|CMS Releases 2023 Medicare Physician Fee Proposed Rule
July 7, 2022
On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that announces and solicits public comments on proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2023. Zotec will publish an in-depth summary next week.
Read the Fact Sheet on CMS.gov.
|POCUS Access: Urban Oases, Rural Deserts
By Dave Pearson | July 6, 2022
Fewer than 40% of rural counties in the U.S. can offer residents any access to point-of-care ultrasound, while nearly 90% of their metropolitan counterparts have POCUS aplenty, according to a study published in the open-access journal Cureus.
Researchers at Carle Illinois College of Medicine, medical school of the University of Illinois Urbana-Champaign, made the finding after reviewing more than 30 million ultrasound-related CPT codes billed to Medicare from more than 3,000 counties between 2015 and 2019.
Of 30,135,085 codes included in the analysis, 73% reflected diagnostic exams and 27% ultrasound-guided procedures, corresponding author Nicholas Peterman and colleagues report.
To merge information germane to the CMS reimbursement records, the authors mined public datasets from the U.S. Department of Agriculture and other county-level sources for 39 variables indicative of socioeconomic, health and ultrasound characteristics.
Their key findings:
38.84% of rural counties had access to POCUS compared to 88.56% of metropolitan counties and 74.19% of counties overall.
POCUS hotspots were concentrated in Southern California and Eastern states.
Coldspot areas were conspicuous in the Great Plains and Midwest.
Compared with coldspot clusters, hotspot clusters were significantly more densely populated, and residents were more urbanized, college-educated and likely to have been seen in an emergency department.
Hotspot populations also were more likely to be obese (19.0% to 12.9%), less likely to be uninsured (10.1% to 13.0%), had more Black representation (8.5% to 3.4%) and less Hispanic representation (2.6% to 5.5%).
To read more, go to Radiology Business.
|Report: These Are the Factors Impacting Individual, Small Group Premiums in 2023
By Paige Minemyer | July 5, 2022
The lingering effects of COVID-19, the end of enhanced subsidies for exchange plans and global inflation are among the key trends impacting premiums in 2023, according to a new report.
The American Academy of Actuaries issued its annual look (PDF) at the landscape for premiums on the individual and small group markets, and analysts said the enhanced subsidies and record enrollment that followed changed the risk pool for plans on the Affordable Care Act’s exchanges, and the end of those tax breaks likely portends a hike in premiums.
Should the subsidies, which were bolstered as part of the American Rescue Plan, fall off, people will leave the market, the actuaries said. Many of those who were lured into the market due to the expanded subsidies were healthier, and if they leave the risk pool costs will go up.
Barb Klever, vice chairperson of the academy’s Health Practice Council, said during a webinar that the timing around the subsidies’ expiration makes it hard for insurers to account for them in rate filing should they be renewed. Some states, she said, are asking plans to submit rate documents that reflect both scenarios.
Other states are asking insurers to include the potential impact of these subsidies on premiums, which could make updates to rates easier, Klever said. However, accounting for the subsidies is not universal across the country, she said.
“Improvement in the risk pool leads to lower gross premiums,” Klever said. “The impact on gross premiums is more incremental, and is directly tied to the health of the risk pool as a whole.”
In addition, Medicaid eligibility redeterminations, which will resume when the public health emergency ends, could also impact the risk pool by bringing in healthier people. This could drive premiums down overall, according to the report, but the effects will vary state by state depending on how quickly they begin the redetermination process.
Inflation’s impact on the healthcare industry is likely to extend to individual and small group premiums as well, the actuaries said. Inflation impacts providers in particular in their supply chain needs, and those challenges will likely bleed into negotiations over rate agreements with health plans. Of note, the actuaries said, is that these reimbursement deals are usually negotiated over the course of several years, so that impact of inflation may be felt for some time.
To read more, go to Fierce Healthcare.
|CMS Shoots Down Request to Reconsider CTC Cancer Screening Coverage
Hannah Murphy | July 5, 2022
The Centers for Medicare and Medicaid Services has denied the American College of Radiology’s request to reconsider their National Coverage Determination regarding coverage of computed tomography colonography exams as a means to screen for colorectal cancer.
