Science.gov

Sample records for medicare program payment

  1. 78 FR 47935 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-06

    ... Medicare cost report data available; a decision that was supported by numerous commenters. We do not agree... 42 CFR Parts 413 and 424 Medicare Program; Prospective Payment System and Consolidated Billing for... & Medicaid Services 42 CFR Parts 413 and 424 RIN 0938-AR65 Medicare Program; Prospective Payment System and...

  2. 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

    ... replaced the basic case-mix adjusted composite payment system and the methodologies for the reimbursement... 42 CFR Parts 413 and 417 Medicare Program; End-Stage Renal Disease Prospective Payment System... Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Bad Debt...

  3. 78 FR 74825 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-10

    ... December 10, 2013 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services... Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value-Based Purchasing Program; Organ Procurement Organizations; Quality Improvement Organizations; Electronic...

  4. 78 FR 38679 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-27

    ...-AR53 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Proposed Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital Conditions of Participation; Corrections AGENCY...

  5. 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…

  6. 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

    ...; Extension of the Payment Adjustment for Low- volume Hospitals and the Medicare-dependent Hospital (MDH) Program Under the Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals for.... SUMMARY: This notice announces changes to the payment adjustment for low-volume hospitals and to the...

  7. 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 permits...

  8. 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 the...

  9. 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 the...

  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 the...

  11. 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 the...

  12. 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 the...

  13. 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

    ....innovations.cms.gov/initiatives/aco/advance-payment/index.html . FOR FURTHER INFORMATION CONTACT: Dan Farmer... undertaken by the Center for Medicare and Medicaid Innovation (Innovation Center). The Advance Payment Model is an Innovation Center initiative designed for participants in the Medicare Shared Savings Program...

  14. 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...

  15. 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...

  16. 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...

  17. 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,...

  18. 76 FR 24213 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-29

    ... 42 CFR Part 412 Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient Rehabilitation Units and... Services 42 CFR Part 412 RIN 0938-AQ28 Medicare Program; Inpatient Rehabilitation Facility...

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-19

    ... Medicare-dependent, small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR Medicare... Methodology for Medicare DSH under Section 3133 of the Affordable Care Act F. Medicare-Dependent, Small...

  20. 77 FR 68209 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-15

    ... Electronic Health Record (EHR) Incentive Program, and revising the various regulations governing Quality... November 15, 2012 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Electronic...

  1. 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...

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-26

    ... undertaken by the Center for Medicare and Medicaid Innovation (Innovation Center). The Advance Payment Model is an Innovation Center initiative designed for participants in the Medicare Shared Savings Program... the application process. In November 30, 2011 Federal Register (76 FR 74067), we published a second...

  3. 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.

  4. 76 FR 47835 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-05

    ... for the IRF prospective payment system (PPS) case-mix groups and a description of the methodology and... research and computations used to support an un-weighted regression methodology. ] Response: We provided... 42 CFR Part 412 Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for...

  5. 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...

  6. 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.

  7. 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

    ...-dependent, small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR Medicare Provider... Fraction of the Medicare DSH Calculation G. Medicare-Dependent, Small Rural Hospitals (MDHs): Change...

  8. 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......

  9. 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...

  10. 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...

  11. Comparison of Medicaid Payments Relative to Medicare Using Inpatient Acute Care Claims from the Medicaid Program: Fiscal Year 2010-Fiscal Year 2011.

    PubMed

    Stone, Devin A; Dickensheets, Bridget A; Poisal, John A

    2017-01-10

    To compare Medicaid fee-for-service (FFS) inpatient hospital payments to expected Medicare payments. Medicaid and Medicare claims data, Medicare's MS-DRG grouper and inpatient prospective payment system pricer (IPPS pricer). Medicaid FFS inpatient hospital claims were run through Medicare's MS-DRG grouper and IPPS pricer to compare Medicaid's actual payment against what Medicare would have paid for the same claim. Average inpatient hospital claim payments for Medicaid were 68.8 percent of what Medicare would have paid in fiscal year 2010, and 69.8 percent in fiscal year 2011. Including Medicaid disproportionate share hospital (DSH), graduate medical education (GME), and supplemental payments reduces a substantial proportion of the gap between Medicaid and Medicare payments. Medicaid payments relative to expected Medicare payments tend to be lower and vary by state Medicaid program, length of stay, and whether payments made outside of the Medicaid claims process are included. © Health Research and Educational Trust.

  12. 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.

  13. 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

    ... July 30, 2012 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... Prospective and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Electronic Reporting Pilot; Inpatient Rehabilitation Facilities Quality Reporting Program; Quality Improvement...

  14. 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

  15. 78 FR 72155 - Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-02

    ... December 2, 2013 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services...; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 413 and 414 RIN... 5. Scoring for the PY 2016 ESRD QIP and Future Payment Years 6. Performance Period for the PY 2016...

  16. 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 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

  17. 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.

  18. 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

    ... category MDH Medicare-dependent, small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR.... Technical Change to Regulations D. Medicare-Dependent, Small Rural Hospitals (MDHs): Change to Criteria 1...-dependent, small rural hospital (MDH) received the higher of the Federal rate or the Federal rate plus...

  19. 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.

  20. 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...

  1. 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

  2. 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.

  3. 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,...

  4. 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 of 2008. In addition, this proposed rule discusses payments under the Ambulance Fee Schedule, Clinical Laboratory Fee Schedule, payments to ESRD facilities, and payments for Part B drugs. Finally, the proposed rule includes a discussion regarding the Chiropractic Services Demonstration program, the Competitive Bidding Program for Durable Medical Equipment and Provider and Supplier Enrollment Issues associated with Air Ambulances. (See the Table of Contents for a listing of the specific issues addressed in this proposed rule.)

  5. 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 adjusted composite payment system and the methodologies for the reimbursement of separately billable outpatient ESRD services.

  6. 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... Consolidated Billing for Skilled Nursing Facilities for FY 2011 AGENCY: Centers for Medicare & Medicaid... forth an update to the payment rates used under the prospective payment system for skilled nursing...

  7. 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...

  8. 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.

  9. 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...

  10. 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...

  11. 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...

  12. 77 FR 43329 - Medicaid Program; State Allotments for Payment of Medicare Part B Premiums for Qualifying...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-24

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services RIN 0938-AR47 Medicaid Program; State Allotments... for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice sets forth the... 2011 through December 31, 2010 to $165 million. Section 110 of the Medicare and Medicaid Extenders Act...

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

    PubMed

    2016-08-05

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

  14. 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

    ...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 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 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 prospective payment system. These proposed changes would be applicable to services furnished on or after January 1, 2011. In addition, this proposed rule would update 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 proposed rule, we set forth the proposed applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these proposed changes would apply, and other pertinent ratesetting information for the CY 2011 ASC payment system. These proposed changes would be applicable to services furnished on or after January 1, 2011. This proposed rule also includes proposals to 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.

  15. 78 FR 27485 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-10

    ...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. Some of the proposed changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and......

  16. 77 FR 53257 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-31

    ...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......

  17. 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......

  18. 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......

  19. 76 FR 48485 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-08

    ... Nursing Facilities for FY 2012; Final Rule #0;#0;Federal Register / Vol. 76 , No. 152 / Monday, August 8... Consolidated Billing for Skilled Nursing Facilities for FY 2012 AGENCY: Centers for Medicare & Medicaid... prospective payment system for skilled nursing facilities (SNFs) for fiscal year 2012. In addition,...

  20. 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.

  1. 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

    ... November 10, 2011 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 413 and 414 RIN 0938-AQ27... Incentive Program (QIP) for PY 2013 and PY 2014 1. PY 2013 ESRD QIP Requirements a. Performance Measures for...

  2. 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.

  3. 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 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.)

  4. 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.

  5. 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...

  6. 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

  7. 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.

  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 40835 - Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-08

    ... July 8, 2013 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services...; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 413 and 414 RIN... address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention...

  10. 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 Reconciliation Act of 2010 (collectively known as the Affordable Care Act) and the Medicare Improvements for Patients and Providers Act of 2008. In addition, this proposed rule discusses payments for Part B drugs; Physician Quality Reporting System; the Electronic Prescribing (eRx) Incentive Program; the Physician Resource-Use Feedback Program and the value modifier; productivity adjustment for ambulatory surgical center payment system and the ambulance, clinical laboratory, and durable medical equipment prosthetics orthotics and supplies (DMEPOS) fee schedules; and other Part B related issues. (See the Table of Contents for a listing of the specific issues addressed in this proposed rule.)

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

    PubMed

    2014-11-06

    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.

  12. 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

  13. 76 FR 74121 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-30

    .... Statutory History of Hospital Outpatient Quality Reporting (Hospital OQR) Program 3. Technical Specification... Beneficiaries (5) Effects on Other Providers (6) Effects on the Medicare and Medicaid Programs (7) Alternatives...) Estimated Effects of This Final Rule With Comment Period on Beneficiaries (4) Alternatives Considered c...

  14. 76 FR 42169 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-18

    ... Quality Reporting Program Updates and ASC Quality Reporting A. Background 1. Overview 2. Statutory History... Other Providers (6) Estimated Effects on the Medicare and Medicaid Programs (7) Alternative Considered b... Beneficiaries (4) Alternatives Considered c. Accounting Statements and Tables d. Effect of Proposed Requirements...

  15. 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, 2013...

  16. 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).

  17. 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 percent reduction applied to the 2.4 percent market basket update factor, as mandated by the Affordable Care Act. This rule also updates the wage index used under the HH PPS, and further reduces home health payments to account for continued nominal growth in case-mix which is unrelated to changes in patient health status. This rule removes two hypertension codes from the HH PPS case-mix system, thereby requiring recalibration of the case-mix weights. In addition, the rule implements two structural changes designed to decrease incentives to upcode and provide unneeded therapy services. Finally, this rule incorporates additional flexibility regarding face-to-face encounters with providers related to home health care.

  18. Assessing Medicare's prospective payment system for hospitals.

    PubMed

    Chulis, G S

    1991-01-01

    The Medicare prospective payment system for hospitals was created to slow the growth of government spending on health care. This analysis has shown that the program has accomplished its cost-containment objective in the first five years of its existence. The average length of hospital stay has dropped sharply under PPS, reducing hospital costs. These reduced costs combined with payments based on higher pre-PPS historic costs have given hospitals high profits in the early years of PPS. One of the expected but unwanted outcomes, more admissions, has never occurred. The unexpected rop in admissions under PPS has been responsible for government savings on Medicare inpatient care. Although Medicare outpatient hospital and physician expenditures have grown at fast rates during PPS, there is no evidence in aggregate date that they have grown any faster because of inpatient care shifting to avoid PPS payment controls. The Medicare PPS savings have extended to all U.S. hospital spending, which has grown at much slower rates since the implementation of PPS. There have also been negative outcomes from PPS, and some questions posed about PPS remain unanswered. The inflation in "DRG creep" or upcoding that was predicted for PPS did occur. The government has since washed much of this code inflation out of the permanent payment base, but this phenomenon may not be a self-limiting problem, as was widely hoped. To date there is no convincing evidence of poorer quality of care under PPS, but most of the available evidence is based on mortality studies, which have limited use in measuring changes in quality of care. While PPS has helped to slow the growth in Medicare and national hospital spending, it has not had an appreciable effect on the rate of growth in the nation's total health spending. Although it was unintended, PPS has been providing a natural experiment on the issue of whether increased cost sharing dampens demand for health care services. By slowing the growth rate of

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

    PubMed Central

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

    2003-01-01

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

  20. 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).

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

    PubMed

    2015-08-06

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

  2. 78 FR 31560 - Medicare Program; Public Meeting in Calendar Year 2013 for New Clinical Laboratory Test Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-24

    ...This notice announces a public meeting to receive comments and recommendations (including accompanying data on which recommendations are based) from the public on the appropriate basis for establishing payment amounts for new or substantially revised Healthcare Common Procedure Coding System (HCPCS) codes being considered for Medicare payment under the clinical laboratory fee schedule (CLFS) for calendar year (CY) 2014.

  3. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2018. Final rule.

    PubMed

    2017-08-03

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2018 as required by the statute. As required by section 1886(j)(5) of the Social Security Act (the Act), this rule includes the classification and weighting factors for the IRF prospective payment system's (IRF PPS) case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2018. This final rule also revises the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes that are used to determine presumptive compliance under the "60 percent rule," removes the 25 percent payment penalty for inpatient rehabilitation facility patient assessment instrument (IRF-PAI) late transmissions, removes the voluntary swallowing status item (Item 27) from the IRF-PAI, summarizes comments regarding the criteria used to classify facilities for payment under the IRF PPS, provides for a subregulatory process for certain annual updates to the presumptive methodology diagnosis code lists, adopts the use of height/weight items on the IRF-PAI to determine patient body mass index (BMI) greater than 50 for cases of single-joint replacement under the presumptive methodology, and revises and updates measures and reporting requirements under the IRF quality reporting program (QRP).

  4. 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.

  5. Medicare program; Home Health Prospective Payment System rate update for calendar year 2013, hospice quality reporting requirements, and survey and enforcement requirements for home health agencies. Final rule.

    PubMed

    2012-11-08

    This final rule updates 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), the non-routine medical supplies (NRS) conversion factor, and outlier payments under the Medicare prospective payment system for home health agencies effective January 1, 2013. This rule also establishes requirements for the Home Health and Hospice quality reporting programs. This final rule will also establish requirements for unannounced, standard and extended surveys of home health agencies (HHAs) and sets forth alternative sanctions that could be imposed instead of, or in addition to, termination of the HHA's participation in the Medicare program, which could remain in effect up to a maximum of 6 months, until an HHA achieves compliance with the HHA Conditions of Participation (CoPs) or until the HHA's provider agreement is terminated.

  6. 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.

  7. 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

    ... July 12, 2011 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... 12, 2011 / Proposed Rules#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare... only: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS...

  8. 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...

  9. 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).

  10. 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);…

  11. 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.

  12. 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

  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 as...

  14. 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

    ... Electronic clinical quality measures EHR Electronic health record EMTALA Emergency Medical Treatment and... December 10, 2013 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services...; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 405, 410, 411...

  15. 78 FR 47859 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-06

    ... August 6, 2013 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services... / Rules and Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid... regulations text, and revise and update quality measures and reporting requirements under the IRF quality...

  16. 76 FR 26363 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-06

    ... 6, 2011 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services 42...; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 413, 424, and... the United States Department of Health and Human Services (the Secretary) and other entities regarding...

  17. Challenges and opportunities for Medicare's original prospective payment system.

    PubMed

    Worzala, Chantal; Pettengill, Julian; Ashby, Jack

    2003-01-01

    The Medicare program initiated prospective payment for inpatient hospital services in 1983. Although the payment system has achieved many of its goals, changes in the health care market and the public nature of the program will continue to present both challenges and opportunities for improvement. Looking forward, policymakers must consider how to balance paying accurately for services with using Medicare to achieve broader policy objectives. Paying for new technologies, responding to market segmentation and specialization, and encouraging quality improvement must also be addressed. To successfully navigate these issues, policymakers and program administrators need accurate and timely information.

  18. 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) inadvertently...

  19. 75 FR 34611 - Medicare Program; Supplemental Proposed Changes to the Hospital Inpatient Prospective Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-17

    ...; Supplemental Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Supplemental Proposed Fiscal Year 2011... the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care...

  20. 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...

  1. 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...

  2. 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.

  3. 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

    ... the PPIS data with Medicare-recognized specialty data. We do not use the PPIS data for sleep medicine... sleep medicine for CY 2015 when we will have a full year of data to make the calculations. Previously...

  4. Higher Incentive Payments in Medicare Advantage's Pay-for-Performance Program Did Not Improve Quality But Did Increase Plan Offerings.

