Challenging Medicaid Prepayment Review

When the North Carolina Division of Medical Assistance (“DMA”) decides to place a Medicaid provider on prepayment review, it can be the equivalent of a death sentence for a small business.  The primary problem is that there are few avenues to appeal the decision to be placed on prepayment review, even when there is little or even no justification for DMA’s decision.  Prepayment review then becomes a waiting game reducing cash flow and overwhelming providers with a paper chase gotcha game. Although the initial decision to place a provider on prepayment review cannot be challenged, this does not mean that a Medicaid provider has no options to challenge the prepayment review process.

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Varsha Gadani

Varsha Gadani

Varsha Gadani focuses her practice on the health care industry. Her clients include hospitals, physicians, behavioral health care providers, long-term care facilities, and other providers. Prior to joining Parker Poe, Ms. Gadani served as Assistant Counsel at the North Carolina Medical Society (NCMS). In this role, she performed a variety of legal functions for the NCMS. She monitored and analyzed emerging state and federal health law issues and advised physicians on health policy matters.

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CMS Releases Proposed Rules on Medicaid and CHIP Managed Care

On Tuesday, May 26, 2015, the Centers for Medicare & Medicaid Services (“CMS”) released the pre-publication proposed rule that updates Medicaid and Children’s Health Insurance Program (CHIP) managed care regulations.  In the accompanying press release, Andy Slavitt, Acting Administrator of CMS, indicated that “[t]his proposal will better align regulations and best practices to other health insurance programs, including the private market and Medicare Advantage plans, to strengthen federal and state efforts at providing quality, coordinated care to millions of Americans with Medicaid or CHIP insurance coverage.”Read More

Varsha Gadani

Varsha Gadani

Varsha Gadani focuses her practice on the health care industry. Her clients include hospitals, physicians, behavioral health care providers, long-term care facilities, and other providers. Prior to joining Parker Poe, Ms. Gadani served as Assistant Counsel at the North Carolina Medical Society (NCMS). In this role, she performed a variety of legal functions for the NCMS. She monitored and analyzed emerging state and federal health law issues and advised physicians on health policy matters.

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Physicians Finally Get Permanent Medicare Payment Solution

On April 16, 2015, President Obama signed into law a permanent sustainable growth rate (“SGR”) fix.  The Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”) eliminates the Medicare SGR methodology, which has been used to determine annual updates to the Medicare Physician Fee Schedule (“MPFS”).

Background
Initially enacted as part of the Balanced Budget Act in 1997, the SGR was intended to limit Medicare spending on physician services.  However, the SGR methodology has called for negative updates annually since 2002, causing Congress to pass 17 short-term “doc fix” bills since 2003.  In April 2015, MACRA, a permanent fix, passed both chambers with bipartisan support despite the estimated $141 billion increase in federal budget deficit that will be attributed to it over the next 10 years.  This new model incorporates a move from fee-for-service to pay-for-performance for physician services.

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Varsha Gadani

Varsha Gadani

Varsha Gadani focuses her practice on the health care industry. Her clients include hospitals, physicians, behavioral health care providers, long-term care facilities, and other providers. Prior to joining Parker Poe, Ms. Gadani served as Assistant Counsel at the North Carolina Medical Society (NCMS). In this role, she performed a variety of legal functions for the NCMS. She monitored and analyzed emerging state and federal health law issues and advised physicians on health policy matters.

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Is Sunlight the Best Disinfectant?

Earlier today, CMS released data revealing financial ties between physicians and other sectors of the healthcare industry.  This August—December 2013 data is now available to the public on CMS’ website and includes 4.4 million transactions amounting to $3.5 billion in payments, involving 546,000 doctors and 1,360 teaching hospitals.  The payments disclosed on the website include:  consulting fees, speaking fees, research payments, gifts, meals, entertainment, travel, educational items, royalties, honoraria, and charitable contributions.

The release of this data was mandated by the Physician Payment Sunshine Act, part of the Patient Protection and Affordable Care Act, which aims to improve transparency of financial relationships and expose conflicts of interest between physicians and the health care industry.  Rules were promulgated requiring manufacturers to disclose certain payments and items of value given to physicians and teaching hospitals.

Starting August 1, 2013, drug and device manufacturers have been required to track all of the following: any “transfer of value” of $10 or more to physicians; transfers of value under $10 that add up to more than $100 a year; and physicians’ ownership stakes in drug and device companies.  Once reported to CMS, physicians have the opportunity to review and challenge these disclosures.

Industry and physician groups have criticized this first data release, stating that it raises more questions than answers.  Before the data was released, life science trade associations sent a letter to CMS Administrator Marilyn Tavenner expressing concern that the data will be misleading since the public will not understand the context of payments.   In August, the American Medical Association requested a delay in the release, stating that physicians were not provided adequate time to confirm the accuracy of the reported payments.  CMS ultimately decided to withhold about one-third of reported payments due to suspected inaccuracies.

