospective payment system and quality incentive program; ambulance fee schedule; durable medical equipment; and competitive acquisition of certain durable medical equipment prosthetics, orthotics and supplies. Final rule.

    PubMed

    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 program (QIP) for payment years (PYs) 2013 and 2014. In addition, this final rule revises the ambulance fee schedule regulations to conform to statutory changes. This final rule also revises the definition of durable medical equipment (DME) by adding a 3-year minimum lifetime requirement (MLR) that must be met by an item or device in order to be considered durable for the purpose of classifying the item under the Medicare benefit category for DME. Finally, this final rule implements certain provisions of section 154 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) related to the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) Competitive Acquisition Program and responds to comments received on an interim final rule published January 16, 2009, that implemented these provisions of MIPPA effective April 18, 2009. (See the Table of Contents for a listing of the specific issues addressed in this final rule.)

  19. Diagnosis-Based Risk Adjustment for Medicare Capitation Payments

    PubMed Central

    Ellis, Randall P.; Pope, Gregory C.; Iezzoni, Lisa I.; Ayanian, John Z.; Bates, David W.; Burstin, Helen; Ash, Arlene S.

    1996-01-01

    Using 1991-92 data for a 5-percent Medicare sample, we develop, estimate, and evaluate risk-adjustment models that utilize diagnostic information from both inpatient and ambulatory claims to adjust payments for aged and disabled Medicare enrollees. Hierarchical coexisting conditions (HCC) models achieve greater explanatory power than diagnostic cost group (DCG) models by taking account of multiple coexisting medical conditions. Prospective models predict average costs of individuals with chronic conditions nearly as well as concurrent models. All models predict medical costs far more accurately than the current health maintenance organization (HMO) payment formula. PMID:10172666

  20. Medicare program; end-stage renal disease prospective payment system, quality incentive program, and durable medical equipment, prosthetics, orthotics, and supplies.

    PubMed

    2013-12-01

    This rule updates and makes revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2014. This rule also sets forth requirements for the ESRD quality incentive program (QIP), including for payment year (PY) 2016 and beyond. In addition, this rule clarifies the grandfathering provision related to the 3-year minimum lifetime requirement (MLR) for Durable Medical Equipment (DME), and provides clarification of the definition of routinely purchased DME. This rule also implements budget-neutral fee schedules for splints and casts, and intraocular lenses (IOLs) inserted in a physician's office. Finally, this rule makes a few technical amendments and corrections to existing regulations related to payment for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items and services.

  1. 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

  2. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... medical education costs; units of blood clotting factor furnished to an eligible patient who is a... 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...

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

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... medical education costs; units of blood clotting factor furnished to an eligible patient who is a... 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...

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

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... medical education costs; units of blood clotting factor furnished to an eligible patient who is a... 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...

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

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... medical education costs; units of blood clotting factor furnished to an eligible patient who is a... 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...

  6. 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......

  7. 77 FR 42735 - Appointments to the Medicare Payment Advisory Commission

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-20

    ... Medicare Payment Advisory Commission (MedPAC) and gave the Comptroller General responsibility for...., Washington, DC 20548. MedPAC: 601 New Jersey Avenue NW., Suite 9000, Washington, DC 20001. FOR FURTHER INFORMATION CONTACT: GAO: Office of Public Affairs, (202) 512-4800. MedPAC: Mark E. Miller, Ph.D., (202)...

  8. 76 FR 5591 - Medicare Payment Advisory Commission Nomination Letters

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-01

    ... the Medicare Payment Advisory Commission (MedPAC) and gave the Comptroller General responsibility for appointing its members. For appointments to MedPAC that will be effective May 1, 2011, I am announcing the.... ADDRESSES: GAO: 441 G Street, NW., Washington, DC 20548. MedPAC: 601 New Jersey Avenue, NW., Suite...

  9. 78 FR 2407 - Medicare Payment Advisory Commission Nomination Letters

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-11

    ... the Medicare Payment Advisory Commission (MedPAC) and gave the Comptroller General responsibility for appointing its members. For appointments to MedPAC that will be effective May 1, 2013, I am announcing the.... ADDRESSES: GAO: MedPACappointments@gao.gov . GAO: 441 G Street NW., Washington, DC 20548. MedPAC: 601...

  10. 76 FR 81503 - Medicare Payment Advisory Commission Nomination Letters

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-28

    ... the Medicare Payment Advisory Commission (MedPAC) and gave the Comptroller General responsibility for appointing its members. For appointments to MedPAC that will be effective May 1, 2012, I am announcing the...: MedPACappointments@gao.gov . GAO: 441 G Street NW., Washington, DC 20548. MedPAC: 601 New...

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

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... plan has denied the claim in whole or in part; or (2) The beneficiary, because of physical or mental... or mental incapacity of the beneficiary. (2) The group health plan fails to furnish information... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for Medicare primary payments....

  12. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... the plan denies the claim in whole or in part; or (2) The beneficiary, because of physical or mental... that failure is for any reason other than the physical or mental incapacity of the beneficiary. (2) The... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for conditional Medicare payments....

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

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... the plan denies the claim in whole or in part; or (2) The beneficiary, because of physical or mental... that failure is for any reason other than the physical or mental incapacity of the beneficiary. (2) The... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for conditional Medicare payments....

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

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... plan has denied the claim in whole or in part; or (2) The beneficiary, because of physical or mental... or mental incapacity of the beneficiary. (2) The group health plan fails to furnish information... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for Medicare primary payments....

  15. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... plan has denied the claim in whole or in part; or (2) The beneficiary, because of physical or mental... or mental incapacity of the beneficiary. (2) The group health plan fails to furnish information... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for Medicare primary payments....

  16. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... the plan denies the claim in whole or in part; or (2) The beneficiary, because of physical or mental... that failure is for any reason other than the physical or mental incapacity of the beneficiary. (2) The... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for conditional Medicare payments....

  17. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... the plan denies the claim in whole or in part; or (2) The beneficiary, because of physical or mental... that failure is for any reason other than the physical or mental incapacity of the beneficiary. (2) The... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for conditional Medicare payments....

  18. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... plan has denied the claim in whole or in part; or (2) The beneficiary, because of physical or mental... or mental incapacity of the beneficiary. (2) The group health plan fails to furnish information... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for Medicare primary payments....

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

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... the plan denies the claim in whole or in part; or (2) The beneficiary, because of physical or mental... that failure is for any reason other than the physical or mental incapacity of the beneficiary. (2) The... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for conditional Medicare payments....

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

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... plan has denied the claim in whole or in part; or (2) The beneficiary, because of physical or mental... or mental incapacity of the beneficiary. (2) The group health plan fails to furnish information... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for Medicare primary payments....

  1. Medicare, Medicaid, and Children's Health Insurance Programs; additional screening requirements, application fees, temporary enrollment moratoria, payment suspensions and compliance plans for providers and suppliers. Final rule with comment period.

    PubMed

    2011-02-01

    This final rule with comment period will implement provisions of the ACA that establish: Procedures under which screening is conducted for providers of medical or other services and suppliers in the Medicare program, providers in the Medicaid program, and providers in the Children's Health Insurance Program (CHIP); an application fee imposed on institutional providers and suppliers; temporary moratoria that may be imposed if necessary to prevent or combat fraud, waste, and abuse under the Medicare and Medicaid programs, and CHIP; guidance for States regarding termination of providers from Medicaid and CHIP if terminated by Medicare or another Medicaid State plan or CHIP; guidance regarding the termination of providers and suppliers from Medicare if terminated by a Medicaid State agency; and requirements for suspension of payments pending credible allegations of fraud in the Medicare and Medicaid programs. This final rule with comment period also discusses our earlier solicitation of comments regarding provisions of the ACA that require providers of medical or other items or services or suppliers within a particular industry sector or category to establish compliance programs. We have identified specific provisions surrounding our implementation of fingerprinting for certain providers and suppliers for which we may make changes if warranted by the public comments received. We expect to publish our response to those comments, including any possible changes to the rule made as a result of them, as soon as possible following the end of the comment period. Furthermore, we clarify that we are finalizing the adoption of fingerprinting pursuant to the terms and conditions set forth herein.

  2. 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

  3. 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 ...

  4. 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.

  5. 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 ...

  6. 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... Medicare is not primary payer. (a) Limits on payments and charges. (1) CMS may not pay for services to the extent that Medicare is not the primary payer under section 1862(b) of the Act and part 411 of...

  7. 42 CFR 447.31 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 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...

  8. 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...

  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... Appointments to the Advisory Panel on Hospital Outpatient Payment AGENCY: Centers for Medicare & Medicaid... announces two new membership appointments to the Advisory Panel on Hospital Outpatient Payment (HOP,...

  10. 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... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription...

  11. 77 FR 59618 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-28

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals; Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription...

  12. 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

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals: Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription...

  13. Medicare program; medical loss ratio requirements for the Medicare Advantage and the Medicare Prescription Drug Benefit Programs.

    PubMed

    2013-05-23

    This final rule implements new medical loss ratio (MLR) requirements for the Medicare Advantage Program and the Medicare Prescription Drug Benefit Program established under the Patient Protection and Affordable Care Act.

  14. Developing a viable alternative to Medicare's physician payment strategy.

    PubMed

    Wilensky, Gail R

    2014-01-01

    Since 1992 Medicare has reimbursed physicians on a fee-for-service basis that weights physician services according to the effort and expense of providing those services and converts the weights to dollars using a conversion factor. In 1997 Congress replaced an existing spending constraint with the Sustainable Growth Rate (SGR) to reduce reimbursements if overall physician spending exceeded the growth in the economy. Congress, however, has routinely overridden the SGR because of concerns that reduced payments to physicians would limit patients' access to care. Under continued pressure to override scheduled fee reductions or eliminate the SGR altogether, Congress is now considering legislation that would reimburse physicians to improve quality and lower costs-two things that the current system does not do. This article reviews several promising models, including patient-centered medical homes, accountable care organizations, and various payment bundling pilots, that could offer lessons for a larger reform of physician payment. Pilot projects that focus exclusively on alternative ways to reimburse physicians apart from payments to hospitals, such as payments for episodes of care, are also needed. Most promising, Congress is now showing bipartisan, bicameral interest in revising how Medicare reimburses physicians.

  15. Developing a viable alternative to Medicare's physician payment strategy.

    PubMed

    Wilensky, Gail R

    2014-01-01

    Since 1992 Medicare has reimbursed physicians on a fee-for-service basis that weights physician services according to the effort and expense of providing those services and converts the weights to dollars using a conversion factor. In 1997 Congress replaced an existing spending constraint with the Sustainable Growth Rate (SGR) to reduce reimbursements if overall physician spending exceeded the growth in the economy. Congress, however, has routinely overridden the SGR because of concerns that reduced payments to physicians would limit patients' access to care. Under continued pressure to override scheduled fee reductions or eliminate the SGR altogether, Congress is now considering legislation that would reimburse physicians to improve quality and lower costs-two things that the current system does not do. This article reviews several promising models, including patient-centered medical homes, accountable care organizations, and various payment bundling pilots, that could offer lessons for a larger reform of physician payment. Pilot projects that focus exclusively on alternative ways to reimburse physicians apart from payments to hospitals, such as payments for episodes of care, are also needed. Most promising, Congress is now showing bipartisan, bicameral interest in revising how Medicare reimburses physicians. PMID:24334312

  16. 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

  17. Alternative geographic adjustments in Medicare payment to health maintenance organizations

    PubMed Central

    Welch, W. Pete

    1992-01-01

    The payment received by a health maintenance organization (HMO) for its Medicare enrollees is proportionate to the average cost of Medicare beneficiaries in that county. However, HMO market share in an area appears to decrease costs in the fee-for-service sector, so that HMOs are paid less. For this and other reasons, alternative payment formulas may be desirable and several are developed in this article. The conceptually simplest location factor would be an input price index. An alternative strategy would also recognize systematic variation in utilization. Utilization rate is regressed on variables such as county population density and physicians per 1,000 persons. The predicted utilization rate times an input price index could serve as a location factor. The value of alternative location factors are presented for specific counties. PMID:10120186

  18. Unintended consequences of eliminating Medicare payments for consultations1

    PubMed Central

    Song, Zirui; Ayanian, John Z.; Wallace, Jacob; He, Yulei; Gibson, Teresa B.; Chernew, Michael E.

