In The News

Federal Independent Dispute Resolution (IDR) Portal Launched

April 15, 2022, the Centers for Medicare & Medicaid Services opened the Federal Independent Dispute Resolution (IDR) process for providers (including air ambulance providers), facilities, and health plans and issuers to resolve payment disputes for certain out-of-network charges.

To start a dispute, an initiating party will need:

  • Information to identify the qualified IDR items or services;  
  • Dates and location of items or services;
  • Type of items or services such as emergency services and post-stabilization services; 
  • Codes for corresponding service and place-of-service;  
  • Attestation that items or services are within the scope of the Federal IDR process; and
  • The initiating party’s preferred certified IDR entity. A list of certified entities can be found here

At the end of the 30-business-day open negotiation period, initiating parties have 4 business days to initiate a dispute via the portal. As a result of the recent decision in Texas Medical Ass’n, et al. v HHS, the Departments will give disputing parties whose open negotiation period expired before today, April 15, 2022, 15 business days to file an initiation notice via the IDR Portal.

Even after starting the Federal IDR process, disputing parties can continue to negotiate until the IDR entity makes a determination. If the parties reach an agreement on the out-of-network payment rate, they should email the certified IDR entity and the Departments (at [email protected]).

If the disputing parties experience extenuating circumstances during the IDR process that prohibit them from complying with deadlines to submit information, they may email the Departments (at [email protected]) to receive a Request for Extension Due to Extenuating Circumstances form and instructions for next steps.

To learn more about the independent dispute resolution process, including to read guidance materials, FAQs, and model notices, visit www.cms.gov/nosurprises

 

Where the Director of the Center for Medicare Wants to See Care Go

Home Health Care News / By Patrick Filbin
 
One of the most important Centers for Medicare & Medicaid Services (CMS) leaders – Dr. Meena Seshamani – is optimistic about the future of the home health care industry.
 
She detailed why last month at Home Health Care News’ Capital+Strategy event, pointing to more care taking place outside of traditional facilities, innovative care models and the shift to value-based care in general.
 
“We in Medicare are looking to increase our footprint in value-based care and in holistic care models where you’re really encouraging that team-based approach to care,” Seshamani said. “You’re enabling providers to come together to take accountability for cost and quality.”
 
Seshamani is the deputy administrator at CMS and the director of the Center for Medicare. In a value-based-care model, the shared goal of keeping patients healthy and out of the hospital drives smarter spending, she said. More importantly, it will ideally put providers, payers and other stakeholders in a position where they’re all “rowing in the same direction.”
 
“When something works in innovation, we have data, we have transparency,” she said. “As you align the various models that are out there, as you grow those models, that enables some of the flexibility to be able to address the needs of people that you are caring for.”
 
Once the data is there and innovative projects and alignments prove successful, Seshamani said the next step is to scale it.
 
An example of a successful pilot model is the Home Health Value-Based Purchasing (HHVBP) Model. A Center for Medicare and Medicaid Innovation (CMMI) creation, the model is being expanded nationwide next year.
 
According to Seshamani, there are two questions that CMS has to ask before it launches any model: whether it improves quality and whether it saves Medicare money.
 
HHVBP is one that met both of those criteria. Seshamani said CMS is now scaling it in order to bring it to more people.

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Congress is Back from Recess – What’s Next?

Congress is returning from a two week recess, with the Senate reconvening today, and the House reconvening tomorrow.  Axios reported that Sen. Kyrsten Sinema (D-AZ) told donors that advancement of a Build Back Better (BBB) reconciliation package is unlikely given other policy priorities at the forefront of the Congressional agenda. Although it could be revisited as soon as this Spring, there is not a current plan to revive BBB. 

Policymakers are expected to focus their efforts on advancing a $10 billion supplemental COVID-19 funding bill, resolving the differences between the House and Senate China competition bills, and considering an insulin drug pricing bill in the Senate.

Earlier this month, Rep. Fred Upton (R-MI) announced his retirement from Congress.  The Congressman is the lead Republican sponsor of the Cures 2.0 Act, and his departure could give momentum to the legislation or its key components. The homecare industry is lobbying to change the EVV provision in the Act that would prohibit the use of global positioning systems (GPS) and biometrics within electronic visit verification (EVV) systems.

