Baker Tilly healthcare update July 23, 2014

At the agencies

On July 15, the Department of Health and Human Services (HHS) announced that it would make up to $100 million dollars of funding available to states under the Medicaid Innovation Accelerator Program (IAP). The program would offer technical assistance to states to help accelerate payment and service delivery reforms and improve health and lower costs. The program will provide funds to help identify and advance new models of payment and care delivery, analyze data, improve quality measurement, and support state-to-state learning and federal evaluation. The IAP will focus on specific categories of Medicaid enrollees such as pregnant women, newborns, children, and individuals with mental illness and those receiving long term care services.

On July 18, the Centers for Medicare & Medicaid Services (CMS) released a thirteen-page letter addressed to all Medicare Part D Plan sponsors and Medicare hospice providers regarding Part D drug payments for Medicare beneficiaries enrolled in Medicare’s hospice program. Under Medicare payment rules, hospice covers payments for drugs related to a beneficiary’s terminal diagnosis, while Part D covers payments for drugs for other conditions. In March, CMS had issued a memorandum that required prior authorizations for all drugs needed by Medicare hospice beneficiaries in order to determine whether the drug was covered under Part D. In the July 18 letter however, CMS recognized the difficulties experienced by both Part D sponsors and Medicare hospice beneficiaries with respect to the prior authorizations. It wrote that rather than requiring prior authorization for all categories of drugs, it now instead “strongly encourage[s]” prior Part D authorization for hospice patients’ medications for only four categories of drugs— analgesics, anti-nauseants, laxatives, and anti-anxiety drugs.

On the Hill

On July 15, Congressmen Greg Walden (R-OR) and Tom Price (R-GA), along with Reps. Cathy McMorris Rodgers (R-WA), Renee Ellmers (R-NC), David McKinley (R-WV), Sean Duffy (R-WI), Sam Graves (R-MO), Glenn Thompson (R-WI), Tom Latham (R-IA), Charles Boustany (R-LA), and Erik Paulsen (R-MN) introduced the “Securing Access Via Excellence (SAVE) Medicare Home Health Act.” The bill would reverse the cuts made to home healthcare in January and replace them with a value-based payments plan. The bill would aim to reduce hospital readmissions and would implement the value-based purchasing program by 2019.  Under the bill, CMS would develop performance measures for the program and a bonus would be paid to well performing home health providers.

Third parties

A report released by the Robert Wood Johnson Foundation and athenahealth says that the Affordable Care Act has not increased new patient volume for providers. According to the report, overall visits with new patients actually decreased slightly. However, primary care doctors in states that expanded Medicaid did report an increase in Medicaid patients from 12.3 percent last December to 15.6 percent currently.

In the courts

On July 10, the Chief Administrative Law Judge (ALJ) for the Office of Medicare Hearings and Appeals (OMHA) told lawmakers at an Oversight and Government Reform health subcommittee meeting that it is planning to hire seven additional ALJs to deal with the current backlog of provider appeals for the Medicare claims. On July 11, OMHA announced that it would be implementing two pilot programs to assist with the backlog. One would create a new settlement conference between providers and suppliers and the other would allow providers with a large volume of claim disputes to use statistical sampling to help expedite the process. OMHA had approximately 800,000 appeals pending as of July 1, 2014.

For more information on this topic, or to learn how Baker Tilly healthcare specialists can help, contact our team.