    2013-01-01

    Background Prior to 2010, Medicare payments for consultations (commonly billed by specialists) were substantially higher than for office visits of similar complexity (commonly billed by primary care physicians). In January 2010, Medicare eliminated consultation payments from the Part B Physician Fee Schedule and increased fees for office visits. This change was intended to be budget neutral and to decrease payments to specialists while increasing payments to primary care physicians. We assessed the impact of this policy on spending, volume, and complexity for outpatient office encounters in 2010. Methods We examined 2007–2010 outpatient claims for 2,247,810 Medicare beneficiaries with Medicare Supplemental (Medigap) coverage through large employers in the Thomson Reuters MarketScan Database. We used segmented regression analysis to study changes in spending, volume, and complexity of office encounters adjusted for age, sex, health status, secular trends, seasonality, and hospital referral region. Results “New” office visits largely replaced consultations in 2010. An average of $10.20 (6.5 percent) more was spent per beneficiary per quarter on physician encounters after the policy. The total volume of physician encounters did not change significantly. The increase in spending was largely explained by higher office visit fees from the policy and a shift toward higher complexity visits to both specialists and primary care physicians. Conclusions The elimination of consultations led to a net increase in spending on visits to both primary care physicians and specialists. Higher prices, partially due to the subjectivity of codes in the physician fee schedule, explained the spending increase, rather than higher volumes. PMID:23336095

  19. 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

  20. Medicaid physician payment reform: using the Medicare Fee Schedule for Medicaid payments.

    PubMed Central

    Reisinger, A L; Colby, D C; Schwartz, A

    1994-01-01

    OBJECTIVES. The purpose of this article is to provide estimates of the costs of basing Medicaid physician payment levels on the new resource-based Medicare Fee Schedule. Two possible policy options are considered: setting all Medicaid physician fees at the Medicare Fee Schedule level and setting only office visit fees at the new Medicare levels. METHODS. Data on Medicaid physician fees, use patterns, and the Medicare Fee Schedule are used to develop state-level estimates of expenditure changes under each option. RESULTS. Setting Medicaid rates at the Medicare Fee Schedule level could increase expenditures by $3.2 to $4.1 billion nationally; the other option would result in substantially lower increases in expenditures. Because of the current variations in Medicaid physician fees and in the breadth of eligibility across states, the cost of adopting the Medicare Fee Schedule varies considerably among states. CONCLUSIONS. Adopting the new Medicare Fee Schedule for Medicaid payments, proposed by policy-makers as a way to increase access to appropriate medical care, could double physician expenditures in some states. Adoption of more limited versions of the fee schedule might achieve some access gains at lower costs. PMID:8154555

  1. 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

    ...; Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit... Prescription Drug Benefit Programs'' which appeared in the April 15, 2010 Federal Register (FR Doc. 2010-7966... all covered Part D drugs must be included in Part D formularies (75 FR 19767), we indicated that...

  2. 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.

  3. 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

  4. 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

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals; Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective... and judicial review at $100 and $1,000, respectively, for Medicare Part A and Part B appeals....

  5. 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

  6. 42 CFR 413.177 - Quality incentive program payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 413.177 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...-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.177 Quality incentive...

  7. 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

  8. Medicare program: Medicare Advantage and Prescription Drug Benefit programs: final marketing provisions. Final rule.

    PubMed

    2008-09-18

    This final rule revises the Medicare Advantage (MA) program (Part C) and Medicare Prescription Drug Benefit Program (Part D). The regulation contains new regulatory provisions regarding marketing processes for both programs. The revisions to the Part C and Part D programs are based on lessons we have learned since 2006, the initial year of the prescription drug program and the revised MA program.

  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. 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. 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...

  11. 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.

  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. Modeling the Impact of Medicare Advantage Payment Cuts on Ambulatory Care Sensitive and Elective Hospitalizations

    PubMed Central

    Nicholas, Lauren Hersch

    2011-01-01

    Objective To assess relationships between changes in Medicare Advantage (MA) payment rates and Medicare beneficiary hospitalizations and to simulate the effects of scheduled payment cuts on ambulatory care sensitive (ACS) and elective hospitalization rates. Data State Inpatient Database discharge abstracts from Arizona, Florida, and New York merged with administrative Medicare enrollment and MA payment data. Study Design Retrospective, fixed effect regression analysis of the relationship between MA payment rates and rates of ACS and elective hospitalizations among Medicare beneficiaries in counties with at least 10,000 Medicare beneficiaries and 3 percent MA penetration from 1999 to 2005. Principal Findings MA payment rates were negatively related to rates of ACS admissions. Simulations suggest that payment cuts could be associated with higher rates of ACS admissions. No relationship between MA payments and rates of elective hospitalizations was found. Conclusions Reductions in MA payment rates may result in a small increase in ACS admissions. Trends in ACS admissions among chronically ill Medicare beneficiaries should be tracked following MA payment cuts. PMID:21609330

  14. Medicare program: hospital outpatient prospective payment system and CY 2011 payment rates; ambulatory surgical center payment system and CY 2011 payment rates; payments to hospitals for graduate medical education costs; physician self-referral rules and related changes to provider agreement regulations; payment for certified registered nurse anesthetist services furnished in rural hospitals and critical access hospitals. Final rule with comment period; final rules; and interim final rule with comment period.

    PubMed

    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 2010 (Affordable Care Act). In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2011. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Affordable Care Act. In this final rule with comment period, we set forth the applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other pertinent ratesetting information for the CY 2011 ASC payment system. These changes are applicable to services furnished on or after January 1, 2011. In this document, we also are including two final rules that implement provisions of the Affordable Care Act relating to payments to hospitals for direct graduate medical education (GME) and indirect medical education (IME) costs; and new limitations on certain physician referrals to hospitals in which they have an ownership or investment interest. In the interim final rule with comment period that is included in this document, we are changing the effective date for otherwise eligible hospitals and critical access hospitals that have been reclassified from urban to rural under section 1886(d)(8)(E) of the Social Security

  15. 75 FR 49215 - Medicare Program; End-Stage Renal Disease Quality Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-12

    .... 110-275) NQF National Quality Forum PPS Prospective payment system QIP Quality incentive program... on http://www.medicare.gov that was modeled after Nursing Home Compare and continues to be used by... national averages for total performance and individual quality measure performance. We believe...

  16. 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

    ... HUMAN SERVICES Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports.... SUMMARY: This notice announces public meetings of the Technical Advisory Panel on Medicare Trustee Reports... assumptions in projecting Medicare health spending for Parts C and D and may make recommendations to...

  17. Using prior utilization to determine payments for Medicare enrollees in health maintenance organizations.

    PubMed

    Beebe, J; Lubitz, J; Eggers, P

    1985-01-01

    The Tax Equity and Fiscal Responsibility Act of 1982 is expected to make it more attractive for health maintenance organizations (HMO's) to participate in the Medicare program on an at-risk basis. Currently, payments to at-risk HMO's are based on a formula known as the adjusted average per capita cost (AAPCC). This article describes the current formula and discusses a modification, based on prior use of Medicare services, that endeavors to more accurately predict risk. Using statistical simulations, formulas incorporating prior use performed better for some types of biased groups than a formula similar to the one currently employed. Major concerns involve the ability to "game the system." The prior-use model is now being tested in an HMO demonstration. This article also outlines the limitations of a prior-use model and areas for future research.

  18. 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.

  19. 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

  20. 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

  1. 42 CFR 411.24 - Recovery of conditional payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Recovery of conditional payments. 411.24 Section 411.24 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Insurance Coverage That Limits Medicare Payment: General Provisions...

  2. Medicare program; Medicare ambulance MMA temporary rate increases beginning July 1, 2004. Interim final rule with comment period.

    PubMed

    2004-07-01

    This interim final rule codifies the four payment provisions for Medicare covered ambulance services contained in section 414 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA).

  3. 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...

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

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ...) The beneficiary, because of physical or mental incapacity, failed to file a proper claim. (b) Any... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for conditional Medicare payment in workers' compensation cases. 411.45 Section 411.45 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT...

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

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ...) The beneficiary, because of physical or mental incapacity, failed to file a proper claim. (b) Any... 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...

  6. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ...) The beneficiary, because of physical or mental incapacity, failed to file a proper claim. (b) Any... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for conditional Medicare payment in workers' compensation cases. 411.45 Section 411.45 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT...

  7. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ...) The beneficiary, because of physical or mental incapacity, failed to file a proper claim. (b) Any... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for conditional Medicare payment in workers' compensation cases. 411.45 Section 411.45 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT...

  8. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ...) The beneficiary, because of physical or mental incapacity, failed to file a proper claim. (b) Any... 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...

  9. No association between Centers for Medicare and Medicaid services payments and volume of Medicare beneficiaries or per-capita health care costs for each state.

    PubMed

    Harewood, Gavin C; Alsaffar, Omar

    2015-03-01

    The Centers for Medicare and Medicaid Services recently published data on Medicare payments to physicians for 2012. We investigated regional variations in payments to gastroenterologists and evaluated whether payments correlated with the number of Medicare patients in each state. We found that the mean payment per gastroenterologist in each state ranged from $35,293 in Minnesota to $175,028 in Mississippi. Adjusted per-physician payments ranged from $11 per patient in Hawaii to $62 per patient in Washington, DC. There was no correlation between the mean per-physician payment and the mean number of Medicare patients per physician (r = 0.09), there also was no correlation between the mean per-physician payment and the overall mean per-capita health care costs for each state (r = -0.22). There was a 5.6-fold difference between the states with the lowest and highest adjusted Medicare payments to gastroenterologists. Therefore, the Centers for Medicare and Medicaid Services payments do not appear to be associated with the volume of Medicare beneficiaries or overall per-capita health care costs for each state.

  10. 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

  11. Medical care program compliance--a year 2000 recipient perspective of Medicare claims.

    PubMed

    Eddy, C A; Liberman, A; Falen, T

    2000-12-01

    This article provides a brief assessment of patient and provider views and concerns regarding reimbursements under the Medicare program. Specifically targeted is the payment of pharmaceutical claims. Also addressed are the ongoing and respective responsibilities of individual clinical providers, associated hospitals, and recipients of care. A summation of significant results of direct interviews and follow-up discussions with 10 Medicare recipients also is provided.

  12. 42 CFR 424.515 - Requirements for reporting changes and updates to, and the periodic revalidation of Medicare...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ..., 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 CONDITIONS FOR MEDICARE PAYMENT Requirements for Establishing and Maintaining...

  13. 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…

  14. Medicare program: changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates; payments for graduate medical education in certain emergency situations; changes to disclosure of physician ownership in hospitals and physician self-referral rules; updates to the long-term care prospective payment system; updates to certain IPPS-excluded hospitals; and collection of information regarding financial relationships between hospitals. Final rules.

