|CMS Instructs IDR Entities to Hold Payment Determinations
By Jacqueline LaPointe | February 16, 2023
CMS recently instructed certified independent dispute resolution (IDR) entities to hold all payment determinations until the Departments of Health and Human Services, Labor, and the Treasury issue further guidance.
The federal agency announced the hold in a Feb. 10 email to subscribers. The email also said that certified IDR entities must recall any payment determinations issued after Feb. 6, 2023.
The US District Court for the Eastern District of Texas issued a judgment and order on Feb. 6, vacating certain parts of federal regulations implementing the IDR process under the No Surprises Act (NSA). This is the second court ruling regarding the implementation of the IDR process.
“The Departments are currently reviewing the court’s decision and evaluating current IDR processes, guidance, templates, and systems for updates that will be necessary to comply with the court’s order,” CMS said in the email.
“The Departments will provide specific directions to certified IDR entities for resuming the issuance of payment determinations that are consistent with the court’s judgment and order. Certified IDR entities should continue working through other parts of the IDR process, including eligibility determinations, as they wait for additional direction from the Departments.”
Judge Jeremy D. Kernodle of the US District Court for the Eastern District of Texas ruled earlier this month that certain parts of the revised IDR process following an August 2022 rule from the Departments were inconsistent with the NSA.
In a previous case from nearly a year ago, Judge Kernodle held that an interim final rule from the Departments also contradicted the NSA by imposing “rebuttable presumption” that the offer closest to the qualifying payment (QPA) amount should be chosen. The Departments then replaced the interim final rule with rulemaking in August 2022.
However, the Texas Medical Association, which filed the original lawsuit, also sought to vacate the new final rule. They argued that, just like the interim final rule, the new rule put more emphasis on the QPA relative to other factors, such as patient acuity, clinician characteristics, and market share. Judge Kerndole agreed with the Texas Medical Association and other plaintiffs.
The payment determination pause issued by CMS earlier this month will delay the IDR process, according to Max Czernin, partner at Squire Patton Boggs, writing in The National Law Review. It is also likely to lead to further backlogs as new claim disputes are submitted, Czernin wrote.
A report from the Departments describes a significantly higher volume of claims than the Departments initially estimated. Payers and providers submitted over 90,000 disputes from April 15 through September 30, 2022, the report stated. The Departments had estimated in the 2021 interim final rule that 17,333 claims would be submitted as part of the federal IDR process each year.
Payers and providers can submit a dispute to the IDR process if both parties fail to arrive at an agreed-upon payment amount during a 30-day open negotiation payment for items and services covered by NSA, which include surprise bills for emergency services, non-emergency items and services furnished by out-of-network providers at in-network facilities, and services provided by out-of-network air ambulance providers. The IDR process is a “baseball-style” arbitration process in which both parties submit payment amounts and explanations to a certified IDR entity, which then selects one of the proposed amounts based on certain factors, including the QPA.
The IDR process launched on April 15, 2022.
To read more, go to Revcycle Intelligence.
Five Unanswered Questions About CMS’ New Medicare Advantage Audit Rule
By Jakob Emerson | February 15, 2023
In January, CMS said it will implement stricter auditing practices around Medicare Advantage plans, but payers and policy experts say they have a lot of questions about the next steps forward.
The new risk-adjustment data validation audit rule is expected to leave commercial payers collectively on the hook for up to $4.7 billion in repayments to the federal government over the next decade. The final rule will only apply to contracts dated from payment year 2018 and up.
Nearly every major insurance company has been accused of or settled allegations of MA fraud in recent years, which the industry disputes. Payers are accused of exploiting the program through “upcoding” schemes that make patients appear sicker on medical records than they actually are — thereby leading to higher payments from CMS. Some diagnoses are at a higher risk for being miscoded, which can also result in overpayments.
During fourth quarter earnings calls with investors over the last month, payer executives made it clear they are still evaluating how to respond to the new rule and are awaiting more information from CMS around how the changes will be applied to MA plans.
“The lack of fee-for-service adjustment and the as yet undefined sampling and extrapolation methodology leaves a number of open questions as to the viability of the final approach,” Centene CEO Sarah London said Feb. 7.
