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CMA Alert – More Bad News for Medicare and ACA, and Some Comments || Center for Medicare Advocacy

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  1. More Well being Care Sabotage: Insufficient Funding for Navigators
  2. Courtroom Ruling Might Result in Even More Overpayments to Medicare Benefit
  3. MedPAC Discusses Requiring a Three-Day Hospital Keep for All Submit-Acute Care, Threatening Entry to Care
  4. Home Committee Holds Listening to on Nursing Residence High quality Points
  5. Proposed DMEPOS Guidelines: Clarification and Enforcement Wanted

More Well being Care Sabotage: Insufficient Funding for Navigators

This week, CMS introduced it was awarding considerably much less funding for navigator organizations than up to now for the upcoming Reasonably priced Care Act open enrollment season. General, this system’s funding has been decreased from 2016’s $100 million price range to $10 million for 2018. Navigator organizations are non-profits that present important help to shoppers who need assistance enrolling in medical insurance plans. Along with the funding cuts, the variety of navigators truly receiving funding dropped from 90 to 39. These cuts are crippling, particularly in mild of different actions taken to undermine the well being care regulation.

Not solely has funding been slashed, navigators are additionally being actively inspired to advertise junk plans comparable to short-term limited-duration insurance coverage and affiliation well being plans. As we now have beforehand highlighted, these junk plans will depart shoppers with out protection once they want care probably the most. Additional, these plans should not have to abide by ACA protection and shopper protections. Such plans ought to definitely not be promoted to weak, “left behind” populations as CMS describes within the press launch saying the awards.

Final yr, we noticed the Administration reduce the ACA enrollment interval in half; slash funding for enrollment help; refuse to take part in enrollment occasions; shut down healthcare.gov throughout essential occasions; and refuse to pay cost-sharing reductions. If that’s any indicator of what’s to return this yr, a robust and absolutely funded Navigator program will probably be wanted greater than ever.  

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Courtroom Ruling Might Result in Even More Overpayments to Medicare Benefit

As reported in FierceHealthcare, “Medicare Advantage insurers scored a significant legal victory” when a U.S. District Courtroom decide lately “struck down a 2014 rule requiring [plans] to report and return overpayments.”  Additional, in response to Trendy Healthcare, this ruling “leaves the federal government with fewer tools to combat upcoding practices that cost the taxpayer-funded Medicare program billions of dollars.”

Well being coverage specialists, based on Trendy Healthcare, “said that the overpayment rule was meant to curb upcoding and fraudulent billing; vacating it paves the way for more of the same.”

In line with the decide’s order, the impact of the rule was that MA insurers have been paid much less to offer the identical protection to their enrollees than the Medicare program pays for comparable people in conventional Medicare. 

Nevertheless, as reported in Trendy Healthcare:

Specialists watching the choice argued analysis flies within the face of those conclusions. In accordance with MedPAC’s newest report, funds to Medicare Benefit have been 2% to three% greater in 2016 than they might have been if those self same sufferers have been handled underneath fee-for-service Medicare. That is as a result of Benefit plans’ coding practices have resulted of their enrollees having a mean danger rating that is eight% greater than comparable Medicare fee-for-service beneficiaries, regardless of robust proof that Benefit members will not be sicker.

At a time when some policymakers proceed to push for vital cuts to Medicare, each Congress and CMS ought to redouble their efforts to make sure that wasteful overpayments to Medicare Benefit plans don’t proceed.  Sadly, this courtroom ruling is a step within the fallacious path.

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MedPAC Discusses Requiring a Three-Day Hospital Keep for All Publish-Acute Care, Threatening Entry to Care

The Medicare Cost Advisory Fee (MedPAC) held a public assembly on September 6, 2018. Commissioners listened as employees introduced on “Aligning Medicare’s statutory and regulatory requirements under a unified payment system for post-acute care.”[1] Particularly, the presentation mentioned the necessity to make level-of-care necessities constant throughout post-acute care (PAC) settings beneath a unified PAC potential cost system (PPS). The target of the unified PAC PPS is to “set payments based on patient characteristics, not site of care.”[2] MedPAC envisions that a “common set of requirements . . . [would] apply to all providers.”[3]

In discussing what insurance policies may guarantee applicable PAC use underneath the unified PAC PPS, MedPAC employees prompt “requiring a three-day stay for PAC to ensure appropriate use.”[4] The presentation highlighted that the three-day hospital keep requirement could also be mitigated by permitting statement days to rely in the direction of the requirement and permitting accountable care organizations or entities at monetary danger to waive the requirement.[5] Even with restricted exceptions, MedPAC’s proposal would create a considerable barrier to care for numerous Medicare beneficiaries who want post-acute care wouldn’t meet an arbitrary three-day hospital keep requirement.

With a purpose to qualify for expert nursing facility protection, beneficiaries should have a qualifying three-day inpatient hospital keep. There’s at present no comparable three-day hospital keep requirement for care at inpatient rehabilitation amenities, long-term care hospitals, or for residence well being. The truth is, Congress particularly eliminated a previous Half A hospital keep requirement for residence well being in 1980.[6] Including a hospital keep requirement now for house well being or another post-hospital care setting is a step again for the Medicare program and beneficiaries.  It’s also opposite to well being coverage objectives of avoiding and decreasing hospitalization, the costliest setting for care.