    PubMed

    Layton, Timothy J; Ryan, Andrew M

    2015-12-01

    To evaluate the effects of the size of financial bonuses on quality of care and the number of plan offerings in the Medicare Advantage Quality Bonus Payment Demonstration. Publicly available data from CMS from 2009 to 2014 on Medicare Advantage plan quality ratings, the counties in the service area of each plan, and the benchmarks used to construct plan payments. The Medicare Advantage Quality Bonus Payment Demonstration began in 2012. Under the Demonstration, all Medicare Advantage plans were eligible to receive bonus payments based on plan-level quality scores (star ratings). In some counties, plans were eligible to receive bonus payments that were twice as large as in other counties. We used this variation in incentives to evaluate the effects of bonus size on star ratings and the number of plan offerings in the Demonstration using a differences-in-differences identification strategy. We used matching to create a comparison group of counties that did not receive double bonuses but had similar levels of the preintervention outcomes. Results from the difference-in-differences analysis suggest that the receipt of double bonuses was not associated with an increase in star ratings. In the matched sample, the receipt of double bonuses was associated with a statistically insignificant increase of +0.034 (approximately 1 percent) in the average star rating (p > .10, 95 percent CI: -0.015, 0.083). In contrast, the receipt of double bonuses was associated with an increase in the number of plans offered. In the matched sample, the receipt of double bonuses was associated with an overall increase of +0.814 plans (approximately 5.8 percent) (p < .05, 95 percent CI: 0.078, 1.549). We estimate that the double bonuses increased payments by $3.43 billion over the first 3 years of the Demonstration. At great expense to Medicare, double bonuses in the Medicare Advantage Quality Bonus Payment Demonstration were not associated with improved quality but were associated with more plan

  5. Medicare's post-acute care payment: a review of the issues and policy proposals.

    PubMed

    Linehan, Kathryn

    2012-12-07

    Medicare spending on post-acute care provided by skilled nursing facility providers, home health providers, inpatient rehabilitation facility providers, and long-term care hospitals has grown rapidly in the past several years. The Medicare Payment Advisory Commission and others have noted several long-standing problems with the payment systems for post-acute care and have suggested refinements to Medicare's post-acute care payment systems that are intended to encourage the delivery of appropriate care in the right setting for a patient's condition. The Patient Protection and Affordable Care Act of 2010 contained several provisions that affect the Medicare program's post-acute care payment systems and also includes broader payment reforms, such as bundled payment models. This issue brief describes Medicare's payment systems for post-acute care providers, evidence of problems that have been identified with the payment systems, and policies that have been proposed or enacted to remedy those problems.

  6. 77 FR 46213 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-02

    ... System and Consolidated Billing for Skilled Nursing Facilities for FY 2013; Notice #0;#0;Federal Register...; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2013 AGENCY: Centers... rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs), for fiscal...

  7. 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

    ... discussion of the HIQR proposed new claims- based measure for the FY 2015 payment determination for hip/knee... claims- based measure for the FY 2015 payment determination for hip/knee readmission, we made a... alphabetical order: ACoS American College of Surgeons' AJCC American Joint Commission on Cancer ASCO American...

  8. 78 FR 61191 - Medicare Program; FY 2014 Inpatient Prospective Payment Systems: Changes to Certain Cost...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-03

    ... Hospital Cost Report Information System (HCRIS) and the proposed rule's IPPS Impact file. The estimate... (FY) 2014 inpatient prospective payment systems (IPPS)/long-term care hospital (LTCH) PPS final rule...; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital...

  9. Medicare program; FY 2014 inpatient prospective payment systems: changes to certain cost reporting procedures related to disproportionate share hospital uncompensated care payments. Interim final rule with comment period.

    PubMed

    2013-10-03

    : In the fiscal year (FY) 2014 inpatient prospective payment systems (IPPS)/long-term care hospital (LTCH) PPS final rule, we established the methodology for determining the amount of uncompensated care payments made to hospitals eligible for the disproportionate share hospital (DSH) payment adjustment in FY 2014 and a process for making interim and final payments. This interim final rule with comment period revises certain operational considerations for hospitals with Medicare cost reporting periods that span more than one Federal fiscal year and also makes changes to the data that will be used in the uncompensated care payment calculation in order to ensure that data from Indian Health Service (IHS) hospitals are included in Factor 1 and Factor 3 of that calculation.

  10. 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.

  11. 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

    ... Requirements for Home Health Agencies and Hospices; Correction AGENCY: Centers for Medicare & Medicaid Services... Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices'' final... Certification Requirements for Home Health Agencies and Hospices'' final rule. Accordingly, the corrections are...

  12. 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...

  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

    ... November 8, 2012 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services..., November 8, 2012 / Rules and Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for..., such as the number of therapy visits, as predictors in the model, as such variables are provider...

  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

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

  15. 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...

  16. 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.

  17. Medicare program; changes to the hospital outpatient prospective payment system and calendar year 2003 payment rates; and changes to payment suspension for unfiled cost reports. Final rule with comment period.

    PubMed

    2002-11-01

    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. In addition, it describes 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, 2003. This rule also allows the Secretary to suspend Medicare payments "in whole or in part" if a provider fails to file a timely and acceptable cost report. In addition, this rule responds to public comments received on the November 2, 2001 interim final rule with comment period (66 FR 55850) that set forth the criteria the Secretary will use to establish new categories of medical devices eligible for transitional pass-through payment under the Medicare's hospital outpatient prospective payment system. Finally, this rule responds to public comments received on the August 9, 2002 proposed rule for revisions to the hospital outpatient prospective payment system and payment rates (67 FR 52092). CMS finds good cause to waive proposed rulemaking for the assignment of new codes to Ambulatory Payment Classifications and for the payment of influenza and pneumococcal vaccines under reasonable cost; justification for the waiver will follow in a subsequent Federal Register notice.

  18. 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.

  19. 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 nursing...

  20. 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...

  1. 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

    ... adjusted to account for the effects of case-mix and wage level differences among HHAs. Section 1895(b)(3)(B... applicable percentage increase. Section 1895(b)(4) of the Act governs the payment computation. Sections 1895... adjusted for case-mix and geographic differences in wage levels. Section 1895(b)(4)(B) of the Act...

  2. 78 FR 43533 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-19

    ... Editor IOL Intraocular lens IOM Institute of Medicine IORT Intraoperative radiation treatment IPPS... Radiopharmaceuticals With HCPCS Codes, but Without OPPS Hospital Claims Data C. Nuclear Medicine Procedure to...) Payment System A. Background 1. Legislative History, Statutory Authority, and Prior Rulemaking for the ASC...

  3. 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)....

  4. Measuring Function for Medicare Inpatient Rehabilitation Payment

    PubMed Central

    Carter, Grace M.; Relies, Daniel A.; Ridgeway, Gregory K.; Rimes, Carolyn M.

    2003-01-01

    We studied 186,766 Medicare discharges to the community in 1999 from 694 inpatient rehabilitation facilities (IRF). Statistical models were used to examine the relationship of functional items and scales to accounting cost within impairment categories. For most items, more independence leads to lower costs. However, two items are not associated with cost in the expected way. The probable causes of these anomalies are discussed along with implications for payment policy. We present the rules used to construct administratively simple, homogeneous, resource use groups that provide reasonable incentives for access and quality care and that determine payments under the new IRF prospective payment system (PPS). PMID:12894633

  5. 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

  6. The effects of predetermined payment rates for Medicare home healthcare.

    PubMed Central

    Brown, R; Phillips, B; Bishop, C; Thornton, C; Ritter, G; Klein, A; Schochet, P; Skwara, K

    1997-01-01

    OBJECTIVE: To assess the effects of an alternative method of paying home health agencies for services to Medicare beneficiaries, based on a demonstration program. DATA SOURCES/STUDY SETTING: Primary and secondary data collected on participating home health agencies in five states and their patients during the three-year demonstration period. Primary data included patient surveys at discharge and six months later, and two rounds of interviews with executive staff of the agencies. Secondary data included agencies' Medicare cost reports, quality assurance reviews, Medicare claims data, demonstration claims data, demonstration patient intake forms, and plan of treatment forms. STUDY DESIGN: The 47 agencies volunteering to participate in the demonstration were each randomly assigned to the treatment or control group. Treatment group agencies were paid a predetermined rate based on their inflation-adjusted cost per visit during the year preceding the demonstration; control group agencies were paid under Medicare's conventional cost reimbursement method. Demonstration impacts were estimated by comparing outcomes for the two groups of agencies and their respective patients, using regression models to control for any remaining differences. PRINCIPAL FINDINGS: Agencies paid under prospective rate setting were slightly better at holding per-visit cost increases below inflation than were control group agencies. The change in payment method had no effect on agencies' volume of Medicare visits or quality of care, nor on patients' use of Medicare services or other formal or informal care services. CONCLUSION: Changing from cost-based reimbursement to predetermined payment rates for Medicare home healthcare visits would not lead to large savings for the Medicare program, but would not increase costs to Medicare or adversely affect patients or their caregivers. PMID:9327810

  7. 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.

  8. Medicare Program; FY 2018 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

    PubMed

    2017-08-04

    This final rule will update the hospice wage index, payment rates, and cap amount for fiscal year (FY) 2018. Additionally, this rule includes new quality measures and provides an update on the hospice quality reporting program.

  9. 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.

  10. Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2001. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.

    PubMed

    2000-11-01

    This final rule with comment period makes several changes affecting Medicare Part B payment. The changes include: refinement of resource-based practice expense relative value units (RVUs); the geographic practice cost indices; resource-based malpractice RVUs; critical care RVUs; care plan oversight and physician certification and recertification for home health services; observation care codes; ocular photodynamic therapy and other ophthalmological treatments; electrical bioimpedance; antigen supply; and the implantation of ventricular assist devices. This rule also addresses the comments received on the May 3, 2000 interim final rule on the supplemental survey criteria and makes modifications to the criteria for data submitted in 2001. Based on public comments we are withdrawing our proposals related to the global period for insertion, removal, and replacement of pacemakers and cardioverter defibrillators and low intensity ultrasound. This final rule also discusses or clarifies the payment policy for incomplete medical direction, pulse oximetry services, outpatient therapy supervision, outpatient therapy caps, HCPCS "G" Codes, and the second 5-year refinement of work RVUs for services furnished beginning January 1, 2002. In addition, we are finalizing the calendar year (CY) 2000 interim physician work RVUs and are issuing interim RVUs for new and revised codes for CY 2001. We are making these changes to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. This final rule also announces the CY 2001 Medicare physician fee schedule conversion factor under the Medicare Supplementary Medical Insurance (Part B) program as required by section 1848(d) of the Social Security Act. The 2001 Medicare physician fee schedule conversion factor is $38.2581.

  11. 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...

  12. 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)...

  13. 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.

  14. 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.

  15. 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

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

    PubMed

    2016-08-22

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

  17. Medicare 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.

  18. 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.

  19. Medicare program; provisions of the Balanced Budget Refinement Act of 1999; hospital inpatient payments and rates and costs of graduate medical education. Health Care Financing Administration (HCFA), HHS. Interim final rule with comment period.

    PubMed

    2000-08-01

    This interim final rule with comment period implements, or conforms the regulations to, certain statutory provisions relating to Medicare payments to hospitals for inpatient services that are contained in the Medicare, Medicaid, and State Children's Health Insurance Program Balanced Budget Refinement Act of 1999 (Public Law 106-113). These provisions relate to reclassification of hospitals from urban to rural status, reclassification of certain hospitals for purposes of payment during Federal fiscal year 2000, critical access hospitals, payments to hospitals excluded from the hospital inpatient prospective payment system, and payments for indirect and direct graduate medical education costs. Many of the provisions of Public Law 106-113 modify changes to the Social Security Act made by the Balanced Budget Act of 1997 (P.L. 105-33). These provisions are already in effect in accordance with Public Law 106-113.

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

    PubMed Central

    Coulam, Robert F.; Gaumer, Gary L.

    1992-01-01

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

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

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Amount of Medicare secondary payment. 411.33 Section 411.33 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... 7 days of inpatient hospital care in 1987 to a Medicare beneficiary. The provider's charges for...

  2. 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...

  3. 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

    ... July 3, 2013 Part II Department of Health and Human Services Centers for Medicare & Medicaid Services... Rules#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR... Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1450-P, P.O. Box 8016...

  4. 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...

  5. 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...

  6. 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...

  7. 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...

  8. 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...

  9. Medicare payments to the neurology workforce in 2012.

    PubMed

    Skolarus, Lesli E; Burke, James F; Callaghan, Brian C; Becker, Amanda; Kerber, Kevin A

    2015-04-28

    Little is known about how neurology payments vary by service type (i.e., evaluation and management [E/M] vs tests/treatments) and compare to other specialties, yet this information is necessary to help neurology define its position on proposed payment reform. Medicare Provider Utilization and Payment Data from 2012 were used. These data included all direct payments to providers who care for fee-for-service Medicare recipients. Total payment was determined by medical specialty and for various services (e.g., E/M, EEG, electromyography/nerve conduction studies, polysomnography) within neurology. Payment and proportion of services were then calculated across neurologists' payment categories. Neurologists comprised 1.5% (12,317) of individual providers who received Medicare payments and were paid $1.15 billion by Medicare in 2012. Sixty percent ($686 million) of the Medicare payment to neurologists was for E/M, which was a lower proportion than primary providers (approximately 85%) and higher than surgical subspecialties (range 9%-51%). The median neurologist received nearly 75% of their payments from E/M. Two-thirds of neurologists received 60% or more of their payment from E/M services and over 20% received all of their payment from E/M services. Neurologists in the highest payment category performed more services, of which a lower proportion were E/M, and performed at a facility, compared to neurologists in lower payment categories. E/M is the dominant source of payment to the majority of neurologists and should be prioritized by neurology in payment restructuring efforts. © 2015 American Academy of Neurology.

  10. Medicare payments to the neurology workforce in 2012

    PubMed Central

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

    2015-01-01

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

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

    PubMed

    2005-01-28

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

  12. 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

  13. 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.

  14. 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

  15. 75 FR 73091 - Medicare Program; Town Hall Meeting on the Fiscal Year 2012 Applications for Add-on Payments for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-29

    ... Fiscal Year 2012 Applications for Add-on Payments for New Medical Services and Technologies Under the... Criteria for Add-on Payments for New Medical Services and Technologies Under the Inpatient and Outpatient... payments for new medical services and technologies under the hospital inpatient prospective payment system...

  16. 42 CFR 405.371 - Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

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

  17. Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program.

    PubMed

    Chen, Lena M; Epstein, Arnold M; Orav, E John; Filice, Clara E; Samson, Lok Wong; Joynt Maddox, Karen E

    2017-08-01

    Medicare recently launched the Physician Value-Based Payment Modifier (PVBM) Program, a mandatory pay-for-performance program for physician practices. Little is known about performance by practices that serve socially or medically high-risk patients. To compare performance in the PVBM Program by practice characteristics. Cross-sectional observational study using PVBM Program data for payments made in 2015 based on performance of large US physician practices caring for fee-for-service Medicare beneficiaries in 2013. High social risk (defined as practices in the top quartile of proportion of patients dually eligible for Medicare and Medicaid) and high medical risk (defined as practices in the top quartile of mean Hierarchical Condition Category risk score among fee-for-service beneficiaries). Quality and cost z scores based on a composite of individual measures. Higher z scores reflect better performance on quality; lower scores, better performance on costs. Among 899 physician practices with 5 189 880 beneficiaries, 547 practices were categorized as low risk (neither high social nor high medical risk) (mean, 7909 beneficiaries; mean, 320 clinicians), 128 were high medical risk only (mean, 3675 beneficiaries; mean, 370 clinicians), 102 were high social risk only (mean, 1635 beneficiaries; mean, 284 clinicians), and 122 were high medical and social risk (mean, 1858 beneficiaries; mean, 269 clinicians). Practices categorized as low risk performed the best on the composite quality score (z score, 0.18 [95% CI, 0.09 to 0.28]) compared with each of the practices categorized as high risk (high medical risk only: z score, -0.55 [95% CI, -0.77 to -0.32]; high social risk only: z score, -0.86 [95% CI, -1.17 to -0.54]; and high medical and social risk: -0.78 [95% CI, -1.04 to -0.51]) (P < .001 across groups). Practices categorized as high social risk only performed the best on the composite cost score (z score, -0.52 [95% CI, -0.71 to -0.33]), low risk had the next

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

    PubMed

    2013-08-07

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

  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. 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

    ... December 2, 2013 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services... Regulations#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR.... CVD Cardiovascular disease. CY Calendar year. DG Diagnostic group. DHHS Department of Health and Human...

  1. 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.

  2. 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.

  3. 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.