    PubMed

    2008-08-19

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital related costs to implement changes arising from our continuing experience with these systems, and to implement certain provisions made by the Deficit Reduction Act of 2005, the Medicare Improvements and Extension Act, Division B, Title I of the Tax Relief and Health Care Act of 2006, the TMA, Abstinence Education, and QI Programs Extension Act of 2007, and the Medicare Improvements for Patients and Providers Act of 2008. In addition, in the Addendum to this final rule, we describe the changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes are generally applicable to discharges occurring on or after October 1, 2008. We also are setting forth the update to the rate-of-increase limits for certain hospitals and hospital units excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits are effective for cost reporting periods beginning on or after October 1, 2008. In addition to the changes for hospitals paid under the IPPS, this document contains revisions to the patient classifications and relative weights used under the long-term care hospital prospective payment system (LTCH PPS). This document also contains policy changes relating to the requirements for furnishing hospital emergency services under the Emergency Medical Treatment and Labor Act of 1986 (EMTALA). In this document, we are responding to public comments and finalizing the policies contained in two interim final rules relating to payments for Medicare graduate medical education to affiliated teaching hospitals in certain emergency situations. We are revising the regulatory requirements relating to disclosure to patients of physician ownership or investment interests in hospitals and responding to public comments on a

  15. The National Market for Medicare Clinical Laboratory Testing: Implications for Payment Reform

    PubMed Central

    Gass Kandilov, Amy M.; Pope, Gregory C.; Kautter, John; Healy, Deborah

    2012-01-01

    Current Medicare payment policy for outpatient laboratory services is outdated. Future reforms, such as competitive bidding, should consider the characteristics of the laboratory market. To inform payment policy, we analyzed the structure of the national market for Medicare Part B clinical laboratory testing, using a 5-percent sample of 2006 Medicare claims data. The independent laboratory market is dominated by two firms—Quest Diagnostics and Laboratory Corporation of America. The hospital outreach market is not as concentrated as the independent laboratory market. Two subgroups of Medicare beneficiaries, those with end-stage renal disease and those residing in nursing homes, are each served in separate laboratory markets. Despite the concentrated independent laboratory market structure, national competitive bidding for non-patient laboratory tests could result in cost savings for Medicare. PMID:24800143

  16. 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

  17. 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

  18. 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.

  19. 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

  20. 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.

  1. 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

    ...This proposed rule would require applicable manufacturers of drugs, devices, biologicals, or medical supplies covered by Medicare, Medicaid or the Children's Health Insurance Program (CHIP) to report annually to the Secretary certain payments or transfers of value provided to physicians or teaching hospitals (``covered recipients''). In addition, applicable manufacturers and applicable group......

  2. 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...

  3. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2007; certain provisions concerning competitive acquisition for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); accreditation of DMEPOS suppliers. Final rule.

    PubMed

    2006-08-18

    This final rule will update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for Federal fiscal year (FY) 2007 (for discharges occurring on or after October 1, 2006 and on or before September 30, 2007) as required under section 1886(j)(3)(C) of the Social Security Act (the Act). We are revising existing policies regarding the prospective payment system within the authority granted under section 1886(j) of the Act. In addition, we are revising the current regulation text to reflect the changes enacted under section 5005 of the Deficit Reduction Act of 2005. This final rule will also establish certain requirements related to competitive acquisition for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and establish accreditation of DMEPOS suppliers as required under section 302 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

  4. Capitation and the Medicare program: History, issues, and evidence

    PubMed Central

    Langwell, Kathryn M.; Hadley, James P.

    1986-01-01

    This article reviews the history of capitation in the Medicare program and examines issues and research findings related to Medicare capitation. Specific capitation issues and related research findings reviewed include: the feasibility and extent of health maintenance organization participation in Medicare; plan marketing; beneficiary choice behavior; quality of care; and the use and cost of services. In addition, areas requiring further study are noted, and the potential for extensions of capitation under Medicare are explored. PMID:10311935

  5. 42 CFR 411.33 - Amount of Medicare secondary payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 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...

  6. 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...

  7. Medicare program; competitive acquisition for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and other issues. Final rule.

    PubMed

    2007-04-10

    This final rule establishes competitive bidding programs for certain Medicare Part B covered items of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) throughout the United States in accordance with sections 1847(a) and (b) of the Social Security Act. These competitive bidding programs, which will be phased in over several years, utilize bids submitted by DMEPOS suppliers to establish applicable payment amounts under Medicare Part B.

  8. Medicare Prospective Payment and the Volume and Intensity of Skilled Nursing Facility Services

    PubMed Central

    Grabowski, David C.; Afendulis, Christopher C.; McGuire, Thomas G.

    2011-01-01

    In 1998, Medicare adopted a per diem Prospective Payment System (PPS) for skilled nursing facility care, which was intended to deter the use of high-cost rehabilitative services. The average per diem decreased under the PPS, but because per diems increased for greater therapy minutes, the ability of the PPS to deter the use of high-intensity services was questionable. In this study, we assess how the PPS affected the volume and intensity of Medicare services. By volume we mean the product of the number of Medicare residents in a facility and the average length-of-stay, by intensity we mean the time per week devoted to rehabilitation therapy. Our results indicate that the number of Medicare residents decreased under PPS, but rehabilitative services and therapy minutes increased while length-of-stay remained relatively constant. Not surprisingly, when subsequent Medicare policy changes increased payment rates, Medicare volume far surpassed the levels seen in the pre-PPS period. PMID:21705100

  9. 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

  10. 77 FR 29647 - Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-18

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Solicitation for Proposals for... 15 pages supporting documentation. Because of staffing and resource limitations, we cannot accept... of the eligible partners with respect to the provision of qualified training; and (2) the...

  11. 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.

  12. 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

  13. Financial Implications to Medicare from Changing the Dialysis Modality Mix under the Bundled Prospective Payment System

    PubMed Central

    Liu, Frank X.; Walton, Surrey M.; Leipold, Robert; Isbell, Deborah; Golper, Thomas A.

    2014-01-01

    ♦ Background: The economic burden of treating end-stage renal disease (ESRD) continues to grow. As one response, effective January 1, 2011, Medicare implemented a bundled prospective payment system (PPS, including injectable drugs) for dialysis patients. This study investigated the 5-year budget impact on Medicare under the new PPS of changes in the distribution of patients undergoing peritoneal dialysis (PD), in-center hemodialysis (ICHD), and home hemodialysis (HHD). ♦ Methods: An Excel-based budget impact model was created to assess dialysis-associated Medicare costs. The model accounted for dialysis access establishment, the current monthly capitation physician payment for ESRD, Medicare dialysis payments (including start-up costs), training, oral drug costs, and the costs and probabilities of adverse events including access failure, hospitalization for access infection, pneumonia, septicemia, and cardiovascular events. United States Renal Data System (USRDS) data were used to project the US Medicare dialysis patient population across time. The baseline scenario assumed a stable distribution of PD (7.7%), HHD (1.3%) and ICHD (91.0%) over 5 years. Three comparison scenarios raised the proportions of PD and HHD by (1) 1% and 0.5%, (2) 2% and 0.75%, and (3) 3% and 1% each year; a fourth scenario held HHD constant and lowered PD by 1% per year. ♦ Results: Under the bundled PPS, scenarios that increased PD and HHD from 7.7% and 1.3% over 5 years resulted in cumulative savings to Medicare of $114.8M (Scenario 1, 11.7% PD and 3.3% HHD at year 5), $232.9M (Scenario 2, 15.7% PD and 4.3% HHD at year 5), and $350.9M (Scenario 3, 19.7% PD and 5.3% HHD at year 5). When the PD population was decreased from 7.7% in 2013 to 3.7% by 2017 with a constant HHD population, the total Medicare payment for dialysis patients increased by over $121.2M. ♦ Conclusions: Under Medicare bundled PPS, increasing the proportion of patients on PD and HHD vs ICHD could generate

  14. 76 FR 21431 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-15

    ....564, 422.624, and 422.626 published April 4, 2003 at 68 FR 16652 are effective June 6, 2011... (70 FR 4588 through 4741 and 70 FR 4194 through 4585, respectively). As we have gained experience with... involving Medicare Advantage (MA) organizations and Medicare Part D prescription drug plan sponsors (72...

  15. The Economics of Skin Cancer: An Analysis of Medicare Payment Data

    PubMed Central

    Chen, Jenny T.; Kempton, Steven J.

    2016-01-01

    Purpose: The incidence and cost of nonmelanoma skin cancers are skyrocketing. Five million cases cost $8.1 billion in 2011. The average cost of treatment per patient increased from $1000 in 2006 to $1600 in 2011. We present a study of the economics and costs of skin cancer management in Medicare patients. Methods: We studied data released by the Centers for Medicare and Medicaid Services in 2014. Treatment modalities for the management of skin cancer were reviewed, and costs of treatment were quantified for a sample of 880,000 providers. Results: Review of Medicare payment records related to the management of skin cancer yielded data from over 880,000 health care providers who received $77 billion in Medicare payments in 2012. From 1992 to 2009, the rate of Mohs micrographic surgery (MMS) has increased by 700%, and these procedures typically have Medicare payments 120% to 370% more than surgical excision, even when including pathology fees. From 1992 to 2009, MMS increased by 700%, whereas surgical excisions increased by only 20%. In 2009, 1800 providers billed Medicare for MMS; in 2012, that number increased to 3209. On average, 1 in 4 cases of skin cancer is treated with MMS. Conclusion: Mohs excision is more expensive than surgical excision in an office setting. Procedures requiring the operating room are much more expensive than office procedures. In an era of high deductible health plans, patients’ financial burden is much less with simple excisions of skin cancers done in a clinic when compared with Mohs surgery or operative interventions. PMID:27757333

  16. Medicare

    MedlinePlus

    ... quality measures for nursing homes Learn more Address change/Medicare card issue? Lost or incorrect Medicare card? Select your card issue Select your card issue... Change your name or address Replace a lost or ...

  17. 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.

  18. 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

  19. 76 FR 19655 - Medicare Program; Waiver Designs in Connection With the Medicare Shared Savings Program and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    .... \\3\\ 75 FR 70165 (2010). \\4\\ Information about the workshop is available on CMS's Web site at http...; Waiver Designs in Connection With the Medicare Shared Savings Program and the Innovation Center AGENCY... Savings Program proposed rule, the Medicare Shared Savings Program is designed to achieve three...

  20. 42 CFR 424.121 - Scope of payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ...) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Special Conditions: Services Furnished in a Foreign Country § 424.121 Scope of payments. Subject to the conditions set forth in this subpart— (a)...

  1. 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

  2. Telehealth and Medicare: Payment Policy, Current Use, and Prospects for Growth

    PubMed Central

    Gilman, Matlin; Stensland, Jeff

    2013-01-01

    Objective Evaluate the growth in various types of Medicare-paid telehealth services. Background There has been a long-standing hope that telehealth could be used to reduce rural patients’ travel times to specialty physicians. Medicare covers telehealth services provided through live, interactive videoconferencing between a beneficiary located at a certified rural site and a distant practitioner. Methods We analyzed 100% of telehealth Medicare claims for 2009 matched to individual patient ZIP codes and individual provider characteristics. Results Despite increases in Medicare payment rates for telehealth services, expansions of covered services, reductions in provider requirements, and provisions of federal grants to encourage telehealth, growth in adoption of telehealth among providers has been modest. Medicare claims indicate that only 369 providers had 10 or more Medicare telehealth consultations in 2009. Roughly half of the 369 were mental health professionals, and about one-in-five of the 369 were non-physician professionals (e.g., physician assistants and nurse practitioners). On balance, the strong areas of telehealth are mental health and, surprisingly, nonphysician professionals. The comparative advantage of mental health could be the verbal (rather than physical contact) nature of mental health care, and the comparative advantage of non-physician professionals could be their lower labor costs. PMID:24834368

  3. 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

  4. Knowing Your Rights. Check Out the Facts before You Check into the Hospital. Medicare's Prospective Payment System.

    ERIC Educational Resources Information Center

    American Association of Retired Persons, Washington, DC.

