RESUMO
Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. The policies included in this final rule provide a new direction for the Shared Savings Program by establishing pathways to success through redesigning the participation options available under the program to encourage ACOs to transition to two-sided models (in which they may share in savings and are accountable for repaying shared losses). These policies are designed to increase savings for the Trust Funds and mitigate losses, reduce gaming opportunities, and promote regulatory flexibility and free-market principles. This final rule also provides new tools to support coordination of care across settings and strengthen beneficiary engagement; and ensure rigorous benchmarking. In this final rule, we also respond to public comments we received on the extreme and uncontrollable circumstances policies for the Shared Savings Program that were used to assess the quality and financial performance of ACOs that were subject to extreme and uncontrollable events, such as Hurricanes Harvey, Irma, and Maria, and the California wildfires, in performance year 2017, including the applicable quality data reporting period for performance year 2017.
Assuntos
Organizações de Assistência Responsáveis/economia , Redução de Custos/economia , Planos de Pagamento por Serviço Prestado/economia , Medicare Part A/economia , Medicare Part B/economia , Medicare/economia , Organizações de Assistência Responsáveis/legislação & jurisprudência , Benchmarking , Redução de Custos/legislação & jurisprudência , Desastres , Planos de Pagamento por Serviço Prestado/tendências , Previsões , Política de Saúde , Humanos , Medicare/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Garantia da Qualidade dos Cuidados de Saúde/legislação & jurisprudência , Estados UnidosRESUMO
This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-forservice beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.
Assuntos
Artroplastia de Quadril/economia , Reabilitação Cardíaca/economia , Assistência Integral à Saúde/economia , Cuidado Periódico , Reembolso de Seguro de Saúde/economia , Medicare Part A/economia , Medicare Part B/economia , Pacotes de Assistência ao Paciente/economia , Reembolso de Incentivo/legislação & jurisprudência , Assistência Integral à Saúde/legislação & jurisprudência , Ponte de Artéria Coronária/economia , Ponte de Artéria Coronária/reabilitação , Humanos , Reembolso de Seguro de Saúde/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Modelos Econômicos , Infarto do Miocárdio/economia , Infarto do Miocárdio/reabilitação , Estados UnidosRESUMO
This document announces a CMS Ruling that states the CMS policies for implementing United States v. Windsor ("Windsor''), in which the Supreme Court held that section 3 of the Defense of Marriage Act (DOMA), enacted in 1996, is unconstitutional. Section 3 of DOMA defined ``marriage'' and "spouse'' as excluding same-sex marriages and same-sex spouses, and effectively precluded the Federal government from recognizing same-sex marriages and spouses.
Assuntos
Homossexualidade , Casamento/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Humanos , Decisões da Suprema Corte , Estados UnidosRESUMO
This final rule implements a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. We believe this model will further our goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures.
Assuntos
Artroplastia de Substituição/economia , Assistência Integral à Saúde/economia , Medicare Part A/economia , Medicare Part B/economia , Sistema de Pagamento Prospectivo/economia , Mecanismo de Reembolso/economia , Assistência Integral à Saúde/legislação & jurisprudência , Economia Hospitalar/legislação & jurisprudência , Humanos , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Sistema de Pagamento Prospectivo/legislação & jurisprudência , Mecanismo de Reembolso/legislação & jurisprudência , Estados UnidosRESUMO
Organizations can prepare for compliance with the two-midnight rule by: Embedding questions from the optional certification form within electronic orders or using the manual form Educating their physicians Empowering their utilization review team
Assuntos
Economia Hospitalar , Fidelidade a Diretrizes , Tempo de Internação , Medicare Part A , Economia Hospitalar/legislação & jurisprudência , Formulário de Reclamação de Seguro/legislação & jurisprudência , Tempo de Internação/economia , Tempo de Internação/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Estados UnidosRESUMO
This notice announces a CMS Ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that the inpatient admission was determined not reasonable and necessary. This revised policy is intended as an interim measure until CMS can finalize a policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward. To that end, elsewhere in this issue of the Federal Register, we published a proposed rule entitled, "Medicare Program; Part B Inpatient Billing in Hospitals,'' to propose a permanent policy that would apply on a prospective basis.
Assuntos
Reembolso de Seguro de Saúde/economia , Medicare Part A/economia , Medicare Part B/economia , Centers for Medicare and Medicaid Services, U.S. , Humanos , Reembolso de Seguro de Saúde/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Estados UnidosRESUMO
Hospital-Issued Notices of Noncoverage (HINN) inform patients that they will be responsible for the bill if they choose to stay in the hospital when the care they are receiving or about to receive will not be covered by Medicare. If hospitals don't give a HINN when services aren't covered by Medicare, they can't bill patients for services later on. CMS gives hospitals the option of using Condition Code 44 to change a patient's status from inpatient to outpatient to correct an unnecessary admission, then collect payment from Medicare for Medicare Part B services. All HINNs must be signed by the patient and a copy included in their file. If the patient refuses to sign, a copy should be placed in the file with a notation of the refusal to sign.
