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Added December 20, 2006
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Added November 20, 2006 Added November 9, 2006
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CMS Demonstration Program Supports Physician-Hospital Collaborations to Improve Quality of Care While Getting Better Value The Centers for Medicare & Medicaid Services (CMS) recently announced a three-year demonstration program to examine whether allowing hospitals to provide financial incentives for physicians to support better care can improve patient outcomes without increasing costs. In the demonstration program, the hospital would be paid its usual inpatient rate for the patient’s care, but would pay to the physician a portion of the savings resulting from quality improvement and efficiency initiatives taken by the physician. Such incentive payments would only be allowed for documented, significant improvements in quality of care and savings in the overall costs of care. The program is known as the Physician-Hospital Collaboration Demonstration (PHCD). To read more click here for CMS Press Release issued today Detailed information about this demonstration is available here. CMS Fee-for-Service Provider Listservs
There are a multitude of listservs that you can subscribe to for up-to-the-minute, accurate news regarding CMS activities. Currently, you are subscribed to the Open Door Forums (ODF) listserv to find out when provider ODFs are scheduled. Did you know that other CMS Electronic Mailing Lists (listservs) can also help you with your business? To get the latest Medicare provider payment regulations and up-to-the minute fee-for-service (FFS) provider news, subscribe to any of the FFS provider-specific mailing lists from the CMS Mailing Lists web page here. For more details on other CMS Mailing Lists that may be helpful, click here for a Fact Sheet on the subject. CMS Posts Data File on Web site That Can Be Used to Model the CMS Methodology for Calculating Proposed Payment Under the Revised Ambulatory Surgical Center (ASC) Payment System The Centers for Medicare & Medicaid Services (CMS) recently posted a data file that can be used to model the CMS methodology for calculating facility payment amounts for services performed in ASCs under the revised payment system proposed for implementation in CY 2008. This file contains the proposed pricing data and historical utilization data that formed the basis for the proposed ASC conversion factor calculation and the alternative ASC conversion factor calculation described in the August 23, 2006 Federal Register ( 42 FR 49506). The file is available online by clicking on the hyperlink titled “Supporting Data Files for CMS-1506-P” in the “Downloads” section located here. This message is a reminder for all providers and physicians who bill Medicare contractors for their services. A brief hold will
be placed on Medicare payments for all claims during the last 9 days
of the Federal fiscal year (September 22 through September 30, 2006).
These payment delays are mandated by section 5203 of the Deficit Reduction
Act of 2005. No interest will be accrued and no late penalties will
be paid to an entity or individual by reason of this one-time hold
on payments. All claims held during this time will be paid on October
2, 2006. Please note, however, that contractors handling large volumes
of paper checks may have some difficulty putting all checks in the
mail in a single day. Consequently, delivery of checks to providers
may take a few extra days. This policy only
applies to claims subject to payment. It does not apply to full denials,
no-pay claims, and other non-claim payments such as periodic interim
payments, home health requests for anticipated payments, and cost
report settlements. For more information, please view the MLN Matters Article here. Physicians, hospitals, and ambulance providers are encouraged to attend one of CMS' outreach and education conferences on the Section 1011 program. Section 1011 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, provides $250 million per year to eligible providers for emergency health services furnished to undocumented and other specified aliens. Since program inception, the Section 1011 program has paid nearly $97 million directly to providers for eligible services. As of August 2006, more than 15,500 providers have enrolled across the United States. CMS will host two provider outreach and education conferences during 2006. The Newark session is also available via teleconference. The conferences will be held:
To register for either conference, visit the TrailBlazer Web site here. For more information on the Section 1011 program or to enroll, providers may contact TrailBlazer Health Enterprises, the national contractor for the program, at (866) 860-1011 or visit their Web site here. FY 2007 Hospital Inpatient Prospective Payment System Final Rule On August 1, 2006, the Centers for Medicare & Medicaid Services (CMS) issued the hospital inpatient prospective payment system (IPPS) final rule for fiscal year (FY) 2007. In this rule, CMS estimates FY 2007 operating and capital payments for hospitals under the Medicare program will increase by $3.4 billion, with payment rates increasing by 3.5 percent on average to all hospitals. Of particular interest are the following changes relating to EMTALA: Emergency Medical Treatment and Labor Act (EMTALA) Technical Advisory Group - Section 945 of the Medicare Modernization Act (MMA) directed the Secretary to convene a Technical Advisory Group (TAG) to review issues related to EMTALA and its implementation. In this rule, CMS is finalizing two revisions to current regulations recommended by the EMTALA TAG. CMS is modifying the current requirement under which only a physician is authorized to determine that a pregnant woman having contractions is in false labor. As recommended by the TAG, CMS will allow hospitals the flexibility to use certified nurse-midwives or other qualified non-physicians acting within their scope of practice, as defined in hospital medical staff bylaws and State law. EMTALA Requirements and Specialty Hospitals - Over the past year, CMS has considered how provisions of EMTALA should apply to specialty hospitals. CMS held a special Open Door Forum to solicit comments on this issue. Additionally, the EMTALA TAG was asked to consider: (1) whether there should be a Federal requirement that all hospitals must have an emergency department; (2) whether EMTALA should be interpreted as meaning that all hospitals (including specialty hospitals) with specialized capabilities or facilities must accept appropriate transfers; and (3) whether specialty hospitals are exacerbating problems with an "on-call" coverage for emergency departments. After taking into account the EMTALA TAG's deliberations and public comments from the EMTALA TAG meeting and the Open Door Forum, CMS does not currently intend to recommend to Congress that all hospitals must have an emergency department; or require, as a condition of Medicare participation, that all hospitals have an emergency department. Furthermore, CMS is not proposing, at this time, any statutory or regulatory changes regarding on-call requirements. However, CMS is requiring that all Medicare-participating hospitals with specialized capabilities, including specialty hospitals, must accept appropriate transfers of unstable individuals, regardless of whether the hospital with specialized capabilities has an emergency department. CMS has, in the past, taken enforcement actions based on its policy that all participating hospitals with specialized capabilities have an EMTALA obligation to accept an appropriate transfer of an unstable individual protected by EMTALA. SOURCE: American Academy of Emergency Medicine NPI: Get It. Share It. Use It.