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

    PubMed

    2016-08-05

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

  5. 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

  6. TRICARE; sub-acute care program; uniform skilled nursing facility benefit; home health care benefit; adopting Medicare payment methods for skilled nursing facilities and home health care providers. Final rule.

    PubMed

    2005-10-24

    This rule partially implements the TRICARE "sub-acute and long-term care program reform" enacted by Congress in the National Defense Authorization Act for Fiscal Year 2002, specifically: Establishment of "an effective, efficient, and integrated sub-acute care benefits program," with skilled nursing facility (SNF) and home health care benefits modeled after those of the Medicare program; adoption of Medicare payment methods for skilled nursing facility, home health care, and certain other institutional health care providers; adoption of Medicare rules on balance billing of beneficiaries, prohibiting it by institutional providers and limiting it by non-institutional providers; and change in the statutory exclusion of coverage for custodial and domiciliary care.

  7. 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

  8. Variations in payment patterns for surgical care in the centers for Medicare and Medicaid Services.

    PubMed

    Bergman, Jonathan; Laviana, Aaron A; Kwan, Lorna; Lerman, Steven E; Aronson, William J; Bennett, Carol J; Hu, Jim J

    2017-02-01

    We investigated provider and regional variation in payments made to surgeons by the Centers for Medicare & Medicaid Services (CMS) by indexing payments to unique beneficiaries treated and examined the proportion of charges that resulted in payments. Understanding variation in care within CMS may prove actionable by identifying modifiable, and potentially unwarranted, variations. We analyzed the Medicare Part B Provider Utilization and Payment Data released by CMS for 2012. We included Medicare B participants in the fee-for-service program. We calculated for each provider the ratio of number of services provided to individual beneficiaries, and the ratio of total submitted charges to total Medicare payments. We also categorized each provider into deciles of total Medicare payments, and calculated the means per decile of total Medicare payment for surgeons and urologists. To determine any associations with ratio of services to beneficiaries, we conducted multivariate linear regressions. The 20th, 40th, 60th, and 80th percentiles for the services-per-beneficiary ratios are 1.6, 2.2, 3.1, and 5.0, respectively (n = 83,376). Greater-earning surgeons offered more services per beneficiary, with a precipitous increase from the lowest decile to the highest. Charges were consistently greater than payments by a factor of 3. In our multivariate analysis of services per beneficiary ratio, female providers had lower ratios (P < .01), and we noted significant regional variation in the ratio of services per unique beneficiary (P < .001 for each of the 10 Standard Federal Regions). We found significant variation in patterns of payments for surgical care in CMS. Published by Elsevier Inc.

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-06

    ...: 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...

  10. 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......

  11. 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

  12. Medicare prospective payment without separate urban and rural rates.

    PubMed

    O'Dougherty, S M; Cotterill, P G; Phillips, S; Richter, E; De Lew, N; Wynn, B; Ault, T

    1992-01-01

    The elimination of urban-rural differences in the Medicare prospective payment system (PPS) standard rates implies a need to re-examine all the PPS payment adjustments. Refinements for case mix, outliers, and the wage index can make a significant contribution to avoiding payment disparities in a single-rate system. However, changes in the adjustments for teaching and disproportionate-share (DSH) hospitals are also needed. The typically urban location of these hospitals makes it difficult to balance PPS payments and costs among major groups of urban and rural hospitals without some form of higher payment for all hospitals located in large urban areas.

  13. 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 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Service and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices. Final rule.

    PubMed

    2017-08-14

    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 2018. Some of these changes implement certain statutory provisions contained in the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, the 21st Century Cures Act, and other legislation. We also are making changes relating to the provider-based status of Indian Health Service (IHS) and Tribal facilities and organizations and to the low-volume hospital payment adjustment for hospitals operated by the IHS or a Tribe. In addition, we are providing the market basket update that will 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 2018. 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 2018. In addition, we are 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). We also are establishing new requirements or revising existing requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. 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. We also are making changes relating to transparency of accrediting organization survey

  14. Medicare Program; Conditions for Coverage for End-Stage Renal Disease Facilities--Third Party Payment. Interim final rule with comment period.

    PubMed

    2016-12-14

    This interim final rule with comment period implements new requirements for Medicare-certified dialysis facilities that make payments of premiums for individual market health plans. These requirements apply to dialysis facilities that make such payments directly, through a parent organization, or through a third party. These requirements are intended to protect patient health and safety; improve patient disclosure and transparency; ensure that health insurance coverage decisions are not inappropriately influenced by the financial interests of dialysis facilities rather than the health and financial interests of patients; and protect patients from mid-year interruptions in coverage.

  15. 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

    ... Major Provisions C. Summary of Costs, Benefits, and Transfers II. Background A. Hospice Care B. History... Quality Reporting 4. Alternatives Considered C. Accounting Statement D. Conclusion 1. Regulatory... rate (Sec. 418.302(e)(4)). B. History of the Medicare Hospice Benefit Before the creation of the...

  16. 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

    ... Procedure Act (APA) (5 U.S.C. 553(b)). However, we can waive this notice and comment procedure if the... the notice. Section 553(d) of the APA ordinarily requires a 30-day delay in effective date of final... Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 210.41).''...

  17. 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

    ... July 8, 2011 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services... / Friday, July 8, 2011 / Proposed Rules#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for... & Medicaid Services, Department of Health and Human Services, Attention: CMS-1577-P, P.O. Box 8010, Baltimore...

  18. 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

  19. Medicare program; changes to the hospital inpatient prospective payment systems and rates and costs of graduate medical education: fiscal year 2002 rates; provisions of the Balanced Budget Refinement Act of 1999; and provisions of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000. Final rules.

    PubMed

    2001-08-01

    We are revising the Medicare hospital inpatient prospective payment systems for operating and capital costs to: implement applicable statutory requirements, including a number of provisions of the Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000 (Public Law 106-554); and implement changes arising from our continuing experience with these systems. In addition, in the Addendum to this final rule, we describe 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 apply to discharges occurring on or after October 1, 2001. We also set forth the rate-of-increase limits as well as policy changes for hospitals and hospital units excluded from the prospective payment systems. We are making changes to the policies governing payments to hospitals for the direct costs of graduate medical education and critical access hospitals. Lastly, we are responding to public comments received on the following two related interim final rules that we published in the Federal Register and finalizing those interim rules: An August 1, 2000 interim final rule with comment period (65 FR 47026, HCFA-1131-IFC) that implemented, or conformed the regulations to, certain statutory provisions relating to Medicare payments to hospitals for inpatient services that were contained in the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (Public Law 106-113), and that were effective during FY 2000. These provisions related to reclassification of hospitals from urban to rural status, reclassification of certain hospitals for purposes of payment during fiscal year 2000, critical access hospitals, payments to hospitals excluded from the prospective payment system, and payments for indirect and direct graduate medical education costs. A June 13, 2001 interim final rule with comment period (66 FR 32172, HCFA-1178

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

    PubMed

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

    2016-01-01

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

  1. Effects of Medicare Payment Reform: Evidence from the Home Health Interim and Prospective Payment Systems

    PubMed Central

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

    2014-01-01

    Medicare continues to implement payment reforms that shift reimbursement from fee-for-service towards episode-based payment, affecting average and marginal payment. We contrast the effects of two reforms for home health agencies. The Home Health Interim Payment System in 1997 lowered both types of payment; our conceptual model predicts a decline in the likelihood of use and costs, both of which we find. The Home Health Prospective Payment System in 2000 raised average but lowered marginal payment with theoretically ambiguous effects; we find a modest increase in use and costs. We find little substantive effect of either policy on readmissions or mortality. PMID:24395018

  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. 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...

  4. 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... following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that... Inpatient Billing in Hospitals,'' to propose a permanent policy that would apply on a prospective basis...

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

    PubMed

    1995-06-27

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

  6. 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.

  7. Diagnosis-Based Risk Adjustment for Medicare Capitation Payments

    PubMed Central

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

    1996-01-01

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

  8. MEDICARE PAYMENTS AND SYSTEM-LEVEL HEALTH-CARE USE: The Spillover Effects of Medicare Managed Care.

    PubMed

    Baicker, Katherine; 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.

  9. 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.

  10. 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...

  11. 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...

  12. 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...

  13. 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...

  14. 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...

  15. 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.)

  16. 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

    ...This proposed rule would implement medical loss ratio (MLR) requirements for the Medicare Advantage Program and the Medicare Prescription Drug Benefit Program under the Patient Protection and Affordable Care Act.

  17. 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.

  18. Episode-Based Payment for the Medicare Outpatient Therapy Benefit.

    PubMed

    Amico, Peter; Pope, Gregory C; Meadow, Ann; West, Pamela

    2016-08-01

    To conduct an analysis of Medicare outpatient therapy episodes of care and associated payment implications. Retrospective observational design using Medicare claims data. To descriptively analyze the composition of outpatient therapy episodes, both variable- and fixed-length episodes are explored. The variable-length episode definition organizes services into episodes based on the time pattern of therapy service utilization, using 60-day clean periods. Fixed-length episodes are also examined, beginning with the first therapy utilization in calendar year 2010 and extending 30, 60, and 90 days. The study is focused on community-dwelling users of outpatient therapy. The sample includes all Medicare patients who used outpatient therapy beginning at any point in 2010. Not applicable. Mean episode payments and episode lengths in calendar days. Variable-length outpatient therapy episodes have a mean payment of $881. On average, outpatient therapy episodes last 43 calendar days. Mean therapy durations for the 30-, 60-, and 90-day fixed-length episodes are 20, 31, and 38 calendar days, respectively. The 30-, 60-, and 90-day fixed-length initial episodes account for 40%, 55%, and 63%, respectively, of total Medicare payments. Simulations of episode-based payment illustrate the difficulty of avoiding a large number of substantial underpayments, because of the right-skewed distribution of total actual payments. A strength of episode payment is that it reduces cost and potentially wasteful variation within episodes. Given the substantial variation in therapy episode expenditures, absent improvements in available data and in predictive information, a pure lump sum episode payment would result in substantial revenue changes for many episodes. Additional data are needed to better explain the wide variation in episode expenditures. Copyright © 2016 American Congress of Rehabilitation Medicine. All rights reserved.

  19. 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.

  20. 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...

  1. 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...

  2. 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...

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

    PubMed

    2014-11-06

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

  4. 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...

  5. 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...

  6. 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)...

  7. 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...

  8. 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.

  9. Rethinking Medicare Payment Adjustments for Quality

    PubMed Central

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

    2016-01-01

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

  10. Rethinking Medicare Payment Adjustments for Quality.

    PubMed

    Averill, Richard F; Fuller, Richard L; McCullough, Elizabeth C; Hughes, John S

    2016-01-01

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

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

    PubMed

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

    2016-06-01

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

  12. 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...

  13. 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...

  14. The origins, development, and passage of Medicare's revolutionary prospective payment system.

    PubMed

    Mayes, Rick

    2007-01-01

    This article explains the origins, development, and passage of the single most influential postwar innovation in medical financing: Medicare's prospective payment system (PPS). Inexorably rising medical inflation and deep economic deterioration forced policymakers in the late 1970s to pursue radical reform of Medicare to keep the program from insolvency. Congress and the Reagan administration eventually turned to the one alternative reimbursement system that analysts and academics had studied more than any other and had even tested with apparent success in New Jersey: prospective payment with diagnosis-related groups (DRGs). Rather than simply reimbursing hospitals whatever costs they charged to treat Medicare patients, the new model paid hospitals a predetermined, set rate based on the patient's diagnosis. The most significant change in health policy since Medicare and Medicaid's passage in 1965 went virtually unnoticed by the general public. Nevertheless, the change was nothing short of revolutionary. For the first time, the federal government gained the upper hand in its financial relationship with the hospital industry. Medicare's new prospective payment system with DRGs triggered a shift in the balance of political and economic power between the providers of medical care (hospitals and physicians) and those who paid for it--power that providers had successfully accumulated for more than half a century.

  15. 75 FR 73169 - Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-29

    ... for diabetes self-management training programs and kidney disease education services. Ryan Howe, (410... Caps B. Diabetes Self-Management Training (DSMT) Services (HCPCS Codes G0108 and G0109) 1. Background 2... American Association of Clinical Endocrinologists AADE American Association of Diabetes Educators...

  16. Medicare hospital outpatient services and costs: Implications for prospective payment

    PubMed Central

    Miller, Mark E.; Sulvetta, Margaret B.

    1992-01-01

    Medicare expenditures of hospital outpatient department (HOPD) services are growing rapidly, prompting congressional interest in a prospective payment system. In this article, the authors identify frequently provided services and examine service volume and charges in the HOPD. Relatively few services drive Medicare HOPD spending, and volume is dominated by visits, imaging and laboratory tests, whereas surgery accounts for a large proportion of charges. Hospital-level variations in charges, costs, case mix, and outliers are also explored. There is substantial variation in charges and costs across hospital types. However, after case-mix adjustment, all hospital types have average costs within 6 percent of the national average. PMID:10171489

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

    PubMed

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

    2006-01-01

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

  18. 42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and purpose. This section implements...

  19. 42 CFR 447.31 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

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

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

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and purpose. This section implements...

  1. 42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and purpose. This section implements...

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

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and purpose. This section implements...

  3. 42 CFR 447.31 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

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

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

    Code of Federal Regulations, 2013 CFR

    2013-10-01

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

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

    Code of Federal Regulations, 2014 CFR

    2014-10-01

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

  6. 42 CFR 405.377 - Withholding Medicare payments to recover Medicaid overpayments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Withholding Medicare payments to recover Medicaid overpayments. 405.377 Section 405.377 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Withholding Medicare payments to recover Medicaid overpayments. (a) Basis and purpose. This section implements...

  7. 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).

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

    PubMed

    Wilensky, Gail R

    2014-01-01

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

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

    PubMed

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

    2014-03-01

    Medicare continues to implement payment reforms that shift reimbursement from fee-for-service toward episode-based payment, affecting average and marginal payment. We contrast the effects of two reforms for home health agencies. The home health interim payment system in 1997 lowered both types of payment; our conceptual model predicts a decline in the likelihood of use and costs, both of which we find. The home health prospective payment system in 2000 raised average but lowered marginal payment with theoretically ambiguous effects; we find a modest increase in use and costs. We find little substantive effect of either policy on readmissions or mortality. Copyright © 2014 Elsevier B.V. All rights reserved.

  11. 78 FR 64953 - Medicare Program; Inpatient Hospital Deductible and Hospital and Extended Care Services...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-30

    ... rates for FY 2014 for hospitals excluded from the inpatient prospective payment system is as follows... Register on August 19, 2013 entitled, ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year...

  12. 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

  13. Medicare

    Cancer.gov

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

  14. 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 ...

  15. Will Medicare Advantage payment reforms impact plan rebates and enrollment?

    PubMed

    Nicholas, Lauren Hersch

    2014-01-01

    To assess the relationship between Medicare Advantage (MA) plan rebates and enrollment and simulate the effects of Affordable Care Act (ACA) payment reforms. First difference regressions of county-level MA payment and enrollment data from CMS from 2006 to 2010. A $10 decrease in the per member/per month rebate to MA plans was associated with a 0.20 percentage point (0.9%) decrease in MA penetration (P < .001) and a 7.1% decline in the average MA enrollee's risk score (P < .001). These effects are small overall, but larger in counties with low levels of traditional Medicare spending; a $10 decrease in monthly rebates was associated with a 0.64 percentage point decline in MA penetration and a 10% decrease in risk score. ACA reforms are predicted to reduce the level of rebates in lower-spending counties, leading to enrollment decreases of 1.7 to 1.9 percentage points in the lowest-spending counties. The simulation predicts that the disenrollment would come from MA enrollees with higher risk scores. MA enrollment responds to availability of supplemental benefits supported by rebates. ACA provisions designed to lower MA spending will predominantly affect Medicare beneficiaries living in counties where MA plans may be unable to offer a comparable product at a price similar to that of traditional Medicare.

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

    PubMed Central

    Milgate, Karen; Hackbarth, Glenn

    2005-01-01

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

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

    PubMed Central

    Johnson, Doug

    2014-01-01

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

  18. 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.

  19. 42 CFR 413.177 - Quality incentive program payment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Quality incentive program payment. 413.177 Section... 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...

  20. 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...

