|Now is the Time to Shape Future Good Faith Estimate Rulemaking |
By Amada Norris | September 20, 2022
The departments of the Treasury, Labor, and Health and Human Services released a request for information regarding the No Surprises Act.
The departments recently released a lengthy request for information for revenue cycle leaders to inform future rulemaking to implement advanced explanation of benefits (AEOB) and good faith estimate (GFE) requirements under the No Surprises Act.
The request asks commenters to share their expertise on a range of issues and even poses specific questions to help inform the development of future regulations. Some of these questions include:
What issues should the departments and office of personnel management (OPM) consider as they weigh policies to encourage the use of a fast healthcare interoperability resources-based application programming interfaces (API) for the real-time exchange of AEOB and GFE data?
What privacy concerns does the transfer of AEOB and GFE data raise, considering these transfers would list the individual’s scheduled (or requested) item or service, including the expected billing and diagnostic codes for that item or service?
How could updates to this program support the ability of providers to exchange GFE information with plans, issuers, and carriers or support alignment between the exchange of GFE information and the other processes providers may engage in involving the exchange of clinical and administrative data, such as electronic prior authorization?
What, if any, burdens or barriers would be encountered by small, rural, or other providers, facilities, plans, issuers, and carriers in complying with industry-wide standards-based API technology requirements for the exchange of AEOB and GFE data?
Comments are due in 60 days and electronic comments on this regulation can be submitted on its website.
To read more, go to HealthLeaders Media.
|AHA, AMA Drop Surprise Billing Lawsuit, Plan Further Legal Action |
By Maya Goldman | September 20, 2022
The American Hospital Association and the American Medical Association have ended one legal challenge to the federal surprise billing arbitration process but have plans to try again, the organizations announced Tuesday.
“We have serious concerns that the August 2022 final rule departs from congressional intent just as the September 2021 interim final rule did. Hospitals and doctors intend to make our voices heard in the courts very soon about these continued problems,” the AHA and AMA said in a joint statement.
The AHA and AMA’s fellow plaintiffs–UMass Memorial Health Care of Worcester, Massachusetts, Renown Health of Reno, Nevada, Dr. Stuart Squires and Dr. Victor Kubit–also dismissed their claims against the government.
The two healthcare associations filed a lawsuit against the federal government in December, contending the surprise billing arbitration process would harm providers by leading to underpayment for out-of-network services. The interim regulation required arbiters to pick the offer closest to the insurer’s median contracted in-network rate.
In February, the U.S. District Court for the Eastern District of Texas ruled in favor of providers in a separate lawsuit over the arbitration process. The decision is reflected in regulators’ final rule on the process, which requires that arbiters consider both an insurer’s median contracted in-network rate and additional information when deciding the payment for a surprise bill.
The AMA and AHA’s current lawsuit is moot after regulators released a final rule on the surprise billing arbitration process in August, an AHA spokesperson said.
Still, providers aren’t happy with the final rule, and plan additional legal action over the arbitration process. The AHA and AMA did not respond when asked their specific concerns. The AMA and AHA’s lawsuit was consolidated with a complaint from the Association of Air Medical Services over the same process in February. The Association of Air Medical Services is not listed as one of the plaintiffs dismissing their claims Tuesday and did not respond to a request for comment.
The parties are scheduled to have a status hearing before Judge Richard Leon of the U.S. District Court for the District of Columbia on Wednesday.
To read more, go to Modern Healthcare.
|Nursing Community Unleashes Aggressive Anti-Physician, Scope of Practice Expansion Bill |
September 19, 2022
On September 13, 2022, legislation was introduced to expand federal scope of practice to a full range of advanced practice registered nurses (APRN), including nurse anesthetists. Advocates for the bill include the American Association of Nurse Practitioners (AANP), the American College of Nurse-Midwives, the American Nurses Association and the AANA. If enacted, the bill, H.R. 8812, the Increasing Access to Nurses (I CAN) Act, would grant full practice authority at the federal level to APRNs, including nurse anesthetists. The “I CAN” Act compromises patient safety and needlessly places the lives of Medicare and Medicaid beneficiaries at risk. The legislation was introduced by longtime anti-physician Members of Congress, Representative David Joyce (R-OH-14) and Representative Lucille Roybal-Allard (D-CA-40) and is cosponsored by Adrian Smith (R-NE-3), Jan Schakowsky (D-IL-9) and Rodney Davis (R-IL-13).
