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Decisions and Developments

Dennis Barry's Reimbursement Advisor

Receivables Report

Headlines (from the Medicare Medicaid Guide):

Physician fee schedule and other Medicare and Medicaid provisions extended for two months

On December 23, President Obama signed into law H. R. 3765, the “Temporary Payroll Tax Cut Continuation Act of 2011” (P.L. 112-78) which extends the 2011 payment rates for Physician Fee Schedule (PFS) services for two months, as well as extends other Medicare and Medicaid provisions that would have expired at the end of 2011.

Medicare specifics

PFS update. A subparagraph is added to Soc. Sec. Act §1848(d)to replace the update to the single conversion factor that would otherwise apply for the period beginning on January 1, 2012, and ending on February 29, 2012, with a zero percent update thereby preventing a 27 percent reduction effective for services provided on or after January 1, 2012..

Geographic adjustment. The “work geographic adjustment” is the Geographic Practice Cost Index (GPCI) calculated for the “work” component of the relative value unit assigned to each PFS service. The 1.0 floor in the work GPCI was established in the Medicare Modernization Act of 2003 (MMA) (P.L. 108-173) (see ¶3409.) As amended, Soc. Sec. Act §1848(e)(1)(E)says that, for purposes of payment for services furnished on or after January 1, 2004, and before March 1, 2012, the Secretary shall increase the work geographic index to 1.00 for any locality for which such work geographic index is less than 1.00.

Therapy caps. Soc. Sec. Act §1833(g)(5), which authorizes an exception for a Medicare beneficiary that has incurred medically necessary expenses in excess of the annual dollar limitation for outpatient therapy services is extended through February 29, 2012 (see ¶3473).

Pathology services. If an independent laboratory furnishes the technical component of a physician pathology service to a fee-for-service Medicare beneficiary who is an inpatient or outpatient of a covered hospital, beginning in January 2001, payment has been made to the laboratory under the PFS as an exception to statutory payment requirements. This exception is extended through February 29, 2012 (see ¶3457).

Ambulance services. Soc. Sec. Act §§1834(l)(12)and (13) are amended to extend for the first two months of 2012 the add-on payments for ground and rural ambulance services. The extension also applies to the provisions of 146(b)(1) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (P.L. 110-275), which treat as a rural area for the purpose of air ambulance services, any area that was designated as a rural area for air ambulance services furnished on December 31, 2006 (see ¶3148).

Mental health. The 5 percent payment increase for psychiatric therapy is extended through February 29, 2012. The increase applies to specific psychiatric therapeutic procedures furnished in office or other outpatient facility settings or in inpatient hospital, partial hospital, or residential care facility settings. The psychiatric services affected by the increase must be in categories that are in the subcategories of services that are: (1) insight oriented, behavior modifying, or supportive psychotherapy; or (2) interactive psychotherapy (see ¶3405).

Imaging services. The payment provisions at Soc. Sec. Act §§1848(b)and (c) for imaging services, including bone mass measurements, are extended through the first two months of 2012.

Other Medicare or Medicaid provisions

Hospital reclassification. Under §508 of the MMA, a one-time process has been implemented for a hospital to appeal its geographic classification for wage index purposes. The extension of any geographic reclassifications of hospitals that would expire on September 30, 2011 has been extended to November 30, 2011 (see ¶4220).

Outpatient services. The outpatient hold harmless provision under Soc. Sec. Act §1833(t)(7)(D)(i)has been extended for the first two months of 2012. Under prior law, between January 1, 2009, until January 1, 2012, the amount of payment for outpatient services at rural hospitals (with 100 or fewer beds and that are sole community hospitals) are increased by 85 percent of the difference between the outpatient prospective payment system (OPPS) amount and the amount paid prior to the implementation of OPPS (see ¶4315).

Qualifying Individual program. Medicaid eligibility for individuals who are eligible for Medicare Part A and have incomes between 120 percent and 135 percent of the federal poverty level (FPL) is extended for the first two months of 2012 and an allocation of funds for the coverage is included (see ¶14,245).

TMA and TANF programs. The Temporary Assistance For Needy Families (TANF) program, which provides block grants for states to offer cash assistance to families for a limited time, and the Transitional Medical Assistance (TMA) program, which covers children who have lost financial eligibility for Medicaid under TANF, are extended for the first two months of 2012 (see ¶14,100). Temporary Payroll Tax Cut Continuation Act of 2011, P.L. 112-78, December 23, 2011.

