Berwick Testifies to the Senate Finance Committee

On November 17th, Donald Berwick testified before the Senate Finance Committee. As you can imagine, there was a lot of political tension surrounding this event.

The video of the entire senate hearing is here: http://finance.senate.gov/hearings/watch/?id=280ebc81-5056-a032-5254-1010c1e9b945

Berwick's prepared statement can be found here: http://finance.senate.gov/imo/media/doc/FINAL%20Donald%20Berwick%20Testimony%2011.15.101.pdf

Bacus' prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/11172010%20Baucus%20Hearing%20Statement%20Regarding%20New%20Patient%20Protections%20to%20Strengthen%20Medicare%20and%20Medicaid1.pdf

Grassley's prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/health%20care%2011-17-10%20hearing%20with%20Dr.pdf

Kaiser Health News, a program of the Kaiser Family Foundation, consolidated a resource page about Dr. Donald Berwick. It contains both what he has said as well as what others have said about him (and what he said). It can be found here: http://www.kaiserhealthnews.org/Stories/2010/June/30/Donald-Berwick-Resource-Guide.aspx

RAC for Medicaid?

The following is a press release from CMS (Nov 5, 2010) announcing some of the details for the implementation of Medicaid RAC. Items of interest to quality professionals are in red.

MEDICAID RECOVERY AUDIT CONTRACTORS RULE ANNOUNCED TO HELP REDUCE IMPROPER PAYMENTS
CMS ANNOUNCES EDUCATION EFFORT TO SUPPORT PROGRAM

The Centers for Medicare & Medicaid Services (CMS) today proposed new rules to help states reduce improper payments for Medicaid health care claims through the use of Medicaid Recovery Audit Contractors (RACs) as part of the Affordable Care Act’s larger strategy to crack down on waste, fraud and abuse in the health care system. Medicaid RACs are contractors, working for States, that will audit payments made to health care providers to identify Medicaid payments that may have been underpaid or overpaid, and recover overpayments or correct underpayments, similar to the RAC program in Medicare.

“Reducing improper payments is a key goal of the Administration, and the tools provided by the Affordable Care Act will help us achieve that goal,” said CMS Administrator Donald Berwick, M.D. “We are using many of the lessons that we learned from the Medicare RAC program in the development and implementation of the Medicaid RACs, including a far-reaching education effort for health care providers and State managers.”

Under the Affordable Care Act, States must establish Medicaid RAC programs by submitting state plan amendments to CMS by December 31, 2010. The law allows CMS to provide extensions or exceptions to States, if necessary, and details regarding these processes are included in the proposed regulation. In addition, the proposed regulation issued by CMS today outlines the requirements that states must meet and the Federal contribution CMS will provide to assist in funding the state RAC programs.

Medicaid RACs will be paid by the States on a contingency basis to review Medicaid provider claims, identify and recover overpayments made for services provided under Medicaid State plans and Medicaid waivers. The proposed regulation allows States the discretion to determine whether to pay their Medicaid RACs on a contingency basis or under some other fee structure for identifying underpayments.

CMS is encouraging interested parties to comment on the proposals included in the regulation. These include the payment methodology for identifying overpayments and underpayments as well as the recovery of overpayments and correction of underpayments, and the requirement that RACs report fraud or criminal activity whenever they have reasonable grounds to believe such activity has occurred.

Under the regulation, as proposed, a State may use its current administrative appeals process or may modify its process for Medicaid RAC-related appeals. All fees paid to the Medicaid RACs must come from amounts recovered after all available appeals have been exhausted.

Because CMS has proposed to require States to implement their programs in a timely manner, CMS is providing educational programs to help States understand both the Medicare and Medicaid RAC programs. On October 1, 2010, CMS released a State Medicaid Director letter which provided initial guidance to the States regarding the RAC program. CMS issued an educational DVD entitled “Medicaid RACs: Are You Ready?” targeted to State Medicaid and Program Integrity Directors and held a webinar for states offering RAC procurement tips. Additionally, on November 4, 2010, CMS hosted an educational forum describing Lessons Learned from CMS’s experience with Medicare RACs.

A copy of the regulation may be viewed at the Federal Register’s website, http://www.ofr.gov/inspection.aspx. For Additional information on the Affordable Care Act can be accessed at, http://www.healthcare.gov/.

