AHA Wants Congress To Pressure CMS To Reverse Updates For Inpatient Payment Rule

CMS issues first price transparency fines to 2 Georgia hospitalsSource: Fierce Healthcare, by Robert King

The American Hospital Association (AHA) is turning to lawmakers to pressure the Biden administration to change “woefully inadequate” payment rates proposed for next year.

 

The AHA sent a letter Friday to congressional leaders surrounding the proposed Inpatient Prospective Payment Systems (IPPS) rule, which sets inpatient rates for next year. The hospital lobbying group charged that facilities are facing major challenges not just from the pandemic.

“Historic inflation has extended and heightened the already severe economic instability brought on by the pandemic resulting in razor-thin operating margins from massive surges in input costs, including a struggling workforce, drug costs, supplies and equipment,” the letter said.

 
 

The Centers for Medicare & Medicaid Services (CMS) had proposed a market basket update of 3.2% to Medicare payments for the 2023 federal fiscal year that begins this fall. This was on top of a 2.7% payment update for 2022. The proposed rule released in April calls for a proposed 0.4 percentage point productivity adjustment.

AHA contends that the market basket and productivity update don’t reflect the major inflation jump and growth in expenses.

“More recent data shows the market basket for [fiscal year] 2022 is trending toward 4%, well above the 2.7% CMS actually implemented last year,” the group wrote. “Additionally, the latest data also indicate decreases in productivity, not gains.”

American Hospital Association Urges CMS To Extend Enforcement Discretion For No Surprises Act

CMS urged to extend enforcement discretion for No Surprises Act requirement  | AHA News

Source: Healthcare Finance, by Jeff Lagasse

The American Hospital Association has urged the Centers for Medicare and Medicaid Services to extend enforcement discretion for the No Surprises Act regulatory requirement that healthcare providers exchange certain information to create a good faith estimate for uninsured and self-pay patients – until the agency identifies, and providers can implement, a standard, automated way to exchange the information.

“In the interim final rule implementing this policy, CMS notes that it is exercising enforcement discretion until Jan. 1, 2023, as it may take time for providers and facilities to ‘develop systems and processes for receiving and providing the required information,’” AHA wrote. “We agree that developing and implementing the solution will take time and cannot be achieved efficiently without additional guidance from CMS that identifies a standard technical solution that can be implemented by all providers.”

One of the main concerns from the AHA is that there are currently no methods for unaffiliated providers to share or receive good faith estimates with a convening provider or facility in an automated manner. To share this information, billing systems would need to be able to request and transmit billing rates, discounts and other necessary information for the good faith estimates between providers/facilities.

This is not something that practice management systems can generally do, said the AHA, since billing information is traditionally sent to health insurers and clearinghouses, not other providers.

“Due to the lack of currently available automated solutions, this process would require a significant manual effort by providers, which would undoubtedly result in the convening provider being unable to meet the short statutory timeframes for delivering good faith estimates to the patients and could also lead to inadvertent errors,” the AHA wrote.

AHA requested an extension in enforcement discretion until a technical solution has been found and implemented.

WHAT’S THE IMPACT

Without an automated standard, the AHA said, providers would need to determine individually how to transmit the information. That in turn could lead to variance throughout the industry, especially considering differences in size and technical sophistication among co-providers and facilities. Navigating a non-standardized process, the AHA contended, would increase administrative burden on providers.

To help work toward a standard solution, The AHA said it’s partnering with the American Medical Association, the Medical Group Management Association and HL7 to create a workgroup to discuss potential technical solutions for sharing and receiving critical information among providers. The group will consist of providers and vendors with knowledge of provider systems.

THE LARGER TREND

In December 2021, the American Hospital Association, American Medical Association and other provider organizations sued the Department of Health and Human Services and other federal agencies over implementation of the No Surprise Act. The groups are not against the legislation, they said in the lawsuit filed in federal court but take issue with how HHS implemented a dispute resolution process in the bill.

The No Surprises Act prevented 2 million surprise bills for the commercially insured, according to a survey by AHIP and the Blue Cross Blue Shield Association released in May. The analysis further showed that, if the trend continues, more than 12 million surprise bills would be avoided in 2022.

After Months Of Warnings, CMS Hands Out Its First Fines To Hospitals Failing On Price Transparency

CMS issues first price transparency fines to 2 Georgia hospitalsSource: Fierce Healthcare, by Dave Muoio

Eighteen months after its final rule on price transparency went into effect, the Centers for Medicare and Medicaid Services issued its first penalties to a pair of Georgia hospitals that did not update their websites or reply to the agency’s warning letters.

