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Sample records for medicare program payment

  1. 75 FR 76293 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-08

    ...; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification... Federal Register entitled ``Medicare Program; Home Health Prospective Payment System Rate Update for... Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes...

  2. 75 FR 42885 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-22

    ... System and Consolidated Billing for Skilled Nursing Facilities for FY 2011; Notice #0;#0;Federal Register... Centers for Medicare & Medicaid Services RIN 0938-AP87 Medicare Program; Prospective Payment System and... forth an update to the payment rates used under the prospective payment system for skilled...

  3. 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…

  4. 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...

  5. 76 FR 1366 - Medicare Program; Amendment to Payment Policies Under the Physician Fee Schedule and Other...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-01-10

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 410 RIN 0938-AP79 Medicare Program; Amendment to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Final rule. SUMMARY: This...

  6. 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...

  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, 2013 CFR

    2013-10-01

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

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

    Code of Federal Regulations, 2011 CFR

    2011-10-01

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

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

    Code of Federal Regulations, 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...

  11. 77 FR 67449 - Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-09

    ...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......

  12. 77 FR 34326 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-11

    ... 0938-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident... Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term...

  13. 77 FR 67067 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2013...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-08

    ... 42 CFR Parts 409, 424, 484, et al. Medicare Program; Home Health Prospective Payment System Rate...; Home Health Prospective Payment System Rate Update for Calendar Year 2013, Hospice Quality Reporting... Prospective Payment System (HH PPS) rates, including the national standardized 60-day episode rates,...

  14. 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

    ...-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific...

  15. 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

    ...-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific...

  16. 74 FR 49921 - Medicare Programs; End-Stage Renal Disease Prospective Payment System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2009-09-29

    ... Programs; End-Stage Renal Disease Prospective Payment System; Town Hall Meeting on End-Stage Renal Disease... & Medicaid Services 42 CFR Parts 410, 413 and 414 RIN 0938-AP57 Medicare Programs; End-Stage Renal Disease...) for Medicare outpatient end-stage renal disease (ESRD) dialysis facilities beginning January 1,...

  17. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements. Final rule.

    PubMed

    2016-11-15

    This major final rule addresses changes to the physician fee schedule and other Medicare Part B payment policies, such as changes to the Value Modifier, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. This final rule also includes changes related to the Medicare Shared Savings Program, requirements for Medicare Advantage Provider Networks, and provides for the release of certain pricing data from Medicare Advantage bids and of data from medical loss ratio reports submitted by Medicare health and drug plans. In addition, this final rule expands the Medicare Diabetes Prevention Program model.

  18. 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

    ... Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY... Rehabilitation and Respiratory Care Services; Medicaid Program: Accreditation for Providers of Inpatient... ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

  19. 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.

  20. 76 FR 41178 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-13

    ...This document corrects technical errors that occurred in Tables 2 and 4J, that were referenced in the proposed rule entitled ``Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2012 Rates'' which appeared in the May 5, 2011 Federal...

  1. 75 FR 23105 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System Payment-Update for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-30

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

  2. 77 FR 31620 - Medicare Program; Public Meeting in Calendar Year 2012 for New Clinical Laboratory Tests Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-29

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Public Meeting in Calendar... for Medicare payment under the clinical laboratory fee schedule (CLFS) for calendar year (CY)...

  3. 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

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Calculation of national beneficiary copayment 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...

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

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Calculation of national beneficiary copayment 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...

  5. 75 FR 71799 - Medicare Program: Hospital Outpatient Prospective Payment System and CY 2011 Payment Rates...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-24

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

  6. Medicare physician payments and spending.

    PubMed

    Dummit, Laura A

    2006-10-09

    The Medicare program's physician payment method is intended to control spending while ensuring beneficiary access to physician services, but there are signs that it may not be working. The physician's role in the health care delivery system as the primary source of information and treatment options, together with growing demand for services and the imperfect state of knowledge about appropriate service use, challenge Medicare's ability to achieve these two goals. This issue brief describes the history of physician spending and the contribution of escalating service use and intensity of services to the rise in Medicare outlays, setting the stage for further discussion about the use of the Medicare payment system to control spending and ensure access.

  7. 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

    ... conversion factor, charge compression, revisions to the cost report, pass-through payments, correct coding...--Hospital Insurance Program; and No. 93.774, Medicare-- Supplementary Medical Insurance Program) Dated:...

  8. Large Variations In Medicare Payments For Surgery Highlight Savings Potential From Bundled Payment Programs

    PubMed Central

    Miller, David C.; Gust, Cathryn; Dimick, Justin B.; Birkmeyer, Nancy; Skinner, Jonathan; Birkmeyer, John D.

    2014-01-01

    Payers are considering bundled payments for inpatient surgery, combining provider reimbursements into a single payment for the entire episode. We found that current Medicare episode payments for certain inpatient procedures varied by 49–130 percent across hospitals sorted into five payment groups. Intentional differences in payments attributable to such factors as geography or illness severity explained much of this variation. But after adjustment for these differences, per episode payments to the highest-cost hospitals were higher than those to the lowest-cost facilities by up to $2,549 for colectomy and $7,759 for back surgery. Postdischarge care accounted for a large proportion of the variation in payments, as did discretionary physician services, which may be driven in turn by variations in surgeons’ practice styles. Our study suggests that bundled payments could yield sizable savings for payers, although the effect on individual institutions will vary because hospitals that were relatively expensive for one procedure were often relatively inexpensive for others. More broadly, our data suggest that many hospitals have considerable room to improve their cost efficiency for inpatient surgery and should look for patterns of excess utilization, particularly among surgical specialties, other inpatient specialist consultations, and various types of postdischarge care. PMID:22068403

  9. 76 FR 68011 - Medicare Program; Advanced Payment Model

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    .../seamless-and-coordinated-care-models/advance-payment/ . FOR FURTHER INFORMATION CONTACT: Questions... provide high quality, coordinated care and generate cost savings. The Advance Payment Model will test....innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/advance-payment . II. Provisions...

  10. 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

    ... Advance Payment Model for certain accountable care organizations participating in the Medicare Shared..., coordinated care and generate cost savings. The Advance Payment Model will test whether and how pre-paying a... Application Deadline for the Advance Payment Model AGENCY: Centers for Medicare & Medicaid Services (CMS),...

  11. 75 FR 45769 - Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Ambulatory...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-03

    ... Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System for CY 2010, and Extension of Part B Payment for Services Furnished by Hospitals or Clinics Operated by the Indian Health... Medicare hospital outpatient payment system (OPPS) for CY 2010. This Notice also contains the payment...

  12. 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

    ... factor, charge compression, revisions to the cost report, pass-through payments, correct coding, new... to, the conversion factor, charge compression, revisions to the cost report, pass-through payments...--Hospital Insurance Program; and No. 93.774, Medicare-- Supplementary Medical Insurance Program)...

  13. 75 FR 70371 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-17

    ...This final rule sets forth an update to the Home Health Prospective Payment System (HH PPS) rates, including: the national standardized 60-day episode rates, the national per-visit rates, the nonroutine medical supply (NRS) conversion factors, and the low utilization payment amount (LUPA) add-on payment amounts, under the Medicare prospective payment system for HHAs effective January 1, 2011.......

  14. 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

    ...This proposed rule would update the Home Health Prospective Payment System (HH PPS) rates, including: The national standardized 60- day episode rates, the national per-visit rates, the low utilization payment amount (LUPA), and outlier payments under the Medicare prospective payment system for home health agencies effective January 1,...

  15. 75 FR 43235 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-23

    ...This proposed rule would set forth an update to the Home Health Prospective Payment System (HH PPS) rates, including: The national standardized 60-day episode rates, the national per-visit rates, the non-routine medical supply (NRS) conversion factors, and the low utilization payment amount (LUPA) add-on payment amounts, under the Medicare prospective payment system for HHAs effective January......

  16. 78 FR 74825 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    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......

  17. 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......

  18. 76 FR 74121 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-30

    ...This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) for CY 2012 to implement applicable statutory requirements and changes arising from our continuing experience with this system. 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......

  19. 76 FR 42169 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-18

    ...This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS.......

  20. MACRA, MIPS, and the New Medicare Quality Payment Program: An Update for Radiologists.

    PubMed

    Rosenkrantz, Andrew B; Nicola, Gregory N; Allen, Bibb; Hughes, Danny R; Hirsch, Joshua A

    2017-03-01

    The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 advances the goal of tying Medicare payments to quality and value. In April 2016, CMS published an initial proposed rule for MACRA, renaming it the Quality Payment Program (QPP). Under QPP, clinicians receive payments through either advanced alternative payment models or the Merit-Based Incentive Payment System (MIPS), a consolidation of existing federal performance programs that applies positive or negative adjustments to fee-for-service payments. Most physicians will participate in MIPS. This review highlights implications of the QPP and MIPS for radiologists. Although MIPS incorporates radiology-specific quality measures, radiologists will also be required to participate in other practice improvement activities, including patient engagement. Recognizing physicians' unique practice patterns, MIPS will provide special considerations in performance evaluation for physicians with limited face-to-face patient interaction. Although such considerations will affect radiologists' likelihood of success under QPP, many practitioners will be ineligible for the considerations under currently proposed criteria. Reporting using qualified clinical data registries will benefit radiologists' performance by allowing expanded arrays of MIPS and non-MIPS specialty-specific measures. A group practice reporting option will substantially reduce administrative burden but introduce new challenges by requiring uniform determination of patient-facing status and performance measurement for all of the group's physicians (diagnostic radiologists, interventional radiologists, and nonradiologists) under the same taxpayer identification number. Given that the initial MIPS performance period begins in 2017, radiologists must begin preparing for QPP and taking actions to ensure their future success under this new quality-based payment system.

  1. Medicare Access and CHIP Reauthorization Act: What do Geriatrics Healthcare Professionals Need to Know About the Quality Payment Program?

    PubMed

    Unroe, Kathleen T; Hollmann, Peter A; Goldstein, Alanna C; Malone, Michael L

    2017-03-17

    Commencing in 2017, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will change how Medicare pays health professionals. By enacting MACRA, Congress brought an end to the (un)sustainable growth rate formula while also setting forth a vision for how to transform the U.S. healthcare system so that clinicians deliver higher-quality care with smarter spending by the Centers for Medicare and Medicaid Services (CMS). In October 2016, CMS released the first of what stakeholders anticipate will be a number of (annual) rules related to implementation of MACRA. CMS received extensive input from stakeholders including the American Geriatrics Society. Under the Quality Payment Program, CMS streamlined multiple Medicare value-based payment programs into a new Merit-based Incentive Payment System (MIPS). CMS also outlined how it will provide incentives for participation in Advanced Alternative Payment Models (called APMs). Although Medicare payments to geriatrics health professionals will not be based on the new MIPS formula until 2019, those payments will be based upon performance during a 90-day period in 2017. This article defines geriatrics health professionals as clinicians who care for a predominantly older adult population and who are eligible to bill under the Medicare Physician Fee Schedule. Given the current paucity of eligible APMs, this article will focus on MIPS while providing a brief overview of APMs.

  2. 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 PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under...

  3. 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

  4. 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.

  5. 75 FR 30917 - Medicare Program; Supplemental Proposed Changes to the Hospital Inpatient Prospective Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-02

    ...This proposed rule is a supplement to the fiscal year (FY) 2011 hospital inpatient prospective payment systems (IPPS) and long- term care prospective payment system (LTCH PPS) proposed rule published in the May 4, 2010 Federal Register. This supplemental proposed rule would implement certain statutory provisions relating to Medicare payments to hospitals for inpatient services that are......

  6. 76 FR 26431 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Rate...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-06

    ...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......

  7. 76 FR 4997 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Rate...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-01-27

    ...This proposed rule would update the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs) for discharges occurring during the rate year beginning July 1, 2011 through September 30, 2012. The proposed rule would also change the IPF prospective payment system (PPS) payment rate update period to a rate year (RY) that coincides with......

  8. 78 FR 46733 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-01

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

  9. 77 FR 47223 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-07

    ...This notice updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs). These changes are applicable to IPF discharges occurring during the fiscal year (FY) beginning October 1, 2012 through September 30,...

  10. 75 FR 49029 - Medicare Program; End-Stage Renal Disease Prospective Payment System

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-12

    ...This final rule implements a case-mix adjusted bundled prospective payment system (PPS) for Medicare outpatient end-stage renal disease (ESRD) dialysis facilities beginning January 1, 2011 (ESRD PPS), in compliance with the statutory requirement of the Medicare Improvements for Patients and Providers Act (MIPPA), enacted July 15, 2008. This ESRD PPS also replaces the current basic case-mix......

  11. 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......

  12. 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

    ...This major final rule with comment period addresses changes to the physician fee schedule, clinical laboratory fee schedule, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. This final rule with comment period also includes a discussion in the Supplementary Information regarding......

  13. 78 FR 43281 - Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-19

    ...This major proposed rule addresses changes to the physician fee schedule and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the...

  14. 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...

  15. 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...

  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. 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...

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

    PubMed

    2003-12-05

    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.

  19. 78 FR 48995 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-12

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

  20. 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

    ...This final rule sets forth updates to the home health prospective payment system (HH PPS) rates, including: the national standardized 60-day episode rates; the national per-visit rates; and the low utilization payment amount (LUPA) under the Medicare PPS for home health agencies effective January 1, 2012. This rule applies a 1.4 percent update factor to the episode rates, which reflects a 1......

  1. 76 FR 25787 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-05

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

  2. 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

    ...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 statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010......

  3. 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......

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

    PubMed

    2014-08-06

    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.

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

    PubMed

    2015-06-09

    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.

  6. 78 FR 40271 - Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-03

    ...This proposed rule would 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, the nonroutine medical supplies (NRS) conversion factor, and outlier payments under the Medicare prospective payment system for home health agencies......

  7. Effect of medicare payment on rural health care systems.

    PubMed

    McBride, Timothy D; Mueller, Keith J

    2002-01-01

    Medicare payments constitute a significant share of patient-generated revenues for rural providers, more so than for urban providers. Therefore, Medicare payment policies influence the behavior of rural providers and determine their financial viability. Health services researchers need to contribute to the understanding of the implications of changes in fee-for-service payment policy, prospects for change because of the payment to Medicare+Choice risk plans, and implications for rural providers inherent in any restructuring of the Medicare program. This article outlines the basic policy choices, implications for rural providers and Medicare beneficiaries, impacts of existing research, and suggestions for further research. Topics for further research include implications of the Critical Access Hospital program, understanding how changes in payment to rural hospitals affect patient care, developing improved formulas for paying rural hospitals, determining the payment-to-cost ratio for physicians, measuring the impact of changes in the payment methodology used to pay for services delivered by rural health clinics and federally qualified health centers, accounting for the reasons for differences in historical Medicare expenditures across rural counties and between rural and urban counties, explicating all reasons for Medicare+Choice plans withdrawing from some rural areas and entering others, measuring the rural impact of proposals to add a prescription drug benefit to the Medicare program, and measuring the impact of Medicare payment policies on rural economies.

  8. 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.

  9. 78 FR 61202 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-03

    ... Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2014... for Skilled Nursing Facilities for FY 2014.'' DATES: These corrections are effective October 1,...

  10. 78 FR 54842 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-06

    ... -1 Genitourinary system 159 5 Integumentary system 130 8 Respiratory system 46 7 Cardiovascular... Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing... Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program; Organ...

  11. Medicare program; prospective payment system for hospital outpatient services--HCFA. Proposed rule.

    PubMed

    1998-09-08

    As required by sections 4521, 4522, and 4523 of the Balanced Budget Act of 1997, this proposed rule would eliminate the formula-driven overpayment for certain outpatient hospital services, extend reductions in payment for costs of hospital outpatient services, and establish in regulations a prospective payment system for hospital outpatient services (and for Medicare Part B services furnished to inpatients who have no Part A coverage). The prospective payment system would simplify our current payment system and apply to all hospitals, including those that are excluded from the inpatient prospective payment system. The Balanced Budget Act provides for implementation of the prospective payment system effective January 1, 1999, but delays application of the system to cancer hospitals until January 1, 2000. The hospital outpatient prospective payment system would also apply to partial hospitalization services furnished by community mental health centers. Although the statutory effective date for the outpatient prospective payment system is January 1, 1999, implementation of the new system will have to be delayed because of year 2000 systems concerns. The demands on intermediary bill processing systems and HCFA internal systems to become compliant for the year 2000 preclude making the major systems changes that are required to implement the prospective payment system. The outpatient prospective payment system will be implemented for all hospitals and community mental health centers as soon as possible after January 1, 2000, and a notice of the anticipated implementation date will be published in the Federal Register at least 90 days in advance. This document also proposes new requirements for provider departments and provider-based entities. These proposed changes, as revised based on our consideration of public comments, will be effective 30 days after publication of a final rule. This proposed rule would also implement section 9343(c) of the Omnibus Budget

  12. 78 FR 72255 - Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-02

    ...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......

  13. 75 FR 40039 - Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-13

    ...This proposed rule addresses proposed changes to the physician fee schedule and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. It also addresses, implements or discusses certain provisions of both the Affordable Care Act and the Medicare Improvements for Patients and Providers Act......

  14. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Final rule with comment period.

    PubMed

    2016-11-04

    The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare sustainable growth rate (SGR) methodology for updates to the physician fee schedule (PFS) and replaces it with a new approach to payment called the Quality Payment Program that rewards the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for eligible clinicians or groups under the PFS. This final rule with comment period establishes incentives for participation in certain alternative payment models (APMs) and includes the criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) in making comments and recommendations on physician-focused payment models (PFPMs). Alternative Payment Models are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. This final rule with comment period also establishes the MIPS, a new program for certain Medicare-enrolled practitioners. MIPS will consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), and will continue the focus on quality, cost, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies. In this final rule with comment period we have rebranded key terminology based on feedback from stakeholders, with the goal of selecting terms that will be more easily identified and understood by our stakeholders.

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

    PubMed

    2014-11-06

    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.

  16. Medicare program; hospital outpatient prospective payment system and CY 2007 payment rates; CY 2007 update to the ambulatory surgical center covered procedures list; Medicare administrative contractors; and reporting hospital quality data for FY 2008 inpatient prospective payment system annual payment update program--HCAHPS survey, SCIP, and mortality. Final rule with comment period and final rule.

    PubMed

    2006-11-24

    This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system, and to implement certain related provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 and the Deficit Reduction Act (DRA) of 2005. In this final rule with comment period, we describe 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, 2007. In addition, this final rule with comment period implements future CY 2009 required reporting on quality measures for hospital outpatient services paid under the prospective payment system. This final rule with comment period revises the current list of procedures that are covered when furnished in a Medicare-approved ambulatory surgical center (ASC), which are applicable to services furnished on or after January 1, 2007. This final rule with comment period revises the emergency medical screening requirements for critical access hospitals (CAHs). This final rule with comment period supports implementation of a restructuring of the contracting entities responsibilities and functions that support the adjudication of Medicare fee-for-service (FFS) claims. This restructuring is directed by section 1874A of the Act, as added by section 911 of the MMA. The prior separate Medicare intermediary and Medicare carrier contracting authorities under Title XVIII of the Act have been replaced with the Medicare Administrative Contractor (MAC) authority. This final rule continues to implement the requirements of the DRA that require that we expand the "starter set" of 10 quality measures that we used in FY 2005 and FY 2006 for the hospital inpatient prospective payment system (IPPS) Reporting Hospital Quality Data

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

    PubMed

    2016-08-05

    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).