    This consumer education document is intended to provide a complete description of Medicare's Prospective Payment System (PPS) for hospitals from the consumer's point of view and to provide basic information on how consumers can protect their rights to appropriate hospital care under Medicare. The first section describes the PPS and also explains…

  5. 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

  6. 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.

  7. Medicare payment policy and the controversy over hospital cost shifting.

    PubMed

    Mayes, Rick; Lee, Jason S

    2004-01-01

    This article examines (i) the background and debate over cost shifting; (ii) hospitals as business institutions that often shift the financial responsibility for their costs in the form of differential pricing; and (iii) how the cost-shifting debate affects and is affected by Medicare. The aim is to gain a better understanding of how changes in reimbursement by large government health insurance programmes affect hospital behaviour. The article argues that the controversy over cost shifting is becoming an increasingly important issue for hospitals in the US and their ability (or willingness) to provide uncompensated charity care. The issue has also become very important for workers and their dependants. This is because workers have shouldered the largest portion of the dramatic growth in healthcare costs that have occurred in the US in recent years, due in large part to increased cost shifting (or 'sharing of financial responsibility') from their employers.

  8. 78 FR 16614 - Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-18

    ..., Section 10; Prospective Payment System for Hospital Outpatient Services, Proposed Rule, 63 FR 47560 (September 8, 1998) and Final Rule, 65 FR 18444 (April 7, 2000); Changes to the Hospital Outpatient... 6, Section 10); Prospective Payment System for Hospital Outpatient Services, Proposed Rule 63...

  9. 42 CFR 447.30 - Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... funds withheld. (k) Recovery of funds from Medicaid agency. A provider is not entitled to recover from... 42 Public Health 4 2010-10-01 2010-10-01 false Withholding the Federal share of payments to... payments to Medicaid providers to recover Medicare overpayments. (a) Basis and purpose. This...

  10. 42 CFR 413.82 - Direct GME payments: Special rules for States that formerly had a waiver from Medicare...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Direct GME payments: Special rules for States that... Direct GME payments: Special rules for States that formerly had a waiver from Medicare reimbursement... of a State reimbursement control system under section 1886(c) of the Act, section 402 of the...

  11. A comparison of hospice programs based on Medicare certification status.

    PubMed

    Sontag, M A

    1996-01-01

    This article presents results from a study of 119 hospice programs in the United States. Personal interviews and questionnaires were utilized to collect data about hospice programs, their directors, nurses, social workers, and chaplains. Specifically, this article describes reasons programs sought Medicare certification, and the perceived advantages and disadvantages to being a Medicare certified program. Characteristics of both certified and non-certified programs are presented, and examined for differences. Potential access barriers such as restrictive admission criteria are examined in this article. Finally, perceptions of staff about hospice services in certified and non-certified programs are compared. Results from this study indicate that Medicare certified programs have longer lengths of stays, were more likely to include a nurse on the first visit, and billed patients more frequently than noncertified programs. Volunteer use was lower in the Medicare certified programs. Staff in Medicare certified programs were much more likely to view patients' medical needs as the primary focus of their programs. Results from this study suggest that Medicare certified programs may reflect a more medical model of palliative care.

  12. 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...

  13. 42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 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...

  14. 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...

  15. Reimbursement of sole community hospitals under Medicare's prospective payment System

    PubMed Central

    Freiman, Marc P.; Cromwell, Jerry

    1987-01-01

    Under the prospective payment system (PPS), designated sole community hospitals (SCH's), usually smaller than other rural hospitals but offering comparable services, have had higher average cost levels, in part because of underutilization of plant and equipment. This has resulted in negative operating margins on patient revenues, although local financial support and other revenue sources bring margins on total revenues into the positive range. The PPS legislation has also provided SCH's temporary protection from volume declines. SCH's are more likely than other rural hospitals to experience large volume swings, but only for declines greater than the threshold specified under PPS. PMID:10312392

  16. 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.

  17. 42 CFR 410.172 - Payment for partial hospitalization services in CMHCs: Conditions.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS Payment of SMI Benefits § 410.172 Payment for partial hospitalization services in CMHCs:...

  18. 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...

  19. 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

    ... CONTACT: Sabrina Ahmed, (410) 786-7499. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2010-28774... accuracy of the proposed rule. IV. Correction of Errors In FR Doc. 2010-28774 filed November 10, 2010, make... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 417, 422, and 423 RIN...

  20. 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

    ... Independent Audit of Sponsoring Organizations under Intermediate Sanction 5. The Ability for CMS to Require... 28, 2005 (70 FR 4588-4741 and 70 FR 4194-4585, respectively). While the provisions of the final rule... Medicare Part D prescription drug plan sponsors (72 FR 68700). In April 2008, we published a final rule...

  1. 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...

  2. 77 FR 69850 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-21

    ... because of entitlement to Medicare under the end-stage renal disease (ESRD) program. Projected monthly costs for disabled enrollees (other than those with ESRD) are prepared in a fashion parallel to the projection for the aged using appropriate actuarial assumptions (see Table 2). Costs for the ESRD program...

  3. Effects of Medicare Payment Changes on Nursing Home Staffing and Deficiencies

    PubMed Central

    Konetzka, R Tamara; Yi, Deokhee; Norton, Edward C; Kilpatrick, Kerry E

    2004-01-01

    Objective To investigate the effects of Medicare's Prospective Payment System (PPS) for skilled nursing facilities (SNFs) and associated rate changes on quality of care as represented by staffing ratios and regulatory deficiencies. Data Sources Online Survey, Certification and Reporting (OSCAR) data from 1996–2000 were linked with Area Resource File (ARF) and Medicare Cost Report data to form a panel dataset. Study Design A difference-in-differences model was used to assess effects of the PPS and the BBRA (Balanced Budget Refinement Act) on staffing and deficiencies, a design that allows the separation of the effects of the policies from general trends. Ordinary least squares and negative binomial models were used. Data Collection Methods The OSCAR and Medicare Cost Report data are self-reported by nursing facilities; ARF data are publicly available. Data were linked by provider ID and county. Principal Findings We find that professional staffing decreased and regulatory deficiencies increased with PPS, and that both effects were mitigated with the BBRA rate increases. The effects appear to increase with the percent of Medicare residents in the facility except, in some cases, at the highest percentage of Medicare. The findings on staffing are statistically significant. The effects on deficiencies, though exhibiting consistent signs and magnitudes with the staffing results, are largely insignificant. Conclusions Medicare's PPS system and associated rate cuts for SNFs have had a negative effect on staffing and regulatory compliance. Further research is necessary to determine whether these changes are associated with worse outcomes. Findings from this investigation could help guide policy modifications that support the provision of quality nursing home care. PMID:15149474

  4. 42 CFR 422.316 - Special rules for payments to Federally qualified health centers.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... health centers. 422.316 Section 422.316 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, 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...

  5. Medicare program; Medicare and laboratory certification program; enforcement procedures for laboratories--HCFA. Final rule.

    PubMed

    1992-02-28

    These regulations set forth the rules for sanctions that HCFA may impose on laboratories that are found not to meet Federal requirements. These include the principal sanctions of suspending, limiting, or revoking the laboratory's certificate issued under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), and cancelling the laboratory's approval to receive Medicare payment for its services, and the alternative sanctions that may be imposed instead of or before the principal sanctions. These amendments are necessary to conform HCFA regulations to changes made in the law by the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) and the 1988 amendments to section 353 of the Public Health Service Act (PHS Act). The latter are commonly referred to as "CLIA 88". The purpose of the amendments is to ensure that functioning laboratories are capable of providing accurate and reliable test results and that the health of individuals served by the laboratory and that of the general public is not adversely affected by laboratory operations and by testing procedures that do not meet the standards set forth in other subparts of part 493 of the HCFA regulations.

  6. 78 FR 12427 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-22

    ... April 5, 2011 (77 FR 22072) and a correction was published June 1, 2012 (77 FR 32407). This proposed... the payment remittance of section 1857(4)(e)(A) of the Act is designed to encourage the provision of... information (RFI) relating to the PHSA MLR provision was published in the April 4, 2010 (75 FR 19297)...

  7. 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

  8. Indirect Medical Education and Disproportionate Share Adjustments to Medicare Inpatient Payment Rates

    PubMed Central

    Nguyen, Nguyen Xuan; Sheingold, Steven H.

    2011-01-01

    The indirect medical education (IME) and disproportionate share hospital (DSH) adjustments to Medicare's prospective payment rates for inpatient services are generally intended to compensate hospitals for patient care costs related to teaching activities and care of low income populations. These adjustments were originally established based on the statistical relationships between IME and DSH and hospital costs. Due to a variety of policy considerations, the legislated levels of these adjustments may have deviated over time from these “empirically justified levels,” or simply, “empirical levels.” In this paper, we estimate the empirical levels of IME and DSH using 2006 hospital data and 2009 Medicare final payment rules. Our analyses suggest that the empirical level for IME would be much smaller than under current law— about one-third to one-half. Our analyses also support the DSH adjustment prescribed by the Affordable Care Act of 2010 (ACA)—about one-quarter of the pre-ACA level. For IME, the estimates imply an increase in costs of 1.88% for each 10% increase in teaching intensity. For DSH, the estimates imply that costs would rise by 0.52% for each 10% increase in the low-income patient share for large urban hospitals. PMID:22340777

  9. 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

  10. 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

  11. 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.

  12. Medicare and Medicaid Programs; Electronic Health Record Incentive Program--Stage 3 and Modifications to Meaningful Use in 2015 Through 2017. Final rules with comment period.

    PubMed

    2015-10-16

    This final rule with comment period specifies the requirements that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and Medicaid electronic health record (EHR) incentive payments and avoid downward payment adjustments under the Medicare EHR Incentive Program. In addition, it changes the Medicare and Medicaid EHR Incentive Programs reporting period in 2015 to a 90-day period aligned with the calendar year. This final rule with comment period also removes reporting requirements on measures that have become redundant, duplicative, or topped out from the Medicare and Medicaid EHR Incentive Programs. In addition, this final rule with comment period establishes the requirements for Stage 3 of the program as optional in 2017 and required for all participants beginning in 2018. The final rule with comment period continues to encourage the electronic submission of clinical quality measure (CQM) data, establishes requirements to transition the program to a single stage, and aligns reporting for providers in the Medicare and Medicaid EHR Incentive Programs.

  13. 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

  14. 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.

  15. 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...

  16. 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...

  17. Medicare in a consumer-choice environment: competitor or residual program?

    PubMed

    Etheredge, L

    1996-01-01

    The Medicare provisions of the reconciliation bill and President Clinton's proposals would both allow many new health plans to compete for Medicare enrollees and structure a competitive, consumer-choice system. Medicare will enter this new environment with serious shortcomings. The logic of market competition will call for upgrading many aspects of Medicare if it is to be successful. Among Medicare's features that need to be reconsidered are benefits, consumer focus, premium financing, payment policies, provider arrangements, performance accountability, management systems, risk adjustment and market strategies, social mission responsibilities, and research and development. PMID:12856666

  18. The Spillover Effects of Medicare Managed Care: Medicare Advantage and Hospital Utilization

    PubMed Central

    Baicker, Katherine; Chernew, Michael; Robbins, Jacob

    2013-01-01

    More than a quarter of Medicare beneficiaries are enrolled in Medicare Advantage, which was created in large part to improve the efficiency of health care delivery by promoting competition among private managed care plans. This paper explores the spillover effects of the Medicare Advantage program on the traditional Medicare program and other patients, taking advantage of changes in Medicare Advantage payment policy to isolate exogenous increases in Medicare Advantage enrollment and trace out the effects of greater managed care penetration on hospital utilization and spending throughout the health care system. We find that when more seniors enroll in Medicare managed care, hospital costs decline for all seniors and for commercially insured younger populations. Greater managed care penetration is not associated with fewer hospitalizations, but is associated with lower costs and shorter stays per hospitalization. These spillovers are substantial – offsetting more than 10% of increased payments to Medicare Advantage plans. PMID:24308880

  19. The spillover effects of Medicare managed care: Medicare Advantage and hospital utilization.

    PubMed

    Baicker, Katherine; Chernew, Michael E; Robbins, Jacob A

    2013-12-01

    More than a quarter of Medicare beneficiaries are enrolled in Medicare Advantage, which was created in large part to improve the efficiency of health care delivery by promoting competition among private managed care plans. This paper explores the spillover effects of the Medicare Advantage program on the traditional Medicare program and other patients, taking advantage of changes in Medicare Advantage payment policy to isolate exogenous increases in Medicare Advantage enrollment and trace out the effects of greater managed care penetration on hospital utilization and spending throughout the health care system. We find that when more seniors enroll in Medicare managed care, hospital costs decline for all seniors and for commercially insured younger populations. Greater managed care penetration is not associated with fewer hospitalizations, but is associated with lower costs and shorter stays per hospitalization. These spillovers are substantial - offsetting more than 10% of increased payments to Medicare Advantage plans.