9/26 NPI Roundtable Transcript Available Now The transcript for the 9/26 NPI Roundtable can be found here on the CMS website.
NPI Training Package: Module 5 Available Now Module 5, Medicare Implementation, provides the NPI requirements specific to Medicare providers. This module will be updated as new requirements are announced or changes are made. Module 5 is now posted here on the CMS NPI Page.
October 25th WEDI Audiocast Registration is open for the WEDI audiocast “NPI 101 – And We’re Off! Getting Up To Speed On NPI” to be held on October 25th from 2-3:30PM ET. Learn more about this audiocast, and how to register, at http://www.wedi.org/npioi/index.shtml on the WEDI website. Please note - there is a cost to participate in this audiocast.
As always, more information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Getting an NPI is free - not having one can be costly. Quarterly Update for Average Sales Price Medicare Part B Drugs
The October 2006 quarterly update for the Average Sales Price (ASP) Medicare Part B Drugs pricing file has been posted on the Centers for Medicare & Medicaid Services (CMS) website at
http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/02_aspfiles.asp News from the Medicare Learning Network
* Below are some recently-released new MLN Matters articles that I thought might be of interest to you:
MM5256 – October 2006 Non-Outpatient Prospective Payment System Outpatient Code Editor (Non-OPPS OCE) Specifications Version 22.0 http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5256.pdf
MM5107 – New Durable Medical Equipment Prosthetic, Orthotics, and Supplies (DMEPOS) Transcutaneous Electrical Nerve Stimulators (TENS) Certificate of Medical Necessity (CMN) for Purchases http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5107.pdf MM5272 – October Update to the 2006 Medicare Physician Fee Schedule (MPFS) Database http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5272.pdf SE0663 – Notifying Medicare Patients about Lifetime Reserve Days (LRDs) http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0663.pdf
SE0674 – Holding of Pancreas Transplant Alone (PA) Claims - Amendment to MLN Matters Article MM5093 http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0674.pdf
MM5276 – Fiscal Year (FY) 2007 Inpatient Prospective Payment System (IPPS), Long Term Care Hospital (LTCH), and Inpatient Psychiatric Facility (IPF) PPS Changes http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5276.pdf
MM5304 – October 2006 Update of the Hospital Outpatient Prospective Payment System (OPPS): Summary of Payment Policy Changes http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5304.pdf
MM5308 – Ending the Contingency Plan for Remittance Advice (RA) and Charging for PC Print, Medicare Remit Easy Print (MREP), and Duplicate RAs http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5308.pdf A Reminder About Medicare Preventive Services Provider Education Products
~ An Overview of Medicare Preventive Services Video ~ The Medicare Learning Network is pleased to announce the availability of the latest provider education resource on Medicare’s coverage of preventive benefits, An Overview of Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals video program. This educational video program provides an overview of preventive services covered by Medicare including the newest preventive services that became effective January 2005 as a result of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. This program provides information on risk factors associated with various preventable diseases and highlights the importance of prevention, detection, and early treatment of disease. The information presented in this program is useful for physicians, providers, suppliers, and other health care professionals involved in providing preventive services to Medicare beneficiaries. The program runs approximately 75 minutes in length.
(CMS has approved this educational video program for .1 International Association for Continuing Education and Training (IACET) CEU for successful completion. This program is appropriate for use by a single individual or may be shown to a large group. To order your DVD or VHS copy of the video program, go to http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5 )
~ Preventive Services Web-Based Training Course ~ The updated Medicare Preventive Services Series: Part 1 Adult Immunizations Web-based training course is now available on the Medicare Learning Network (MLN) Product Ordering Page located at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5 The course provides information about Medicare coverage for the following adult immunizations:
(CMS has approved this web-based training course for .1 IACET CEU for successful completion. The Centers for Medicare & Medicaid Services (CMS) has been reviewed and approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET), 1620 I Street, NW, Suite 615, Washington, DC 20006. The authors of these programs have no conflicts of interest to disclose. These courses were developed without the use of any commercial support.)