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Essential Health Benefit guidelines released

Beginning in 2014, non-grandfathered plans in the individual and small group markets will be required to provide a comprehensive package of items and services known as “Essential Health Benefits,” (EHB) as required by 1302(b)of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148). CMS has begun the process of defining EHB with the release of a guidance document describing how EHB will be determined. These plans, as well as most Medicaid plans, will have to cover at least 10 general EHB categories, including (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive, wellness, and chronic disease management services; and (10) pediatric services, including oral and vision care.

EHB determination

While PPACA requires the inclusion of EHB in most health plans starting in 2014, it was unclear how strict the federal rules would be regarding the provision of these basic benefits. According to the HHS guidance, “HHS aims to balance comprehensiveness, affordability, and State flexibility while taking into account public input throughout the process of establishing and implementing EHB.” CMS is attempting to accomplish these goals for EHB by;

    including the 10 categories of services identified in the statute;
    reflecting typical employer health benefit plans;
    reflecting balance among the categories;
    accounting for diverse health needs across many populations;
    ensuring there are no incentives for coverage decisions, cost sharing or reimbursement rates to discriminate because of age, disability, or expected length of life;
    ensuring compliance with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA);
    providing states a role in defining EHB; and
    balancing comprehensiveness and affordability for those purchasing coverage.

Under the HHS guidance, states would be permitted to select a single benchmark health plan to serve as the standard for qualified health plans. The benchmark health plan for EHB purposes could be one of the following:

the largest plan by enrollment in any of the three largest small group insurance products in the State’s small group market;

any of the largest three State employee health benefit plans by enrollment;

any of the largest three national FEHBP plan options by enrollment; or

the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the state.

If a state does not choose a benchmark health plan, then HHS would choose as the benchmark plan for a state the largest plan by enrollment in the largest product in the state’s small group market.

HHS also recognized that not all benchmark plans may offer the 10 basic categories of services required by law. According to HHS, “in selecting a benchmark plan, a state may need to supplement the benchmark plan to cover each of the 10 categories.” The most commonly non-covered categories of benefits among typical employer plans are habilitative services, pediatric oral services, and pediatric vision services.

According to the HHS guidance, a health insurance issuer under a benchmark plan will have some flexibility to adjust benefits as long as they offer coverage for all 10 statutory EHB categories. “Permitting flexibility will provide greater choice to consumers, promoting plan innovation through coverage and design options, while ensuring that plans providing EHB offer a certain level of benefits,” according to HHS.

This approach is based on the approach established by Congress for the Children’s Health Insurance Program (CHIP), created in 1997, and for certain Medicaid populations.


The Secretary must not make coverage decisions, determine reimbursement rates, or establish incentive programs. Benefits must not be designed in ways that discriminate based on age, disability, or expected length of life, but must consider the health care needs of diverse segments of the population.

Generally state employee plans, and the Federal Employees Health Benefits Program (FEHBP) Blue Cross Blue Shield (BCBS) Standard Option and Government Employees Health Association (GEHA) plans do not differ significantly in the range of services they cover. The following benefits are consistently covered by insurers: physician and specialist office visits, inpatient and outpatient surgery, hospitalization, organ transplants, emergency services, maternity care, inpatient and outpatient mental health and substance use disorder services, generic and brand prescription drugs, physical, occupational and speech therapy, durable medical equipment, prosthetics and orthotics, laboratory and imaging services, preventive care and nutritional counseling services for patients with diabetes, and well child and pediatric services such as immunizations. Additional guidance will be released on cost sharing and the calculation of actuarial value at a later date.

In addition, section 1311(d)(3)of PPACA requires states to defray the cost of any benefits required by State law to be covered by qualified health plans beyond the EHB. All States have adopted at least one health insurance mandate, and there are more than 1,600 specific service and provider coverage requirements across the 50 States and the District of Columbia. CMCS Informational Bulletin, December 19, 2011, ¶53,789, and Essential Health Benefits Bulletin, December 16, 2011, ¶53,790

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Wage index calculation method statutorily permissible

The U.S. Court of Appeals for the Seventh Circuit recently held that the Secretary’s inclusion of paid lunch hours in calculating the wage index for a metropolitan statistical area (MSA) properly captures “the relative hospital wage level” for reimbursement purposes in the prospective payment system (PPS).