New RAC Rules for Document Request Limits

Yesterday, CMS updated its rules regarding limits on the number of additional documentation requests. Excerpts from the document has been cut and pasted below.

You can download the original document at:http://www.cms.hhs.gov/RAC/Downloads/DRGvalidationADRlimitforFY2010.pdf

You can find the RAC homepage at: http://www.cms.hhs.gov/RAC/


Additional Documentation Limits for FY 2010 for DRG Validation
as of December 1, 2009 (Excerpts)

• CMS has modified the additional documentation request limits for the RAC program in FY 2010. These limits will be set by each RAC (CMS) on an annual basis to establish a cap per campus on the maximum number of medical records that may be requested per 45-day period.
• A campus unit (defined below) may consist of one or more separate facilities/practices under a single organizational umbrella; each limit will be based on that unit’s prior fiscal year Medicare claims volume.
• Limits will be based on the servicing provider/supplier’s Tax Identification Number (TIN) and the first three positions of the ZIP code where they are physically located.
• Limits will be set at 1% of all claims submitted for the previous calendar year (2008), divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days. A provider’s limit will be applied across all claim types, including professional services. Note: FY 2010 limits are based on submitted claims, irrespective of paid/denied status and/or individual lines, although interim/final bills and RAPs/final claims shall be considered as a unit.
• While respecting a provider’s overall limit, the RAC may exercise discretion in the exact composition of an additional documentation request. For example, the RAC may request inpatient records up to the full limit even though the provider’s inpatient business may only be a small portion of their total claim volume.
• Two caps will exist in FY 2010: Through March 2010, the cap will remain at 200 additional documentation requests per 45 days for all providers/suppliers. However, from April through September 2010, providers/suppliers who bill in excess of 100,000 claims to Medicare (per TIN, across all claims processing contractors) will have a cap of 300 additional documentation requests per campus unit, per 45 days.
• In addition, in FY 2010 CMS will allow the RACs to request permission to exceed the cap. Permission to exceed the cap cannot be requested in the first six (6) months of the fiscal year. The expanded cap will not be automatic; the RACs must request approval from CMS on a case-by-case basis and affected providers will be notified prior to receiving additional requests.

CMS updates RAC Schedule

CMS released an updated schedule of RAC roll out. The updated schedule can be found here: http://www.cms.hhs.gov/RAC/Downloads/CMS%20RAC%20review%20strategy.pdf

Note that Indiana is considered a yellow/green state.

Medicare Fraud Strike Force Hits Detroit

HHS issued a press release on 6/24/09 detailing the arrests of 53 physicians and healthcare executives. You can find the complete release at: http://www.hhs.gov/news/press/2009pres/06/20090624a.html

Excerpts:

Today, federal agents from the FBI and the HHS Office of Inspector General
(HHS-OIG) began executing arrest warrants in Detroit, Miami and Denver as part
of a concentrated effort to address fraud in the metro-Detroit area. Charges
were unsealed today against 53 individuals who are accused of various Medicare
fraud offenses, including conspiracy to defraud the Medicare program, criminal
false claims and violations of the anti-kickback statutes. The Strike Force
operations in Detroit have identified two primary areas – infusion therapy and
physical/occupational therapy providers – in which schemes were allegedly
orchestrated to defraud the Medicare program.

According to the indictments, the defendants charged today participated in
schemes to submit claims to Medicare for treatments that were in fact medically
unnecessary and oftentimes, never provided. In many cases, indictments
allege that beneficiaries accepted cash kickbacks in return for allowing
providers to submit forms saying they had received the unnecessary and not
provided treatments. Collectively, the physicians, medical assistants,
patients, company owners and executives charged in the indictments are accused
of conspiring to submit more than $50 million in false claims to the Medicare
program.

First RAC, now HEAT????

The new HHS Secretary issued a press release on May 20th announcing a new interagency Healthcare Fraud Prevention and Enforcement Action Team (HEAT).

