CMS final rule aims to save $1.6B in fraud

This article was originally posted on FierceHealthcare.com

 The Centers for Medicare & Medicaid Services issued a final rule yesterday that requires stronger protections against fraudsters ordering and certifying medical services, supplies and services. 

The goal of the final rule is that only qualified, identifiable providers and suppliers can order or certify certain medical services, equipment and supplies for Medicare beneficiaries, and CMS will verify provider credentials. Providers and suppliers still will need to include their National Provider Identifier number (NPI) when they apply for Medicare and Medicaid and when they submit claims for reimbursement. CMS and states can then tie specific claims to the ordering or certifying physician or eligible professional and check for suspicious activity, CMS said.

"Thanks to the Affordable Care Act, we are expanding our work to combat fraud," Deputy Administrator for Program Integrity Peter Budetti said in a statement yesterday. "This rule will save money for taxpayers and ensure people with Medicare get high-quality care."

Despite the critical eye of the Office of Inspector General on how well CMS is doing on actually combating fraud, CMS said it will save taxpayers nearly $1.6 billion over 10 years through anti-Medicare fraud efforts.

For more information:
- see the CMS announcement
- check out the final rule (.pdf)

Health Reform……One Year Later

Health Reform, now commonly known as the Affordable Care Act, is one year old this month. About a year ago, I wrote a blog post discussing my initial thoughts on the legislation from an unbiased perspective, and while there were many disagreements and differing opinions when it was passed (and since), the one thing everyone agreed on was that the law was going to continue to change as it was implemented.

Almost immediately its constitutionality became suspect, with 26 states appealing the law. A Virginia judge ruled the individual mandate is unconstitutional, and a Florida judge has ruled the entire legislation is unconstitutional. As a result, many of the 26 states are refusing to implement health reform in its current form. Despite this opposition, the Federal administration continues to hold its position that health reform will result in a large cost savings in Medicare that would be lost if provider reimbursement reform were sacrificed. The Federal administration has also appealed the Florida judge’s ruling, and this case is expected to reach the U.S. Supreme Court.

In addition to the argument over the constitutionality, two of the largest challenges posed are the feasibility of certain types of plans operating under the new guidelines and the Individual Mandate clause. By way of compromise, the administration has approved two types of waivers. One waiver exempts certain plans, including Mini-Med plans (plans that offer limited or reduced set of benefits at a low cost) from the 80% Medical Loss Ratio mandate portion of the law. This is important, as one of Merrill’s largest healthcare clients is a Mini-Med plan. The second waiver type allows states to “opt out” of the Individual Mandate if they can prove their state-run alternative meets or exceeds expectations as outlined in the law. Again, this is important, as another one of Merrill's large healthcare clients operates in the individual market.

As we continue to move through the implementation of health reform, we must be knowledgeable and agile, understanding our health plan partners’ day-to-day challenges in adjusting and adapting to frequent and ongoing alterations to the law. The more we understand the changing climate of healthcare, the better positioned we will be to strengthen our partner relationships and manage internal change to accommodate market conditions.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

Mandated Member Communications: A Case Study

At the end of 2010, we discussed in abstract the resource-draining, time-consuming process that is the preparation, distributing and reporting of CMS mandated member communications, highlighting how the enactment of the Affordable Care Act and tightening regulatory guidelines have only compounded this already trying process and how the penalties for non-compliance include monitoring, fines, and the risk of contract non-renewal.

We wanted to start 2011 off with a scenario, and while this is a true case study, we believe that there are aspects of this specific issue that are relatable to a number of organizations that are part of the healthcare marketing space:

THE CHALLENGE:

A nationally-known insurance company was having difficulty managing the creation and distribution of mandated letters for their Medicare members. They lacked an in-house solution and their current production vendors could not manage the growing volume, facilitate mass template changes nor provide adequate reporting. This resulted in inaccurate mailings, missed deadlines, and poor CMS audit results. 

Additionally, the organization realized that in an effort to improve their CMS Five-STAR Rating, they needed to reduce the amount of appeals and grievances filed with CMS as a result of non-compliant communications.

Next week, we will discuss the solution that was developed that helped both reduce costs and improve workflow.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

Mandated Member Communications in Healthcare: An Introduction

Preparing, distributing, and reporting on mandated member communications is often a resource-draining and time-consuming process. The enactment of the Affordable Care Act and tightening regulatory guidelines have only compounded this already trying process. Worse, failure to comply with strict service level agreements and deadlines can result in penalties for non-compliance including monitoring, fines, and the risk of contract non-renewal.

Today, this blog is commencing a series on the topic of mandated member communications, including the different types that currently (and potentially) could exist, as well as new methods for companies to improve their process for staying compliant.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact her at Pamela.Argeris@merrillcorp.com.

Dr. Berwick: New Admin of CMS

At Merrill Corp., we like change. We like it because we see it as an opportunity to grow, to expand and to better provide our services for our clients in newer and more efficient ways because as the winds of change blow, we embrace the new direction of travel.

The latest winds have brought Dr. Donald Berwick to serve as the Administrator of the Centers for Medicare & Medicaid Services (CMS) through a recess appointment. A “recess appointment” means that the president is putting Berwick in place while Congress is not in session, therefore bypassing the Senate confirmation process (an act that is both legal and surrounded in precedent).

While the recess appointment has generated much debate, the current administration feels there is no time for delays in Dr. Berwick’s appointment, especially with health reform in full on-boarding mode. Dr. Berwick’s appointment is supported by AARP, three prior directors of the CMS, and American Association of Family Physicians, the American Medical Association, and the American Hospital Association.

The hiring of Dr. Berwick shows the importance the administration is placing on health reform. “With the agency facing new responsibilities to protect seniors’ care under the Affordable Care Act, there’s no time to waste with Washington game-playing,” stated a White House Spokesperson.

While the administration is placing great importance on health reform, we are making sure to embrace the change and use it to better provide for our clients. As organizations look for ways to strengthen and improve communications to their membership, they will turn to vendors who remain informed and stand out as progressive thought leaders. We welcome Dr. Berwick and are excited to see what changes come about from his new position.