Court’s reasoning

The Seventh Circuit held the Secretary’s policy of counting all paid hours, including paid unworked hours, serves the important purpose of administrative simplicity. The court reasoned that under 42 U.S.C. §1395ww(d)(3)(E)(i), the Secretary is required to adjust the proportion of a hospital’s costs attributable to wages and wage-related costs of the diagnosis related groups for area differences by a factor that reflects the relative wage level in the geographical areas of the hospital compared to the national average hospital wage level. The Seventh Circuit stated that the all-paid-hours approach is a “reasonable and statutorily permissible” method although it is not a totally accurate way of measuring relative wage levels. Accordingly, the Seventh Circuit affirmed the district court’s grant of summary judgment in favor of the Secretary. Adventis GlenOaks Hospital v. Sebelius, 7th Cir., December 15, 2011, ¶303,928.

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Physician disclosure of ownership interests in drug and device manufacturers

CMS has proposed regulations that would require reporting of payments to physicians and their financial interests in manufacturers of drugs, medical devices and supplies and in group purchasing organizations. Manufacturers would be required to report payments to physicians or teaching hospitals to the HHS Secretary by March 31 each year beginning in 2013. Group purchasing organizations (GPOs) would be required to report ownership or investment interests held by physicians or their immediate family members. The Secretary will publish the information on a public web site. Reportable payments will be connected with items which require pre-marketing approval by the Food and Drug Administration and are available only by prescription. Both the form and the nature of the payment must be reported. Proposed rule, 76 FR 78742, December 19, 2011, ¶220,857.

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CMS need not give notice of ESRD exception disapprovals

The United States Court of Appeals for the District of Columbia has decided that a medical provider need not be notified by a fiscal intermediary of a CMS disapproval of its application for an exception to the composite reimbursement rate for dialysis treatments within 60 days, as required by the Medicare Act, for the disapproval to be effective. The case involved Medicare reimbursement of a medical center that provides dialysis treatments to individuals with end-stage renal disease (ESRD).

The Medicare Act (Soc. Sec. Act §1881(b)(7)) sets a “composite rate” for reimbursements for each dialysis treatment a provider furnishes, but allows a provider to seek an exception by submitting an application to a CMS fiscal intermediary which then must pass the application on to CMS for review. Under the Act “each application for such an exception shall be deemed to be approved unless the Secretary disapproves it by not later than 60 working days after the date the application is filed.”


The medical center properly sought an exception to the composite rate and CMS notified the fiscal intermediary in writing that the exception was denied, but the fiscal intermediary did not notify the medical center of the disapproval until after the 60th working day. The Provider Reimbursement Review Board (PRRB) found that the exception request was automatically deemed approved as CMS’ determination was not sent to the provider in a timely fashion (see ¶81,608). The CMS Administrator, however, reversed the PRRB’s decision because CMS sent the disapproval to the fiscal intermediary before the expiration of 60 working day deadline, and it is the disapproval decision, not the provider’s receipt of the notice, that must occur by the deadline (see ¶81,633). The U.S. District Court for the District of Columbia upheld the Administrator’s decision and granted summary judgment to the Secretary of HHS, finding that the statute was designed to require prompt consideration of exception requests, but was silent on the question of providing notice to the provider within the time period afforded for the Secretary to make a determination (see ¶302,853).

On appeal, the medical center argued that the Secretary’s decision to disapprove an exception application is ineffective until it is communicated to the provider; the mere communication to the fiscal intermediary is inadequate. Also, because by regulation the provider has only 180 days to appeal CMS’ decision up through HHS, if a disapproval decision is not communicated to the provider, its appeal rights could be jeopardized. The medical center further argued the Freedom of Information Act (FOIA) (5 U.S.C. §552(a)(2)) prohibits an agency from relying on or using final administrative orders unless they have been “made available,” published in an agency’s reading room, or a party has actual and timely notice of its terms, none of which occurred in this case.

HHS responded that the disputed statutory language, unlike other provisions of the Medicare Act, does not call for notice of the Secretary’s disapproval decision within a specific time period. As a result, even if the word “disapproves” is thought ambiguous, the government is entitled to deference, and it’s interpretation that the Secretary “disapproves” an application when the decision is “rendered” is permissible.

Appellate court analysis

The appellate court agreed with the medical center’s belief that the term “disapproves” is meaningless unless communicated to the provider in some manner. As to the medical center’s argument that FOIA requires actual notice, the court pointed out that FOIA can be satisfied by making an order “available.” According to the court, by sending a denial letter to the fiscal intermediary, CMS certainly made it “available” to the provider. In the court’s opinion, all the medical center had to do was to call the fiscal intermediary or CMS to determine whether their exception was disapproved within 60 working days.

