Month: January 2018

The Healthcare Cost Report Information System (HCRIS) contains annual reports submitted by institutional providers to Medicare. It provides information to CMS that assists with the annual settlement summary between CMS and the institutional provider.

The cost report information includes facility level:

• utilization statistics,
• costs,
• charges,
• Medicare payments, and
• fiancial information.

Further reading –

https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Cost-Reports/

The Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as “hick picks”) is a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT).[1]

The acronym HCPCS originally stood for HCFA Common Procedure Coding System, a medical billing process used by the Centers for Medicare and Medicaid Services (CMS). Prior to 2001, CMS was known as the Health Care Financing Administration (HCFA). HCPCS was established in 1978 to provide a standardized coding system for describing the specific items and services provided in the delivery of health care. Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner. Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for transactions involving health care information became mandatory.[2]

HCPCS includes three levels of codes:

• Level I consists of the American Medical Association’s Current Procedural Terminology (CPT) and is numeric.
• Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I).
• Level III codes, also called local codes, were developed by state Medicaid agencies, Medicare contractors, and private insurers for use in specific programs and jurisdictions. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) instructed CMS to adopt a standard coding systems for reporting medical transactions. The use of Level III codes was discontinued on December 31, 2003, in order to adhere to consistent coding standards.

Further reading –

https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html

Risk Adjustment and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Centers for Medicare and Medicaid Services (CMS) in 1997. Implemented in 2003, this model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual’s health conditions and demographic details. The individual’s health conditions are identified via International Classification of Diseases – 10 (ICD –10) diagnoses that are submitted by providers on incoming claims. There are more than 9000 ICD-10 codes that map to 79 HCC codes in the Risk Adjustment model.

CMS requires documentation in the person’s medical record by a qualified health care provider to support the submitted diagnosis. Documentation must support the presence of the condition and indicate the provider’s assessment and/or plan for management of the condition. This must occur at least once each calendar year in order for CMS to recognize the individual continues to have the condition.

Further reading –

https://www.icd10monitor.com/what-you-need-to-know-about-hierarchical-condition-categories-and-icd-10

CDC’s Health Alert Network (HAN) is CDC’s primary method of sharing cleared information about urgent public health incidents with public information officers; federal, state, territorial, and local public health practitioners; clinicians; and public health laboratories.

CDC’s HAN collaborates with federal, state, territorial, and city/county partners to develop protocols and stakeholder relationships that will ensure a robust interoperable platform for the rapid distribution of public health information. The HAN project is intended to “ensure that each community has rapid and timely access to emergent health information; a cadre of highly-trained professional personnel; and evidence-based practices and procedures for effective public health preparedness, response, and service on a 24/7 basis.”

Currently, HAN is a strong national program, providing vital health information and the infrastructure to support the dissemination of that information at the state and local levels, and beyond. A vast majority of the State-based HAN programs have over 90% of their population covered under the umbrella of HAN. The HAN Messaging System currently directly and indirectly transmits Health Alerts, Advisories, and Updates to over one million recipients. The current system is being phased into the overall PHIN messaging component.[1] CDC’s HAN is a strong national program, providing vital health information and the infrastructure to support dissemination at state and local levels, and beyond. The vast majority of the state-based HAN programs have over 90% of their populations covered under the umbrella of HAN. The HAN messaging system directly and indirectly transmits Health Alerts, Advisories, Updates, and Info Services to over one million recipients.

HAN Message Types

Health Alert: provides vital, time-sensitive information for a specific incident or situation; warrants immediate action or attention by health officials, laboratorians, clinicians, and members of the public; and conveys the highest level of importance.

Health Advisory: provides important information for a specific incident or situation; contains recommendations or actionable items to be performed by public health officials, laboratorians, and/or clinicians; may not require immediate action.

Health Update: provides updated information regarding an incident or situation; unlikely to require immediate action.

Info Service: provides general public health information; unlikely to require immediate action.

Further reading –

https://emergency.cdc.gov/han/index.asp

The Affordable Care Act Federal Upper Limit — or ACA FUL — is a drug pricing benchmark based on a new formula detailed in the Affordable Care Act. ACA FUL will be included among a variety of commonly consulted drug pricing benchmarks. They are derived from various methods and represent nuanced different assessments for comparison, analysis, and decisions related to reimbursement and product positioning.

Further reading –

https://www.medicaid.gov/medicaid/prescription-drugs/federal-upper-limits/index.html

There are two slightly different versions of the federal poverty measure: poverty thresholds and poverty guidelines.

The poverty thresholds are the original version of the federal poverty measure. They are updated each year by the Census Bureau. The thresholds are used mainly for statistical purposes — for instance, preparing estimates of the number of Americans in poverty each year. (In other words, all official poverty population figures are calculated using the poverty thresholds, not the guidelines.) Poverty thresholds since 1973 (and for selected earlier years) and weighted average poverty thresholds since 1959 are available on the Census Bureau’s Web site. For an example of how the Census Bureau applies the thresholds to a family’s income to determine its poverty status, see “How the Census Bureau Measures Poverty” on the Census Bureau’s web site.

The poverty guidelines are the other version of the federal poverty measure. They are issued each year in the Federal Register by the Department of Health and Human Services (HHS). The guidelines are a simplification of the poverty thresholds for use for administrative purposes — for instance, determining financial eligibility for certain federal programs.

The poverty guidelines are sometimes loosely referred to as the “federal poverty level” (FPL), but that phrase is ambiguous and should be avoided, especially in situations (e.g., legislative or administrative) where precision is important. The January 2018 poverty guidelines are calculated by taking the 2016 Census Bureau’s poverty thresholds and adjusting them for price changes between 2016 and 2017 using the Consumer Price Index (CPI-U). The poverty thresholds used by the Census Bureau for statistical purposes are complex and are not composed of standardized increments between family sizes. Since many program officials prefer to use guidelines with uniform increments across family sizes, the poverty guidelines include rounding and standardizing adjustments in the formula.

Further reading –

http://familiesusa.org/product/federal-poverty-guidelines

https://aspe.hhs.gov/poverty-guidelines

Fully Integrated Dual Eligible (FIDE) SNPs were created by Congress in section 3205 of the Affordable Care Act (ACA). Designed to promote the full integration and coordination of Medicare and Medicare benefits for dual eligible beneficiaries by a single managed care organization, FIDE-SNPs are described in section 1853(a)(1)(B)(iv) of the Social Security Act and at 42 CFR §422.2.

FIDE SNPs must meet the following five elements:

• Enroll special needs individuals entitled to medical assistance under a Medicaid State Plan, as defined in Section 1859(b)(6)(B)(ii) of the Act and 42 CFR Section 422.2 and described in detail in Section 40.5.3 of this chapter;
• Provide dually-eligible beneficiaries access to Medicare and Medicaid benefits under a single managed care organization;
• Have a CMS approved MIPPA compliant contract with a State Medicaid Agency that includes coverage of specified primary, acute, and long-term care benefits and services, consistent with State policy, under risk-based financing;
• Coordinate the delivery of covered Medicare and Medicaid health and long-term care services, using aligned care management and specialty care network methods for high-risk beneficiaries; and,
• Employ policies and procedures approved by CMS and the State to coordinate or integrate enrollment, member materials, communications, grievance and appeals, and quality improvement.

Further reading –

https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/Downloads/Special-Need-Plans-SNP-Frequently-Asked-Questions-FAQ.pdf