  18. 77 FR 44721 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-30

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

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

    PubMed

    2011-11-02

    This final rule implements 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 the Medicare Shared Savings Program. Under these provisions, providers of services and suppliers can continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, and be eligible for additional payments if they meet specified quality and savings requirements.

  20. 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

    .... Thirty-Day Hospital Readmissions b. Efficiency c. Population/Community Health 6. Proposed Scoring for the... July 11, 2012 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... Register / Vol. 77, No. 133 / Wednesday, July 11, 2012 / Proposed Rules#0;#0; ] DEPARTMENT OF HEALTH...

  1. 76 FR 42771 - Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-19

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

  2. 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).

  3. 42 CFR 421.304 - Medicare integrity program contractor functions.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... services for which Medicare payment may be made either directly or indirectly. (b) Auditing, settling and.... 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...

  4. 76 FR 24213 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-29

    ...This proposed rule would implement section 3004 of the Affordable Care Act, which establishes a new quality reporting program that provides for a 2 percent reduction in the annual increase factor beginning in 2014 for failure to report quality data to the Secretary of Health and Human Services. This proposed rule would also update the prospective payment rates for inpatient rehabilitation......

  5. 76 FR 47835 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-05

    ...This final rule will implement section 3004 of the Affordable Care Act, which establishes a new quality reporting program that provides for a 2 percent reduction in the annual increase factor beginning in 2014 for failure to report quality data to the Secretary of Health and Human Services. This final rule will also update the prospective payment rates for inpatient rehabilitation facilities......

  6. 77 FR 68891 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-16

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

  7. Medicare program; schedules of limits and prospectively determined payment rates for skilled nursing facility inpatient routine service costs--HCFA. Final notice with comment period.

    PubMed

    1997-10-01

    This final notice with comment period sets forth an updated schedule of limits on skilled nursing facility (SNF) routine service costs for which payment may be made under the Medicare program and sets forth an updated schedule of payment rates for low Medicare volume SNFs that elect to receive prospectively determined payment rates for routine service costs. Section 1888(a) of the Social Security Act (the Act) requires that the Secretary update the per diem cost limits for SNF routine service costs for cost reporting periods beginning on or after October 1, 1995, and every 2 years thereafter. In addition, section 1888(d)(4) of the Act requires the Secretary to establish and publish prospectively determined payment rates at least 90 days prior to the beginning of the Federal fiscal year (FY) to which such rates are to be applied.

  8. 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);…

  9. 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

    ... 10314 of the Affordable Care Act expanded the definition of low-volume hospital and modified the methodology for determining the payment adjustment for hospitals meeting that definition. Specifically, the... Act expanded the definition of low- volume hospital and modified the methodology for determining...

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

    PubMed

    2015-08-06

    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. 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

  12. 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.

  13. 78 FR 73547 - Medicare Program; Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment (HOP...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-06

    ... Advisory Panel on Hospital Outpatient Payment (HOP Panel) March 10-11, 2014 AGENCY: Centers for Medicare...: Monday, March 10, 2014, 1 p.m. to 5 p.m. EST Tuesday, March 11, 2014, 9 a.m. to 5 p.m. EST Meeting... for the March 2014 meeting will provide for discussion and comment on the following topics...

  14. 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 Payments for Care Improvement Deadline: Interested organizations must submit a Model 1 Open Period... regarding Model 1 of the Bundled Payments for Care Improvement initiative. For additional information...

  15. 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

    ... Opportunity for Participation in the Advance Payment Model for Accountable Care Organizations (ACOs) AGENCY... opportunity for participation in the Advance Payment Model for certain accountable care organizations..., coordinated care and generate cost savings. The Advance Payment Model will test whether and how prepaying...

  16. 76 FR 59265 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-26

    ...; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2012; Correction... Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2012'' that appeared in the... Nursing Facility (SNF) Prospective Payment System (PPS) final rule (76 FR 48486, 48540)...

  17. 75 FR 31118 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-02

    ...This notice contains the final wage indices, hospital reclassifications, payment rates, impacts, and other related tables effective for the fiscal year (FY) 2010 hospital inpatient prospective payment systems (IPPS) and rate year 2010 long-term care hospital (LTCH) prospective payment system (PPS). The rates, tables, and impacts included in this notice reflect changes required by or resulting......

  18. 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

    ... radiology payment methodology. This notice updates the CY 2010 OPPS/ASC final rule to include these... payment for office-based procedures and covered ancillary radiology services to the lesser of the ASC rate... ASC payment amounts for office-based procedures and covered ancillary radiology services...

  19. 77 FR 63751 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-17

    ...; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory...

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

    PubMed

    2013-08-06

    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.

  1. 77 FR 68209 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-15

    ... making to improve the regulations reflect CMS' commitment to the principles of the President's Executive... services within an Ambulatory Payment Classification (APC) group, the unit of payment. To improve our cost... designed to improve the regulations. The technical changes to the QIO regulations that we are making...

  2. 78 FR 47935 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-06

    ...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......

  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

    ...This proposed rule would update the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2014, would revise and rebase the SNF market basket, and would make certain technical and conforming revisions in the regulations text. This proposed rule also includes a proposed policy for reporting the SNF market basket forecast error......

  4. Medicare payment system for hospital inpatients: diagnosis-related groups.

    PubMed

    Baker, Judith J

    2002-01-01

    Diagnosis-Related Groups (DRGs) are categories of patient conditions that demonstrate similar levels of hospital resources required to treat the conditions. Each inpatient that is discharged from an acute care hospital can be classified into one of the 506 DRGs currently utilized by the Medicare program. The Medicare DRG prospective payment methodology has been in use for almost two decades and is used by hospital managers for planning and decisionmaking. The viability of DRGs for future prospective payment depends on the ability to keep up with the times through updates of the current methodology.

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

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... prospective payment system (PPS) will be based on that PPS. For example, payment for inpatient hospital services shall be made per discharge based on the applicable PPS used by the Medicare program to pay for... based on a PPS used in the Medicare program to pay for similar hospital services under 42 CFR part...

  6. 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

    ...). A QMB is an individual entitled to Medicare Part A with income at or below 100 percent of the... income is above 100 percent of the FPL and does not exceed 120 percent of the FPL. Effective January 1, 2010, the resource limits for a QMB, SLMB, and QI are $6,600 for a single person and $9,910 for...

  7. 76 FR 48485 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-08

    ...-148, the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152, enacted on March 30... August 8, 2011 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services..., 2011 / Rules and Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for...

  8. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2010. Final rule.

    PubMed

    2009-08-07

    This final rule updates the payment rates for inpatient rehabilitation facilities (IRFs) for Federal fiscal year (FY) 2010 (for discharges occurring on or after October 1, 2009 and on or before September 30, 2010) as required under section 1886(j)(3)(C) of the Social Security Act (the Act). Section 1886(j)(5) of the Act requires the Secretary to publish in the Federal Register on or before the August 1 that precedes the start of each fiscal year, the classification and weighting factors for the IRF prospective payment system's (PPS) case-mix groups and a description of the methodology and data used in computing the prospective payment rates for that fiscal year. We are revising existing policies regarding the IRF PPS within the authority granted under section 1886(j) of the Act.

  9. 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

    2015-11-05

    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.

  10. 77 FR 32407 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-01

    ... Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for...; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year...), the final rule with comment period entitled ``Medicare Program; Changes to the Medicare Advantage...

  11. 78 FR 26879 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-08

    ...This proposed rule would update 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. We are also proposing to revise the list of diagnosis codes that are used to determine presumptive compliance under the ``60 percent......

  12. 76 FR 32085 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Rate...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-03

    ... the diagnosis code ``V451'' rather than ``V4512'' for the description of comorbidity for chronic renal... renal failure. These changes are not substantive changes to the policies or payment methodologies in the... renal failure, chronic diagnoses codes, replace code ``V451'' with ``V4512'' and add code ``V4511.''...

  13. 78 FR 47859 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-06

    ...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......

  14. 76 FR 70227 - Medicare Program; End-Stage Renal Disease Prospective Payment System and Quality Incentive...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-10

    ... Advisors IGI IHS Global Insight IPPS Inpatient Prospective Payment System KDIGO Kidney Disease: Improving Global Outcomes KDOQI Kidney Disease Outcome Quality Initiative Kt/V A measure of dialysis adequacy where... basket update based on IHS Global Insight (IGI), Inc.'s forecast using the most recently available...

  15. 75 FR 55801 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-14

    ... Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2011; Correction AGENCY... for Skilled Nursing Facilities for FY 2011.'' DATES: Effective Date: This correction is effective... 42911 of the July 22, 2010 notice with comment period. These two tables illustrate the skilled...

  16. 75 FR 42835 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-22

    ... factors for the IRF prospective payment system's (PPS) case-mix groups and a description of the.... Update to the Case-Mix Group (CMG) Relative Weights and Average Length of Stay Values for FY 2011 IV... Case-Mix Group DRG Diagnostic Related Group DSH Disproportionate Share Hospital FI Fiscal...

  17. 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

    ... Adjustment Authorized by Section 7(b)(1)(B) of Public Law 110-90 7. Background on the Application of the... Hospital-Specific Rates for FY 2011 and Subsequent Fiscal Years 9. Application of the Documentation and... (AutoLITT\\TM\\) 4. FY 2013 Applications for New Technology Add-On Payments a. Glucarpidase (Trade...

  18. 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

    ... Inpatient Prospective Payment Systems for Acute Care Hospitals and Fiscal Year 2011 Final Wage Indices...), HHS. ACTION: Notice. SUMMARY: This notice contains the final fiscal year (FY) 2011 wage indices and... the expiration date for certain geographic reclassifications and special exception wage...

  19. 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

    ... Payment System (HH PPS) rates, including: The national standardized 60-day episode rates, the national per...'' (hereinafter referred to as the CY 2011 HH PPS final rule), there was a technical error that is identified and... 2011 HH PPS final rule, we made a technical error in the regulation text of Sec. 424.22(b)(1)....

  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

    ... Ambulatory Payment Classification (APC) Group Policies A. Proposed OPPS Treatment of New CPT and Level II HCPCS Codes 1. Proposed Treatment of New Level II HCPCS Codes and Category I CPT Vaccine Codes and.... Proposed Treatment of New Codes 1. Proposed Process for Recognizing New Category I and III CPT Codes...

  1. 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

    ... following: http://www.cms.hhs.gov/FACA/05_AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp#TopOfPage... David Halsey, M.D. Judith T. Kelly, B.S.H.A., RHIT, RHIA, CCS Michael D. Mills, Ph.D.* Agatha L. Nolen..., CPHIMS, CCS, CCS-P, CHC Gregory J. Przbylski, M.D. Russ Ranallo, M.S., B.S.* Michael A. Ross, M.D.,...

  2. 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

  3. The Medicare Prospective Payment System: Intent and Future Direction

    PubMed Central

    Dobson, Allen

    1984-01-01

    Increases in health care expenditures, especially for hospital care, have been a persistent and growing problem for the Medicare program and the Nation for nearly two decades. Recognizing its potential as a pragmatic yet immediate solution to spiralling costs, Congress recently enacted the Prospective Payment System (PPS) for most inpatient hospital services covered by Medicare. The PPS legislation represents a fundamental change in the way hospitals are paid for care delivered to Medicare beneficiaries. Hospitals can be expected to respond to behavioral incentives created by the new payment approach with both immediate and long-term adjustments. Changes in the ways hospitals will manage themselves and conduct their business — present and future — are examined, and some initial data trends are presented. Significant future policy issues related to the PPS and the health care delivery system are lastly discussed.

  4. The cost of privatization: extra payments to Medicare Advantage plans.

    PubMed

    Biles, Brian; Nicholas, Lauren Hersch; Cooper, Barbara S

    2004-05-01

    The recently enacted Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) includes a broad set of provisions intended to enlarge the role of private health plans (called Medicare Advantage plans) in Medicare. This issue brief examines the payments that private plans are receiving in 2004 relative to costs in traditional fee-for-service Medicare, using data from the 2004 Medicare Advantage Rate Calculation Data spreadsheet. The authors find that, for 2004, Medicare Advantage payments will average 8.4 percent more than costs in traditional fee-for-service Medicare: $552 for each of the 5 million Medicare enrollees in managed care, for a total of more than $2.75 billion. In some counties, extra payments by Medicare are more than double this amount. Although the stated objective of efforts to increase enrollment in private plans is to lower costs, the policies of MMA regarding private plans explicitly increase Medicare costs in 2004 and through 2013.

  5. 42 CFR 413.82 - Direct GME payments: Special rules for States that formerly had a waiver from Medicare...

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Direct GME payments: Special rules for States that... FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES... Direct GME payments: Special rules for States that formerly had a waiver from Medicare...

  6. 76 FR 40497 - Medicare Program; Changes to the End-Stage Renal Disease Prospective Payment System for CY 2012...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-08

    ...This proposed rule would update and make certain revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2012. This proposed rule would also set forth proposed requirements for the ESRD quality incentive program (QIP) for payment years (PYs) 2013 and 2014. In addition, this proposed rule would revise the ambulance fee schedule regulations to......

  7. 75 FR 32858 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-10

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

  8. Medicare program; inpatient psychiatric facilities prospective payment system--update for fiscal year beginning October 1, 2014 (FY 2015). Final rule.

    PubMed

    2014-08-06

    This final rule will update the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs). These changes will be applicable to IPF discharges occurring during the fiscal year (FY) beginning October 1, 2014 through September 30, 2015. This final rule will also address implementation of ICD-10-CM and ICD-10-PCS codes; finalize a new methodology for updating the cost of living adjustment (COLA), and finalize new quality measures and reporting requirements under the IPF quality reporting program.

  9. Medicare Telehealth Services and Nephrology: Policies for Eligibility and Payment.

    PubMed

    Frilling, Stephanie

    2017-01-01

    The criteria for Medicare payment of telehealth nephrology services, and all other Medicare telehealth services, are set forth in section 1834(m) of the Social Security Act. There are just over 80 professional physician or practitioner services that may be furnished via telehealth and paid under Medicare Part B, when an interactive audio and video telecommunication system that permits real-time communication between a beneficiary at the originating site and the physician or practitioner at the distant site substitutes for an in-person encounter. These services include 16 nephrology billing codes for furnishing ESRD services for monthly monitoring and assessment and two billing codes for chronic kidney disease education. In recent years, many mobile health devices and other web-based tools have been developed in support of monitoring, observation, and collaboration for people living with chronic disease. This article reviews the statutory and program guidance that governs Medicare telehealth services, defines payment policy terms (e.g., originating site and distant site), and explains payment policies when telehealth services are furnished.

  10. 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

  11. 77 FR 217 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-04

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

  12. 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

  13. Medicare physician payments: impacts of changes on rural physicians.

    PubMed

    Mueller, Keith J; MacKinney, A Clinton; McBride, Timothy D

    2006-09-01

    Medicare payment disproportionately impacts rural physicians compared to urban. For example, 51% of rural physicians, compared to 44% of urban physicians, receive at least 38% of their payments from Medicare.1 Thus, the Medicare physician payment system is of significant rural interest. In this policy brief, we present the effects of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 on physician payment rates in rural areas. Specifically, we examine the impact of creating a floor of 1.00 in the geographic practice cost index (GPCI) for work expense. We also show the effects of the Medicare incentive payment (MIP) for providing services in shortage areas and of the bonus for practicing in a physician scarcity area. Our principal findings are the following: (1) Increases to the GPCI for work expense accounted for a substantial percentage of the two-year increases in total payment to physicians in rural payment areas. (2) Increases in the conversion factor (CF) (base payment) accounted for most of the increases in total payment in all but 6 of the 89 Medicare payment localities; in those 6 areas, the dominant factor was GPCI adjustment. (3) Bonus payments are a more direct means of targeting increased payments to physicians in specific areas than is a general increase in one part of the payment formula.

  14. 78 FR 43820 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-22

    ... Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug...; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug Benefit...-referencing errors in the Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and...

  15. Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Procurement Organization Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; Electronic Health Record (EHR) Incentive Programs; Payment to Nonexcepted Off-Campus Provider-Based Department of a Hospital; Hospital Value-Based Purchasing (VBP) Program; Establishment of Payment Rates Under the Medicare Physician Fee Schedule for Nonexcepted Items and Services Furnished by an Off-Campus Provider-Based Department of a Hospital. Final rule with comment period and interim final rule with comment period.

    PubMed

    2016-11-14

    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 2017 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, in this final rule with comment period, we are making changes to tolerance thresholds for clinical outcomes for solid organ transplant programs; to Organ Procurement Organizations (OPOs) definitions, outcome measures, and organ transport documentation; and to the Medicare and Medicaid Electronic Health Record Incentive Programs. We also are removing the HCAHPS Pain Management dimension from the Hospital Value-Based Purchasing (VBP) Program. In addition, we are implementing section 603 of the Bipartisan Budget Act of 2015 relating to payment for certain items and services furnished by certain off-campus provider-based departments of a provider. In this document, we also are issuing an interim final rule with comment period to establish the Medicare Physician Fee Schedule payment rates for the nonexcepted items and services billed by a nonexcepted off-campus provider-based department of a hospital in accordance with the provisions of section 603.

  16. 42 CFR 411.37 - Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement. 411.37 Section 411.37 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE...

  17. 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

    ... 42 CFR Parts 422 and 423 Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage... Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug Benefit Programs... proposed rule would implement medical loss ratio (MLR) requirements for the Medicare Advantage Program...

  18. 77 FR 1877 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-12

    ...; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing and Remaining Revisions..., governing what was renamed the Medicare Advantage (MA) program (formerly Medicare+Choice). The MMA...

  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

    ... Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit... Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2012 and Other... the Office of the Federal Register base the comment period closing date on the date the proposed...

  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, 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...

  3. 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...

  4. 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...

  5. Medicare Payment: Surgical Dressings and Topical Wound Care Products.

    PubMed

    Schaum, Kathleen D

    2014-08-01

    Medicare patients' access to surgical dressings and topical wound care products is greatly influenced by the Medicare payment system that exists in each site of care. Qualified healthcare professionals should consider these payment systems, as well as the medical necessity for surgical dressings and topical wound care products. Scientists and manufacturers should also consider these payment systems, in addition to the Food and Drug Administration requirements for clearance or approval, when they are developing new surgical dressings and topical wound care products. Due to the importance of the Medicare payment systems, this article reviews the Medicare payment systems in acute care hospitals, long-term acute care hospitals, skilled nursing facilities, home health agencies, durable medical equipment suppliers, hospital-based outpatient wound care departments, and qualified healthcare professional offices.

  6. Medicare Payment: Surgical Dressings and Topical Wound Care Products

    PubMed Central

    Schaum, Kathleen D.

    2014-01-01

    Medicare patients' access to surgical dressings and topical wound care products is greatly influenced by the Medicare payment system that exists in each site of care. Qualified healthcare professionals should consider these payment systems, as well as the medical necessity for surgical dressings and topical wound care products. Scientists and manufacturers should also consider these payment systems, in addition to the Food and Drug Administration requirements for clearance or approval, when they are developing new surgical dressings and topical wound care products. Due to the importance of the Medicare payment systems, this article reviews the Medicare payment systems in acute care hospitals, long-term acute care hospitals, skilled nursing facilities, home health agencies, durable medical equipment suppliers, hospital-based outpatient wound care departments, and qualified healthcare professional offices. PMID:25126477

  7. Medicare Program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system changes and FY2011 rates; provider agreements and supplier approvals; and hospital conditions of participation for rehabilitation and respiratory care services; Medicaid program: accreditation for providers of inpatient psychiatric services. Final rules and interim final rule with comment period.

