Provider Information
CMS Issues E-Prescribing RegulationsThe Centers for Medicare and Medicaid Services (CMS) issued a final rule for electronic prescribing standards under the Medicare prescription drug benefit on April 2. While physicians are not currently required to use electronic prescribing, those who do so will have to follow the new standards when electronically transmitting prescriptions and prescription information for covered drugs for Medicare beneficiaries under the Medicare prescription drug program or Medicare Part D.
The final rule establishes the following requirements: give prescribers information about which drugs are covered by a Medicare beneficiary’s prescription drug benefit plan; provide prescribers with information about medications a beneficiary is already taking, including those prescribed by other providers, to help reduce the number of adverse drug events; and allow prescribers to receive an electronic notice from the pharmacy telling them that a patient’s prescription has been picked up, not picked up, or has been partially filled, to help monitor medication adherence in patients with chronic conditions, among other things. In announcing the final rule, Department of Health and Human Services (HHS) Secretary Michael O. Leavitt stated, “Establishing standards for e-prescribing under Medicare’s prescription drug program will help pave the way for widespread adoption of e-prescribing throughout the medical community. The final rule is effective April 1, 2009.
Legislation Introduced to Require Reporting of Gifts to Physicians
U.S. House of Representative Ways and Means Health Subcommittee Chairman Fortney “Pete” Stark and Representative Peter DeFazio introduced the “Physician Payment Sunshine Act of 2008” (H.R. 5605) on March 13. The legislation was introduced to require the disclosure of certain information by prescription drug and medical device manufacturers. Under the bill, the manufactures would be required to report any gift to a physician with a value of $25 or more. The reported information is to be made publicly available to help ensure marketing by drug and medical device manufacturers does not adversely impacting the health care delivery system. H.R. 5605 is a companion bill to S. 2029 introduced by U.S. Senators Charles Grassley and Herb Kohl. Both bills await action by their respective chambers of Congress.
HHS Announces EHR Demo
The Department of Health and Human Services (HHS) announced on February 20, a demonstration project that will provide Medicare incentive payments to physicians for the use of certified electronic health records (EHRs) to improve patient care. The demonstration project is directed at small and medium-sized primary care physician practices with the intent of reducing medical errors and improving the quality of care. The program is intended to impact the delivery of care for approximately 3.6 million Americans. According to HHS, total payments under the demonstration for all five years may be as much $58,000 per physician or $290,000 per practice. The application period is open through Mid-May. For more information on the demonstration program, you may visit www.cms.hhs.gov.
Medicare Spending Experiences Largest Annual Increase in 25 Years
A report examining the annual healthcare spending in the United States was published recently in the journal Health Affairs. According to the released findings, healthcare expenditures in 2006 totaled about $2.1 trillion. This amounts to spending about $7,026 per person and is a 6.7 percent increase over 2005 levels. Also included in this data is a finding that Medicare spending rose to about $401.3 billion in 2006 from $338 billion the previous year. While a large part of the Medicare increase from 2005 levels is attributed to the first full year of the Medicare prescription drug benefit ($41 billion), the 18.7 percent increase in Medicare outlays was the largest in 25 years. In light of this and other data contained in the report, the cost and availability of healthcare services is certain to remain a hot topic in healthcare policy circles.
CMS Releases List of Poor Performing Nursing Homes
The Centers for Medicare and Medicaid Services (CMS) recently released the first list of the nation’s poor-performing nursing homes. According to CMS, “Nearly three million Americans, most of who are enrolled in Medicare or Medicaid, depend on the nation’s 16,000 nursing homes at some point during each year to provide life saving care.” The list was released in an effort to provide consumers with valuable information and to promote improvements in the quality care provided to nursing home residents. The list of the 52 worst-performing special focus facilities (SFF), as designate by CMS, can be viewed at www.hhs.gov/.
New Preventive Services Guide Made Available by CMS
CMS announced the availability of the 2nd Edition of “The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals.” The guide provides fee-for-service physicians and others with coverage, coding, billing and reimbursement information for preventive services and screenings covered by Medicare. You can obtain a copy of the guide by visiting the Medicare Learning Network (MLN) at www.cms.hhs.gov/MLNGenInfo/.