  1. 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...

  2. 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...

  3. 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...

  4. 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...

  5. 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...

  6. 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...

  7. 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...

  8. 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...

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

    DTIC Science & Technology

    1983-12-22

    Fogel Director, Human Resources Division United States General Accounting Office Washington, D.C. 20548 Re: U . S . General Accounting Ofrice Draft...AD-A137 516 HOSPITAL MERGER INCREASED MEDICARE AND MEDICAID PAYMENTS FOR CAP I A COSTS( S ) GENERA L AC COUNT IN G OFFICE WASHINGTON DC HUMAN RESOURCES...DIV 22 DEC 83 UNCLASSIFIED GAO/HRDR84 0 FOE 6/21111111 mmIo mommo EEmmhEE mhohsohhhmhhhI mhE~hEE~’EEEmhhhE~hE~IM 11111 ~ u ~112 T~ U .. L IIL ~ 1.25 1.4

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

    PubMed

    2016-02-12

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

  11. 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...

  12. 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...

  13. 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.

  14. Reforming Medicare's Dialysis Payment Policies: Implications for Patients with Secondary Hyperparathyroidism

    PubMed Central

    Gupta, Charu; Chertow, Glenn M; Linthicum, Mark T; Van Nuys, Karen; Belozeroff, Vasily; Quarles, Darryl; Lakdawalla, Darius N

    2014-01-01

    Objective To demonstrate how expanding services covered by a “bundled payment” can also expand variation in the costs of treating patients under the bundle, using the Medicare dialysis program as an example. Data Sources/Study Setting Observational claims-based study of 197,332 Medicare hemodialysis beneficiaries enrolled for at least one quarter during 2006–2008. Study Design We estimated how resource utilization (all health services, dialysis-related services, and medications) changes with intensity of secondary hyperparathyroidism (sHPT) treatment. Data Extraction Methods Using Medicare claims, a patient-quarter level dataset was constructed, including a measure of sHPT treatment intensity. Principal Findings Under the existing, narrow dialysis bundle, utilization of covered services is relatively constant across treatment intensity groups; under a broader bundle, it rises more rapidly with treatment intensity. Conclusions The broader Medicare dialysis bundle reimburses providers uniformly, even though patients treated more intensively for sHPT cost more to treat. Absent any payment adjustments or efforts to ensure quality, this flat payment schedule may encourage providers to avoid high-intensity patients or reduce their treatment intensity. The first incentive harms efficiency. The second may improve or worsen efficiency, depending on whether it reduces appropriate or inappropriate treatment. PMID:25040130

  15. Strategic planning for Medicare coverage and payment of new diabetes technologies.

    PubMed

    Spurgin, Elizabeth A

    2004-12-01

    This article reviews the process for gaining Medicare coverage and payment for new technologies and suggests factors to consider when developing a reimbursement strategy. Integrating Medicare reimbursement planning within the broader product commercialization strategy builds efficiencies and may enhance product uptake across both Medicare and private payer segments.

  16. 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.

  17. 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.

  18. The continuing cost of privatization: extra payments to Medicare Advantage plans in 2008.

    PubMed

    Biles, Brian; Adrion, Emily; Guterman, Stuart

    2008-09-01

    The Medicare Modernization Act of 2003 explicitly increased Medicare payments to private Medicare Advantage (MA) plans. As a result, every MA plan in the nation is paid more for its enrollees than they would have been expected to cost in traditional fee-for-service Medicare. The authors calculate that payments to MA plans in 2008 will be 12.4 percent greater than the corresponding costs in traditional Medicare-an average increase of $986 per MA plan enrollee, for a total of more than $8.5 billion. Over the five-year period 2004-2008, extra payments to MA plans are estimated to have totaled nearly $33 billion. Although Congress recently enacted modest reductions in MA plan payments, these changes will not take effect until 2010. Moreover, while the new legislation removes a few factors contributing to the extra payments, a number of other factors remain unaffected.

  19. 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.

  20. 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.

  1. Modeling the impact of Medicare Advantage payment cuts on ambulatory care sensitive and elective hospitalizations.

    PubMed

    Nicholas, Lauren Hersch

    2011-10-01

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

  2. 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

  3. 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).

  4. 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...

  5. 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...

  6. 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...

  7. 76 FR 76541 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-07

    ... 42 CFR Part 401 Medicare Program; Availability of Medicare Data for Performance Measurement; Final... 401 RIN 0938-AQ17 Medicare Program; Availability of Medicare Data for Performance Measurement AGENCY... the comments were from organizations engaged in performance measurement or data aggregation that...

  8. 76 FR 33565 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-08

    ... measurement errors and assessing measure reliability. Identifying appropriate peer groups of providers and... 42 CFR Part 401 Medicare Program; Availability of Medicare Data for Performance Measurement; Proposed...-AQ17 Medicare Program; Availability of Medicare Data for Performance Measurement AGENCY: Centers...

  9. 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.

  10. Medicare's policy to limit payment for hospital-acquired conditions: the impact on safety net providers.

    PubMed

    McHugh, Megan; Martin, Timothy C; Orwat, John; Dyke, Kevin Van

    2011-05-01

    In 2008, Medicare implemented a policy limiting reimbursement to hospitals for treating avoidable hospital-acquired conditions (HACs). Although the policy will expand nationally to Medicaid programs in 2011, little is known about the impact on safety-net hospitals. Using data from the 2006 American Hospital Association Annual Survey and MEDPAR, we compared the incidence of cases that met the HACs criteria at safety-net and non-safety-net hospitals. We found that safety-net hospitals had an average of 65.5 HACs per 1,000 Medicare discharges compared with 57.6 at non-safety-net hospitals. Hospitals in the lowest quintile for financial margins had higher rates of HACs on average than other hospitals. Safety-net hospitals and hospitals with the lowest financial margins may be more likely than others to be affected by policies that reduce payment for HACs.

  11. 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.

  12. 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

  13. Medicare hospice benefit: Early program experiences

    PubMed Central

    Davis, Feather Ann

    1988-01-01

    In this article, an overview of the Medicare hospice benefit is presented and selected preliminary findings from the Medicare hospice benefit program evaluation are provided. By mid-1987, about one-half of all community home health agency-based hospices were Medicare certified, compared with about one-fifth of all independent/freestanding hospices and one-seventh of hospital and skilled nursing facility-based hospices. Medicare beneficiary election of the hospice benefit increased from about 2,000 beneficiaries in fiscal year 1984 to about 11,000 during fiscal year 1986. Medicare reimbursed hospices an average of $1,798, $2,078 and $2,337 per patient during fiscal years 1984, 1985, and 1986, respectively. PMID:10312635

  14. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2018, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, Survey Team Composition, and Correction of the Performance Period for the NHSN HCP Influenza Vaccination Immunization Reporting Measure in the ESRD QIP for PY 2020. Final rule.

    PubMed

    2017-08-04

    This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2018. It also revises and rebases the market basket index by updating the base year from 2010 to 2014, and by adding a new cost category for Installation, Maintenance, and Repair Services. The rule also finalizes revisions to the SNF Quality Reporting Program (QRP), including measure and standardized resident assessment data policies and policies related to public display. In addition, it finalizes policies for the Skilled Nursing Facility Value-Based Purchasing Program that will affect Medicare payment to SNFs beginning in FY 2019. The final rule also clarifies the regulatory requirements for team composition for surveys conducted for investigating a complaint and aligns regulatory provisions for investigation of complaints with the statutory requirements. The final rule also finalizes the performance period for the National Healthcare Safety Network (NHSN) Healthcare Personnel (HCP) Influenza Vaccination Reporting Measure included in the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) for Payment Year 2020.

  15. 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...

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

    PubMed

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

    2015-05-01

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

  17. 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.

  18. Impact of Continued Biased Disenrollment from the Medicare Advantage Program to Fee-for-Service

    PubMed Central

    Riley, Gerald F

    2012-01-01

    Background Medicare managed care enrollees who disenroll to fee-for-service (FFS) historically have worse health and higher costs than continuing enrollees and beneficiaries remaining in FFS. Objective To examine disenrollment patterns by analyzing Medicare payments following disenrollment from Medicare Advantage (MA) to FFS in 2007. Recent growth in the MA program, introduction of limits on timing of enrollment/disenrollment, and initiation of prescription drug benefits may have substantially changed the dynamics of disenrollment. Study design The study was based on MA enrollees who disenrolled to FFS in 2007 (N=248,779) and a sample of “FFS stayers” residing in the same counties as the disenrollees (N=551,616). Actual Medicare Part A and Part B payments (excluding hospice payments) in the six months following disenrollment were compared with predicted payments based on claims experience of local FFS stayers, adjusted for CMS-Hierarchical Condition Category (CMS-HCC) risk scores. Results Disenrollees incurred $1,021 per month in Medicare payments, compared with $798 in predicted payments (ratio of actual/predicted=1.28, p < 0.001). Differences between actual and predicted payments were smaller for disenrollees of Preferred Provider Organizations and Private Fee-for-Service plans than of Health Maintenance Organizations. Analysis of 10 individual MA plans revealed variation in the degree of selective disenrollment. Conclusions Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries, raising concerns about care experiences among sicker enrollees and increased costs to Medicare. PMID:24800156

  19. 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.

  20. 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...

  1. 2012 rural Medicare Advantage quality ratings and bonus payments.

    PubMed

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

    2014-01-01

    Key Data Findings. (1) The average rural Medicare Advantage (MA) plan enrollee in 2012 experienced a quality rating of 3.60 stars (of a potential 5.0), compared with a rating of 3.71 stars experienced by urban enrollees. (2) The measured rural-urban difference in the MA plan quality is a result of the difference in the composition of the enrollment and plan availability in MA markets, rather than differences between MA plans of the same type. (a) In general, rural Medicare beneficiaries often have limited MA plans available from which to choose, and typically have lower quality ratings than urban MA plans. (b) Rural MA beneficiaries are more likely to be enrolled in preferred provider organization (PPO) plans than in health maintenance organization (HMO) plans. (c) PPO plans have lower quality ratings on average than HMO plans. (d) HMO plans had the highest average quality rating at 3.83 and 3.78 stars, respectively, in rural and urban areas. PPO plans had lower quality ratings, at 3.52 and 3.50, respectively. (3) In rural areas, 32% of the MA population is enrolled in a plan with a star rating of 4.0 or higher, and 92% are enrolled in a plan with a star rating of at least 3.0, as contrasted to urban enrollment of 36% and 94% respectively, making these plans eligible for quality based bonus payments. (4) The quality rating of rural MA plans varies significantly across the country, with the highest quality ratings in rural areas in Minnesota, Iowa, Wisconsin, Oregon, Pennsylvania, and Maine.

  2. 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...

  3. 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...

  4. 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.

  5. 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.

  6. Statistical uncertainty in the Medicare shared savings program.

    PubMed

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

    2012-01-01

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

  7. 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.)

  8. 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

    ... Arrangements and as a Basis for Termination or Non- Renewal of a Medicare Contract (Sec. 422.504, Sec. 422.510... Past Contract Termination or CMS-Initiated Non-Renewal (Sec. 422.502 and Sec. 423.503) D. Improving Program Efficiencies 1. Cost Contract Plan Public Notification Requirements in Cases of Non-Renewal...

  9. 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

    ... Termination or Non- Renewal of a Medicare Contract (Sec. Sec. 422.504, 422.510, 423.505, and 423.509) 3...-Initiated Non-Renewal (Sec. Sec. 422.502 and 423.503) D. Improving Program Efficiencies 1. Cost Contract Plan Public Notification Requirements in Cases of Non-Renewal (Sec. 417.492) 2. New Benefit...

  10. 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…

  11. 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…

  12. 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

  13. Medicare program; revisions to payment policies, five-year review of work relative value units, changes to the practice expense methodology under the physician fee schedule, and other changes to payment under part B; revisions to the payment policies of ambulance services under the fee schedule for ambulance services; and ambulance inflation factor update for CY 2007. Final rule with comment period.

    PubMed

    2006-12-01

    This final rule with comment period addresses certain provisions of the Deficit Reduction Act of 2005, as well as making other changes to Medicare Part B payment policy. These changes are intended 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 geographic practice cost indices (GPCI) changes; requests for additions to the list of telehealth services; payment for covered outpatient drugs and biologicals; payment for renal dialysis services; policies related to private contracts and opt-out; policies related to bone mass measurement (BMM) services, independent diagnostic testing facilities (IDTFs), the physician self-referral prohibition; laboratory billing for the technical component (TC) of physician pathology services; the clinical laboratory fee schedule; certification of advanced practice nurses; health information technology, the health care information transparency initiative; updates the list of certain services subject to the physician self-referral prohibitions, finalizes ASP reporting requirements, and codifies Medicare's longstanding policy that payment of bad debts associated with services paid under a fee schedule/charge-based system are not allowable. We are also finalizing the calendar year (CY) 2006 interim RVUs and are issuing interim RVUs for new and revised procedure codes for CY 2007. In addition, this rule includes revisions to payment policies under the fee schedule for ambulance services and the ambulance inflation factor update for CY 2007. As required by the statute, we are announcing that the physician fee schedule update for CY 2007 is -5.0 percent, the initial estimate for the sustainable growth rate for CY 2007 is 2.0 percent and the CF for CY 2007 is $35.9848.

  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. Medicare payment reform and provider entry and exit in the post-acute care market.

    PubMed

    Huckfeldt, Peter J; Sood, Neeraj; Romley, John A; Malchiodi, Alessandro; Escarce, José J

    2013-10-01

    To understand the impacts of Medicare payment reform on the entry and exit of post-acute providers. Medicare Provider of Services data, Cost Reports, and Census data from 1991 through 2010. We examined market-level changes in entry and exit after payment reforms relative to a preexisting time trend. We also compared changes in high Medicare share markets relative to lower Medicare share markets and for freestanding relative to hospital-based facilities. We calculated market-level entry, exit, and total stock of home health agencies, skilled nursing facilities, and inpatient rehabilitation facilities from Provider of Services files between 1992 and 2010. We linked these measures with demographic information from the Census and American Community Survey, information on Certificate of Need laws, and Medicare share of facilities in each market drawn from Cost Report data. Payment reforms reducing average and marginal payments reduced entries and increased exits from the market. Entry effects were larger and more persistent than exit effects. Entry and exit rates fluctuated more for home health agencies than skilled nursing facilities. Effects on number of providers were consistent with entry and exit effects. Payment reform affects market entry and exit, which in turn may affect market structure, access to care, quality and cost of care, and patient outcomes. Policy makers should consider potential impacts of payment reforms on post-acute care market structure when implementing these reforms. © Health Research and Educational Trust.

  16. Medicare Payment Reform and Provider Entry and Exit in the Post-Acute Care Market

    PubMed Central

    Huckfeldt, Peter J; Sood, Neeraj; Romley, John A; Malchiodi, Alessandro; Escarce, José J

    2013-01-01

    Objective To understand the impacts of Medicare payment reform on the entry and exit of post-acute providers. Data Sources Medicare Provider of Services data, Cost Reports, and Census data from 1991 through 2010. Study Design We examined market-level changes in entry and exit after payment reforms relative to a preexisting time trend. We also compared changes in high Medicare share markets relative to lower Medicare share markets and for freestanding relative to hospital-based facilities. Data Extraction Methods We calculated market-level entry, exit, and total stock of home health agencies, skilled nursing facilities, and inpatient rehabilitation facilities from Provider of Services files between 1992 and 2010. We linked these measures with demographic information from the Census and American Community Survey, information on Certificate of Need laws, and Medicare share of facilities in each market drawn from Cost Report data. Principal Findings Payment reforms reducing average and marginal payments reduced entries and increased exits from the market. Entry effects were larger and more persistent than exit effects. Entry and exit rates fluctuated more for home health agencies than skilled nursing facilities. Effects on number of providers were consistent with entry and exit effects. Conclusions Payment reform affects market entry and exit, which in turn may affect market structure, access to care, quality and cost of care, and patient outcomes. Policy makers should consider potential impacts of payment reforms on post-acute care market structure when implementing these reforms. PMID:23557215

  17. 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.

