News for Anesthesia Groups: ACA Repeal, ADRs, Opioid Prescribing and Medicare ID Cards
SUMMARY
This eAlert offers news briefs of interest to anesthesia practices on: the Republicans' latest attempt to repeal and replace the Affordable Care Act; the new Medicare ID number initiative and what practices should be doing now to prepare; a primer on additional documentation requests (ADRs) and why a timely response is essential; and connections between early opioid prescribing patterns and the risk of opioid dependence.
Graham-Cassidy Heads to Senate Floor
The current Republican proposal to repeal the Affordable Care Act (ACA), known as Graham-Cassidy for its lead sponsors (Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana), could come up for a Senate vote this week. Essentially, the bill would change or eliminate such major provisions of the ACA as subsidized insurance coverage and Medicaid expansion, and give federal block grants to states to use in large part as they choose.
The budget reconciliation process that would allow the ACA to be overhauled by a simple majority expires this Saturday, September 30, giving the Republicans possibly their last chance to repeal the landmark legislation. As this eAlert is being published, two Republican Senators, Rand Paul of Kentucky and John McCain of Arizona, oppose the bill, and two (Senators Susan Collins of Maine and Lisa Murkowski of Alaska) are undecided. However, they voted against the last ACA repeal effort, and if only one of the undecideds votes against Graham-Cassidy, the bill would not pass.
In brief, the Graham-Cassidy bill proposes to:
Eliminate federal funding for Medicaid and reallocate it in a lump sum for states.
Eliminate subsidy payments in 2020 to insurers to cover out-of-pocket medical costs for low-income participants in the ACA's insurance exchanges. States would be able to use a portion of their block grants to fund similar cost-sharing subsidies.
Eliminate in 2020 the federal tax credits for low- and middle-income Americans that helped cover insurance premiums under the ACA. States could choose to use block grants to fund the tax credits.
Remove both the individual and employer health insurance mandates.
Repeal the tax on medical device manufacturers while leaving most of the other ACA taxes intact.
Allow states to apply for waivers of the ACA's 10 essential health benefits, including maternity care.
Allow states to apply for waivers to allow insurers to charge different premiums based on an individual's age.
In a letter to the Senate, the American Medical Association said the amendment "would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets and decrease access to affordable coverage and care." Stating that "coverage could be at risk for tens of millions of Americans," Rick Pollack, president and CEO of the American Hospital Association, called for "senators to work in a bipartisan manner to address the challenges facing our health system. This proposal would erode key protections for patients and consumers and does nothing to stabilize the insurance market now or in the long term."
America's Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association (BCBS) also oppose the bill, saying the legislation would create an unstable market that would harm insurers as well as patients, "making coverage more expensive and jeopardizing Americans' choice of health plans."
The Center on Budget and Policy Priorities estimates the bill would "cut $239 billion from current spending levels, and then divide the remaining funding among states according to a complicated block-grant scheme that results in gains for some states at the expense of deep losses in other states," Sara R. Collins of The Commonwealth Fund said in an article. Although the Congressional Budget Office has not yet released its analysis, CBO analyses of earlier Republican bills indicated the removal of certain key ACA provisions would lead to a loss of health insurance coverage for 32 million people. A George Washington University study estimated a repeal of the ACA's coverage expansions would also lead to a loss of 2.6 million jobs, Ms. Collins reported.
However, Vice President Mike Pence said the bill's grounding in federalism (shared governing power between national and state governments) would allow "states to innovate and create new ideas and new products that will better serve all of their citizens by block-granting resources to the states instead of creating a one-size-fits-all program in Washington, D.C."
(Please note that this eAlert is for your information only and does not represent a position either for or against the proposal.)
Get Ready for New Medicare IDs
The Centers for Medicare and Medicaid Services' (CMS's) New Medicare Card project, previously known as the Social Security Number Removal Initiative (SSNRI), will issue a new Medicare card containing a new Medicare Beneficiary Identifier (MBI) to beneficiaries beginning in April 2018. On its website, CMS has already replaced references to the old social security number-based Health Insurance Claim Number (HICN) with the new name, the Medicare I.D.
