RegWatch


Interoperability (CMS-9115-P):  

Although publication of the final rule is due by year-end, an Accenture survey published on October 15th revealed that more than fifty percent (50%) of health IT executives say they are only somewhat familiar with these requirements, and seventeen percent (17%) said that they are completely unaware of them.  Payers appear to be better prepared, with twenty-six percent (26%) reporting they are “very familiar” with the new regs, while only five percent (5%) of providers share that view.   DHHS’ Office of the National Coordinator for Health Information Technology (ONC) submitted the corresponding “information blocking” rule to OMB in September to define exceptions to data blocking and determine corresponding financial penalties.

For further reading:

https://newsroom.accenture.com/news/federal-requirements-for-sharing-patient-medical-records-pose-major-challenges-and-opportunities-for-healthcare-organizations.htm

https://www.fiercehealthcare.com/tech/onc-unveils-long-awaited-information-blocking-rule

https://www.cms.gov/Center/Special-Topic/Interoperability/CMS-9115-P.pdf

Transparency (CMS-1717-P)

Each year, CMS publishes the final rule for hospital prospective payment system rates by November 1st for an effective date on January 1st of the following year.  This rule specifies the payment method and dollar amounts the federal government pays for services to Medicare beneficiaries, and it is publicly available.  For calendar year 2020, the proposed rule also includes language requiring hospitals to publish the rates they’ve negotiated with payers for 300 services (including 70 specified by CMS) in a searchable online format.   CMS meets with the Office of Management and Budget on 10/24/19;  CMS will either delay or issue final approval no later than November 1st.

For further reading:

https://www.fiercehealthcare.com/special-report/price-transparency

https://www.beckershospitalreview.com/finance/cms-pitches-3-sweeping-payment-rules-for-2020-10-things-to-know.html

https://www.cms.gov/newsroom/fact-sheets/cy-2020-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

Program Integrity Enhancements (CMS-6058-FC)

Effective November 4th, 2019, this final rule is a “critical step forward” in CMS’ longstanding fight against “pay and chase” payment recovery from fraudulent providers.  Rather than pursuing often fruitless recovery efforts after payment has been made, this rule prevents payment to unscrupulous providers up front using predictive logic and better tracking of persons and entities with past history of fraudulent behavior.  The rule also adds new “affiliations” authority, allowing CMS to identify providers and organizations that pose an undue risk of fraud, waste or abuse based on their relationships with previously sanctioned entities. 

For further reading:

https://www.cms.gov/newsroom/press-releases/cms-announces-new-enforcement-authorities-reduce-criminal-behavior-medicare-medicaid-and-chip

https://www.aha.org/news/headline/2019-09-05-cms-issues-program-integrity-final-rule-medicare-providers-suppliers

https://healthpayerintelligence.com/news/cms-finalizes-rule-to-crack-down-on-medicare-medicaid-fraud

Medicaid Access to Covered Services – Rescission (CMS-2406-P2)

This proposed rule significantly reduces the administrative burden placed on states for validation of beneficiary access to care.  While access to high quality care remains a primary objective for all stakeholders, this rule removes regulatory text that is overly prescriptive in relation to data collection methods and state submission of access monitoring review plans (AMRPs).  The rule also gives states flexibility in selecting the types of data they would use to demonstrate access and sufficiency of payment rates.  The comment period ended on September 23rd.

For further reading:

https://www.regulations.gov/docket?D=CMS-2018-0031

https://www.federalregister.gov/documents/2019/07/15/2019-14943/medicaid-program-methods-for-assuring-access-to-covered-medicaid-services-rescission

https://www.modernhealthcare.com/payment/repealing-medicaid-access-rule-could-vastly-lower-provider-pay-say-opponents

Physician Self-Referral (CMS-1720-P)

This proposed rule is currently open for public inspection and comment until December 31st, 2019.  As part of CMS’ “Patients Over Paperwork” initiative, the proposed rule advances transition from fee-for-service reimbursement to a value-based system that rewards quality and effective coordination of care.  The proposed rule would create exceptions to the Stark Law specific to value-based payment arrangements but also includes safeguards against the overutilization and other harms that Stark was originally passed in 1989 to prevent.

For further reading:

https://www.federalregister.gov/documents/2019/10/17/2019-22028/medicare-program-modernizing-and-clarifying-the-physician-self-referral-regulations

https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-proposed-rule

https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Significant-Regulatory-History-Items/SRH-CMS-1720-P.html

State Medicaid Programs and 340B

Section 340B of 1992’s Public Health Service Act was originally intended to reduce costs for providers who deliver care for government program enrollees.  Since then, practical application of 340B’s drug pricing provisions has grown increasingly complex – even more so with the promulgation of Medicaid managed care.  A recently published 50-state study conducted by Manatt Health demonstrates the inconsistency with which state Medicaid programs administer 340B drug pricing requirements.  Of note is whether 340B drugs are identified and excluded from drug rebates either by the state Medicaid agency or the managed care organization – these mechanisms appear to vary from state to state.

For further reading:

https://www.manatt.com/Insights/Press-Releases/2019/Manatt-Health-Releases-50-State-Survey-on-340B-in

https://www.hrsa.gov/opa/program-requirements/medicaid-exclusion/index.html

https://news.yahoo.com/murky-approach-tracking-340b-drugs-195652123.html

TennCare’s Block Grant Proposal

Tennessee could become the first state to receive its federal Medicaid funding in a lump sum, known as a “block grant”.  Released on September 17th, Governor Bill Lee’s $7.9 billion proposal has three key components:  a base block grant calculated by the federal Congressional Budget Office using a three-year look back period; a mechanism to account for per capita growth; and a shared savings proposal for the state to split any savings above a budget neutral cap with the federal government. 

For further reading:

 https://www.tennessean.com/story/news/politics/2019/09/17/how-tenncare-medicaid-block-grant-works-explained/2342012001/

https://wreg.com/2019/09/18/tennessee-unveils-7-9b-block-grant-proposal-for-medicaid/

https://www.washingtonpost.com/health/tennessee-becomes-first-state-with-a-plan-to-turn-medicaid-into-a-block-grant/2019/09/17/9a4ba518-d88e-11e9-ac63-3016711543fe_story.html

x