States Now Have Until January 1, 2014 – or Beyond HHS Relaxes Health Plan Exchange Implementation Deadline

States Now Have Until January 1, 2014 –
or Beyond
 
HHS Relaxes Health Plan Exchange Implementation Deadline
 
State Health Insurance Exchange implementation rules announced in June by HHS Secretary Kathleen Sebelius include a cooling carrot for state leaders, who were sweating in summer heat over a January 1, 2013 deadline to have their exchanges up and running.
 
Now, in one of the worst heat waves in years, administrators might perspire a bit less.  HHS is proposing to relax the previously strict 2013 date, allowing states conditional approval to extend their deadline to January 1, 2014 or beyond provided that the state demonstrates "advanced preparation" by that date.
 
The proposal rules reflect the Administration’s consultation with state leaders, consumer groups, employers and insurers.  HHS is taking public comment on the proposed rules through August 25.  So far, though, not everyone is satisfied.
 
The new rules set minimum standards for setting up a Small Business Health Options Program (SHOP), performing basic functions of the exchange, certifying health plans for participation in the exchange, and ensuring stable premiums.
 
The Administration offers to partner with states to make exchange development and operations more efficient.  It would assist with business functions such as eligibility and enrollment, financial management, and health plan management. However, accepting federal help is not mandatory.  States can choose to develop their exchanges themselves, as long as they meet the basic requirements of the Affordable Care Act (ACA).
 
After the proposal’s release, states and employer groups still questioned the costs of implementing and running exchanges.  Karen Kerrigan is President and CEO of the Small Business and Entrepreneurship Council (SBE Council), a nationwide small business advocacy, research, and networking organization dedicated to protecting small business and promoting entrepreneurship.
 
Kerrigan said that government conditions involve costs and complexities, even with added “flexibility,” that will make exchanges too expensive for some states to operate.  For example, Kerrigan noted that each state exchange is required to operate and maintain a website allowing people to compare plans and pricing.  Each state also must certify that its plan meets ACA requirements, and maintain and staff a toll-free number to assist callers who have questions.
 
Kerrigan pointed to a significant key item that ultimately affects the affordability of plans offered by exchanges.  The “essential health package” has not been developed yet, but Kerrigan cautions that mandates could make the essential package too costly for many small businesses.
 
Instead, Kerrigan favors a system that would allow small businesses to shop nationally for the best and most affordable coverage.  One-size-fits-all mandates from the federal government, she said, only limit choices and drive up costs.

CMS Releases 2012 Proposed Physician Rule on July 1 SGR Rule would Slash Physician Pay by 29.5% in 2012

On July 1, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2012 physician fee schedule, calling for the SGR-mandated 29.5% cut in the physician payments conversion factor effective January 1, 2012 unless Congress again overrides, or else passes legislation to replace, the SGR formula.  CMS will accept public comments until August 30th before issuing the final rule by November 1.

If the SGR pay cut takes effect January 1, 2012, the national physician conversion factor will plummet from $33.9764 currently to $23.9635 for 2012, according to CMS.

In contrast, the annual letter to Congress from the Medicare Payment Advisory Commission (MedPAC) recommended a 2012 Medicare physician reimbursement schedule increase of 1.0%.

In a letter released June 27, MGMA and 112 physician organizations urged the Obama administration and Congress to repeal the SGR formula as part of the deficit reduction plan. The SGR scheduled cuts involve an estimated $300 billion in federal health care costs over the next ten years.

In other provisions, CMS proposes to:
Extend the multiple procedure payment reduction (MPPR) policy to the professional component (PC) of imaging services, resulting in significant reductions in payment for radiology and interventional radiology; the highest PC payment will be paid in full with each additional procedure reduced by 50% when performed on the same patient on the same day in the same imaging session
Pay for physician services at facility rather than in-office rates for non-diagnostic services that are performed within three days prior to an inpatient admission, related to the admission, and performed in a physician practice wholly owned or operated by the hospital.
Continue the Physician Quality Reporting Initiative (PQRI) .5% bonus in 2012 for physicians and other eligible health care professionals who successfully participate
Add 26 new measures for individual claims and/or registry based reporting and an additional way to meet the clinical quality reporting objective
Use CY 2013 as the initial performance year for purposes of adjusting payments in CY 2015
Review reimbursement for specific CPT codes in 2012 to determine if they are overvalued or undervalued; candidates include Manual Therapy (97140), Group Therapy (97150), and possibly Therapeutic Activities (97530), Neuromuscular Reeducation (97112) and Physical Therapy Evaluation (97001)
Substitute 103% of the Average Manufacturer’s Price (AMP) for certain drugs currently paid at 106% of manufacturer’s Average Sales Price (ASP); applicable to drugs that exceed a price substitution threshold in two consecutive quarters or three of the preceding four quarters
The proposed rule also contains information on how to earn the 2012 e-prescribing bonus of 1.0% of allowed charges and how to avoid e-prescribing penalties in 2013 and 2014

Therapy Clinic Offered Cash Kickbacks, Free Transportation PT Clinic Employees Face 10 Years in Medicare Fraud Case

Three employees of a Brooklyn-area physical therapy establishment each pleaded guilty in June to one count of conspiracy to commit health care fraud in a case involving $3.4 million in charges billed to Medicare.

In court documents, authorities alleged that Dmitry Shteyman, 36, Aleksey Shteyman, 42, and Maxsim Shvedkin, 39, were involved in a scheme to pay cash kickbacks to Medicare beneficiaries who visited the physical therapy clinic, known as Solstice Wellness Center.  In addition, beneficiaries allegedly were transported to and from Solstice purportedly to receive the unnecessary physicians’ services, physical therapy and diagnostic tests.  Free transportation or transportation provided for less than market rates can be ruled as an inducement.

In plea hearings, Dmitry and Aleksey Shteyman and Maxsim Shvedkin admitted that they paid kickbacks to the beneficiaries so that Medicare could be billed for services and diagnostic tests that were not medically necessary.

Each defendant faces a maximum sentence of 10 years in prison.

Other employees and clinic operators also were involved.  Ilya Gershkovich, Evgeny Gil, Yefim Kornfeld, Valentina Mushinskaya, Shelya Pinskaya and Vladimir Rubin have been charged and are scheduled for trial in October 2011.
 The guilty pleas were announced by Assistant Attorney General Lanny A. Breuer of the Criminal Division, U.S. Attorney Loretta E. Lynch for the Eastern District of New York and Special Agent-in-Charge Thomas O’Donnell of the HHS-Office of Inspector General (HHS-OIG).

The case was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Eastern District of New York.

Since their inception in March 2007, Strike Force operations in nine cities have charged more than 1,000 defendants who collectively have falsely billed the Medicare program for more than $2.3 billion.  In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.