  20. 75 FR 78247 - Medicare Program; Town Hall Meeting on Physician Quality Reporting System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-15

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Town Hall Meeting on Physician Quality Reporting System AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of... Building of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD...

  1. 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 Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the renewal of the Medicare...

  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.

  3. 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

  4. 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...

  5. 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...

  6. 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

  7. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2007 rates; fiscal year 2007 occupational mix adjustment to wage index; health care infrastructure improvement program; selection criteria of loan program for qualifying hospitals engaged in cancer-related health care and forgiveness of indebtedness; and exclusion of vendor purchases made under the competitive acquisition program (CAP) for outpatient drugs and biologicals under part B for the purpose of calculating the average sales price (ASP). Final rules and interim final rule with comment period.

    PubMed

    2006-08-18

    -based hospital payments for services and health information technology, as well as how to improve health data transparency for consumers. In addition, we are responding to public comments received on a proposed rule issued in the Federal Register on May 17, 2006 that proposed to revise the methodology for calculating the occupational mix adjustment to the wage index for the FY 2007 hospital inpatient prospective payment system by applying an adjustment to 100 percent of the wage index using new 2006 occupational mix survey data collected from hospitals. We are finalizing two policy documents published in the Federal Register relating to the implementation of the Health Care Infrastructure Improvement Program, a hospital loan program for cancer research, established under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This final rule also revises the definition of the term "unit" to specify the exclusion of units of drugs sold to approved Medicare Competitive Acquisition Program (CAP) vendors for use under the CAP from average sales price (ASP) calculations for a period of up to 3 years, at which time we will reevaluate our policy.

  8. 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

  9. 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.

  10. 42 CFR 409.102 - Amounts of payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM HOSPITAL INSURANCE BENEFITS Payment of Hospital Insurance Benefits § 409.102 Amounts of payment. (a) The amounts Medicare pays for hospital insurance benefits are generally determined in accordance with part...

  11. 75 FR 52960 - Medicare Program; Rural Community Hospital Demonstration Program: Solicitation of Additional...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-30

    ... the June 2, 2010 Federal Register (75 FR 30918)). B. Participation in the Demonstration To participate... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Rural Community Hospital... hospitals to participate in the Rural Community Hospital Demonstration program for a 5-year period....

  12. 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...

  13. 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

    ... 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 of... enrolling new members, and ultimately contract termination. In the February 22, 2013 Federal Register (78...

  14. 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

    ..., using a 5-star system where 5 stars indicates the highest quality, of Part C and D plan sponsors. The... C and D programs. We have established that 3 stars reflects an average level of performance and is... achieve at least a 3-star rating have demonstrated that they have substantially failed to meet...

  15. Perceived impact of the Medicare policy to adjust payment for health care-associated infections

    PubMed Central

    Lee, Grace M.; Hartmann, Christine W.; Graham, Denise; Kassler, William; Linn, Maya Dutta; Krein, Sarah; Saint, Sanjay; Goldmann, Donald A.; Fridkin, Scott; Horan, Teresa; Jernigan, John; Jha, Ashish

    2014-01-01

    Background In 2008, the Centers for Medicare and Medicaid Services (CMS) ceased additional payment for hospitalizations resulting in complications deemed preventable, including several health care-associated infections. We sought to understand the impact of the CMS payment policy on infection prevention efforts. Methods A national survey of infection preventionists from a random sample of US hospitals was conducted in December 2010. Results Eighty-one percent reported increased attention to HAIs targeted by the CMS policy, whereas one-third reported spending less time on nontargeted HAIs. Only 15% reported increased funding for infection control as a result of the CMS policy, whereas most reported stable (77%) funding. Respondents reported faster removal of urinary (71%) and central venous (50%) catheters as a result of the CMS policy, whereas routine urine and blood cultures on admission occurred infrequently (27% and 13%, respectively). Resource shifting (ie, less time spent on nontargeted HAIs) occurred more commonly in large hospitals (odds ratio, 2.3; 95% confidence interval: 1.0–5.1; P = .038) but less often in hospitals where front-line staff were receptive to changes in clinical processes (odds ratio, 0.5; 95% confidence interval: 0.3–0.8; P = .005). Conclusion Infection preventionists reported greater hospital attention to preventing targeted HAIs as a result of the CMS nonpayment policy. Whether the increased focus and greater engagement in HAI prevention practices has led to better patient outcomes is unclear. PMID:22541855

  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.

  17. 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

  18. 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

    ... Nominations to the Advisory Panel on Hospital Outpatient Payment AGENCY: Centers for Medicare & Medicaid... Advisory Panel on Hospital Outpatient Payment (HOP, the Panel). There will be two vacancies on the Panel... Classification (APC) groups and their associated weights, and supervision of hospital outpatient services....

  19. 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

  20. 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...

  1. 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 program contractors. 421.302 Section 421.302 Public Health CENTERS FOR MEDICARE & MEDICAID...

  2. 78 FR 53769 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-30

    ... effectiveness of consumer education strategies concerning Medicare, Medicaid and the Children's Health Insurance... enrolled in, or eligible for, Medicare, Medicaid and the Children's Health Insurance Program (CHIP... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  3. 42 CFR 424.127 - Payment to the beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Special Conditions: Services Furnished in a Foreign Country § 424.127 Payment to the beneficiary. (a) Conditions for payment of inpatient hospital... amount payable to the beneficiary is determined in accordance with § 424.109(b). (c) Conditions...

  4. 42 CFR 413.215 - Basis of payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 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; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Payment for End-Stage Renal Disease...

  5. 42 CFR 413.215 - Basis of payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 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; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Payment for End-Stage Renal Disease...

  6. 42 CFR 413.176 - Amount of payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 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; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Payment for End-Stage Renal Disease...

  7. 42 CFR 413.176 - Amount of payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 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; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Payment for End-Stage Renal Disease...

  8. 42 CFR 414.210 - General payment rules.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false General payment rules. 414.210 Section 414.210 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 Durable...

  9. 42 CFR 409.100 - To whom payment is made.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false To whom payment is made. 409.100 Section 409.100 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM HOSPITAL INSURANCE BENEFITS Payment of Hospital Insurance Benefits § 409.100 To whom payment is made. (a) Basic rule. Except as provided...

  10. 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...

  11. 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...

  12. 42 CFR 412.541 - Method of payment under the long-term care hospital prospective payment system.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 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...

  13. 42 CFR 412.505 - Conditions for payment under the prospective payment system for long-term care hospitals.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... payment system for long-term care hospitals. 412.505 Section 412.505 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 Long-Term Care Hospitals § 412.505 Conditions...

  14. 77 FR 71600 - Medicare Program; Request for Information To Aid in the Design and Development of a Survey...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-12-03

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Request for Information To Aid in the Design and Development of a Survey Regarding Patient Experiences With Emergency Department Care AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Request for...

  15. Understanding the Impacts of the Medicare Modernization Act: Concerns of Congressional Staff

    ERIC Educational Resources Information Center

    Mueller, Keith J.; Coburn, Andrew F.; MacKinney, A. 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…

  16. 76 FR 46814 - Medicare Program; Evaluation Criteria and Standards for Quality Improvement Program Contracts...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-03

    ... Restraints, Nursing Home Systemic Improvement, Adverse Drug Events, Quality Reporting and Improvement... Standards for Quality Improvement Program Contracts (10th Statement of Work) AGENCY: Centers for Medicare... Conditions in Nursing Homes-- Pressure Ulcers and Physical Restraints; Developing a learning and...

  17. 42 CFR 412.348 - Exception payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 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...

  18. 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...

  19. 42 CFR 412.348 - Exception payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 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...

  20. 42 CFR 412.348 - Exception payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 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...

  1. 42 CFR 412.348 - Exception payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 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...

  2. 76 FR 79193 - Medicare Program; Independence at Home Demonstration Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-21

    ... beneficiaries are defined as Medicare fee-for-service (FFS) patients, who have at least 2 chronic illnesses... practitioners and must have experience providing home-based primary care to patients with multiple chronic illnesses. These practices will also be organized, at least in part, for the purpose of providing...

  3. 42 CFR 412.125 - Effect of change of ownership on payments under the prospective payment systems.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL... described in § 489.18 of this chapter, the following rules apply: (a) Payment for the operating and...

  4. 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

  5. Section 506 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003--limitation on charges for services furnished by Medicare participating inpatient hospitals to individuals eligible for care purchased by Indian health programs. Final rule.

    PubMed

    2007-06-01

    The Secretary of the Department of Health and Human Services (HHS) hereby issues this final rule establishing regulations required by section 506 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), (Pub. L. 108-173). Section 506 of the MMA amended section 1866 (a)(1) of the Social Security Act to add subparagraph (U) which requires hospitals that furnish inpatient hospital services payable under Medicare to participate in the contract health services program (CHS) of the Indian Health Service (IHS) operated by the IHS, Tribes, and Tribal organizations, and to participate in programs operated by urban Indian organizations that are funded by IHS (collectively referred to as I/T/Us) for any medical care purchased by those programs. Section 506 also requires such participation to be in accordance with the admission practices, payment methodology, and payment rates set forth in regulations established by the Secretary, including acceptance of no more than such payment rates as payment in full. PMID:17577967

  6. 76 FR 13418 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-11

    ... MCAC, see the December 14, 1998 Federal Register (63 FR 68780).) This notice announces the May 11, 2011... Evidence Development and Coverage Advisory Committee, May 11, 2011 AGENCY: Centers for Medicare & Medicaid... Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee''). The...

  7. 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...

  8. 77 FR 64997 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-24

    ... December 14, 1998 Federal Register (63 FR 68780). This notice announces the Wednesday, January 30, 2013... Evidence Development and Coverage Advisory Committee--January 30, 2013 AGENCY: Centers for Medicare... meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'')...

  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. 76 FR 44011 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-22

    ... Register (63 FR 68780).) This notice announces the September 21, 2011, public meeting of the Committee... Evidence Development and Coverage Advisory Committee--September 21, 2011 AGENCY: Centers for Medicare... meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'')...

  11. 75 FR 8980 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-26

    ... MCAC, see the December 14, 1998 Federal Register (63 FR 68780).) This notice announces the April 21... Evidence Development and Coverage Advisory Committee--April 21, 2010 AGENCY: Centers for Medicare... meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'')...

  12. 75 FR 73094 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-29

    ... information on MCAC, see the December 14, 1998 Federal Register (63 FR 68780).) This notice announces the... Evidence Development and Coverage Advisory Committee--January 19, 2011 AGENCY: Centers for Medicare... meeting of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'')...

