News Briefs
News Briefs
TX doctors immune from antitrust
The Texas attorney general’s office has ruled that the state’s physicians can negotiate jointly in the state without violating antitrust laws set into effect by the Sherman Antitrust Act of 1890. Competing doctors now may discuss and negotiate some issues (which are spelled out in the final rule) with health care plan providers. The regulations became effective June 6 and have put into action a 1999 law. Once in effect, the state attorney general expects to see about 112 negotiation applications annually. Meanwhile, in the U.S. Congress, the House is also examining whether to give physicians the legal right to collectively bargain with health care plans. Currently, the proposed bill has 218 House sponsors and, if passed, will in all likelihood prompt action within the Senate.
Medicare Patient Access to Technology Act
On May 10, Reps. Jim Ramstad (R-MN) and Karen Thurman (D-FL), members of the Subcommittee on Health of the House Ways and Means Committee, introduced HR 4395, the Medicare Patient Access to Technology Act of 2000. This bipartisan legislation addresses significant problems in Medicare that could deny beneficiary access to innovative technologies that could improve lives and help reduce health care costs.
Ramstad and Thurman have taken the lead in responding to this problem by introducing a bill to eliminate the delays and barriers to access that have arisen in the way Medicare decides to cover, code, and pay for new devices and diagnostics. Currently, hurdles under Medicare result in delays of 4½ years or more to make new technology fully available to beneficiaries. This bill eliminates the delays and removes barriers to access.
HR 4395 builds upon the enactment of several provisions in the bill introduced last year by Ramstad. The provisions, enacted last year as part of the Balanced Budget Refinement Act, fundamentally reform Medicare services furnished in the outpatient setting, preserving access to technology in that environment.
The current bill targets similar reforms for hospital inpatient and other settings such as ambulatory surgical centers. One of the most significant additions to the bill is the new section devoted to clinical laboratory tests and other fee-schedule items.
Provisions of the bill would require the Health Care Financing Administration to:
• annually update several payment programs;
••issue temporary procedure codes for new technologies at the time of the Food and Drug Administration review;
• update codes every quarter instead of annually;
• make better use of external data to improve the timeliness and appropriations of reimbursement decisions;
• prepare an annual report on the timeliness of its coverage, coding and payment decisions;
• create open, timely procedures and sound methods for making coding and payment decisions for new diagnostic tests.
OIG may target HHA’s DME contracts
Skilled nursing facilities (SNF) and durable medical equipment (DME) suppliers both have been investigated, and in some cases prosecuted, for violating anti-kickback laws under SNF prospective payment system (PPS), and it now appears that the Health and Human Services’ Office of the Inspector General (OIG) may have home health agencies (HHA) in its sights. Home health advocates recommend that agencies put all their DME contracts in writing prior to the October enactment of PPS and that agencies make certain these contracts comply with the safe harbor regulations of the kickback law (42 CFR 10001.952). These regulations clarify which payment practices would be in accordance with the law and therefore would be immune under the anti-kickback statute.
The government currently views the intent of sales discounts on purchases of goods and services as being to obtain business, and unless your contracts fit under the safe harbor guidelines, the government will assume your agency has violated the kickback laws.
The government, according to industry watchers, is concerned that DME suppliers will offer HHAs deeply discounted supplies, with the intent of making up their profits when patients are discharged from home care and the supplier is able to bill Medicare Part B for the patient’s supplies at a much higher price.
Health care companies pilot Internet program
Aetna U.S. Healthcare, Baxter International, Columbia/HCA Healthcare, Merck-Medco, and United Health group have joined with Medtegrity, a provider of health care industry-accepted identification, authentication, security, and privacy services, to create the first industrywide security and privacy service for electronic health care transactions.
Through the issuance of a digital ID — acquired through a stringent Web-based registration process, says Medtegrity — the company will be able to certify an individual’s identity prior to accessing personal health care services, thus allowing consumers to conduct health care business over the Internet with confidence.
HCFA publishes insulin infusion pump criteria
The Health Care Financing Administration (HCFA) announced in September 1999 that, as a result of scientific evidence of the insulin infusion pump’s effectiveness in diabetic control and prevention of complications, Medicare coverage would begin in the near future. In a subsequent transmittal two months later, HCFA issued a revision to change its policy from noncoverage to limited coverage of insulin pumps. Unfortunately, the coverage criteria established by HCFA is extremely rigid and will severely limit access for many Type I diabetics who require home health services.
According to Transmittal 120, Coverage Issues Manual, Medicare coverage will be limited to Type I diabetics, as documented by a C-peptide level of less than 0.5, who also meet either of the following criteria:
• The patient has completed a comprehensive diabetes education program and has been on a program of multiple daily injections of insulin of at least three times a day for at least six months prior to initiation of the insulin pump.
In addition, these individuals must have documented frequency of glucose self-testing an average of four times a day during the two months prior to initiation of the insulin pump, and meet one or more of the following criteria while on the multiple daily injection regimen: glycosylated hemoglobin level above 7.0%; history of recurring hypoglycemia; wide fluctuations of blood glucose before mealtime; dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl; or history of severe glycemic excursions.
• The patient has been on a pump prior to enrollment in Medicare and has documented frequency of glucose self-testing an average of at least four times per day during the month prior to Medicare enrollment.
Continued coverage requires a physician evaluation quarterly, at a minimum. The physician ordering coverage and providing follow-up care must manage multiple patients with pumps and work closely with other health professionals knowledgeable in the use of pumps.
Hepatitis C on-line
The Centers for Disease Control and Prevention (CDC) has posted on its Web site an interactive training program on hepatitis C for health professionals. The program provides users with up-to-date information on epidemiology, diagnosis, and management of hepatitis C infection and related chronic disease. Continuing medical and nursing education credits are available free from CDC upon completion of the training. The training course is at www.cdc.gov/ncidod/diseases/hepatitis.
HCFA to be user-friendly?
Health care providers may soon see a new and improved Health Care Financing Admini-stration (HCFA) if the organization’s planned initiative goes as it should. HCFA is hoping the two-part program will improve consumer confidence in the Medicare and Medicaid programs. As part of the program, HCFA plans to educate health care providers and suppliers about billing rules coupled with program integrity activities targeted at those who abuse the system. The initiative, says HCFA, is geared toward improving the effectiveness of the medical review and provider enrollment as well as its communications with the provider community.
It is hoped that through the initiative, providers will gain greater insight into the rationale behind program integrity activities, something HCFA hopes to achieve by improving its quality of customer service and by making the providers a part of the process. One of the first steps HCFA will undertake is the creation of a survey which will be sent to selected providers and beneficiaries, asking them about the quality of customer care they received from either HCFA or its contractors. HCFA says it will develop action plans to respond to the survey results as well as contractor training sessions and outreach activities to see that the new plans are implemented. Key to these surveys will be the areas of the development of local medical review policy, medical review of claims, processing of enrollment applications, and response to fraud complaints.
Before proceeding with the survey it must be approved by the Office of Management and Budget. The project, which is expected to take at least two years to complete, may begin as early as late summer or early fall. To access local medical review policies, visit www.lmrp.net. HCFA also plans to develop a user-friendly, "plain-English" publication intended for widespread distribution to explain HCFA’s program integrity activities. Questions about the Customer Service Initiative may be directed to Bill Gould of HCFA’s Office of Program Integrity at [email protected] or (410) 786-1458.
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