CMS finalizes changes to payment policy under the 340B drug discount program

The Centers for Medicare and Medicaid Services (CMS) on November 1, 2017, released the 2018 Hospital Outpatient Prospective Payment System (OPPS) final rule, moving forward with a significant change in payment policy under the 340B drug discount program that was included in the proposed rule earlier released in July.

Beginning January 1, 2018, CMS will no longer reimburse most 340B-purchased drugs at the standard Part B rate of Average Sales Price (ASP) plus 6 percent, and instead will pay a rate of ASP minus 22.5 percent. The change in payment policy has drawn sharp criticism from hospital organizations, including litigation by the American Hospital Association, the Association of American Medical Colleges, America’s Essential Hospitals and member hospitals to block the change in payment policy.

Continue reading “CMS finalizes changes to payment policy under the 340B drug discount program”

A renewed focus on the future of the 340B program

On Thursday, July 13, 2017, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that updates the payment rates and policy changes in the Hospital Outpatient Prospective Payment System (OPPS). In the provisions, CMS proposes to change the payment rate for certain Medicare Part B drugs purchased by hospitals through the 340B program.

The proposed changes include adjusting the applicable payment rate for drugs acquired under the 340B program from average sales prices (ASP) plus 6 percent to ASP minus 22.5 percent. This potentially represents a significant reduction to how much Medicare pays 340B hospitals for Part B drugs under OPPS.

Continue reading “A renewed focus on the future of the 340B program”

Pressing ahead: Update on Congress’s oversight of the implementation of MACRA

CMS takes next steps in implementation of new Medicare payment lawPosted by Anne Phelps, US Health Care Regulatory Leader, and Daniel Esquibel, Senior Manager, Deloitte & Touche LLP on March 18, 2016.

On March 17, 2016, Patrick Conway,  Deputy Administrator for Quality and Innovation and Chief Medical Officer at the Centers for Medicare and Medicaid Services (CMS), testified at the House Energy & Commerce Health Subcommittee’s hearing on implementation of the new Medicare payment law, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Overview of MACRA

MACRA repeals the Sustainable Growth Rate (SGR) formula and establishes a path toward a new payment system that will more closely align reimbursement with quality and outcomes measures while steering health care providers to participate in risk-bearing coordinated care models and away from the fee-for-service reimbursement system. Continue reading “Pressing ahead: Update on Congress’s oversight of the implementation of MACRA”

“Two-midnight” scrutiny may change, but the need for documentation remains

Low-angle view of hospital sign

Posted by Nancy Perilstein, on October 22, 2015.

Regulators are poised to change the ways they police short-stay requirements, and those changes will make a difference – but they should not give provider organizations a false sense of security.

Under Medicare’s “two-midnight rule,” quality improvement organizations (QIOs) affiliated with the Centers for Medicare and Medicaid Services (CMS) will not take over the job of reviewing short inpatient hospital stay claims until January 1, 2016, more than two months later than earlier planned.

Continue reading ““Two-midnight” scrutiny may change, but the need for documentation remains”

CMS takes next steps in implementation of new Medicare payment law: critical new details emerging for health care professionals, hospitals and health plans

CMS takes next steps in implementation of new Medicare payment law
Posted by Anne Phelps, on October 21, 2015.

The Centers for Medicare and Medicaid Services (CMS) is beginning the process of seeking comment and developing regulatory guidance on the recently passed Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA fundamentally changes how Medicare provider payments will be set in the future. It is critically important for health systems and health plans that employ physicians to begin to assess now how the law might affect their revenue and strategic priorities. Health systems and health plans may want to revisit their strategic relationship with health care providers in light of the law’s financial incentives for health care professionals to participate in risk-bearing coordinated care models.

Stakeholders should keep abreast of the critical regulations that the Administration is releasing over the next six to 12 months in order to be prepared to adapt to new requirements and processes that will start to be rolled out as soon as July 2016.