~ Flu Season Resources for Health Care Professionals ~ The Medicare Learning Network has developed the 2006 - 2007 Influenza (Flu) Season Educational Products and Resources online PDF document. This online document includes links to flu-related educational products developed by CMS for provider use and links to other resources where clinicians may find useful information and tools for the 2006 - 2007 flu season. The resource document will be updated as new flu information becomes available. The 2006 - 2007 Influenza (Flu) Season Educational Products and Resources online document can be accessed by going to the Downloads section of the MLN Preventive Services Educational Products web page, located at http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp#TopOfPage Frontier Extended Stay Clinic Demonstration QUESTION AND ANSWER CONFERENCE CALL
Monday, October 16, 2006 3:30 to 4:30 PM EDT
The Centers for Medicare & Medicaid Services (CMS) is announcing “The Frontier Extended Stay Clinic Demonstration Project” conference call. This conference call will be a question and answer session to address some of the delivery and financial issues faced by small providers in some of the most remote rural areas. The demonstration is mandated under section 434 of the Medicare Modernization Act and is commonly known as the FESC. The demonstration addresses the needs of seriously or critically ill or injured patients who, due to adverse weather conditions or other reasons, cannot be transferred to acute care referral centers; or, patients who need monitoring and observation for a limited period of time.
The FESC must be located in a community which is at least 75 miles away from the nearest acute care hospital or critical access hospital, or which is inaccessible by public road. The FESC demonstration will last for three years. In addition, the demonstration must be budget neutral.
We are soliciting applications for this project. The application due date is November 24, 2006. For further information, please call Sid Mazumdar at (410) 786-6673.
Conference Participation Instructions
Toll free dial-in number: 1-888-469-0691
Verbal Passcode: DEMO
We look forward to your participation.
On Thursday, October 26, 2006, from 3:00 to 4:00 pm ET, the Centers for Medicare & Medicaid Services (CMS) will hold a briefing to discuss the Medicaid Integrity Program.
Under the provisions of the Deficit Reduction Act (DRA) of 2005, Congress provided resources to CMS to establish the Medicaid Integrity Program (MIP). MIP represents the first national strategy to detect and prevent Medicaid fraud and abuse in the program’s history. Under the leadership of the Center for Medicaid & State Operations (CMSO), the agency will fulfill the mandates of this new program. The Comprehensive Medicaid Integrity Plan, released July 18, 2006, will guide CMSO’s efforts to fulfill this new obligation.
Please join Robb Miller, the Acting Director of the Medicaid Integrity Group on a conference call as he describes the broad responsibilities, guiding principles, and operational functions and strategies of the MIP included in the Plan.
For more information about the Comprehensive Medicaid Integrity Plan, visit: http://www.cms.hhs.gov/DeficitReductionAct/02_CMIP.asp
Call-in information for the call is found below:
DATE: Thursday, October 26, 2006
TIME: 3:00 PM ET
DURATION: 1 Hr.
TOLL FREE #: 1-888-552-9191
PASSCODE: 8866043 New Tools Available to Help with Medicare Prescription Drug Plan Choices for 2007 Medicare has made enhancements to www.medicare.gov that will provide new help for people with Medicare prescription drug coverage who want to consider changing plans, the Centers for Medicare & Medicaid Services (CMS) announced today. The changes will make it easier for beneficiaries to get personalized information about their coverage options and costs for 2007. With the enhancements to the website, beneficiaries who want to find out more about their Medicare drug plan choices can do so before open enrollment begins on November 15.
In addition to new 2007 plan year information, updates to the Medicare Prescription Drug Plan Finder web tool include a cleaner look, increased usability, and reduced page scrolling and includes a Monthly Cost Estimator, a personalized chart illustrating 12 months of expected drug spending for each plan. New features help users compare plans based on price and benefit structure, estimate how their monthly costs may vary over the course of the year, and print clear reports they can refer to later.
For more information on please click here for the CMS Press Release issued today at http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2033
Also for more information, please find the helpful partner tip sheet on the enhancements to the planfinder tool at http://www.cms.hhs.gov/partnerships/downloads/PartnerTipSheet-WebEnhancement11216-P.PDF
CMS also issued a fact sheet on Price Analysis for Drugs for Common Health Problems and Savings in 2007. This report presents updated findings for the drug plans available in 2007, as part of an ongoing analysis by the Centers for Medicare & Medicaid Services (CMS) that has tracked prescription drug savings in the Medicare prescription drug benefit since it began.