  18. Regional variation in Medicare payments for medical imaging: radiologists versus nonradiologists.

    PubMed

    Rosman, David A; Nsiah, Eugene; Hughes, Danny R; Duszak, Richard

    2015-05-01

    The purpose of this article was to study regional variation in Medicare Physician Fee Schedule (MPFS) payments for medical imaging to radiologists compared with nonradiologists. Using a 5% random sample of all Medicare enrollees, which covered approximately 2.5 million Part B beneficiaries in 2011, total professional-only, technical-only, and global MPFS spending was calculated on a state-by-state and United States Census Bureau regional basis for all Medicare Berenson-Eggers Type of Service-defined medical imaging services. Payments to radiologists versus nonradiologists were identified and variation was analyzed. Nationally, mean MPFS medical imaging spending per Medicare beneficiary was $207.17 ($95.71 [46.2%] to radiologists vs $111.46 [53.8%] to nonradiologists). Of professional-only (typically interpretation) payments, 20.6% went to nonradiologists. Of technical-only (typically owned equipment) payments, 84.9% went to nonradiologists. Of global (both professional and technical) payments, 70.1% went to nonradiologists. The percentage of MPFS medical imaging spending on nonradiologists ranged from 32% (Minnesota) to 69.5% (South Carolina). The percentage of MPFS payments for medical imaging to nonradiologists exceeded those to radiologists in 58.8% of states. The relative percentage of MPFS payments to nonradiologists was highest in the South (58.5%) and lowest in the Northeast (48.0%). Nationally, 53.8% of MPFS payments for medical imaging services are made to nonradiologists, who claim a majority of MPFS payments in most states dominated by noninterpretive payments. This majority spending on nonradiologists may have implications in bundled and capitated payment models for radiology services. Medical imaging payment policy initiatives must consider the roles of all provider groups and associated regional variation.

  19. 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.

  20. Medicare Chronic Care Management Payments and Financial Returns to Primary Care Practices: A Modeling Study.

    PubMed

    Basu, Sanjay; Phillips, Russell S; Bitton, Asaf; Song, Zirui; Landon, Bruce E

    2015-10-20

    Physicians have traditionally been reimbursed for face-to-face visits. A new non-visit-based payment for chronic care management (CCM) of Medicare patients took effect in January 2015. To estimate financial implications of CCM payment for primary care practices. Microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements. National Ambulatory Medical Care Survey and other published sources. Medicare patients. 10 years. Practice-level. Comparison of CCM delivery approaches by staff and physicians. Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services. If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 ,00 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services. If physicians were to deliver all CCM services, approximately 25% of practices nationwide could expect net revenue losses due to opportunity costs of face-to-face visit time. The CCM program may alter long-term primary care use, which is difficult to predict. Practices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs. None.

  1. 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.

  2. The Relationship between Medicare Payment and Service Volume for Retina Procedures from 2005 through 2009.

    PubMed

    Gong, Dan; Jun, Lin; Tsai, James C

    2015-08-01

    To calculate the relationship between Medicare payment and service volume for the 3 highest-volume retina procedures: intravitreal injection (Current Procedural Terminology [CPT] code 67028), laser treatment for retinal edema (CPT code 67210), and laser treatment for proliferative retinopathy (CPT code 67228). Retrospective, longitudinal database study. One hundred percent dataset of all retina procedures performed on Medicare Part B beneficiaries within the United States from 2005 through 2009. Fixed-effects regression model using Medicare Part B carrier data for all 50 states and the District of Columbia, controlling for time-invariant carrier-specific characteristics, national trends in service volume, Medicare beneficiary population, number of ophthalmologists, and income per capita. Medicare payment-service volume elasticities, defined as the percent change in service volume per 1% change in Medicare payment, for intravitreal injection, laser treatment for retinal edema, and laser treatment for proliferative retinopathy. For all 3 retina procedures, the regression coefficients representing the Medicare payment-service volume elasticity were nonsignificant: intravitreal injection elasticity, -0.75 (95% confidence interval [CI], -1.62 to 0.13; P = 0.09); laser treatment for retinal edema elasticity, 0.14 (95% CI, -0.38 to 0.65; P = 0.59); and laser treatment for proliferative retinopathy elasticity, 0.05 (95% CI, -0.26 to 0.35; P = 0.77). This study found no evidence suggesting that there is an association between Medicare payment and service volume for the 3 highest-volume retina procedures from 2005 through 2009. Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

  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. 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

  5. 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.

  6. 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...

  7. How will provider-focused payment reform impact geographic variation in Medicare spending?

    PubMed

    Auerbach, David; Mehrotra, Ateev; Hussey, Peter; Huckfeldt, Peter J; Alpert, Abby; Lau, Christopher; Shier, Victoria

    2015-06-01

    The Institute of Medicine has recently argued against a value index as a mechanism to address geographic variation in spending and instead promoted payment reform targeted at individual providers. It is unknown whether such provider-focused payment reform reduces geographic variation in spending. We estimated the potential impact of 3 Medicare provider-focused payment policies-pay-for-performance, bundled payment, and accountable care organizations-on geographic variation in Medicare spending across Hospital Referral Regions (HRRs). We compared geographic variation in spending, measured using the coefficient of variation (CV) across HRRs, between the baseline case and a simulation of each of the 3 policies. Policy simulation based on 2008 national Medicare data combined with other publicly available data. Compared with the baseline (CV, 0.171), neither pay-for-performance nor accountable care organizations would change geographic variation in spending (CV, 0.171), while bundled payment would modestly reduce geographic variation (CV, 0.165). In our models, the bundled payment for inpatient and post acute care services in Medicare would modestly reduce geographic variation in spending, but neither accountable care organizations nor pay-for-performance appear to have an impact.

  8. 78 FR 25013 - Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-04-29

    ... against the Medicare program under Title XVIII of the Social Security Act (the Act). Provider enrollment... defined in Sec. 424.502), corporate officers, corporate directors, and/or board members. We note that...

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

    PubMed

    2008-06-27

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

  10. 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...

  11. 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...

  12. 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...

  13. 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...

  14. Medicare program; home health agencies; financial security requirements--HCFA. Proposed rule.

    PubMed

    1985-11-25

    These proposed regulations would implement sections 930(n) and (p) of the Omnibus Reconciliation Act of 1980 (Pub. L. 96-499). Section 930(n) authorizes the Secretary to require home health agencies (HHAs) participating in Medicare to meet conditions, including bonding or establishment of escrow accounts, to ensure the financial security of the Medicare trust fund. Section 930(p) excludes from Medicare reimbursement any costs incurred by an HHA in connection with bonding or establishing an escrow account. It also excludes interest payments made by an HHA that are charged on amounts borrowed to repay Medicare overpayments. The intent of these additional requirements is to assure the availability of funds to repay overpayments, and thereby ensure the financial security of the Medicare program.

  15. 42 CFR 447.30 - Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... Medicaid providers to recover Medicare overpayments. 447.30 Section 447.30 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE... payments to Medicaid providers to recover Medicare overpayments. (a) Basis and purpose. This section...

  16. 42 CFR 447.30 - Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... Medicaid providers to recover Medicare overpayments. 447.30 Section 447.30 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE... payments to Medicaid providers to recover Medicare overpayments. (a) Basis and purpose. This section...

  17. 42 CFR 447.30 - Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Medicaid providers to recover Medicare overpayments. 447.30 Section 447.30 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE... payments to Medicaid providers to recover Medicare overpayments. (a) Basis and purpose. This section...

  18. 42 CFR 447.30 - Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Medicaid providers to recover Medicare overpayments. 447.30 Section 447.30 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE... payments to Medicaid providers to recover Medicare overpayments. (a) Basis and purpose. This section...

  19. 42 CFR 447.30 - Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Medicaid providers to recover Medicare overpayments. 447.30 Section 447.30 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE... payments to Medicaid providers to recover Medicare overpayments. (a) Basis and purpose. This section...

  20. 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.

  1. 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.

  2. 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....

  3. 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...

  4. A Comparison of Ambulatory Surgery Center Production Costs and Medicare Payments: Evidence on Colonoscopy and Endoscopy.

    PubMed

    Mitchell, Jean M; Carey, Kathleen

    2016-02-01

    Ambulatory surgery centers (ASCs) are freestanding facilities that specialize in surgical and diagnostic procedures that do not require an overnight stay. While it is generally assumed that ASCs are less costly than hospital outpatient surgery departments, there is sparse empirical evidence regarding their relative production costs. To estimate ASC production costs using financial and claims records for procedures performed by surgery centers that specialize in gastroenterology procedures (colonoscopy and endoscopy). We estimate production costs in ASCs that specialize in gastroenterology procedures using financial cost and patient discharge data from Pennsylvania for the time period 2004-2013. We focus on the 2 primary procedures (colonoscopies and endoscopies) performed at each ASC. We use our estimates to predict average costs for each procedure and then compare predicted costs to Medicare ACS payments for these procedures. Comparisons of the costs of each procedure with 2013 national Medicare ASC payment rates suggest that Medicare payments exceed production costs for both colonoscopy and endoscopy. This study demonstrated that it is feasible to estimate production costs for procedures performed in freestanding surgery centers. The procedure-specific cost estimates can then be compared with ASC payment rates to ascertain if payments are aligned with costs. This approach can serve as an evaluation template for CMS and private insurers who are concerned that ASC facility payments for specific procedures may be excessive.

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

    Code of Federal Regulations, 2014 CFR

    2014-10-01

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

  6. 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) technology. This final rule specifies--the initial criteria EPs, eligible hospitals, and CAHs must meet in order to qualify for an incentive payment; calculation of the incentive payment amounts; payment adjustments under Medicare for covered professional services and inpatient hospital services provided by EPs, eligible hospitals and CAHs failing to demonstrate meaningful use of certified EHR technology; and other program participation requirements. Also, the Office of the National Coordinator for Health Information Technology (ONC) will be issuing a closely related final rule that specifies the Secretary's adoption of an initial set of standards, implementation, specifications, and certification criteria for electronic health records. ONC has also issued a separate final rule on the establishment of certification programs for health information technology.

  7. Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR); Delay of Effective Date. Final rule; delay of effective date.

    PubMed

    2017-05-19

    This final rule finalizes May 20, 2017 as the effective date of the final rule titled "Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR)" originally published in the January 3, 2017 Federal Register. This final rule also finalizes a delay of the applicability date of the regulations at 42 CFR part 512 from July 1, 2017 to January 1, 2018 and delays the effective date of the specific CJR regulations listed in the DATES section from July 1, 2017 to January 1, 2018.

  8. New risk-adjusted Medicare payment system promises more accurate patient profiles.

    PubMed

    1998-12-01

    Use your knowledge of PIP-DCGs to bolster rate negotiations with your plan. A researcher with experience in operating a plan under Medicare's new risk-adjusted payment methodology reveals what you need to know about principal inpatient diagnostic cost groups.

  9. Medicare

    MedlinePlus

    ... more news See all your Medicare plan choices (TV Ad) Open to lower Medicare costs or extra benefits? (TV Ad) Open to lower costs or extra benefits? (TV Ad) Medicare & You: flu prevention Watch more videos ...

  10. Examination of Industry Payments to Radiation Oncologists in 2014 Using the Centers for Medicare and Medicaid Services Open Payments Database.

    PubMed

    Jairam, Vikram; Yu, James B

    2016-01-01

    To use the Centers for Medicare and Medicaid Services Open Payments database to characterize payments made to radiation oncologists and compare their payment profile with that of medical and surgical oncologists. The June 2015 release of the Open Payments database was accessed, containing all payments made to physicians in 2014. The general payments dataset was used for analysis. Data on payments made to medical, surgical, and radiation oncologists was obtained and compared. Within radiation oncology, data regarding payment category, sponsorship, and geographic distribution were identified. Basic statistics including mean, median, range, and sum were calculated by provider and by transaction. Among the 3 oncologic specialties, radiation oncology had the smallest proportion (58%) of compensated physicians and the lowest mean ($1620) and median ($112) payment per provider. Surgical oncology had the highest proportion (84%) of compensated physicians, whereas medical oncology had the highest mean ($6371) and median ($448) payment per physician. Within radiation oncology, nonconsulting services accounted for the most money to physicians ($1,042,556), whereas the majority of the sponsors were medical device companies (52%). Radiation oncologists in the West accepted the most money ($2,041,603) of any US Census region. Radiation oncologists in 2014 received a large number of payments from industry, although less than their medical or surgical counterparts. As the Open Payments database continues to be improved, it remains to be seen whether this information will be used by patients to inform choice of providers or by lawmakers to enact policy regulating physician-industry relationships. Copyright © 2016 Elsevier Inc. All rights reserved.

  11. 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

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

    PubMed

    Perlis, Roy H; Perlis, Clifford S

    2016-01-01

    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. 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. 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. 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.

  13. 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

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

    PubMed Central

    Langwell, Kathryn M.; Hadley, James P.

    1986-01-01

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

  15. 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.

  16. 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.

  17. 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.

  18. Financial implications to Medicare from changing the dialysis modality mix under the bundled prospective payment system.

    PubMed

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

    2014-01-01

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

  19. 42 CFR 412.29 - Classification criteria for payment under the inpatient rehabilitation facility prospective...

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE... Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs §...

  20. 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.

  1. Comparing mandated health care reforms: the Affordable Care Act, accountable care organizations, and the Medicare ESRD program.

    PubMed

    Watnick, Suzanne; Weiner, Daniel E; Shaffer, Rachel; Inrig, Jula; Moe, Sharon; Mehrotra, Rajnish

    2012-09-01

    In addition to extending health insurance coverage, the Affordable Care Act of 2010 aims to improve quality of care and contain costs. To this end, the act allowed introduction of bundled payments for a range of services, proposed the creation of accountable care organizations (ACOs), and established the Centers for Medicare and Medicaid Innovation to test new care delivery and payment models. The ACO program began April 1, 2012, along with demonstration projects for bundled payments for episodes of care in Medicaid. Yet even before many components of the Affordable Care Act are fully in place, the Medicare ESRD Program has instituted legislatively mandated changes for dialysis services that resemble many of these care delivery reform proposals. The ESRD program now operates under a fully bundled, case-mix adjusted prospective payment system and has implemented Medicare's first-ever mandatory pay-for-performance program: the ESRD Quality Incentive Program. As ACOs are developed, they may benefit from the nephrology community's experience with these relatively novel models of health care payment and delivery reform. Nephrologists are in a position to assure that the ACO development will benefit from the ESRD experience. This article reviews the new ESRD payment system and the Quality Incentive Program, comparing and contrasting them with ACOs. Better understanding of similarities and differences between the ESRD program and the ACO program will allow the nephrology community to have a more influential voice in shaping the future of health care delivery in the United States.

  2. 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.

  3. 75 FR 3742 - Medicare Program; Meeting of the Advisory Panel on Medicare Education; Cancellation of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-22

    ... on Medicare Education; Cancellation of the February 3, 2010 Meeting and Announcement of the March 31... notice also announces a public meeting on March 31, 2010. The Panel advises and makes recommendations to... the Medicare program. This meeting is open to the public. DATES: Meeting Date: Wednesday, March 31...

  4. 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.

  5. Medicare program; rural health clinics: amendments to participation requirements and payment provisions; and establishment of a quality assessment and performance improvement program; suspension of effectiveness. Interim final rule with comment period; partial suspension of effectiveness.

    PubMed

    2006-09-22

    This interim final rule with comment period revises the rural health clinic (RHC) regulations to revert to those provisions set forth in regulations before publication of the December 24, 2003 RHC final rule. That final rule implemented certain provisions of the Balanced Budget Act (BBA) of 1997 to establish a process and criteria for disqualifying from the RHC program clinics that no longer meet basic location requirements (rural and medically underserved), and to require RHCs to establish quality assessment and performance improvement programs. That rule also prohibited "commingling" (the use of the space, professional staff, equipment, and other resources) of an RHC with another entity. [In addition, it addressed comments on the February 28, 2000 proposed rule. Since the publication of the RHC final rule exceeded the 3-year timeline for finalizing proposed rules set by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, we are suspending the effectiveness of the current provisions by removing the RHC provisions set forth in the December 2003 final rule and reverting to those RHC provisions previously in effect.] We intend to reissue new proposed and final RHC rules to reinstate the current provisions. However, these revisions do not impact the effectiveness of the self-implementing provisions of the BBA or any provisions we had previously implemented or enforced through program memoranda.

