The Centers for Medicare & Medicaid Services (CMS) implemented the Comprehensive Error Rate Testing (CERT) program to measure improper payments in the Medicare Fee-for-Service (FFS) program.  CERT is designed to comply with the Improper Payments Information Act (IPIA) of 2002, as amended by the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012.  IPIA and IPERIA require the heads of Federal agencies, including the Department of Health and Human Services (HHS), to annually review programs it administers to improve agency efforts to reduce and recover improper payments. The Medicare FFS improper payment rate was first measured in 1996. HHS Office of Inspector General (OIG) was responsible for estimating the national Medicare FFS improper payment rate from 1996 through 2002. Based on available resources, OIG reviewed about 6,000 claims.  Currently CERT selects a stratified random sample of approximately 50,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical...

  On October 1, 2014, the United States health care system will undergo a major transformation. We will transition from the decades-old Ninth Edition of the International Classification of Diseases (ICD-9) set of diagnosis and inpatient procedure codes to the Tenth Edition of those code sets—or ICD-10. The Tenth Edition is the version currently used by most developed countries throughout the world. ICD-10 allows for greater specificity and detail in describing a patient’s diagnosis and in classifying inpatient procedures, so reimbursement can better reflect the intensity of the patient’s condition and diagnostic needs. This transition will have a major impact on anyone who uses health care information that contains a diagnosis and/or inpatient procedure code, including hospitals, physicians, other providers, payers, clearinghouses, billing companies, etc. The change will affect all covered entities as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Covered entities are required to adopt...

In May of this year, CMS released information on the average charges for the one hundred most common inpatient services at more than 3,000 hospitals nationwide.  The following month, the Agency published average charges for 30 outpatient procedures.  Are average charges—or payments—for physicians’ professional services next? CMS would like to make physician payment data available, being strongly committed to greater data transparency in general.  Accordingly, it has published a request for public comments, in which it noted that “Since 2010, CMS has released an unprecedented amount of aggregated data in machine-readable form. These data range from previously unpublished statistics on Medicare spending, utilization, and quality at the state, hospital referral region, and county level, to detailed information on the quality performance of hospitals, nursing homes, and other providers.”  The questions on which CMS seeks comments are the following: (1) whether physicians have a privacy interest in information concerning payments they receive...

Legislation to repeal the Sustainable Growth Rate (SGR) formula is emerging in the House of Representatives. On July 31st, the Energy and Commerce Committee voted unanimously to pass H.R. 2810, the Medicare Patient Access and Quality Improvement Act of 2013.   This is the culmination of more than two years of work involving members of both the Energy and Commerce Committee and the House Ways and Means Committee, with feedback from healthcare providers.  The bill now advances to the full Ways and Means Committee;  the Senate Finance Committee is expected to produce its version in the fall.Summary of H.R. 2810In Phase I, “Stabilizing Fee Updates,” the bill would permanently repeal the SGR formula at the end of 2013 and replace it with fixed 0.5 percent updates to the Medicare Fee Schedule for each of the years 2014-2018.  The positive and negative adjustments or incentives available through the PQRS and EHR programs would...

As of August 1st, certain manufacturers of drugs, medical devices and biologicals are tracking their payments to physicians, as required by the Physician Payments Sunshine Act (Sunshine Act), which is part of the Affordable Care Act.  They will report payments and other items of value worth more than $10, as well as certain ownership interests held by physicians and immediate family members, to CMS annually.  Reporting may begin immediately, on a voluntary basis, and must begin by next January.  CMS will post the information, by physician, on a public, searchable website.  CMS published the final regulations implementing the Act on February 1, 2013, and we summarized the rule in an Alert dated February 18th.  We refer readers to that Alert for information on the “applicable manufacturers,” the definition of “covered products,” the form and nature of payments and other “transfers of value” that must be reported and reportable ownership and investment...