Federal Court Strikes Down Part of HHS Surprise Billing Rule
By Rachel Cohrs | February 23, 2022
A federal court on Wednesday struck down the Biden administration’s interpretation of a controversial part of the federal law banning surprise medical bills.
Health care providers have filed several lawsuits challenging how the Department of Health and Human Services created a mediation process for hospitals and doctors and insurers to settle disputes over out-of-network medical bills.
A federal court judge in Texas sided with Texas Medical Association, a trade association representing more than 55,000 physicians, and decided that HHS was mistaken in its decision to instruct mediators to give rates insurers and providers contracted with in the past extra weight compared with other factors.
“This decision is an important step towards restoring the fair and balanced process that Congress enacted to resolve surprise billing disputes between health insurers and physicians,” said Diana Fite, immediate past president of the Texas Medical Association.
The legal dispute cuts to the heart of an issue that roiled Capitol Hill ahead of the law’s passage in December 2020 — what specific factors an arbitrator would be allowed to consider in mediating the disputes, and how much weight each of those factors should get.
Lawmakers involved in drafting the bill have split on whether they think the Biden administration interpreted the law correctly. Senate health committee Chair Patty Murray (DWash.) and House Energy & Commerce Chair Frank Pallone (D-N.J.) said they think the Biden administration’s interpretation is correct, but Ways & Means Chair Richard Neal (D-Mass.), Rep. Kevin Brady (R-Texas), and a bipartisan group of 152 other lawmakers who prefer the more doctor- and hospital-friendly approach argued that lawmakers intended for all factors to have the same weight.
Pallone tweeted Wednesday night that the Texas court decision “ignores the clear letter and intent” of the No Surprises Act, and wrote that the lawsuit will endanger patient protections and raise costs for consumers.
The patient protections in the law went into effect in January, but the mediations between insurers and providers have not yet begun. The patient protections were not struck down by the Texas judge.
The American Hospital Association and American Medical Association filed a separate lawsuit as well, and a decision has not been made in that case.
To read more, go to Stat News.
CMS Ends ACO Track in Rural Pay Transformation Model
By Maya Goldman | February 22, 2022
The Centers for Medicare and Medicaid Services eliminated a program meant to increase the adoption of Accountable Care Organizations in rural areas, the agency announced Tuesday afternoon.
On the agency’s website, CMS cites “broader efforts underway” as its reasoning for removing the ACO Transformation Track, which was part of an alternative payment demonstration for rural health system transformation, known as the Community Health and Rural Transformation Model. The Trump administration’s Center for Medicare and Medicaid Innovation announced the model in 2020.
CMS said in an emailed update on the program that it remains invested in creating opportunities to spur ACO adoption in rural communities. According to the email, the agency is developing a vision and strategy for accountable care, as it will look at lessons from the previous ACO Investment Model to inform future policies. It also expects to announce additional proposals soon.
CMS did not respond by publication to questions about the end of the program.
The next ACO proposals from CMS will likely focus on broader health equity, rather than geography, said David Pittman, senior policy advisor at the National Association of ACOs.
“Despite today’s announcement, NAACOS remains optimistic that CMS will soon launch more options to encourage ACO participation… the administration recognizes the value of ACOs and has stated their commitment to increase MSSP participation, which is critical for reaching
their goals of expanding value-based care to all Medicare beneficiaries,” the organization said in a statement.
CMS originally slated the ACO Transformation Track to begin January 2022, but regulators delayed applications in March 2021, after the Biden team took over the agency. The agency has moved forward with the model’s separate Community Transformation Track.
The ACO Transformation Track would have given rural ACOs upfront payments of at least $200,000 per beneficiary, along with monthly prospective payments for each beneficiary, for two years if they took part in the Medicare Shared Savings Program and CHART Model. CMS had planned to allow up to 20 rural ACOs to join the track.
To read more, go to Modern Healthcare.
HHS Floats $30B COVID-19 Request With No New Provider Funding, Senior Senator Says
By Jessie Hellmann | February 16, 2022
More COVID-19 response funding could be coming from the federal government but—as of now—none of it would be for healthcare providers, a senior senator said Tuesday.