  6. Comparison of Long-run Trends in 30-day Readmission by Degrees of Medicare Payment Cuts.

    PubMed

    Shen, Yu-Chu; Wu, Vivian Y

    2016-09-01

    The Affordable Care Act enacted significant Medicare payment reductions to providers, yet long-term effects of such major reductions on patient outcomes remain uncertain. Using the 1997 Balanced Budget Act (BBA) as an experiment, we compare long-run trends in 30-day readmission across hospitals with different amount of payment cuts. Using 100% Medicare claims between 1995 and 2011 and instrumental variable hospital fixed-effects regression models, we compared changes in 30-day readmission trends for 5 leading Medicare conditions between urban hospitals facing small, moderate, and large BBA payment reductions across 4 periods [1995-1997 (pre-BBA period), 1998-2000, 2001-2005, 2006-2001]. Patient sample includes Medicare patients who were admitted to general, acute, urban, short-stay hospitals in the United States 1995-2011. Sample size ranges from 1.4 million patients for acute myocardial infarction to 3 million for pneumonia. We found that 30-day readmission trends diverged post-BBA (2001-2005) between hospitals facing small and large payment cuts, where large-cut hospitals experience slower improvement in readmission rates relative to small-cut hospitals. The gap between small-cut and large-cut hospitals readmission trend was 6% for acute myocardial infarction, 4% for congestive heart failure and pneumonia (all P<0.01) in the 2001-2005 period. The gaps between hospitals were eliminated by the 2006-2011 period as the effect of BBA naturally dissipated over time. Although payment-cut differences are associated with widening gaps in readmission rates across hospitals, the negative association appears to dissipate in the long run.

  7. What Financial Incentives Will Be Created by Medicare Bundled Payments for Total Hip Arthroplasty?

    PubMed

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

    2016-09-01

    Bundled payments are gaining popularity in arthroplasty as a tactic for encouraging providers and hospitals to work together to reduce costs. However, this payment model could potentially motivate providers to avoid unprofitable patients, limiting their access to care. Rigorous risk adjustment can prevent this adverse effect, but most current bundling models use limited, if any, risk-adjustment techniques. This study aims to identify and quantify the financial incentives that are likely to develop with total hip arthroplasty (THA) bundled payments that are not accompanied by comprehensive risk stratification. Financial data were collected for all Medicare-eligible patients (age 65+) undergoing primary unilateral THA at an academic center over a 2-year period (n = 553). Bundles were considered to include operative hospitalizations and unplanned readmissions. Multivariate regression was performed to assess the impact of clinical and demographic factors on the variable cost of THA episodes, including unplanned readmissions. (Variable costs reflect the financial incentives that will emerge under bundled payments). Increased costs were associated with advanced age (P < .001), elevated body mass index (BMI; P = .005), surgery performed for hip fracture (P < .001), higher American Society of Anaesthesiologists (ASA) Physical Classification System grades (P < .001), and MCCs (Medicare modifier for major complications; P < .001). Regression coefficients were $155/y, $107/BMI point, $2775 for fracture cases, $2137/ASA grade, and $4892 for major complications. No association was found between costs and gender or race. If generalizable, our results suggest that Centers for Medicare and Medicaid Services bundled payments encompassing acute inpatient care should be adjusted upward by the aforementioned amounts (regression coefficients above) for advanced age, increasing BMI, cases performed for fractures, elevated ASA grade, and major complications (as defined by Medicare MCC

  8. 77 FR 1877 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-12

    ... adequate time be allowed to implement the changes needed to report costs based on pass- through, because...; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing and Remaining Revisions... finalizes provisions regarding the reporting of gross covered retiree plan-related prescription drug costs...

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

    PubMed Central

    Gilman, Matlin; Stensland, Jeff

    2013-01-01

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

  10. Telehealth and Medicare: payment policy, current use, and prospects for growth.

    PubMed

    Gilman, Matlin; Stensland, Jeff

    2013-01-01

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

  11. 75 FR 71189 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-22

    ... Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 417, 422, and 423..., No. 224 / Monday, November 22, 2010 / Proposed Rules#0;#0; ] DEPARTMENT OF HEALTH AND HUMAN SERVICES...: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-4144-P...

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

    Code of Federal Regulations, 2010 CFR

    2010-10-01

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

  13. 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.

  14. Adverse selection in the Medicare prescription drug program.

    PubMed

    Riley, Gerald F; Levy, Jesse M; Montgomery, Melissa A

    2009-01-01

    The Medicare Part D drug benefit created choices for beneficiaries among many prescription drug plans with varying levels of coverage. As a result, Medicare enrollees with high prescription drug costs have strong incentives to enroll in Part D, especially in plans with more comprehensive coverage. To measure this potential problem of "adverse selection," which could threaten plans' finances, we compared baseline characteristics among groups of beneficiaries with various drug coverage arrangements in 2006. We found some significant differences. For example, enrollees in stand-alone prescription drug plans, especially in plans offering benefits in the coverage gap, or "doughnut hole," had higher baseline drug costs and worse health than enrollees in Medicare Advantage prescription drug plans. Although risk-adjusted payments and other measures have been put in place to account for selection, these patterns could adversely affect future Medicare costs and should be watched carefully.

  15. 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......

  16. 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...

  17. 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...

  18. 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...

  19. 76 FR 59136 - Medicare and Medicaid Programs; Application by Community Health Accreditation Program for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-23

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Application by... Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2377-PN, P.O. Box... following address only: Centers for Medicare & Medicaid Services, Department of Health and Human Services...

  20. 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.

  1. 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.

  2. 76 FR 13515 - Medicare Program; Revisions to the Reductions and Increases to Hospitals' FTE Resident Caps for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-14

    ... inpatient prospective payment system (IPPS) for hospitals that have residents in an approved GME program in...; Revisions to the Reductions and Increases to Hospitals' FTE Resident Caps for Graduate Medical Education... Medicare and Medicaid Extenders Act of 2010 relating to the treatment of teaching hospitals that are...

  3. 78 FR 71619 - Medicare and Medicaid Programs; Continued Approval of American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-29

    ... standards to include staff qualification requirements for rehabilitation therapy services. To meet the... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Continued... Hospital Accreditation Program AGENCY: Centers for Medicare & Medicaid Services, HHS. ACTION: Final notice...

  4. 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

  5. 42 CFR 421.302 - Eligibility requirements for Medicare integrity program contractors.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Eligibility requirements for Medicare integrity program contractors. 421.302 Section 421.302 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medicare Integrity...

  6. 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...

  7. Industry Payments to Urologists in 2014: an Analysis of the Open Payments Program

    PubMed Central

    Modi, Parth K.; Farber, Nicholas J.; Zavaski, Michael E.; Jang, Thomas L.; Singer, Eric A.; Chang, Steven L.

    2017-01-01

    Introduction Physician-industry relationships are common in the U.S. and a source of considerable public scrutiny. The Open Payments program is a public database of all physician-industry financial interactions in the U.S. administered by the Centers for Medicare & Medicaid Services. In this study we describe payments received by urologists for research and nonresearch purposes. Methods The number and value of payments to urologists were determined using Open Payments program data. The nature of each payment and identity of industry partners were analyzed. Descriptive statistics were calculated separately for research and nonresearch payment data. The total number of practicing physicians per specialty was obtained from the Association of American Medical Colleges Physician Specialty Data Book for 2014. Results In 2014, 8,620 urologists had nonresearch financial relationships with industry for a total value of $32.4 million, with 2,698 urologists receiving more than $1,000 in total nonresearch payments. Urologists as a whole had the 8th highest total value received of all specialties. A total of $22.4 million was spent by industry for urology directed research funding, representing a small proportion of the more than $3 billion spent by industry on medical research in 2014. The majority (93.1%) of urology directed research funding was provided to nonteaching institutions. Conclusions The Open Payments program database is an important public database of financial transactions between industry and physicians. A large proportion of urologists received nonresearch related transfers of value from industry sources. Industry supported research funding is primarily awarded to nonteaching institutions. PMID:28775998

  8. 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.

  9. 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.

  10. 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.

  11. 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

  12. Medicare Postacute Care Payment Reforms Have Potential to Improve Efficiency, but May Need Changes to Cut Costs

    PubMed Central

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

    2012-01-01

    The Affordable Care Act mandates changes in payment policies for Medicare postacute care services intended to contain spending in the long run and help ensure the program’s financial sustainability. In addition to reducing annual payment increases to providers under the existing prospective payment systems, the act calls for demonstration projects of bundled payment, accountable care organizations, and other strategies to promote care coordination and reduce spending. Experience with the adoption of Medicare prospective payment systems in postacute care settings approximately a decade ago suggests that current reforms could, but need not necessarily, produce such undesirable effects as decreased access for less profitable patients, poorer patient outcomes, and only short-lived curbs on spending. Policy makers will need to be vigilant in monitoring the impact of the Affordable Care Act reforms and be prepared to amend policies as necessary to ensure that the reforms exert persistent controls on spending without compromising the delivery of patient-appropriate postacute services. PMID:22949442

  13. 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). Dated...

  14. 42 CFR 423.2315 - Medicare Coverage Gap Discount Program Agreement.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) VOLUNTARY MEDICARE PRESCRIPTION DRUG... NDCs for pharmacy claims processing. (9) Enter into and have in effect, under terms and conditions...

  15. 76 FR 10598 - Medicare and Medicaid Programs; Approval of the Joint Commission for Deeming Authority for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-25

    ... rehabilitation, physical therapy, occupational therapy, audiology, or speech pathology services, the services are... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Approval of the Joint Commission for Deeming Authority for Psychiatric Hospitals AGENCY: Centers for Medicare & Medicaid...

  16. Has the Medicare Prospective Payment System Led to Increased Nursing Home Efficiency?

    PubMed Central

    Zhang, Ning Jackie; Unruh, Lynn; Wan, Thomas T H

    2008-01-01

    Research Objective To assess the impact of recent Medicare prospective payment system (PPS) changes on efficiency in skilled nursing homes. Data Source/Study Setting Medicare Cost Reports (MCR), On-line Survey Certification and Reporting System (OSCAR), Area Resource Files (ARF), a Centers for Medicare and Medicaid Services (CMS) hospital wage index website, a Consumer Price Index (CPI) database, and a survey of state Medicaid reimbursement rates. The sample was 8,361 nursing homes in the Medicare Cost Report databases from the years 1997 to 2003. Study Design Data-envelopment analyses (DEA) calculated efficiency scores for three separate DEA models: unadjusted, acuity-adjusted, and acuity-and-quality-adjusted efficiency. The efficiency scores from these models were regressed on the Medicare PPS changes (the Balanced Budget Act [BBA], the Balanced Budget Refinement Act [BBRA] and the Benefits Improvement and Protection Act) and other organizational and market explanatory variables using a panel-data truncated regression. Principal Findings Mean values for all efficiency measures decreased over time, the acuity-quality-adjusted efficiency measures decreasing the most. All policy variables were significantly negatively related to all efficiency measures. Higher nurse staffing was negatively related to efficiency in all but the acuity-quality-adjusted model. Other explanatory variables varied in their relationships to the efficiency variables. Conclusions The results suggest that the reimbursement policy changes had a significantly negative impact on efficiency. Higher nurse staffing contributed to lower efficiency only when efficiency was not adjusted for quality. Various organizational and market factors also played significant roles in all efficiency models. PMID:18454780

  17. 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.

  18. 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.

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

    PubMed

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

    2016-07-01

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

  20. 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 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.

  1. 77 FR 9255 - Medicare Program: Notice of Six Membership Appointments to the Advisory Panel on Hospital...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-16

    ... Appointments to the Advisory Panel on Hospital Outpatient Payment AGENCY: Centers for Medicare & Medicaid... announces six new membership appointments to the Advisory Panel on Hospital Outpatient Payment (HOP, the... prepare the annual updates for the hospital outpatient prospective payment system. FOR FURTHER INFORMATION...

  2. 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,...

  3. Identifying the Transgender Population in the Medicare Program

    PubMed Central

    Proctor, Kimberly; Haffer, Samuel C.; Ewald, Erin; Hodge, Carla; James, Cara V.

    2016-01-01

    Abstract Purpose: To identify and describe the transgender population in the Medicare program using administrative data. Methods: Using a combination of International Classification of Diseases ninth edition (ICD-9) codes relating to transsexualism and gender identity disorder, we analyzed 100% of the 2013 Centers for Medicare & Medicaid Services (CMS) Medicare Fee-For-Service (FFS) “final action” claims from both institutional and noninstitutional providers (∼1 billion claims) to identify individuals who may be transgender Medicare beneficiaries. To confirm, we developed and applied a multistage validation process. Results: Four thousand ninety-eight transgender beneficiaries were identified, of which ∼90% had confirmatory diagnoses, billing codes, or evidence of a hormone prescription. In general, the racial, ethnic, and geographic distribution of the Medicare transgender population tends to reflect the broader Medicare population. However, age, original entitlement status, and disease burden of the transgender population appear substantially different. Conclusions: Using a variety of claims information, ranging from claims history to additional diagnoses, billing modifiers, and hormone prescriptions, we demonstrate that administrative data provide a valuable resource for identifying a lower bound of the Medicare transgender population. In addition, we provide a baseline description of the diversity and disease burden of the population and a framework for future research. PMID:28861539

  4. 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...

  5. 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.

  6. 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.

  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. 76 FR 39006 - Medicare Program; Hospital Inpatient Value-Based Purchasing Program; Correction

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-05

    ... Program; Hospital Inpatient Value-Based Purchasing Program; Correction AGENCY: Centers for Medicare...) entitled ``Medicare Program; Hospital Inpatient Value-Based Purchasing Program.'' DATES: Effective Date... the new combined section ``II. A Overview of the January 7, 2011 Hospital Inpatient VBP Program...

  9. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Denial of enrollment in the Medicare program. 424.530 Section 424.530 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND... Establishing and Maintaining Medicare Billing Privileges § 424.530 Denial of enrollment in the Medicare program...

  10. 42 CFR 424.530 - Denial of enrollment in the Medicare program.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Denial of enrollment in the Medicare program. 424.530 Section 424.530 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND... Establishing and Maintaining Medicare Billing Privileges § 424.530 Denial of enrollment in the Medicare program...

  11. 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...

  12. 76 FR 28040 - Medicare and Medicaid Programs; Application by the Joint Commission for Continued Deeming...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-13

    ... HUMAN SERVICES Centers for Medicare and Medicaid Services Medicare and Medicaid Programs; Application by... Medicare and Medicaid Services (CMS), HHS. ACTION: Proposed Notice. SUMMARY: This proposed notice with... participate in the Medicare or Medicaid programs. Section 1865(a)(3)(A) of the Social Security Act requires...

  13. 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

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

    PubMed

    2015-10-16

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

  15. Favorable selection, risk adjustment, and the Medicare Advantage program.

    PubMed

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

    2013-06-01

    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. From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures. 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. 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. 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. © Health Research and Educational Trust.

  16. 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

  17. Registered Nurse Staffing in Pennsylvania Nursing Homes: Comparison before and after Implementation of Medicare's Prospective Payment System.

    ERIC Educational Resources Information Center

    Kanda, Katsuya; Mezey, Mathy

    1991-01-01

    Examined changes in resident acuity and registered nurse staffing in all nursing homes in Pennsylvania before and after introduction of Medicare Prospective Payment System (PPS) in 1983. Found that acuity of nursing home residents increased significantly since introduction of PPS, full-time registered nurse staffing remained unchanged, and…

  18. Medicare Payment Policy Creates Incentives For Long-Term Care Hospitals To Time Discharges For Maximum Reimbursement.

    PubMed

    Kim, Yan S; Kleerup, Eric C; Ganz, Patricia A; Ponce, Ninez A; Lorenz, Karl A; Needleman, Jack

    2015-06-01

    Long-term care hospitals are postacute care facilities for patients requiring extended hospital-level care. These facilities are reimbursed by Medicare under a prospective payment system with a short-stay outlier policy, which results in substantially lower payments for patients discharged before a diagnosis-related group-specific short-stay threshold. Using Medicare data, we examined the impact of the short-stay policy on lengths-of-stay and Medicare reimbursement among patients in long-term care hospitals who require prolonged mechanical ventilation. After accounting for case-mix and facility-level differences, we found that discharges for reasons other than death in the period 2005-10 were most likely to occur on the day of or immediately after the short-stay threshold; this held true regardless of facility ownership. In contrast, live discharges in 2002—the year before the prospective payment system started phasing out cost-based payment—were evenly distributed around the day that later became the short-stay threshold. Our findings confirm that the short-stay outlier payment policy created a strong financial incentive for long-term care hospitals to time patient discharges to maximize Medicare reimbursement. The results suggest that the new very-short-stay policy implemented in December 2012 could have a similar effect.

