WASHINGTON – To help Americans become smarter health care shoppers, Medicare this month started publishing a range of what it pays for 30 common procedures and report how frequently hospitals perform them.

The release of the information fits with the Bush administration’s strategy of moving more people into health savings accounts and high-deductible insurance policies. Such insurance policies require people to bear more of their initial medical expenses.

As more people buy such policies, the administration maintains, cost increases would slow because people would work harder to look for the best deal or decide they don’t really need a medical service after all.

The Medicare data – released June 1 – covers such procedures as heart operations, the implant of heart defibrillators and back and neck operations.

The most common elective surgery paid for by Medicare is the replacement of a hip or knee. The government information shows that those procedures cost an average of $11,761. Medicare paid between $9,992-$12,173, on average.

The Pueblo Chiefton

We continue to remain committed to fixing your Part D issues and we are confident that between your email access to us

(PRIT@cms.hhs.gov) and our participation in the Open Door Forums (ODF) you will not feel abandoned. We are asking that physicians and other health care providers take their Part D issues to their respective ODF calls. If you do not currently participate in the ODFs, you are encouraged to sign up to receive the ODF announcements by going to: http://www.cms.hhs.gov/apps/mailinglists/default.asp?audience=4 or http://www.cms.hhs.gov/opendoorforums/

Again, the last Weekly Part D Providers call will occur on May 30th at 2PM EST. The next Skilled Nursing Facilities/Long-Term Care ODFs is June 6th (1-800-837-1935, Reference ID: 8266876) and the next Physician ODF is June 27th. Both will start at 2pm EST.

Medicare Advantage plans in most cases offer more benefits than traditional Medicare because of higher reimbursement rate increases established under the 2003 Medicare law, in addition to separate subsidies from the federal government for plans that provide prescription drug coverage.

Karen Ignagni, president of America’s Health Insurance Plans, said, “No member of Congress will be able to conclude that plans are overpaid next year.”

Visit AISHealth to read the entire story.

Details on the CMS website.

AISHealth

CMS said recently that hospitals can’t charge Medicare for more than one IV push injection of the same drug during the same patient encounter (HCPCS code C8952C), according to new guidance on billing for drug administration under the outpatient prospective payment system (OPPS). Only multiple injections of different drugs can be charged separately, according to the guidance, which comes in the form of answers to frequently asked questions (FAQs) and was posted on the CMS Web site in mid-February.

This is the latest in a series of OPPS drug administration changes to cause revenue and/or compliance challenges for hospitals.

The Medicare Modernization Update (MMU) was updated on Wednesday, March 1, 2006.

For your convenience, we offer the following topics and links that this office maintains. Please update your bookmarks and favorites accordingly.

Subject area on the web site Link
Medicare Modernization Update (MMU) http://www.cms.hhs.gov/MMAUpdate/
Quarterly Provider Update (QPU) http://www.cms.hhs.gov/QuarterlyProviderUpdates/
CMS Manuals http://www.cms.hhs.gov/Manuals/IOM/list.asp
CMS Transmittals http://www.cms.hhs.gov/Transmittals/
Office of the Attorney Advisor http://www.cms.hhs.gov/OfficeAttorneyAdvisor/
FOIA http://www.cms.hhs.gov/AboutWebsite/04_FOIA.asp
Advisory Committees http://www.cms.hhs.gov/FACA/
SBA Ombudsman Liaison http://www.cms.hhs.gov/CMSSmallBusAdminOmbuds/
CMS Rulings http://www.cms.hhs.gov/Rulings/
eComments http://www.cms.hhs.gov/eRulemaking/
Paperwork Reduction Act (PRA) http://www.cms.hhs.gov/PaperworkReductionActof1995/

In addition, a summary of changes in this month’s issue follows and is also available at the What’s New page under downloads.

