Archive for July, 2018


GAO Looks at Medicaid Managed Care Spending

The federal government should do more to help states ensure the accuracy and integrity of their payments to Medicaid managed care organizations and the payments those Medicaid managed care organizations make to health care providers.

This is the conclusion reached in a new study of Medicaid managed care performed by the U.S. Government Accountability Office at the request of the Permanent Subcommittee on Investigations of the Senate Committee on Homeland Security and Government Affairs.

The GAO study identified six payment risks among various transactions between state governments, Medicaid managed care organizations, and health care providers.  The two biggest risks, the GAO concluded, were:

  1. incorrect fee-for-service payments from MCOs, where the MCO paid providers for improper claims, such as claims for services not provided; and
  2. inaccurate state payments to MCOs resulting from using data that are not accurate or including costs that should be excluded in setting payment rates.

The GAO traces some of these problems to a delay in the Centers for Medicare & Medicaid Services’ planned Medicaid managed care guidance to states; limited implementation of new auditing practices CMS introduced in 2016; and CMS’s failure to account for overpayments to providers when it reviews state capitation rates for Medicaid …

Supreme Court Nominee’s Health Care Views

How has Supreme Court nominee Brett Kavanaugh ruled in health care cases that have come before him?

In a new review, the Commonwealth Fund examines Judge Kavanaugh’s past opinions on cases involving the Affordable Care Act, abortion and contraception, and Medicare entitlement.

It also examines how Judge Kavanaugh approaches adjudicating the cases that come before him and his views on precedent, procedure, and executive and judicial authority.

Learn more about the man who could soon join the Supreme Court in the Commonwealth Fund article “Examining Supreme Court Nominee Kavanaugh’s Health Care Opinions.”…

New Reg Pushes Medicare Toward Site-Neutral Outpatient Payments

Medicare would make more payments for outpatient services on a site-neutral basis under a newly proposed regulation just released by the Centers for Medicare & Medicaid Services.

The 2019 Medicare outpatient prospective payment system regulation, published in proposal form, calls for:

  • paying physician fee schedule rates rather than hospital outpatient rates at excepted off-campus provider-based departments;
  • slashing payments for office visits;
  • extending this year’s 340B prescription drug discount payments, already cut nearly 30 percent this year, to additional providers; and
  • raising ambulatory surgical center rates and expanding the list of procedures that can be performed in such facilities so they can compete with hospitals for outpatient services.

The proposed regulation also calls for reducing quality reporting requirements and giving providers financial incentives to prescribe non-opioid pain medicine for surgery patients.

The regulation, which would affect provider payments beginning on January 1, 2019, was published in proposed form and will be finalized later in the year.  Stakeholders have until September 24 to submit comments to CMS.  For further information about what CMS has proposed, see this CMS fact sheet outlining the proposed regulation and the 761-page proposed regulation itself.…

Proposal Would Equalize Medicare Physician Payments

All physicians would be paid equally for Medicare-covered office visits under a new proposal published recently by the Centers for Medicare & Medicaid Services.

Under the proposed regulation, Medicare would collapse four levels of patient evaluation and management office visits, eliminate the extensive documentation required to justify the payments physicians seek, and pay one simple rate for office visits.

CMS estimates that reducing the documentation requirements would save every doctor 51 hours a year.

Some critics are concerned that specialists and those caring for especially ill or especially complex patients would be shortchanged by the proposed policy while others fear that the resulting reduction of payment for some physicians might lead them to reduce the number of Medicare patients they are willing to treat, thereby potentially reducing access to care for some Medicare patients.

Currently, Medicare payments for established patients range from $45 to $148, depending on the nature of the office visit.  Under the CMS proposal, physicians would receive a uniform rate for Medicare-covered office visits:  $93.

The proposed policy is budget-neutral.

Learn more about Medicare’s proposed changes in physician reimbursement in this New York Times article.  Go here to see a fact sheet on the proposed Medicare …

Pay Raise Didn’t Lead More Docs to Participate in Medicaid

The temporary rate increase that the Affordable Care Act provided as means of encouraging more doctors to serve Medicaid patients did not work, according to two new studies published in the journal Health Affairs.

According to the studies, the increase in the number of physicians who decided to begin serving Medicaid patients as a result of the fee increase was negligible.

Among the reasons the studies’ authors offer for the lack of growth in the participation of doctors are the limited nature of the pay raise and the documentation required to receive it.

Despite this, the authors note, access to care did improve as a result of the Affordable Care Act’s Medicaid expansion.

Learn more about the studies, their results, and their significance by going here to see the Health Affairs report “No Association Found Between The Medicaid Primary Care Fee Bump And Physician-Reported Participation In Medicaid and here for the study “Physicians’ Participation In Medicaid Increased Only Slightly Following Expansion.”…