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Source: Kaiser Health News

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Greater Use of Clinical Validation Puts DRGs at Risk, Turns Queries Upside Down (with: Sample Query for Documented Diagnosis…

Clinical validation is changing the nature of MS-DRG audits, which are eating away at hospital revenue. As Medicare auditors layer clinical validation onto coding validation, diagnoses that affect MS-DRG assignment may not be safe just because the physician documented them. “The bulk of recent audit findings are related to medical necessity, but there is still a lot of money at risk with DRG validation,” says Sandra Routhier, senior healthcare consultant for Panacea Healthcare Solutions.

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Source: Compliance | AIS Health

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Headlines from AHANews.com:

AHA webinar Wednesday to review latest RAC survey data&nbsp&nbsp&nbsp06/17/2013 Hospitals are invited to review results from the AHA's latest RACTrac survey and learn more about the initiative during a webinar on June 19 at 2 p.m. Eastern Time. The free web-based survey helps gauge the impact of Medicare recovery audit contractors and helps AHA advocate for needed changes to the program. The latest results include new data on RAC medical necessity reviews and appeals. For more on the AHA's RACTrac initiative, visit www.aha.org/ractrac.

AMA reports on claims processing performance of large insurers&nbsp&nbsp&nbsp06/17/2013 The American Medical Association today released its sixth annual report on the claims processing performance of the nation’s largest health insurers. This year’s report looks at the timeliness, transparency and accuracy of claims processing by Medicare and seven commercial insurers: Aetna, Anthem Blue Cross and Blue Shield, Cigna Corp., Health Care Services Corp., Humana Inc., Regence, and UnitedHealthcare. While error rates for commercial insurers on paid medical claims dropped from nearly 20% in 2010 to 7.1% in 2013, AMA estimates that more than $43 billion could have been saved if commercial insurers consistently paid claims correctly. Claim denials by the commercial insurers declined from 3.5% in 2012 to 1.8% in 2013, while Medicare had the highest denial rate at 4.9%. This year’s report includes a new index ranking the commercial insurers according to the level of unnecessary cost they contribute to the billing and payment of claims.

Appeals court strikes down NLRB notice posting rule&nbsp&nbsp&nbsp06/17/2013 The National Labor Relations Board exceeded its authority when it issued a rule requiring all employers subject to the National Labor Relations Act, including most hospitals, to post notices informing employees of their rights under the NLRA, the U.S. Court of Appeals for the 4th Circuit ruled Friday. The Board lacks authority to promulgate such a rule pursuant to Section 6 of the NLRA, the court said, affirming a district court decision last April that resulted from a challenge brought by the U.S. and South Carolina Chambers of Commerce. This is the second decision from a federal appeals court invalidating the rule. The rule also was invalidated by the U.S. Court of Appeals for the District of Columbia in April.  A similar notice posting requirement issued by the Labor Department’s Office of Federal Contracts Compliance Programs currently applies to certain federal contractors.

Coalition launches new hospital advocacy website&nbsp&nbsp&nbsp06/17/2013 The Coalition to Protect America’s Health Care today launched a new state-of-the-art website, a crucial step in its efforts to create a significant online presence with hospital executives, allied health professionals, patients and members of the general public. “This new website is another major step forward by the Coalition to engage caregivers and the public to protect patient care,” said Coalition Chairman Thomas Zenty III, CEO of University Hospitals in Cleveland. “That is our mission and our goal.” Since March, the Coalition has recruited more than 125,000 hospital supporters through e-mail sign up, Facebook “likes” and Twitter followers. All hospital leaders and employees are encouraged to join the national movement of grassroots supporters at www.ProtectHealthCare.org. AHA is a founding member of the Coalition, a broad-based group dedicated to educating the public about issues affecting hospitals' financial situation, and what this means for patients and their families.

Hospital prices unchanged in May&nbsp&nbsp&nbsp06/17/2013 Overall hospital prices were unchanged in May, and 1.8% higher than a year ago, the Bureau of Labor Statistics reported Friday. Prices for the subgroup of general medical and surgical hospitals increased 0.1%, and were 1.8% higher than in May 2012, according to the BLS' Producer Price Indices, which measure average changes in selling prices received by domestic producers for their output. For hospitals, this translates into actual or expected reimbursement for a sample of treatments or services. The PPI for hospitals measure changes in actual or expected reimbursement received for services across the full range of payer types. This includes the negotiated contract rate from the payer plus any portion expected to be paid by the patient.

AHA urges Congress to focus on 'real reform,' not further post-acute cuts&nbsp&nbsp&nbsp06/14/2013 In a statement submitted today to the House Ways and Means Health Subcommittee, AHA expressed deep concern with certain budget and regulatory proposals that would further reduce Medicare payments for long-term care hospitals, inpatient rehabilitation facilities, skilled nursing facilities and home health providers. Submitted for a hearing on the issue, the statement opposes the president’s fiscal year 2014 budget proposals for an additional market basket reduction for all post-acute care providers, a return to the 75% Rule for IRFs, and site-neutral payments for certain IRF and SNF procedures. It also expresses deep concern with the Centers for Medicare & Medicaid Services’ FY 2014 proposal to allow the 25% Rule for LTCHs to expire; CMS research on a policy that would shift a majority of LTCH cases to the inpatient prospective payment system; and Medicare Payment Advisory Commission research on reform approaches that would eliminate the LTCH PPS. “The AHA believes we need real reform, not the further ratcheting of post-acute care provider payments as outlined in the president’s budget proposal, and by CMS and MedPAC,” the statement adds, and includes a bipartisan list of alternatives to cutting payments for hospital services.