 

Northside Hospital Atlanta and Northside Hospital Cherokee have been issued civil monetary penalties of roughly $880,000 and $214,000, respectively, according to letters published on CMS’ Hospital Price Transparency website. Both hospitals are part of the same health system.

The agency calculated the penalties based on the hospitals’ size and how long their websites were non-compliant (up to $300 per day). The hospitals may submit a request for a hearing to have their penalties appealed.

“CMS expects hospitals to comply with the Hospital Price Transparency regulations that require providing clear, accessible pricing information online about the items and services they provide,” Director of Medicare Meena Seshamani, M.D., said in an email statement provided to Fierce Healthcare. “This enforcement action affirms the Biden-Harris Administration’s commitment to making health care pricing information accessible to people across the country and we are committed to ensuring that consumers have the information they need to make fully informed decisions regarding their healthcare.”

Since Jan. 1, 2021, CMS has required hospitals to post a comprehensive machine-readable list of their services and prices as well as a patient-friendly tool to help shop for 300 common services.

Hospitals that are not compliant with the requirements receive warning letters from CMS requesting they submit a corrective action plan to amend their websites.

 

The agency began delivering those letters in April, saying at the time it was hesitant to issue civil monetary penalties due to the harm that publicly naming noncompliant hospitals could bring to those organizations.

In the warning letters, CMS said it had conducted reviews of their websites, requested corrective action plans and delivered warning notices to both hospitals last fall. CMS issued warning to the hospitals in April and May, according to the letters, which neither hospital responded to.

CMS has issued a total 352 warning letters to hospitals as of this month, according to a CMS spokesperson. Among these, 171 received case closure notices after addressing the agency’s citations while 157 remain non-compliant, the spokesperson said.

Industry-wide compliance with the federal transparency requirements has been spotty to date. Only 14.3% of hospitals were compliant with both major components of the mandate one year after it went into effect, according to a review by PatientRightsAdvocate.org.

 

A study published in JAMA earlier this week corroborated low compliance as of the six to nine months after the rule went into effect, noting that hospitals in low-concentration healthcare markets, urban hospitals and those with lower per patient-day revenue were more likely to be in compliance.

Hospitals and health systems say their adherence struggles are the result of the high cost and complexity of implementation. They’ve also pointed to the final rule’s language, which they say is vague and difficult to interpret.

“Many organizations are not investing beyond the bare minimum requirements, and they don’t plan to do more until there is further clarity around the regulations and the expectations going forward,” KLAS Research wrote in an April report polling 66 hospital revenue cycle leaders on price transparency compliance.

American Hospital Association Urges CMS To Extend Enforcement Discretion For No Surprises Act

3.2% payment increase is not enough, American Hospital Association says |  Healthcare Finance NewsSource: Healthcare Finance, by Jeff Lagasse

The American Hospital Association has urged the Centers for Medicare and Medicaid Services to extend enforcement discretion for the No Surprises Act regulatory requirement that healthcare providers exchange certain information to create a good faith estimate for uninsured and self-pay patients – until the agency identifies, and providers can implement, a standard, automated way to exchange the information.

“In the interim final rule implementing this policy, CMS notes that it is exercising enforcement discretion until Jan. 1, 2023, as it may take time for providers and facilities to ‘develop systems and processes for receiving and providing the required information,’” AHA wrote. “We agree that developing and implementing the solution will take time and cannot be achieved efficiently without additional guidance from CMS that identifies a standard technical solution that can be implemented by all providers.”

One of the main concerns from the AHA is that there are currently no methods for unaffiliated providers to share or receive good faith estimates with a convening provider or facility in an automated manner. To share this information, billing systems would need to be able to request and transmit billing rates, discounts and other necessary information for the good faith estimates between providers/facilities.

This is not something that practice management systems can generally do, said the AHA, since billing information is traditionally sent to health insurers and clearinghouses, not other providers.

“Due to the lack of currently available automated solutions, this process would require a significant manual effort by providers, which would undoubtedly result in the convening provider being unable to meet the short statutory timeframes for delivering good faith estimates to the patients and could also lead to inadvertent errors,” the AHA wrote.

AHA requested an extension in enforcement discretion until a technical solution has been found and implemented.

WHAT’S THE IMPACT

Without an automated standard, the AHA said, providers would need to determine individually how to transmit the information. That in turn could lead to variance throughout the industry, especially considering differences in size and technical sophistication among co-providers and facilities. Navigating a non-standardized process, the AHA contended, would increase administrative burden on providers.