Health and Human Services Secretary Xavier Becerra said his department might soon request an additional $30 billion, according to Sen. Roy Blunt (Mo.), the senior Republican on the HHS appropriations subcommittee.
Rather than seeking further relief for providers that have struggled during the pandemic, HHS is focused on other priorities, such as testing, treatment and vaccines, Blunt said. The department would allocate new money toward the following areas, he said:
• $18 billion to purchase oral antivirals, monoclonal antibodies and vaccines
• $5 billion for testing capacity and at-home test development
• $3 billion for the HHS fund that reimburses providers treating uninsured COVID-19 patients, which is expected to run dry as soon as this spring
• $4 billion to advance vaccines against future variants of the novel coronavirus
• $500 million for the Centers for Disease Control and Prevention to maintain outbreak surveillance and other operations
The American Hospital Association and other provider groups have been lobbying for the Provider Relief Fund to be replenished, so far without success. According to HHS, the program’s $178 billion has either been spent or set aside for pending distributions.
The AHA asked Congress for another $25 billion, citing financial pressure on hospitals related to the omicron and delta variants and to increased labor costs. That request appears to have fallen flat on Capitol Hill as the omicron variant wanes. Hospitalizations are down by about 38% compared to two weeks ago, according to the CDC.
To read more, go to Modern Healthcare.
Only 14% of Hospitals Met Price Transparency Rule Compliance
By Victoria Bailey | February 14, 2022
Less than 20 percent of hospitals are complying with the CMS price transparency rule that went into effect on January 1, 2021, according to a report from PatientRightsAdvocate.org.
The hospital price transparency rule requires health systems to publicly post the costs of their items and services online. The prices must include standard charges for all items and services for all payers and health plans and a standard charges list or a price estimator tool for the 300 most common services.
The policy aims to help consumers compare hospital prices and better estimate their cost of care before a hospital visit. However, compliance with the regulation has been lacking among hospitals since the rule went into effect.
PatientRightsAdvocate.org reviewed 1,000 hospitals and their websites between December 7, 2021, and January 28, 2022, to glean how many hospitals were complying with the rule.
The report builds on the nonprofit’s initial analysis of hospital compliance with the rule in July 2021, which found that out of 500 hospitals, only 5.6 percent were compliant with the rule requirements.
The most recent review found that only 143 of the 1,000 hospitals (14.3 percent) complied with all aspects of the price transparency rule, indicating that 85 percent of hospitals did not meet at least one of the price transparency requirements.
“Unfortunately, the vast majority of hospitals remain noncompliant after more than a year has passed since the hospital price transparency rule took effect,” Cynthia Fisher, founder and chairman of PatientsRightsAdvocate.org, said in a press release. “Hospitals’ omission of comparative price information in advance of care blocks consumers from benefiting from knowing the competition, seeking fair and equitable prices, and having the choice to lower their costs.”
The biggest noncompliance area was posting a complete machine-readable file of standard charges, which 85 percent of hospitals did not do. Similarly, 84.9 percent of hospitals did not provide national drug codes and the associated prices for the drugs and pharmacy items the health system offered.
Just over 600 hospitals did not publish an adequate amount of negotiated rates, while 586 hospitals did not post all payer-specific negotiated charges that the rule requires.
Compliance was slightly higher for the price estimator requirement, with 84 percent of hospitals publishing a price estimator tool. However, 20 percent of these hospitals did not allow uninsured or self-pay individuals to view discounted cash prices, which violates the rule, the survey found.
In addition, only 28 percent of the hospitals posted the 300 most common services in a consumer-accessible way. The majority of these hospitals (216) were still considered noncompliant because their standard charges files were incomplete, the report stated.
To read more, go to RevCycle Intelligence.
Prior Authorization Adversely Impacts Patient Care, Workforce Productivity
By Anthony Vecchione | February 14, 2022
Prior authorization (PA) may delay patient access to care, lead patients to abandon recommended treatments, and result in hospitalization, according to new survey results from the American Medical Association.