Assuntos
Administração de Caso/economia , Cobertura do Seguro/economia , Medicare Part A/economia , Medicare Part B/economia , Crédito e Cobrança de Pacientes/legislação & jurisprudência , Administração de Caso/normas , Humanos , Pacientes Internados/legislação & jurisprudência , Cobertura do Seguro/legislação & jurisprudência , Reembolso de Seguro de Saúde/economia , Reembolso de Seguro de Saúde/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Pacientes Ambulatoriais/legislação & jurisprudência , Direitos do Paciente/legislação & jurisprudência , Estados UnidosRESUMO
Under the procedures in this final rule, Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B pursuant to sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. After publication of a proposed rule implementing the section 521 changes, additional new statutory requirements for the appeals process were enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). In March 2005, we published an interim final rule with comment period to implement these statutory changes. This final rule responds to comments on the interim final rule regarding changes to these appeal procedures, makes revisions where warranted, establishes the final implementing regulations, and explains how the new procedures will be put into practice.
Assuntos
Revisão da Utilização de Seguros/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Humanos , Estados UnidosRESUMO
This final rule provides a special enrollment period (SEP) for Medicare Part B and premium Part A for certain individuals who are sponsored by prescribed organizations as volunteers outside of the United States and who have health insurance that covers them while outside the United States. Under the SEP provision, qualifying volunteers can delay enrollment in Part B and premium Part A, or terminate such coverage, for the period of service outside of the United States and reenroll without incurring a premium surcharge for late enrollment or reenrollment. This final rule also codifies provisions that require certain beneficiaries to pay an income-related monthly adjustment amount (IRMAA) in addition to the standard Medicare Part B premium, plus any applicable increase for late enrollment or reenrollment. The income-related monthly adjustment amount is to be paid by beneficiaries who have a modified adjusted gross income that exceeds certain threshold amounts. It also represents the amount of decreases in the Medicare Part B premium subsidy, that is, the amount of the Federal government's contribution to the Federal Supplementary Medicare Insurance (SMI) Trust Fund.
Assuntos
Cobertura do Seguro/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Definição da Elegibilidade/legislação & jurisprudência , Humanos , Estados UnidosRESUMO
This final rule updates the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). We are also consolidating the annual July 1 update for payment rates and the October 1 update for Medicare severity long-term care diagnosis-related group (MS-LTC-DRG) weights to a single rulemaking cycle that coincides with the Federal fiscal year (FFY). In addition, we are clarifying various policy issues. This final rule also finalizes the provisions from the Electronic Submission of Cost Reports: Revision to Effective Date of Cost Reporting Period interim final rule with comment period that was published in the May 27, 2005 Federal Register which revises the existing effective date by which all organ procurement organizations (OPOs), rural health clinics (RHCs), Federally qualified health centers (FQHCs), and community mental health centers (CMHCs) are required to submit their Medicare cost reports in a standardized electronic format from cost reporting periods ending on or after December 31, 2004 to cost reporting periods ending on or after March 31, 2005. This final rule does not affect the current cost reporting requirement for hospices and end-stage renal disease (ESRD) facilities. Hospices and ESRD facilities are required to continue to submit cost reports under the Medicare regulations in a standardized electronic format for cost reporting periods ending on or after December 31, 2004.
Assuntos
Economia Hospitalar/legislação & jurisprudência , Assistência de Longa Duração/economia , Medicare Part A/economia , Sistema de Pagamento Prospectivo/economia , Processamento Eletrônico de Dados/economia , Processamento Eletrônico de Dados/legislação & jurisprudência , Humanos , Assistência de Longa Duração/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Sistema de Pagamento Prospectivo/legislação & jurisprudência , Estados UnidosAssuntos
Assistência Ambulatorial/economia , Centers for Medicare and Medicaid Services, U.S./economia , Economia Hospitalar , Serviço Hospitalar de Emergência/economia , Assistência Ambulatorial/legislação & jurisprudência , Assistência Ambulatorial/tendências , Centers for Medicare and Medicaid Services, U.S./legislação & jurisprudência , Serviço Hospitalar de Emergência/normas , Serviço Hospitalar de Emergência/tendências , Humanos , Tempo de Internação/economia , Tempo de Internação/legislação & jurisprudência , Medicare Part A/economia , Medicare Part A/legislação & jurisprudência , Medicare Part B/economia , Medicare Part B/legislação & jurisprudência , Observação , Mecanismo de Reembolso/economia , Mecanismo de Reembolso/legislação & jurisprudência , Mecanismo de Reembolso/tendências , Estados UnidosRESUMO
For once, the final Outpatient Prospective Payment System payment rule issued by the Centers for Medicare & Medicaid Services generally has been praised by emergency medicine observers. There are, however, some new wrinkles you should be aware of, because they could save - or cost - you money: A separate coding category has been established for EDs that are not open 24/7. The payment rates are lower than those in full-time EDs, except for Level 5 visits. Imaging procedures have been grouped into five milies," and multiple tests on the same patient within the same family will be reimbursed as if only a single test was performed. Visits coded for "trauma response with critical care" will be reimbursed at a rate nearly three times as high as last year's rate.