To read more, go to ASA’s website.
|New ASA-Endorsed Legislation to Address Impending Medicare Payment Cuts |
September 19, 2022
The American Society of Anesthesiologists (ASA) announced its endorsement of newly introduced bipartisan legislation to mitigate Medicare payment cuts scheduled for January 1, 2023. The bill, H.R. 8800, Supporting Medicare Providers Act, was recently introduced by Representative Ami Bera, M.D. (D-CA-7) and Representative Larry Bucshon, M.D. (R-IN-8) and seeks to prevent at least a 4.42 percent Medicare payment cut for anesthesiologists and other health care professionals. While the bill addresses 4.42% of the nearly 10% in payment cuts scheduled to go into effect January 1, ASA applauds Representatives Bera and Bucshon for their leadership on this important issue. The bill would provide an important first step in adding stability and predictability for physician practices and in beginning to fix a broken Medicare physician payment system.
Read the full bill text here.
Review the list of cosponsors here.
|House Passes Medicare Advantage Prior Authorization Oversight Bill |
By Maya Goldman | September 14, 2022
Medicare Advantage carriers would be subject to new requirements governing the prior authorization process under legislation that passed the House Wednesday.
The measure would compel Medicare Advantage insurers to use electronic prior authorization programs, annually submit lists of items and services subject to prior authorization, and adopt beneficiary protection standards. The Improving Seniors’ Timely Access to Care Act now moves the Senate, where supporters hope it will advance after the November congressional elections.
Prior authorization in Medicare Advantage has come under fire this year. Approximately 13% of denied prior authorization requests during a week-long period in June 2019 met fee-for-service Medicare coverage rules, according to a Health and Human Services Department report released in April. Hospitals have called on the Justice Department to use the False Claims Act against Medicare Advantage insurers that improperly deny coverage.
The legislation, first introduced in 2019, is a rare bipartisan healthcare initiative that boasts more than 300 cosponsors in the House and support from both provider and insurance groups. After the vote, lawmakers who led the measure through the House called on the Senate and President Joe Biden to advance it into law.
“Seniors and their families should be focused on getting the care they need, not faxing forms multiple times for procedures that are routinely approved. This takes away valuable time from providers who on average spend 13 hours a week on administrative paperwork related to prior authorization,” Reps. Suzan DelBene (D-Wash.), Ami Bera (D-Calif.), Larry Bucshon (R-Ind.) and Mike Kelly (R-Pa.) said in a joint news release.
Advocates are optimistic about the bill’s chances in the Senate.
“We are encouraged by conversations with Senate bill champions and leaders that the legislation could be included in an end-of-year omnibus package,” said Peggy Tighe, a healthcare lobbyist and legislative counsel to the Regulatory Relief Coalition, an umbrella group comprising physician organizations.
The bill is slated for inclusion in a mental health package the Senate Finance Committee is considering, according to a spokesperson for Sen. Roger Marshall (R-Kansas), a cosponsor of the legislation. The committee did not respond to a request for comment.
“For nearly four years, my colleagues and I have worked tirelessly on this bipartisan, bicameral legislation to modernize Medicare Advantage to better serve America’s seniors,” Marshall said in a statement prior to the House vote. “This week marks an important step forward, but our work is not finished. I urge Senate leadership to work with me in moving the Improving Seniors’ Timely Access to Care Act to the president’s desk.”
To read more, go to Modern Healthcare.
|Majority of Providers Say Fee-for-Service is a Thing of the Past, Survey Finds |
By Rylee Wilson | September 14, 2022
A majority of healthcare executives think value-based-care has replaced fee-for-service billing, a new survey found.
Of 160 C-suite executives and other high-level staff surveyed, just 4 percent said they think payers use traditional fee-for-service billing with no connection to quality and value. The majority of executives think payers use FFS models with connections to the quality and value of care taken into account.
The survey, conducted by business intelligence firm Morning Consult and health tech company Innovaccer, found just 1 percent of executives think FFS billing with no connection to value will be in use in 2025.