“Health insurance companies entice employers with claims that prior authorization requirements keep healthcare costs in check, but often these promises obscure the full consequences on an employer’s bottom line or employees’ well-being,” AMA President Gerald Harmon, MD, said in a statement. “Benefit plans with excessive authorization controls create serious problems for employers when delayed, denied or abandoned care harms the health of employees and results in missed work-days, lost productivity and other costs.”
Among the survey’s key findings are:
• 51% of physicians reported that PA had interfered with a patient’s job responsibilities.
• 34% said PA led to a serious adverse event including hospitalization, disability, or even death for a patient in their care.
• 93% reported care delays while waiting for health insurers to authorize necessary care.
• 82% said PA can lead to treatment abandonment.
In addition, 24% of physicians who responded to the survey report that PA has led to a patient’s hospitalization while 18% said it has resulted in a life-threatening event or required intervention to prevent permanent impairment or damage.
Meanwhile, 8% of respondents said that PA has led to a patient’s disability, permanent bodily harm, a birth defect, or death, according to the survey results.
Only 7% of respondents reported that prior authorizations had no impact on patient outcomes.
“Now is the time for employers to demand transparency from health plans on the growing impact of prior authorization programs on the health of their workforce,” said Harmon.
ASA Collecting Measure Concepts for 2022-2023 Measure Development
February 9, 2022
The American Society of Anesthesiologists (ASA) invites members and the public to submit measure concepts for consideration in the development of quality measures for the 2022 and 2023 years.
The call for concepts is open from February 9 – February 28, 2022.
Quality measure development is essential for practices to measure local quality improvement activities and the success of physician anesthesiologists in federal pay-for-performance programs, including the Merit-Based Incentive Payment System (MIPS). Measure concepts
should focus on the most important patient outcomes and aspects of anesthesia care with the most room for improvement. For a concept to be successfully developed into a quality measure, it should be able to differentiate high quality care from low-quality care and be supported by evidence. Measure concepts submitted in the past have allowed thousands of anesthesiologists to collect, report and analyze data that reflects their practice needs via the AQI NACOR.
The ASA Committee on Performance and Outcomes Measurement will review all submitted measure concepts and determine which measure concepts should be developed into full measures.
To read more, go to ASA’s website.
Senators Introduce Bipartisan Bill to Extend Patient Access to Telehealth Through 2024
By Heather Landi | February 8, 2022
Two U.S. senators introduced bipartisan legislation Monday to extend current Medicare telehealth reimbursement waivers an additional two years following the end of the public health emergency.
If passed, the bill, the Telehealth Extension and Evaluation Act (PDF), would also extend current Drug Enforcement Administration telehealth prescribing waivers for two years after the COVID-19 PHE period.
U.S. Sens. Catherine Cortez Masto, D-Nevada, and Todd Young, R-Indiana, introduced the bill.
“Seniors across Nevada have benefited immensely from having access to a wide range of telehealth services throughout the pandemic, and we need to make sure they continue to have access to quality care from their homes” said Cortez Masto in a statement. “We’re still feeling the impacts of coronavirus, especially in older and more vulnerable populations, which is why these telehealth services must be extended.”
The legislation would allow the Centers for Medicare & Medicaid Services to extend Medicare payments for a broad range of telehealth services, including substance abuse treatment, for an additional two years. The bill would also commission a study on the impact of the pandemic telehealth flexibilities extended in the bill in order to better inform Congress’ work to make telehealth flexibilities permanent.
Cortez Masto also introduced bipartisan legislation to permanently expand access to telehealth services for Americans with high-deductible health plans and legislation to ensure Medicare Advantage enrollees can access affordable to telehealth during the pandemic, even if they can only make an audio connection to providers.
“The telehealth flexibilities put in place by Congress during the early days of the COVID pandemic played a critical role in allowing the most vulnerable Hoosiers to access care safely. As Congress evaluates which changes to make permanent, many of these flexibilities are set to expire. We should act now to ensure seniors continue to benefit from these important remote health care services,” said Young in a statement.