    PubMed

    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 the rates for Medicare acute care hospital inpatient services for operating costs and capital-related costs. We also are setting forth the update 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. We are updating the payment policy and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and setting forth the changes to the payment rates, factors, and other payment rate policies under the LTCH PPS. In addition, we are finalizing the provisions of the August 27, 2009 interim final rule that implemented statutory provisions relating to payments to LTCHs and LTCH satellite facilities and increases in beds in existing LTCHs and LTCH satellite facilities under the LTCH PPS. We are making changes affecting the: Medicare conditions of participation for hospitals relating to the types of practitioners who may provide rehabilitation services and respiratory care services; and determination of the effective date of provider agreements and supplier approvals under Medicare. We are also setting forth provisions that offer psychiatric hospitals and hospitals with inpatient psychiatric programs increased flexibility in obtaining accreditation to participate in the Medicaid program. Psychiatric hospitals and hospitals with inpatient psychiatric programs will have the choice of undergoing a State survey or of obtaining accreditation from a national accrediting organization whose hospital accreditation

  8. 75 FR 41503 - Medicare and Medicaid Programs; Approval of the Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-16

    ... services, and the conditions for Medicare payment for hospice care. Provider agreement regulations are... Community Health Accreditation Program for Continued Deeming Authority for Hospices AGENCY: Centers for... the Community Health Accreditation Program (CHAP) hospice accreditation program meet or exceed...

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-18

    ... Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B... Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program) Dated: March 13, 2013..., Utilization and Quality Control Peer Review, private health insurance, and related matters. They are...

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

    PubMed

    Biles, Brian; Pozen, Jonah; Guterman, Stuart

    2009-05-01

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

  11. Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System--Update for Fiscal Year Beginning October 1, 2015 (FY 2016). Final rule.

    PubMed

    2015-08-05

    This final rule updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs) (which are freestanding IPFs and psychiatric units of an acute care hospital or critical access hospital). These changes are applicable to IPF discharges occurring during fiscal year (FY) 2016 (October 1, 2015 through September 30, 2016). This final rule also implements: a new 2012-based IPF market basket; an updated IPF labor-related share; a transition to new Core Based Statistical Area (CBSA) designations in the FY 2016 IPF Prospective Payment System (PPS) wage index; a phase-out of the rural adjustment for IPF providers whose status changes from rural to urban as a result of the wage index CBSA changes; and new quality measures and reporting requirements under the IPF quality reporting program. This final rule also reminds IPFs of the October 1, 2015 implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), and updates providers on the status of IPF PPS refinements.

  12. Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and Alternative Payment Models in dermatology.

    PubMed

    Barbieri, John S; Miller, Jeffrey J; Nguyen, Harrison P; Forman, Howard P; Bolognia, Jean L; VanBeek, Marta J

    2017-03-30

    With the introduction of the Medicare Access and Children's Health Insurance Program Reauthorization Act, clinicians who are not eligible for an exemption must choose to participate in 1 of 2 new reimbursement models: the Merit-based Incentive Payment System or Alternative Payment Models (APMs). Although most dermatologists are expected to default into the Merit-based Incentive Payment System, some may have an interest in exploring APMs, which have associated financial incentives. However, for dermatologists interested in the APM pathway, there are currently no options other than joining a qualifying Accountable Care Organization, which make up only a small subset of Accountable Care Organizations overall. As a result, additional APMs relevant to dermatologists are needed to allow those interested in the APMs to explore this pathway. Fortunately, the Medicare Access and Children's Health Insurance Program Reauthorization Act establishes a process for new APMs to be approved and the creation of bundled payments for skin diseases may represent an opportunity to increase the number of APMs available to dermatologists. In this article, we will provide a detailed review of APMs under the Medicare Access and Children's Health Insurance Program Reauthorization Act and discuss the development and introduction of APMs as they pertain to dermatology.

  13. 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

  14. 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

  15. Medicare program: request for public comments on implementation of risk adjusted payment for the Medicare+Choice program and announcement of public meeting--HCFA. Solicitation of comments; announcement of meeting.

    PubMed

    1998-09-08

    This notice solicits further public comments on issues related to the implementation of risk adjusted payment of Medicare+Choice organizations. Section 1853(a)(3) of the Social Security Act (the Act) requires the Secretary to implement a risk adjustment methodology that accounts for variation in per capita costs based on health status and demographic factors for payments no later than January 1, 2000. The methodology is to apply uniformly to all Medicare+Choice plans. This notice outlines our proposed approach to implementing risk adjusted payment. In order to carry out risk adjustment, section 1853(a)(3) of the Act also requires Medicare+Choice organizations, as well as other organizations with risk sharing contracts, to submit encounter data. Inpatient hospital data are required for discharges on or after July 1, 1997. Other data, as the Secretary deems necessary, may be required beginning July 1998. The Medicare+Choice interim final rule published on June 26, 1998 (63 FR 34968) describes the general process for the collection of encounter data. We also included a schedule for the collection of additional encounter data. Physician, outpatient hospital, skilled nursing facility, and home health data will be collected no earlier than October 1, 1999, and all other data we deem necessary no earlier than October 1, 2000. Given any start date, comprehensive risk adjustment will be made about three years after the year of initial collection of outpatient hospital and physician encounter data. Comments on the process for encounter data collection are requested in that interim final rule. We intend to consider comments received in response to this solicitation as we develop the final methodology for implementation of risk adjustment. This notice also informs the public of a meeting on September 17, 1998, to discuss risk adjustment and the collection of encounter data. The meeting will be held at the Health Care Financing Administration headquarters, located at 7500

  16. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2013 rates; hospitals' resident caps for graduate medical education payment purposes; quality reporting requirements for specific providers and for ambulatory surgical centers. final rule.

    PubMed

    2012-08-31

    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, 2012, 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, 2012. 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) and implementing certain statutory changes made by the Affordable Care Act. Generally, these changes will be applicable to discharges occurring on or after October 1, 2012, unless otherwise specified in this final rule. In addition, we are implementing changes relating to determining a hospital's full-time equivalent (FTE) resident cap for the purpose of graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or 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 also are establishing new administrative, data completeness, and extraordinary circumstance waivers or extension requests requirements, as well as a reconsideration process, for quality reporting by ambulatory surgical centers

  17. 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

    ...: Changes to the End-Stage Renal Disease Prospective Payment System Transition Budget-Neutrality Adjustment...) transition budget-neutrality adjustment finalized in the CY 2011 ESRD Prospective Payment System (PPS) final... the transition budget-neutrality adjustment to reflect the actual election decision to receive...

  18. 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

    ...This notice announces the name change of the Advisory Panel on Ambulatory Payment Classification Groups to the Advisory Panel on Hospital Outpatient Payment (HOP) (the Panel). In addition, it announces the renewal and amendments to the charter including changing the scope of the Panel to include supervision of outpatient hospital services, changing the Panel membership to include Critical......

  19. 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

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 410, 414, 415, and 495 RIN 0938... general questions about memory should be included in the HRA.'' is corrected to read ``One commenter... the HRA. However, the commenter believed that general questions about memory should be included in...

  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. Reform of the Medicare program.

    PubMed

    Rubin, R N

    1988-01-01

    Financing of the Medicare program is under stress because of national economic and demographic trends. A comprehensive overview of the required changes is imperative. The American Medical Association has proposed to place Medicare funding out of the political arena and to place it under the administration of an independent commission such as the Federal Reserve Board. Further, the plan would initiate a voucher system financed by a tax on adjusted gross income during the working years invested through a new public trust fund.

  2. Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System.

    PubMed

    Barbieri, John S; Miller, Jeffrey J; Nguyen, Harrison P; Forman, Howard P; Bolognia, Jean L; VanBeek, Marta J

    2017-03-30

    As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists.

  3. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

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

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

    Code of Federal Regulations, 2011 CFR

    2011-10-01

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

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

    Code of Federal Regulations, 2013 CFR

    2013-10-01

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

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

    Code of Federal Regulations, 2014 CFR

    2014-10-01

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

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

    Code of Federal Regulations, 2010 CFR

    2010-10-01

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

  8. 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

    ... Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs; Final Rule... Parts 417, 422, 423, and 480 [CMS-4085-F] RIN 0938-AP77 Medicare Program; Policy and Technical Changes.... Provisions of the Proposed Rule and Analysis and Responses to Public Comments A. Changes to Strengthen...

  9. 78 FR 48233 - Medicare Program; FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-07

    ... to the public on hospice payment reform. Additionally, this final rule changes the requirements for... Regulatory Text Change IV. Analysis and Responses to Public Comments A. Diagnosis Reporting on Hospice Claims... Clarifying Regulatory Text Change V. Collection of Information Requirements VI. Regulatory Impact Analysis...

  10. 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

    ... deal with the following issues: Addressing whether procedures within an APC group are similar both... 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...

  11. 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.)

  12. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ..., whether provided as inpatient, outpatient, skilled nursing facility care, as other services of a.... Payment for skilled nursing facility (SNF) services shall be based on a PPS used in the Medicare program... hemophiliac; and the costs of qualified non-physician anesthetists, to the extent such costs would be...

  13. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ..., whether provided as inpatient, outpatient, skilled nursing facility care, as other services of a.... Payment for skilled nursing facility (SNF) services shall be based on a PPS used in the Medicare program... hemophiliac; and the costs of qualified non-physician anesthetists, to the extent such costs would be...

  14. 42 CFR 136.30 - Payment to Medicare-participating hospitals for authorized Contract Health Services.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ..., whether provided as inpatient, outpatient, skilled nursing facility care, as other services of a.... Payment for skilled nursing facility (SNF) services shall be based on a PPS used in the Medicare program... hemophiliac; and the costs of qualified non-physician anesthetists, to the extent such costs would be...

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

    PubMed

    2013-12-02

    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.

  16. Medicare program; revisions to payment policies under the physician fee schedule, and other Part B payment policies for CY 2008; revisions to the payment policies of ambulance services under the ambulance fee schedule for CY 2008; and the amendment of the e-prescribing exemption for computer generated facsimile transmissions. Final rule with comment period.

    PubMed

    2007-11-27

    This final rule with comment period addresses certain provisions of the Tax Relief and Health Care Act of 2006, as well as making other proposed changes to Medicare Part B payment policy. 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 with comment period also discusses refinements to resource-based practice expense (PE) relative value units (RVUs); geographic practice cost indices (GPCI) changes; malpractice RVUs; requests for additions to the list of telehealth services; several coding issues including additional codes from the 5-Year Review; payment for covered outpatient drugs and biologicals; the competitive acquisition program (CAP); clinical lab fee schedule issues; payment for renal dialysis services; performance standards for independent diagnostic testing facilities; expiration of the physician scarcity area (PSA) bonus payment; conforming and clarifying changes for comprehensive outpatient rehabilitation facilities (CORFs); a process for updating the drug compendia; physician self referral issues; beneficiary signature for ambulance transport services; durable medical equipment (DME) update; the chiropractic services demonstration; a Medicare economic index (MEI) data change; technical corrections; standards and requirements related to therapy services under Medicare Parts A and B; revisions to the ambulance fee schedule; the ambulance inflation factor for CY 2008; and amending the e-prescribing exemption for computer-generated facsimile transmissions. We are also finalizing the calendar year (CY) 2007 interim RVUs and are issuing interim RVUs for new and revised procedure codes for CY 2008. As required by the statute, we are announcing that the physician fee schedule update for CY 2008 is -10.1 percent, the initial estimate for the sustainable growth rate for CY 2008 is -0.1 percent, and the conversion factor (CF) for CY 2008 is $34.0682.

  17. Medicare program; prospective payment system for long-term care hospitals RY 2009: annual payment rate updates, policy changes, and clarifications; and electronic submission of cost reports: revision to effective date of cost reporting period. Final rule.

    PubMed

    2008-05-09

    This final rule updates the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). We are also consolidating the annual July 1 update for payment rates and the October 1 update for Medicare severity long-term care diagnosis-related group (MS-LTC-DRG) weights to a single rulemaking cycle that coincides with the Federal fiscal year (FFY). In addition, we are clarifying various policy issues. This final rule also finalizes the provisions from the Electronic Submission of Cost Reports: Revision to Effective Date of Cost Reporting Period interim final rule with comment period that was published in the May 27, 2005 Federal Register which revises the existing effective date by which all organ procurement organizations (OPOs), rural health clinics (RHCs), Federally qualified health centers (FQHCs), and community mental health centers (CMHCs) are required to submit their Medicare cost reports in a standardized electronic format from cost reporting periods ending on or after December 31, 2004 to cost reporting periods ending on or after March 31, 2005. This final rule does not affect the current cost reporting requirement for hospices and end-stage renal disease (ESRD) facilities. Hospices and ESRD facilities are required to continue to submit cost reports under the Medicare regulations in a standardized electronic format for cost reporting periods ending on or after December 31, 2004.

  18. 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...

  19. 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...

  20. 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)...

  1. 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...

  2. 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

    2011-02-02

    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.

  3. 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.

  4. 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 ...

  5. 42 CFR 422.520 - Prompt payment by MA organization.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

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

  6. 42 CFR 422.520 - Prompt payment by MA organization.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

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

  7. 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

    ... plan shall reimburse the appropriate Medicare Trust Fund for Medicare's payments for items and services... to such items and services. The responsibility for payment on the part of workers' compensation... right under MSP of an individual or any other entity to payment for items or services under a...

  8. Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures. Final rule.

    PubMed

    2017-01-17

    This final rule revises the procedures that the Department of Health and Human Services (HHS) follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, this final rule revises procedures that the Department of Health and Human Services follows at the Centers for Medicare & Medicaid Services (CMS) and the Medicare Appeals Council (Council) levels of appeal for certain matters affecting the ALJ level.

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

    PubMed Central

    Cotterill, Philip G.

    1992-01-01

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

  10. Medicare and Medicaid Programs; CY 2017 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

    PubMed

    2016-11-03

    This final rule updates the Home Health Prospective Payment System (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor; effective for home health episodes of care ending on or after January 1, 2017. This rule also: Implements the last year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates; updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the 2nd-year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between CY 2012 and CY 2014; finalizes changes to the methodology used to calculate payments made under the HH PPS for high-cost "outlier" episodes of care; implements changes in payment for furnishing Negative Pressure Wound Therapy (NPWT) using a disposable device for patients under a home health plan of care; discusses our efforts to monitor the potential impacts of the rebasing adjustments; includes an update on subsequent research and analysis as a result of the findings from the home health study; and finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model, which was implemented on January 1, 2016; and updates to the Home Health Quality Reporting Program (HH QRP).

  11. 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

  12. 76 FR 54599 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-01

    ... 42 CFR Parts 417, 422, and 423 Medicare Program; Medicare Advantage and Prescription Drug Benefit... Prescription Drug Benefit Programs AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Final... (MA) program (Part C), prescription drug benefit program (Part D) and section 1876 cost...

  13. 77 FR 31362 - Medicare and Medicaid Programs; Application From the Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-25

    ... program, the scope of covered services, and the conditions for Medicare payment for hospice care... the Community Health Accreditation Program for Continued Approval of Its Hospice Accreditation Program... Accreditation Program (CHAP) for continued recognition as a national accrediting organization for hospices...

  14. 75 FR 29555 - Medicare Program; Medicare Coverage Gap Discount Program Model Manufacturer Agreement and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-05-26

    ... Services [CMS-4151-NC] RIN 0938-AQ04 Medicare Program; Medicare Coverage Gap Discount Program Model... contains a draft model agreement for use by the Secretary and manufacturers under the Medicare Coverage Gap Discount Program established by section 3301 of the Patient Protection and Affordable Care Act, as...

  15. 5 CFR 890.906 - Retired enrolled individuals coinsurance payments.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... equivalent to the Medicare part B payment under the Medicare Participating Physician Fee Schedule for Medicare participating physicians and the Medicare Nonparticipating Physician Fee Schedule for Medicare... SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM Limit on Inpatient...

  16. 5 CFR 890.906 - Retired enrolled individuals coinsurance payments.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... equivalent to the Medicare part B payment under the Medicare Participating Physician Fee Schedule for Medicare participating physicians and the Medicare Nonparticipating Physician Fee Schedule for Medicare... SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM Limit on Inpatient...

  17. 5 CFR 890.906 - Retired enrolled individuals coinsurance payments.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... equivalent to the Medicare part B payment under the Medicare Participating Physician Fee Schedule for Medicare participating physicians and the Medicare Nonparticipating Physician Fee Schedule for Medicare... SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM Limit on Inpatient...

  18. 5 CFR 890.906 - Retired enrolled individuals coinsurance payments.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... equivalent to the Medicare part B payment under the Medicare Participating Physician Fee Schedule for Medicare participating physicians and the Medicare Nonparticipating Physician Fee Schedule for Medicare... SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM Limit on Inpatient...

  19. 5 CFR 890.906 - Retired enrolled individuals coinsurance payments.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... equivalent to the Medicare part B payment under the Medicare Participating Physician Fee Schedule for Medicare participating physicians and the Medicare Nonparticipating Physician Fee Schedule for Medicare... SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM Limit on Inpatient...

  20. 77 FR 23722 - Medicare Program; Extension of Certain Wage Index Reclassifications and Special Exceptions for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-20

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Extension of Certain Wage... Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces changes to wage indices and hospital... exception wage indices through March 31, 2012 for the hospital inpatient prospective payment systems...

  1. 75 FR 31788 - Appointments to the Medicare Payment Advisory Commission (MedPAC)

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-04

    ... OFFICE Appointments to the Medicare Payment Advisory Commission (MedPAC) AGENCY: Government... the 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...

  2. 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.

  3. The cost of privatization: extra payments to Medicare Advantage plans--updated and revised.

    PubMed

    Biles, Brian; Hersch Nicholas, Lauren; Cooper, Barbara S; Adrion, Emily; Guterman, Stuart

    2006-11-01

    The Medicare Modernization Act of 2003 sharply increased payments to private Medicare Advantage plans. As a result, every plan in every county in the nation was paid more in 2005 than its enrollees would have been expected to cost if they had been enrolled in traditional fee-for-service Medicare. The authors calculate that payments to Medicare Advantage plans averaged 12.4 percent more than costs in traditional Medicare during 2005: a total of more than $5.2 billion, or $922 for each of the 5.6 million Medicare enrollees in managed care. This issue brief updates an earlier analysis of Medicare Advantage payments in 2005 previously published by The Commonwealth Fund; the updated estimates in this report are based on final 2005 enrollment figures that were not available at the time the previous estimates were developed, and they include the effect of policy decisions that were not reflected in the previous estimates.

  4. 42 CFR 413.177 - Quality incentive program payment.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 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 program payment. (a) With respect to renal dialysis services as defined under § 413.171 of this part, in the...

  5. 42 CFR 413.177 - Quality incentive program payment.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 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 program payment. (a) With respect to renal dialysis services as defined under § 413.171 of this part, in the...

  6. 42 CFR 413.177 - Quality incentive program payment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 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 program payment. (a) With respect to renal dialysis services as defined under § 413.171 of this part, in the...

  7. 42 CFR 413.177 - Quality incentive program payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 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 program payment. (a) With respect to renal dialysis services as defined under § 413.171 of this part, in the...

  8. The current status of local medicare payment policy: how specialty societies can influence local coverage determinations.