CMS Issues Final Physician Self-Referral Rules
The Centers for Medicare and Medicaid Services issued final regulations prohibiting physicians from referring Medicare patients for certain designated health services (DHS) provided by businesses in which they or their immediate family members have a financial interest, unless an exception applies. This regulation is Phase III of the physician self-referral law which is often referred to as the Stark Law. According to CMS, “The rule does not establish any new exceptions to the physician self-referral prohibition, but rather makes certain refinements that could permit or, in some cases, require restructuring of some existing arrangements.” In order to obtain more information on the physician self-referral law, you may visit www.cms.hhs.gov/physicianselfreferral/.
Final NCD for Use of Anemia Drugs in Cancer Treatments Issued by CMS
The Centers for Medicare and Medicaid Services (CMS) released a final national coverage decision (NCD) to limit Medicare coverage of Erythropoiesis Stimulating Agents (ESAs) on July 30. Under the final NCD, which is effective immediately, CMS limited Medicare coverage of ESAs for certain cancers and related neoplastic conditions. The final coverage decision was issued after reviewing and including comments provided by the ACOI and others. In its comments, the ACOI raised concerns with CMS’s one-size-fits all approach to cancer care and suggested further review of additional data. You may view the final NCD www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=203.
Physician Quality Reporting Initiative Underway
Reporting is underway for the 2007 Physician Quality Reporting Initiative (PQRI) on claims for dates of service as of July 1. Physicians who participate in the PQRI may qualify for bonus payments totaling 1.5 percent by reporting the appropriate quality measure data on claims submitted to their Medicare claims processing contractor. Links to additional information and materials, including the PQRI Tool Kit and frequently asked questions (FAQs), are available at http://www.acoi.org/GovRelationsLinks.html.
Medicare Prescription Drug Formularies Available
The President signed into law the “Medicare Prescription Drug and Modernization Act of 2003” (MMA) (P.L. 108-173) on December 8, 2003. Included in the MMA was a provision establishing Part D of the Medicare program to provide prescription drug benefits to Medicare beneficiaries. The benefit took effect January 1 and enrollment continues until May 15.
In order to assist in patient care and determine whether specific drugs are covered under a plan’s formulary, there are several resources that may be of assistance. Epocrates, Inc. has provided their comprehensive formulary through its free Epocrates Rx® software. The software can be downloaded at www.epocrates.com. In addition, the Centers for Medicare and Medicaid Services (CMS) created a web-based formulary finder at http://formularyfinder.medicare.gov/formularyfinder/selectstate.asp.
CMS Announces Oncology Demonstration Project
The Centers for Medicare and Medicaid Services (CMS) has announced implementation of the Medicare Oncology Demonstration Project for 2006. The one-year demonstration project is to identify and assess office-based oncology practices and services to improve upon the efficient and effective delivery of oncological services to Medicare beneficiaries in thirteen diagnostic categories.
Participation in the project is voluntary and limited to physician specialists in the areas of hematology, medical oncology, and hematology/oncology. For additional information, you may contact Tim McNichol at tmcnichol@acoi.org or by calling toll-free 1-800-327-5183.
CMS Releases Medicare Remit Easy Print Software
The Centers for Medicare and Medicaid Services (CMS) announced the availability of Medicare Remit Easy Print (MREP) software. The software is available from your Medicare carrier or Durable Medical Equipment Regional Carrier’s (DMERC) website. MREP software allows physicians to view and print Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant 835s. The software allows physicians to print, view and search remittance information, among other things. Additional information on the MREP software can be obtained at www.cms.hhs.gov/MedlearnMattersArticles/downloads/se0611.pdf.
HHS Issues Final Rule on Imposition of Penalties for HIPAA Violations
The Department of Health and Human Services (HHS) released its final rule on the imposition of civil monetary penalties for violating the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The final rule, which took effect March 16, 2006, clarifies the investigation process, bases for liability, determination of the penalty amount, grounds for a waiver, conduct of the hearing and the appeals process. Under the final rule, a civil monetary penalty may not exceed more than $100 per violation and $25,000 per calendar year. In addition, the rule sets forth safeguards to prevent imposition of a penalty even if a violation of the HIPAA rules occurred. Detailed information on the final rule may be viewed at www.hhs.gov/ocr/hipaa/.