Many healthcare groups applauded the legislation as a way to expand access to virtual care.
“By extending the current telehealth waivers by two years after the end of the COVID-19 PHE, the Telehealth Expansion and Evaluation Act would provide much-needed certainty to providers and patients who have come to rely on telehealth as a critical tool to deliver and access high-quality care,” said Jen Covich Bordenick, CEO of Executives for Health Innovation (EHI), in a statement. “We urge Congress to quickly act to pass this bipartisan legislation as an important step toward permanent reform.”
Last week, more than 330 organizations, including EHI, the Alliance for Connected Care and the American Telemedicine Association, sent a letter to congressional leaders calling for temporary extension of telehealth waivers as a pathway toward permanent telehealth policies.
To read more, go to Fierce Healthcare.
HHS Running Out of Money to Pay Providers for Treating Uninsured COVID-19 Patients
By Jessie Hellmann | February 8, 2022
A federal program that reimburses healthcare providers that care for uninsured COVID-19 patients is expected to run out of money by spring or summer.
The Provider Relief Fund has paid out more than $17 billion to providers treating, testing and vaccinating the uninsured throughout the pandemic. The Health and Human Services Department program has been a lifeline for providers, especially in states such as Texas and Florida with high rates of people who don’t have health coverage.
But there’s only $7.6 billion left and the money will run out in the coming months, an HHS spokesperson said. Congress isn’t currently considering making more funding available, meaning providers and patients are likely to soon have to bear the costs themselves.
Hospitals continue to urge Congress to replenish the Provider Relief Fund, which has helped offset providers’ pandemic-related losses.
“One of the most helpful and patient-oriented use of the PRF was to help those people who for whatever reasons are uninsured and suffer from COVID-19,” said Federation of American Hospitals CEO Chip Kahn. “It meant that no one should have any reluctance to go to the hospital if they have COVID but no insurance.”
Amid the omicron variant’s widespread, HHS has been processing about $500 million in claims for uninsured patients, so the fund is quickly depleting, the HHS spokesperson said.
Of the $17 billion HHS has distributed to providers from the uninsured fund, nearly $10 billion paid for testing, more than $6 billion reimbursed for treatment and the remainder covered vaccinations.
Providers in states with high uninsured rates and in states that haven’t expanded Medicaid to low-income adults under the Affordable Care Act are among those receiving the most money, according to a Modern Healthcare analysis of HHS data.
If the Provider Relief Fund runs out of money and Congress doesn’t appropriate more, hospitals could be left footing the bill. Not-for-profit hospitals and many for-profit hospitals must provide financial assistance to people with low incomes, many of whom are uninsured.
To read more, go to Modern Healthcare.
Payments to Anesthesiologists From Medical Industry Stable and Comparatively Modest
February 7, 2022
When it comes to industry payments to physicians, anesthesiologists lag well behind other specialties, a new study has concluded.
A multicenter team of investigators found that anesthesiologists received less in industry payments than surgeons and non-surgeons, and received less than a composite of all physicians. The analysis also found that cash transactions represented the most common payment method among these various groups.
“The Open Payments database is a regulated catalog of payments made by industry affiliates—including pharmaceutical companies and device manufacturers—to medical professionals in the United States,” said Andrew W. Jensen, MD, a resident at the Baylor College of Medicine, in Houston. “The database started back in 2013, following the passing of the Physician Payments Sunshine Act, to promote transparency in the relationship between industry and medical professionals.”
Focus on Ascertaining Trends
Despite the comprehensiveness of the database, few investigations have used it to examine trends in physician payments, and no study to date has comprehensively reported payments made to anesthesiologists. As such, Jensen and his colleagues sought to characterize trends and payments made to anesthesiologists between 2014 and 2019. (The first full year of data were collected and are publicly available.)
To do so, the investigators obtained general payment information from the database for the period in question, but only investigated payments made to allopathic or osteopathic physicians within the United States. These data were then analyzed to determine annual trends in the amounts received, types of payment transactions executed and geographic distribution of payments. They also performed a cohort analysis to compare anesthesiologist physicians with surgeons, non-surgeons (including anesthesiologists) and all doctors.