For more information on please click here for the CMS Press Release issued today at http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2035
Navigating the Medicare Prescription Drug Plan Finder The Centers for Medicare & Medicaid Services is preparing for the 2007 Prescription Drug Open Enrollment that begins on November 15, 2006. A part of this preparation is launching the Drug Plan Finder tool to help people with Medicare and their families and friends compare plans now and prepare for the start of open enrollment. The Plan Finder tool has been improved based on both consumer testing and suggestions from many partners. A recorded Webinar is now available to help people learn more about this tool before it is scheduled to go live later this week. Click http://www.cms.hhs.gov/center/partner.asp to view Navigating the Medicare Prescription Drug Plan Finder. This short tutorial walks you through the Drug Plan Finder and highlights the changes for 2007. Competitive Acquisition Program (CAP)
Physicians participating in the Medicare Part B Drug Competitive Acquisition Program (CAP) are encouraged to subscribe to the new CMS-CAP-Physicians-L mailing list to receive pertinent and timely information regarding the CAP. Go to http://www.cms.hhs.gov/apps/mailinglists/default.asp?audience=3, then subscribe to the CMS-CAP-Physicians-L mailing list.
As a reminder, the 2007 physician election period for the Medicare Part B Drug Competitive Acquisition Program (CAP) began on October 1, 2006 and concludes on November 15, 2006. The CAP is an alternative to the Average Sales Price (ASP) method of acquiring many drugs and biologicals administered incident to a physician’s services.
CAP physician election is an annual process that provides an opportunity for physicians who are not participating in the CAP to join. Physicians who are currently participating in the CAP must submit an election form in order to continue participation or to terminate participation. Physicians who are not participating in the CAP and do not wish to participate in the CAP at this time are not required to take any action. Completed and signed physician election forms should be returned by mail to your local carrier. Forms must be postmarked on or before November 15, 2006.
Additional information about the CAP is available at http://www.cms.hhs.gov/CompetitiveAcquisforBios/01_overview.asp
Additional information about the 2007 CAP physician election process is at http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp
The list of drugs supplied by the CAP vendor, including NDCs, is in the Downloads section at http://www.cms.hhs.gov/CompetitiveAcquisforBios/15_Approved_Vendor.asp Medicare Finds Billions in Savings to Taxpayers New Contractors to Help Identify Fraud, Waste and Abuse
Through more aggressive local oversight and specially targeted fraud and abuse initiatives, the Centers for Medicare & Medicaid Services (CMS) has saved more than $2 billion in Medicare claims in special projects focusing on infusion therapy and those services provided by Independent Diagnostic Testing Facilities. CMS has made more than 980 Medicare fee-for-service program referrals to law enforcement authorities since October 2004. In addition, CMS is continuing its aggressive local efforts in fee-for-service oversight and helping to identify and combat fraud in the new Medicare prescription drug benefit with the addition of four new Medicare Drug Integrity Contractors (MEDICs). To review the CMS Press Release issued today click here http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2030 CMS is dedicated to reducing fraud and abuse in the Medicare system. When open enrollment begins on November 15, there are a number of steps you can take to help protect the people you counsel from potential scams. Please find the
helpful tip sheet,
Medicare Awards Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Competitive Bidding Implementation Contractor (CBIC) The Centers for Medicare & Medicaid Services (CMS) recently announced award of a contract to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Implementation Contractor (CBIC), Palmetto GBA, LLC. Palmetto is located in Columbia, South Carolina. Awarding this contract is a key step in timely implementation of the Medicare DMEPOS Competitive Bidding Program, which will reduce beneficiary out-of-pocket expenses and save the Medicare program money while ensuring beneficiary access to quality DMEPOS items and services. See full announcement at: http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/05_CBIC_Contractor.asp Medicare Proposes to Improve Care Through Learning from Prescription Drug Data
The Centers for Medicare & Medicaid Services (CMS) seek public input on a proposed regulation on using Medicare Part D claims data for research and quality initiatives that will improve the health care and health of seniors and persons with a disability.
Medicare drug claims would be linked to other Medicare information on patient care such as hospitalizations and physician visits, and made available to researchers and Federal agencies for studies only with appropriate privacy protections and safeguards, as required by the Privacy Act and HIPAA regulations.
The proposed regulation continues the approach of using Medicare data through data use agreements with individual institutions to assess health care for beneficiaries. Medicare data has been used in prior studies to evaluate rates of Medicare spending and spending growth, to assess the impact of drugs and procedures on health outcomes, and to identify the extent to which practice parallels evidence based standards.
The public is invited to comment on the most effective use of the data, including whether CMS should consider additional regulatory limitations for external researchers in order to further guard against the potential misuse of data for non-research commercial purposes, to assure that priority questions are addressed as quickly and effectively as possible, or to ensure that proprietary plan data or confidential beneficiary data are not released.
The proposed rule will appear in the Oct. 17, 2006 Federal Register. Comments will be accepted on the proposed rule until December 18th , 2006.