The press has also been critical of CMS’ data.  Although the goal of the release is increased transparency, the website is not user-friendly.  The Wall Street Journal summarizes the problems: there is no search box; there are multiple databases; there are no bottom-line numbers; the chart has numerous columns, making it difficult to peruse.  In spite of these shortcomings, various news outlets and organizations, including Policy & Medicine, have analyzed and aggregated the data for the public.

The next release of data covering the 2014 calendar year will occur in the summer of 2015.  In the meantime, we will be watching to see if this new transparency leads to any changes in the relationships between physicians and drug and device manufacturers.

Varsha Gadani

Varsha Gadani

Varsha Gadani focuses her practice on the health care industry. Her clients include hospitals, physicians, behavioral health care providers, long-term care facilities, and other providers. Prior to joining Parker Poe, Ms. Gadani served as Assistant Counsel at the North Carolina Medical Society (NCMS). In this role, she performed a variety of legal functions for the NCMS. She monitored and analyzed emerging state and federal health law issues and advised physicians on health policy matters.

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How Much Does this Procedure Cost? North Carolina Proposes Temporary Rules on Cost Reporting Requirements for Hospitals and Ambulatory Surgery Centers

The recently adopted North Carolina Health Care Cost Reduction and Transparency Act aims to improve transparency in healthcare costs by providing information to the public.  By January 1, 2015, the Medical Care Commission (MCC) is required to adopt rules establishing reporting requirements for hospitals and ambulatory surgical facilities.  This information will then be available to the public on the North Carolina Department of Health and Human Services’ (Department) website.  The MCC has submitted proposed temporary rules and is accepting public comments through October 17, 2014.  The public hearing on these rules will be on October 15, 2014.  The reporting requirements of these proposed rules are summarized below.

Reporting Requirements for Hospitals
The Department will determine the 100 most frequently reported diagnosis related groups (“DRGs”), the 20 most common outpatient imaging procedures, and the 20 most common outpatient surgical procedures performed in hospitals statewide.  Hospitals will be required to provide the following:

  1. The average gross charge for each DRG or procedure if paid in full without any portion paid by a public or private third party;
  2. The average negotiated settlement for patients not covered by a public or private third party;
  3. The amount of Medicaid reimbursement for each DRG or procedure;
  4. The amount of Medicare reimbursement for each DRG or procedure; and
  5. For the top five largest health insurers (meaning Department of Justice (“DOJ”)-licensed third parties and the State Health Plan):
  • Identify the top five largest health insurers by dollar volume of payments;
  • List the lowest payment from each insurer for each DRG or procedure;
  • List the average of each of the five insurer payment amounts;
  • List the highest payment from each insurer for each DRG or procedure; and
  • Redact names of top five health insurers prior to submission.

Reporting Requirements for Ambulatory Surgical Facilities
The Department will determine the 20 most common outpatient imaging procedures and the 20 most common outpatient surgical procedures performed in ambulatory surgical facilities statewide.  Ambulatory surgical facilities will be required to provide the following:

  1.  The average gross charge for each DRG or procedure if paid in full without any portion paid by a public or private third party;
  2. The average negotiated settlement for patients not covered by a public or private third party;
  3. The amount of Medicaid reimbursement for each DRG or procedure;
  4. The amount of Medicare reimbursement for each DRG or procedure; and
  5. For the top five largest health insurers (meaning DOI-licensed third parties and the State Health Plan):
  • Identify the top five largest health insurers by dollar volume of payments;
  • List the lowest payment from each insurer for each DRG or procedure;
  • List the average of each of the five insurer payment amounts;
  • List the highest payment from each insurer for each DRG or procedure; and
  • Redact names of top five health insurers prior to submission.

Each quarter, hospitals and ambulatory surgical facilities must report on the quarter ending three months previous to the date of reporting.

 

Comments to these proposed temporary rules can be submitted by:

Email: DHSR.RulesCoordinator@dhhs.nc.gov;
Fax: 919-733- 7021;
Mail: Megan Lamphere, Division of Health Service Regulation, 2701 Mail Service Center, Raleigh, NC 27699-2701.

The Public Hearing on October 15, 2014 at 10:00 a.m. will be held at 801 Biggs Drive, Raleigh, NC 27603, Brown Building, Room 104.

Varsha Gadani

Varsha Gadani

Varsha Gadani focuses her practice on the health care industry. Her clients include hospitals, physicians, behavioral health care providers, long-term care facilities, and other providers. Prior to joining Parker Poe, Ms. Gadani served as Assistant Counsel at the North Carolina Medical Society (NCMS). In this role, she performed a variety of legal functions for the NCMS. She monitored and analyzed emerging state and federal health law issues and advised physicians on health policy matters.

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