The court also rejected the medical center’s argument that a decision communicated only to the fiscal intermediary could not be thought a reasonable interpretation of the word “disapproves” because the decision could be altered before it was communicated to an applicant. The court reasoned that the only way a CMS disapproval decision could be altered would be to revoke the disapproval, which would only benefit the applicant and eliminate any reason to complain.

The court felt that the medical center’s better argument was based on a provider’s appeal rights, i.e., if CMS’ disapproval was not communicated to an applicant in a timely manner, the applicant’s appeal rights could be jeopardized. This argument, however, struck the court as a theoretical problem only, because once the disapproval is communicated to the fiscal intermediary within the 60 day period, it is “available” to the applicant. If, according to the court, the CMS decision was not “available” to the applicant in a timely manner, the relevant question would be how to interpret the appeal regulation, not the reimbursement statute. As such, the court found it would be unreasonable to apply the 180 day appeal requirement to a provider who failed to file a timely appeal through no fault of its own.

The decision of the district court was affirmed. Gundersen Lutheran Medical Center, Inc. v. Sebelius, CA-DC, December 20, 2011, ¶303,931.

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HHS funds initiative to reduce hospital infections

$218 million was awarded to 26 state, regional, national, or hospital system organizations by HHS to identify solutions already working to reduce health care acquired conditions, and to spread the solutions to other hospitals and health care providers. The organizations are called Hospital Engagement Networks participating in the Partnership for Patients initiative.

Funding and goals

The Hospital Engagement Networks will be funded with $500 million from the CMS Innovation Center, which was established by the Patient Protection and Affordable Care Act (PPACA)(P.L. 111-148). Hospital Engagement Networks will work to develop learning collaboratives for hospitals and provide a wide array of initiatives and activities to improve patient safety. They will be required to conduct intensive training programs to teach and support hospitals in making patient care safer, provide technical assistance to hospitals so that hospitals can achieve quality measurement goals, and establish and implement a system to track and monitor hospital progress in meeting quality improvement goals. The activities of the Hospital Engagement Networks will be closely monitored by CMS to ensure that they are improving patient safety.

Launched in April 2011, the Partnership for Patients now consists of more than 6,500 partners, including over 3,167 hospitals, along with 2,345 physicians, nurses, patient advocates, 892 consumers and consumer groups, and 256 employers and unions. In addition, health plans, Area Agencies on Aging, and state and federal government officials who have pledged to work together to reduce the number of hospital-acquired conditions by 40 percent and reduce hospital readmissions by 20 percent by the end of 2013.

In addition to the Hospital Engagement Contract awards, HHS has awarded three other contracts to assist in achieving the Partnership for Patients’ goals: the National Content Developer Contractor, the Beneficiary and Medical Professional Engagement Contractor, and the Evaluation Contractor. More information is provided at http://www.healthcare.gov/partnershipforpatients. CCH Chicago Bureau, December. 14, 2011.

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Texas Medicaid waiver expands managed care

CMS has approved a Medicaid waiver under Soc. Sec. Act §1115allowing the Texas Medicaid agency to require most Medicaid beneficiaries to receive services through managed care organizations (MCO) and to substitute a new incentive payment system for the traditional supplemental payments to disproportionate share hospitals. Building on a previous managed care waiver that was limited to specific counties, Texas will implement managed care statewide.

Low-income families with children will receive benefits through the STAR program. The STAR-PLUS program will provide both acute and long-term care services, including home and community-based services (HCBS) to the elderly and individuals with disabilities or chronic illnesses. The new managed care requirements become effective March 1, 2012.

Reform incentive payments

An uncompensated care pool will be established to help reimburse states for otherwise uncompensated costs of providing services to Medicaid beneficiaries and the uninsured. A delivery system reform incentive payment (DSRIP) program will reward providers’ efforts to improve access to care and health outcomes for beneficiaries. The state is developing four broad areas of focus for DSRIP: infrastructure development, program innovation and redesign, quality improvements and population-focused improvements. Regional healthcare partnerships (RHPs), financially supported by public hospitals or government entities, will work with healthcare providers to evaluate community needs and develop a plan to invest in improvements. CCH Chicago Bureau, December 12, 2011.