To help work toward a standard solution, The AHA said it’s partnering with the American Medical Association, the Medical Group Management Association and HL7 to create a workgroup to discuss potential technical solutions for sharing and receiving critical information among providers. The group will consist of providers and vendors with knowledge of provider systems.

THE LARGER TREND

In December 2021, the American Hospital Association, American Medical Association and other provider organizations sued the Department of Health and Human Services and other federal agencies over implementation of the No Surprise Act. The groups are not against the legislation, they said in the lawsuit filed in federal court but take issue with how HHS implemented a dispute resolution process in the bill.

The No Surprises Act prevented 2 million surprise bills for the commercially insured, according to a survey by AHIP and the Blue Cross Blue Shield Association released in May. The analysis further showed that, if the trend continues, more than 12 million surprise bills would be avoided in 2022.

Medicare Recipients To See Premium Cut — But Not Until 2023

Medicare recipients to see premium cut — but not until 2023 - ABC News

Source: Associated Press

Medicare recipients will get a premium reduction — but not until next year — reflecting what Health and Human Services Secretary Xavier Becerra said Friday was an overestimate in costs of covering an expensive and controversial new Alzheimer’s drug.

Becerra’s statement said the 2022 premium should be adjusted downward but legal and operational hurdles prevented officials from doing that in the middle of the year. He did not say how much the premium would be adjusted.

Medicare Part B premiums jumped by $22 a month, to $170.10, for 2022, in part because of the cost of the drug Aduhelm, which was approved despite weak evidence that it could slow the progression of Alzheimer’s.

The Centers for Medicare and Medicaid Services has limited coverage of Aduhelm to use in clinical trials approved by the Food and Drug Administration or the National Institutes of Health. It began reassessing the premium increase under pressure by Congress and consumers.

The drug’s manufacturer, Cambridge, Massachusetts-based Biogen, has cut the cost of the drug in half, to about $28,000 a year.

CMS cited the sharp reduction in the price of the drug and the limitations on coverage in concluding that cost savings could be passed on to Medicare beneficiaries. In a report to Becerra, the agency said the premium recommendation for 2022 would have been $160.40 a month had the price cut and the coverage determination both been in place when officials calculated the figure.

The premium for 2023 for Medicare’s more than 56 million recipients will be announced in the fall.

“We had hoped to achieve this sooner, but CMS explains that the options to accomplish this would not be feasible,” Becerra said. “CMS and HHS are committed to lowering health care costs — so we look forward to seeing this Medicare premium adjustment across the finish line to ensure seniors get their cost-savings in 2023.”

A Reduction In Medicare Part B Premiums Remains In Play. Here’s Where Things Stand

A possible reduction for Medicare Part B premiums is still in playSource: CNBC, by Sarah O’Brien

For Medicare beneficiaries wondering whether their Part B premiums could be reduced, the waiting continues.

More than three months after Health and Human Services Secretary Xavier Becerra ordered a reassessment of this year’s $170.10 standard monthly premium — a bigger-than-expected jump from $148.50 in 2021 — it remains uncertain when a determination will come and whether it would affect what beneficiaries pay this year.

 

“A mid-course reduction in premiums would be unprecedented,” said Tricia Neuman, executive director of the Medicare policy program at the Kaiser Family Foundation.

A spokesperson for the Centers for Medicare & Medicaid Services said the agency continues to reexamine the premium and will announce further information when it’s available.

About half of the larger-than-expected 2022 premium increase, set last fall, was attributed to the potential cost of covering Aduhelm — a drug that battles Alzheimer’s disease — despite actuaries not yet knowing the particulars of how it would be covered because Medicare officials were still determining that.

By law, CMS is required to set each year’s Part B premium at 25% of the estimated costs that will be incurred by that part of the program. So in its calculation for 2022, the agency had to account for the possibility of broadly covering Aduhelm.

Things have changed, however.

Several weeks ago, CMS officials announced that the program will only cover Aduhelm for beneficiaries who receive it as part of a clinical trial. Additionally, the per-patient price tag that actuaries had used in their calculation last year was cut in half, effective Jan. 1, by manufacturer Biogen — to $28,000 annually from $56,000.

“Certainly the rationale for an increase that high is gone,” said Paul Ginsburg, a nonresident senior fellow at the Brookings Institution and a health care policy expert.  “The question would be what’s administratively feasible.”

If a premium reduction occurs, there’s also the chance it could be applied for 2023 instead of 2022. There have been year-to-year drops in the Part B premium in the past for various reasons, including legislative changes to how the premium is calculated.