    PubMed

    Allen, Bibb; Pennington, Anita; Keysor, Kathryn J

    2008-06-01

    The Medicare Fee-for-Service Program is in the midst of numerous administrative and regulatory changes that may affect the way local Medicare payment policy is implemented. These changes involve redefining the contractors' jurisdictions, competitive bidding for the contractor selection process, combining the administration of Part A and Part B services, and error rate auditing. In addition, the roles of the Contractor Medical Directors and Contractor Advisory Committees are yet to be defined, and the future of the existing advisory process, while currently unchanged, remains uncertain. Most likely, the majority of coverage decisions will continue to be made at the local level; however, the Centers for Medicare & Medicaid Services (CMS) has begun to increase its use of Technology Assessments and National Coverage Determinations for new technology and has developed a new payment category for coverage of new technology: Coverage with Evidence Development. Specialty societies continue to have the ability to exert influence on the coverage process. The American College of Radiology (ACR) monitors the activity of the local contractors and assists local physicians through the ACR Carrier Advisory Committee Network. The ACR has used a combination of clinical and economic experts to develop model Local Coverage Determinations for use by the local contractors, and some of these model policies have been developed in conjunction with other specialty societies, which bolsters their effectiveness. The changing administrative environment presents challenges and opportunities for specialty societies to influence local CMS payment policy.

  9. 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

    ... the Medicare Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes... Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes; Considering Changes to... (MA) program (Part C) regulations and prescription drug benefit program (Part D) regulations...

  10. Achieving equity in Medicare disproportionate share payments to rural hospitals: an assessment of the financial impact of recent and proposed changes to the disproportionate share hospital payment formula.

    PubMed

    Sutton, Janet P; Stensland, Jeffrey; Zhao, Lan; Cheng, Michael

    2002-01-01

    Historically, the Medicare Disproportionate Share Hospital (DSH) payment program has been less favorable to rural hospitals: eligibility thresholds were higher and the payment adjustment was smaller for rural than for urban hospitals. Although the Medicare, Medicaid, and SCHIP Benefit Improvement and Protection Act (BIPA) of 2000 established a uniform low-income threshold and increased the magnitude of the adjustment for certain small and rural hospitals as a means to promote payment equity, the DSH distribution formula continues to vary by location. This study examines how the DSH revisions mandated under BIPA are likely to affect rural hospitals' financial performance and simulates the financial impact of implementing a uniform DSH payment adjustment. Using data from the 1998 Medicare cost report and impact files, this study found that two-thirds of both rural and urban hospitals would have qualified for DSH payments following BIPA compared with only one-fifth of rural hospitals and one-half of urban hospitals prior to BIPA. Although the impact of BIPA revisions on rural hospitals' total margins were found to be modest, the financial impact of a uniform payment adjustment would be somewhat greater: rural hospitals' average total margins would have increased by 1.6 percentage points. Importantly, 20% of rural hospitals with negative total margins would have been "in the black" if rural and urban hospitals were reimbursed using the same DSH formula. These findings suggest that elimination of rural and urban disparities in DSH payment could strengthen the rural health care safety net.

  11. Medicare program; Medicare Advantage and prescription drug benefit programs: negotiated pricing and remaining revisions. Final rule with comment period.

    PubMed

    2009-01-12

    This rule contains final regulations governing the Medicare Advantage (MA) program (Part C) and prescription drug benefit program (Part D), and interim final regulations governing certain aspects of the Retiree Drug Subsidy (RDS) Program, and reflecting new statutory definitions relating to Special Needs Plans under Part C. The final regulations revising the Part C and Part D regulations include provisions regarding medical savings account (MSA) plans, cost-sharing for dual eligible enrollees in the MA program, the prescription drug payment and novation processes in the Part D program, and the enrollment and appeals processes for both programs. This final rule with comment period also responds to public comments on the May 16, 2008 proposed rule and takes into account statutory revisions contained in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).

  12. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... receiving payments via EFT, providers and suppliers must agree to receive Medicare payments via EFT, if not already receiving payment through EFT. In order to receive Medicare payments via EFT, providers and... Medicare payment via electronic funds transfer (EFT) at the time of enrollment, revalidation, change...

  13. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... receiving payments via EFT, providers and suppliers must agree to receive Medicare payments via EFT, if not already receiving payment through EFT. In order to receive Medicare payments via EFT, providers and... Medicare payment via electronic funds transfer (EFT) at the time of enrollment, revalidation, change...

  14. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... receiving payments via EFT, providers and suppliers must agree to receive Medicare payments via EFT, if not already receiving payment through EFT. In order to receive Medicare payments via EFT, providers and... Medicare payment via electronic funds transfer (EFT) at the time of enrollment, revalidation, change...

  15. 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.

  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... Health Expenditures and Medicare expenditures. The Panel's discussion is expected to be very technical...

  17. 75 FR 44313 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-28

    ...This final rule implements the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) that provide incentive payments to eligible professionals (EPs), eligible hospitals and critical access hospitals (CAHs) participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified electronic health record (EHR)......

  18. 75 FR 1843 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-13

    ...This proposed rule would implement the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) that provide incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use certified electronic health record (EHR) technology. The proposed rule would specify the--initial......

  19. Redesigning the Medicare inpatient PPS to reduce payments to hospitals with high readmission rates.

    PubMed

    Averill, Richard F; McCullough, Elizabeth C; Hughes, John S; Goldfield, Norbert I; Vertrees, James C; Fuller, Richard L

    2009-01-01

    A redesign of the Medicare inpatient prospective payment system (IPPS) that reduces payments to hospitals that have high-risk adjusted readmission rates is proposed. The redesigned IPPS uses a readmission performance standard from best practice hospitals to determine the risk-adjusted number of excess readmissions in a hospital and determines the payment reduction for a hospital based on its excess number of readmissions. Extrapolating from Florida Medicare 2004-2005 discharge data, the redesigned IPPS is estimated to reduce overall annual Medicare inpatient expenditures nationally by $1.25, 1.92, and 2.58 billion for readmission windows of 7, 15, and 30 days, respectively.

  20. 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

  1. 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.

  2. 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

  3. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... via EFT, providers and suppliers must agree to receive Medicare payments via EFT, if not already receiving payment through EFT. In order to receive Medicare payments via EFT, providers and suppliers must... Medicare payment via electronic funds transfer (EFT) at the time of enrollment, revalidation, change...

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

    PubMed Central

    Wu, Vivian Y; Shen, Yu-Chu

    2014-01-01

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

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

    PubMed

    Hallam, K; Gardner, J

    1999-11-08

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

  6. The Relationship Between Magnet Designation, Electronic Health Record Adoption, and Medicare Meaningful Use Payments.

    PubMed

    Lippincott, Christine; Foronda, Cynthia; Zdanowicz, Martin; McCabe, Brian E; Ambrosia, Todd

    2017-03-02

    The objective of this study was to examine the relationship between nursing excellence and electronic health record adoption. Of 6582 US hospitals, 4939 were eligible for the Medicare Electronic Health Record Incentive Program, and 6419 were eligible for evaluation on the HIMSS Analytics Electronic Medical Record Adoption Model. Of 399 Magnet hospitals, 330 were eligible for the Medicare Electronic Health Record Incentive Program, and 393 were eligible for evaluation in the HIMSS Analytics Electronic Medical Record Adoption Model. Meaningful use attestation was defined as receipt of a Medicare Electronic Health Record Incentive Program payment. The adoption electronic health record was defined as Level 6 and/or 7 on the HIMSS Analytics Electronic Medical Record Adoption Model. Logistic regression showed that Magnet-designated hospitals were more likely attest to Meaningful Use than non-Magnet hospitals (odds ratio = 3.58, P < .001) and were more likely to adopt electronic health records than non-Magnet hospitals (Level 6 only: odds ratio = 3.68, P < .001; Level 6 or 7: odds ratio = 4.02, P < .001). This study suggested a positive relationship between Magnet status and electronic health record use, which involves earning financial incentives for successful adoption. Continued investigation is needed to examine the relationships between the quality of nursing care, electronic health record usage, financial implications, and patient outcomes.

  7. 42 CFR 422.316 - Special rules for payments to Federally qualified health centers.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

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

  8. 42 CFR 422.316 - Special rules for payments to Federally qualified health centers.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

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

  9. 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

    ... payments to providers and suppliers of services. 405.371 Section 405.371 Public Health CENTERS FOR MEDICARE... and Loans Suspension and Recoupment of Payment to Providers and Suppliers and Collection and... suppliers of services. (a) General. Medicare payments to providers and suppliers, as authorized under...

  10. Medicare program; prospective payment system for federally qualified health centers; changes to contracting policies for rural health clinics; and changes to Clinical Laboratory Improvement Amendments of 1988 enforcement actions for proficiency testing referral. Final rule with comment period.

    PubMed

    2014-05-02

    This final rule with comment period implements methodology and payment rates for a prospective payment system (PPS) for federally qualified health center (FQHC) services under Medicare Part B beginning on October 1, 2014, in compliance with the statutory requirement of the Affordable Care Act. In addition, it establishes a policy which allows rural health clinics (RHCs) to contract with nonphysician practitioners when statutory requirements for employment of nurse practitioners and physician assistants are met, and makes other technical and conforming changes to the RHC and FQHC regulations. Finally, this final rule with comment period implements changes to the Clinical Laboratory Improvement Amendments (CLIA) regulations regarding enforcement actions for proficiency testing (PT) referrals.

  11. 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.

  12. Medicare program; revisions to payment policies under the physician fee schedule, DME face-to-face encounters, elimination of the requirement for termination of non-random prepayment complex medical review and other revisions to Part B for CY 2013. Final rule with comment period.

    PubMed

    2012-11-16

    This major final rule with comment period addresses changes to the physician fee schedule, payments for Part B drugs, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. It also implements provisions of the Affordable Care Act by establishing a face-to-face encounter as a condition of payment for certain durable medical equipment (DME) items. In addition, it implements statutory changes regarding the termination of non-random prepayment review. This final rule with comment period also includes a discussion in the Supplementary Information regarding various programs . (See the Table of Contents for a listing of the specific issues addressed in this final rule with comment period.)

  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. The national market for Medicare clinical laboratory testing: implications for payment reform.

    PubMed

    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.

  15. 76 FR 58514 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-21

    ... 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... spending in the long run. The Panel's discussion is expected to be very technical in nature and will...

  16. The Center For Medicare And Medicaid Innovation's blueprint for rapid-cycle evaluation of new care and payment models.

    PubMed

    Shrank, William

    2013-04-01

    The Affordable Care Act established the Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models. The goal is to reduce program expenditures while preserving or improving the quality of care provided to beneficiaries of Medicare, Medicaid, and the Children's Health Insurance Program. Central to the success of the Innovation Center is a new, rapid-cycle approach to evaluation. This article describes that approach--setting forth how the Rapid Cycle Evaluation Group aims to deliver frequent feedback to providers in support of continuous quality improvement, while rigorously evaluating the outcomes of each model tested. This article also describes the relationship between the group's work and that of the Office of the Actuary at the Centers for Medicare and Medicaid Services, which plays a central role in the assessment of new models.

  17. Can health promotion programs save Medicare money?

    PubMed Central

    Goetzel, Ron Z; Shechter, David; Ozminkowski, Ronald J; Stapleton, David C; Lapin, Pauline J; McGinnis, J Michael; Gordon, Catherine R; Breslow, Lester

    2007-01-01

    The impact of an aging population on escalating US healthcare costs is influenced largely by the prevalence of chronic disease in this population. Consequently, preventing or postponing disease onset among the elderly has become a crucial public health issue. Fortunately, much of the total burden of disease is attributable to conditions that are preventable. In this paper, we address whether well-designed health promotion programs can prevent illness, reduce disability, and improve the quality of life. Furthermore, we assess evidence that these programs have the potential to reduce healthcare utilization and related expenditures for the Medicare program. We hypothesize that seniors who reduce their modifiable health risks can forestall disability, reduce healthcare utilization, and save Medicare money. We end with a discussion of a new Senior Risk Reduction Demonstration, which will be initiated by the Centers for Medicare and Medicaid Services in 2007, to test whether risk reduction programs developed in the private sector can achieve health improvements among seniors and a positive return on investment for the Medicare program. PMID:18044084

  18. 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

  19. Lessons for the new CMS innovation center from the Medicare health support program.

    PubMed

    Barr, Michael S; Foote, Sandra M; Krakauer, Randall; Mattingly, Patrick H

    2010-07-01

    The Patient Protection and Affordable Care Act establishes a new Center for Medicare and Medicaid Innovation in the Centers for Medicare and Medicaid Services (CMS). The center is intended to enhance the CMS's role in promoting much-needed improvements in payment and service delivery. Lessons from the Medicare Health Support Program, a chronic care pilot program that ran between 2005 and 2008, illustrate the value of drawing on experience in planning for the center and future pilot programs. The lessons include the importance of strong leadership; collaboration and flexibility to foster innovation; receptivity of beneficiaries to care management; and the need for timely data on patients' status. The lessons also highlight pitfalls to be avoided in planning future pilot programs, such as flawed strategies for selecting populations to target when testing payment and service delivery reforms.

  20. 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.

  1. 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.

  2. 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.

  3. Value-Based Payment Reform and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015: A Primer for Plastic Surgeons.

    PubMed

    Squitieri, Lee; Chung, Kevin C

    2017-03-06

    In 2015, the U.S. Congress passed the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA), which effectively repealed the Centers for Medicare and Medicaid Services (CMS) sustainable growth rate (SGR) formula and established the CMS Quality Payment Program (QPP). MACRA represents an unparalleled acceleration toward value-based payment models and a departure from traditional volume-driven fee-for-service reimbursement. The QPP includes two paths for provider participation: the merit-based incentive payment system (MIPS) and advanced alternative payment models (APMs). The MIPS pathway replaces existing quality reporting programs and adds several new measures to create a composite performance score for each provider (or provider group) that will be used to adjust reimbursed payment. The advanced APM pathway is available to providers who participate in qualifying APMs and is associated with an initial 5% payment incentive. The first performance period for MIPS opens January 1, 2017 and closes December 31, 2017 and is associated with payment adjustments in January 2019. CMS estimates that the majority of providers will begin participation in 2017 through the MIPS pathway, but aims to have 50% of payments tied to quality or value through APMs by 2018. In this article, we describe key components of MACRA to providers navigating through the QPP and discuss how plastic surgeons may optimize their performance in this new value-based payment program.

  4. 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...

  5. Impact of Medicare's prospective payment system on hospitals, skilled nursing facilities, and home health agencies: how the Balanced Budget Act of 1997 may have altered service patterns for Medicare providers.

    PubMed

    Kulesher, Robert R

    2006-01-01

    The prospective payment system is one of many changes in reimbursement that has affected the delivery of health care. Originally developed for the payment of inpatient hospital services, it has become a major factor in how all health insurance is reimbursed. The policy implications extend beyond the Medicare program and affect the entire health care delivery system. Initially implemented in 1982 for payments to hospitals, prospective payment system was extended to payments for skilled nursing facility and home health agency services by the Balanced Budget Act of 1997. The intent of the Balanced Budget Act was to bring into balance the federal budget through reductions in spending. The decisions that providers have made to mitigate the impact are a function of ownership type, organizational mission, and current level of Medicare participation. This article summarizes the findings of several initial studies on the Balanced Budget Act's impact and discusses how changes in Medicare reimbursement policy have influenced the delivery of health care for the general public and for Medicare beneficiaries.

  6. 42 CFR 424.510 - Requirements for enrolling in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... contractors where the provider or supplier was already receiving payments via EFT, providers and suppliers must agree to receive Medicare payments via EFT, if not already receiving payment through EFT. In order to receive Medicare payments via EFT, providers and suppliers must submit the CMS-588 form....

  7. 42 CFR 413.76 - Direct GME payments: Calculation of payments for GME costs.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 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...

  8. 42 CFR 413.76 - Direct GME payments: Calculation of payments for GME costs.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 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...

  9. 42 CFR 413.76 - Direct GME payments: Calculation of payments for GME costs.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 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...

  10. 42 CFR 413.76 - Direct GME payments: Calculation of payments for GME costs.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 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...

  11. 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.

  12. 77 FR 13697 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-07

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

  13. 77 FR 53967 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-04

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

  14. 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.

  15. Medicare program; application of certain appeals provisions to the Medicare prescription drug appeals process. Final rule.

    PubMed

    2009-12-09

    This final rule will implement the procedures that the Department of Health and Human Services will follow at the Administrative Law Judge and Medicare Appeals Council levels in deciding appeals brought by individuals who have enrolled in the Medicare prescription drug benefit program. In addition, it will implement the reopening procedures that will be followed at all levels of appeal.

  16. 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.

  17. 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

  18. Medicare program; revisions to payment policies and five-year review of and adjustments to the relative value units under the physician fee schedule for calendar year 2002. Final rule with comment period.

    PubMed

    2001-11-01

    This final rule with comment period makes several changes affecting Medicare Part B payment. The changes affect: refinement of resource-based practice expense relative value units (RVUs); services and supplies incident to a physician's professional service;anesthesia base unit variations;recognition of CPT tracking codes; and nurse practitioners, physician assistants, and clinical nurse specialists performing screening sigmoidoscopies. It also addresses comments received on the June 8, 2001 proposed notice for the 5-year review of work RVUs and finalizes these work RVUs. In addition,we acknowledge comments received on our request for information on our policy for CPT modifier 62 that is used to report the work of co-surgeons. The rule also updates the list of certain services subject to the physician self-referral prohibitions to reflect changes to CPT codes and Healthcare Common Procedure Coding System codes effective January 1, 2002. These refinements and changes will ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 modernizes the mammography screening benefit and authorizes payment under the physician fee schedule effective January 1, 2002; provides for biennial screening pelvic examinations for certain beneficiaries effective July 1, 2001; provides for annual glaucoma screenings for high-risk beneficiaries effective January 1,2002; expands coverage for screening colonoscopies to all beneficiaries effective July 1, 2001; establishes coverage for medical nutrition therapy services for certain beneficiaries effective January 1, 2002; expands payment for telehealth services effective October 1, 2001; requires certain Indian Health Service providers to be paid for some services under the physician fee schedule effective July 1, 2001; and revises the payment for certain physician pathology services effective January 1

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

    PubMed

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

    2015-03-01

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

  20. Patient mix in outpatient surgery settings and implications for Medicare payment policy.

    PubMed

    Meyerhoefer, Chad D; Colby, Margaret S; McFetridge, Jeffrey T

    2012-02-01

    In 2008, Medicare implemented a new payment policy for ambulatory surgical centers (ASCs), which aligns the ASC payment system with that used for hospital outpatient departments and reimburses ASCs approximately 65% of what hospitals receive for the same outpatient surgery. The authors assess patient selection across ASCs and hospital outpatient departments for four common surgeries (colonoscopy, hernia repair, knee arthroscopy, cataract repair), using data on procedures performed in Florida from 2004 to 2008. The authors construct measures of patient illness severity and cost risk and find that ASCs benefit from positive selection. Nonetheless, the degree of selection varies by surgery type and patient population. While similar studies in other states are needed, the findings suggest that modifications to the Medicare outpatient payment system may be appropriate to account for the different populations that each setting attracts.

  1. 75 FR 81885 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Correcting Amendment

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-29

    ... Programs; Electronic Health Record Incentive Program; Correcting Amendment AGENCY: Centers for Medicare...; Electronic Health Record Incentive Program'' that appeared in the July 28, 2010 Federal Register. DATES... 44314) the final rule entitled ``Medicare and Medicaid Programs; Electronic Health Record...

  2. Hospital Merger Increased Medicare and Medicaid Payments for Capital Costs.

    DTIC Science & Technology

    1983-12-22

    some value as intangible assets , 4 the value of the hospitals’ assets should not be assigned to HCA because it does not own the hospitals. Therefore, we...nothing in §203, or in any other Medicare rule, which supports the draft report’s suggestion that intangible assets related to patient care should be...owners’ investment of funds used to acquire a facility will be applied to intangible assets . GAO ANALYSIS: We did not suggest that intangible assets should

  3. 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.