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Florida Medicaid reform demonstration extended five years

Florida’s Medicaid reform experiment, requiring most beneficiaries to receive their services through managed care organizations, will continue in five counties until December, 2016. Low-income families with children, the elderly and beneficiaries with disabilities whose Medicaid eligibility is related to receipt of Supplemental Security Income (SSI) must join managed care organizations. Individuals with developmental disabilities, those receiving institutional care or hospice benefits, foster children, higher-income pregnant women and children enrolled in the Children’s Health Insurance Program (CHIP) may participate voluntarily. Individuals eligible as refugees, the medically needy, elderly residents of mental institutions and those whose benefits are limited to family planning or treatment of breast or cervical cancer are excluded from the demonstration.

The demonstration also includes an enhanced benefits account to encourage health behaviors. A low income pool assures continued compensation for services to Medicaid beneficiaries and individuals who are uninsured or underinsured. Managed care organizations may offer benefits targeted to the needs of their beneficiary populations. They must offer all services required under the state plan.

New protections for participants

CMS has imposed a new requirement that the state’s expenditures meet an 85 percent medical loss ratio. The provisions permitting annual benefit limits has been eliminated, and the requirements for network adequacy, access to services and continuity of care have been strengthened. The state will be required to collect encounter data and apply additional standards to evaluation of the demonstration for network adequacy and access to services as well as the effectiveness of the enhanced benefit accounts. Beneficiaries with access to employer-sponsored insurance will no longer be able to opt out of Medicaid and choose premium assistance. CMS release, December 15, 2011.

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Failure to raise Medicaid provider rates

Providers of residential habilitation services have enforceable rights to challenge the failure of Idaho Medicaid officials to increase payment rates after a study of the providers’ costs recommended an increase. The court relied on previous Ninth Circuit rulings (see ¶45,001, ¶302,951) that the requirements of ¶14,713.51 that Medicaid payment be consistent with efficiency, economy and quality of care, are both substantive and procedural, and that state officials must consider providers’ costs in setting payment rates. After obtaining an independent study of the providers’ costs to provide habilitation services, it could not disregard the results solely on the ground that the legislature had refused to appropriate additional funds. The court did not order specific relief out of concern that it should not interfere by micromanaging the state’s program. Inclusion, Inc. v. Armstrong, D. Idaho, December 12, 2011, ¶303,925.

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California class action settlement continues adult day services

A federal court in California has given preliminary approval to the settlement of a class action in which the court ordered state Medicaid officials not to implement service cuts for individuals with cognitive impairments (see ¶303,298). California’s Medicaid Agency will continue to make adult day health care (ADHC) services available to individuals with chronic mental illness, traumatic or other brain injury, Alzheimer’s disease or similar cognitive impairments and individuals with developmental disabilities, under criteria specified in the settlement, and, upon CMS’ approval of a waiver, the benefit will be offered only through managed care plans in all counties where managed care is available.

Adult day health services

The class is comprised of individuals with the conditions described who received ADHC services at ADHC centers. Eligibility was determined in accordance with diagnosis and inability to perform at least two of 15 activities of daily living (ADLs) or instrumental ADLs without assistance. In 2009, legislation was passed reducing the maximum services available and narrowing the eligibility criteria, eliminating from eligibility individuals who required assistance with accessing resources, transportation, meal preparation, housework or laundry but not with dressing, bathing, using the toilet, self feeding.

In particular, the class alleged that the reduction of ADLs considered from 15 to eight discriminated against individuals with mental illness, developmental disabilities or cognitive impairments, in violation of the Americans with Disabilities Act (ADA) and the Rehabilitation Act (RA). In granting the preliminary injunction, the court ruled that the new standards failed to account for beneficiaries’ individual needs, violating Soc. Sec. Act §1902(a)(17)and 1902(a)(10)(B), which require reasonable standards and comparability of services, respectively.

Terms of the settlement

The settlement agreement allows the state agency to terminate ADHC as an optional benefit and replace it with community-based adult services (CBAS) under an existing waiver program. CBAS would be an outpatient, facility-based service offering skilled nursing, social services, therapies, personal care, training and support for family/caregivers, meals and transportation. In addition, individuals who are not eligible for CBAS will receive enhanced case management services to meet their individual needs for long-term services and supports, including services not covered by Medicaid.

To qualify for CBAS, beneficiaries must have: (1) a need for level A nursing facility care and meet criteria established under state law; (2) a diagnosis of acquired, organic or traumatic brain injury or chronic mental illness and a need for help either with two of nine ADLs (for example, medication management and hygiene) or one of the nine ADLs and money management, accessing resources, meal preparation or transportation; (3) Alzheimer’s disease or other dementia, and specified eligibility and medical necessity criteria specified in state regulations; or (4) developmental disabilities meeting criteria to receive service at the state’s regional centers.

