Archive for February, 2014


CMS Offers Additional Guidance on “Two-Midnight Rule”

The Centers for Medicare & Medicaid Services (CMS) has issued additional information about its plans for implementing the so-called Medicare two-midnight rule.

The rule, which officially took effect last August, has been the subject of controversy, questions, and clarifications ever since, with CMS issuing addiitonal guidance last September and again this last month.

Among other things, CMS’s latest guidance explains that

CMS is requesting that the Medicare Administrative Contractors (MACs) re-review all claim denials under the Probe & Educate process to ensure the claim decision and subsequent education is consistent with the most recent clarifications.  The MAC may reverse their decision and issue payment outside of the appeals process if the MAC determines that a claim is payable upon re-review by the MAC.  Therefore, CMS urges providers to work with their MACs to determine if a claim has undergone final adjustment (in other words, has been re-reviewed) prior to submitting an appeal request. To ensure that the re-review process does not affect the ability of a provider to file a timely appeal of a denied claim, CMS will waive the 120 day timeframe for filing redetermination requests received before September 30, 2014 for claim denials under the Probe & Educate

PA “Medical Homes” Program Shows Disappointing Results

A demonstration project in the use of “medical homes” as a means of coordinating care and reducing health care costs produced neither better care nor lower costs in three years, according to a new study published in the Journal of the American Medical Association.

The Southeastern Pennsylvania Chronic Care Initiative, one of the first multi-payer medical homes programs in the country, sought to give primary care physicians greater responsibility for coordinating the care of program participants.  The only concrete improvement the program produced was better screening of diabetics for kidney disease.

Despite the lack of tangible results, program leaders believe they have learned lessons that will lead to improved performance in the future.

See the Journal of the American Medical Association study, “Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care,” here.  Read a commentary on the study’s findings from the Commonwealth Fund, which co-funded the project, here.  And read a Philadelphia Inquirer report on the project and its results here.


States Face Challenges in Outside-the-Box Medicaid Expansion

For most states expanding their Medicaid program in response to the opportunity afforded by the Affordable Care Act, expansion has been fairly straightforward:  they simply let more people into their existing Medicaid programs.

But several states – Arkansas, Iowa, and Michigan – have tried something different:  pursuing fundamental changes in their Medicaid programs.

Among the nearly half of the states still holding out against Medicaid expansion, the “something different” approach appears likely to be more common in the future, and in particular, those that do pursue expansion appear likely to seek to do so through greater use of private health insurers.  Through such an approach, states seek to use new federal Medicaid money to purchase private health insurance for newly qualified Medicaid recipients.

Among the states pursuing, or preparing to pursue, Medicaid expansion through private option coverage or other approaches in 2014 are New Hampshire, Pennsylvania, Tennessee, Virginia, Indiana, Missouri, Montana, and Utah, and others may follow as well.  Many of the programs these and other states propose will require federal waivers to exempt them from current Medicaid law, so the fate of these programs will rest on the Obama administration’s willingness to grant such waivers.

Read more about what …

Enthusiasm Waning for Permanent Medicare Doc Fix

While most health care interests and members of Congress want to see a permanent end to the annual Medicare “doc fix” problem, it appears increasingly likely that the next “fix” will be yet another short-term patch.

The obstacle?  How to pay for a permanent solution.

With the price tag for a permanent solution of around $150 billion, members of Congress have found themselves hard-pressed to find offsets that do not engender swift, angry response from health care interest groups.  Those groups want a permanent solution to the problem but also want others to pay for it.

The result, many suspect, will be a shorter solution and yet another attempt at a permanent solution either later this year or early next year.

Read about the multi-faceted challenges involved in addressing this perennial problem in this article from the online publication The Hill.…

PA Submits Medicaid Expansion Proposal to Feds

Yesterday the administration of Pennsylvania Governor Tom Corbett submitted a waiver application to the federal government requesting permission to expand the state’s Medicaid program as described in its September 2013 “Healthy Pennsylvania” proposal.

The Pennsylvania proposal seeks to vary from the approach taken by most states expanding their Medicaid programs in accordance with the Affordable Care Act by directing the expansion population into private health insurance plans.

The state’s waiver application and other documents associated with the application can be found here, on the web site of the Pennsylvania Department of Public Welfare.…