  4. 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.

  5. 77 FR 25283 - Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-27

    ...This final rule finalizes several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment......

  6. A simulation shows limited savings from meeting quality targets under the Medicare Shared Savings Program.

    PubMed

    Eddy, David M; Shah, Roshan

    2012-11-01

    The Medicare Shared Savings Program, created under the Affordable Care Act, will reward participating accountable care organizations that succeed in lowering health care costs while improving performance. Depending on how the organizations perform on several quality measures, they will "share savings" in Medicare Part A and B payments-that is, they will receive bonus payments for lowering costs. We used a simulation model to analyze the effects of the Shared Savings Program quality measures and performance targets on Medicare costs in a simulated population of patients ages 65-75 with type 2 diabetes. We found that a ten-percentage-point improvement in performance on diabetes quality measures would reduce Medicare costs only by up to about 1 percent. After the costs of performance improvement, such as additional tests or visits, are accounted for, the savings would decrease or become cost increases. To achieve greater savings, accountable care organizations will have to lower costs by other means, such as through improved use of information technology and care coordination.

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

    PubMed

    1983-08-18

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

  8. Medicare program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B). Notice of CMS ruling.

    PubMed

    2013-03-18

    This notice announces a CMS Ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that the inpatient admission was determined not reasonable and necessary. This revised policy is intended as an interim measure until CMS can finalize a policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward. To that end, elsewhere in this issue of the Federal Register, we published a proposed rule entitled, "Medicare Program; Part B Inpatient Billing in Hospitals,'' to propose a permanent policy that would apply on a prospective basis.

  9. 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

    ..., and others. Overall, commenters supported our decision to model Medicare MLR policy after the commercial MLR rules. In this final rule, we address comments and concerns regarding the policies included in... applicability to various plan types. Part 422 of the Code of Federal Regulations (CFR) regulates the MA...

  10. 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...

  11. 42 CFR 413.77 - Direct GME payments: Determination of per resident amounts.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 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...

  12. 42 CFR 413.77 - Direct GME payments: Determination of per resident amounts.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 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...

  13. 42 CFR 413.77 - Direct GME payments: Determination of per resident amounts.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 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...

  14. Recommendations of the Medicare Payment Advisory Commission (MEDPAC) on the Health Care Delivery System: the impact on interventional pain management in 2014 and beyond.

    PubMed

    Manchikanti, Laxmaiah; Benyamin, Ramsin M; Falco, Frank J E; Hirsch, Joshua A

    2013-01-01

    Continuing rise in health care costs in the United States, the Affordable Care Act (ACA), and a multitude of other regulations impact providers in 2013. Despite federal spending slowing in the past 2 years, the Board of Medicare Trustees believes that cost savings are only achievable if health care providers are able to realize productivity improvements at a quicker pace than experienced historically. Consequently, the re-engineering of U.S. health care and bridging of the divide between health and health care have been proposed beyond affordable care. Thus, the Medicare Payment Advisory Commission (MedPAC) envisions alignment of Medicare payment systems to eliminate variable rates for the same ambulatory services provided to similar patients in different settings, such as the physician's office, hospital outpatient departments (HOPDs), and ambulatory surgery centers (ASCs). MedPAC believes that if the same service can be safely provided in different settings, a prudent purchaser should not pay more for that service in one setting than in another. MedPAC is also concerned that payment variations across settings encourage arrangements among providers that result in care being provided in high paid settings. MedPAC recommends that payment rates be based on the resources needed to treat patients in the most efficient setting, adjusting for differences in patient severity, to the extent the severity differences affect costs. MedPAC has analyzed the costs of evaluation and management (E&M) services and the differences between providing them in a HOPD setting compared to a physician office setting, echocardiography services, and multiple services provided in ASCs and HOPDs. MedPAC has shown that for an established patient office visit (CPT 99213) provided in a free-standing physician's office, the program pays the physician 70% less than in HOPD setting with a payment for physician practice of $72.50 versus $123.38 for HOPD setting. Similarly, for a Level II

  15. Medicare

    MedlinePlus

    ... supplies Quality, planning, & compare tools Latest Updates Get smart about antibiotics Saving money on health costs: get ... Get Medicare forms Publications Information in other languages Phone numbers & websites Helpful Links Site Map Site policies & ...

  16. 75 FR 76471 - Medicare Program; Renewal of the Medicare Evidence Development & Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-08

    ..., patient advocacy, the economics of health care, medical ethics and other related professions such as... functions on a committee basis. The MEDCAC--(1) Hears public testimony; (2) reviews medical literature... Federal Domestic Assistance Program No. 93.774, Medicare--Supplementary Medical Insurance Program)....

  17. 77 FR 51542 - Medicare Program; Solicitation of Two Nominations to the Advisory Panel on Hospital Outpatient...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-24

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Solicitation of Two... Health and Human Services (DHHS) (the Secretary) and the Administrator of the Centers for Medicare... of the following: geography; rural or urban practice; race, ethnicity, sex, and disability;...

  18. Medicare Program; End-Stage Renal Disease Prospective Payment System, Coverage and Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program Bid Surety Bonds, State Licensure and Appeals Process for Breach of Contract Actions, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program and Fee Schedule Adjustments, Access to Care Issues for Durable Medical Equipment; and the Comprehensive End-Stage Renal Disease Care Model. Final rule.

    PubMed

    2016-11-04

    This rule updates and makes revisions to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year 2017. It also finalizes policies for coverage and payment for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury. This rule also sets forth requirements for the ESRD Quality Incentive Program, including the inclusion of new quality measures beginning with payment year (PY) 2020 and provides updates to programmatic policies for the PY 2018 and PY 2019 ESRD QIP. This rule also implements statutory requirements for bid surety bonds and state licensure for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). This rule also expands suppliers' appeal rights in the event of a breach of contract action taken by CMS, by revising the appeals regulation to extend the appeals process to all types of actions taken by CMS for a supplier's breach of contract, rather than limit an appeal for the termination of a competitive bidding contract. The rule also finalizes changes to the methodologies for adjusting fee schedule amounts for DMEPOS using information from CBPs and for submitting bids and establishing single payment amounts under the CBPs for certain groupings of similar items with different features to address price inversions. Final changes also are made to the method for establishing bid limits for items under the DMEPOS CBPs. In addition, this rule summarizes comments on the impacts of coordinating Medicare and Medicaid Durable Medical Equipment for dually eligible beneficiaries. Finally, this rule also summarizes comments received in response to a request for information related to the Comprehensive ESRD Care Model and future payment models affecting renal care.

  19. 42 CFR 460.180 - Medicare payment to PACE organizations.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE... risk adjustment model. (5) CMS may adjust the monthly capitation amount to take into account...

  20. Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2012; changes in size and square footage of inpatient rehabilitation units and inpatient psychiatric units. Final rule.

    PubMed

    2011-08-05

    This final rule will implement section 3004 of the Affordable Care Act, which establishes a new quality reporting program that provides for a 2 percent reduction in the annual increase factor beginning in 2014 for failure to report quality data to the Secretary of Health and Human Services. This final rule will also update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for Federal fiscal year (FY) 2012 (for discharges occurring on or after October 1, 2011 and on or before September 30, 2012) as required under section 1886(j)(3)(C) of the Social Security Act (the Act). Section 1886(j)(5) of the Act requires the Secretary to publish in the Federal Register on or before the August 1 that precedes the start of each FY the classification and weighting factors for the IRF prospective payment system (PPS) case-mix groups and a description of the methodology and data used in computing the prospective payment rates for that fiscal year. We are also consolidating, clarifying, and revising existing policies regarding IRF hospitals and IRF units of hospitals to eliminate unnecessary confusion and enhance consistency. Furthermore, in accordance with the general principles of the President's January 18, 2011 Executive Order entitled "Improving Regulation and Regulatory Review," we are amending existing regulatory provisions regarding ''new'' facilities and changes in the bed size and square footage of IRFs and inpatient psychiatric facilities (IPFs) to improve clarity and remove obsolete material.

  1. 76 FR 67743 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-02

    ... Medicare or Medicaid programs or Children's Health Insurance Program (CHIP); revalidating their Medicare... Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment..., Medicaid, and Children's Health Insurance Program (CHIP) provider enrollment processes. Specifically,...

  2. Hospitals respond to Medicare payment shortfalls by both shifting costs and cutting them, based on market concentration.

    PubMed

    Robinson, James

    2011-07-01

    The coverage expansions planned under the Affordable Care Act are to be financed in part by slowing Medicare payment updates to hospitals, thereby reigniting the debate over whether low prices paid by public payers cause hospitals to increase prices to private insurers--a practice known as cost shifting. Recently, the Medicare Payment Advisory Commission (MedPAC) proposed an alternative explanation of hospital pricing and profitability that could be used to support policies that pressure hospitals to reduce overall costs rather than to only raise prices. This study evaluated the cost-shift and MedPAC perspectives using 2008 data on hospital margins for 30,514 Medicare and privately insured patients undergoing any of seven major procedures in markets where robust hospital competition exists and in markets where hospital care is concentrated in the hands of a few providers. The study presents empirical evidence that, faced with shortfalls between Medicare payments and projected costs, hospitals in concentrated markets focus on raising prices to private insurers, while hospitals in competitive markets focus on cutting costs. Policy makers need to examine whether efforts to promote clinical coordination through provider integration may interfere with efforts to restrain overall health care cost growth by restraining Medicare payment rates.

  3. 42 CFR 421.302 - Eligibility requirements for Medicare integrity program contractors.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Eligibility requirements for Medicare integrity program contractors. 421.302 Section 421.302 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE...

  4. Medicare and Medicaid programs; changes in provider and supplier enrollment, ordering and referring, and documentation requirements; and changes in provider agreements. Interim final rule with comment period.

    PubMed

    2010-05-05

    This interim final rule with comment period implements several provisions set forth in the Patient Protection and Affordable Care Act (Affordable Care Act). It implements the provision which requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. This interim final rule with comment period also requires physicians and eligible professionals to order and refer covered items and services for Medicare beneficiaries to be enrolled in Medicare. In addition, it adds requirements for providers, physicians, and other suppliers participating in the Medicare program to provide documentation on referrals to programs at high risk of waste and abuse, to include durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), home health services, and other items or services specified by the Secretary.

  5. 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

  6. 76 FR 78741 - Medicare, Medicaid, Children's Health Insurance Programs; Transparency Reports and Reporting of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-19

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

  7. 42 CFR 411.2 - Conclusive effect of QIO determinations on payment of claims.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Conclusive effect of QIO determinations on payment of claims. 411.2 Section 411.2 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT General Exclusions and Exclusion...

  8. Favorable Selection, Risk Adjustment, and the Medicare Advantage Program

    PubMed Central

    Morrisey, Michael A; Kilgore, Meredith L; Becker, David J; Smith, Wilson; Delzell, Elizabeth

    2013-01-01

    Objectives To examine the effects of changes in payment and risk adjustment on (1) the annual enrollment and switching behavior of Medicare Advantage (MA) beneficiaries, and (2) the relative costliness of MA enrollees and disenrollees. Data From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures. Study Design Retrospective, fixed effects regression analysis of July enrollment and year-long switching into and out of MA. Similar regression analysis of the costliness of those switching into (out of) MA in the 6 months prior to enrollment (after disenrollment) relative to nonswitchers in the same county over the same period. Findings Payment generosity and more sophisticated risk adjustment were associated with substantial increases in MA enrollment and decreases in disenrollment. Claims experience of those newly switching into MA was not affected by any of the policy reforms, but disenrollment became increasingly concentrated among high-cost beneficiaries. Conclusions Enrollment is very sensitive to payment levels. The use of more sophisticated risk adjustment did not alter favorable selection into MA, but it did affect the costliness of disenrollees. PMID:23088500

  9. 42 CFR 409.41 - Requirement for payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM HOSPITAL INSURANCE BENEFITS Home Health Services Under Hospital Insurance § 409.41 Requirement for payment. In order for home health services to qualify for payment under the Medicare program the...

  10. Active Duty (AD) Claims Payment Program

    DTIC Science & Technology

    1991-08-26

    Claims Payment Program References: (a) Sections 1073 and 1074(c) of title 10, United States Code (b) DoD 6010.8-R, "Civilian Health and Medical Program...Provider) 1. This payment was calculated under the CHAMPUS DRG-based payment system as directed by Sections 1073 and 1074(c) of title 10, United

  11. 7 CFR 1469.23 - Program payments.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... payment at the time of the sign-up notices on the NRCS website and in USDA Service Centers. (3) NRCS will... 7 Agriculture 10 2010-01-01 2010-01-01 false Program payments. 1469.23 Section 1469.23 Agriculture... AGRICULTURE LOANS, PURCHASES, AND OTHER OPERATIONS CONSERVATION SECURITY PROGRAM Contracts and Payments §...

  12. 7 CFR 1469.23 - Program payments.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... payment at the time of the sign-up notices on the NRCS website and in USDA Service Centers. (3) NRCS will... 7 Agriculture 10 2014-01-01 2014-01-01 false Program payments. 1469.23 Section 1469.23 Agriculture... AGRICULTURE LOANS, PURCHASES, AND OTHER OPERATIONS CONSERVATION SECURITY PROGRAM Contracts and Payments §...

  13. 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.

  14. Medicare and Medicaid programs; changes in provider and supplier enrollment, ordering and referring, and documentation requirements; and changes in provider agreements. Final rule.

    PubMed

    2012-04-27

    This final rule finalizes several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare. Finally, it mandates document retention and provision requirements on providers and supplier that order and certify items and services for Medicare beneficiaries.

  15. 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.

  16. 42 CFR 414.707 - Basis of payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ...) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Payment for Drugs and Biologicals § 414.707 Basis of payment. (a) Method of payment. (1) Payment for a drug in calendar year 2004 is based... paragraphs (a)(2) through (a)(8) of this section. (2) The payment limits for the following drugs...

  17. Federal employees health benefits program: limitation on physician charges and FEHB Program payments--Office of Personnel Management. Final rule.

    PubMed

    1996-09-27

    The Office of Personnel Management (OPM) is making final its interim regulation that amends current Federal Employees Health Benefits (FEHB) Program regulations. The final regulation requires that the charges and FEHB fee-for-service plans' benefit payments for certain physician services furnished to retired enrolled individuals do not exceed the limits on charges and payments established under the Medicare fee schedule for physician services.

  18. 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.

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

    PubMed Central

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

    1995-01-01

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

  20. Medicare, Medicaid, Children's Health Insurance Programs; transparency reports and reporting of physician ownership or investment interests. Final rule.

    PubMed

    2013-02-08

    This final rule will 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 purchasing organizations (GPOs) are required to report annually certain physician ownership or investment interests. The Secretary is required to publish applicable manufacturers' and applicable GPOs' submitted payment and ownership information on a public Web site.

  1. 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

    .... Sec. 423.100 and 423.104) 9. Medication Therapy Management Comprehensive Medication Reviews and... Medication Therapy Management MTMP Medication Therapy Management Program NAIC National Association Insurance... publication First Tier and applicable 01/01/13 Downstream Entities. II.E.9 Medication Therapy effective...

  2. 77 FR 64344 - Medicare and Medicaid Programs; Approval of the Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-19

    ..., and the conditions for Medicare payment for hospice care. Generally, to enter into an agreement, a... provide hospice care and services.'' To meet the requirements at Sec. 418.100(c), CHAP revised its standards to specify that a hospice must be primarily engaged in providing care and services consistent...

  3. 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...

  4. 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.

  5. Components of Medicare reimbursement.

    PubMed

    Malatestinic, William; Braun, LeeAnn; Jorgenson, James A; Eskew, Jim

    2003-11-01

    The history of the Medicare reimbursement system, how it works, and issues related to fraud and abuse are discussed. The statutory charge of Medicare is to ensure adequate reimbursement through a Prospective Payment System (PPS) to cover the costs for providing a given service to Medicare beneficiaries. The PPS was introduced as a way to change hospital behavior through financial incentives that encourage cost-efficient management of resources. The system utilizes a rate of payment in which a hospital is paid a fixed amount that is expected to cover the costs of care while treating a typical patient in a particular diagnosis-related group (DRG). The PPS uses DRGs as payment categories and Major Diagnostic Categories (MDCs) for classifying the DRGs into similar groupings. One of the first steps in DRG assignment is identification of the principal diagnosis represented by an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code. The secondary diagnoses (referred to as complications or comorbidities), presence or absence of surgery, age of the patient, and discharge status are the other pieces of information making up assignment of a specific DRG to a patient. A basic knowledge of the Medicare program will help in the understanding of how hospitals will be reimbursed for patient care, as well as how changes in Medicare payment may affect reimbursement. Medicare is one of the largest health insurance providers in the United States. A basic understanding of the Medicare system will provide valuable insights into Medicare reimbursement and the influence it has on a hospital's bottom line.

  6. 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

    ... integrated-care models envisioned by the Medicare Shared Savings Program. Section 1899(f) of the Act... models. We may consider waivers (where authorized under the Affordable Care Act), exceptions, or safe harbors, as applicable, for other types of ACOs, integrated-care delivery models, or...

  7. Medicare program; establishing additional Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier enrollment safeguards. Final rule.

    PubMed

    2010-08-27

    This final rule will clarify, expand, and add to the existing enrollment requirements that Durable Medical Equipment and Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers must meet to establish and maintain billing privileges in the Medicare program.

  8. 76 FR 33306 - Medicare Program; Pioneer Accountable Care Organization Model, Request for Applications; Correction

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-08

    ... Care Organization Model: Request for Applications.'' FOR FURTHER INFORMATION CONTACT: Maria Alexander... http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/pioneer-aco... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Pioneer Accountable...

  9. 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...

  10. 76 FR 39110 - Medicare Program; Section 3113: The Treatment of Certain Complex Diagnostic Laboratory Tests...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-05

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Section 3113: The Treatment of... participate in the Treatment of Certain Complex Diagnostic Laboratory Tests Demonstration. The Demonstration... Treatment of Certain Complex Diagnostic Laboratory Tests Demonstration. The authorizing legislation...

  11. 76 FR 46814 - Medicare Program; Evaluation Criteria and Standards for Quality Improvement Program Contracts...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-03

    ...) Model (See Section C.10 of the 10th Statement of Work) Learning and Action Networks are mechanisms by... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Evaluation Criteria and... & Medicaid Services (CMS), HHS. ACTION: Notice with comment period. SUMMARY: This notice with comment...

  12. The new bundled payment program for joint replacement may unfairly penalize hospitals that treat patients with medical comorbidities

    PubMed Central

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

    2017-01-01

    The Centers for Medicare & Medicaid Services (CMS) recently implemented the Comprehensive Care for Joint Replacement (CJR) model. While many stakeholders are enthusiastic that the program will reduce spending for joint replacement, others are concerned that the program will unintentionally penalize hospitals that treat medically complex patients. This concern stems from the fact that the program may not include a mechanism to sufficiently account for patient complexity (i.e., risk adjustment). Using Medicare claims, we examined this concern and found an inverse association between patient complexity and year-end bonuses (i.e., reconciliation payments). Specifically, reconciliation payments were reduced by $827 per episode for each standard deviation increase in a hospital’s patient complexity (p<0.01). 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 CJR model and future bundled payment programs. PMID:27605647

  13. 76 FR 19527 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    ... Guidance Relating to Tax Exempt Organization 3. Antitrust Policy Statement 4. Prohibition Against the... Innovation CMP Civil Monetary Penalties CMS Centers for Medicare and Medicaid Services CNM Certified Nurse... new approach to the delivery of health care aimed at: (1) Better care for individuals; (2)...

