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Expensive Medicare patients aren't who you think Print E-mail
Written by Peter Ubel, MD | KevinMD   
Wednesday, 23 October 2019 18:12

Over half of Medicare spending is concentrated in 10 percent of patients. With Medicare expenditures rising at an unsustainable clip, reigning in the costs of those patients is key to controlling health care spending. So who are those patients and what expenses are they racking up? It's not who or what I expected. When I think of high-cost patients, I envision people with drawn-out hospital stays, or imagine people readmitted to the hospital time and time again for chronic problems. Hospital care is expensive, meaning most of the most expensive patients in any given year have probably experienced a hospital stay or two. Or at least that's what I used to think. But when José Figueroa and colleagues at Harvard looked at Medicare expenditures, they discovered that chronically costly patients didn't become costly because of expensive hospital stays. Instead, it is outpatient expenses that stand out among these patients, including many very high-priced medications. The researchers were focused on identifying patients that weren't only expensive this year, say, but also next year and the next. Chronically expensive patients.

Bankruptcy Court Stops Medicare from Recouping Monies Owed by Provider Print E-mail
Written by Michael P. Gennett   
Saturday, 05 October 2019 14:01

A Delaware Bankruptcy Court Judge has entered an order prohibiting Medicare from withholding payments to a diagnostic testing provider, True Health Diagnostics, LLC, while the bankruptcy case is pending. Prior to filing the bankruptcy case, Medicare identified two large overpayments owed by True Health and also suspended its future payments. The Judge determined that it was not necessary to consider entering an injunction prohibiting Medicare from withholding payment to True Health because the government was already prohibited from doing so under the automatic stay of creditors’ collection efforts that is in effect in every bankruptcy case.

This is potentially a landmark case for Medicare providers that have been forced into insolvency by Medicare audits or payment suspensions because, if upheld on appeal, it may give the provider a mechanism to reinstate Medicare payments to either facilitate restructuring or as leverage to payment suspension that Medicare is unwilling to lift, regardless of the financial impact to the company—an all too common argument that has, historically, fallen on deaf ears within the agency. Recent similar efforts in other non-bankruptcy courts across the country have led to inconsistent decisions, with some courts halting Medicare recovery while others have rejected such efforts by the providers. Attorneys for Medicare immediately appealed the True Health decision, and expect a decision on the in the short term rather than long-term because the case is in bankruptcy court. Providers with large overpayments or payment suspensions should follow this appeal to see whether bankruptcy or the preparations for a restructuring may be used as an offensive strategy where the Centers for Medicare and Medicaid Services is unwilling to consider any alternative remedies other than a payment suspension which effectively cripples the operations of the company. Providers and suppliers, of course, should be mindful of the fact that the strategy should be carefully balanced by other alternative remedies that the agency might pursue including revocation of the company’s provider agreement or supplier number either during or after a plan of confirmation or other actions that the agency might pursue including ongoing payment or pre-payment audits upon the emergence of bankruptcy. Nevertheless, this arrow in the quiver is a tool that should be evaluated.
New Round of Medicare Readmission Penalties Hits 2,583 Hospitals Print E-mail
Written by Jordan Rau | KHN   
Tuesday, 01 October 2019 17:48

Medicare cut payments to 2,583 hospitals Tuesday, continuing the Affordable Care Act's eight-year campaign to financially pressure hospitals into reducing the number of patients who return for a second stay within a month. The severity and broad application of the penalties, which Medicare estimates will cost hospitals $563 million over a year, follows the trend of the past few years. Of the 3,129 general hospitals evaluated in the Hospital Readmission Reduction Program, 83% received a penalty, which will be deducted from each payment for a Medicare patient stay over the fiscal year that begins today. Although Medicare began applying the penalties in 2012, disagreements continue about whether they have improved patient safety. On the positive side, they have encouraged hospitals to focus on how their patients recuperate, and some now assist them in procuring medications and follow-up appointments. But the hospital industry and some academics have raised concerns that some hospitals may be avoiding readmitting patients who require additional inpatient care out of fear of the financial repercussions, while others have said the program is not showing major benefits.

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CMS wants to force hospitals to reveal negotiated rates. Can it do that? Print E-mail
Written by FHInews   
Friday, 09 August 2019 16:17

Samantha Liss reports for Healthcare Dive:

The Trump administration believes it has the authority to compel hospitals to reveal secret pricing information tucked into their contracts with insurance plans, but the case isn't entirely clear-cut. A legal challenge to the proposed rule requiring the disclosure from hospitals and insurance companies is likely, and experts are split on the odds payers and providers could beat back the effort in court. Hospitals and insurers are loathe to share payer-specific negotiated prices, arguing it would harm patients in the form of higher prices or limited access to care. Payers believe it would create a floor for hospital prices, encouraging any hospital being paid less to demand higher reimbursement, while hospitals argue it will fuel anticompetitive behavior among payers and reduce access to care.

CMS’s Targeted Probe and Educate (TPE) Program: Top 5 Things to Know Print E-mail
Written by Matt Fischer   
Tuesday, 21 May 2019 10:01
In 2014, the Centers for Medicare and Medicaid Services (CMS) started a program that combined the process of reviewing a sample of claims with providing follow up education as a way to help reduce errors in the claim submission process.  This is called the Targeted Probe and Educate Program (TPE).  The goal of the program is to help providers and suppliers identify errors made and quickly make improvements.  CMS has acknowledged that since its inception the program needs improvements and that this type of review can be burdensome.  Most providers and suppliers never experience a TPE review; however, for the ones that receive notification, here are the top five things you should know before moving forward:
  • Who is selected?
Medicare Administrative Contractors (MACs) use data analysis to identify providers and suppliers with high error rates or unusual billing practices (i.e. they vary significantly from their peers).  The focus is placed on particular items or services with a high national error rate and that are a financial risk to the Medicare program.
  • What is the process?
If selected, you will first receive a notification letter.  This letter will provide the services under review in addition to a local MAC contact person.  The letter will also identify a sample of 20 to 40 claims to be reviewed.  Once the review is complete, a summary results letter will follow outlining the error rate and next steps.  This is considered one round.  Overall, the TPE process is up to three rounds.  With each round, the provider and supplier will be provided time to correct any identified issues.
  • What are the common errors?
Errors can include simple mistakes such as missing signatures or certification documents to more complex denials such as lacking medical necessity or notes failing to support all elements of eligibility.
  • Can I be subject to multiple reviews at one time?
Yes, providers and suppliers could be subject to separate probes for more than one item or service.
  • What do they mean by education?
The education will be tailored to the most recent round of review and based on the errors identified. The education will address the errors along with the specific corrections that need to be made.

Here are some other important reminders…the Medicare Targeted Probe and Educate program does not replace other automated MAC reviews such as utilization reviews; you are still required to respond to and are subject to other records requests from other contractors and agencies (e.g. CERT, QIO, UPIC, OIG); and there are no changes to the appeals process.  If notification is received, it’s important to know what to expect during this process.
ABOUT THE AUTHOR: Mr. Fischer is an attorney with the Florda Healthcare Law Firm based in Delray Beach, FL.
Last Updated on Tuesday, 21 May 2019 10:09
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