CMS Releases Physician Voluntary Reporting Program Information
The Centers for Medicare and Medicaid Services (CMS) released additional information on how to participate in the Physician Voluntary Reporting Program (PVRP). Under the program, CMS will ask physicians to voluntarily report information to CMS about the quality of care they provide to Medicare beneficiaries.
Through participation in the program, physicians will help gather data about the quality of care provided to Medicare beneficiaries and will help identify the most effective ways to use quality measures in practice to improve quality of care. In addition, physicians who participate in the PVRP will begin to receive data feedback on the measures. This will allow participants to compare the quality of care they provide with that of their peers. The program is starting with 16 quality measures; seven are primary care measures, two are for emergency physicians, two are for nephrologists and five are for surgeons. Detailed information about the PVRP may be obtained at www.cms.hhs.gov/PVRP/01_Overview.asp. Physicians may register to participate in the program by visiting www.quality.net.prg/pvrpintent.
Utilization of National Provider Identifiers Approaching
All health care providers must begin using National Provider Identifiers (NPIs) in Health Insurance Portability and Accountability Act (HIPAA) transactions by May 23, 2007. Failure to do so could result in the denial of claims. If you have not applied for your NPI, you may do so by doing one of the following:
- Accessing the web-based National Plan and Provider Enumeration System (NPPES);
- Filling out a paper NPI application/update form and mailing it to the NPI Enumerator; or
- Having your NPI application information, along with the application information submitted to NPPES through the Electronic File Interchange (EFI) by an organization on your behalf.
CMS Launch Medicare Preventive Services Outreach
Building on efforts to educate Medicare beneficiaries and providers about the Medicare Part D drug benefit, Centers for Medicare and Medicaid Administrator Mark McClellan, MD announced efforts to conduct outreach to promote the use of preventive services. According to McClellan, Medicare screening benefits are used by 50 percent or fewer of beneficiaries. Current statistics show the utilization rate for pap tests and pelvic exams is 36.3 percent; prostate cancer screening is 54.2 percent; screening mammograms is 54.7 percent; obtaining a pneumonia and flu shot is 65.2 percent and 68 percent respectively; and, cardiovascular screening is 82.6 percent. It is believed that greater utilization of these and other preventive services could save billions of dollars in medical expenses and preventable medical conditions.
Preventive Services Covered by Medicare Expanded for 2007
The number of preventive and screening services under the Medicare program has expanded as a result of a series of legislative enactments. The additional services, a “Welcome to Medicare” physical exam, cardiovascular screening, additional cancer tests and more, are available to beneficiaries who are enrolled in Medicare Part B. For additional information on these and other benefits, visit www.medicare.gov/Health/Overview.asp.
CMS Addresses Looming NPI Compliance Deadline
The Centers for Medicare and Medicaid Services (CMS) has announced a mechanism to address non-compliance with the National Provider Identifier (NPI) final rule. All covered entities must utilize NPIs and replace “legacy identifiers” by May 23, 2007, except for small plans, which must be in compliance by May 23, 2008. Recognizing that covered entities may not be able to be in full compliance by May 23, 2007, CMS has announced a contingency plan. CMS has announced that it will rely on voluntary compliance and utilize a complaint driven process after May 23, 2007 for covered entities that fall under the earlier deadline. If a complaint is registered for non-compliance, the covered entity accused of failure to comply with the NPI provisions will have the option to demonstrate compliance, document its good faith efforts to comply with the standards and/or submit a corrective action plan. CMS has stated that it will review non-compliance complaints on a case-by case basis. According to CMS, contingency plans may not extend beyond May 23, 2008. To this end, you are encouraged to obtain and utilize your NPI as soon as possible. Additional information on the NPI can be found at the Centers for Medicare and Medicaid Services’ webpage at www.cms.hhs.gov/.