IN THIS WEEK’S ISSUE:
- CMS Submits More Wage Index Revisions
- DME Competitive Bidding Committee Appointed
- Edits Required On Part B Inpatient Services
- MedPAC Finds Specialty Hospital Picture Unclear
- GAO Recommendations Signify Increased MSP Collection Efforts
- Number of Uninsured Adults Grows
- Patients with Chronic Conditions Face Steep Expenses Despite Insurance
- Outpatient Behavioral Health Service Use Grows
- Quick Links
- In the HFMA Resource Center
1. CMS SUBMITS MORE WAGE INDEX REVISIONS
CMS has posted additional changes to the wage index tables, the second series of revisions since the inpatient payment system rule was published in the August 11 Federal Register. The data was first revised at the end of August.
CMS will be republishing the tables, but they are available now on the CMS web site. There has been at least one report to CMS that the data in these latest tables may still be incorrect. Hospitals are urged to review the hospital-specific data and advise CMS if more errors are found. Individual hospital data is shown in Table 2, Table 4J, Table 9 series, and the FY05 Final Rule Wage Data Public Use File.
2. DME COMPETITIVE BIDDING COMMITTEE APPOINTED
On September 24, CMS announced the appointment of a committee to advise the agency about the implementation of competitive bidding for certain supplies and equipment provided to Medicare beneficiaries. The committee will advise CMS on competitive bidding, beneficiary access issues, appropriate educational strategies, and financial and quality standards for suppliers.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires CMS to make competitive bidding a permanent part of Medicare, phasing it in beginning in 2007. The process will start with 10 of the largest metropolitan statistical areas.
.
3. EDITS REQUIRED ON PART B INPATIENT SERVICES
CMS will make claims processing system edit changes to ensure payment is made
only for those services defined as inpatient Part B services, according to Transmittal 301, issued on September 17. This transmittal replaces number 251, issued July 23.
The changes, CMS says, will prevent payment for services under the 12x and 22x types of bills that do not meet the definition of inpatient Part B hospital services as defined in Pub. 100-02, Benefit Policy Manual, chapter 6, section 10. The transmittal lists the revenue codes that are not to be paid on a 12x or 22x. The change is effective January 1, 2005. The implementation date is January 3.
4. MEDPAC FINDS SPECIALTY HOSPITAL PICTURE UNCLEAR
The Medicare Payment Advisory Commission (MedPAC) is undecided on whether the positives of the MMA-mandated specialty hospital moratorium outweigh the negatives, according to findings presented by MedPAC staff September 10. MedPAC was directed to study the issues related to the moratorium and its impact and report to Congress next March.
MedPAC found that 94 percent of specialty hospitals are located in states without certificate of need requirements, and 59 percent are located in just four states: Kansas, Oklahoma, South Dakota, and Texas.
Some benefits were noted, including:
- Increasing physician productivity and revenue opportunities
- Stimulating community hospitals to increase operational efficiency
Among concerns raised were:
- Patient risk selection, both in terms of patient complexity and the payer mix
- Questions about whether specialty hospitals increased community services
The moratorium prohibits the development of new physician-owned hospitals for 18 months, ending in June 2005. MedPAC plans further research.
5. GAO RECOMMENDATIONS SIGNIFY INCREASED MSP COLLECTION EFFORTS
Even though employer-sponsored group health plans were responsible for about $134 million of almost $183 million in outstanding Medicare secondary payer (MSP) debt in FY03, CMS instructed contractors not to pursue cases in which the amount of mistaken payments made on behalf of the same beneficiary was less than $1,000, according to a September 20 Government Accountability Office (GAO) report. Additionally, CMS neglected to transmit more than 2,000 cases to the claims administration contractors during FY00, FY01, and FY03.
CMS has agreed to the GAO recommendations, which include improving the efficiency of MSP payment recovery activities by consolidating them under a smaller number of contractors. CMS said it has started action on another recommendation, to expedite the use of a new recovery management and accounting system.
6. NUMBER OF UNINSURED ADULTS GROWS
The number of uninsured adults under age 65 increased by 5.1 million between 2000 and 2003, according to a new report released by the Kaiser Commission on Medicaid and the Uninsured. Factors contributing to the decline include:
- Increased unemployment
- A shift away from employment in high-coverage industries
- A shift from large firms to small firms and self employment
Additionally, the growth in the number of low-income Americans, particularly below the poverty line, has increased significantly, compounding the problems surrounding the decline in coverage.
7. PATIENTS WITH CHRONIC CONDITIONS FACE STEEP EXPENSES DESPITE INSURANCE
Low-income working individuals with chronic health conditions are experiencing difficulties paying their medical bills, even though they have private health insurance, according to a report published by the Center for Studying Health System Change (HSC). Between 2001 and 2003, the proportion of low-income, chronically ill people with private health coverage who spent more than 5 percent of their income on out-of-pocket healthcare costs grew from 28 to 42 percent. The study’s author notes that increased out-of-pocket costs reflect a rise in healthcare costs that rapidly outpaces incomes and increases cost-sharing obligations for insured patients. The study’s findings are based on an analysis of the data from HSC’s 2003 Community Tracking Study (CTS) Household Survey.
8. OUTPATIENT BEHAVIORAL HEALTH SERVICE USE GROWS
The use of outpatient professional services for behavioral health disorders has increased more than 25 percent during the three-year period from 2000 through 2002, the American Managed Behavioral Healthcare Association (AMBHA) reported September 14. AMBHA attributes the trend in part to declining societal stigma associated with seeking mental health services.
AMBHA surveyed outpatient service utilization for more than 47 million commercially insured members enrolled in managed behavioral healthcare organizations. Outpatient services included both psychotherapy and the management of psychiatric medications.
For more information, fax a request to (202) 434-4564.
9. QUICK LINKS
PAYMENT POLICY FOR NURSING FACILITY PATIENT VISITS. A revised payment policy will be implemented on October 25 to enable non-physician practitioners to provide other covered, medically necessary visits to a nursing facility resident before and after the initial comprehensive visit is performed by a physician, according to CMS transmittal 302.
UPDATED CORPORATE INTEGRITY AGREEMENTS. Recent and closed corporate integrity agreements and enforcement actions are available at the OIG website. .
FAMILIES USA: PREMIUMS RISING FASTER THAN EARNINGS. Average health insurance premium costs for employees rose at least three times faster than average earnings from 2000 through2004. For 14.3 million Americans, healthcare costs consumed more than one-quarter of their earnings in 2004.
10. IN THE HFMA RESOURCE CENTER
UPDATED: HFMA’S INTERNET GUIDE TO MEDICARE CODING AND BILLING - Use this handy billing compliance reference to be sure you are up to date on important Medicare coding and billing instructions.
Copyright 2004 Healthcare Financial Management Association, all rights reserved. HFMA Express News ISSN: 1540-0689. Volume XI, Number 39.
For customer service, send an e-mail to HFMA’s Member Service Center or call (800) 252-HFMA, and press 2..