On November 15, 2011 CMS announced three demonstration projects that are set to begin on January 1, 2012 with aims to reduce fraud, waste, and abuse in the Medicare program. The Recovery Audit Prepayment Review demonstration project will allow Medicare Recovery Auditors (RACs) to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments. These reviews will focus on seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. (Contact: RAC@cms.hhs.gov.). A second demonstration program on Prior Authorization of Power Mobility Devices will require Prior Authorization for power mobility devices for all people with Medicare who reside in seven states with high populations of fraud- and error-prone providers (CA, FL, IL, MI, NY, NC and TX). This demonstration will help ensure that a beneficiary’s medical condition warrants their medical equipment under existing coverage guidelines. (Contact: PAdemo@cms.hhs.gov.) The third demonstration program Part A to Part B Rebilling will allow hospitals to re-bill for 90 percent of the Part B payment when a Medicare contractor denies a Part A inpatient short stay claim as not reasonable and necessary due to the hospital billing for the wrong setting. CMS says that currently when outpatient services are billed as inpatient services, the entire claim is denied in full. This demonstration will be limited to a representative sample of 380 hospitals nationwide that volunteer to be part of the program. This demonstration will allow hospitals to resubmit claims for 90 percent of the allowable Part B payment when a Medicare Administrative Contractor, Recovery Auditor, or the Comprehensive Error Rate Testing Contractor finds that a Medicare patient met the requirements for Part B services but did not meet the requirements for a Part A inpatient stay. (FMI: Contact ABRebillingDemo@cms.hhs.gov.) FMI: To read more about the demonstration projects, visit http://go.cms.gov/cert-demos. CMS has posted a set of questions and answers on the site as well. The QA is available at https://www.cms.gov/CERT/downloads/Prior_Auth_11_18.pdf.
On November 18, the Centers for Medicare and Medicaid Services (CMS) announced the first sites selected for the Community Based Care Transition Program (CCTP). The CCTP is an initiative of the Partnership for Patients, a new public-private partnership created by the Affordable Care Act. The goals of the CCTP are to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program. The demonstration will be conducted under the authority of Section 3026 of the Affordable Care Act of 2010. Click here for the first site selections for the Community Based Care Transitions Program: http://www.CMS.gov/DemoProjectsEvalRpts/downloads/CCTP_FirstSiteSelections.pdf. Comments or questions can be sent to: CareTransitions@CMS.hhs.gov. For more information about the Community Based Care Transitions Program, visit http://go.CMS.gov/caretransitions.
A new release of the Short-Term (ST) Acute Care Program for Evaluating Payment Patterns Electronic Report (PEPPER), with statistics through the third quarter of FY2011, is available for short-term acute care hospitals nationwide open as of Thursday, June 30. PEPPER files were distributed in late November 2011 through a My QualityNet secure file exchange to hospital QualityNet Administrators and user accounts with the PEPPER recipient role. This release of PEPPER includes a new report, the “National High Outlier Ranking Report,” which ranks hospitals by the total number of high outliers as compared to all other hospitals in the nation. A new training session reviewing the new report is available at www.PEPPERresources.org.
On November 18 President Obama signed the first the FY 2012 “minibus” (HR 2112) into law. The bill funds the departments of Agriculture, Justice, Commerce, Transportation and Housing and Urban Development. The bill also includes a continuing resolution to fund the remaining parts of the federal government through December 16. This includes all programs for which FY 2012 appropriations have not been enacted and continues a 1.5 percent across-the-board cut for such programs that had been enacted earlier this year as part of a previous continuing resolution. Additionally, the continuing resolution provides Congress with four weeks to approve an FY 2012 omnibus spending bill following the collapse in minibus negotiations earlier this month. Congress is now expected to approve the nine remaining FY 2012 spending bills as a single omnibus in mid-December.
On November 21 PA DPW Office of Developmental Programs (ODP) released its final Bulletin #00-11-06 entitled “Continuing Participation Allowance (Use allowance) for Residential Habilitation Service Providers’ rates. The bulletin announces changes to the Office of Developmental Programs (ODP) policy regarding payment rates to licensed and unlicensed residential habilitation providers in waiver service locations. Effective November 15, 2011, providers of licensed and unlicensed residential habilitation services operating waiver service locations will see a change in their waiver ineligible payment rates and the sum of a base payment rate. The base rate for a base funded individual in a waiver service location shall have the Individual Support Plan updated to reflect the rate change. Effective November 15, 2011 ODP will no longer fund use allowance expenses for assets included on the residential occupancy schedule (J). ODP says hat it removed those expenses during the rate development process for residential ineligible rates effective November 15, 2011 through June 30, 2012. The policy is applicable to waiver ineligible payment rates and base payment rates for providers offering residential habilitation services to waiver and base individuals in waiver service locations. FMI: See www.odpconsulting.net. See http://services.dpw.state.pa.us/olddpw/bulletinsearch.aspx?BulletinId=4746.
On November 15 the PA Office of Developmental Programs (ODP) issued ODP Informational Memo 156-11 concerning its request for renewals of its Medicaid waiver programs. ODP Informational Memo 156-11 is intended to inform all interested parties that the office in the process of requesting a 5 year Waiver Renewal for both the Consolidated and Person/Family Direct Support (P/FDS) Waivers from the Centers for Medicare and Medicaid Services (CMS). Home and Community-Based Waiver services provided under Section 1915 (c) of the Social Security Act, with the exception of new Waivers, are approved by CMS for five-year renewal periods. ODP reports that it has collected feedback on suggested changes to the waiver through multiple forums over the past 2 years. ODP says that prior to submission of the Consolidated and Person/Family Directed Support 5 Year Waiver Renewals, ODP will solicit feedback regarding proposed changes via the ODP Stakeholder Workgroup and the Medical Assistance Advisory Council (MAAC). In an effort to allow sufficient time for review and approval by CMS, the ODP goal is to submit the waiver renewals to CMS by December 23, 2011.