  19. 42 CFR 416.173 - Publication of revised payment methodologies and payment rates.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Web site, the payment methodologies and payment rates for ASC services and designates the covered... payment rates. 416.173 Section 416.173 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) AMBULATORY SURGICAL SERVICES...

  20. 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...

  1. 76 FR 79193 - Medicare Program; Independence at Home Demonstration Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-21

    ... beneficiaries are defined as Medicare fee-for-service (FFS) patients, who have at least 2 chronic illnesses...-specific spending target derived from claims, based on expected Medicare FFS utilization for each of the.... Under this 3-year demonstration, IAH providers will continue to bill and be paid standard Medicare FFS...

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

    PubMed Central

    Baicker, Katherine; Chernew, Michael; Robbins, Jacob

    2013-01-01

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

  3. 76 FR 21431 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-15

    ... Programs SSA Social Security Administration SSI Supplemental Security Income TMR Targeted Medication Review... 1851 through 1859 of the Social Security Act (the Act) which established the current MA program (known...

  4. Design Challenges of an Episode-Based Payment Model in Oncology: The Centers for Medicare & Medicaid Services Oncology Care Model.

    PubMed

    Kline, Ronald M; Muldoon, L Daniel; Schumacher, Heidi K; Strawbridge, Larisa M; York, Andrew W; Mortimer, Laura K; Falb, Alison F; Cox, Katherine J; Bazell, Carol; Lukens, Ellen W; Kapp, Mary C; Rajkumar, Rahul; Bassano, Amy; Conway, Patrick H

    2017-07-01

    The Centers for Medicare & Medicaid Services developed the Oncology Care Model as an episode-based payment model to encourage participating practitioners to provide higher-quality, better-coordinated care at a lower cost to the nearly three-quarter million fee-for-service Medicare beneficiaries with cancer who receive chemotherapy each year. Episode payment models can be complex. They combine into a single benchmark price all payments for services during an episode of illness, many of which may be delivered at different times by different providers in different locations. Policy and technical decisions include the definition of the episode, including its initiation, duration, and included services; the identification of beneficiaries included in the model; and beneficiary attribution to practitioners with overall responsibility for managing their care. In addition, the calculation and risk adjustment of benchmark episode prices for the bundle of services must reflect geographic cost variations and diverse patient populations, including varying disease subtypes, medical comorbidities, changes in standards of care over time, the adoption of expensive new drugs (especially in oncology), as well as diverse practice patterns. Other steps include timely monitoring and intervention as needed to avoid shifting the attribution of beneficiaries on the basis of their expected episode expenditures as well as to ensure the provision of necessary medical services and the development of a meaningful link to quality measurement and improvement through the episode-based payment methodology. The complex and diverse nature of oncology business relationships and the specific rules and requirements of Medicare payment systems for different types of providers intensify these issues. The Centers for Medicare & Medicaid Services believes that by sharing its approach to addressing these decisions and challenges, it may facilitate greater understanding of the model within the oncology

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

    PubMed Central

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

    2003-01-01

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

  6. 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

  7. 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.

  8. 42 CFR 495.206 - Timeframe for payment to qualifying MA organizations.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... under the Medicare FFS EHR incentive program according to § 495.102. (b) Payments to qualifying MA... the Medicare FFS EHR incentive program, following the timeline in specified in § 495.104 of this part... common corporate governance under the Medicare FFS EHR incentive program, payment is made under the MA...

  9. 42 CFR 495.206 - Timeframe for payment to qualifying MA organizations.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... under the Medicare FFS EHR incentive program according to § 495.102. (b) Payments to qualifying MA... the Medicare FFS EHR incentive program, following the timeline in specified in § 495.104 of this part... common corporate governance under the Medicare FFS EHR incentive program, payment is made under the MA...

  10. 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.

  11. Making Medicare Advantage a Middle-Class Program

    PubMed Central

    Glazer, Jacob; McGuire, Thomas

    2013-01-01

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

  12. 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.

  13. Medicare payment data for spine reimbursement; important but flawed data for evaluating utilization of resources.

    PubMed

    Menger, Richard P; Wolf, Michael E; Kukreja, Sunil; Sin, Anthony; Nanda, Anil

    2015-01-01

    Medicare data showing physician-specific reimbursement for 2012 were recently made public in the mainstream media. Given the ongoing interest in containing healthcare costs, we analyze these data in the context of the delivery of spinal surgery. Demographics of 206 leading surgeons were extracted including state, geographic area, residency training program, fellowship training, and academic affiliation. Using current procedural terminology (CPT) codes, information was evaluated regarding the number of lumbar laminectomies, lumbar fusions, add-on laminectomy levels, and anterior cervical fusions reimbursed by Medicare in 2012. In 2012 Medicare reimbursed the average neurosurgeon slightly more than an orthopedic surgeon for all procedures ($142,075 vs. $110,920), but this was not found to be statistically significant (P = 0.218). Orthopedic surgeons had a statistical trend illustrating increased reimbursement for lumbar fusions specifically, $1187 versus $1073 (P = 0.07). Fellowship trained spinal surgeons also, on average, received more from Medicare ($125,407 vs. $76,551), but again this was not statistically significant (P = 0.112). A surgeon in private practice, on average, was reimbursed $137,495 while their academic counterparts were reimbursed $103,144 (P = 0.127). Surgeons performing cervical fusions in the Centers for Disease Control West Region did receive statistically significantly less reimbursement for that procedure then those surgeons in other parts of the country (P = 0.015). Surgeons in the West were reimbursed on average $849 for CPT code 22,551 while those in the Midwest received $1475 per procedure. Medicare reimbursement data are fundamentally flawed in determining healthcare expenditure as it shows a bias toward delivery of care in specific patient demographics. However, neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and interpret these data as it will affect healthcare reimbursement and delivery moving

  14. 42 CFR 420.410 - Establishment of a program to collect suggestions for improving Medicare program efficiency and...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Medicare Fraud and Abuse, and Establishment of a Program to Collect Suggestions for Improving Medicare... for improving Medicare program efficiency and to reward suggesters for monetary savings. 420.410 Section 420.410 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...

  15. 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.

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

    PubMed Central

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

    2014-01-01

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

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

    PubMed

    2014-12-05

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

  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. Use of Medicare summary notice inserts to generate interest in the Medicare stop smoking program.

    PubMed

    Maglione, Margaret; Larson, Carrie; Giannotti, Tierney; Lapin, Pauline

    2007-01-01

    Evaluations of outreach strategies that effectively and efficiently reach the senior population often go unreported. The Medicare Stop Smoking Program (MSSP) was a seven-state demonstration project funded by the Centers for Medicare and Medicaid Services. The 1-year recruitment plan for MSSP included a multifaceted paid media campaign; however, enrollment was slower than anticipated. The purpose of this substudy was to test the effects of including envelope-sized advertisement inserts with Medicare Summary Notices (MSNs) as a supplemental recruitment strategy. Information obtained from enrollees on where they had learned about the program as well as overall enrollment rates were analyzed and compared with the time periods during which the inserts were included in MSN mailings. Average call volume to the enrollment center increased by 65.7% in Alabama, the pilot state, and by more than 200% in the subsequent demonstration states. Despite the introduction of the MSN inserts late in the recruitment period, 32.2 % of the 7354 total enrollees stated that they learned about the project through the inserts. This recruitment method is highly recommended as a cost-effective way to reach the senior population.

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

    PubMed

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

    2016-09-01

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

  1. 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

  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

    ... incorporated into the plan of care and considered in the bereavement plan of care.'' To meet the requirements..., and the conditions for Medicare payment for hospice care. Generally, to enter into an agreement, a... to address the needs of ``other individuals'' in the bereavement assessment. In addition,...

  3. Practice patterns, case mix, Medicare payment policy, and dialysis facility costs.

    PubMed

    Hirth, R A; Held, P J; Orzol, S M; Dor, A

    1999-02-01

    To evaluate the effects of case mix, practice patterns, features of the payment system, and facility characteristics on the cost of dialysis. The nationally representative sample of dialysis units in the 1991 U.S. Renal Data System's Case Mix Adequacy (CMA) Study. The CMA data were merged with data from Medicare Cost Reports, HCFA facility surveys, and HCFA's end-stage renal disease patient registry. We estimated a statistical cost function to examine the determinants of costs at the dialysis unit level. The relationship between case mix and costs was generally weak. However, dialysis practices (type of dialysis membrane, membrane reuse policy, and treatment duration) did have a significant effect on costs. Further, facilities whose payment was constrained by HCFA's ceiling on the adjustment for area wage rates incurred higher costs than unconstrained facilities. The costs of hospital-based units were considerably higher than those of freestanding units. Among chain units, only members of one of the largest national chains exhibited significant cost savings relative to independent facilities. Little evidence showed that adjusting dialysis payment to account for differences in case mix across facilities would be necessary to ensure access to care for high-cost patients or to reimburse facilities equitably for their costs. However, current efforts to increase dose of dialysis may require higher payments. Longer treatments appear to be the most economical method of increasing the dose of dialysis. Switching to more expensive types of dialysis membranes was a more costly means of increasing dose and hence must be justified by benefits beyond those of higher dose. Reusing membranes saved money, but the savings were insufficient to offset the costs associated with using more expensive membranes. Most, but not all, of the higher costs observed in hospital-based units appear to reflect overhead cost allocation rather than a difference in real resources devoted to treatment

  4. 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

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

  5. 76 FR 19527 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-07

    ... Schedule MS-DRGs Medicare Severity-Diagnosis Related Groups MSP Minimum Savings Percentage MSR Minimum... term care, children's, and cancer hospitals.) Section 1899(h)(3) of the Act defines the term...

  6. 78 FR 17677 - Medicare and Medicaid Programs: Application From the American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-22

    ... Program; No. 93.773 Medicare--Hospital Insurance Program; and No. 93.774, Medicare--Supplementary Medical...-Approval of Its Hospital Accreditation Program AGENCY: Centers for Medicare and Medicaid Services, HHS...) for continued recognition as a national accrediting organization for hospitals that wish to...

  7. 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...

  8. Medicare program; schedule of target rate percentages for limits on the rate of hospital cost increases and updating factors for transition prospective payments rates--HCFA. Interim final notice with comment period.

    PubMed

    1983-09-01

    This interim notice sets forth target rate percentages needed to limit the rate of increase of hospital inpatient operating costs and related updating factors for use in computing the hospital-specific portions of transition payment rates under the prospective payment system. The notice also explains which hospitals are subject to the ceiling on the rate of hospital cost increases (as established by the Tax Equity and Fiscal Responsibility Act of 1982, and amended by the Social Security Amendments of 1983), and describes how the calendar year target rate percentages are applied to cost reporting periods that span two calendar years.

  9. 75 FR 58203 - Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-23

    ... enrollment and Medicaid payment suspension issues. Joseph Strazzire (410) 786-2775 for Medicare payment... Practitioner Data Bank (NPDB), accreditation status of institutional providers and suppliers with national... Provider Identifier (NPI), the National Practitioner Data Bank (NPDB) licensure, an OIG exclusion,...

  10. 77 FR 51542 - Medicare Program; Solicitation of Two Nominations to the Advisory Panel on Hospital Outpatient...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-24

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

  11. 76 FR 66931 - Medicare Program: Notice of Two Membership Appointments to the Advisory Panel on Ambulatory...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-28

    ... Appointments to the Advisory Panel on Ambulatory Payment Classification Groups AGENCY: Centers for Medicare... notice announces two new membership appointments to the Advisory Panel on Ambulatory Payment Classification (APC) Groups (the Panel). The two appointments are for 4-year periods through January 31, 2016...

  12. 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....

  13. 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....

  14. 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....

  15. 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.

  16. 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...

  17. 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.

  18. Changes in Postacute Care in the Medicare Shared Savings Program.

    PubMed

    McWilliams, J Michael; Gilstrap, Lauren G; Stevenson, David G; Chernew, Michael E; Huskamp, Haiden A; Grabowski, David C

    2017-04-01

    Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care. To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred. With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014. Patient attribution to an ACO in the MSSP. Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics. For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, -$106 per beneficiary [95% CI, -$176 to -$35], or -9.0% of the precontract unadjusted mean of $1172; P = .003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (-0.6 percentage points [95% CI, -1.1 to 0.0], or -2.7% of the unadjusted precontract mean of 22.6%; P = .03), and length of SNF stays (-0.60 days per stay [95% CI, -0.99 to -0.22], or -2.2% of the precontract unadjusted mean of 27.07 days; P = .002). Reductions in use of SNFs and length of stay were largely due to within-hospital or

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

    Code of Federal Regulations, 2012 CFR

    2012-10-01

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

  20. 75 FR 70165 - Medicare Program; Request for Information Regarding Accountable Care Organizations and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-17

    ... Information Regarding Accountable Care Organizations and the Medicare Shared Saving Program AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Request for information. SUMMARY: This document... accountable care organizations (ACOs) participating in the Medicare program under section 3021 or 3022 of the...

  1. 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...

  2. 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...

  3. High Variation of Intravitreal Injection Rates and Medicare Anti-Vascular Endothelial Growth Factor Payments per Injection in the United States.

    PubMed

    Erie, Jay C; Barkmeier, Andrew J; Hodge, David O; Mahr, Michael A

    2016-06-01

    To estimate geographic variation of intravitreal injection rates and Medicare anti-vascular endothelial growth factor (VEGF) drug costs per injection in aging Americans. Observational cohort study using 2013 Medicare claims database. United States fee-for-service (FFS) Part B Medicare beneficiaries and their providers. Medicare Provider Utilization and Payment Data furnished by the Centers for Medicare and Medicaid Services was used to identify all intravitreal injection claims and anti-VEGF drug claims among FFS Medicare beneficiaries in all 50 states and the District of Columbia in 2013. The rate of FFS Medicare beneficiaries receiving intravitreal injections and the mean Medicare-allowed drug payment per anti-VEGF injection was calculated nationally and for each state. Geographic variations were evaluated by using extremal quotient, coefficient of variation, and systematic component of variance (SCV). Rate of FFS Medicare Part B beneficiaries receiving intravitreal injections (Current Procedural Terminology [CPT] code, 67028), nationally and by state; mean Medicare-allowed drug payment per anti-VEGF injection (CPT code, 67028; and treatment-specific J-codes, J0178, J2778, J9035, J3490, and J3590) nationally and by state. In 2013, the rate of FFS Medicare beneficiaries receiving intravitreal injections varied widely by 7-fold across states (range by state, 4 per 1000 [Wyoming]-28 per 1000 [Utah]), averaging 19 per 1000 beneficiaries. The mean SCV was 8.5, confirming high nonrandom geographic variation. There were more than 2.1 million anti-VEGF drug claims, totaling more than $2.3 billion in Medicare payments for anti-VEGF agents in 2013. The mean national Medicare drug payment per anti-VEGF injection varied widely by 6.2-fold across states (range by state, $242 [South Carolina]-$1509 [Maine]), averaging $1078 per injection. Nationally, 94% of injections were office based and 6% were facility based. High variation was observed in intravitreal injection rates and

  4. 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,...

  5. 42 CFR 412.348 - Exception payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... Capital Costs Determination of Transition Period Payment Rates for Capital-Related Costs § 412.348... hospital will equal a fixed percentage of the hospital's capital-related costs. The minimum payment...

  6. 42 CFR 412.348 - Exception payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... Capital Costs Determination of Transition Period Payment Rates for Capital-Related Costs § 412.348... hospital will equal a fixed percentage of the hospital's capital-related costs. The minimum payment...

  7. 42 CFR 412.348 - Exception payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... Capital Costs Determination of Transition Period Payment Rates for Capital-Related Costs § 412.348... hospital will equal a fixed percentage of the hospital's capital-related costs. The minimum payment...