Please click here to read the CMS Press Release at http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2036 An Updated Link from The Medicare Learning Network
We recently sent you notice about a new MLN product, “Understanding the Medicare Learning Network Fact Sheet.” In that notice, we listed the incorrect web link to get to the fact sheet. The correct link is
http://www.cms.hhs.gov/MLNproducts/downloads/Fact_Sheet_Sept2006.pdf Medicare & You 2007 Handbook Now Available Online
The general “Medicare & You 2007” handbook is now available at http://www.Medicare.gov/publications/pubs/pdf/10050.pdf to help people with Medicare review their coverage options and prepare to enroll in a new plan if they choose. This official government handbook contains important information about what’s new, health plans, prescription drug plans, and rights for people with Medicare. You can find 48 geographic-specific versions of the handbook on the website listed below, with drug and health plan comparison charts for particular states or regions. These are the versions that will be mailed to people with Medicare in the next few weeks. The Centers for Medicare & Medicaid Services is encouraging people with Medicare to review their current coverage this fall to see if it will meet their needs in 2007. Now is the time to help people think about the cost, coverage, and customer service that they need in a plan to get the most out of their Medicare. The state specific books are online at http://www.cms.hhs.gov/Partnerships/PFP/list.asp#TopOfPage. Beneficiaries will receive their Handbooks by the end of October. NPI: Get It. Share It. Use It.
October 23rd means only 7 months remain until the National Provider Identifier (NPI) compliance date. Over 1,300,000 NPIs have been issued so far --- do you have your NPI yet?
Act Now! Don’t procrastinate; getting your NPI is only the first step in preparing for the compliance date. You should allow time to share your NPI with payers and other trading partners, update your referral lists, as well as modify and test computer systems.
Resources for Commonly Asked Questions CMS has compiled a list of resources that will help to answer many questions on NPI. Visit http://www.cms.hhs.gov/NationalProvIdentStand/07_Questions.asp#TopOfPage to view this resource. Additionally, CMS continues to build its database of Frequently Asked Questions (FAQs) on NPI. Recently, an FAQ on Electronic File Transfer (EFT) of payments from health plans to health care providers was added. You can view all existing NPI FAQs here on the CMS website.
Participate in the Latest WEDI Industry Survey WEDI is currently conducting a survey to measure the next stage of NPI readiness across the healthcare industry. To access the survey, go to: http://www.surveymonkey.com/s.asp?u=415952639752 on the web. Also note, this survey will only be open for a short time. The last day to participate is October 31, 2006.
***Special Information for Medicare Providers***
Billing Medicare Medicare is testing the new software that has been developed to use the National Provider Identifier (NPI) in the existing Medicare fee-for-service claims processing systems. Providers have until May 23, 2007, before they are required to submit claims with only an NPI.
Until testing is complete within the Medicare processing systems, Medicare urges providers to continue submitting Medicare fee-for-service claims in one of two ways:
Until testing of the new software that uses the NPI in the Medicare systems is complete and until further notice from Medicare, the following may occur if you submit Medicare claims with only an NPI:
Required Use of NPI on Medicare Paper Claim Forms Medicare will require the NPI on its paper claim forms. A variety of MLN Matters articles are available on this topic at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/MMArticles_npi.pdf on the CMS NPI web page.
How to Share Your NPI with Medicare Medicare providers may share their NPIs with Medicare in three different ways:
Still not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Getting an NPI is free - not having one can be costly. Urgent Medicare CAP Claims Message
If your company provides services to physicians who participate in the Medicare Part B Drug Competitive Acquisition Program (CAP), please read the CAP billing information in MLN Matters Article SE0672 for information on how to submit Medicare Part B Drug CAP claims correctly.
MLN Matters Article SE0672, Clarification of Requirements for the Competitive Acquisition Program (CAP) for Part B Drugs and Biologicals was released on 9/29/06 and can be located at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0672.pdf on the CMS website.
The CAP is an alternative to the Average Sales Price (ASP) method of acquiring many Part B drugs and biologicals administered incident to a physician’s services. More information on the CAP is located at http://www.cms.hhs.gov/CompetitiveAcquisforBios/ on the CMS website. New From the Medicare Learning Network The updated Guidelines for Teaching Physicians, Interns, and Residents Fact Sheet is now available in print format from the Centers for Medicare & Medicaid Services Medicare Learning Network. To place your order, visit www.cms.hhs.gov/mlngeninfo, scroll down to “Related Links Inside CMS,” and select “MLN Product Ordering Page.”
NOW AVAILABLE! The new Medicare Fraud & Abuse fact sheet directs Medicare providers to a number of sources of information pertaining to Medicare fraud and abuse and helps them understand what to do if they suspect or become aware of incidents of potential Medicare fraud or abuse. This fact sheet is now available in downloadable format at www.cms.hhs.gov/MLNProducts/downloads/081606_Medicare_Fraud_and_Abuse_brochure.pdf on the MLN products web page. Hard copies can be ordered at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5 through the MLN Product Ordering Page on the CMS website.
