Telehealth Gets Short Extension, Physician Pay is Cut in Spending Bill

Healthcare Finance / By Susan Morse

President Joe Biden on Saturday signed a spending bill that averts a government shutdown, but some healthcare provisions that were in the original bill didn't make it to final passage.

Acute hospital-care-at-home and telehealth temporary waivers were continued, but were not given the long-term extensions that were included in a Dec. 18 bipartisan resolution. Both received short-term extensions until March 31.

The original bill extended telehealth for two years and acute hospital care at home by five years.

Stripped out of the bill is a provision to prevent the Medicare pay cut to physicians. This means physicians get a 2.8% Medicare payment cut on January 1, 2025...

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OASIS-E1 Manual Finalized

The Alliance / By Katie Wehri

CMS posted the final OMB-approved OASIS-E1 time points Instruments, effective 1/1/2025, are now available in a zip file in the Downloads section of the OASIS Data Sets webpage.  The Agency has also reposted the final OASIS-E1 Manual effective 1/1/2025. Alliance staff are in the process of reviewing the materials.

A change table OASIS-E1 Instruments March 2024 – December 2024 Changes, also available in the Downloads section of the OASIS Data Sets webpage, lists minor corrections from the draft to final versions. The final OASIS-E1 All Items instrument will be posted when available.

OIG Issues MA Plan Fraud Alert

Alliance Daily

The Office of Inspector General (OIG), U.S. Department of Health and Human Services, has issued a Special Fraud Alert warning about certain marketing schemes involving the Medicare Advantage (MA) program. These schemes involve questionable payments and referrals between Medicare Advantage plans, health care professionals ( HCPs) , and third-party marketers such as agents and brokers.

The Special Fraud Alert focuses on two types of remuneration that have been the subject of recent settlements under the False Claims Act and that implicate the Federal anti-kickback statute: (1) payments from Medicare Advantage Organizations (MAOs) to HCPs or their staff relating to MA plan marketing and enrollment; and (2) payments from HCPs (including payments from corporations that contract with or employ HCPs and payments from management services organizations with which HCPs contract) to agents, brokers, and others in exchange for referring Medicare enrollees to a particular HCP.

One area of risk involves MAOs, directly or indirectly, paying remuneration to HCPs or their staff in exchange for referring patients to the MAOs’ plans. For example, MAOs have provided gift cards or in-kind payments to HCPs and their office staff in exchange for those HCPs or their staff referring or recommending individuals for enrollment in a particular MA plan. In some cases, these tactics have resulted in individuals, sometimes without their consent, being enrolled in an MA plan when they wanted to stay in Original Medicare or another MA plan. Additionally, an MAO may use these payments to HCPs or their staff to selectively target individuals for enrollment that benefits the MAO

A second area of risk involves payments from HCPs to agents and brokers, such as payments from an HCP to agents and brokers to recommend that HCP to a particular MA enrollee or to refer the enrollee to the HCP. In some cases, HCPs make these payments to refer Medicare enrollees to the HCP to become designated as the primary care provider for the enrollee at their particular MA plan, which can carry a substantial financial benefit for the HCP. Enrollees are often unaware of these financial arrangements and may rely on the recommendation of an agent or broker in making HCP selection.

Abusive arrangements involving MAOs, agents, brokers, and HCPs may also lead to criminal, civil, or administrative liability under several Federal laws.

The OIG has developed a list of suspect characteristics related to arrangements involving the types of marketing activities described above. These characteristics, taken together or separately, could suggest that an arrangement presents a heightened risk of fraud and abuse.

• MAOs, agents, brokers, or any other individual or entity offering or paying HCPs or their staff remuneration (such as bonuses or gift cards) in exchange for referring or recommending patients to a particular MAO or MA plan.
  
  
• MAOs, agents, brokers, or any other individual or entity offering or paying HCPs remuneration that is disguised as payment for legitimate services but is actually intended to be payment for the HCPs’ referral of individuals to a particular MA plan.
  
  
• MAOs, agents, brokers, or any other individual or entity offering or paying HCPs or their staff remuneration in exchange for sharing patient information that may be used by the MAOs to market to potential enrollees.
  
  
• MAOs, agents, brokers, or any other individual or entity offering or paying remuneration to HCPs that is contingent upon or varies based on the demographics or health status of individuals enrolled or referred for enrollment in an MA plan.
  
  
• MAOs, agents, brokers, or any other individual or entity offering or paying remuneration to HCPs that varies based on the number of individuals referred for enrollment in an MA plan.
  
  
• HCPs offering or paying remuneration to an agent, broker, or other third party that is contingent upon or varies based on the demographics or health status of individuals enrolled or referred for enrollment in an MA plan.
  
  
• HCPs offering or paying remuneration to an agent, broker, or other third party to recommend that HCP to a Medicare enrollee or refer an enrollee to the HCP.
  
  
• HCPs offering or paying remuneration to an agent, broker, or other third party that varies with the number of individuals referred to the HCP.

These practices, alone or in combination, represent potentially abusive practices that could

implicate various fraud and abuse laws. Additionally, these types of suspect practices could result in various harms to Medicare enrollees and should be scrutinized closely by any parties to such arrangements.

DOGE Has a Plan for Medicare, Medicaid. Will it Work?

Politico / By Ben Leonard and Chelsea Cirruzzo

Presented by the Coalition to Strengthen America’s Healthcare
 
UNPACKING DOGE CLAIMS — Biotech entrepreneur Vivek Ramaswamy, co-leader of President-elect Donald Trump’s Department of Government Efficiency, is eyeing Medicare and Medicaid as potential sources to cut federal spending by trillions, Ben reports.
The goal of DOGE — an outside group that will recommend spending and regulation cuts — is a tall task that would likely involve cutting entitlement programs to extract significant savings. Ramaswamy said last week on CNBC that “hundreds of billions of dollars in savings” could come from just “basic program integrity measures” in Medicare, Medicaid and Social Security.

He’s generally in the right ballpark for the numbers. HHS estimated that, in fiscal year 2024, Medicare and Medicaid accounted for about $86 billion in improper payments, and other estimates peg fraud and waste higher annually.
 
But the devil’s in the details. 
 
Jessica Farb, managing director of the Government Accountability Office’s health care team, noted that most of the improper payments in HHS’ estimates are due to insufficient documentation.

“If these documentation errors were corrected, it is very possible that these payments would no longer be considered improper and therefore there would not be any ‘savings’ to the programs,” Farb said, adding that she doesn’t know what estimates Ramaswamy was using. “Improper payment rate is not an estimate of fraud or waste.”

Controlling fraud might be more difficult than Ramaswamy suggests because many before him have pointed to curbing fraud, waste and abuse as a way to control government spending. Experts on health care fraud say there are ways to reduce it.

“Internal controls are extremely important in trying to deter fraudulent activity from occurring, and to be honest, the government has the worst system of any organization,” Patrick Malloy, program coordinator at the University of New Haven’s health care fraud, waste and abuse program, told Pulse.

He suggested the government could follow the private sector by auditing its waste control processes annually and reporting on their findings. Fraud in private organizations is generally about 5 percent of revenues, he said, compared with up to 15 percent in government.

Still, others are more skeptical that Ramaswamy’s vision could be achieved…

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