Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies. Final rule

This final rule revises the conditions of participation (CoPs) that home health agencies (HHAs) must meet in order to participate in the Medicare and Medicaid programs. The requirements focus on the care delivered to patients by HHAs, reflect an interdisciplinary view of patient care, allow HHAs greater flexibility in meeting quality care standards, and eliminate unnecessary procedural requirements. These changes are an integral part of our overall effort to achieve broad- based, measurable improvements in the quality of care furnished through the Medicare and Medicaid programs, while at the same time eliminating unnecessary procedural burdens on providers.

Medicare program; establishing additional Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier enrollment safeguards. Final rule

This final rule will clarify, expand, and add to the existing enrollment requirements that Durable Medical Equipment and Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers must meet to establish and maintain billing privileges in the Medicare program.

Medicare and Medicaid programs; hospital conditions of participation: laboratory services. Final rule

This final rule finalizes the hospital conditions of participation requirements for hospitals that transfuse blood and blood components. It requires hospitals to: Prepare and follow written procedures for appropriate action when it is determined that blood and blood components the hospitals received and transfused are at increased risk for transmitting hepatitis C virus (HCV); quarantine prior collections from a donor who is at increased risk for transmitting HCV infection; notify transfusion recipients, as appropriate, of the need for HCV testing and counseling; and extend the records retention period for transfusion-related data to 10 years. The intent is to aid in the prevention of HCV infection and to create opportunities for disease prevention that, in most cases, can occur many years after recipient exposure to a donor.

Medicare program; appeals of CMS or CMS contractor determinations when a provider or supplier fails to meet the requirements for Medicare billing privileges. Final rule

This final rule implements a number of regulatory provisions that are applicable to all providers and suppliers, including durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. This final rule establishes appeals processes for all providers and suppliers whose enrollment, reenrollment or revalidation application for Medicare billing privileges is denied and whose Medicare billing privileges are revoked. It also establishes timeframes for deciding enrollment appeals by an Administrative Law Judge (ALJ) within the Department of Health and Human Services (DHHS) or the Departmental Appeals Board (DAB), or Board, within the DHHS; and processing timeframes for CMS' Medicare fee-for-service (FFS) contractors. In addition, this final rule allows Medicare FFS contractors to revoke Medicare billing privileges when a provider or supplier submits a claim or claims for services that could not have been furnished to a beneficiary. This final rule also specifies that a Medicare contractor may establish a Medicare enrollment bar for any provider or supplier whose billing privileges have been revoked. Lastly, the final rule requires that all providers and suppliers receive Medicare payments by electronic funds transfer (EFT) if the provider or supplier, is submitting an initial enrollment application to Medicare, changing their enrollment information, revalidating or re-enrolling in the Medicare program.

Reassignment Reform: A Possible Regulatory Tool to Stunt the Growth of In-Office Imaging

The expansion of the Medicare reassignment rule in 2003 to permit independent contractors to perform professional services off-site has been cited as a factor potentially contributing to the marked increase in physician practices billing for diagnostic testing. In an effort to curb this growth, the Centers for Medicare and Medicaid Services is contemplating further revisions to the Medicare reassignment rules as described below that would effectively preclude ordering physicians from marking up not only the technical, but also the professional components of any services purchased or obtained under contract from radiology groups or other imaging service providers.

Fighting for their share. As Congress ponders how to fix the sustainable growth-rate formula for physicians, hospitals are wary they'll be a target

As Congress tries to figure out how to fix Medicare's physician payment system, other sectors of the industry are poised to protect their share of reimbursement. Hospitals in particular are worried that they'll be targeted to fix the problem with doctors' reimbursement, which Bill Petasnick, left, blames for driving the growth of specialty hospitals, imaging centers and ambulatory surgical centers.

Medicare physician payments: impacts of changes on rural physicians

Medicare payment disproportionately impacts rural physicians compared to urban. For example, 51% of rural physicians, compared to 44% of urban physicians, receive at least 38% of their payments from Medicare.1 Thus, the Medicare physician payment system is of significant rural interest. In this policy brief, we present the effects of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 on physician payment rates in rural areas. Specifically, we examine the impact of creating a floor of 1.00 in the geographic practice cost index (GPCI) for work expense. We also show the effects of the Medicare incentive payment (MIP) for providing services in shortage areas and of the bonus for practicing in a physician scarcity area. Our principal findings are the following: (1) Increases to the GPCI for work expense accounted for a substantial percentage of the two-year increases in total payment to physicians in rural payment areas. (2) Increases in the conversion factor (CF) (base payment) accounted for most of the increases in total payment in all but 6 of the 89 Medicare payment localities; in those 6 areas, the dominant factor was GPCI adjustment. (3) Bonus payments are a more direct means of targeting increased payments to physicians in specific areas than is a general increase in one part of the payment formula.

Medicare, Medicaid, and access to dermatologists: the effect of patient insurance on appointment access and wait times

BACKGROUND

In 2002, the Centers for Medicare and Medicaid Services implemented a 5.4% cut in Medicare physician payments, and further reductions are expected in 2004. These cuts have raised concerns that beneficiaries of Medicare will face significant problems obtaining needed physician services. Although there is clear evidence of poor access to care for patients with Medicaid, data measuring access to physicians for patients with Medicare are sparse. Given current lengthy appointment wait times resulting from a relative shortage of dermatologists, we hypothesized that patients with lower-paying coverage might be more likely to experience appointment refusals, longer wait times, or both.

METHODS

Because the ability to obtain timely appointments is a key measure of access, we surveyed dermatologists in 12 medium- and large-sized communities to assess wait times for routine new-patient visits. Dermatologists in these areas (or their staff) received a telephone call asking about the next available appointment for a hypothetical patient with a randomly assigned insurance type (ie, Medicaid, Medicare, or fee-for-service private insurance).

RESULTS

Of 631 physicians (or staff members) contacted, 612 (97%) agreed to participate. Overall acceptance rates were similar for patients with Medicare (85%) and private insurance (87%), but were much lower for those with Medicaid (32%). Among patients whose insurance was accepted, mean wait times for patients with Medicare and private insurance were 37 days, but patients with Medicaid experienced significant queuing (50 days). There was dramatic geographic variation. In areas where Medicare payments are low relative to commercial payers, there were increases in Medicare rejection rates and wait times. In communities with relatively low Medicaid payment rates, patients with Medicaid faced higher rejection rates and longer wait times. There were also longer overall wait times for female dermatologists and in communities where the concentration of dermatologists was low.

CONCLUSION

Although overall access to dermatologists appears comparable for patients with Medicare and private insurance, some access limitations in "hot spots" where Medicare payments are low relative to commercial insurers suggest that patients in these areas may be most sensitive to further payment reductions. Significant access problems for beneficiaries of Medicaid, particularly in areas where Medicaid payments are relatively low, may be a harbinger of the potential consequences of sustained declines in Medicare physician reimbursement.

Accept a substitute. But make sure to file claims for locum tenens services appropriately

With the rapid growth of the locum tenens industry, it's increasingly important to know how to bill Medicare for locum tenens' services. The author describes when physicians and medical practices may bill Medicare for locum tenens' work and the sanctions they face for improper billing.

New Jersey experiment. Eight hospitals will participate in CMS 'gainsharing' project, in which doctors can earn bonuses of up to 25% on Medicare fees

A CMS project will let doctors earn bonuses for helping hospitals cut inpatient costs, using software designed by Michael Kalison, left. But not everyone is excited about the plan, including U.S. Rep. Pete Stark, the California Democrat who championed the physician self-referral legislation the CMS is waiving for the program.