Presenting at the 2021 annual meeting of the American Society of Anesthesiologists (abstract A2041), Jensen reported that 796,260 physicians received 61,000,728 payments during the six-year study period, for a total of $11,815,248,549 transferred to U.S. allopathic and osteopathic physicians. Included among these were 39,671 anesthesiologists, who received a total of $174,196,663.94 from 1,042,879 payments.
When the investigators examined mean annual compensation received per physician group, they found that anesthesiologists received $8,249 less than surgeons. Indeed, anesthesiologists also received $1,551 less than non-surgeons, and $2,627 less than all doctors. Perhaps not surprisingly, the standard deviation per payment also was lower among anesthesiologists (mean, $3,448.02) than surgeons ($35,909.97), non-surgeons ($9,968.56) and all physicians ($15,083.89).
“This trend continued year by year between 2014 and 2019,” Jensen said.
Compensation Appears Stable Over Study Period
With respect to the type of industry payments received by physicians, the researchers found that “cash or cash equivalent” was the most common form of payment made in each of the four physician subgroups analyzed. This was followed by “in-kind items and services” in all groups.
To read more, go to Anesthesiology News.
House Punts Sequester Relief, Telehealth Reform in Short-term Spending Bill
By Robert King | February 7, 2022
(The House passed this bill on 2/8 and the Senate passed it 2/17 to avoid a shutdown.)
House appropriators bypassed addressing major health priorities on telehealth and sequester relief in a short-term spending bill introduced Monday that funds the federal government through March 11.
The House Appropriations Committee released legislation Monday for the short-term continuing resolution to avert a government shutdown by Feb. 18. Health groups have been pressing for additional relief from a 2% cut to Medicare payments expected to go back into effect this summer.
But the short-term spending bill will give congressional negotiators more time to work on a larger omnibus package.
“We are close to reaching a framework government funding agreement, but we will need additional time to complete the legislation in full,” said House Appropriations Committee Chairwoman Rep. Rosa DeLauro, D-Connecticut, in a statement Monday.
The legislation does extend the enhanced federal matching rate for Medicaid funding for certain territories through March 11.
However, it does not include any policies that provider groups have been lobbying for, as groups have another month to make their case to lawmakers.
Several hospital groups are hoping to get relief from a 2% cut to Medicare payments made under sequestration. The payment cuts were suspended by Congress in 2020 at the onset of the pandemic to help providers facing massive revenue shortfalls.
Congress reached a deal late last year to keep the 2% moratorium through April, when it then declines to 1% through June and then resumes the full cut after that month.
But hospital groups say that the landscape has dramatically changed since that deal was made in early December, as the omicron-fueled surge of the virus and crippling labor shortages has caused massive strain on facility finances. Groups are hoping to use the must pass spending bill as a vehicle for policy changes.
Some groups, such as the American Hospital Association, want the 2% moratorium to be extended through the duration of the COVID-19 public health emergency, which was extended into April by the Biden administration and could be extended again.
Other groups have wanted key flexibilities for telehealth use to be made permanent for another year or two to give the federal government more time to study the use of telehealth. The Centers for Medicare & Medicaid Services removed many barriers to Medicare reimbursement for telehealth, but those flexibilities go away after the public health emergency ends.
To read more, go to Fierce Healthcare.
5 Things Moody’s Is Watching In Healthcare This Year
By Nona Tepper | February 1, 2022
High labor costs, insurance coverage changes and the continued presence of the COVID-19 pandemic will hit healthcare industry finances hard in 2022, although some segments will be impacted more than others, according to a recent report.
While patient changes in insurance eligibility pose a hardship for health plans and hospital systems, the aging population will continue to boost residency senior housing facilities, according to a quarterly report from Moody’s Investors Service. The pandemic will also propel mergers among medtech operators in 2022, although the value of deals will fall from previous years, the credit rating agency said.
Below are five things analysts Moody’s expects to see in the coming year:
To read more, go to Modern Healthcare.