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Home Committee Holds Listening to on Nursing House High quality Points

For the primary time in a few years, Congress held a listening to on nursing residence high quality of care on September 6, 2018.  The listening to of the Subcommittee on Oversight and Investigations of the Home Power and Commerce Committee, entitled “Examining Federal Efforts to Ensure Quality of Care and Resident Safety in Nursing Homes,” featured three witnesses: Kate Goodrich, Director, Middle for Medical Requirements and High quality, and Chief Medical Officer, Facilities for Medicare & Medicaid Providers (CMS), Ruth Ann Dorrill, Regional Inspector Basic, HHS Workplace of Inspector Common (OIG), and John Dicken, Director, Well being Care, Authorities Accountability Workplace (GAO).[1] 

Dr. Goodrich summarized CMS’s actions with respect to emergency preparedness, the 5-Star High quality Score System, the Payroll-Based mostly Journal system for reporting nurse staffing, and the brand new federal survey course of.  The OIG and GAO witnesses recounted highlights of their many nursing residence studies during the last a number of years.  Ms. Dorrill reported “widespread, serious problems in nursing homes” and the “low-level substandard of care [that] harms a tremendous number of people.”  As Chairman Gregg Harper (R, MS) underscored, the OIG has recognized nursing house high quality as a prime administration problem for CMS for the previous decade.  Over the previous 20 years, the GAO issued greater than two dozen studies discovering shortcomings in nursing house care and in state and federal oversight.

Many Members of Congress targeted on Hollywood Hills, the Florida nursing facility the place 14 residents died in 2017 when Hurricane Irma resulted within the facility’s dropping its air con.  One query, raised by a number of Members, was how the proprietor of that now-terminated nursing facility, who had additionally been topic to a Company Integrity Settlement years earlier, might nonetheless proceed to personal 11 totally different amenities that obtain Medicare and Medicaid reimbursement.  Dr. Goodrich indicated that nothing within the Medicare regulation prevents the proprietor from persevering with to personal different amenities, however that a proposed rule from 2016 might improve CMS’s authority.[2]

Congresswoman Jan Schakowsky (D, IL) raised considerations concerning the ongoing misuse of antipsychotic medicine, insufficient nurse staffing ranges, and the shortage of a requirement for registered nurses across the clock, whereas Congresswoman Mimi Walters (R, CA) targeted on switch and discharge points.

The American Well being Care Affiliation (AHCA), the nursing residence commerce affiliation, issued a press release describing the progress the business has made in decreasing hospitalizations and using antipsychotic medicine and enhancements in 20 of 24 high quality measures and staffing ranges.[3]   AHCA’s CEO Mark Parkinson stated that though nursing houses’ progress ought to be acknowledged, “The reality is that nursing homes are a convenient political punching bag.”   He continued, “At a time when Congress faces public criticism for its failure to work together and accomplish shared goals, this hearing seems like a misguided effort to find more ways to regulate an already overburdened sector.”

The Middle for Medicare Advocacy ready a Assertion for the report describing the shortage of significant enforcement of federal requirements of care; “the virtually non-existent oversight, at both the federal and state levels, of who owns and manages nursing facilities;” the continued gaming by amenities within the high quality measures area of the 5-Star High quality Score System; and the necessity for improved nurse staffing ranges.[4]

It isn’t but recognized what the Subcommittee’s subsequent steps will probably be.


[1] The witnesses’ written statements, opening statements of the complete Committee and Subcommittee Chairs, and Background Memo can be found at https://energycommerce.house.gov/hearings/examining-federal-efforts-to-ensure-quality-of-care-and-resident-safety-in-nursing-homes/. 
[2] Dr. Goodrich seems to have been referring to a proposed rule required by the Reasonably priced Care Act, “Medicare, Medicaid, and Children’s Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process,” CMS-6058-P, 81 Fed. Reg. 10720 (Mar. 1, 2016), https://www.gpo.gov/fdsys/pkg/FR-2016-03-01/pdf/2016-04312.pdf.  It’s unlikely that the proposed rule shall be revealed as a remaining rule. 
[3] “AHCA Statement on Congressional Hearing,” https://www.ahcancal.org/News/news_releases/Pages/AHCA-Statement-on-Congressional-Hearing-.aspx. 
[4] http://www.medicareadvocacy.org/wp-content/uploads/2018/09/Centers-Statement-on-Nursing-Home-Hearing.pdf. 

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Proposed DMEPOS Guidelines: Clarification and Enforcement Wanted

The Middle for Medicare Advocacy (the Middle) submitted feedback to the Facilities for Medicare & Medicaid Providers (CMS) relating to proposed guidelines affecting sturdy medical gear, prosthetics, orthotics and provides (DMEPOS). The Middle requested that CMS:

  • Search to maximise beneficiary entry to DMEPOS;
  • Make clear provider duties to offer beneficiaries with applicable merchandise and well timed providers;
  • Develop applicable enforcement mechanisms to make sure suppliers are following laws and insurance policies as a way to shield each beneficiaries and the Medicare program;
  • Correctly talk to suppliers that the proposed cost technique, Lead Merchandise Pricing, will probably be monitored to stop adaptive profit-making that might end in decreased entry to gear or provides; and
  • Outline “Value” in DMEPOS provider contracts as a multi-faceted CMS dedication that’s grounded in additional than short-term monetary outcomes and consists of efficient/high quality merchandise, responsive service, follow-up, long-term outcomes and long-term value financial savings.

See our full feedback at: http://www.medicareadvocacy.org/center-comments-on-proposed-dmepos-rules/

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