 

First Complete Sequence of a Human Genome

National Institutes of Health

The Human Genome Project, completed in 2003, covered about 92% of the total human genome sequence. The technologies to decipher the gaps that remained didn’t exist at the time. But scientists knew that the last 8% likely contained information important for fundamental biological processes.

Since then, researchers have developed better laboratory tools, computational methods, and strategic approaches. The final, complete human genome sequence was described in a set of six papers in the April 1, 2022, issue of Science. Companion papers were also published in several other journals.

The work was done by the Telomere to Telomere (T2T) consortium. T2T is led by researchers at NIH’s National Human Genome Research Institute (NHGRI), the University of California, Santa Cruz, and the University of Washington, Seattle. NHGRI was the primary funder.

“Short-read” technologies were originally used to sequence the human genome. These provide several hundred bases of DNA sequence at a time, which are then stitched together by computers. Such methods still leave some gaps in genome sequences. 

Over the past decade, two new DNA sequencing technologies emerged that can read longer sequences without compromising accuracy. The PacBio HiFi DNA sequencing method can read about 20,000 letters with nearly perfect accuracy. The Oxford Nanopore DNA sequencing method can read even more—up to 1 million DNA letters at a time—with modest accuracy. Both were used to generate the complete human genome sequence.

In total, the new project added nearly 200 million letters of the genetic code. This last 8% of the genome includes numerous genes as well as repetitive DNA sequences, which may influence how cells function. Most of the newly added sequences were in the centromeres, the dense middle sections of chromosomes, and near the repetitive ends of each chromosome.

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A Staffing Crisis is Causing a Months Long Wait for Medicaid, and it Could Get Worse

Korra Elliott has tried to avoid seeing a doctor while waiting to get on Medicaid. She worries she can't afford more bills without any insurance coverage. But in early March — five months, she said, after applying and with still no decision about her application — a suspected case of the flu sent her blood pressure soaring and landed her in the emergency room.

The 28-year-old mother of four from Salem, Mo., is among the tens of thousands of uninsured Missourians stuck waiting as the state slogs through a flood of applications for the state-federal health insurance program. Missouri expanded the program last year after a lengthy legal and political battle, and it now covers adults who earn up to 138% of the federal poverty level — about $18,800 annually for an individual

Missouri had nearly 72,000 pending Medicaid applications at the end of February and was averaging 119 days to process one, more than twice the maximum turnaround time of 45 days allowed by federal rules. Adding people to Medicaid is labor intensive, and the jobs require training and expertise. The program covers many populations — children, people with disabilities, seniors, adults who are pregnant or have children, and some without children. Different rules dictate who qualifies.

Missouri simply doesn't have the workers to keep up. Last fiscal year, 20% of its employees who handled Medicaid applications left their jobs, said Heather Dolce, a spokesperson for the Missouri Department of Social Services. And the average number of job applications received for each opening in the department's Family Support Division — which oversees enrollment — dropped from 47 in March of 2021 to 10 in February of 2022.

Just about every industry is struggling to find workers now, but staffing shortages in state Medicaid agencies around the country come at a challenging time. States will soon need to review the eligibility of tens of millions of people enrolled in the program nationwide — a Herculean effort that will kick off once President Joe Biden's administration lets the covid-19 public health emergency declaration expire. If Missouri's lengthy application backlogs are any indication, the nation is on course for a mass-scale disruption in people's benefits — even for those who still qualify for the insurance.

"If you don't have people actually processing the cases and answering the phone, it doesn't matter what policies you have in place," said Jennifer Wagner, director of Medicaid eligibility and enrollment for the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C.

Federal officials have said they will give states 60 days notice before ending the public health emergency, so it's unlikely to expire before summer. Once it does, enrollees won't be kicked off immediately: States can take up to 14 months to complete renewals, although budget pressures may push many to move faster. A bump in federal Medicaid funds to states, provided by Congress through covid relief legislation in 2020, will end shortly after the emergency's expiration.

Ultimately, workers are needed to answer questions, process information confirming that someone's Medicaid enrollment should be renewed, or see whether the person qualifies for a different health coverage program — all before the benefits lapse and they become uninsured.

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