HFMA Express News - July 16, 2004

IN THIS WEEK’S ISSUE:

1. CMS Issues Proposed Rule on Provider Payment Appeals
2. Number of Uninsured Americans Increases
3. OIG, AHLA Publish Corporate Compliance Guidance
4. HCPCS Codes for HH and SNF Consolidated Billing Updated
5. GSA Inspector General Nominated for HHS Position
6. Aetna Will Cover Claims for Fluoroscopy
7. CMS Announces Draft Policy for Monitoring Erythropoietin Claims
8. Call for HFMA National Leadership Nominations
9. Quick Links
10. New In The HFMA Resource Center

1. CMS ISSUES PROPOSED RULE ON PROVIDER PAYMENT APPEALS

CMS has published a proposed rule that would update, clarify, and revise various provisions of regulations that govern provider reimbursement determinations, appeals before the Provider Reimbursement Review Board (PRRB), appeals before fiscal intermediaries, and the CMS Administrator’s review of decisions made by the PRRB.

Of particular note are changes that affect how providers form groups for the purpose of such appeals. One such change would require individual providers in a group appeal to satisfy the requirements of a single-provider appeal.

Comments on the proposed rule are due by August 24.

2. NUMBER OF UNINSURED AMERICANS INCREASE

The total number of uninsured Americans increased to 43.6 million in 2003 (15.2 percent of the population), up from 41.5 million in 2002, according to an early release of health insurance estimates by the Centers for Disease Control and Prevention (CDC). While the number of uninsured children has continued to decline since 1997, the decrease between the 2003 level (7.3 million, or 10.1 percent of all Americans under age 18) and the 2002 level (7.6 million, or 10.5 percent) is not a statistically significant change, the CDC notes.

The annual caseload of uninsured people, measured by the total number of people uninsured for at least part of the past year, increased to 53.1 million (18.6 percent of the population), up from 51.7 million in 2002. The number of people uninsured for more than a year increased to 28.5 million (10 percent of the population), up from 26.2 million in 2002.

3. OIG, AHLA PUBLISH CORPORATE COMPLIANCE GUIDANCE

The OIG and the American Health Lawyers Association (AHLA) recently published new guidance on corporate responsibility and legal professional ethics. A supplement to last year’s Corporate Responsibility and Corporate Compliance: A Resource for Health Care Boards of Directors, this document addresses the roles of the in-house corporate general counsel and an organization’s chief compliance officer in supporting the compliance oversight function of governing boards.

The new resource also addresses issues raised by modifications to the Federal Sentencing Guidelines for Organizations published in April 2004 and recommendations of the American Bar Association Task Force on Corporate Responsibility. It includes questions and commentary on seven key issues boards should address, such as “where and how is the General Counsel involved in each of the fundamental elements of the compliance program?”

4. HCPCS CODES FOR HH AND SNF CONSOLIDATED BILLING UPDATED

CMS has published its first 2004 quarterly update to the list of HCPCS codes that are subject to consolidated billing under the home health PPS. Effective October 1, HCPCS code G0329 (electromagnetic therapy for ulcers) is included in the list of codes used for home health consolidated billing enforcement. The next change to the home health consolidated billing code list will be the annual update for CY05.

CMS also published October quarterly updates to the 2004 list of HCPCS codes subject to consolidated billing for skilled nursing facilities (SNFs). Included are changes related to outpatient surgery, customized prosthetic devices, chemotherapy administration, and therapies.

5. GSA INSPECTOR GENERAL NOMINATED FOR HHS POSITION

On July 13, President Bush nominated the General Services Administration's (GSA’s) inspector general Daniel Levinson as the next HHS inspector general. If confirmed by the Senate, Levinson will replace Dara Corrigan, who has been serving as the HHS interim inspector general since Janet Rehnquist resigned in mid-2003.

Levinson previously served as chief of staff of the GSA. Prior to joining the GSA, Levinson maintained a private law practice.

6. AETNA WILL COVER CLAIMS FOR FLUOROSCOPY

Aetna announced it would separately cover fluoroscopic guidance for spinal and paraspinal injections (CPT 76005). In a July 8 letter to the American Society of Anesthesiologists, the health insurer said it will cover claims for fluoroscopy performed together with epidurals and other spinal injections filed after August 15, except where the CPT descriptor includes imaging, or where the fluoroscopy is used to facilitate more intense imaging procedures. The change will appear in the next update of Aetna’s claims processing systems, which will be complete on August 15.

7. CMS ANNOUNCES DRAFT POLICY FOR MONITORING ERYTHROPOIETIN CLAIMS

On July 8, CMS announced a proposed revision to its policy for monitoring claims for erythropoietin (EPO) for end-stage renal disease (ESRD) patients. EPO is used for anemia management of patients with ESRD. Contractor medical review is proposed for claims with certain hemoglobin/hematocrit levels and EPO dosage. EPO furnished incident to a physician’s service is not included in this proposed policy.
Currently, monitoring of EPO claims is limited to post-payment review based on 90-day rolling average of claims. A hematocrit level of 37.5 percent is the target to trigger review. Also, treating physicians can maintain higher hematocrit levels with documentation to justify the need.

8. CALL FOR HFMA NATIONAL LEADERSHIP NOMINATIONS

The HFMA Board of Directors and the Governance Committee invite you to participate in HFMA's governance process by nominating officers for fiscal year 2005-06 and directors for fiscal years 2005-08. Nominees should be individuals who have contributed positively to the healthcare field and/or HFMA and who have demonstrated leadership capabilities, including strategic and systems thinking and change-management skills.

All nominations are strictly confidential and are due August 20. The National Governance Committee will meet in September and October to select a slate of officers and directors. The committee's recommendations will be presented to the National Board of Directors at the November board meeting.

9. QUICK LINKS

CAST A VOTE FOR HEALTHCARE FINANCE LEADERSHIP. Make sure healthcare finance leaders are represented among Modern Healthcare's 2004 list of the "Top 100 Most Powerful People in Healthcare"! HFMA President and CEO Richard Clarke has been recognized on this list for the past two years. Go to Modern Healthcare's web site between June 28 and July 23 to vote for finalists.

CMS PUBLISHES CORRECTIONS FOR INPATIENT PPS. CMS published in the June 25 Federal Register corrections to its proposed changes to the hospital inpatient PPS and FY05 rates. Tables affected include average hourly wages for urban areas, wage index and capital geographic adjustment factor, pre-classified wage index for urban areas, new diagnosis codes, and new procedure codes.

CY04 PHYSICIAN FEE SCHEDULE AND PAYMENT FOR DRUGS. Also in the June 25 Federal Register were corrections to the January 7 final rule “Changes to Medicare Payment for Drugs and Physician Fee Schedule Payments for Calendar Year 2004.” Included are changes affecting 30 CPT codes.

UPDATED LIST OF EXCLUDED INDIVIDUALS/ENTITIES (LEIE) AND CORPORATE INTEGRITY AGREEMENTS. The HHS OIG has posted the full "Updated LEIE" database file reflecting all OIG exclusion and reinstatement actions taken through June 2004. The OIG also updated its list of corporate integrity agreements and settlement agreements with integrity provisions.

10. NEW IN THE HFMA RESOURCE CENTER

HFMA EXECUTIVE ROUNDTABLE: IMPROVING OR THROUGHPUT. Read the real-world insights of healthcare executives, who recently discussed their efforts to improve throughput in their operating rooms.

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