Category — Centers for Medicare & Medicaid Services

On November 10, 2010, the Centers for Medicare & Medicaid Services published a Notice in the Federal Register soliciting comments on Accountable Care Organizations.  The Notice specifically requests that interested parties comment on various areas including the following:

• Policies to ensure that solo and small practice providers may participate in ACOs;
• Beneficiary attribution to the ACO;
• Methods to assess beneficiary experience within the ACO;
• Patient-centeredness criteria for assessment of ACOs;
• Quality measures that should be used in the ACO program; and
• Other payment methodologies should be tested through the Centers for Medicare & Medicaid Innovation

Comments must be submitted to the agency by December 3, 2010.

On Thursday, September 23, 2010, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule outlining how it intends to implement several of the new anti-fraud measures called for under PPACA.  According to CMS Administrator Donald Berwick, these measures are part of the government’s efforts to take a proactive approach to fraud prevention, by preventing improper payments before they are made as opposed to seeking to recoup monies improperly paid.  The proposed rule addresses the following measures:

• Screening for new providers and suppliers, including licensure checks, database checks, unannounced site visits, and, for “high risk” entities such as certain home health providers and durable medical equipment suppliers, criminal background checks;
• $500 application fee for institutional providers;
• Six-month moratorium on enrollment where necessary; and
• Suspension of payments pending “credible” allegations of fraud, which could include complaints to CMS, the Department of Health and Human Services Office of Inspector General, or other law enforcement.

Under PPACA, these new measures are scheduled to take effect March 23, 2011, and will apply to new provider and supplier applicants, as well as renewal applicants.  CMS is accepting comments on the proposed rule through November 16, 2010.

On October 5, 2010, the Centers for Medicare & Medicaid Services, the HHS Office of the Inspector General and the Federal Trade Commission (FTC) will co-host a workshop on issues related to Accountable Care Organizations (ACOs). The workshop will address the legal issues presented by various ACO models.

The deadline for comments to be submitted for inclusion in the workshop is September 27, 2010. Instructions on how to submit comments and how to register for the event are provided in the Federal Register Notice.

On July 2, 2010, CMS issued for display its Proposed Rule entitled “Medicare Program; Proposed Changes to the Hospital Outpatient Prospective Payment System and CY 2011 Payment Rates.”  This Proposed Rule, which is expected to be published in the Federal Register on August 3, 2010, would implement key provisions of the health reform legislation that waive Medicare beneficiary cost-sharing for preventive services, reduce the 2011 hospital fee schedule update payment by 0.25 percentage points, and revise certain physician self-referral and graduate medical education program policies as well as proposing updates to payments and policies for certain outpatient department services.  Comments will be accepted by CMS through August 31st, with the Final Rule expected out on November 1st.  The policies contained in the rules are applicable for services furnished on or after January 1, 2011.

The rule can be found here.

The Centers for Medicare & Medicaid Services (CMS) will delay its requirement that Medicare contractors automatically reject claims for health services, durable medical equipment, prosthetics, orthotics, and supplies, and certain other items and services based on orders or certifications from physicians and other eligible professionals who are not enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS).  The Patient Protection and Affordable Care Act  permits only Medicare-enrolled providers to certify or order such items and services under Medicare Part B.  CMS issued an Interim Final Rule in May 2010 that would have allowed Medicare contractors to automatically reject, starting on July 6, 2010, claims based on orders from providers not enrolled in PECOS.  Due to providers’ reports of problems with enrollment, however, CMS will delay the automatic rejection procedures.  Other provisions of the regulations will go into effect on July 6, 2010.  Providers should not see any change in the processing of submitted claims until the automatic rejection procedures are operational.

Click here for the CMS Press Release.

On June 25, 2010, CMS issued for display its Proposed Rule entitled “Medicare Program: Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011.”  This Proposed Rule, which is expected to be published in the Federal Register on July 13, 2010, would implement key provisions of the health reform legislation that expand preventive services for Medicare beneficiaries, improve payments for primary care services, and promote access to health care services in rural areas.  These rules are applicable for services furnished on or after January 1, 2011. Stay tuned for our posting when the official Proposed Rule is published, which will include additional information on the comment period.

CMS released letter to Part D sponsors providing additional guidance regarding the implementation of the Medicare Part D coverage gap discount program, including additional guidance regarding Part D supplemental benefits, application of the discount to Part D employer group waiver plans, Platino plans and subrogation claims.

CMS publishes the draft manufacturer’s coverage gap discount model agreement in the Federal Register. In the preamble to the draft agreement, CMS states that it intends to use the model agreement as a standard agreement and that it will not negotiate amendments with individual manufacturers. The draft model agreement includes provisions defining key terms; outlining the manufacturer’s and CMS’s responsibilities; describing penalties and payment amount dispute resolution; and providing for confidentiality.

CMS released a letter to Part D sponsors providing guidance regarding the implementation of the Medicare Part D coverage gap discount program as it relates to generic drugs.

CMS released a letter to Part D sponsors providing draft guidance regarding the implementation of the Medicare Part D coverage gap discount program.  Although PPACA requires manufacturers to enter into agreements with CMS to provide these discounts in order for their drugs to be covered under Part D, the guidance states that because a conflict in timing–Part D sponsors were required to submit their 2011 formularies by April 2010 and CMS will not release the model manufacturer agreement until July/August–”CMS must allow coverage in 2011 of Part D drugs irrespective of manufacturer discount agreements.”