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Besides restoring $35 billion in previous cuts in federal health care spending, the massive budget bill approved during the final days of December’s lame duck session of Congress also included a variety of provider and beneficiary provisions.
• Regulatory relief. The bill directs the Government Accounting Office (GAO) to study the post-payment audit process for physician services. The study is to determine the proper level of resources the Health Care Financing Administration (HCFA) should devote to calculating overpayments, and to educate physicians about coding and billing documentation requirements.
The GAO is also required to study the aggregate effects of regulatory, audit, oversight, and paperwork burdens on physicians and other health care providers participating in Medicare.
• Ambulatory surgical centers. The bill delayed implementation of proposed regulatory changes to the ambulatory payment classification system until Jan.1, 2002. At that time, the changes would be phased in over four years. In the first year the payment amounts would be 25% of the revised rates and 75% of the prior system rates. In the second year, payments would be 50% of the revised rates and 50% of the prior system rates. The provision also requires that the revised system, based on 1999 (or later) cost data, be implemented Jan. 1, 2003. The phase-in of the revised system and 1994 data would end when the system with 1999 or later data was implemented.
• Physician services. A provision in the budget bill requires the GAO to study the appropriateness of furnishing physician offices specialist services (such as gastrointestinal endoscopic physicians services) that ordinarily are furnished in hospital outpatient departments. The GAO also is required to study the refinements to the practice expense relative value units made during the transition to the resource-based system.
• Medicare enrollment. The bill requires the GAO to study the current Medicare enrollment process for groups that retain independent contractor physicians. Particular emphasis would be placed on hospital-based physicians, such as emergency department staffing groups.
• Physical therapy. The bill extends the moratorium on the physical therapy and occupational therapy caps through 2002, and extends the rule requiring focused reviews of therapy claims during that same period. The Department of Health and Human Services (HHS) must conduct a study on the implications of eliminating the "in the room" supervision requirement for Medicare payment for physical therapy assistants who are supervised by physical therapists, and the implications of this requirement on the physical therapy cap.
• Skilled nursing facility staffing. Skilled nursing facilities have to post nurse staffing information daily for each shift in the facility, effective Jan. 1, 2003.
• EMTALA study. The bill asks the GAO to evaluate the impact of the Emergency Medical Treatment and Active Labor Act on hospitals, emergency physicians, and physicians on-call to emergency departments, and report back its findings by May 1, 2001.
• Alternative providers. The law requires the Medicare Payment Advisory Council to study the appropriateness of current payment rates for services provided by a certified nurse midwives, physician assistants, nurse practitioners, and clinical nurse specialists, including specifically for orthopedic physician assistants.
• Medicare+Choice. The measure sets the minimum payment amount for aged enrollees within the 50 states and the District of Columbia in a Metropolitan Statistical Area with a population of more than 250,000 at $525 in 2001. For all other areas within the 50 states and the District of Columbia, the minimum would be $475. For any area outside the 50 states and the District of Columbia, the $525 and $475 minimum amounts would also be applied, except that the 2001 minimum payment amount could not exceed 120% of the 2000 minimum payment amount. This increase would go into effect March 1, 2001.
• Advisory opinions. The bill gives the Office of the Inspector General (OIG) authority to issue advisory opinions to outside parties who request guidance on the applicability of the anti-kickback statute, safe harbor provisions, and other OIG health care fraud and abuse sanctions.
The bill also addressed a number of fraud and abuse topics.
• Drug costs. The GAO is required to study reimbursement practices for drugs and biologicals under Medicare Part B and make recommendations for revised payment methodologies.
Until the report is presented, there will be a temporary freeze on the rates the federal government pays for drugs until HHS reviews the study. This provision is aimed at correcting complaints from Congress that drug companies have been taking advantage of loopholes in the current system to manipulate Medicare reimbursement rates for covered drugs, causing the government to overpay for these drugs compared to the private market.
• Hospice certification. Current law is changed to specify that the certification of terminal illness by a physician or hospice medical director should be based on his or her clinical judgment regarding the normal course of an individual’s illness. This is intended to address complaints that overzealous auditors have threatened to prosecute providers and take away benefits if beneficiaries receiving hospice care live more than the maximum six-month life expectancy.
• Physician audits. The GAO is to study the post-payment audit process for physician services to determine the effect of regulatory burdens on physicians and the proper level of resources HCFA should devote to educating physicians about coding and billing.