You can find the press release here: HEAT

The following are some excerpts from the press release:

• Holder (Attny General) and Sebelius (HHS Secretary) also announced the expansion of Strike Force team operations to Detroit and Houston. Medicare Fraud Strike Forces, currently in operation in South Florida and Los Angeles, fight Medicare fraud on a targeted local level.
• “Today, we are turning up the heat on perpetrators who steal from the taxpayers and threaten the future of Medicare and Medicaid,” said Secretary Sebelius. “Most providers are doing the right thing and providing care with integrity. But we cannot and will not allow billions of dollars to be stolen from Medicare and Medicaid through fraud, waste and serious abuse of the system.
• The HEAT team will include senior officials from DOJ and HHS who will build upon and strengthen existing programs to combat fraud while also investing new resources and technology to prevent fraud, waste and abuse before it happens.
• Efforts will include the expansion of joint DOJ-HHS Medicare Fraud Strike Force teams that have been successfully fighting fraud in South Florida and Los Angeles. Established in 2007, these teams have a proven record of success using a “data-driven” approach to identify unexplainable billing patterns and investigating these providers for possible fraudulent activity.
• Prevention is critical to reforming the system and the HEAT team will also focus critical resources on preventing fraud from occurring in the first place. The team will build on demonstration projects by the HHS Inspector General and the Centers for Medicare & Medicaid Services (CMS) that focus on suppliers of durable medical equipment (DME).
• The Attorney General and the HHS Secretary also called on the American people to visit a new Web site www.hhs.gov/stopmedicarefraud or call 1-800-HHS-TIPS (1-800-447-8477) to report suspected Medicare fraud.
  

Feb 11 IHA Newsletter

The most recent IHA newsletter was released on Feb 11. The following is a cut and paste of items relevant to the Healthcare Quality Professional. The full newsletter can be found here.

IHA Board Takes Action on Issues
At its Feb. 6 meeting, the IHA Board of Directors passed a resolution encouraging hospitals to test the WHO Surgical Safety Checklist. A study published in the New England Journal of Medicine demonstrates that use of the checklist during major operations can reduce the incidence of deaths and complications by more than one-third.

More Indiana Hospitals Test Surgical Checklist
More IHA members have reported testing the WHO Surgical Safety Checklist. IHA and IHI are challenging hospitals to test the checklist in one operating room, by one surgical team, one time before April 1. Click here to view the list of IHA members who have already participated. Contact Mikell Brown at 317/423-7726 or mbrown@ihaconnect.org when your hospital has tested the checklist to have your hospital added to the IHA list.

IHA Monitors Stimulus Bill; Compile Project Lists
Congress is still hammering out a compromise between the House and Senate on the stimulus legislation. IHA is uncertain of what will be in the final version of the American Recovery and Reinvestment Act, and even its passage is not guaranteed. However, similarities between the House and Senate approaches allow us to prepare for what the President may sign into law as early as next week.

In the interest of being prepared for funds being available to Indiana’s hospitals, IHA is suggesting that you quickly compile information on projects that could be eligible for grants or other funding assistance. Much of the health care-related funding may flow directly to providers (such as Medicaid dollars and most of the health information technology funding), but state governments may be provided discretion in certain areas. For example, the Senate-passed version of the ARRA appropriates $1.6 billion for “grants to make schools and hospitals, significant users of energy, more energy efficient” (see summary available on http://appropriations.senate.gov/). It is unclear exactly how it would be allocated, but it may be prudent to prepare for some sort of competitive grant process.

Mitch Roob, CEO of the Indiana Economic Development Corporation, has been asked by Gov. Daniels to coordinate the state’s management of stimulus dollars. IHA anticipates that once the final bill is known, we will contact members again with more details on (1) what kind of projects might be eligible for funding; and (2) what information is needed by IEDC or any other grant-making entities.

Based on reviews of the stimulus legislation, the following list is provided as a guideline for you to compile projects in these areas along with supporting information that would likely be needed. IHA cannot be sure that these projects will be eligible for any funding, but we simply want to be prepared. We will follow-up with a more formal survey after passage of any stimulus legislation and additional conversations with IEDC.

NOTE: These categories of projects are listed in the order of the likelihood of available funding.