The agency will begin mailing new cards with the MBI to all Medicare beneficiaries beginning in April 2018. The cards will be valid as soon as they are received. However, during a transition period (April 1, 2018 – December 31, 2019) both HICNs and MBIs will be accepted in the Medicare ID field on electronic and paper claims. Your systems (and those of your billing vendor) will need to be ready to accept the new MBI by April 2018.
Starting October 2018, only the MBI will appear on claims communications and payments from CMS. However, providers will not be required to bill with the MBI until the end of the transition period. CMS will provide an online MBI lookup tool to assist during the transition.
The agency will not provide the same end-to-end testing that it has done with other initiatives, such as the shift to ICD-10, because of this project's long (21-month) transition period.
We encourage you to use the next few months to educate yourself, your billing and other office staff, and your Medicare patients about the new identification numbers. Mandated by the Medicare and CHIP Reauthorization Act of 2015 (MACRA), the new system is designed to reduce identity theft among older Americans.
CMS recommends that providers and/or office staff:
Review the CMS provider website and signup for the weekly MLN Connects newsletter
Attend the CMS quarterly calls as announced in the MLN Connects newsletter
Verify Medicare patients' addresses, and notify patients if there is a need to update their address with the social security office
Test your system changes and make sure your billing and registration staff is ready.
ABC clients: ABC has implemented all of the necessary systems changes and is prepared for the transition to the new Medicare identification numbers. If you have any questions on what you should be doing, please contact your account manager.
ADRs: What You Should Know
After receiving a claim submission, Medicare Administrative Contractors (MACs) and other government reviewers can issue an additional documentation request letter (ADR). The purpose of an ADR is to help CMS ensure the correct use of Medicare resources.
An ADR isn't a denial; it's a request for more information. Don't ignore an ADR if you receive one. Educate your billing and office staff about them and make sure they know to forward these documents to the appropriate staff or clinicians for a prompt and thorough response.
If you don't respond by the deadline indicated in the letter, the claim could be denied. In fact, CGS Administrators, LLC, a MAC, encourages providers to respond as quickly as possible. If your response is received too close to the deadline, a non-response denial may be issued, and the claim may need to be reopened once the response is received. Sending your response early reduces the chances of an unnecessary delay in deciding whether your claim should be paid.
Any Medicare claim may be selected for an ADR, either pre- or post-payment. For example, this can include a claim that falls within the parameters of a MAC's pre-payment audit that has revealed specific troublespots indicating potential for inappropriate payments. MACs aren't the only contractors who can issue an ADR. You could receive one from a Zone Program Integrity Contractor (ZPIC), Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC) or Comprehensive Error Rate Testing (CERT) Contractor. Of course, your group's response to the ADR will play a major role in the contractor's determination.
ABC clients: If your practice receives an ADR, your account manager will be glad to assist you with a timely response.
Prescribing Patterns and Opioid Abuse
Addiction experts report that the opioid epidemic is shifting more to the illicit trade of heroin and fentanyl. However, that doesn't diminish the central role of prescription painkillers in the crisis.
The Centers for Disease Control and Prevention's March 17, 2017 Morbidity and Mortality Weekly Report offers new insight about how early opioid prescribing practices might help pain specialists and other physicians protect patients from dependence.
The study found the highest probability of continued opioid use at one and three years among patients who started on a long-acting opioid followed by starting on tramadol; that authorization of a second opioid prescription doubles the likelihood of continued opioid use at one year; and that the risk of chronic opioid use increases with each additional day of opioid supplied.
The authors suggest that clinicians might use these findings to modify their opioid prescribing practices in ways that could reduce dependence risk, and talk with patients early on in the opioid prescribing process about the dangers of long-term opioid use.
We want to hear from you. Do you have a topic you would like to see covered in an ABC eAlert? Please send your suggestions to info@anesthesiallc.com.
With best wishes,
Tony Mira
President and CEO