According to a Sept.14 news release, payers report that FFS billing with no account for value makes up more than 10 percent of billing, higher than providers estimated. “So, providers think the transition to value has substantially occurred, when in fact we’re only at the very beginning,” Brian Silverstein, MD, Innovaccer’s chief population health officer, said in the release. “The amount of financial risk providers have is going to increase significantly in the next few years.”
To read more, got to Becker’s Payer Issues.
|New Playbook Aims to Help Employers, Plan Sponsors Negotiate Hospital Prices |
By Paige Minemyer | September 8, 2022
A new playbook aims to arm employers with the tools needed to negotiate hospital prices.
The National Alliance of Healthcare Purchased Conditions released the book on Thursday, and it offers strategies for plan sponsors to harness newly released price transparency and quality data as leverage to drive down prices. The book notes that hospitals charge commercial plans significantly more than Medicare, often with prices 140% to 200% higher than Medicare rates.
The group says a “fair price” would instead “allow for a reasonable markup from costs and a price that is competitive with peer hospitals” without price-gouging the commercial market.
“For the first time, we finally have data that reinforces what we’ve long known—hospitals prices are out of control—and we can’t rely on health systems and health plans to course correct,” said Michael Thompson, National Alliance president and CEO, in a release. “Employers not only have the right, but a responsibility as plan fiduciaries, to negotiate fair prices. Now is the time for honest discourse and action on what is reasonable to pay for services provided.”
So what can employers do in these negotiations? For one, using the data now available, they can identify what a hospital needs to earn to break even and can build potential rates from there. Once that breakeven point is determined, plan sponsors can compare prices between hospitals to get a feel for market dynamics.
The Employers’ Forum of Indiana has launched Sage Transparency, a free hospital pricing dashboard that employers can use to compare hospital pricing and quality data. The tool pulls from multiple data sources, including RAND Corporation, the Centers for Medicare & Medicaid Services and Turquoise Health.
The National Alliance says that this tool and others like it are valuable resources that employers can tap into when determining a fair market price for hospital services. And While there isn’t a one-size-fits-all solution, plan sponsors can mix and match the suggestions in the playbook to meet their local needs, the alliance said.
To read more, go to Fierce Healthcare.
|ASA Submits Comments on CMS’s Proposed Rule for the CY2023 Medicare Physician Fee Schedule/Quality Payment Program |
September 7, 2022
Today, ASA submitted comments to the Centers for Medicare & Medicaid Services (CMS) opposing significant payment cuts to anesthesiologists while providing comprehensive and detailed solutions on a wide range of issues surrounding physician payment and the agency’s quality programs. ASA’s comments were issued in response to CMS’ CY2023 Medicare Physician Fee Schedule and Quality Payment Program proposed rule, released in July 2022.
ASA’s comments expressed concern about the magnitude of Medicare payment cuts and the cuts to the Anesthesia Conversion Factors. The proposed rule underscored how the Medicare payment system is broken, especially during a time when anesthesia groups are faced with inflation pressures and the COVID-19 pandemic. ASA asked CMS to work with Congress and other policymakers to resolve this issue and mitigate any negative impacts on physician practices and clinical patient outcomes. ASA will continue to advocate to legislative stakeholders and regulatory agencies to minimize and reverse these cuts that negatively impact anesthesiologists.
ASA met with CMS representatives in August to convey concerns with the proposed valuations of the recently reviewed Somatic Nerve injection codes. ASA reiterated these concerns in the comment letter to CMS and urged the agency to consider RUC recommended values.
Other recommendations in ASA’s letter include support for establishing coding and billing to describe chronic pain management services; a request to delay revisions to the Medicare Economic Index until after the COVID-19 Public Health Emergency; a push for more frequent updates to indirect practice expense data; and support for adjustments in the physician fee schedule for the purchase of domestically made and approved N95 surgical respirators.
On the Quality Payment Program section of the rule, ASA supported policies that will maintain a 75-point threshold for the Merit-based Incentive Payment System (MIPS) and the implementation of the anesthesia MIPS Value Pathway for 2023. ASA opposed the removal of MIPS76: Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections and asked CMS to delay onerous testing requirements on Qualified Clinical Data Registry measures. ASA also requested CMS to establish policies that will prevent physicians from being excluded in alternative payment models and aid the transition from legacy and paper records to electronic health records.