  14. 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

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Establishment of a program to collect suggestions... Medicare Fraud and Abuse, and Establishment of a Program to Collect Suggestions for Improving Medicare... collect suggestions for improving Medicare program efficiency and to reward suggesters for...

  15. 42 CFR 413.75 - Direct GME payments: General requirements.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE... Categories of Costs § 413.75 Direct GME payments: General requirements. (a) Statutory basis and scope—(1... the methodology for Medicare payment of the cost of direct graduate medical educational activities....

  16. 42 CFR 413.75 - Direct GME payments: General requirements.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE... Categories of Costs § 413.75 Direct GME payments: General requirements. (a) Statutory basis and scope—(1... the methodology for Medicare payment of the cost of direct graduate medical educational activities....

  17. 42 CFR 413.75 - Direct GME payments: General requirements.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE... Categories of Costs § 413.75 Direct GME payments: General requirements. (a) Statutory basis and scope—(1... the methodology for Medicare payment of the cost of direct graduate medical educational activities....

  18. 42 CFR 412.540 - Method of payment for preadmission services under the long-term care hospital prospective payment...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Method of payment for preadmission services under the long-term care hospital prospective payment system. 412.540 Section 412.540 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT...

  19. 77 FR 14989 - Medicare Program; Revisions to the Durable Medical Equipment, Prosthetics, Orthotics, and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-14

    ... are included in the definition of ``medical and other health services'' in section 1861(s)(8) of the... HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 424 RIN 0938-AQ57 Medicare Program... Safeguards AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Final rule. SUMMARY:...

  20. 78 FR 65660 - Medicare Program; Solicitation of Five Nominations to the Advisory Panel on Hospital Outpatient...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-01

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Solicitation of Five... Department of Health and Human Services and the Administrator of the Centers for Medicare & Medicaid Services... The Secretary of the Department of Health and Human Services (the Secretary) is required by...

  1. 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…

  2. 7 CFR 1469.23 - Program payments.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ...) NRCS will publish the stewardship payment rates at the announcement of each program sign-up. (b... payment at the time of the sign-up notices on the NRCS website and in USDA Service Centers. (3) NRCS will... standards described in the FOTG. (7) The Chief may reduce the rates in any given sign-up notice. (c)...

  3. 7 CFR 1469.23 - Program payments.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ...) NRCS will publish the stewardship payment rates at the announcement of each program sign-up. (b... payment at the time of the sign-up notices on the NRCS website and in USDA Service Centers. (3) NRCS will... standards described in the FOTG. (7) The Chief may reduce the rates in any given sign-up notice. (c)...

  4. 42 CFR 413.184 - Payment exception: Pediatric patient mix.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 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:...

  5. 42 CFR 413.184 - Payment exception: Pediatric patient mix.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 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:...

  6. 42 CFR 413.184 - Payment exception: Pediatric patient mix.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 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:...

  7. 42 CFR 413.184 - Payment exception: Pediatric patient mix.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 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:...

  8. 42 CFR 408.84 - Billing and payment procedures.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... MEDICARE PROGRAM PREMIUMS FOR SUPPLEMENTARY MEDICAL INSURANCE Direct Remittance: Group Payment § 408.84... advance. (c) Group payers must make their payments within 30 days after billing, to avoid infringing...

  9. 42 CFR 419.2 - Basis of payment.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... PROGRAM (CONTINUED) PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES General... system, predetermined amounts are paid for designated services furnished to Medicare beneficiaries. These... Procedure Coding System (HCPCS). The prospective payment rate for each service or procedure for...

  10. 42 CFR 414.408 - Payment rules.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ...) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Competitive Bidding for.... (a) Payment basis. (1) The payment basis for an item furnished under a competitive bidding program is... bidding program is furnished to a beneficiary who does not maintain a permanent residence in a CBA,...

  11. 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...

  12. 76 FR 76541 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-07

    ...This final rule implements Section 10332 of the Affordable Care Act regarding the release and use of standardized extracts of Medicare claims data for qualified entities to measure the performance of providers of services (referred to as providers) and suppliers. This rule explains how entities can become qualified by CMS to receive standardized extracts of claims data under Medicare Parts A,......

  13. 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

    ..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription Drug... the consumer price index for all urban consumers (U.S. city average) for July 2003 to July of the year... (Prescription Drug Plan) Appeals The annually adjusted AIC threshold amounts for ALJ hearings and...

  14. Medicare program: changes to the Medicare claims appeal procedures. Interim final rule with comment period.

    PubMed

    2005-03-08

    Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services, can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B under sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. This interim final rule responds to comments on the November 15, 2002 proposed rule regarding changes to these appeal procedures, establishes the implementing regulations, and explains how the new procedures will be implemented. It also sets forth provisions that are needed to implement the new statutory requirements enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

  15. 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...

  16. 42 CFR 412.108 - Special treatment: Medicare-dependent, small rural hospitals.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Special treatment: Medicare-dependent, small rural 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...

  17. 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...

  18. 42 CFR 414.408 - Payment rules.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ...) MEDICARE PROGRAM PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Competitive Bidding for Certain...) Payment basis. (1) The payment basis for an item furnished under a competitive bidding program is 80... beneficiary maintains a permanent residence. (2) If an item that is included in a competitive bidding...

  19. 78 FR 75304 - Medicare Program; Medicare Secondary Payer and Certain Civil Money Penalties

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-11

    ... Washington, DC--Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G... of the building. A stamp- in clock is available for persons wishing to retain a proof of filing...

  20. 77 FR 38067 - Medicare Program; Public Meeting Regarding Inherent Reasonableness of Medicare Fee Schedule...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-26

    ... what Medicare pays for mail order supplies versus non-mail order supplies may encourage fraud and abuse... or other animals except Seeing Eye dogs and other dogs trained to assist the handicapped,...

  1. 77 FR 71423 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-30

    ... 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...

  2. 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...

  3. 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...

  4. 42 CFR 418.308 - Limitation on the amount of hospice payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Payment for Hospice Care § 418.308 Limitation... total Medicare payment to a hospice for care furnished during a cap period is limited by the hospice cap... 42 Public Health 3 2010-10-01 2010-10-01 false Limitation on the amount of hospice payments....

  5. 42 CFR 418.308 - Limitation on the amount of hospice payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Payment for Hospice Care § 418.308... total Medicare payment to a hospice for care furnished during a cap period is limited by the hospice cap... 42 Public Health 3 2014-10-01 2014-10-01 false Limitation on the amount of hospice payments....

  6. 42 CFR 418.308 - Limitation on the amount of hospice payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Payment for Hospice Care § 418.308 Limitation... total Medicare payment to a hospice for care furnished during a cap period is limited by the hospice cap... 42 Public Health 3 2011-10-01 2011-10-01 false Limitation on the amount of hospice payments....

  7. 42 CFR 418.308 - Limitation on the amount of hospice payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Payment for Hospice Care § 418.308... total Medicare payment to a hospice for care furnished during a cap period is limited by the hospice cap... 42 Public Health 3 2013-10-01 2013-10-01 false Limitation on the amount of hospice payments....

  8. 42 CFR 418.308 - Limitation on the amount of hospice payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Payment for Hospice Care § 418.308... total Medicare payment to a hospice for care furnished during a cap period is limited by the hospice cap... 42 Public Health 3 2012-10-01 2012-10-01 false Limitation on the amount of hospice payments....

  9. 42 CFR 412.424 - Methodology for calculating the Federal per diem payment amount.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... payment amount. 412.424 Section 412.424 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Services of Inpatient Psychiatric...

  10. 42 CFR 412.529 - Special payment provision for short-stay outliers.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    .... 412.529 Section 412.529 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 based on the sum of the applicable operating inpatient prospective payment...

  11. Federal Employees Health Benefits Program: limitation on physician charges and FEHB program payments--OPM. Interim regulation with request for comments.

    PubMed

    1995-05-18

    The Office of Personnel Management (OPM) is issuing an interim regulation that amends current Federal Employee Health Benefits (FEHB) Program regulations to require that the charges and FEHB fee-for-service plans' benefit payments for certain physician services furnished to retired enrolled individuals do not exceed the limits on charges and payments established under the Medicare fee schedule for physician services. The regulation authorizes the FEHB plans, under the oversight of OPM, to notify the Secretary of Health and Human Services (HHS) of a Medicare participating hospital, physician or supplier who knowingly and willfully fails to accept, on a repeated basis, the Medicare rate as payment in full from an FEHB plan. The regulation also authorizes the FEHB plans, under the oversight of OPM, to notify the Secretary of HHS of a Medicare nonparticipating physician or supplier who knowingly and willfully charges, on a repeated basis, more than the Medicare limiting charge amount (115 percent of the Medicare Nonparticipating Physician Fee Schedule amount).

  12. 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

  13. 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... extended care services coinsurance amounts for services furnished in calendar year (CY) 2012 under...

  14. 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...

  15. 76 FR 35683 - Medicare Program; Conditions of Participation (CoPs) for Community Mental Health Centers

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-17

    ... 42 CFR Part 485 Medicare Program; Conditions of Participation (CoPs) for Community Mental Health... 485 RIN 0938-AP51 Medicare Program; Conditions of Participation (CoPs) for Community Mental Health... (no password required). I. Background A. Introduction In 2007, 224 certified Community Mental...

  16. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs Determination of Transition Period Payment Rates for Capital-Related Costs § 412.332 Payment based on the hospital-specific rate. The payment amount for...

  17. Medicare program: changes to the Medicare claims appeal procedures. Final rule.

    PubMed

    2009-12-09

    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.

  18. 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...

  19. 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...

  20. Impact of Medicare Shared Savings Program Accountable Care Organizations at Screening Mammography: A Retrospective Cohort Study.

    PubMed

    Narayan, Anand K; Harvey, Susan C; Durand, Daniel J

    2017-02-01

    Purpose To evaluate the impact of accountable care organizations (ACOs) on use of screening mammography in the Medicare Shared Savings Program (MSSP), the largest value-based reimbursement program in U.S.

  1. The interaction of partial public insurance programs and residual private insurance markets: evidence from the US Medicare program.

    PubMed

    Finkelstein, Amy

    2004-01-01

    A ubiquitous form of government intervention in insurance markets is to provide compulsory, but partial, public insurance coverage and to allow voluntary purchases of supplementary private insurance. This paper investigates the effects of such programs on insurance coverage for the risks not covered by the public program, using the example of the US Medicare program. I find that Medicare does not have substantial effects-in either direction-on coverage in residual private insurance markets. In particular, there is no evidence that Medicare is associated with reductions in private insurance coverage for prescription drug expenditures, an expenditure risk not covered by Medicare. Medicare is, however, associated with a shift in the source of prescription drug coverage, from employer-provided coverage to Medicare HMOs.

  2. 42 CFR 424.535 - Revocation of enrollment and billing privileges in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Revocation of enrollment and billing privileges in... Requirements for Establishing and Maintaining Medicare Billing Privileges § 424.535 Revocation of enrollment and billing privileges in the Medicare program. (a) Reasons for revocation. CMS may revoke a...

  3. 42 CFR 424.535 - Revocation of enrollment and billing privileges in the Medicare program.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Revocation of enrollment and billing privileges in... Requirements for Establishing and Maintaining Medicare Billing Privileges § 424.535 Revocation of enrollment and billing privileges in the Medicare program. (a) Reasons for revocation. CMS may revoke a...

  4. 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...

  5. 78 FR 16632 - Medicare Program; Part B Inpatient Billing in Hospitals

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-18

    .... Screening pap smears. Influenza, pneumococcal pneumonia, and hepatitis B vaccines. Colorectal screening... Program; Part B Inpatient Billing in Hospitals AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed rule. SUMMARY: The proposed rule would revise Medicare Part B billing policies when...

  6. 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

    ... to the Amount in Controversy Threshold Amounts for Calendar Year 2011 AGENCY: Centers for Medicare... July of the preceding year involved and rounded to the nearest multiple of $10. B. Calendar Year 2011... judicial review will rise to $1,300 for the 2011 calendar year. These updated amounts are based on the...

  7. 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

    ... to the Amount in Controversy Threshold Amounts for Calendar Year 2013 AGENCY: Centers for Medicare... for requests for ALJ hearings and judicial review filed on or after January 1, 2013. The calendar year... nearest multiple of $10. B. Calendar Year 2013 The AIC threshold amount for ALJ hearing requests...

  8. 78 FR 59702 - Medicare Program; Medicare Appeals: Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-27

    ...This notice announces the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective for requests for ALJ hearings and judicial review filed on or after January 1, 2014. The calendar year 2014 AIC threshold amounts are......

  9. 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

    ... under the Medicare statute. This meeting will focus on selected genetic tests for cancer diagnosis (for cancers of unknown primary site and for cervical cytology findings of uncertain clinical significance... selected genetic tests for cancer diagnosis (for cancers of unknown primary site and for cervical...

  10. 75 FR 52629 - Medicare Program; Establishing Additional Medicare Durable Medical Equipment, Prosthetics...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-08-27

    ... to furnish outpatient physical therapy or speech pathology services, or a community mental health... From the Federal Register Online via the Government Publishing Office ] DEPARTMENT OF HEALTH AND... health agency (HHA), or a hospice that has in effect an agreement to participate in Medicare, or a...

  11. 77 FR 50110 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-20

    ... reviews and evaluates medical literature, technology assessments, and hears public testimony on the evidence available to address the impact of medical items and services on health outcomes of Medicare... Federal Official. The MEDCAC reviews and evaluates medical literature, technology assessments, and...

  12. 42 CFR 413.74 - Payment to a foreign hospital.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payment to a foreign hospital. 413.74 Section 413.74 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...

  13. 42 CFR 413.74 - Payment to a foreign hospital.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Payment to a foreign hospital. 413.74 Section 413.74 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...

  14. 42 CFR 413.60 - Payments to providers: General.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

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

  15. 42 CFR 413.74 - Payment to a foreign hospital.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Payment to a foreign hospital. 413.74 Section 413.74 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...

  16. 42 CFR 413.64 - Payments to providers: Specific rules.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Payments to providers: Specific rules. 413.64 Section 413.64 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...

  17. 42 CFR 413.64 - Payments to providers: Specific rules.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Payments to providers: Specific rules. 413.64 Section 413.64 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...

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

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 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 413.74 - Payment to a foreign hospital.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Payment to a foreign hospital. 413.74 Section 413.74 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...

  20. 42 CFR 413.74 - Payment to a foreign hospital.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Payment to a foreign hospital. 413.74 Section 413.74 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...

  1. 42 CFR 413.64 - Payments to providers: Specific rules.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Payments to providers: Specific rules. 413.64 Section 413.64 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...

  2. 42 CFR 413.60 - Payments to providers: General.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 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...

  3. 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...

  4. 42 CFR 413.64 - Payments to providers: Specific rules.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Payments to providers: Specific rules. 413.64 Section 413.64 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...

  5. 42 CFR 413.60 - Payments to providers: General.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 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...

  6. 42 CFR 421.103 - Payment to providers.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payment to providers. 421.103 Section 421.103... (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Intermediaries § 421.103 Payment to providers. Providers... Contractors (MACs) are implemented, providers are reassigned from intermediaries to MACs in accordance...

  7. 42 CFR 408.6 - Methods and priorities for payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Methods and priorities for payment. 408.6 Section 408.6 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PREMIUMS FOR SUPPLEMENTARY MEDICAL INSURANCE General Provisions § 408.6 Methods and priorities for payment. (a) Methods of...

  8. 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....

  9. Alternative strategies for Medicare payment of outpatient prescription drugs--Part B and beyond.

    PubMed

    Danzon, Patricia M; Wilensky, Gail R; Means, Kathleen E

    2005-03-01

    Reimbursement options for pharmaceuticals reimbursed under Medicare Part B (physician-dispensed drugs) are changing and the new comprehensive Part D Medicare outpatient drug benefit brings further changes. The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) replaces traditional policy, of reimbursing Part B drugs at 95% of average wholesale price (AWP, a list price), with a percentage markup over the manufacturer's average selling price; in 2005 an indirect competitive procurement option will be introduced. In our view, although AWP-based reimbursement has been fraught with problems in the past, these could be fixed by constraining growth in AWP and periodically adjusting the discount off AWP. With these revisions, an AWP-based rule would preserve incentives for competitive discounting and deliver savings to Medicare. By contrast, basing Medicare reimbursement on a manufacturer's average selling price undermines incentives for discounting and, like any cost-based reimbursement rule, may result in higher prices to both public and private purchasers. Indirect competitive procurement for drugs alone, using specialty pharmacies, pharmacy benefit managers, or prescription drug plans, is unlikely to constrain costs to acceptable levels unless contractors retain flexibility to use standard benefit management tools. Folding Part B and Part D into comprehensive contracting with health plans for full health services is likely to offer the most efficient approach to managing the drug benefit.

  10. 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.

  11. Medicare program; aggregation of Medicare claims for administrative appeals--HCFA. Final rule.

    PubMed

    1994-03-16

    Medicare beneficiaries and, under certain circumstances, providers, physicians and other entities furnishing health care services may appeal adverse determinations regarding certain claims for benefits payable under part A and part B of Medicare. For administrative appeals at the carrier or intermediary hearing level or administrative law judge (ALJ) level and for any subsequent judicial review, the amount remaining in dispute must meet or exceed threshold amounts set by statute. Section 1869(b)(2) of the Social Security Act permits claims to be aggregated to reach the ALJ hearing threshold amounts. This final rule establishes a system of aggregation under which individual appellants have one set of requirements for aggregating claims and two or more appellants have a different set of requirements for aggregating claims.

  12. Change in the Medicare case-mix index in the 1980s and the effect of the prospective payment system.

    PubMed Central

    Goldfarb, M G; Coffey, R M

    1992-01-01

    Persistent increases in the Medicare case-mix index over the 1980s have been ascribed to changes both in medical treatment ("real changes") and in the way medical information is recorded ("coding changes") in hospitals. These changes have been attributed, in the absence of appropriate data and analyses, to the incentives of the Medicare prospective payment system (PPS). Using data for 1980-1986 from 235 hospitals, we estimate the effect on the Medicare case-mix index of a series of variables that reflect medical treatments and coding practices. Each of these underlying real or coding variables was changing prior to PPS and would likely have continued to change even in the absence of PPS. Furthermore, PPS may have had a distinct effect on these variables. These underlying trends and the PPS effects must each be estimated. Thus, the analysis begins by developing separate estimates for each of these real and coding variables (1) in the absence of PPS (autonomous effects) and (2) as a result of PPS (induced effects). Then, changes in the case-mix index are regressed against all of these variables to determine the degree to which specific autonomous real or coding variables or induced real or coding variables actually influenced measured case mix. Results show that real and coding changes each accounted for about half of the change in the Medicare case-mix index between 1980 and 1986, with the influence of coding starting to wane by 1986. PPS-induced factors explain about 80 percent of the change in measured case mix over time, autonomous factors about 20 percent. Especially powerful determinants of case-mix change included PPS-induced substitution of surgical for medical care and PPS-induced improvements in the accuracy of coding that led to assignment of patients to higher-weighted DRGs. Also, stringent Medicare peer review organizations appeared to restrain rises in case-mix indexes for their hospitals. Outpatient substitution for inpatient treatment, which others

  13. Duplicate Federal Payments for Dual Enrollees in Medicare Advantage Plans and the Veterans Affairs Health Care System

    PubMed Central

    Trivedi, Amal N.; Grebla, Regina C.; Jiang, Lan; Yoon, Jean; Mor, Vincent; Kizer, Kenneth W.