Continue reading “CMS takes next steps in implementation of new Medicare payment law: critical new details emerging for health care professionals, hospitals and health plans”

CMS kicks off regulatory process on new Medicare payment law: hospitals should move quickly to evaluate their strategic options

Long-awaited release of drug discount rule mega-guidance means hospitals need to act quickly—but think long-term

The Centers for Medicare and Medicaid Services (CMS) on September 28, 2015, released a Request for Information (RFI) related to the implementation of provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  The law fundamentally changes how Medicare provider payments will be set in the future. MACRA repeals the Sustainable Growth Rate formula and establishes a path toward a new payment system that will more closely align reimbursement with quality and outcomes measures while steering health care providers away from the fee-for-service reimbursement system. The RFI was published in the October 1 Federal Register and is open to a 30-day comment period.

Continue reading “CMS kicks off regulatory process on new Medicare payment law: hospitals should move quickly to evaluate their strategic options”

US Supreme Court Rules in Favor of Administration

Tax Credits Will Continue Through All ACA Exchanges

US Supreme Court building

Posted by Anne Phelps, Deloitte Advisory Principal, US Health Care Regulatory Leader on June 25, 2015.

Download the report
The United States Supreme Court today (June 25, 2015) ruled 6-3 in favor of the Administration to permit federal premium assistance tax credits under the Affordable Care Act (ACA) to continue to be made available in the 34 states that currently have federally-facilitated Exchanges, in addition to Exchanges established by the states, to help individuals purchase Exchange coverage. The Department of Health and Human Services (HHS) operates federally-facilitated Exchanges in states that have not established their own Exchanges under the ACA. Of the 7.3 million people who enrolled via ACA Exchanges in the open enrollment period for 2015 in states with federally-facilitated Exchanges, 87% were determined eligible for premium assistance tax credits1.

Continue reading “US Supreme Court Rules in Favor of Administration”

Medicare Claims at Risk

Medicare Claims at RiskPosted by Kelly Sauders, Partner, Deloitte & Touche LLP

The Centers for Medicare and Medicaid Services (CMS) have now started to implement their long-anticipated Risk Adjustment Data Validation (RADV) audits. These audits could pose a serious financial risk for health plans, since CMS will be extrapolating the audit findings from a small sample of 201 plan members and then using the results to statistically value and recoup overpayments across the plan’s entire member base. The initial audits will cover the 2011 payment year with diagnosis codes submitted with 2010 dates of service.

Continue reading “Medicare Claims at Risk”

Physician Arrangements

Physician ArrangementsPosted by Kelly Sauders, Partner, Deloitte & Touche LLP

Entering into contractual agreements with non-hospital employed physicians and other ancillary providers is becoming a high priority for hospitals as they seek to increase patient numbers and keep up with competition. As a result, hospitals are dealing with increased regulatory scrutiny and facing settlements being brought forward by whistleblowers. This furthers the need to evaluate practices for identifying and monitoring physician arrangements. Hospitals should be implementing compliance procedures to monitor
such arrangements on an on-going basis. Including:

Continue reading “Physician Arrangements”

CMS Offers Partial Payment for Medicare Denials; Hospitals Should Eye Options Carefully

CMS Offers Partial Payment for Medicare Denials Hospitals Should Eye Options Carefully

The global settlement offer announced by the Centers for Medicare and Medicaid Services (CMS) on August 29,2014 has given acute care and critical access hospitals an opportunity to recoup some losses from earlier claim denials under Medicare Part A. But each hospital will have to weigh its options carefully before deciding whether to take part.

Under the settlement, CMS is offering to pay 68 cents on the dollar for claims currently under appeal that were denied prior to October 1, 2013 on grounds that involved short stays or level-of-care determinations. To secure that partial payment, hospitals must submit an accounting of all relevant cases in spreadsheet form by October 31, 2014. After a validation process, CMS will determine the final payment amounts and make them within 60 days or face interest charges.

CMS regards the settlement as a way to clear its backlog of almost 800,000 appeals at a single stroke. For the hospitals, however, this is a mixed opportunity. It will take careful analysis for each hospital to decide whether it will benefit by taking part.

Continue reading “CMS Offers Partial Payment for Medicare Denials; Hospitals Should Eye Options Carefully”