Assuntos
Serviço Hospitalar de Emergência/economia , Tratamento de Emergência/economia , Medicaid/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Sistema de Pagamento Prospectivo/legislação & jurisprudência , Centers for Medicare and Medicaid Services, U.S. , Current Procedural Terminology , Tratamento de Emergência/classificação , Controle de Formulários e Registros , Humanos , Pacientes Ambulatoriais/classificação , Fatores de Tempo , Estados UnidosRESUMO
Skeptics say the federal critical access hospital program is too expensive and that too much of the funding is spent on construction projects. But leaders of CAHs and other proponents say upgrading aging facilities is just one step in bringing new technology and improved services to their rural communities.
Assuntos
Acessibilidade aos Serviços de Saúde , Arquitetura Hospitalar , Hospitais Rurais , Garantia da Qualidade dos Cuidados de Saúde , Acessibilidade aos Serviços de Saúde/economia , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Hospitais Rurais/economia , Hospitais Rurais/legislação & jurisprudência , Hospitais Rurais/normas , Humanos , Kansas , Medicare Part A/legislação & jurisprudência , Montana , Mecanismo de Reembolso/legislação & jurisprudência , Estados UnidosRESUMO
We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs to implement changes arising from our continuing experience with these systems, and to implement certain provisions made by the Deficit Reduction Act of 2005 (Pub. L. 109-171), the Medicare Improvements and Extension Act under Division B, Title I of the Tax Relief and Health Care Act of 2006 (Pub. L. 109-432), and the Pandemic and All Hazards Preparedness Act (Pub. L. 109-417). In addition, in the Addendum to this final rule with comment period, we describe the changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. We also are setting forth the rate of increase limits for certain hospitals and hospital units excluded from the IPPS that are paid on a reasonable cost basis subject to these limits, or that have a portion of a prospective payment system payment based on reasonable cost principles. These changes are applicable to discharges occurring on or after October 1, 2007. In this final rule with comment period, as part of our efforts to further refine the diagnosis related group (DRG) system under the IPPS to better recognize severity of illness among patients, for FY 2008, we are adopting a Medicare Severity DRG (MS DRG) classification system for the IPPS. We are also adopting the structure of the MS-DRG system for the LTCH prospective payment system (referred to as MS-LTC-DRGs) for FY 2008. Among the other policy decisions and changes that we are making, we are making changes related to: limited revisions of the reclassification of cases to MS-DRGs, the relative weights for the MS-LTC-DRGs; applications for new technologies and medical services add-on payments; the wage data, including the occupational mix data, used to compute the FY 2008 wage indices; payments to hospitals for the indirect costs of graduate medical education; submission of hospital quality data; provisions governing the application of sanctions relating to the Emergency Medical Treatment and Labor Act of 1986 (EMTALA); provisions governing the disclosure of physician ownership in hospitals and patient safety measures; and provisions relating to services furnished to beneficiaries in custody of penal authorities.
Assuntos
Medicare Part A/economia , Sistema de Pagamento Prospectivo/economia , Humanos , Medicare Part A/legislação & jurisprudência , Métodos de Controle de Pagamentos , Estados UnidosRESUMO
Hospitals should take these steps to ensure their wage reporting follows Medicare directives and that all information is reported accurately: Check the reasonability of your hospital's wage data; Ensure your hospital's compliance with reporting directives; Consider your hospital demographics; Take corrective action, if needed.
Assuntos
Administração Financeira de Hospitais/métodos , Custos Hospitalares/classificação , Medicare Part A/legislação & jurisprudência , Sistema de Pagamento Prospectivo/legislação & jurisprudência , Métodos de Controle de Pagamentos/métodos , Salários e Benefícios/classificação , Centers for Medicare and Medicaid Services, U.S. , Alocação de Custos , Grupos Diagnósticos Relacionados/economia , Humanos , Estados UnidosRESUMO
Whether the CMS' pay-for-performance plan ever materializes is inconsequential. Executives say quality performance will undoubtedly play a larger role in reimbursement. Opal Reinbold, left, from Palomar Pomerado Health says the system participated in a quality incentive demonstration project because "it prepared us for how this evidence-based practice was going to be applied."
