HFMA Express News - November 12, 2004

IN THIS WEEK’S ISSUE:

1. Governor Moves to End Tenncare
2. GME Affiliated Group Audit Instructions Issued
3. IRF Classification Requirements Clarified
4. OIG Addresses Charitable Corporation’s Services to Needy Patients
5. CMS Hosts Town Hall to Gather Provider Feedback
6. Report Notes Minimal Improvements In Nation's Health
7. Quick Links
8. In the HFMA Resource Center

1. GOVERNOR MOVES TO END TENNCARE

The governor of Tennessee announced this week that the state has begun the process of dissolving TennCare, the state’s Medicaid waiver program that uses a managed care approach to expand health coverage of the uninsured beyond the traditional Medicaid population to more than 400,000 additional residents. Gov. Phil Bredesen said the state can’t continue to put up its share of the funding for the benefits provided under the waiver and coverage of the additional members. Patient advocates, assisted by public-interest attorneys, have won court decisions that overturned coverage restrictions proposed by the state, but those decisions would not apply if the waiver is scrapped in favor of returning to a basic Medicaid program.

“The sad reality is we can’t afford TennCare in its current form,” Bredesen said, though he held out a slim chance that negotiations with the patient advocates over the coming week might yet result in a solution. “It pains me to set this process in motion, but I won’t let TennCare bankrupt our State,” he continued. “This is the option of last resort.” As many as 430,000 enrollees (out of a total of 1.3 million, or roughly one fifth of the state’s population) could lose health coverage.

TennCare, which began in 1994, was closely watched as a testing ground for the key healthcare reform concept that managed care principles could hold costs down enough to expand coverage to a substantial portion of the uninsured population.

2. GME AFFILIATED GROUP AUDIT INSTRUCTIONS ISSUED

On November 5, CMS issued to fiscal intermediaries (FIs) additional clarification on the redistribution of unused resident positions and audits of hospitals that are part of a graduate medical education (GME) affiliated group. This most recent transmittal, one of three since the spring, includes a description of the process for identification of GME affiliated groups; discusses an audit program to be used for the groups’ cost reports; spells out communications that are to take place between the FI, CMS, and hospitals; and notes an April 15, 2005, deadline for the audits.

3. IRF CLASSIFICATION REQUIREMENTS CLARIFIED

CMS has issued a clarification of its policies on the criteria that inpatient rehabilitation facilities (IRFs) must meet to be paid under the IRF PPS. In a Medlearn Matters article, CMS elaborates on the IRF qualification criteria of the May 7 final “75 percent rule” and addresses certain care-related issues, such as patient status in facilities that lose their IRF classification.

The article also provides information on the type of documentation required by FIs for the review of certain medical conditions in the criteria, along with guidelines on determining compliance with the regulations.

4. OIG ADDRESSES CHARITABLE CORPORATION’S SERVICES TO NEEDY PATIENTS

A charitable organization that provides grants and financial counseling to needy patients would not be subjected to administrative sanctions if it accepts donations from providers, suppliers, or patients, according to OIG advisory opinion 04-15.

In addition to providing financial assistance, the charitable organization requesting the opinion would:

• Serve as a liaison between patients and its insurers, employers, and creditors to resolve insurance, job retention, and debt crisis matters relative to patients’ diagnoses
• Provide professional case managers who negotiate with patients’ insurers to resolve coverage and benefits issues
• Mediate job discrimination issues
• Deal with patients’ creditors to facilitate the resolution of debt crisis matters

The requestor would accept donations from a variety of sources, including providers and suppliers of healthcare services, pharmaceutical companies, and individuals, but would maintain its independence from the donors. It would make its assistance awards on a first-come, first-served basis, and not disclose donors to the beneficiaries, or the beneficiaries to the donors.

OIG opinions apply only to the organization requesting them and cannot be relied on by any other entity or individual.

5. CMS HOSTS TOWN HALL TO GATHER PROVIDER FEEDBACK

CMS will conduct a town hall meeting from 2 to 3 p.m. (EST) on November 16 to hear from Medicare fee-for-service providers on how the agency can provide better service. CMS staff will explain the agency’s plan for getting provider feedback and provide the opportunity for reaction and suggestions by providers. For participation by teleconference, dial 877-357-7851 and reference conference ID #1040512.

6. REPORT NOTES MINIMAL IMPROVEMENTS IN NATION'S HEALTH

Although America’s overall health has consistently improved over the last 15 years, the rate of improvement has slowed during the past four years, according to the 2004 edition of America’s Health: State Health Rankings. The report, released by the United Health Foundation, the American Public Health Association, and the Partnership for Prevention, reveals an annual health improvement rate of 1.5 percent each year during the 1990s, compared to a 0.2 percent annual health improvement rate each year since 2000.

The report highlights recent increases in obesity, children living in poverty, the uninsured population, and the infant mortality rate. Data was gathered using 18 measures to reflect three major contributors to overall health: individual behavior, community environment, and public health policies and practices. Minnesota, New Hampshire, and Vermont ranked as the nation’s healthiest states, according to the report.

7. QUICK LINKS

OPEN DOOR FORUM ON PHYSICIAN FEE SCHEDULE. Through the Physician, Nurses & Allied Health Professionals Open Door Forum, on November 15, CMS will provide an opportunity for providers to ask questions about the 2005 Medicare physician fee schedule regulation, which was posted last week on the CMS web site. For participation by teleconference, dial 800-837-1935 and reference ID #4368978.

CMS LISTENING SESSION ON LONG-TERM CARE PHARMACY SERVICES. On November 16, CMS will conduct a “listening” session to hear from stakeholders about pharmacy practice standards and issues relating to the implementation of the Medicare Part D prescription drug benefit in long-term care facilities. For participation by teleconference, dial 800-837-1935 and reference conference ID# 1710525

MEDICARE OVER/UNDERPAYMENTS INTEREST RATE. The interest rate for Medicare over/underpayments rose 0.25 percent to 12.00 percent, effective November 12, CMS announced in a November 4 transmittal.

CMS ISSUES CORRECTION TO EMTALA CLARIFICATION. CMS has clarified the transmittal number for the Emergency Medical Treatment and Labor Act (EMTALA) clarification published in last week’s HFMA Express News.

8. IN THE HFMA RESOURCE CENTER

KEY STRATEGIES FOR SUSTAINED PERFORMANCE IMPROVEMENT. Download this educational supplement, sponsored by McKesson, to learn about a multidemensional approach to performance improvement.

Copyright 2004 Healthcare Financial Management Association, all rights reserved. HFMA Express News ISSN: 1540-0689. Volume XI, Number 46.

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