    2013-01-01

    Context Some veterans are eligible to enroll simultaneously in a Medicare Advantage (MA) plan and the Veterans Affairs health care system (VA). This scenario produces the potential for redundant federal spending because MA plans would receive payments to insure veterans who receive care from the VA, another taxpayer-funded health plan. Objective To quantify the prevalence of dual enrollment in VA and MA, the concurrent use of health services in each setting, and the estimated costs of VA care provided to MA enrollees. Design Retrospective analysis of 1 245 657 veterans simultaneously enrolled in the VA and an MA plan between 2004–2009. Main Outcome Measures Use of health services and inflation-adjusted estimated VA health care costs. Results Among individuals who were eligible to enroll in the VA and in an MA plan, the number of persons dually enrolled increased from 485 651 in 2004 to 924 792 in 2009. In 2009, 8.3% of the MA population was enrolled in the VA and 5.0% of MA beneficiaries were VA users. The estimated VA health care costs for MA enrollees totaled $13.0 billion over 6 years, increasing from $1.3 billion in 2004 to $3.2 billion in 2009. Among dual enrollees, 10% exclusively used the VA for outpatient and acute inpatient services, 35% exclusively used the MA plan, 50% used both the VA and MA, and 4% received no services during the calendar year. The VA financed 44% of all outpatient visits (n=21 353 841), 15% of all acute medical and surgical admissions (n=177 663), and 18% of all acute medical and surgical inpatient days (n=1 106 284) for this dually enrolled population. In 2009, the VA billed private insurers $52.3 million to reimburse care provided to MA enrollees and collected $9.4 million (18% of the billed amount; 0.3% of the total cost of care). Conclusions The federal government spends a substantial and increasing amount of potentially duplicative funds in 2 separate managed care programs for the care of same individuals. PMID:22735360

  14. Medicare and state health care programs; fraud and abuse: OIG civil money penalties under the Medicare prescription drug discount card program. Interim final rule with comment period.

    PubMed

    2004-05-19

    In accordance with section 1860D-31 of the Social Security Act, this rule sets forth the OIG's new authority for imposing civil money penalties (CMPs) against endorsed sponsors under the Medicare prescription drug discount card program that knowingly engage in false or misleading marketing practices; overcharge program enrollees; or misuse transitional assistance funds.

  15. Medicare and state health care programs; fraud and abuse: OIG civil money penalties under the Medicare prescription drug discount card program. Final rule.

    PubMed

    2004-12-14

    In accordance with section 1860D-31 of the Social Security Act, this rule finalizes OIG's new authority for imposing civil money penalties (CMPs) against endorsed sponsors under the Medicare prescription drug discount card program that knowingly engage in false or misleading marketing practices; overcharge program enrollees; or misuse transitional assistance funds.

  16. 78 FR 59704 - Medicare, Medicaid, and CLIA Programs; Clinical Laboratory Improvement Amendments of 1988...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-27

    ... Services (HHS). Under section 1861(s) of the Social Security Act (the Act), the Medicare program will only... enforcement procedures for laboratories found to be out of compliance with its requirements. The ability...

  17. 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.

  18. 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

  19. 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)...

  20. Experience with Designing and Implementing a Bundled Payment Program for Total Hip Replacement

    PubMed Central

    Whitcomb, Winthrop F.; Lagu, Tara; Krushell, Robert J.; Lehman, Andrew P.; Greenbaum, Jordan; McGirr, Joan; Pekow, Penelope S.; Calcasola, Stephanie; Benjamin, Evan; Mayforth, Janice; Lindenauer, Peter K.

    2015-01-01

    Background Bundled payments, also known as episode-based payments, are intended to contain health care costs and promote quality. In 2011 a bundled payment pilot program for total hip replacement was implemented by an integrated health care delivery system in conjunction with a commercial health plan subsidiary. In July 2015 the Centers for Medicare & Medicaid Services (CMS) proposed the Comprehensive Care for Joint Replacement Model to test bundled payment for hip and knee replacement. Methods Stakeholders were identified and a structure for program development and implementation was created. An Oversight Committee provided governance over a Clinical Model Subgroup and a Financial Model Subgroup. Results The pilot program included (1) a clinical model of care encompassing the period from the preoperative evaluation through the third postoperative visit, (2) a pricing model, (3) a program to share savings, and (4) a patient engagement and expectation strategy. Compared to 32 historical controls— patients treated before bundle implementation—45 post-bundle-implementation patients with total hip replacement had a similar length of hospital stay (3.0 versus 3.4 days, p = .24), higher rates of discharge to home or home with services than to a rehabilitation facility (87% versus 63%), similar adjusted median total payments ($22,272 versus $22,567, p = .43), and lower median posthospital payments ($704 versus $1,121, p = .002), and were more likely to receive guideline-consistent care (99% versus 95%, p = .05). Discussion The bundled payment pilot program was associated with similar total costs, decreased posthospital costs, fewer discharges to rehabilitation facilities, and improved quality. Successful implementation of the program hinged on buy-in from stakeholders and close collaboration between stakeholders and the clinical and financial teams. PMID:26289235

  1. 77 FR 9179 - Medicare Program; Reporting and Returning of Overpayments

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-16

    ...), HHS. ACTION: Proposed rule. SUMMARY: This proposed rule would require providers and suppliers... approximately 47 million enrolled beneficiaries. Providers and suppliers furnishing Medicare items and services... ``person'' as a provider of services, supplier, Medicaid managed care organization (MCO) (as defined...

  2. Cost of Smoking to the Medicare Program, 1993

    PubMed Central

    Zhang, Xiulan; Miller, Leonard; Max, Wendy; Rice, Dorothy P.

    1999-01-01

    Medicare expenditures attributable to smoking in 1993 were estimated using a multivariate model that related expenditures to smoking history, health status, and the propensity to have had a smoking-related disease, controlling for sociodemographics, economic variables, and other risk factors. Smoking-attributable Medicare expenditures are presented separately for each State and by type of expenditure. Nationally, smoking accounted for 9.4 percent of Medicare expenditures—$14.2 billion, with considerable variation among States. Smoking accounted for 11.4 percent of Medicare expenditures for hospital care, 11.3 percent of nursing home care, 5.9 percent of home health care, and 5.6 percent of ambulatory care. PMID:11482121

  3. 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...

  4. 75 FR 32480 - Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-08

    ... Outreach and Assistance Program Funding for Title VI Native American Programs Purpose of Notice... Medicare Beneficiary Outreach and Assistance Program Funding for Title VI Native American Programs... Older Americans Act Title VI Native American program awardee. The purpose of these grants will be...

  5. 77 FR 35917 - Medicare Program; Medicare Secondary Payer and “Future Medicals”

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-15

    ... trauma,'' and ``major trauma,'' specifically, whether they are accurate and usable in terms of the... definition of ``major trauma.'' The Injury Severity Score (ISS) is one of several methods used to measure the.../beneficiary's settlement, judgment, award, or other payment. Physical Trauma: refers to an injury (as a...

  6. Impact Of The YMCA Of The USA Diabetes Prevention Program On Medicare Spending And Utilization.

    PubMed

    Alva, Maria L; Hoerger, Thomas J; Jeyaraman, Ravikumar; Amico, Peter; Rojas-Smith, Lucia

    2017-03-01

    The YMCA of the USA received a Health Care Innovation Award from the Centers for Medicare and Medicaid Services to provide a diabetes prevention program to Medicare beneficiaries with prediabetes in seventeen regional networks of participating YMCAs nationwide. The goal of the program is to help participants lose weight and increase physical activity. We tested whether the program reduced medical spending and utilization in the Medicare population. Using claims data to compute total medical costs for fee-for-service Medicare participants and a matched comparison group of nonparticipants, we found that the overall weighted average savings per member per quarter during the first three years of the intervention period was $278. Total decreases in inpatient admissions and emergency department (ED) visits were significant, with nine fewer inpatient stays and nine fewer ED visits per 1,000 participants per quarter. These results justify continued support of the model.

  7. 75 FR 41397 - Asparagus Revenue Market Loss Assistance Payment Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-16

    ... Commodity Credit Corporation 7 CFR Part 1429 RIN 0560-AI02 Asparagus Revenue Market Loss Assistance Payment... Market Loss Assistance Payment (ALAP) Program authorized by the Food, Conservation, and Energy Act of... Secretary of Agriculture to ``make payments to producers of the 2007 crop of asparagus for market...

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

    Code of Federal Regulations, 2010 CFR

    2010-10-01

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

  9. 78 FR 63984 - Medicare and Medicaid Programs: Application From the Joint Commission for Continued Approval of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-25

    ... and approval of a national accrediting organization's requirements consider, among other factors, the... will be conducted in accordance with, but not necessarily limited to, the following factors: The... Program No. 93.778, Medical Assistance Program; No. 93.773 Medicare--Hospital Insurance Program; and...

  10. 76 FR 5861 - Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-02

    ...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......

  11. 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...

  12. 42 CFR 413.70 - Payment for services of a CAH.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Payment for services of a CAH. 413.70 Section 413.70 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...

  13. 42 CFR 413.70 - Payment for services of a CAH.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payment for services of a CAH. 413.70 Section 413.70 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...

  14. 42 CFR 413.70 - Payment for services of a CAH.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Payment for services of a CAH. 413.70 Section 413.70 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...

  15. 42 CFR 413.70 - Payment for services of a CAH.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Payment for services of a CAH. 413.70 Section 413.70 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...

  16. 42 CFR 413.70 - Payment for services of a CAH.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Payment for services of a CAH. 413.70 Section 413.70 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...

  17. 42 CFR 412.624 - Methodology for calculating the Federal prospective payment rates.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... interrupted patient stay is to receive inpatient acute care hospital services, an amount based on the... payment rates. 412.624 Section 412.624 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT...

  18. 42 CFR 413.172 - Principles of prospective payment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE...-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.172 Principles of prospective payment. (a) Payment for renal dialysis services as defined in § 413.171 and home dialysis services...

  19. 42 CFR 413.172 - Principles of prospective payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE...-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.172 Principles of prospective payment. (a) Payment for renal dialysis services as defined in § 413.171 and home dialysis services...

  20. 42 CFR 413.172 - Principles of prospective payment.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE...-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.172 Principles of prospective payment. (a) Payment for renal dialysis services as defined in § 413.171 and home dialysis services...

  1. 42 CFR 413.172 - Principles of prospective payment.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE...-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.172 Principles of prospective payment. (a) Payment for renal dialysis services as defined in § 413.171 and home dialysis services...

  2. 42 CFR 413.172 - Principles of prospective payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE...-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.172 Principles of prospective... text is set forth as follows: § 413.172 Principles of prospective payment. (a) Payment for...

  3. 42 CFR 447.207 - Retention of payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Retention of payments. 447.207 Section 447.207 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PAYMENTS FOR SERVICES Payment Methods: General Provisions §...

  4. 42 CFR 418.307 - Periodic interim payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Periodic interim payments. 418.307 Section 418.307... (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Payment for Hospice Care § 418.307 Periodic interim payments. Subject to the provisions of § 413.64(h) of this chapter, a hospice may elect to receive periodic...

  5. 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....

  6. 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....

  7. 42 CFR 418.306 - Determination of payment rates.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Payment for Hospice Care § 418.306 Determination of payment rates. (a) Applicability. CMS establishes payment rates for each of the categories of hospice care... hospice care are as follows: (1) The following rates, which are 120 percent of the rates in effect...

  8. 42 CFR 418.306 - Determination of payment rates.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... (CONTINUED) MEDICARE PROGRAM (CONTINUED) HOSPICE CARE Payment for Hospice Care § 418.306 Determination of payment rates. (a) Applicability. CMS establishes payment rates for each of the categories of hospice care... hospice care are as follows: (1) The following rates, which are 120 percent of the rates in effect...

  9. Medicare’s Policies and Prospective Payment Rates for Cardiac Pacemaker Surgeries need Review and Revision.

    DTIC Science & Technology

    1985-02-26

    pacemaker manufacturers whose sales account for about 80 percent of the pacemaker sales in the United States. The four manufacturers are: -- Cordis ...percentage increase in the hospital market basket (an index designed to measure changes in the prices hospitals pay for goods and services) plus 0.25 percent...For fiscal year 1986, the DRG payment rates cannot be in- creased by more than the estimated change in the hospital market basket plus 0.25 percent

  10. Impact of Medicare Advantage Prescription Drug Plan Star Ratings on Enrollment before and after Implementation of Quality-Related Bonus Payments in 2012

    PubMed Central

    Li, Pengxiang; Doshi, Jalpa A.

    2016-01-01

    Objective Since 2007, the Centers for Medicare and Medicaid Services have published 5-star quality rating measures to aid consumers in choosing Medicare Advantage Prescription Drug Plans (MAPDs). We examined the impact of these star ratings on Medicare Advantage Prescription Drug (MAPD) enrollment before and after 2012, when star ratings became tied to bonus payments for MAPDs that could be used to improve plan benefits and/or reduce premiums in the subsequent year. Methods A longitudinal design and multivariable hybrid models were used to assess whether star ratings had a direct impact on concurrent year MAPD contract enrollment (by influencing beneficiary choice) and/or an indirect impact on subsequent year MAPD contract enrollment (because ratings were linked to bonus payments). The main analysis was based on contract-year level data from 2009–2015. We compared effects of star ratings in the pre-bonus payment period (2009–2011) and post-bonus payment period (2012–2015). Extensive sensitivity analyses varied the analytic techniques, unit of analysis, and sample inclusion criteria. Similar analyses were conducted separately using stand-alone PDP contract-year data; since PDPs were not eligible for bonus payments, they served as an external comparison group. Result The main analysis included 3,866 MAPD contract-years. A change of star rating had no statistically significant effect on concurrent year enrollment in any of the pre-, post-, or pre-post combined periods. On the other hand, star rating increase was associated with a statistically significant increase in the subsequent year enrollment (a 1-star increase associated with +11,337 enrollees, p<0.001) in the post-bonus payment period but had a very small and statistically non-significant effect on subsequent year enrollment in the pre-bonus payment period. Further, the difference in effects on subsequent year enrollment was statistically significant between the pre- and post-periods (p = 0

  11. Does It Pay to Penalize Hospitals for Excess Readmissions? Intended and Unintended Consequences of Medicare's Hospital Readmissions Reductions Program.

    PubMed

    Mellor, Jennifer; Daly, Michael; Smith, Molly

    2016-07-15

    To incentivize hospitals to provide better quality care at a lower cost, the Affordable Care Act of 2010 included the Hospital Readmissions Reduction Program (HRRP), which reduces payments to hospitals with excess 30-day readmissions for Medicare patients treated for certain conditions. We use triple difference estimation to identify the HRRP's effects in Virginia hospitals; this method estimates the difference in changes in readmission over time between patients targeted by the policy and a comparison group of patients and then compares those difference-in-differences estimates in patients treated at hospitals with readmission rates above the national average (i.e., those at risk for penalties) and patients treated at hospitals with readmission rates below or equal to the national average (those not at risk). We find that the HRRP significantly reduced readmission for Medicare patients treated for acute myocardial infarction (AMI). We find no evidence that hospitals delay readmissions, treat patients with greater intensity, or alter discharge status in response to the HRRP, nor do we find changes in the age, race/ethnicity, health status, and socioeconomic status of patients admitted for AMI. Future research on the specific mechanisms behind reduced AMI readmissions should focus on actions by healthcare providers once the patient has left the hospital. Copyright © 2016 John Wiley & Sons, Ltd.

  12. Medicare Part D and the Federal Employees Health Benefits Program: A Comparison of Prescription Drug Coverage

    PubMed Central

    Lovett, Annesha

    2013-01-01

    Background There is much debate currently about how to restructure the Medicare program to achieve better value for the money. Many have cited the Federal Employees Health Benefits Program (FEHBP) as a model for reform. Objective To compare drug coverage and cost-sharing between Medicare Part D and the FEHBP plans. Methods A cross-sectional comparison was conducted of January 2009 data obtained from the Centers for Medicare & Medicaid Services, the Office of Personnel Management, and 3 health plan websites. Regression analysis and t-tests were used to examine drug coverage, copayment, and coinsurance amounts among Medicare Part D and FEHBP plans. The final study sample of Medicare Part D plans consisted of 19 formularies, covering 63% of total Part D enrollment. These 19 formularies represented 232 stand-alone prescription drug plans. In addition, 5 prescription drug plans or formularies in the FEHBP plans were included, which represents 70% of total FEHBP enrollment. Results The results of this study reveal that formulary coverage of the top drugs dispensed and sold in the United States in 2009 ranged from 72% to 94% (average, 84%) in Medicare Part D plans and from 85% to 99% (average, 94%) in the FEHBP plans (P <.01). The mean copayment for generic drugs in Medicare Part D plans was $4.53 compared with a mean of $7.67 (P <.05) in the FEHBP plans. The difference between the 2 programs in mean copayment for brand-name drugs was nonsignificant. For generic drugs, the mean coinsurance rate was 17% for Medicare Part D plans and a mean of 20% for the FEHBP plans (P <.05). Conclusions This analysis shows that there are differences in prescription drug coverage and cost-sharing among plans within Medicare Part D and the FEHBP. To avoid extreme increases in payroll taxes and other revenues or major cutbacks in services, Medicare must explore ways to change the healthcare system to achieve better value for the money. The experience of the FEHBP suggests a possible means of

  13. 77 FR 17070 - Medicare and Medicaid Programs; Application From Det Norske Veritas Healthcare (DNVHC) for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-23

    ... national accrediting organization's requirements consider, among other factors, the applying accrediting... accordance with, but not necessarily limited to, the following factors: The equivalency of DNVHC's standards.... 93.778, Medical Assistance Program; No. 93.773 Medicare--Hospital Insurance Program; and No....

  14. 77 FR 37681 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-22

    ... Health Insurance Program (CHIP). This meeting is open to the public. ] DATES: Meeting Date: Thursday... 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...

  15. 78 FR 32664 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-31

    ... the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES: Meeting... 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...

  16. 76 FR 11782 - Medicare, Medicaid, and Children's Health Insurance Programs; Renewal, Expansion, and Renaming of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-03

    ... with or who are eligible for Medicare, Medicaid and the Children's Health Insurance Program (CHIP... Insurance Assistance Programs (SHIPs), health insurance plans, aging, Web health education, e-prescribing... insurance exchanges, and minority health education. We are requesting that all curricula vitae include...

  17. 77 FR 70785 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-27

    ... the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES: Meeting..., Medicare, Medicaid and the Children's Health Insurance Program (CHIP). Enhancing the federal government's... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  18. 76 FR 61365 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-04

    ... the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES: Meeting..., Medicare, Medicaid and the Children's Health Insurance Program (CHIP). Enhancing the Federal government's... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  19. 78 FR 12327 - Medicare, Medicaid, and Children's Health Insurance Programs; Meeting of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-22

    ... the Children's Health Insurance Program (CHIP). This meeting is open to the public. DATES: Meeting..., Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). Enhancing the federal governments... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  20. 78 FR 32661 - Medicare, Medicaid, and Children's Health Insurance Programs; Renewal of the Advisory Panel on...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-31

    ... the Children's Health Insurance Program (CHIP), and also expanded the availability of other options... are eligible for Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) about options... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  1. 42 CFR 413.220 - Methodology for calculating the per-treatment base rate under the ESRD prospective payment system...

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 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... utilized: (1) Medicare data available to estimate the average cost and payments for renal dialysis...

