Course | Basic | Medicare Payment and Reimbursement
In this course we will address scheduling processes, including<div><ul><li>Patient identification</li><li>Requested service</li><li>Medical necessity screening</li><li>Medicare Advance Beneficiary Notice of Noncoverage processing</li><li>Pa...
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Course | Overview | Medicare Payment and Reimbursement
This course provides a brief history and overview of Medicare and Medicaid. It describes government organizations that regulate and administer this program. This course also discusses Medicare reimbursement. In addition, it highlights recen...
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Course | Intermediate | Medicare Payment and Reimbursement
This course provides a general discussion and overview of reimbursement provided by Medicare under the outpatient prospective payment system. It also discusses the use of ambulatory payment classifications in the outpatient prospective paym...
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Course | Intermediate | Medicare Payment and Reimbursement
This course provides an overview of the prospective payment systems used in the Medicare program and as well as Medicare fee schedules. This course provides a general discussion and overview of Medicare reimbursement under the Inpatient Pro...
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On Demand Webinar | Intermediate | Medicare Payment and Reimbursement
As the senior population continues to outpace the relative growth of the general population, and Medicare Advantage is accounting for about one-third (and growing every year) of all new Medicare eligible enrollees, providers are increasingl...
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News | Medicare Payment and Reimbursement

Proposed mandatory models should be voluntary or delayed, providers say

News | Medicare Payment and Reimbursement

Proposed mandatory models should be voluntary or delayed, providers say

  • Several providers and provider advocates urged changing proposed mandatory payment models to voluntary programs.
  • The oncology and kidney care models at least should be delayed to give participants more time to prepare, providers said.
  • The radiation oncology model places providers at 100% risk for all spending beyond the set payment.

The latest proposed mandatory Medicare payment models drew concerns from many providers, including hospitals that cited the potential for adverse financial impacts.

The Centers for Medicare & Medicaid Services (CMS) proposed the Radiation Oncology (RO) model in July to test whether prospective bundled payments for 90-day radiotherapy episodes of care would reduce Medicare spending while at least maintaining care quality. The model — scheduled to launch in early 2020 — was proposed for physician group practices, hospital outpatient departments and freestanding radiation therapy centers that deliver radiotherapy services for 17 types of cancer in certain geographic areas. The model would require participating providers (40% of such practices) to report certain quality, patient experience and clinical data to CMS over the five years of the model, with providers at 100% risk for any spending beyond their allotted payments.

Also proposed was the ESRD Treatment Choices (ETC) model. The 6 ½-year model includes a three-year bonus payment for home dialysis services and a two-sided payment adjustment based on performance on home dialysis and transplantation rates.

AHA, Premier among those voicing concerns

The components of the RO model led the American Hospital Association (AHA) to echo many oncology practices across the country in urging CMS to shift the model to a voluntary approach, delay it and redesign its structure.

“We are concerned with CMS’s proposal to make participation in this model mandatory,” AHA wrote. “As a matter of course, hospitals and health systems should not be forced to bear the expense of participation in complicated programs if they do not believe they will benefit patients.”

The AHA’s views were among about 100 public comments submitted to CMS by this week’s deadline.

The Las Vegas Prostate Cancer Center also asked for a shift to a voluntary approach, or at least to a four-year voluntary model before a mandatory phase that would apply only to large practices.

“The proposed RO model would heap additional administrative tasks and costly requirements on our practice,” wrote Doug Debenham, MD, medical director.

Premier, a learning alliance of hospitals, wrote CMS to oppose mandatory enrollment in the ETC model because “providers should be able to decide what alternative payment models are appropriate for their organization.”

AMA proposes specific changes to the RO model

The American Medical Association also urged that RO be shifted to a limited voluntary model and called for structural changes that included:

  • Stratifying bundled payments based on patients’ clinical characteristics
  • Modifying efficiency and quality adjustments to avoid penalties related to patients with greater needs
  • Adjusting payments for costlier rural communities
  • Setting payments at the cost of care and starting with budget-neutral payments
  • Adjusting payments annually based on evidence, technology and inflation
  • Paying providers for data collection

Changes urged by Allina Health, a 12-hospital system based in Minneapolis, included incorporating ways to account for new technology and service lines in a rapidly advancing field.

“We suggest consideration of an adjustment to the episode or reimbursing the traditional fee-for-service for new technology and service lines until there is sufficient cost data to incorporate into the episode payment,” wrote Brian Vamstad, PhD, manager of regulatory affairs and payment policy for Allina Health.

How to address problems with the ETC model

Ochsner Health System, a 40-hospital system based in New Orleans, urged at least a four-month delay of the ETC model, to April 2020, and elimination of a proposed payment cut for underperforming clinicians.

The cut does not make sense “given that managing clinicians have limited control over a patient’s ability to go on home dialysis or receive a kidney transplant,” wrote Will Crump, director of public health policy for the health system.

Premier likewise sought ETC model changes that included:

  • Delaying the model’s start to as late as July 30, 2020
  • Modifying home dialysis rates to adjust for clinical appropriateness and patient preference
  • Removing the transplant rate from payment calculations

“Providers have limited influence over transplant rate,” Premier noted. “Premier recommends that CMS consider alternative measures to capture efforts to increase renal transplantation rates.”

About the Author

Rich Daly, HFMA senior writer/editor,

is based in the Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

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