Does Medicaid work with a work requirement?

Conditioning Medicaid eligibility on a work requirement could adversely affect beneficiaries from accessing needed health coverage in a manner that is contrary to the program’s purpose—providing health coverage. A Kaiser Family Foundation (KFF) issue brief examined the policy arguments related to Medicaid work requirements and the likely impacts of such requirements, in light of a March 14, 2017, CMS letter to state governors announcing that it will begin to use Section 1115 Medicaid expansion waivers to approve provisions related to “training, employment, and independence.”

Work requirements 

In the past several years, CMS has denied multiple requests to include work requirements as a condition of Medicaid eligibility. Those requests were made as part of states’ Section 1115 waiver requests to expand their Medicaid program under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The requests were denied on the premise that work requirements would not further program goals of promoting coverage and access. The March 14 letter signals a fundamental change in policy for CMS.

Policy

KFF opined that the reversion to work requirements in Medicaid turns the program into a cash welfare program instead of a program focused on health care coverage. Proponents of the work requirement argue that the expansion of the Medicaid program to able-bodied adults provides a disincentive for those adults to work. Some states have advocated the inclusion of work requirements to ensure that beneficiaries have “skin in the game.” Opponents of the work requirement note that good health is a precondition of work and often an inability to access care can serve, itself, as a barrier to obtaining work.

Statistics

The vast majority (80 percent) of Medicaid adults live in working families. Additionally, more than half (59 percent) of Medicaid adults are working themselves. Thus, KFF estimated that work requirements would have a narrow reach, impacting primarily those who are already at a disadvantage and not working due to disability or caregiver responsibilities.

Trump Administration appoints controversial figure to HHS’ anti-discrimination office

The Trump Administration appointed Roger Severino as Director of the HHS Office for Civil Rights (OCR). Previously, Severino worked for the Heritage Foundation as the director of the DeVos Center for Religion and Civil Society in the Institute for Family, Community, and Opportunity. Prior to his work with the Heritage foundation, he was a trial attorney in the Department of Justice’s Civil Rights Division. Severino was also the Chief Operations Officer and Legal Counsel for the Becket Fund for Religious Liberty.

OCR 

The OCR enforces federal laws designed to prohibit discriminatory practices in health care by providers who receive HHS funds. The OCR also protects the privacy and security of health information through its investigatory and enforcement actions related to the Health Insurance Portability and Accountability Act (HIPAA) (P.L. 104-191).

Opposition

Senator Patty Murray (D-Wash) spoke out in opposition to the Trump Administration’s appointment, calling it an “appalling hire.” Murray criticized Severino’s work with the Heritage foundation and the Becket Fund, where he “fought against transgender equality in health care, against the separation of church and state, and in support of defunding Planned Parenthood.” Severino has previously worked to oppose the OCR’s implementation of Section 1557 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148)—a law which prohibits discrimination in health care on the basis of race, color, national origin, sex, age, or disability.

Florida hospital improperly billed Medicare almost $300,000 over two years

For over two years, University of Florida Health Jacksonville did not comply with Medicare billing requirements, due to inadequate billing controls. The noncompliance resulted in overpayments of at least $273,000, according to an audit by the HHS Office of the Inspector General (OIG).

Claims

The 695-bed not-for-profit hospital submitted 11,134 inpatient claims during the audit period (January 2013 through September 2014). Medicare paid the hospital $167 million on those claims. The OIG audit evaluated 1,305 inpatient claims that were potentially at risk for billing errors. From those claims, the OIG selected a random sample of 154 paid claims, totaling $1,964,826. Although the OIG determined that the hospital complied with billing requirements for the majority of the claims (133), the audit revealed that the hospital failed to comply with Medicare billing requirements for 21 claims, resulting in a net overpayment of $63,881 for the audit period. Based upon the sample, the OIG extrapolated that the hospital improperly received overpayments of at least $273,346 between January 2013 and September 2014.

Errors

For 19 of the 154 claims, the hospital billed incorrect diagnosis-related group (DRG) codes. For example, in one case, the hospital submitted a claim with a secondary diagnosis code 599.0 (urinary tract infection), despite the fact that the patient’s medical record indicated the patient had no signs or symptoms of a urinary tract infection. In other words, the hospital had no basis to assign code 599.0. The hospital attributed the billing mistakes to human error. The noncompliance related to the DRG codes accounted for the vast majority of the errors and led to net overpayments of $47,165.

When a patient is discharged from an acute care hospital and readmitted to the same hospital on the same day for symptoms related to the prior stay, the hospital is required to combine the original and subsequent stay into a single claim. The OIG determined that for 2 of the 154 audited claims, the hospital incorrectly billed Medicare for related discharges and readmissions that occurred on the same day. The hospital attributed the improper billing to human error.

Recommendations

The OIG recommended that the hospital:

  • refund the estimated $273,346 in overpayments to the Medicare program;
  • identify and return similar overpayments; and
  • strengthen billing and coding controls to ensure future compliance.

 

Objections

The hospital objected to the findings regarding 11 of 21 inpatient claims. Additionally, although the hospital acknowledged that human error contributed to the 10 other errors, there was “no evidence to support systemic coding or billing concerns.” The hospital also challenged the OIG’s authority to extrapolate a payment error rate.

 

 

HHS is ‘slowing’, not stopping, the Medicare appeals backlog

HHS will not be able to clear the backlog of Medicare appeals by its December 30, 2020, deadline, the agency said in a report to the U.S. District Court for the District of Columbia. HHS informed the court that due to a higher number of pending appeals than anticipated, without more money or resources, the agency will not be able to meet the deadline without violating its statutory requirement to decide appeals on the merits. Richard P. Kusserow, former HHS Inspector General (IG) and current CEO of Strategic Management, LLC, noted that the HHS position is not new. He said, “They have been making that argument from the beginning of the case.”

Mandamus

In February 2016, the D.C. Court of Appeals revived a 2014 case brought by the American Hospital Association (AHA) and three hospitals asking the court to issue a writ of mandamus to compel HHS to process their long-pending Medicare claim-reimbursement appeals in accordance with statutory timelines. On remand, the district court determined that because backlog numbers were unacceptably high, there were equitable grounds for mandamus. Accordingly, the court imposed a timetable, imposing increasing backlog reduction expectations, with elimination of the backlog of cases pending at the ALJ level by December 31, 2020 (see Court sets a timeline for Medicare claims backlog, December 6, 2016).

Status

The order granting a writ of mandamus instructed HHS to file status reports with the court every 90 days. The most recent report indicates that as of March 5, 2017, there are 667,326 pending appeals at the Office of Medicare Hearings and Appeals (OMHA). HHS projections put the number of expected pending appeals at 1,009,768 by the end of FY 2021, higher numbers than those found in previous HHS estimates. Because the backlog is not a static obstacle, despite some resolution through settlement or formal adjudication, the agency has struggled to keep appeals numbers from growing. Kusserow said, “The best that they have been able to accomplish to date has been slowing the backlog development.” According to HHS, the revised projections are the result of setbacks from lower than expected provider interest in the agency’s settlement initiatives and stalled settlement discussions.