“If I were administering this, I’d be concerned about setting a precedent for making changes in the middle of the year,” Ginsburg said.

It’s also possible that lower-than-projected spending on Aduhelm could be at least partially offset by increased costs in other areas of Part B coverage, which includes outpatient care and medical equipment. While Medicare Part D provides prescription drug coverage, some medicines are administered in a doctor’s office — as with Aduhelm, which is delivered intravenously — and therefore covered under Part B.

“Even if fewer people are using Aduhelm than originally projected and at a lower price than assumed, the actuaries may be inclined to take into account other changes that could moderate that amount,” Neuman said.

Roughly 6 million Americans suffer from Alzheimer’s, a degenerative neurological disease that slowly destroys memory and thinking skills, and has no known cure. It also can destroy the lives of families and friends of those with the disease.

Most of these patients are age 65 or older and generally enrolled in Medicare, which covers more than 63 million individuals. In 2017, about 2 million beneficiaries used one or more of the then-available Alzheimer’s treatments covered under Part D, according to the Kaiser Family Foundation.

CMS Proposes 5 Medicare Special Enrollment Periods

CMS proposes 5 Medicare special enrollment periods | Modern Healthcare

Source: Modern Healthcare, by Maya Goldman

Arbiters To Expand Surprise Billing Dispute Resolution Reviews, CMS Says

Surprise Medical Bills: New Protections for Consumers Take Effect in 2022 |  KFFSource: Modern Healthcare, by Maya Goldman

AHIP Warns Proposed ACA Exchange Rule Could Threaten Market’s Growing Stability

AHIP warns proposed ACA exchange rule could threaten market's growing  stability | Fierce HealthcareSource: Fierce Healthcare, by Paige Minemyer

AHIP, the top lobbying organization for commercial insurers, is warning the feds that provisions in its proposed rule governing the Affordable Care Act’s exchanges for 2023 could “undermine” the growing stability there.

For instance, the group says in comments (PDF) submitted late Thursday that potential changes to requirements for essential health benefits would limit the ability for insurers to manage costs, particularly for prescription drugs, and manage chronic illnesses.

In addition, AHIP said that a proposed requirement for insurers to offer standardized plan options on the exchanges would “stifle innovation” and includes provisions that would be hard for payers to roll out, such as common drug formulary designs.

 
 

Instead, AHIP suggests that the Centers for Medicare & Medicaid Services deploy an approach in which payers are required to offer one standardized silver plan option for 2023, and then gather enrollment data to see if the plan designs are meeting consumer needs.

“The continued stability and growth of the ACA marketplaces is also due in large part to policies that have promoted a stable regulatory environment, increased competition, and enabled issuers to offer innovative products that consumers want and need,” AHIP said. “However, we are concerned that some of the policies proposed in this Payment Notice may take large steps backward, undermining this hard-won stability and significantly limiting innovation and competition.”

 

CMS said earlier Thursday that the final tally for ACA open enrollment was 14.5 million, a record. The market had been improving for some time, luring big-name insurers such as UnitedHealthcare and Aetna back in, but the Biden administration’s temporary expansion of premium tax credits has led enrollment to skyrocket.

In the rule, CMS also proposes mandating network adequacy reviews for plans offered on the federal exchange, Healthcare.gov.

AHIP said proposed network adequacy standards could make it harder for payers to design innovative plans, lead to higher premiums and place an undue burden on both payers and providers.

“If finalized, we recommend network adequacy standards be deferred to plan year 2024 to provide time to address these outstanding issues and allow issuers the time to change to their networks,” the group said.

 

The organization is urging CMS to extend the comment window on the rule to allow additional time for feedback on its proposals.

Older Americans Oppose Approval Process for Home Care Services

Eighty-three percent of seniors oppose a Medicare policy that requires a government contractor to approve claims for physician-prescribed home health care, according to a poll sponsored by Bring The Vote Home. The Centers for Medicare & Medicaid Services (CMS) recently implemented a pre-claim review demonstration that imposes documentation requirements on home health agencies and referring physicians. Doctors have to provide a broad array of eligibility-related documentation and clinical support for review by government contractors. Home health leaders warn that the new requirements could delay care and increase healthcare costs. Seniors say that requiring a government contractor to approve home heath care will have the following results:

  • 80% say it will delay care.
  • 77% say it will increase Medicare costs.
  • 75% say that will increase out-of- pocket costs.
  • 45% say it will decrease fraudulent home health claims.

For more information, visit bringthevotehome.org.

Last Updated 06/29/2022

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