Five key unanswered questions:
How will CMS determine which MA plans to audit?What methodology will CMS use for audits going forward?How will CMS decide when to extrapolate its results?Is there a specific sampling methodology and error estimation strategy that CMS will use?Will CMS’ audits be coordinated with OIG offices? Sean Creighton is managing director at Avalere Health, a Washington, D.C.-based healthcare consulting firm. He said payer executives need to be engaged in the policy response and any advocacy that takes place around the new rule.
“This is a multifaceted issue and health plans can best prepare by developing enterprise level work streams to address implications for the 2024 bid, potential liability and financial accruals, compliance and coding practices, and provider contracting,” he said.
The new rule may also increase regulatory burden on providers, who could face more scrutiny over how they document a MA patient’s medical conditions.
To read more, go to Becker’s Payer Issues.
AMA Urges CMS to Finalize Medicare Advantage Prior Authorization Reforms
By Victoria Bailey | February 14, 2023
The American Medical Association (AMA) and 118 other medical organizations have urged CMS to finalize its proposed prior authorization reforms for the Medicare Advantage program.
In a letter to CMS Administrator Chiquita Brooks-LaSure, AMA responded to CMS’ Notice of Proposed Rule Making for Part C & Part D (CMS-4201-P), urging the agency to finalize the proposed reforms that would minimize the inappropriate use of prior authorization requirements by Medicare Advantage plans.
“Physicians appreciate the efforts of CMS to address the significant and multifaceted challenges that prior authorization requirements pose to Medicare beneficiaries and physicians,” Jack Resneck Jr, MD, president of AMA, said in the press release.
“We applaud CMS for listening to physicians, patients, federal inspectors, and many other stakeholders, and recognizing a vital need to rein in Medicare Advantage plans from placing excessive and unnecessary administrative obstacles between patients and evidence-based treatments.”
The proposed rule included provisions that aim to streamline prior authorization requirements by adding continuity of care requirements and reducing disruptions in ongoing care. CMS proposed that when a beneficiary is granted prior authorization approval, it will remain valid for the entire course of treatment.
The agency also proposed that prior authorization policies for coordinated care plans may only be used to confirm the presence of diagnoses or other clinical criteria and ensure that a service is medically necessary. In addition, the rule stated that plans must provide a minimum 90-day transition period when a beneficiary currently undergoing treatment switches to a new Medicare Advantage plan.
To read more, go to Revcycle Intelligence.
Cardiac Imagers Need to Understand AI as It Enters Clinical Use and ACC Guidelines
By Dave Fornell | February 14, 2023
The vast majority of 500 artificial intelligence (AI) algorithms now cleared for clinical use in the U.S. are for radiology and cardiology. For this reason, cardiologists and radiologists need to learn how these technologies work and realize the clinical use of AI is no longer science fiction.
Ed Nicol, MD, consultant cardiologist and honorary senior clinical lecturer with Kings College London and president-elect of the Society of Cardiovascular Computed Tomography (SCCT), explained AI in cardiac CT is here to stay and its use is expanding. One AI-based algorithm is already included in recent cardiology guidelines and more will likely follow.
“We really need to upscale cardiologists’ understanding of this technology. We live in a digital world and medicine tends to be fairly conservative, but I think people are recognizing AI is here to stay and we have to embrace it. In the clinical community, we need to be at the forefront,” Nicol explained.
The academic discussions on AI and its future applications at conferences are largely over. What is now being discussed are actual U.S. Food and Drug Administration (FDA)-cleared products sold on the market and in clinical use.
According to Nicol, AI has now become real, and the first cardiology AI algorithm is now included in practice guidelines in both Europe and the United States. The ACC/AHA 2021 Chest Pain Guidelines include the recommended use of AI-driven fractional flow reserve hemodynamic flow measurements derived from noninvasive CT imaging (FFR-CT).
“If you had said to me 15 years ago, we were going to have some sort of computational fluid dynamics tool in the U.S. chest pain guidelines, you would have been laughed at. Everyone would have said you were crazy. But that is the reality, we see FFR-CT in the international guidelines, based on evidence. That will be the first, I suspect, of many,” Nicol said.
To read more, go to Radiology Business.
Cloud Storage Helps Solve Radiology IT and Cybersecurity Issues and Is Growing
By Dave Fornell | February 13, 2023
When cloud was first offered as a solution for radiology data and image storage a decade ago, many hospitals were hesitant about moving their data offsite. But today, things are rapidly changing as people are comfortable using the cloud in both their personal and professional lives. Cloud migration all helps solve several key issues with remote access, enabling web based PACS or enterprise imaging systems, easier integration with the electronic medical record (EMR), it can help solve cybersecurity issues, and reduce IT burdens of maintaining on premise server farms.