Assuntos
Hospitais/normas , Medicare Part A/normas , Indicadores de Qualidade em Assistência à Saúde/economia , Reembolso de Incentivo , Idoso , Benchmarking , Centers for Medicare and Medicaid Services, U.S. , Revelação , Humanos , Medicare Part A/legislação & jurisprudência , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Estados UnidosRESUMO
As the CMS pushes its "value-based purchasing" model, hospitals are left wondering if they'll get squeezed by a program that will require them to invest big bucks in technology. "People need to ... understand it is a way of transforming Medicare from a passive payer of claims to an active purchaser of higher-quality, more-efficient services," says the CMS' Thomas Valuck.
Assuntos
Sistemas de Informação Hospitalar/economia , Legislação Hospitalar/economia , Sistemas Computadorizados de Registros Médicos/economia , Medicare Part A/legislação & jurisprudência , Qualidade da Assistência à Saúde/economia , Reembolso de Incentivo/legislação & jurisprudência , Centers for Medicare and Medicaid Services, U.S. , Eficiência Organizacional/economia , Pesquisas sobre Atenção à Saúde , Humanos , Doença Iatrogênica , Qualidade da Assistência à Saúde/legislação & jurisprudência , Estados UnidosRESUMO
Navigating the byzantine rules governing disproportionate-share supplements presents hospitals with a special challenge. But some have discovered a little-known secret: By combining two or more hospitals under a single Medicare provider number, some can increase their level of reimbursement. "We had to do something to stem the losses that were occurring in both institutions at that time," says Bob Reh, left.
Assuntos
Medicare Part A/legislação & jurisprudência , Sistemas Multi-Institucionais/organização & administração , Afiliação Institucional/economia , Reembolso Diferenciado/legislação & jurisprudência , Catolicismo , Fidelidade a Diretrizes , Hospitais Psiquiátricos/economia , Hospitais Religiosos/classificação , Hospitais Religiosos/economia , Hospitais Religiosos/organização & administração , Medicaid/estatística & dados numéricos , Medicare Part A/economia , Sistemas Multi-Institucionais/classificação , Sistemas Multi-Institucionais/economia , Reembolso Diferenciado/organização & administração , Cuidados de Saúde não Remunerados/estatística & dados numéricos , Estados UnidosRESUMO
CMS identifies 13 different conditions that may eventually be included. Quality managers take on even greater importance in light of new proposal. Accurate, timely documentation will be a key to optimizing reimbursement.
Assuntos
Infecção Hospitalar/economia , Doença Iatrogênica , Erros Médicos/economia , Medicare Part A/legislação & jurisprudência , Garantia da Qualidade dos Cuidados de Saúde/economia , Reembolso de Incentivo/legislação & jurisprudência , Centers for Medicare and Medicaid Services, U.S. , Infecção Hospitalar/prevenção & controle , Humanos , Doença Iatrogênica/prevenção & controle , Erros Médicos/prevenção & controle , Garantia da Qualidade dos Cuidados de Saúde/legislação & jurisprudência , Estados UnidosRESUMO
Hospitalists and other providers must classify hospitalized patients as inpatient or outpatient, the latter of which includes all observation stays. These orders direct hospital billing and payment, as well as patient out-of-pocket expenses. The Centers for Medicare & Medicaid Services (CMS) audits hospital billing for Medicare beneficiaries, historically through the Recovery Audit program. A recent U.S. Government Accountability Office (GAO) report identified problems in the hospital appeals process of Recovery Audit program audits to which CMS proposed reforms. In the context of the GAO report and CMS's proposed improvements, we conducted a study to describe the time course and process of complex Medicare Part A audits and appeals reaching Level 3 of the 5-level appeals process as of May 1, 2016 at 3 academic medical centers. Of 219 appeals reaching Level 3, 135 had a decision--96 (71.1%) successful for the hospitals. Mean total time since date of service was 1663.3 days, which includes mean days between date of service and audit (560.4) and total days in appeals (891.3). Government contractors were responsible for 70.7% of total appeals time. Overall, government contractors and judges met legislative timeliness deadlines less than half the time (47.7%), with declining compliance at successive levels (discussion, 92.5%; Level 1, 85.4%; Level 2, 38.8%; Level 3, 0%). Most Level 1 and Level 2 decision letters (95.2%) cited time-based (24-hour) criteria for determining inpatient status, despite 70.3% of denied appeals meeting the 24-hour benchmark. These findings suggest that the Medicare appeals system merits process improvement beyond current proposed reforms. Journal of Hospital Medicine 2017;12:251-255.