Accomplishments

February 3, 2006: MMA Section 721 Voluntary Chronic Care Improvement Under Traditional Fee-For-Services

CMS announced that more than 100, 000 Medicare beneficiaries are now participating in the voluntary Medicare Health Support programs designed to reduce health risks and improve the quality of life of chronically ill patients. Medicare Health Support connects program participants with specially trained health professionals. The eight pilot programs were announced in December 2005. These programs were required by Section 721 of the MMA.

February 6, 2006: MMA Section 303(d) Payment Reform for Covered Outpatient Drugs and Biologicals

CMS issued a manual instruction (CR 4309) that allows payments beginning in 2005 to be based on 106 percent of the average sales price for drugs and biologicals.

February 15, 2006: MMA Section 923 – Medicare Beneficiary Ombudsman

CMS hosted the first Medicare Beneficiary Ombudsman Open Door forum. This forum provided an opportunity for beneficiaries, caregivers, and advocates to discuss issues and concerns regarding ways to improve the systems within the Medicare program. This is required by Section 923 of the MMA.

February 24, 2006: MMA Section 301- Medicare Secondary Payer

CMS published an interim final rule with comment period (CMS-6272-IFC) that clarifies when CMS may make a conditional Medicare payment when other insurance cannot reasonably be expected to make a prompt payment. This is required by MMA Section 301.

What to Expect

Final Rule: MMA Section 936(b)(1) – Requirements for Establishing and Maintaining Medicare Billing Privileges and Provider Enrollment Process

This final rule (CMS-6002-F) is needed as part of the Administration’s anti-fraud and abuse efforts. It gives CMS the authority to enroll and re-enroll providers, with time frames for re-enrollment. The rule also responds to comments received on the proposed rule and implements section 936 of the MMA, which establishes deadlines for action on enrollments and renewals.

Targeted Release: First Quarter of CY 2006

Final Rule: MMA Section 1860D-4 – Physicians’ Referrals to Health Care Entities with Which They Have Financial Relationships- E-Prescribing Exception (CMS-1303-F)

This final rule (CMS-1303-F) creates an exception to the physician self- referral prohibition for certain non-monetary renumeration related to electronic prescribing Section 1860D-4 of the MMA.

Targeted Release: First Quarter of CY 2006

Proposed Rule: MMA Section 302- Competitive Acquisition for Certain Durable Medical Equipment (DME) Prosthetic, Orthotics, and Supplies

This proposed rule would create national competitive bidding that will provide a program for using market forces to set Medicare payment amounts. It will also create incentives for suppliers to provide quality items and services, while at the same time providing Medicare with reasonable prices for payment.

Targeted Release: First Quarter of CY 2006

Proposed Rule: MMA Section 936(b)(3) – Provider Enrollment Process: Right of Appeal–Hearing Rights

This proposed rule (CMS-6003-P2) would extend appeal rights to all suppliers whose enrollment applications for Medicare billing privileges are disallowed by a carrier or whose Medicare billing privileges are revoked, except for those suppliers covered under other existing appeals provisions of CMS regulations. This rule is required by MMA Section 936(b)(3).

Targeted Release: First Quarter of CY 2006

Notice: MMA Section 623 – Payment for Renal Dialysis Services ESRD Advisory Group Announcement of Meeting – March 2006

This notice (CMS-5033-N7) announces a meeting of the ESRD Advisory Group for March 2006.

Targeted Release: First Quarter of CY 2006

Notice: MMA Section 434(a) Frontier Extended Stay Clinic Demonstration

This notice (CMS-5030-N) announces the establishment of a demonstration project under which frontier extended stay clinics in isolated rural areas are treated as providers of items and services under the Medicare program.

Targeted Release: First Quarter of CY 2006

Notice: MMA Section 623 – Demonstration of Bundled Case-Mix Adjusted Payment System for ESRD

This notice (CMS-5034-N) announces a 3-year demonstration to test a fully case-mix adjusted payment system for end stage renal disease (ESRD) services.

Targeted Release: First Quarter of CY 2006

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http://www.cms.hhs.gov/PrescriptionDrugCovContra/01_Overview.asp#TopOfPage