Radiology Business spoke with Amy Thompson, a senior analyst at Signify Research, explains what she is seeing in radiology PACS and enterprise imaging systems in the market in terms of cloud adoption. She said there has been rising interest in adopting cloud the past few years, and the COVID pandemic showed many healthcare systems the value of having a cloud-based system for easier remote access to access or share patient data and imaging.
“One trend that we cannot deny, and it keeps growing each year is cloud, especially in radiology IT,” Thompson explained. “It has been a buzz term for a couple years. We started to see an emphasis at RSNA 2020 on cloud PACS and cloud imaging IT. But we are really starting to see the vendors and the market become more accepting of it.”
Not only are radiology IT vendors talking more about cloud and how it can help medical imaging, but there has been rapid growth in major cloud providers entering healthcare, and especially the imaging side. These include Google, Amazon Web Services (AWS) and Microsoft being much more visible in healthcare IT and numerous health IT vendors making partnership announcements with them.
She said these partnerships are helping drive further adoption of cloud and in the types of services being offered to healthcare IT departments. She said this is a major shift in how data has been stored and made accessible from the past and she expected the large on-premises data storage market to shift in the coming years to more and more cloud adoption because it solves many issues.
“It’s really about re-architecting and leveraging the technical components that cloud offers. This includes containerization and the ability to scale. When you look at the U.S. market and the amount of consolidation going on with outpatient imaging centers, healthcare systems need that flexibility to scale up and expand their platform,” Thompson said.
She said there is a movement across radiology IT vendors toward becoming cloud native platforms. She said this is incremental, but that is clearly where many vendors are headed.
Thompson said providers today need to do more with less, so they are trying to find ways to maximize efficiency, and the cloud can offer than for clinical workflows, including easier access to patient images and data across healthcare systems. From an IT perspective, outsourcing data storage to the cloud can help simplify and streamline many of their functions so their limited staff can concentrate on other needs for maintaining, updating, or expanding IT systems.
Cybersecurity of healthcare data is enhanced using cloud storage vendors.
Ironically, it was concerns about data security and HIPAA compliance that caused many providers to shy away from cloud over the past decade, but today they are seriously looking at how the cloud can actually enhance cybersecurity.
To read more, go to Radiology Business.
LDCT Lung Cancer Screening Reduces Mortality, but Uptake Remains Low
By Kate Madden Yee | February 13, 2023
A study that included more than a million people screened for lung cancer with low-dose CT (LDCT) shows that screening finds cancer earlier, thus improving patient outcomes, according to a study published February 10 in Chest.
But of course, that’s only among those who actually get screened — and adherence to lung cancer screening remains low, wrote a team led by Dr. Gerard Silvestri of the Medical University of South Carolina in Charleston.
“[Our study found that] adherence to lung cancer screening was poor and likely contributes to the lower than expected cancer detection rate, all of which will impact the outcomes of patients undergoing screening for lung cancer,” the group noted.
In 2013, the U.S. Preventive Services Task Force (USPSTF) recommended annual LDCT lung cancer screening after results from the National Lung Cancer Screening Trial (NLST) had been released. In 2015, the Centers for Medicare and Medicaid Services (CMS) made lung cancer screening a covered benefit and required facilities to report screening incidence to an approved registry (currently, the American College of Radiology maintains the only CMS-approved registry for this information). In 2021 the USPSTF updated its recommendation to expand the pool of individuals eligible for screening.
“Adherence is critical for realizing the promise of lung cancer screening, and the cancer detection rate is an important outcome when we think about whether the USPSTF recommendations include the most efficient criteria for identifying high-risk individuals who will benefit most from lung cancer screening,” the authors wrote.
The team sought to assess adherence and outcomes among people eligible to screen for lung cancer according to the USPSTF’s 2013 recommendation by conducting a study that included 1.2 million individuals from the ACR’s Lung Cancer Screening Registry (LCSR) who underwent baseline LDCT for lung cancer screening at 3,625 facilities between 2015 and 2019. The researchers identified predictors of adherence to screening and compared LDCT interpretations by Lung-RADS score, cancer detection rates, and stage at diagnosis to data from the National Lung Cancer Screening Trial (NLST).
To read more, go to Aunt Minnie.