  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

    ... information on MCAC, see the December 14, 1998 Federal Register (63 FR 68780). This notice announces the... Evidence Development and Coverage Advisory Committee--May 1, 2013 AGENCY: Centers for Medicare & Medicaid... Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) (``Committee'') will be held...

  14. 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......

  15. 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)...

  16. 78 FR 78802 - Medicare Program; Right of Appeal for Medicare Secondary Payer Determination Relating to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-27

    ... Self- Insurance), No Fault Insurance, and Workers' Compensation Laws and Plans AGENCY: Centers for...-fault insurance, and workers' compensation laws or plans when Medicare pursues a Medicare Secondary Payer (MSP) recovery claim directly from the liability insurance (including self-insurance), no...

  17. The effects of market structure and payment rate on the entry of private health plans into the Medicare market.

    PubMed

    Frakt, Austin B; Pizer, Steven D; Feldman, Roger

    2012-01-01

    Private insurance firms participating in Medicare can offer up to three principal plan types: coordinated care plans (CCPs), prescription drug plans (PDPs), and private fee-for-service (PFFS) plans. Firms can make entry and marketing decisions separately across plan types and geographic regions. In this study, we estimate firm-level models of Medicare private plan entry using data from the years 2007 to 2009. Our models include a measure of market structure and separately identify CCP, PDP, and PFFS entry. We find evidence that entry barriers associated with CCP market concentration affect all three product types. We also find evidence of cross-product competition and common cost or demand factors that make entry with certain product combinations more likely. We predict that the market presence of CCPs and PFFS plans will decrease and that of PDPs will increase in response to payment reductions included in the new health reform law.

  18. 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...

  19. 42 CFR 412.82 - Payment for extended length-of-stay cases (day outliers).

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES... rate for inpatient operating costs and inpatient capital-related costs determined under subpart D...

  20. 42 CFR 460.182 - Medicaid payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Medicaid payment. 460.182 Section 460.182 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Payment § 460.182 Medicaid payment....

  1. 42 CFR 412.108 - Special treatment: Medicare-dependent, small rural hospitals.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... hospitals. 412.108 Section 412.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES... § 412.108 Special treatment: Medicare-dependent, small rural hospitals. (a) Criteria for...

  2. Medicare cost controls and program compliance: the rationale of physician claims edits.

    PubMed

    Carter, Darren

    2002-01-01

    This article attempts to demystify and create a context for the enactment of several Medicare cost control and compliance systems for physician reimbursement. The focus is on claims "edits" and Medicare compliance. Portions of Medicare, including health care provider reimbursement, remain fee-for-service programs that can be easily defrauded. To protect the Trust, the Centers for Medicare and Medicaid Services (CMS) has taken a multi-pronged approach, using program administration, enforcement, and rules-based claims editing systems. The Evaluation and Management codes, the Correct Coding Initiative (CCI), and medical necessity rules are claims edits that affect procedure codes. The Medicare program has a complicated system of billing procedures and an apparatus to enforce them. A solid compliance plan must incorporate proper claims editing, because consistent incorrect Medicare billing can be considered abuse. Many resources are available to aid physicians, including computerized tools, new CMS initiatives, and Internet materials.

  3. 42 CFR 424.124 - Conditions for payment for physician services and ambulance services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Special Conditions: Services Furnished in a Foreign Country § 424.124 Conditions for payment for physician services... 42 Public Health 3 2010-10-01 2010-10-01 false Conditions for payment for physician services...

  4. 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...

  5. 42 CFR 414.232 - Special payment rules for transcutaneous electrical nerve stimulators (TENS).

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Special payment rules for transcutaneous electrical nerve stimulators (TENS). 414.232 Section 414.232 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...

  6. 42 CFR 414.508 - Payment for a new clinical diagnostic laboratory test.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... test. 414.508 Section 414.508 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 New Clinical Diagnostic Laboratory Tests § 414.508 Payment for a new...

  7. 42 CFR 414.508 - Payment for a new clinical diagnostic laboratory test.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... test. 414.508 Section 414.508 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 New Clinical Diagnostic Laboratory Tests § 414.508 Payment for a new...

  8. 42 CFR 414.508 - Payment for a new clinical diagnostic laboratory test.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... test. 414.508 Section 414.508 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 New Clinical Diagnostic Laboratory Tests § 414.508 Payment for a new...

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

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... years from the date of payment of the invoice. (6) Comply with the audit and dispute resolution...) Maintain up-to-date NDC listings with the electronic database vendors for which the manufacturer provides... on the invoice, as part of the Medicare Part D Discount Information, or upon audit or dispute...

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

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... years from the date of payment of the invoice. (6) Comply with the audit and dispute resolution...) Maintain up-to-date NDC listings with the electronic database vendors for which the manufacturer provides... on the invoice, as part of the Medicare Part D Discount Information, or upon audit or dispute...

  11. 42 CFR 423.2315 - Medicare Coverage Gap Discount Program Agreement.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... years from the date of payment of the invoice. (6) Comply with the audit and dispute resolution...) Maintain up-to-date NDC listings with the electronic database vendors for which the manufacturer provides... on the invoice, as part of the Medicare Part D Discount Information, or upon audit or dispute...

  12. 77 FR 9255 - Medicare Program: Notice of Six Membership Appointments to the Advisory Panel on Hospital...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-16

    ..., 2011 final rule, (76 FR 74363)) to address appropriate supervision level for hospital outpatient... FR 72708). The notice requested nominations to be added to the Panel by replacing one Panel member... Appointments to the Advisory Panel on Hospital Outpatient Payment AGENCY: Centers for Medicare &...

  13. 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... Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment... From the Federal Register Online via the Government Publishing Office ] DEPARTMENT OF HEALTH...

  14. 76 FR 16422 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-23

    ... Health Insurance Programs; Provider Enrollment Application Fee Amount for 2011 AGENCY: Centers for... with comment period entitled: ``Medicare, Medicaid, and Children's Health Insurance Programs... Health Insurance Program (CHIP) provider enrollment processes. Specifically, and as stated in 42 CFR...

  15. The role of critical access hospital status in mitigating the effects of new prospective payment systems under Medicare.

    PubMed

    Dalton, K; Slifkin, R T; Howard, H A

    2000-01-01

    This article examines rural hospitals that potentially qualify as critical access hospitals (CAH) and identifies facilities at substantial financial risk as a result of Medicare's expansion of prospective payment systems (PPS) to nonacute settings. Using Health Care Financing Administration (HCFA) cost reports from the federal year ending Sept. 30, 1996, combined with county-level sociodemographic data from the Area Resource File (ARF), characteristics of potential CAHs were identified and their finances analyzed to determine whether they could benefit from the cost-based reimbursement rules applicable to CAH status. Rural hospitals were identified as potential CAHs if they met a combination of federal and state criteria for necessary providers. Rural facilities were classified as "at risk" if they had poor financial ratios in conjunction with high levels of dependence on outpatient, home-care or skilled nursing services. Almost 30 percent of all rural hospitals were identified as potential CAHs. Ninety percent of potential CAH facilities were identified as "at risk" by at least one of five possible risk criteria, and one-third were identified by at least three. Of those classified "at risk," 48 percent might not benefit from conversion to CAH because their inpatient Medicare reimbursement would likely be less under CAH payment rules than under their current PPS payment rules. Many potential CAHs were doing well under inpatient PPS because they were sole community hospitals (SCH) and were therefore eligible for special adjustments to the PPS rates. The Rural Hospital Flexibility Act would be more beneficial to the population of isolated rural hospitals if those eligible for both CAH and SCH status were given the option of retaining their SCH inpatient payment arrangements while still qualifying for outpatient cost-based reimbursement.

  16. 76 FR 67567 - Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-01

    ... Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts... Services RIN 0938-AQ14 Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care.... ACTION: Notice. SUMMARY: This notice announces the inpatient hospital deductible and the hospital...

  17. 76 FR 37120 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-24

    ..., and Children's Health Insurance (CHIP) programs. This meeting is open to the public. DATES: Meeting..., Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). Informing Medicare, Medicaid and... availability of other health coverage that may be available to them (for example, via health...

  18. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 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...

  19. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 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...

  20. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 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...

  1. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 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...

  2. Medicare Beneficiary Counseling Programs: What Are They and Do They Work?

    PubMed Central

    McCormack, Lauren A.; Schnaier, Jenny A.; Lee, A. James; Garfinkel, Steven A.

    1996-01-01

    Medicare beneficiaries face myriad rules, conditions, and exceptions under the Medicare program. As a result, State Information, Counseling, and Assistance (ICA) programs were established or enhanced with Federal funding as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. ICA programs utilize a volunteer-based and locally-sponsored support system to deliver free and unbiased counseling on the Medicare program and related health insurance issues. This article discusses the effectiveness of the ICA model. Because the ICA programs serve as a vital link between HCFA and its beneficiaries, information about the programs' success may be useful to HCFA and other policymakers during this era of consumer information. PMID:10165027

  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 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...

  5. 7 CFR 1469.23 - Program payments.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... Agriculture Statistics Service (NASS) land rental data, and Conservation Reserve Program (CRP) rental rates...) The State Conservationists can also contribute additional local data, with advice from the State... payments for any practice that is required to meet conservation compliance requirements found in 7 CFR...

  6. 7 CFR 1469.23 - Program payments.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... Agriculture Statistics Service (NASS) land rental data, and Conservation Reserve Program (CRP) rental rates...) The State Conservationists can also contribute additional local data, with advice from the State... payments for any practice that is required to meet conservation compliance requirements found in 7 CFR...

  7. 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... needed for a determination; (2) In cases of suspected fraud, suspended, in whole or in part, by CMS or a... Department of Justice, and determined that a credible allegation of fraud exists against a provider...

  8. 42 CFR 412.541 - Method of payment under the long-term care hospital prospective payment system.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Method of payment under the long-term care hospital..., DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long-Term Care Hospitals § 412.541 Method of payment under the...

  9. 78 FR 26038 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-January Through March 2013

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-03

    ... (CMS), HHS. ACTION: Notice. SUMMARY: This quarterly notice lists CMS manual instructions, substantive... through March 2013, relating to the Medicare and Medicaid programs and other programs administered by CMS... & Medicaid Services (CMS) is responsible for administering the Medicare and Medicaid programs...

  10. 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

    ... (CMS), HHS. ACTION: Notice. SUMMARY: This quarterly notice lists CMS manual instructions, substantive... through June 2013, relating to the Medicare and Medicaid programs and other programs administered by CMS... & Medicaid Services (CMS) is responsible for administering the Medicare and Medicaid programs...

  11. 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.

  12. 42 CFR 495.206 - Timeframe for payment to qualifying MA organizations.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... organizations for qualifying MA EPs under the MA EHR incentive program after computing incentive payments due under the Medicare FFS EHR incentive program according to § 495.102. (b) Payments to qualifying MA... the Medicare FFS EHR incentive program, following the timeline in specified in § 495.104 of this...

  13. 42 CFR 495.206 - Timeframe for payment to qualifying MA organizations.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... organizations for qualifying MA EPs under the MA EHR incentive program after computing incentive payments due under the Medicare FFS EHR incentive program according to § 495.102. (b) Payments to qualifying MA... the Medicare FFS EHR incentive program, following the timeline in specified in § 495.104 of this...

  14. 42 CFR 495.206 - Timeframe for payment to qualifying MA organizations.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... organizations for qualifying MA EPs under the MA EHR incentive program after computing incentive payments due under the Medicare FFS EHR incentive program according to § 495.102. (b) Payments to qualifying MA... the Medicare FFS EHR incentive program, following the timeline in specified in § 495.104 of this...

  15. 42 CFR 423.875 - Payment to fallback plans.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Payment to fallback plans. 423.875 Section 423.875 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Guaranteeing Access to a Choice...

