Centers for Medicare & Medicaid Services

CMS Programs & Information

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Medicare Provider Enrollment & Certification Fee-for-Service Payment Coverage CMS Forms Health Plans Coding Prescription Drug Coverage More...	Regulations & Guidance Manuals Transmittals Quarterly Provider Updates Legislation Health Insurance Portability and Accountability Act (HIPAA) Freedom of Information Act (FOIA) More...
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CHIP Low-Cost Health Insurance National CHIP Policy More...	Outreach & Education Medicare Learning Network Partner with CMS Training More...
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Accountable Care Organizations: Improving Care Coordination for People with Medicare | HealthCare.gov

The Affordable Care Act includes a number of policies to help physicians, hospitals, and other caregivers improve the safety and quality of patient care and make health care more affordable.  By focusing on the needs of patients and linking payments to outcomes, these delivery system reforms will help improve the health of individuals and communities and slow cost growth.

On March 31, 2011, the Department of Health and Human Services (HHS) released proposed new rules to help doctors, hospitals, and other providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs).  ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities.  The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first.  Patient and provider participation in an ACO is purely voluntary.

via healthcare.gov

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Want Medicare To Pay For Home Care? See Your Doctor : Shots - Health Blog : NPR

Starting next month, seniors getting health care in their homes will have to see a doctor to make sure they actually need the service. Otherwise Medicare won't pay.

Sounds logical, right?

Not so, says a coalition of health providers and consumer groups that complains the rule is overly burdensome on seniors and doctors.

 

Home health agencies, doctor and consumer groups say frail, homebound seniors won't be able to get to a doctor's office because of their health status or lack of doctors in rural areas.

They also worry that many doctors are either unaware of the new regulation or won't know how to comply with its documentation requirements that call on physicians to certify they or another health care provider, such as a nurse practitioner, have seen a patient for the specific reason of certifying the need for home health care.

"There is a lot of confusion out there, and patients may lose access to their care," said Nora Super, an AARP lobbyist.

via npr.org

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Governors: Medicaid More A Budget Buster Than Ever : NPR

The federal government and the states have shared the cost of Medicaid, the health insurance program for some 60 million low-income Americans, since it was created in 1965.

They've shared something else almost that long — arguments about who should foot how much of the ever-escalating bill.

"Medicaid cost growth has been a problem for time immemorial," says Alan Weil, executive director of the National Academy for State Health Policy.

But this time, he says, things are different.

For one thing, "the program is bigger, so growth on a larger base is more real dollars that's harder to find."

via npr.org

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Medical News: Operation Targets $225M in Healthcare Fraud - in Public Health & Policy, Medicare from MedPage Today

By Joyce Frieden, News Editor, MedPage Today Published: February 18, 2011

WASHINGTON -- The largest healthcare fraud operation in U.S. history has nabbed suspects accused of collectively defrauding Medicare of more than $225 million, according to officials from the Department of Health and Human Services (HHS) and the Department of Justice (DOJ).

The Medicare Fraud Strike Force charged 111 defendants in nine cities for their alleged participation in Medicare fraud schemes, officials announced on Thursday. Defendants included doctors, nurses, and healthcare company owners and executives, among others.

"With this takedown, we have identified and shut down large-scale fraud schemes operating throughout the country. We have safeguarded precious taxpayer dollars. And we have helped to protect our nation's most essential healthcare programs, Medicare and Medicaid," said Attorney General Eric Holder in a statement. "As [these] arrests prove, we are waging an aggressive fight against healthcare fraud."

More than 700 law enforcement agents from the FBI, the HHS Office of Inspector General, multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies participated in the operation.

via medpagetoday.com

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Hospice Under Medicare | Accepting Hospice Under Medicare | Caring.com

Hospice is a type of care that focuses on relieving pain and other suffering for patients nearing the end of life. To qualify for Medicare-covered hospice care, a patient's treating physician must certify that the patient's illness is likely to be terminal within six months. Once hospice care is begun, there's no more medical treatment for the terminal illness itself.

Given this requirement of a prognosis of only six months to live, and the ending of treatment for the terminal disease, many people resist hospice because it seems like "choosing to die." Many people also fear hospice because they believe that all medical care will end. For several reasons, though, neither one of these fears should stop someone from choosing hospice care.

In the first place, the decision to choose hospice isn't final. If a patient's condition stabilizes or improves, he or she can give up hospice and return to regular Medicare coverage. All it takes is to have a change of mind about giving up treatment, or a doctor's advice to try a new treatment. Or for some reason the patient might not like hospice care and prefer to return to regular Medicare coverage. Patients don't have to give Medicare or the hospice provider a reason -- they can end hospice and return to regular Medicare coverage at any time.

via caring.com

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CMS Initiative Will Link Incentives With Reduced Infections, Readmissions - California Healthline

CMS is planning a "major multi-year financial commitment" involving Medicare, Medicaid and private insurers that aims to curb hospital-acquired infections and readmissions, according to a confidential draft of a CMS document, Inside Health Reform reports.

The so-called National Patient Safety Initiative -- which is being developed by CMS' innovation center -- would link $70 billion in Medicare funds across 10 years to hospitals' ability to achieve new standardized performance metrics. Under the plan, 6% of hospitals' Medicare payments will be contingent on reporting errors and meeting safety measures, with the proportion of payments increasing to 9% by 2015.

By hiring state contractors, CMS will develop measures and monitor progress, and then use results to determine payments.
Medicaid and private insurance plans that chose to participate in initiative also will link a larger portion of payments to patient safety goals, affordability and patient-centered care.

The innovation center also will fund studies that aim to determine how to disseminate best practices data, and support states and health systems that develop networked learning projects, Inside Health Reform reports (Inside Health Reform, 1/26).

via californiahealthline.org

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Doctors who order tests for their own financial gain-KevinMD.com

Doctors who order tests for their own financial gain

6 comments

in Physician practice

by Kohar Jones, MD

“What a shame,” said my eighty eight year old Armenian grandmother, shaking her head with sorrow, and I had to agree. “US officials charge 73 people, mostly Armenians, over a massive fraud against the country’s medical insurance system,” read the BBC headline.

A (mostly) Armenian crime syndicate set up 115 sham clinics in the United States, using real doctors’ names and real patient information, stolen from different systems, to generate false Medicare claims.

Dermatologists examined hearts.  ENT doctors performed pregnancy ultrasounds. (And Medicare beneficiaries, it must be noted, are usually past child-bearing age.)

At some point, $35 million later, someone noticed the discrepancies. How broken is our health care payment system that an interstate, international mafia could steal $35 million from US taxpayers via false Medicare claims? How broken is our health care payment systems than an upstart Armenian mafia would even decide that Medicare should become the new black market, filled with low-hanging fruitful ways to make an easy buck? Whatever gave them the idea?

Perhaps they learned from low-level not-quite-gangsters racketeering their way to easy profits—the real doctors in real storefront clinics seeing real patients, for example, who happen to have high blood pressure– performing EKGs every three months for no good medical reason. Should we call it a scam when real doctors refer real patients to the imaging sites down the road in which the doctors have partial ownership, to perform imaging studies for no strong medical indication? How might this contribute to a “massive fraud” of medical overutilization?

The Armenian Medicare Mafia brings shame to my ethnicity. Doctors who order for their own financial gain, I believe, bring shame to my profession.

Three cheers for shame-free doctoring! Let us give patients what patients need, no less and certainly no more.

Kohar Jones is a family physician who blogs at Progress Notes.

via kevinmd.com

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