  8. 42 CFR 412.348 - Exception payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... Capital Costs Determination of Transition Period Payment Rates for Capital-Related Costs § 412.348... hospital will equal a fixed percentage of the hospital's capital-related costs. The minimum payment...

  9. 42 CFR 412.348 - Exception payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... Capital Costs Determination of Transition Period Payment Rates for Capital-Related Costs § 412.348... hospital will equal a fixed percentage of the hospital's capital-related costs. The minimum payment...

  10. 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...

  11. 42 CFR 419.31 - Ambulatory payment classification (APC) system and payment weights.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Ambulatory payment classification (APC) system and... Hospital Outpatient Services § 419.31 Ambulatory payment classification (APC) system and payment weights... OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PROSPECTIVE PAYMENT SYSTEM FOR...

  12. 42 CFR 419.31 - Ambulatory payment classification (APC) system and payment weights.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Ambulatory payment classification (APC) system and... Hospital Outpatient Services § 419.31 Ambulatory payment classification (APC) system and payment weights... OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PROSPECTIVE PAYMENT SYSTEM FOR...

  13. 42 CFR 419.31 - Ambulatory payment classification (APC) system and payment weights.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Ambulatory payment classification (APC) system and... Hospital Outpatient Services § 419.31 Ambulatory payment classification (APC) system and payment weights... OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PROSPECTIVE PAYMENT SYSTEM FOR...

  14. 77 FR 64755 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2; Corrections

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-23

    ... Medicare and Medicaid Programs; Electronic Health Record Incentive Program--Stage 2; Corrections AGENCY... Medicaid Programs; Electronic Health Record Incentive Program--Stage 2'' which appeared in the September 4... Programs; Electronic Health Record Incentive Program--Stage 2'' there were a number of technical errors and...

  15. 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...

  16. 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…

  17. 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…

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

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH... an area with a shortage of primary care physicians or specialty physicians to the Medicare population...

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

    PubMed

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

    2012-01-01

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

  1. What Drives Variation in Episode-of-care Payments for Primary TKA? An Analysis of Medicare Administrative Data.

    PubMed

    Cram, Peter; Ravi, Bheeshma; Vaughan-Sarrazin, Mary S; Lu, Xin; Li, Yue; Hawker, Gillian

    2015-11-01

    Episode-of-care payments are defined as a single lump-sum payment for all services associated with a single medical event or surgery and are designed to incentivize efficiency and integration among providers and healthcare systems. A TKA is considered an exemplar for an episode-of-care payment model by many policymakers, but data describing variation payments between hospitals for TKA are extremely limited. We asked: (1) How much variation is there between hospitals in episode-of-care payments for primary TKA? (2) Is variation in payment explained by differences in hospital structural characteristics such as teaching status or geographic location, patient factors (age, sex, ethnicity, comorbidities), and discharge disposition during the postoperative period (home versus skilled nursing facility)? (3) After accounting for those factors, what proportion of the observed variation remains unexplained? We used Medicare administrative data to identify fee-for-service beneficiaries who underwent a primary elective TKA in 2009. After excluding low-volume hospitals, we created longitudinal records for all patients undergoing TKAs in eligible hospitals encompassing virtually all payments by Medicare for a 120-day window around the TKA (30 days before to 90 days after). We examined payments for the preoperative, perioperative, and postdischarge periods based on the hospital where the TKA was performed. Confounding variables were controlled for using multivariate analyses to determine whether differences in hospital payments could be explained by differences in patient demographics, comorbidity, or hospital structural factors. There was considerable variation in payments across hospitals. Median (interquartile range) hospital preoperative, perioperative, postdischarge, and 120-day payments for patients who did not experience a complication were USD 623 (USD 516-768), USD 13,119 (USD 12,165-14,668), USD 8020 (USD 6403-9933), and USD 21,870 (USD 19,736-25,041), respectively

  2. 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).

  3. Medicare program; revised civil money penalties, assessments, exclusions, and related appeals procedures. Final rule.

    PubMed

    2007-07-20

    This final rule establishes the procedures for imposing exclusions for certain violations of the Medicare program and is based on the procedures that the Office of Inspector General has published for civil money penalties, assessments, and exclusions under their delegated authority. Implementation of this final rule protects beneficiaries from persons (that is, health care providers and entities) found in noncompliance with Medicare regulations, and otherwise improves the safeguard provisions under the Medicare statute. This final rule also establishes procedures that enable a person targeted for exclusion from the Medicare program to request the Centers for Medicare & Medicaid Services to act on its behalf to recommend to the Inspector General that the exclusion from Medicare be waived due to hardship that would be placed on Medicare beneficiaries as a result of the person's exclusion.

  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. 75 FR 8374 - Medicare Program; Meeting of the Practicing Physicians Advisory Council, March 8, 2010; Correction

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-02-24

    ... Physicians Advisory Council, March 8, 2010; Correction AGENCY: Centers for Medicare & Medicaid Services (CMS... Program; Meeting of the Practicing Physicians Advisory Council, March 8, 2010.'' FOR FURTHER INFORMATION...

  10. 78 FR 59702 - Medicare Program; Medicare Appeals: Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-27

    ..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription Drug... are to be adjusted, as of January 2005, by the percentage increase in the medical care component of the consumer price index (CPI) for all urban consumers (U.S. city average) for July 2003 to July of...

  11. 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...

  12. 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).

  13. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

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

  14. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

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

  15. 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...

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

    Code of Federal Regulations, 2011 CFR

    2011-10-01

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

  17. 42 CFR 412.332 - Payment based on the hospital-specific rate.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

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

  18. 77 FR 31361 - Medicare and Medicaid Programs; Application by American Osteopathic Association/Healthcare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-25

    ...-Approval of its Ambulatory Surgery Center (ASC) Accreditation Program AGENCY: Centers for Medicare and... Program (AOA/HFAP) for continued recognition as a national accrediting organization for ambulatory surgery...--Ambulatory surgery center Insurance Program; and No. 93.774, Medicare--Supplementary Medical...

  19. 76 FR 41260 - Supplemental Funding for the Senior Medicare Patrol (SMP) Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-13

    ... HUMAN SERVICES Administration on Aging Supplemental Funding for the Senior Medicare Patrol (SMP) Program... provide supplemental grant funds for the support of the Senior Medicare Patrol (SMP) program. The goal of...: Supplemental funding to provide expanded support for the SMP program network. C. Amount of the Award: $178,000...

  20. 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...

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

    Code of Federal Regulations, 2013 CFR

    2013-10-01

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

  2. 42 CFR 412.108 - Special treatment: Medicare-dependent, small rural hospitals.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

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

  3. 42 CFR 412.108 - Special treatment: Medicare-dependent, small rural hospitals.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

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

  4. 42 CFR 412.108 - Special treatment: Medicare-dependent, small rural hospitals.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

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

  5. 77 FR 44242 - Medicare Program; Hospice Wage Index for Fiscal Year 2013

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-27

    ... ``CBSA-based'' refers to wage index values and designations based on the OMB revised MSA designations in... index. In the August 8, 1997 Federal Register (62 FR 42860), we published a final rule implementing a...). The reduction in overall Medicare payments if a new wage index were adopted was noted in the November...

  6. Association of Hospital Participation in a Quality Reporting Program with Surgical Outcomes and Expenditures for Medicare Beneficiaries

    PubMed Central

    Osborne, Nicholas H.; Nicholas, Lauren H.; Ryan, Andrew M.; Thumma, Jyothi R.; Dimick, Justin B.

    2015-01-01

    Importance The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) provides feedback to hospitals on risk-adjusted outcomes. It is not known if NSQIP participation improves outcomes and reduces costs relative to non-participating hospitals. Objective To evaluate the association of enrollment and participation in the ACS-NSQIP with outcomes and Medicare payments compared to control hospitals that did not participate in this program. Design Quasi-experimental study using national Medicare data (2003 to 2012) for patients undergoing general and vascular surgery. A difference-in-difference analytic approach was used to evaluate whether participation in ACS-NSQIP was associated with improved outcomes and reduced Medicare payments compared to non-participating hospitals that were otherwise similar. Control hospitals were selected using propensity score matching (2 control hospitals for each ACS-NSQIP hospital). Setting and Participants 263 hospitals participating in ACS NSQIP and 526 non-participating hospitals and a total of 1,226,479 patients undergoing general and vascular surgical procedures Main Outcome Measures 30-day mortality, serious complications (e.g. pneumonia, myocardial infarction, or acute renal failure and a length of stay > 75th percentile), reoperation and readmission within 30 days. Hospital costs were assessed using price-standardized Medicare payments during hospitalization and 30 days post-discharge. Results After accounting for patient factors and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes at 1-, 2- or 3-years after (vs before) enrollment in ACS-NSQIP. For example, in analyses comparing outcomes at 3-years after (vs. before) enrollment, there were no statistically significant differences in risk-adjusted 30-day mortality (4.3% vs. 4.5%, Relative risk [RR] 0.96, 95% CI, 0.89–1.03), serious complications (11.1% vs. 11.0%, RR 0.96, 95% CI, 0

  7. Do heart failure disease management programs make financial sense under a bundled payment system?

    PubMed

    Eapen, Zubin J; Reed, Shelby D; Curtis, Lesley H; Hernandez, Adrian F; Peterson, Eric D

    2011-05-01

    Policy makers have proposed bundling payments for all heart failure (HF) care within 30 days of an HF hospitalization in an effort to reduce costs. Disease management (DM) programs can reduce costly HF readmissions but have not been economically attractive for caregivers under existing fee-for-service payment. Whether a bundled payment approach can address the negative financial impact of DM programs is unknown. Our study determined the cost-neutral point for the typical DM program and examined whether published HF DM programs can be cost saving under bundled payment programs. We used a decision analytic model using data from retrospective cohort studies, meta-analyses, 5 randomized trials evaluating DM programs, and inpatient claims for all Medicare beneficiaries discharged with an HF diagnosis from 2001 to 2004. We determined the costs of DM programs and inpatient care over 30 and 180 days. With a baseline readmission rate of 22.9%, the average cost for readmissions over 30 days was $2,272 per patient. Under base-case assumptions, a DM program that reduced readmissions by 21% would need to cost $477 per patient to be cost neutral. Among evaluated published DM programs, 2 of the 5 would increase provider costs (+$15 to $283 per patient), whereas 3 programs would be cost saving (-$241 to $347 per patient). If bundled payments were broadened to include care over 180 days, then program saving estimates would increase, ranging from $419 to $1,706 per patient. Proposed bundled payments for HF admissions provide hospitals with a potential financial incentive to implement DM programs that efficiently reduce readmissions. Copyright © 2011 Mosby, Inc. All rights reserved.

  8. 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...

  9. 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...

  10. 78 FR 57857 - Medicare and Medicaid Programs; Application from the Compliance Team for Initial CMS-Approval of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-20

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare and Medicaid Programs; Application from...: Centers for Medicare and Medicaid Services, HHS. ACTION: Proposed notice. SUMMARY: This proposed notice... accrediting organization for rural health clinics (RHCs) that wish to participate in the Medicare or Medicaid...

  11. Medicare and Medicaid; payment for the cost of malpractice insurance--HCFA. Interim final rule with comment period.

    PubMed

    1986-04-01

    In this final rule we are adopting an apportionment methodology for determining reasonable cost reimbursement for hospital malpractice insurance costs. The new apportionment policy for hospitals will divide total malpractice insurance premium cost into two components. The "administrative component," which accounts for 8.5 percent of total premium cost, will be included in the General and Administrative cost center and will be apportioned on the basis of the individual hospital's Medicare utilization rate. The "risk component," which comprises 91.5 percent of total cost, will be apportioned on the basis of a formula that takes into account the individual hospital's utilization as well as the national Medicare patient utilization rate and the national Medicare malpractice loss ratio (as adjusted to account for associated claims handling costs). Effectively, the "scaling factor formula" will relate the national utilization rate to the adjusted national loss ratio. As a hospital's own utilization rate exceeds or falls below the national utilization rate, the risk component will be reimbursed on the basis of a "scaling factor" that is more or less than the national Medicare malpractice loss ratio. Different apportionment policies are being adopted for Medicare skilled nursing facilities and for providers of services under the Medicaid and Maternal and Child Health programs. This final rule replaces our current apportionment policy for reimbursement of malpractice insurance costs and is applicable, subject to the rules of reopening and administrative finality, to cost reporting periods beginning on or after July 1, 1979.

  12. 42 CFR 460.182 - Medicaid payment.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Medicaid payment. 460.182 Section 460.182 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED...) Payment § 460.182 Medicaid payment. (a) Under a PACE program agreement, the State administering agency...

  13. Predicting the Incremental Hospital Cost of Adverse Events Among Medicare Beneficiaries in the Comprehensive Joint Replacement Program During Fiscal Year 2014.

    PubMed

    Culler, Steven D; Jevsevar, David S; McGuire, Kevin J; Shea, Kevin G; Little, Kenneth M; Schlosser, Michael J

    2017-06-01

    The Medicare program's Comprehensive Care for Joint Replacement (CJR) payment model places hospitals at financial risk for the treatment cost of Medicare beneficiaries (MBs) undergoing lower extremity joint replacement (LEJR). This study uses Medicare Provider Analysis and Review File and identified 674,777 MBs with LEJR procedure during fiscal year 2014. Adverse events (death, acute myocardial infarction, pneumonia, sepsis or shock, surgical site bleeding, pulmonary embolism, mechanical complications, and periprosthetic joint infection) were studied. Multivariable regressions were modeled to estimate the incremental hospital cost of treating each adverse event. The risk-adjusted estimated hospital cost of treating adverse events varied from a high of $29,061 (MBs experiencing hip fracture and joint infection) to a low of $6308 (MBs without hip fracture that experienced pulmonary embolism). Avoidance of adverse events in the LEJR hospitalization will play an important role in managing episode hospital costs in the Comprehensive Care for Joint Replacement program. Copyright © 2017 Elsevier Inc. All rights reserved.

  14. Radiation oncology services in the modern era: evolving patterns of usage and payments in the office setting for medicare patients from 2000 to 2010.

    PubMed

    Shen, Xinglei; Showalter, Timothy N; Mishra, Mark V; Barth, Sanford; Rao, Vijay; Levin, David; Parker, Laurence

    2014-07-01

    We evaluated long-term changes in the volume and payments for radiation oncology services in the intensity-modulated radiation therapy (IMRT) era from 2000 to 2010 using a database of Medicare claims. We used the Medicare Physician/Supplier Procedure Summary Master File (PSPSMF) for each year from 2000 to 2010 to tabulate the volume and payments for radiation oncology services. This database provides a summary of each billing code submitted to Medicare part B. We identified all codes used in radiation oncology services and categorized billing codes by treatment modality and place of service. We focused our analysis on office-based practices. Total office-based patient volume increased 8.2% from 2000 to 2010, whereas total payments increased 217%. Increase in overall payments increased dramatically from 2000 to 2007, but subsequently plateaued from 2008 to 2010. Increases in complexity of care, and image guidance in particular, have also resulted in higher payments. The cost of radiation oncology services increased from 2000 to 2010, mostly due to IMRT, but also with significant contribution from increased overall complexity of care. A cost adjustment occurred after 2007, limiting further growth of payments. Future health policy studies should explore the potential for further cost containment, including differences in use between freestanding and hospital outpatient facilities. Copyright © 2014 by American Society of Clinical Oncology.

  15. 76 FR 15105 - Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-18

    ... Services 42 CFR Part 488 Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes; Final... and Medicaid Programs; Civil Money Penalties for Nursing Homes AGENCY: Centers for Medicare & Medicaid... nursing homes are not in compliance with Federal participation requirements in accordance with section...

  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

    ... requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA) for a period of 6 years. DATES... CLIA is a user-fee funded program. The registration fee paid by laboratories is intended to cover the... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare, Medicaid, and CLIA Programs; Clinical...

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

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-06-24

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

  18. 42 CFR 412.48 - Denial of payment as a result of admissions and quality review.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

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

  19. 42 CFR 412.48 - Denial of payment as a result of admissions and quality review.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

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

  20. 42 CFR 412.48 - Denial of payment as a result of admissions and quality review.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

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