New Web-based Training Course for Institutional Providers! Understanding the Remittance Advice for Institutional Providers Web-based training (WBT) course is now available through the Medicare Learning Network. This WBT course is designed to provide institutional providers and their billing staff with general remittance advice (RA) information. This course provides instructions to help institutional providers interpret the RA received from Medicare and reconcile it against submitted claims. Course participants will receive guidance on how to read Electronic Remittance Advices (ERAs) and Standard Paper Remittance Advices (SPRs), as well as information regarding balancing an RA. The course also provides an overview of software that Medicare provides free to providers for viewing ERAs. The course takes approximately 90 minutes to complete and participants may receive .2 CEUs for successful completion. To register to take this WBT course participants can go to the Medicare Learning Network’s Product Ordering Page located at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5 and click on the course title. DHHS “Own Your Future” Campaign
The Centers for Medicare & Medicaid Services, the Assistant Secretary for Planning and Evaluation, and the Administration on Aging have just announced partnerships with six new states (Georgia, Massachusetts, Michigan, Nebraska, South Dakota, and Texas) that will be participating in the Department of Health and Human Services (HHS) “Own Your Future” campaign, an aggressive education and outreach effort designed to promote long-term care planning among state residents.
Campaign activities over the next year will include direct mail solicitations from the governors of participating states; dissemination of an “Own Your Future” Planning Kit; and development of a National Clearinghouse for Long-Term Care Information website. The goal of the Campaign is to increase awareness about long-term care and encourage Americans to take an active role in planning ahead for their future long-term care needs.
The new federal-state partnerships represent the next round of the education campaign, which HHS has been working on with the National Governors Association (NGA) for the last three years with nine other states. Consumer response to the campaign to date has exceeded expectations, both in terms of consumer interest and in the number of residents who have initiated long-term care planning actions.
Medicare providers can view a recent MLN Matters article on this topic at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0671.pdf on the web. To find materials associated with the “Own Your Future” campaign, including a partner tip sheet and a press release, visit http://www.cms.hhs.gov/center/longtermcare.asp on the web.
To order or download the “Own Your Future” Planning Kit, visit the www.aoa.gov/ownyourfuture website. This website also contains a wealth of information about the “Own Your Future” Long-Term Care Awareness Campaign. New CMS Initiative to Pay Physicians for Care Provided to Patients with Chronic Conditions
New Demonstration Program
Tests Financial Incentives for
The Centers for Medicare & Medicaid Services (CMS) announced a new initiative to pay physicians for the quality of the care they provide to seniors and disabled beneficiaries with chronic conditions, reflecting the Administration’s ongoing commitment to reward innovative approaches to get better patient outcomes for the health dollar.
We intend to provide better financial support for quality care,” said CMS Administrator Mark B. McClellan, “Through this demonstration and the rest of our set of value-based payment demonstrations, we are finding better approaches to doing that than ever before. This is another important step toward paying for what we really want: better care at a lower cost, not simply the amount of care provided.”
As the next step in its efforts to make higher payments for better quality, CMS today announced the implementation of a new demonstration aimed at physicians practicing in solo or small to medium sized group practices. CMS has already implemented several other “pay-for- performance” demonstrations, including the Premier Hospital Quality Incentives Demonstration which involves acute care hospitals and the Physician Group Practice demonstration which involves 10 large multi-specialty group practices across the country.
The Medicare Care Management Performance (MCMP) Demonstration was authorized under section 649 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). It will be implemented in four states: Arkansas, California, Massachusetts, and Utah in 2007.
For more information about this demonstration, go to: http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?filterType=keyword&filter Value=medicare%20care&filterByDID=0&sortByDID=3&sortOrder=ascending&itemID=CMS057286.
To view the entire press release, go to: http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2038 . Flu Season is upon us! Begin now to take advantage of each office visit as an opportunity to talk with your patients about the flu virus and their risks for complications associated with the flu, and encourage them to get their flu shot. And don’t forget, health care professionals need to protect themselves also. Get Your Flu Shot. – Protect yourself, your patients, and your family and friends. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of adult immunizations and educational resources, go to (http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf) Payment Rates and Policies for 2007 New Payment Rates will Encourage Increased Physician/Patient Communication Starting next year, the Medicare program will pay physicians more for the time they spend talking with Medicare beneficiaries about their health care and will pay for a broader range of preventive services. The changes, which will become effective January 1, 2007, are included in the Medicare Physician Fee Schedule (MPFS) final rule released today by the Centers for Medicare & Medicaid Services (CMS). CMS projects that it will pay approximately $61.5 billion to over 900,000 physicians and other health care professionals in 2007 as a result of the payment rates and policies adopted in this rule. This new spending figure reflects current law requirements to reduce payment by 5 percent to account for the combined growth in volume and intensity of physician services. To view CMS-1321-FC and CMS-1317-F, go to http://www.cms.hhs.gov/PhysicianFeeSched/PFSFRN/itemdetail.asp?filterType=keyword&filterValue =1321&filterByDID=0&sortByDID=4&sortOrder=ascending&itemID=CMS1188377. To view the entire press release, go to http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2044. Hospital Outpatient Prospective Payment System and CY 2007 Payment Rates; CY 2007 Update to the Ambulatory Surgical Center Covered Procedures List; Medicare Administrative Contractors; and Reporting Hospital Quality Data for FY 2008 Inpatient The Centers for Medicare & Medicaid Services (CMS) yesterday issued a final rule, in part, for Medicare payment for Ambulatory Surgical Center services in calendar year (CY) 2007 titled: Medicare Program; Hospital Outpatient Prospective Payment System and CY 2007 Payment Rates; CY 2007 Update to the Ambulatory Surgical Center Covered Procedures List; Medicare Administrative Contractors; and Reporting Hospital Quality Data for FY 2008 Inpatient Prospective Payment System Annual Payment Update Program--HCAHPS Survey, SCIP, and Mortality; CMS-1506-FC; CMS-4125-F
The link to CMS-1506-FC is available online in the “Spotlights” section at: http://www.cms.hhs.gov/center/asc.asp. Or, you can go to http://www.cms.hhs.gov/ASCPayment/06a_CMS1506fc.asp . To view the press release, go to http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2042. Home Health Prospective Payment System Rate Update for Calendar Year 2007 and Deficit Reduction Act of 2005 Changes to Medicare Payment for Oxygen Equipment and Capped Rental Durable Medical Equipment” Today the Centers for Medicare & Medicaid Services (CMS) announced a 3.3 percent increase in Medicare payment rates to home health agencies for calendar year 2007. The home health prospective payment system (HH PPS) annual update will bring an estimated extra $410 million in wage adjusted payments to home health agencies next year. As part of this final rule, CMS is implementing pay-for-reporting provisions of the Deficit Reduction Act of 2005. In addition, CMS is implementing changes to Medicare payment for oxygen equipment and capped rental durable medical equipment due to the Deficit Reduction Act of 2005. The final rule changes how Medicare will pay for oxygen and oxygen equipment, as well as capped rental items, such as wheelchairs and hospital beds, and establishes new protections for beneficiaries who require these items. Oxygen and oxygen equipment and capped rental items are paid under the Medicare Part B durable medical equipment (DME) benefit. These changes will save beneficiaries and taxpayers money, while ensuring that beneficiaries get the items and services they need.
To view the regulation (CMS-1304-F), go to http://www.cms.hhs.gov/HomeHealthPPS/downloads/CMS1304Fdisplay.pdf on the CMS website. To view the press release, go to http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2040.
For a one-stop resource on Home Health information, go to http://www.cms.hhs.gov/center/hha.asp. For a one-stop resource on DME information, go to http://www.cms.hhs.gov/center/dme.asp. The Centers for Medicare & Medicaid Services is forwarding the following message from the Social Security Administration to inform you of this new initiative. Any questions should be directed to the contacts listed below. Social Security Administration Electronic Records Express “Embracing Technology to Deliver Benefits”
Technology is helping the Social Security Administration transform the disability decision-making process which will mean better service for Social Security disability benefit applicants across the country. You can help ensure more accurate and timely decisions for your patients by sharing your medical records electronically with Social Security and its partner agencies. This will also save you time and money copying and mailing medical records. If you would like to begin using the Social Security Administration’s secure website to send medical records or obtain more information about the options available for submitting records electronically, visit http://www.socialsecurity.gov/ere/, send an e-mail to electronic-records-express@ssa.gov or call 1-866-691-3061.
DECEMBER 13, 2006: MEDICARE COVERAGE ADVISORY COMMITTEE MEETING ON CLINICAL TRIAL POLICY
The Centers for Medicare & Medicaid Services (CMS) will convene its Medicare Coverage Advisory Committee (MCAC) on December 13, 2006 at the CMS Headquarters in Baltimore, Maryland. The purpose of this meeting is to advise CMS on changes under consideration as the Agency re-visits Medicare’s Clinical Trial Policy.
Medicare has covered certain items or services provided in the context of clinical trials since 2000. The implementation of the Clinical Trial Policy has allowed CMS to increase access to cutting-edge medical technologies for Medicare beneficiaries who participate in clinical research studies. The Agency is seeking to update the policy to address some of the changes to the clinical research landscape that have occurred since 2000, as well as to answer some of the questions the beneficiary and provider communities have had in delivering items and services to Medicare study participants.
The Committee will call on the expertise of clinical research and methodological experts from private industry, academia, and other Federal agencies to review the standards Medicare uses to determine which studies should be eligible for Medicare coverage; recommend processes through which a trial is determined to meet these standards; and advise on the services that should be covered for the Medicare beneficiaries enrolled in these trials.
After the Committee meets in December, CMS will issue a proposed decision memorandum no later than April 2007, followed by a 30-day public comment period, and with a final policy expected 60 days after the close of the comment period.
For more information on the Clinical Trial Policy, including details about the December meeting, please visit the Coverage web site at http://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=186. New from the Medicare Learning Network! The Hospice Payment System Fact Sheet, which is the second in the Medicare Learning Network’s (MLN) series of payment fact sheets, is now available in downloadable format on the MLN Products Page. To access the fact sheet, visit http://www.cms.hhs.gov/MLNProducts/downloads/HospicePaymtSysfctsht.pdf. Print versions of the fact sheet will be available from the MLN in approximately six weeks (just in time for that perfect holiday gift!). NPI: Get It. Share It. Use It.
Over 1.4M National Provider Identifiers (NPIs) have been issued. Do you have yours?