Final regulations will be issued on or around November 1, and unless otherwise noted, policies will be effective January 1, 2023.
To read more, go to ASA’s website.
|How Signify Health Fits into CVS’ Healthcare Strategy |
By Paige Minemyer | September 6, 2022
CVS Health has taken the first step in its bid to branch further into healthcare services with its acquisition of Signify Health, executives said Tuesday.
CVS announced late Monday that it will buy home health company Signify in a deal valued at about $8 billion in cash. The retail healthcare giant beat out a number of competitors including big names like Amazon and UnitedHealth Group to snap up Signify.
Bringing Signify into the fold advances the company further into both the home health and the managed service organization (MSO) markets, Sree Chaguturu, M.D., CVS Health’s chief medical officer, told Fierce Healthcare. It also builds on the foundation CVS has built in retail health through its pharmacies and MinuteClinic locations.
“Our relationship with Signify Health helps us meaningfully advance that strategy in two of the three verticals, MSO and home health, so we’re really excited about that,” he said. In addition to home health and value-based care, CVS flagged primary care as a focus for its expansion efforts. On its second-quarter earnings call, executives said that the company was eyeing a major play in the primary care market by the end of this year.
To read more, go to Fierce Healthcare.
|Private Equity Investors Sharpen Focus on Specialty Healthcare |
By Caroline Hudson | September 6, 2022
Healthcare private equity deals in 2022 aren’t living up to last year’s red-hot performance, but investors still want in on specialty care.
More than 740 deals occurred in healthcare services in the first half of the year, down 20% from the same period in 2021 but an increase of 16% from 2019, according to an Oliver Wyman report. Private equity deals continue to play a significant role in healthcare, even as inflation and higher costs change the landscape.
Investors’ interest in physician practices began years ago, starting in areas such as urgent care, dermatology and anesthesia. Healthcare’s recession resilience is attractive to investors. There is also money to be made on such a large portion of the economy – about 20% of U.S. gross domestic product, according to the Centers for Medicare & Medicaid Services.
Investors today are increasingly interested in the “-ologies,” higher-level care services including cardiology, neurology and radiology, said Ashraf Shehata, partner and U.S. national sector leader for healthcare and life sciences at consultancy KPMG. Orthopedics is another area garnering attention. Physician practices historically have been fragmented and often inefficient, creating additional opportunities for private equity firms to step in.
“Any ability to include or have a value-based component around those practices is very attractive to private equity firms,” said Angela Humphreys, co-chair of the healthcare private equity team at Nashville, Tennessee-based Bass, Berry & Sims. “They are able to bring to bear efficiencies that of course help with the bottom line but also improve patient care.”
In late 2021, private equity firm Welsh, Carson, Anderson & Stowe acquired Resurgens Orthopaedics, Georgia’s largest orthopedic group serving roughly 800,000 patients, to form a new physician-owned company. Silver Oak Services Partners invested in Integrated Oncology Network in 2018, a deal followed by additional cancer-related acquisitions, and in 2021, the creation of a new platform for urology services. Financial terms were not disclosed.
Shehata also noted a renewed interest in home health services, such as physical therapy or skilled nursing.
However, some private equity investors have recently come under fire for implementing cost-cutting measures that critics say ultimately jeopardize patient care. Englewood Cliffs, New Jersey-based investment company Portopiccolo Group, which began investing in nursing facilities several years ago, has been accused of mishandling the COVID-19 response in some of its 100-plus facilities. Employees and family members alleged the company failed to follow protocols or obtain supplies needed to stem the pandemic, while employing too few workers.
A common thread running through the wide-ranging investor interest in specialty care is healthcare organizations’ own push to operate more efficiently. That is especially important in the current environment, as providers try to navigate high labor costs, rising prices and patient volumes not yet back to pre-pandemic levels.
Chet Hosch, partner at law firm Burr & Forman, said he understands the scrutiny associated with private equity investments in healthcare, but he thinks these deals can improve patient care. The firms are not as constrained by quarterly profits and can make necessary infrastructure and technology investments, he said. “The perception is – and I don’t think it’s fair – but the perception is that private equity will always sacrifice patient care for profit,” Hosch said. “I think both of those things can be served, and I think they’re enhanced in private equity anyway because they can take the long-term.”
To read more, go to Modern Healthcare.