  16. 42 CFR 413.184 - Payment exception: Pediatric patient mix.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Section 413.184 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...-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.184 Payment exception:...

  17. 42 CFR 413.184 - Payment exception: Pediatric patient mix.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Section 413.184 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...-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.184 Payment exception:...

  18. 42 CFR 413.60 - Payments to providers: General.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payments to providers: General. 413.60 Section 413.60 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...

  19. 42 CFR 416.120 - Basis for payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Basis for payment. 416.120 Section 416.120 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM AMBULATORY SURGICAL SERVICES Prospective Payment System for Facility Services Furnished Before January 1, 2008 § 416.120 Basis...

  20. 42 CFR 412.523 - Methodology for calculating the Federal prospective payment rates.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL... inpatient operating and capital-related costs per discharge for which payment is made to each inpatient...

  1. 42 CFR 412.48 - Denial of payment as a result of admissions and quality review.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL... Inpatient Capital-Related Costs § 412.48 Denial of payment as a result of admissions and quality review....

  2. 42 CFR 412.48 - Denial of payment as a result of admissions and quality review.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL... Inpatient Capital-Related Costs § 412.48 Denial of payment as a result of admissions and quality review....

  3. 42 CFR 412.48 - Denial of payment as a result of admissions and quality review.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL... Inpatient Capital-Related Costs § 412.48 Denial of payment as a result of admissions and quality review....

  4. 42 CFR 412.48 - Denial of payment as a result of admissions and quality review.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL... Inpatient Capital-Related Costs § 412.48 Denial of payment as a result of admissions and quality review....

  5. 42 CFR 412.48 - Denial of payment as a result of admissions and quality review.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL... Inpatient Capital-Related Costs § 412.48 Denial of payment as a result of admissions and quality review....

  6. 75 FR 70165 - Medicare Program; Request for Information Regarding Accountable Care Organizations and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-17

    ... (CMMI) within CMS, which is authorized to test innovative payment and service delivery models to reduce... innovative payment and delivery system models that complement the Shared Savings Program in the CMMI. In both... the Shared Savings Program and other innovative payment models that CMMI is authorized to test...

  7. 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...

  8. 76 FR 66931 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-28

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Accountable Care Organization... Organizations (ACOs) deliver better care and reduce costs. We invite all new or existing ACO entities to register a team of senior executives to attend the in- person ADLS. The ADLS will provide executives...

  9. 75 FR 72830 - Medicare Program; Quality Improvement Organization (QIO) Contracts: Solicitation of Proposals...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-26

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Quality Improvement... fulfills the Secretary's obligation under section 1153(i) of the Social Security Act (the Act) to provide at least 6 months' advance notice of the expiration dates of contracts with out- of-State...

  10. 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...

  11. 76 FR 28195 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-16

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 418 RIN 0938-AQ31 Medicare Program; Hospice Wage Index for Fiscal Year 2012 Correction In proposed rule document 2011-10689 appearing on...

  12. 78 FR 38043 - Medicare and Medicaid Programs; Application From the American Osteopathic Association/Health...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-25

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Application From.... ADDRESSES: In commenting, please refer to file code CMS-3285-PN. Because of staff and resource limitations... & Medicaid Services, Department of Health and Human Services, Attention: CMS-3285-PN, P.O. Box...

  13. 76 FR 67801 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    ... Body 4. Leadership and Management Structure 5. Processes To Promote Evidence-Based Medicine, Patient.... 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)....

  14. 76 FR 54599 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-01

    ... on (70 FR 4588 through 4741 and 70 FR 4194 through 4585, respectively). As we gained more experience... programs and issued a proposed rule on May 16, 2008 (73 FR 28556) that would have clarified existing... September 18, 2008 IFC (73 FR 54226), our November 14, 2008 IFC (73 FR 67406), our November 21,...

  15. 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... life care; Bayesian statistics; clinical epidemiology; clinical trial methodology; knee, hip, and...

  16. 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

    ... trial methodology; knee, hip, and other joint replacement surgery; ophthalmology; psychopharmacology... 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...

  17. Medicaid program; payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children program. Final rule.

    PubMed

    2012-11-01

    This final rule implements Medicaid payment for primary care services furnished by certain physicians in calendar years (CYs) 2013 and 2014 at rates not less than the Medicare rates in effect in those CYs or, if greater, the payment rates that would be applicable in those CYs using the CY 2009 Medicare physician fee schedule conversion factor. This minimum payment level applies to specified primary care services furnished by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine, and also applies to services rendered by these provider types paid by Medicaid managed care plans contracted by states to provide the primary care services. It also provides for 100 percent federal financial participation (FFP) for any increase in payment above the amounts that would be due for these services under the provisions of the approved Medicaid state plan, as of July 1, 2009. In other words, there will not be any additional cost to states for payments above the amount required by the 2009 rate methodology. In this final rule, we specify which services and types of physicians qualify for the minimum payment level in CYs 2013 and 2014, and the method for calculating the payment amount and any increase for which increased federal funding is due. In addition, this final rule will update the interim regional maximum fees that providers may charge for the administration of pediatric vaccines to federally vaccine-eligible children under the Pediatric Immunization Distribution Program, more commonly known as the Vaccines for Children (VFC) program.

  18. Beneficiary complaints, provider numbers and carrier shopping: Medicare contractor operations.

    PubMed

    Kusserow, R P

    1991-11-01

    The number of Medicare claims processed annually will double in the next 10 years, making it imperative that contractors review claims accurately and ensure that payments are made only for medically necessary, high-quality care. Effective identification and prosecution of fraud and abuse in the Medicare program will depend on a cooperative effort between Medicare contractors, the Health Care Financing Administration, and the Office of Inspector General.

  19. 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...

  20. 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...

  1. Savings estimate for a Medicare insured group.

    PubMed

    Birnbaum, H; Holland, S K; Lenhart, G; Reilly, H L; Hoffman, K; Pardo, D P

    1991-01-01

    Estimates of the savings potential of a managed-care program for a Medicare retiree population in Michigan under a hypothetical Medicare insured group (MIG) are presented in this article. In return for receiving an experience-rated capitation payment, a MIG would administer all Medicare and employer complementary benefits for its enrollees. A study of the financial and operational feasibility of implementing a MIG for retirees of a national corporation involving an analysis of 1986 claims data finds that selected managed-care initiatives implemented by a MIG would generate an annual savings of 3.8 percent of total (Medicare plus complementary) expenditures. Although savings are less than the 5 percent to be retained by Medicare, this finding illustrates the potential for savings from managed-care initiatives to Medicare generally and to MIGs elsewhere, where savings may be greater if constraints are less restrictive.

  2. Payment Rates for Personal Care Assistants and the Use of Long-Term Services and Supports among Those Dually Eligible for Medicare and Medicaid

    PubMed Central

    Ko, Michelle; Newcomer, Robert; Kang, Taewoon; Hulett, Denis; Chu, Philip; Bindman, Andrew B

    2014-01-01

    Objective To examine the association between payment rates for personal care assistants and use of long-term services and supports (LTSS) following hospital discharge among dual eligible Medicare and Medicaid beneficiaries. Data Sources State hospital discharge, Medicaid and Medicare claims, and assessment data on California Medicaid LTSS users from 2006 to 2008. Study Design Cross-sectional study. We used multinomial logistic regression to analyze county personal care assistant payment rates and postdischarge LTSS use, and estimate marginal probabilities of each outcome across the range of rates paid in California. Data Extraction Methods We identified dual eligible Medicare and Medicaid adult beneficiaries discharged from an acute care hospital with no hospitalizations or LTSS use in the preceding 12 months. Principal Findings Personal care assistant payment rates were modestly associated with home and community-based services (HCBS) use versus nursing facility entry following hospital discharge (RRR 1.2, 95 percent CI: 1.0–1.4). For a rate of $6.75 per hour, the probability of HCBS use was 5.6 percent (95 percent CI: 4.2–7.1); at $11.75 per hour, 18.0 percent (95 percent CI: 12.5–23.4). Payment rate was not associated with the probability of nursing facility entry. Conclusions Higher payment rates for personal care assistants may increase utilization of HCBS, but with limited substitution for nursing facility care. PMID:25327166

  3. Medicare as insurance innovator: the case of hospice.

    PubMed

    Taylor, Donald H

    2013-09-01

    The stylized fact is that while private insurance has tended to innovate on the benefit design side of the insurance contract, Medicare has lead innovation on the payment side. Traditional or Fee-For-Service Medicare has produced many innovations in the payment for health care services, such as Prospective Payment for hospitals, Diagnostic-Related Groups to categorize care, and the Resource-Based Relative Value System used by the program to pay physicians, while private insurance has produced a series of benefit design innovations. This story misses one important example of Medicare benefit innovation: the creation of the Medicare hospice benefit. A key question is whether Medicare can again lead a system-wide benefit design effort to improve upon current hospice and palliative care policy.

  4. 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

  5. Medicare risk contracting: determinants of market entry.

    PubMed

    Porell, F W; Wallack, S S

    1990-01-01

    The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 made it more attractive for health maintenance organizations (HMOs) and other competitive medical plans to enter into risk contracts with Medicare. Since the start of the TEFRA program in April 1985, more than 160 HMOs have had risk contracts with Medicare under the program. An investigation of factors associated with TEFRA risk-market entry at the end of 1986 revealed that high adjusted average per capita cost payment levels, prior Medicare cost-contract experience, and prior Federal qualification were the most important factors distinguishing market entrants from nonentrants. PMID:10113567

  6. 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.

  7. 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

  8. 42 CFR 495.102 - Incentive payments to EPs.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 5 2011-10-01 2011-10-01 false Incentive payments to EPs. 495.102 Section 495.102... PROGRAM Requirements Specific to the Medicare Program § 495.102 Incentive payments to EPs. (a) General...) Increase in incentive payment limit for EPs who predominantly furnish services in a geographic HPSA. In...

  9. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    .... (a) Principle. CMS pays the full reasonable cost incurred by an HMO or CMP for activities that are... decreases in the number of Medicare enrollees. (2) Obtaining independent certification of the HMO's or...

  10. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... requirements. (a) Principle. CMS pays the full reasonable cost incurred by an HMO or CMP for activities that... decreases in the number of Medicare enrollees. (2) Obtaining independent certification of the HMO's or...

  11. 42 CFR 417.550 - Special Medicare program requirements.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... requirements. (a) Principle. CMS pays the full reasonable cost incurred by an HMO or CMP for activities that... decreases in the number of Medicare enrollees. (2) Obtaining independent certification of the HMO's or...

  12. 42 CFR 421.316 - Limitation on Medicare integrity program contractor liability.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Contractors § 421.316 Limitation on Medicare integrity program contractor liability. (a) A MIP contractor, a... services to a MIP contractor is not in violation of any criminal law or civilly liable under any law of...

  13. 42 CFR 421.316 - Limitation on Medicare integrity program contractor liability.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Contractors § 421.316 Limitation on Medicare integrity program contractor liability. (a) A MIP contractor, a... services to a MIP contractor is not in violation of any criminal law or civilly liable under any law of...

  14. 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)...

  15. 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.

  16. 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

  17. 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...: Availability of funding opportunity announcement. Funding Opportunity Title/Program Name: Affordable Care Act... Protection and Affordable Care Act of 2010 (Affordable Care Act). Catalog of Federal Domestic...

  18. 77 FR 38067 - Medicare Program; Public Meeting Regarding Inherent Reasonableness of Medicare Fee Schedule...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-26

    ... Reasonableness Authority In the December 13, 2005 Federal Register (70 FR 73623), we published a final rule.... ++ Differences in charges. ++ Costs. ++ Use. ++ Payment amounts in other localities. Use of Valid and Reliable... is significant. Although we recognize that there are pricing differences between mail order and...

