A Medicare reform primer

The use of the federal budget process to change Medicare policy is of importance to physician executives because of its impact on the health care delivery system. In particular, changes in Medicare policy, driven by the need to shore up the solvency of a politically popular program, will create changes for other public and private purchasers of health care. Reforming Medicare through the budget process is not new. Physician fees have been frozen, reduced, and selectively increased as a result. In 1983, the hospital reimbursement methodology was changed to prospective payment through this process. The budget process will continue to be used to make policy changes because of the large amount that Medicare occupies of the federal budget. Given the profound impact changes in Medicare can have in other health care sectors, the lack of consensus for a long-term solution would mean those in the health care arena will have to be prepared for significant annual policy changes through the reconciliation process.

Medicare+Choice plans. Medicare risk contracting opportunities for provider-sponsored organizations

New federal legislation approves provider sponsored networks as direct contractors with Medicare. To date, financial, licensure and requirements differ, but providers should prepare to enter the new market. Niche physician groups, physician-hospital organizations and physician-HMO alliances are all configurations that should meet federal requirements.

Liability under the False Claims Act for inadequate care of nursing facility residents

The False Claims Act (FCA) was invoked recently to sue the owners of a long-term-care facility for inadequate care of facility residents. The theory is simple: Medicare and Medicaid provider certification agreements require compliance with all federal and state laws applicable to the services provided. Submitting claims for reimbursement while providing inadequate care and, thus, failing to comply with the extensive nursing home quality-of-care federal and state laws, constitutes fraud on the government, actionable under the FCA. No court considered the government's theory in this case, as parties settled early in the litigation. Nevertheless, owners of facilities should not expect to rely on written patient records and case notes to avoid liability for false claims if the records are inconsistent with the physical condition of the residents.

Medicare and Medicaid programs: effective dates of provider agreements and supplier approvals--HCFA. Final rule

This rule establishes uniform criteria for determining the effective dates of Medicare and Medicaid provider agreements and of the approval of Medicare suppliers when the provider or supplier is subject to survey and certification as a basis for determining participation in those programs. It also establishes appeal rights and procedures for entities that are dissatisfied with effective date determinations.

Brave new world

The new budget bill means big changes in Medicare. The elderly are expected to help save the program by switching to less costly health care options. But some experts warn seniors that more choice means more risk.

Medicare program; end-stage renal disease (ESRD) payment exception requests and organ procurement costs--HCFA. Final rule

These final regulations specify the criteria HCFA uses to determine if a facility that furnished dialysis services to Medicare patients with end-stage renal disease (ESRD) qualifies for a higher payment under an exception to its prospectively determined payment rate and the procedures HCFA uses to evaluate ESRD payment exception requests. These regulations also revise the way HCFA computes acquisition costs for organs that are transplanted into Medicare beneficiaries.