  2. 42 CFR 413.220 - Methodology for calculating the per-treatment base rate under the ESRD prospective payment system...

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 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... utilized: (1) Medicare data available to estimate the average cost and payments for renal dialysis...

  3. 42 CFR 413.220 - Methodology for calculating the per-treatment base rate under the ESRD prospective payment system...

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 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... utilized: (1) Medicare data available to estimate the average cost and payments for renal dialysis...

  4. ACOs in real life: a reflection on the Medicare Shared Savings Program.

    PubMed

    Behm, Craig R

    2015-01-01

    The Medicare Shared Savings Program introduced Accountable Care Organizations (ACOs) as one potential method for meeting the often-cited triple aim of better individual care, improved population health, and lower cost. Built on concepts originating from HMOs and then Medicare Advantage plans, ACOs provide incentives based on total cost of care rather than any individual provider's cost. Early quality and cost results are mixed, and, more importantly, so is physician response. The ACO program still has potential to be a bright spot for the future of healthcare, but until there is widespread physician engagement, achieving the triple aim is likely to remain elusive.

  5. Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2003 and inclusion of registered nurses in the personnel provision of the critical access hospital emergency services requirement for frontier areas and remote locations. Final rule with comment period.

    PubMed

    2002-12-31

    This final rule with comment period refines the resource-based practice expense relative value units (RVUs) and makes other changes to Medicare Part B payment policy. In addition, as required by statute, we are announcing the physician fee schedule update for CY 2003. The update to the physician fee schedule occurs as a result of a calculation methodology specified by law. That law required the Department to set annual updates based in part on estimates of several factors. Although subsequent after-the-fact data indicate that actual increases were different to some degree from earlier estimates, the law does not permit those estimates to be revised. A subsequent law required estimates to be revised for FY 2000 and beyond. Although we have exhaustively examined opportunities for a different interpretation of law that would allow us to correct the flaw in the formula administratively, current law does not permit such an interpretation. Accordingly, without Congressional action to address the current legal framework, the Department is compelled to announce herein a physician fee schedule update for CY 2003 of -4.4 percent. Because the Department would adopt a change in the formula that determines the physician update if the law permitted it, we have examined how proper adjustments to past data could result in a positive update. The Department believes that revisions of estimates used to establish the sustainable growth rates (SGR) for fiscal years (FY) 1998 and 1999 and Medicare volume performance standards (MVPS) for 1990-1996 would, under present calculations, result in a positive update. The Department intends to work closely with Congress to develop legislation that could permit a positive update, and hopes that such legislation can be passed before the negative update takes effect. Because the Department wishes to change the update promptly in the event that Congress provides the Department legal authority to do so, we are requesting comments regarding how

  6. 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...

  7. 76 FR 19710 - Tobacco Transition Payment Program; Cigar and Cigarette Per Unit Assessments; Correction

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-08

    ... Payment Program; Cigar and Cigarette Per Unit Assessments; Correction AGENCY: Commodity Credit Corporation... correction to the Request for Comments titled ``Tobacco Transition Payment Program; Cigar and Cigarette...

  8. Medicare program; physician fee freeze sanctions--HHS. Notice of proposed rulemaking.

    PubMed

    1985-09-13

    This notice of proposed rulemaking sets forth OIG procedures for the imposition of civil money penalties and Medicare program exclusions on physicians who choose not to be participating physicians and who raise charges to Medicare beneficiaries in violation of the freeze on such fees contained in Section 2306 of Pub. L. 98-369 (the Deficit Reduction Act of 1984). The proposed rule also modifies existing regulations to permit the OIG to impose civil money penalties and assessments on those who choose to be participating physicians under the Medicare program and who violate their participation agreements as set forth in Section 2306. This regulation does not pertain to HCFA's responsibility for the Physician Fee Freeze.

  9. 78 FR 79201 - Medicare and State Health Care Programs: Fraud and Abuse; Electronic Health Records Safe Harbor...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-27

    ... 1001 Medicare and State Health Care Programs: Fraud and Abuse; Electronic Health Records Safe Harbor... Inspector General 42 CFR Part 1001 RIN 0991-AB33 Medicare and State Health Care Programs: Fraud and Abuse... and technologies in the health care industry. In accordance with this authority, OIG published a...

  10. 42 CFR 411.54 - Limitation on charges when a beneficiary has received a liability insurance payment or has a...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer. 411.54 Section 411.54 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE...

  11. 42 CFR 413.81 - Direct GME payments: Application of community support and redistribution of costs in determining...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Direct GME payments: Application of community... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Specific Categories of Costs §...

  12. 42 CFR 412.526 - Payment provisions for a “subclause (II)” long-term care hospital.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... reimbursement rules. Medicare inpatient operating costs are paid based on reasonable cost, subject to a ceiling..., DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL... payment amount is determined based on reasonable cost, as described at § 412.526(c). (c) Determining...

  13. 42 CFR 414.426 - Adjustments to competitively bid payment amounts to reflect changes in the HCPCS.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Adjustments to competitively bid payment amounts to reflect changes in the HCPCS. 414.426 Section 414.426 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PAYMENT FOR PART B...

  14. 42 CFR 414.426 - Adjustments to competitively bid payment amounts to reflect changes in the HCPCS.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Adjustments to competitively bid payment amounts to reflect changes in the HCPCS. 414.426 Section 414.426 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR...

  15. 76 FR 16793 - Medicare and Medicaid Programs; Renewal of Deeming Authority of the National Committee for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-25

    ... Deeming Authority of the National Committee for Quality Assurance for Medicare Advantage Health... Medicare Advantage Deeming Authority of the National Committee for Quality Assurance (NCQA) for Health... through a Medicare Advantage (MA) organization that contracts with the Centers for Medicare &...

  16. 77 FR 26553 - Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel-May 21, 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-04

    ... Economic Index Technical Advisory Panel--May 21, 2012 AGENCY: Centers for Medicare & Medicaid Services (CMS... Economic Index Technical Advisory Panel (``the Panel'') will be held on Monday, May 21, 2012. The purpose of the Panel is to review all aspects of the Medicare Economic Index (MEI). This first meeting...

  17. Medicare program; end-stage renal disease program; prospective reimbursement for dialysis services and approval of special purpose renal dialysis facilities--HCFA. Final rule.

    PubMed

    1983-05-11

    These regulations change the reimbursement system by which Medicare pays for outpatient maintenance dialysis and related physician and laboratory services. These changes establish a prospective method of payment for maintenance dialysis, whether furnished at home or in a hospital-based or independent dialysis facility, and revise other aspects of the reimbursement system to encourage home dialysis and provide incentives for economy and efficiency in furnishing these services. These amendments implement section 2145 of the Omnibus Budget Reconciliation Act of 1981. We expect that these changes will improve our administration of the end-stage renal disease program and enable us to control the rapidly growing costs of furnishing dialysis. The controls on quality of care that have been in effect since the beginning of the program will continue to apply. These regulations will also ensure access to care by providing for adequate reimbursement to isolated, essential facilities, where patients have no alternative sources of dialysis care. These regulations also provide for time-limited approval for Medicare participation of special purpose renal dialysis facilities. As a general rule we have not approved facilities such as transient or mobile units set up for emergency purposes or to serve vacationing dialysis patients in State parks and children's camps. This change in regulations will remove this limitation.

  18. 76 FR 22709 - Medicare and Medicaid Programs; Approval of the American Association for Accreditation of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-22

    ... Organizations That Provide Outpatient Physical Therapy and Speech-Language Pathology Services AGENCY: Centers... therapy and speech-language pathology services seeking to participate in the Medicare or Medicaid programs... therapy and speech language pathology covered services from a provider of services, a clinic,...

  19. 75 FR 39641 - Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-07-12

    ... and Medicaid Programs; Civil Money Penalties for Nursing Homes AGENCY: Centers for Medicare & Medicaid... when nursing homes are not in compliance with Federal participation requirements in accordance with the... certified as meeting Federal participation requirements. Long-term care facilities include skilled...

  20. 75 FR 65282 - Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-10-22

    ... skilled nursing facility (SNF) in the Medicare program, or as a nursing facility (NF) in the Medicaid..., approximately 1.4 million elderly and disabled nursing home residents are receiving care in nearly 16,000... percent of older Americans die in nursing homes. (Johnson, Sandra H., Hastings Center Report, Making...

  1. Evaluation of Student Outcomes after Participating in a Medicare Outreach Program

    ERIC Educational Resources Information Center

    Hollingsworth, Joshua C.; Teeter, Benjamin S.; Westrick, Salisa C.

    2015-01-01

    This article describes the development of a service-learning project and analysis of student pharmacists' participation therein. Using a mixed-methods approach, this study analyzed student pharmacists' knowledge and attitudes after volunteering in the inaugural Medicare Outreach Program, a collaboration between the School of Pharmacy and State…

  2. 78 FR 308 - Medicare Program; Request for Information on Hospital and Vendor Readiness for Electronic Health...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-03

    ... Health Records Hospital Inpatient Quality Data Reporting AGENCY: Centers for Medicare & Medicaid Services... associated with hospital collection and submission of patient-level data on clinical quality measures (CQMs... quality reporting programs through automatic collection and reporting of data on CQMs using CEHRT....

  3. 76 FR 47301 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-04

    ... Medicare and Medicaid Programs h. Accounting Statement i. Conclusion B. Regulatory Flexibility Act Analysis....306(c) require each hospice's labor market to be established using the most current hospital wage data... the most current available hospital wage data, as well as any changes by the OMB to the definitions...

  4. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    .... (a) Reasons for denial. CMS may deny a provider's or supplier's enrollment in the Medicare program for the following reasons: (1) Compliance. The provider or supplier at any time is found not to be in..., rape, or assault, and other similar crimes for which the individual was convicted, including...

  5. 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

    ... supplier, unless there is good cause not to suspend payments; or (3) Offset or recouped, in whole or in... supplier to whom payments are to be made has been overpaid. (b) Good cause exceptions applicable to payment suspensions. (1) CMS may find that good cause exists not to suspend payments or not to continue to...

  6. 76 FR 6313 - Asparagus Revenue Market Loss Assistance Payment Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-04

    ... Commodity Credit Corporation 7 CFR Part 1429 RIN 0560-AI02 Asparagus Revenue Market Loss Assistance Payment...: This rule implements the Asparagus Revenue Market Loss Assistance Payment (ALAP) Program authorized by... domestic production, reduced U.S. market share for domestic producers, and reduced market prices for...

  7. Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program

    PubMed Central

    Schwartz, Aaron L.; Chernew, Michael E.; Landon, Bruce E.; McWilliams, J. Michael

    2016-01-01

    Importance Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services. Objective To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services. Design, Setting and Participants In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other providers (control group) before (2009–2011) vs. after (2012) Pioneer ACO contracts began. We adjusted comparisons for beneficiaries’ sociodemographic and clinical characteristics and for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs. lower baseline use of low-value services. Main Outcomes and Measures Use of, and spending on, 31 services in instances that provide minimal clinical benefit. Results During the pre-contract period, trends in use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction of 0.8 low-value services per 100 beneficiaries for the ACO group (95% CI: −1.2, −0.4; P<0.001), corresponding to a 1.9% reduction in service quantity (95% CI: −2.9%, −0.9%) and a 4.5% differential reduction in spending on low-value services (95% CI: −7.5%, −1.4%; P=0.004). Differential reductions were similar for services less vs. more sensitive to patient preferences and for higher- vs. lower-priced services. ACOs with higher than their markets average baseline levels of low-value service use experienced greater service reductions (−1.2 services

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-17

    ... (CMS), HHS. ACTION: Notice. SUMMARY: This quarterly notice lists CMS manual instructions, substantive... through June 2012, relating to the Medicare and Medicaid programs and other programs administered by CMS... each of the addenda published in this notice. Addenda Contact Phone No. I CMS Manual...

  9. 77 FR 55479 - Medicare, Medicaid, and CHIP Programs: Research and Analysis on Impact of CMS Programs on the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-10

    ... and Analysis on Impact of CMS Programs on the Indian Health Care System AGENCY: Centers for Medicare... expansion of research on the impact of CMS programs on the Indian health care system through a single source... health care services to American Indian/ Alaska Native (AI/AN) people through a network of...

  10. Three decades of Medicare: what the numbers tell us.

    PubMed

    Davis, M H; Burner, S T

    1995-01-01

    The Medicare program was first implemented to meet a critical need in American society, and over its thirty-year history it has evolved into an integral part of the U.S. health care system. This DataWatch provides a broad overview of the program, outlining both historical and current trends in coverage, financing, payment mechanisms, beneficiary status, benefits, and spending.

  11. 42 CFR 412.632 - Method of payment under the inpatient rehabilitation facility prospective payment system.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR.... (a) General rule. Subject to the exceptions in paragraphs (b) and (c) of this section, an inpatient... intermediary estimates PIP based on that payment experience, adjusted for projected changes supported...

  12. 42 CFR 417.104 - Payment for basic health services.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Payment for basic health services. 417.104 Section 417.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  13. 42 CFR 416.120 - Basis for payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 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... covers the cost of services such as supplies, nursing services, equipment, etc., as specified in §...

  14. 42 CFR 417.105 - Payment for supplemental health services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payment for supplemental health services. 417.105 Section 417.105 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS,...

  15. 42 CFR 417.105 - Payment for supplemental health services.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Payment for supplemental health services. 417.105 Section 417.105 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  16. 42 CFR 417.104 - Payment for basic health services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payment for basic health services. 417.104 Section 417.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS,...

  17. 42 CFR 417.104 - Payment for basic health services.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Payment for basic health services. 417.104 Section 417.104 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  18. 42 CFR 417.808 - Interim per capita payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Interim per capita payments. 417.808 Section 417.808 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH...

  19. 42 CFR 417.808 - Interim per capita payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Interim per capita payments. 417.808 Section 417.808 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH...

  20. 42 CFR 417.105 - Payment for supplemental health services.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Payment for supplemental health services. 417.105 Section 417.105 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  1. 42 CFR 412.422 - Basis of payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis of payment. 412.422 Section 412.422 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... as specified in subpart G of part 409 of this chapter) for inpatient operating and...

  2. 42 CFR 413.335 - Basis of payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis of payment. 413.335 Section 413.335 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... (routine, ancillary, and capital-related) associated with furnishing inpatient SNF services to...

  3. 42 CFR 495.312 - Process for payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES... PROGRAM Requirements Specific to the Medicaid Program § 495.312 Process for payments. (a) General rule... disburses an incentive payment to the provider based on the criteria described in subpart A and this...

  4. 42 CFR 412.531 - Special payment provisions when an interruption of a stay occurs in a long-term care hospital.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Special payment provisions when an interruption of a stay occurs in a long-term care hospital. 412.531 Section 412.531 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL...

  5. 42 CFR 412.304 - Implementation of the capital prospective payment system.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES... the capital prospective payment system. (a) General rule. As described in §§ 412.312 through 412.370... after October 1, 1991 and before October 1, 2001, the capital payment amount is based on either...

  6. 42 CFR 447.362 - Upper limits of payment: Nonrisk contract.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Upper limits of payment: Nonrisk contract. 447.362 Section 447.362 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PAYMENTS FOR SERVICES Payment Methods for...

  7. 42 CFR 412.304 - Implementation of the capital prospective payment system.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Implementation of the capital prospective payment... HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs General Provisions § 412.304 Implementation...

  8. Setting Physicians' Prices in FFS Medicare: An Economic Perspective

    PubMed Central

    Dowd, Bryan; Feldman, Roger; Nyman, John; Town, Bob

    2006-01-01

    Recent policy discussions by the Medicare Payment Advisory Commission (MedPAC) regarding physician prices in the traditional fee-for-service (FFS) Medicare Program reflect movement toward a market pricing model. Earlier objectives such as sustainable levels of spending have given way to concerns over the relationship between fees and actual costs, access to care, and the importance of demand and supply in local markets. An important objective in other policy settings is economically efficient distribution of services. We explain the meaning of economic efficiency for Medicare physician prices and explore difficulties one might encounter in pursuing economic efficiency, as well as the cost of not pursuing it. PMID:17427848

  9. Physician profiling: can Medicare paint an accurate picture?

    PubMed

    Dummit, Laura A

    2007-09-10

    Physician profiling, that is, the comparison of the health care services used by a physician's patients to average service use or another benchmark, has been proposed as a way to improve Medicare. It has been used by private health plans and physician groups to identify both efficient practice patterns and the physicians who practice efficiently. The Medicare Payment Advisory Commission (MedPAC) and the Government Accountability Office (GAO) have recommended that Medicare adopt physician profiling to slow spending growth and improve efficiency. Recent legislation would mandate that Medicare employ profiling. This issue brief reviews MedPAC and GAO's analyses of profiling, concerns about using this type of information, and the obstacles in incorporating profiling in the Medicare program.

  10. Medicare and Medicaid programs; conditions for coverage for organ procurement organizations (OPOs). Final rule.

    PubMed

    2006-05-31

    This rule finalizes the February 4, 2005 proposed rule entitled "Medicare and Medicaid Programs; Conditions for Coverage for Organ Procurement Organizations (OPOs)." It establishes new conditions for coverage for organ procurement organizations (OPOs) that include multiple new outcome and process performance measures based on organ donor potential and other related factors in each service area of qualified OPOs. Our goal is to improve OPO performance and increase organ donation. In addition, this final rule re-certifies these 58 OPOs from August 1, 2006 through July 31, 2010 and provides an opportunity for them to sign agreements with the Secretary that will begin on August 1, 2006 and end on January 31, 2011. New agreements are needed so that the Medicare and Medicaid Programs can continue to pay them for their organ procurement activities after July 31, 2006.

  11. 77 FR 31364 - Medicare Program; Approved Renewal of Deeming Authority of the Utilization Review Accreditation...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-25

    ... Authority of the Utilization Review Accreditation Commission for Medicare Advantage Health Maintenance...), HHS. ACTION: Final notice. SUMMARY: This notice announces our decision to renew the Medicare Advantage... receive covered services through a Medicare Advantage (MA) organization that contracts with CMS....

  12. 77 FR 29001 - Medicare and Medicaid Program; Regulatory Provisions to Promote Program Efficiency, Transparency...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-16

    ... May 16, 2012 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services..., 2012 / Rules and Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare... Medicaid regulations that CMS has identified as unnecessary, obsolete, or excessively burdensome on...

  13. Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Final rule.

    PubMed

    2016-09-16

    This final rule establishes national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to plan adequately for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It will also assist providers and suppliers to adequately prepare to meet the needs of patients, residents, clients, and participants during disasters and emergency situations. Despite some variations, our regulations will provide consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters.

  14. 42 CFR 413.230 - Determining the per treatment payment amount.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL... for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.230 Determining the...

  15. 42 CFR 413.230 - Determining the per treatment payment amount.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL... for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.230 Determining the...

  16. 42 CFR 413.230 - Determining the per treatment payment amount.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL... for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.230 Determining the...

  17. 42 CFR 413.230 - Determining the per treatment payment amount.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL... for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.230 Determining the...

  18. 42 CFR 413.230 - Determining the per treatment payment amount.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL... for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs § 413.230 Determining the...

  19. 42 CFR 495.206 - Timeframe for payment to qualifying MA organizations.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... organizations for qualifying MA-affiliated eligible hospitals under common corporate governance are made under... common corporate governance under the Medicare FFS EHR incentive program, payment is made under the...

  20. 42 CFR 495.206 - Timeframe for payment to qualifying MA organizations.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... organizations for qualifying MA-affiliated eligible hospitals under common corporate governance are made under... common corporate governance under the Medicare FFS EHR incentive program, payment is made under the...