  19. 78 FR 5458 - Medicare Program; Request for Information To Aid in the Design and Development of a Survey...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-25

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Request for Information To Aid in the Design and Development of a Survey Regarding Patient and Family Member/Friend Experiences With Hospice Care AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Request for...

  20. 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

  1. 42 CFR 405.517 - Payment for drugs and biologicals that are not paid on a cost or prospective payment basis.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payment for drugs and biologicals that are not paid on a cost or prospective payment basis. 405.517 Section 405.517 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Criteria...

  2. 42 CFR 412.204 - Payment to hospitals located in Puerto Rico.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payment to hospitals located in Puerto Rico. 412... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Operating Costs for Hospitals Located in Puerto Rico § 412.204 Payment...

  3. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payment based on the hospital-specific rate. 412... 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...

  4. 42 CFR 412.374 - Payments to hospitals located in Puerto Rico.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs Special Rules for Puerto Rico Hospitals § 412.374 Payments to hospitals located in Puerto Rico. (a) FY 1998 through FY 2004. Payments for...

  5. 42 CFR 412.525 - Adjustments to the Federal prospective payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long-Term Care Hospitals § 412.525 Adjustments to the Federal prospective payment. (a) Adjustments for high-cost outliers. (1) CMS provides for an additional payment to a long-term care hospital...

  6. 42 CFR 412.374 - Payments to hospitals located in Puerto Rico.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs Special Rules for Puerto Rico Hospitals § 412.374 Payments to hospitals located in Puerto Rico. (a) FY 1998 through FY 2004. Payments for...

  7. 42 CFR 412.374 - Payments to hospitals located in Puerto Rico.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs Special Rules for Puerto Rico Hospitals § 412.374 Payments to hospitals located in Puerto Rico. (a) FY 1998 through FY 2004. Payments for...

  8. 42 CFR 412.374 - Payments to hospitals located in Puerto Rico.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs Special Rules for Puerto Rico Hospitals § 412.374 Payments to hospitals located in Puerto Rico. (a) FY 1998 through FY 2004. Payments for...

  9. 42 CFR 447.512 - Drugs: Aggregate upper limits of payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Drugs: Aggregate upper limits of payment. 447.512 Section 447.512 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PAYMENTS FOR SERVICES Payment for Drugs § 447.512 Drugs: Aggregate upper limits of payment....

  10. 42 CFR 405.2464 - Payment rate.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Payment rate. 405.2464 Section 405.2464 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED Rural Health Clinic and Federally Qualified...

  11. 77 FR 9179 - Medicare Program; Reporting and Returning of Overpayments

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-16

    ... 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. L... Federal Register, (63 FR 58400) the OIG published a notice stating-- is intended to facilitate...

  12. 42 CFR 422.324 - Payments to MA organizations for graduate medical education costs.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 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 (CONTINUED) MEDICARE ADVANTAGE...

  13. 42 CFR 423.520 - Prompt payment by Part D sponsors.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Prompt payment by Part D sponsors. 423.520 Section 423.520 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Application Procedures and Contracts with Part D plan sponsors §...

  14. 42 CFR 423.520 - Prompt payment by Part D sponsors.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Prompt payment by Part D sponsors. 423.520 Section 423.520 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Application Procedures and Contracts with Part D...

  15. 42 CFR 414.67 - Incentive payments for services furnished in Health Professional Shortage Areas.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Incentive payments for services furnished in Health Professional Shortage Areas. 414.67 Section 414.67 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...

  16. 42 CFR 414.67 - Incentive payments for services furnished in Health Professional Shortage Areas.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Incentive payments for services furnished in Health Professional Shortage Areas. 414.67 Section 414.67 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...

  17. 42 CFR 412.428 - Publication of Updates to the inpatient psychiatric facility prospective payment system.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Publication of Updates to the inpatient psychiatric facility prospective payment system. 412.428 Section 412.428 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES...

  18. 42 CFR 419.32 - Calculation of prospective payment rates for hospital outpatient services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... hospital outpatient services. 419.32 Section 419.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES Basic Methodology for Determining Prospective Payment Rates for...

  19. 42 CFR 413.123 - Payment for screening mammography performed by hospitals on an outpatient basis.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payment for screening mammography performed by hospitals on an outpatient basis. 413.123 Section 413.123 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...

  20. 42 CFR 413.125 - Payment for home health agency services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payment for home health agency services. 413.125 Section 413.125 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; OPTIONAL...

  1. 42 CFR 419.66 - Transitional pass-through payments: Medical devices.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Transitional pass-through payments: Medical devices. 419.66 Section 419.66 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES Transitional...

  2. 42 CFR 414.416 - Determination of competitive bidding payment amounts.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Determination of competitive bidding payment amounts. 414.416 Section 414.416 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER...

  3. 42 CFR 414.34 - Payment for services and supplies incident to a physician's service.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payment for services and supplies incident to a physician's service. 414.34 Section 414.34 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND...

  4. 42 CFR 414.58 - Payment of charges for physician services to patients in providers.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payment of charges for physician services to patients in providers. 414.58 Section 414.58 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND...

  5. 42 CFR 414.66 - Incentive payments for physician scarcity areas.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Incentive payments for physician scarcity areas. 414.66 Section 414.66 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH...

  6. 42 CFR 414.36 - Payment for drugs incident to a physician's service.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payment for drugs incident to a physician's service. 414.36 Section 414.36 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH...

  7. 42 CFR 414.32 - Determining payments for certain physicians' services furnished in facility settings.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Determining payments for certain physicians' services furnished in facility settings. 414.32 Section 414.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART...

  8. 42 CFR 414.60 - Payment for the services of CRNAs.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Payment for the services of CRNAs. 414.60 Section 414.60 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...

  9. 42 CFR 405.351 - Incorrect payments for which the individual is not liable.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Incorrect payments for which the individual is not liable. 405.351 Section 405.351 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,...

  10. 42 CFR 412.76 - Recovery of excess transition period payment amounts resulting from unlawful claims.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Recovery of excess transition period payment amounts resulting from unlawful claims. 412.76 Section 412.76 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Determination...

  11. 42 CFR 414.313 - Initial method of payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... inpatients who were not admitted solely to receive maintenance dialysis. (iv) Administration of hepatitis B... (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Determination of Reasonable... of this subchapter. (b) Services for which payment is not included in the add-on payment....

  12. 42 CFR 414.313 - Initial method of payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... inpatients who were not admitted solely to receive maintenance dialysis. (iv) Administration of hepatitis B... (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Determination of Reasonable... of this subchapter. (b) Services for which payment is not included in the add-on payment....

  13. 42 CFR 447.203 - Documentation of payment rates.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Documentation of payment rates. 447.203 Section 447.203 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PAYMENTS FOR SERVICES Payment Methods: General Provisions §...

  14. 78 FR 46339 - Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of Temporary Moratoria...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-31

    ... Children's Health Insurance Program (CHIP). Section 6401(a) of the Affordable Care Act added a new section... titled, ``Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements... and the Children's Health Insurance Program (CHIP) The February 2, 2011 final rule also...

  15. Payment for Physician and Other Health Care Professional Services Purchased by Indian Health Programs and Medical Charges Associated With Non-Hospital-Based Care. Final rule with comment period.

    PubMed

    2016-03-21

    The Secretary of the Department of Health and Human Services (HHS) hereby issues this final rule with comment period to implement a methodology and payment rates for the Indian Health Service (IHS) Purchased/Referred Care (PRC), formerly known as the Contract Health Services (CHS), to apply Medicare payment methodologies to all physician and other health care professional services and non-hospital-based services. Specifically, it will allow the health programs operated by IHS, Tribes, Tribal organizations, and urban Indian organizations (collectively, I/T/U programs) to negotiate or pay non-I/T/U providers based on the applicable Medicare fee schedule, prospective payment system, Medicare Rate, or in the event of a Medicare waiver, the payment amount will be calculated in accordance with such waiver; the amount negotiated by a repricing agent, if applicable; or the provider or supplier's most favored customer (MFC) rate. This final rule will establish payment rates that are consistent across Federal health care programs, align payment with inpatient services, and enable the I/T/U to expand beneficiary access to medical care. A comment period is included, in part, to address Tribal stakeholder concerns about the opportunity for meaningful consultation on the rule's impact on Tribal health programs.

  16. The Affordable Care Act and the Medicare program: the engines of true health reform.

    PubMed

    Kinney, Eleanor D

    2013-01-01

    The Patient Protection and Affordable Care Act and its amendments by the Health Care and Education Reconciliation Act of 2010 constitute landmark legislation known as the Affordable Care Act (ACA). The ACA has made many changes in the Medicare program as part of comprehensive health reform for the U.S. health care sector. Title III of the ACA pertains to improving the efficiency and quality of health care. Title VI calls for greater program integrity for all federally funded health insurance programs. Collectively, the changes in Medicare in these two titles address the three major problems that the Medicare program has faced since its inception: cost and volume inflation, quality assurance, and fraud and abuse. These changes, if successfully implemented, will have a dramatic impact on the reform of the American health care sector. The policy-making process in the Medicare program is exemplary of the process of "muddling through," as described by the Yale economist Charles E. Lindblom. Nevertheless, these changes may also prepare the Medicare program to be transformed, through several incremental changes in upcoming years, into a single payer system.

  17. 76 FR 24343 - Advanced Biofuel Payment Program; Correction

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-02

    ... Service Rural Utilities Service 7 CFR Part 4288 RIN 0570-AA75 Advanced Biofuel Payment Program; Correction... Advanced Biofuel Payment Program authorized under the Food, Conservation, and Energy Act of 2008. This... contracts with advanced biofuel producers to pay such producers for the production of eligible...

  18. 75 FR 76921 - Tobacco Transition Payment Program; Tobacco Transition Assessments

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-10

    ... Corporation 7 CFR Part 1463 RIN 0560-AH30 Tobacco Transition Payment Program; Tobacco Transition Assessments... Commodity Credit Corporation (CCC) is modifying the regulations for the Tobacco Transition Payment Program (TTPP) to clarify, consistent with current practice and as required by the Fair and Equitable...

  19. 75 FR 41397 - Asparagus Revenue Market Loss Assistance Payment Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-16

    ... available funding), an AGI limit of $2.5 million and a $100,000 cap on payments is proposed. This program is... the maximum payment rates. Without the cap, all or most of the funds would go, in terms of substantial... to the $100,000 cap if there is an oversubscription of the program. CCC estimates that if...

  20. Medicare overpayments to private plans, 1985-2012: shifting seniors to private plans has already cost Medicare US$282.6 billion.

    PubMed

    Hellander, Ida; Himmelstein, David U; Woolhandler, Steffie

    2013-01-01

    Previous research has documented Medicare overpayments to the private Medicare Advantage (MA) plans that compete with traditional fee-for-service Medicare. This research has assessed individual categories of overpayment for, at most, a few years. However, no study has calculated the total overpayments to private plans since the program's inception. Prior to 2004, selective enrollment of healthier seniors was the major source of excess payments. We estimate this has added US$41 billion to Medicare's costs since 1985. Medicare adopted a risk-adjustment scheme in 2004, but this has not curbed private plans' ability to game the payment system. This has added US$122.5 billion to Medicare's costs since 2004. Congress mandated increased payment to private plans in the 2003 Medicare Modernization Act, which was mitigated, to a degree, by the subsequent Affordable Care Act. In total, we find that Medicare has overpaid private insurers by US$282.6 billion since 1985. Risk adjustment does not work in for-profit MA plans, which have a financial incentive, the data, and the ingenuity to game whatever system Medicare devises. It is time to end Medicare's costly experiment with privatization. The U.S. needs to adopt a single-payer national health insurance program with effective methods for controlling costs.