• Energy efficiency or “green building” projects: Do you have “shovel-ready” energy efficiency or “green building” capital projects in the pipeline on which work could be underway within six months after receipt of federal funding assistance? If so, what phases have been completed and what would be the level of assistance required for completion?
• Health Information Technology: Do you have projects such as electronic health records or upgraded infrastructure/servers/systems in the pipeline? If so, what phases have been completed and what would be the level of assistance required for completion?
• “Brick and mortar” capital projects: Do you have “shovel-ready” traditional capital projects in the pipeline that could be underway within six months after receipt of federal funding assistance? If so, what phases have been completed and what would be the level of assistance required for completion?

Provisions Worth Noting in Senate Stimulus Deal
The Senate Appropriations Committee has released a summary of the stimulus legislation, and there are several health-related provisions worth noting. This summary is available on the Committee's Web page here: http://appropriations.senate.gov/.

The total amount appropriated for health information technology is $3 billion. This is significantly below the $20 billion in the earlier House version. The Senate summary also reports $1.1 billion will be given to the Agency for Healthcare Research and Quality, National Institutes of Health, and the Health and Human Services Office of the Secretary to evaluate the effectiveness of health care services. The House stimulus legislation appropriated $4.1 billion for similar research. In another area of the bill, $1.6 billion would be available in energy efficiency grants for schools and hospitals. More updates will be provided.

Leaders Ask Congress to Replicate Health IT Model
Leaders in Indiana are encouraging Congress to consider replicating Indiana’s Health Information Exchange model as it looks to invest billions in health IT infrastructure as part of the American Recovery and Reinvestment Act of 2009. IHIE provides the country’s best working model of a health information exchange— securely connecting 39 hospitals, 10,000 physicians, and more than 6 million patients. The exchange delivers lab results, reports, medication histories, and treatment histories, in real-time regardless of the hospital system or location. Studies have shown that efficient exchange of medical records among doctors and hospitals in the U.S. could save billions annually. Click here to read IHIE’s letter to Congress.

RAC Rollout to Proceed; Contract Protests Resolved
The Centers for Medicare & Medicaid Services has announced it will now continue with the rollout of the permanent Medicare recovery audit contractor program. The program had been on hold as a result of contract bid protests, which have now been resolved. Details on CMS’ plans to resume the program are pending and will be shared when available. IHA plans to schedule a RAC briefing in the near future.

Registration Now Open for Nurse Retention Briefing
Registration is now open for Engaging and Retaining Nurses: A Prescription for Redesign in Tough Economic Times. It is set for March 18 at the Hilton Indianapolis North. The program will provide Indiana’s nursing leaders with practical strategies that lead to: improved staff satisfaction and retention; improved quality of patient care; more effective care teams; and greater efficiency. The program will use the tested principles and processes of Transforming Care at the Bedside, a program of the Institute for Healthcare Improvement/Robert Wood Johnson Foundation. Presenters will share the evidence base that supports practical tools, techniques, and resources for improvement. To register, visit www.regonline.com/iha2009rnretention.

ECRI Issues High Priority Alert on Bassinet Warmers
ECRI Institute, an independent, nonprofit organization that researches the best approaches to improving patient care, has issued a high priority medical device alert for several older models of infant radiant warmers. ECRI Institute recommends the removal of a series of warmer models manufactured by Borning and Hill-Rom. Complete findings and recommendations are posted for free public access on ECRI Institute's Web site in its Patient Safety Center.

Time Running Out to Register for Just Culture Program.
The registration deadline for the Just Culture Champion Training Session is Feb. 24. The program will be held March 3 at the Montage, Indianapolis. This training session will examine the Just Culture model—focusing on risk, system design, and the management of behavioral choices. The Just Culture Algorithm will also be introduced. The algorithm is a structured process for conducting an investigation of an event or near misses—identifying system contributions and assessing accountability for those involved. The session will be presented by experts from Outcome Engineering, the developers of the Just Culture Algorithm. Following the session, participating hospital teams will be ready to implement the just culture concepts learned during the session into their respective hospitals. To register, visit www.regonline.com/iha2009justculture.

RAC is Back!

Posted on the CMS Website today:

Protest Resolved: On February 4, 2009 the parties involved in the protest of the award of the Recovery Audit Contractor (RAC) contracts settled the protests. The settlement means that the stop work order has been lifted and CMS will now continue with the implementation of the RAC program.

You can find the full posting as well as additional RAC resources at: http://www.cms.hhs.gov/RAC/