The agency will not cut or terminate ADHC services until a beneficiary has been screened for eligibility for CBAS, including a face-to-face assessment and an opportunity for a second review. The ADHC centers will make initial assessments of eligibility. If the ADHC center determines that an individual is not eligible for CBAS, in addition to the second review and a right to a hearing, the individual must be informed of the right to receive enhanced case management services. The ADHC must prepare a discharge plan for the agency and the individual, after which the Medicaid agency and/or the managed care plan will develop a care plan with the beneficiary before the ADHC services may be terminated.

A hearing on final approval of the settlement is scheduled for January 24, 2012. Darling v. Douglas, N.D. Cal., December 14, 2011, ¶303,926.

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Access to Part D vaccinations

Very few beneficiaries received the routinely recommend vaccines that are covered under Part D in 2009. There are several reasons that effect beneficiaries access to vaccines including very few physicians stock the new shingles vaccine due to the cost of purchasing a supply and the challenges they face when billing Medicare Part D for the vaccine. Physicians also recommend the shingles vaccine less often than other vaccines, and when they are recommended, beneficiaries often refuse to have them administered. To complicate matters further, the shingles vaccine is in short supply and only one-third of all national pharmacies stock the vaccine. In 2009, beneficiaries also had a $57 cost share for the shingles vaccine and they faced challenges getting reimbursement from Part D plans. The GAO recommended that CMS check its options and address administrative challenges such as physicians’ having difficulty verifying beneficiary coverage and billing for Part D covered vaccinations. GAO Report, No. GAO-12-61, December 20, 2011, ¶68,048.

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Decisions and Developments

CMS Manuals

Pharmacy billing for drugs provided "incident to" a physician service

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 2368, December 15, 2011, ¶159,896.

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Independent end-stage renal disease cost report form CMS-265-11

Medicare Provider Reimbursement Manual, Pub. 15-2, Transmittal No. 1, December 16, 2011, ¶159,897.

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Update to Medicare deductible, coinsurance and premium rates for 2012

Medicare General Information, Eligibility, and Entitlement Manual, Pub. 100-01, Transmittal No. 74, December 16, 2011, ¶159,898.

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Summary of policies in the CY 2012 Medicare physician fee schedule (MPFS) Final rule and the telehealth originating site facility fee payment amount

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 2369, December 16, 2011, ¶159,899.

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January 2012 integrated outpatient code editor (I/OCE) specifications, version 13.0

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 2370, December 16, 2011, ¶159,900.

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Claim status category and claim status codes update

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 2371, December 22, 2011, ¶159,901.

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Claim adjustment reason code (CARC), remittance advice remark code (RARC), and Medicare remit easy print (MREP) and PC print update

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 2372, December 22, 2011, ¶159,902.

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Additional instructions regarding demand bills under the home health prospective payment system

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 2374, December 22, 2011, ¶159,903.

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Clarifications to Appendix L, ambulatory surgical center interpretive guidelines - obtaining consent before observing surgical procedures

State Operations Provider Certification Manual, Pub. 100-07, Transmittal No. 76, December 22, 2011, ¶159,904.

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Revised Appendix A, Interpretive guidelines for hospitals, and revised Appendix W, Interpretive guidelines for critical access hospitals

State Operations Provider Certification Manual, Pub. 100-07, Transmittal No. 78, December 22, 2011, ¶159,905.

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Dennis Barry's Reimbursement Advisor

The November 2011 issue of Dennis Barry’s Reimbursement Advisor presents the first article in a series regarding a bundling demonstration initiative required under the Affordable Care Act. In addition, authors examine potential Medicare spending cuts -- by deliberate plan or by sequestration if a congressional committee charged with reducing federal spending fails to come up with a plan to cut $1.2 million over the next decade.

Potential Medicare cuts on “supercommittee“ agenda: Congressional, White House proposals outline options to curb Medicare spending.

The Budget Control Act of 2011, signed into law in August, requires a joint congressional “supercommittee” to come up with a $1.2 trillion deficit reduction package. The cost-cutting package will include reduced Medicare spending, and Democrats, Republicans and the White House all have proposals on the table on how to cut Medicare costs. In this article, the author examines those proposals intended to curb Medicare spending.

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Receivables Report

Managing a Heavy Workload

It isn’t unusual to find overburdened staff these days. How a manager handles the situation can make all the difference. This is the topic of the Management Corner in the November issue of Receivables Report. It’s an important topic, especially now.

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