AHA urges MedPAC to re-evaluate LTCH proposals&nbsp&nbsp&nbsp06/14/2013 The AHA yesterday expressed deep concern with Medicare Payment Advisory Commission research on a potential reform approach that would eliminate the long-term care hospital prospective payment system and make all payments for LTCH services under the inpatient PPS. “We are deeply concerned that the commission has not adequately justified the need for such extreme reforms, especially considering how drastically they differ from its prior goal of using criteria to define the type of patient who is appropriate for admission to an LTCH,” AHA Senior Vice President of Public Policy Analysis and Development Linda Fishman wrote in a letter to MedPAC. “Rather than continuing on this radical path toward elimination of the LTCH PPS, we urge the commission to consider more reasonable reforms that would maintain the LTCH PPS for a narrower range of appropriate cases.” MedPAC staff discussed this reform at its April meeting and defined a new subcategory of patients – chronically, critically ill patients. In its letter, AHA said MedPAC’s proposed CCI criterion “is arbitrary and excludes appropriate LTCH patients,” and that the commission “presented no clinical rationale for excluding from the CCI category many cases with the highest acuity levels.”

CMS issues proposed program integrity rule for Health Insurance Marketplace&nbsp&nbsp&nbsp06/14/2013 The Centers for Medicare & Medicaid Services today issued a proposed rule outlining program integrity guidelines for the Patient Protection and Affordable Care Act’s Health Insurance Marketplace and premium stabilization programs. According to CMS, the rule also proposes standards for enrollee satisfaction survey vendors, handling of consumer complaints by issuers in the Marketplace, and provisions meant to ensure smooth operation of Marketplaces, protect consumers and give flexibility to states. The proposed rule will be published in the June 19 Federal Register with comments accepted for 30 days. For more information, see the CMS factsheet.

MACPAC issues June report to Congress&nbsp&nbsp&nbsp06/14/2013 The Medicaid and CHIP Payment and Access Commission (MACPAC) today released its annual June report to Congress. Among other key issues, the report examines eligibility and coverage for maternity services under Medicaid and the Children’s Health Insurance Program, which pay for almost half of all U.S. births; and challenges in implementing the recent increase in Medicaid physician payment for primary care services. The Patient Protection and Affordable Care Act mandates maternity care for those covered by health insurance exchange plans and requires coverage of other pregnancy-related services. “Because separate eligibility pathways based on pregnancy will continue under the ACA, the possibility of churning exists among Medicaid, CHIP, exchange coverage, and uninsurance as women gain and lose eligibility based on pregnancy,” the commission said. In January, the ACA increased Medicaid payment rates for primary care physicians to Medicare levels in 2013 and 2014. “Interviews with states, providers and managed care organizations highlight concerns about the time allotted to implement the provision, difficulty in identifying eligible providers, and challenges in making the system modifications necessary for the increased payment,” the commission said.

MedPAC issues June report to Congress&nbsp&nbsp&nbsp06/14/2013 The Medicare Payment Advisory Commission today submitted its June report to Congress, which includes a chapter reviewing several proposals to expand site-neutral payments, a discussion the commission expects to continue this fall. One proposal would expand the site-neutral policy to 66 additional ambulatory payment classifications, reducing hospital payments by another $900 million. Another more targeted proposal would equalize payment between physician offices and hospital outpatient departments for three high-volume cardiac imaging APCs, reducing hospital outpatient payments by $500 million. In addition, the report discusses equalizing payments for certain surgical services commonly furnished in ambulatory surgical centers, which would reduce hospital payments for 12 surgical APCs by $590 million. In January 2012, MedPAC recommended Congress reduce total payments for 10 hospital evaluation and management (E/M) services to the level paid under the physician fee schedule, a policy that would reduce payments to hospital outpatient departments by $1 billion. “AHA believes that it was premature and ill-advised for MedPAC to include a site-neutral payment policy chapter in its report,” said Joanna Kim, AHA vice president for payment policy. “Given the complexity involved in crafting a site-neutral payment policy, we believe that a more robust analysis of impact should have been conducted before this issue was committed to a published chapter. The impact of these potential cuts is very significant. Although MedPAC staff did not provide exact estimates, based on the information provided, the impact of implementing site-neutral payments as described in the chapter would likely be well over $2 billion in a single year, reducing payments to the chronically underfunded Medicare outpatient system by 5.5%, and reducing hospitals’ Medicare outpatient margins from negative 11% to negative 17%, all else being equal.”

Source: AHA News

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