Think you don’t need an NPI? Think again, and be sure. If you are a health care provider who bills for services, you probably do need an NPI. If you bill Medicare for services, you definitely do!
The bad news is that as of November 23rd, only six months remain until the NPI compliance date. The implementation of the NPI is a complex process that will impact all business functions of your practice, office or institution including: billing, reporting and payment. This is why providers are urged to get, share, and use their NPI NOW to avoid a disruption in cash flow.
If you don’t have an NPI, get one. If you have one, start the testing process with your health plan and use it on your claims and other transactions.
CMS continues to urge providers to include legacy identifiers on their NPI applications. This information is critical for health plans and health care clearinghouses in the development of crosswalks to aid in the transition to the NPI.
Key NPI Facts The Centers for Medicare and Medicaid Services (CMS) along with the Workgroup for Electronic Data Interchange (WEDI) and other industry health plans would like to remind providers of the following key NPI facts:
Sharing NPIs Once providers have received their NPIs, they should share their NPIs with other providers with whom they do business, and with health plans that request it. In fact, as outlined in current regulation, all providers must share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes -- including designation of ordering or referring physician. Providers should also consider letting health plans, or institutions for whom they work, share their numbers for them.
NPIs are FREE! Health care providers should know that getting an NPI is free. You do not need to pay an outside source to obtain your NPI for you. All CMS education on the NPI is also free. CMS does not charge for its education or materials.
NPI Questions CMS continues to update our Frequently Asked Questions (FAQs) to answer many of the NPI questions we receive on a daily basis. Visit the following link to view all NPI FAQs: Providers should remember that the NPI Enumerator can only answer/address the following types of questions/issues:
Providers needing this type of assistance may contact the enumerator at 1-800-465-3203.
Upcoming WEDI Events WEDI has several NPI events scheduled in the upcoming month. Visit http://www.wedi.org/npioi/index.shtml to learn more about these events. Please note that there is a charge to participate in WEDI events.
Important Information for Medicare Providers
Communicating NPIs to Medicare Medicare providers should know that there is no “special process” or need to call to communicate NPIs to the Medicare program. NPIs can be shared with the Medicare program in three different ways, as part of the following standard procedures:
Still Confused? Not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203.
Getting an NPI is free - not having one can be costly. National Influenza Vaccination Week
November 27 to December 3 is National Influenza Vaccination Week. The Centers for Disease Control and Prevention has designated the week after Thanksgiving as National Influenza Vaccination Week. This week long event is designed to raise awareness of the importance of continuing influenza (flu) vaccination, as well as foster greater use of flu vaccine through the months of November, December and beyond. Since flu activity typically does not peak until February or later, November and December still provide good opportunities to get vaccinated. The Centers for Medicare & Medicaid Services (CMS) invites you to join in this event as an opportunity to ensure that people with Medicare get their flu shot. The flu vaccine is the best way to protect your patients from the flu. Though Medicare provides coverage for the flu vaccine and its administration, there are still many beneficiaries who don’t take advantage of this benefit. If you have Medicare patients who have not yet received their flu shot, we ask that you encourage these patients to protect themselves from the risk and severity of the flu virus. – And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s website: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf IPPS New Technology Applications
CMS is extending the deadline for FY 2008 inpatient prospective payment system (IPPS) New Technology Applications to December 30, 2006. Complete information (criteria to qualify, application information, etc…) on the IPPS new medical services and technology add on payment process is available at http://www.cms.hhs.gov/AcuteInpatientPPS/08_newtech.asp on the CMS Website. The Medicare Learning Network (MLN) is pleased to announce that the Hospital Outpatient Prospective Payment System Fact Sheet is now available in downloadable format on the MLN Products Web Page at www.cms.hhs.gov/MLNProducts/downloads/HospitalOutpaysysfctsht.pdf. This fact sheet provides general information about the Hospital Outpatient Prospective Payment System, ambulatory payment classifications, and how payment rates are set. Print versions of the fact sheet will be available from the MLN in approximately six weeks. Medicare Prescription Drug Coverage The Centers for Medicare & Medicaid Services (CMS) announced the start of the 2007 open enrollment period for Medicare health and drug coverage. Generally, Medicare beneficiaries have six weeks to change or add coverage to their current Medicare health and prescription drug plans during the annual Open Enrollment Period, which runs from November 15 through December 31, 2006. In addition, CMS released on the Medicare Prescription Drug Finder an additional tool to assist beneficiaries in comparing plans and choosing one that meets their needs. Plans are rated on how well they perform in the following five different categories:
Please find attached the CMS News released issued on this topic, as well as “How to Access Plan Performance Information” and “Making the Most of Your Medicare Drug Plan Options.” Medicare Publishes New Hospital Requirements History and Physical Examinations, Authentication of Verbal Orders, Securing Medications, and Postanesthesia Evaluations Addressed
The Centers for Medicare & Medicaid Services (CMS) recently published a final rule |
“Information
Partners Can Use On Preventing Fraud.” This tip sheet describes
how to safeguard personal information, give the rules that plans must
follow for marketing activities, what to do if you suspect fraud,
and lists other resources.