In the June 29 announcement, the ACR revealed CMS said the additional evidence provided to them was “insufficient” to support the reconsideration of their non-coverage decision that was made in May of 2009.
The ACR refuted this claim, stating: “The ACR and the patient advocacy groups contend ample clinical evidence was provided to support coverage of this valuable preventive screening service.”
The evidence submitted by the ACR and other organizations included recommendations provided by the United States Preventive Services Task Force (USPSTF). In May 2021, the USPSTF included the use of computed tomography colonography (CTC) in their final colorectal cancer screening recommendations. That recommendation also suggested reducing the screening eligibility age to 45.
Despite this endorsement, CTC screening remains the only test recommended by the USPSTF and American Cancer Society (ACS) that is not covered by Medicare or traditional Medicaid as a primary cancer screening option. The Affordable Care Act requires that private insurers cover all USPSTF-recommended screenings without cost-sharing, so when patients who have been utilizing CTC screening become eligible for Medicare, they are at risk of losing access to the exam.
A meeting between the ACR and the CMS Coverage and Analysis Group to discuss the reasoning behind the denial is set to take place in July.
Read the full ACR statement here. To read more, go to Health Imaging.
|Price Transparency Rule Leads to Insurer Confusion
By Nona Tepper | July 5, 2022
Health insurance companies may not be ready to fully comply with new price transparency rules, but the government is ready to issue the fines.
At the start of July, federal regulators began enforcing a requirement that health insurers disclose the negotiated rates they pay to in-network providers and the potential out-of-network billable amounts patients may owe. Insurance carriers must present these data in a publicly available, machine-readable format online. Along with a related rule mandating hospitals disclose prices, the policy aims to help patients understand their costs and seek lower prices.
The regulation is vague and underwent changes late in the process, which makes it difficult for insurers to understand just what it means to be in compliance, said Dan Kuperstein, a senior vice president of compliance at consultancy Corporate Synergies and an attorney who specializes in employee benefits law. That’s even more true for smaller carriers, employers and third-party administrators, he said.
“The rule was written in very ‘legalese’ terms,” Kuperstein said. “It’s my job to break the legalese down, and even I found this one tough compared to other regulations I have been looking at.”
A week before the regulations took effect, the Centers for Medicare and Medicaid Services clarified that self-funded employers lacking consumer-facing websites could post the prices negotiated with providers on their third-party administrators’ websites.
But many other details about how to comply remain unclear. For example, businesses that use recruitment services to find job candidates are unclear about whether it’s sufficient to only post negotiated rates on third-party careers websites, Kuperstein said. Insurers that rent provider networks from other carriers are also unsure whether they are responsible for posting rates on their own websites, or if it’s enough for the other health insurance company to make the prices publicly available, he said.
And starting Jan. 1, insurers will be required to disclose out-of-pocket costs for 500 common, covered services via online, self-service tools. In 2024, health insurers will need to include personalized information for all medical services.
To read more, go to Modern Healthcare.
|Big Private Payer Reverses Course on Cardiac PET/CT Coverage
By Dave Pearson | July 1, 2022
One of the largest private health insurers in the U.S. has gone from considering hybrid PET/CT for cardiac indications “experimental/investigational”—and thus not coverable—to displaying willingness to pay for the modality, evidently at the urging of two imaging associations.
The Society for Nuclear Medicine and Molecular Imaging publicized the change June 27, saying 39 million-enrollee Aetna reversed course on PET/CT a few days after SNMMI and the American Society of Nuclear Cardiology (ASNC) sent the insurance giant a pointed letter.
“Not covering hybrid PET/CT denies patient access to standard-of-care testing that is required to make life-saving clinical decisions,” SNMMI says in a press release conveying the gist of the letter. “SNMMI and ASNC’s recommendations regarding the role of PET/CT in the evaluation of coronary artery disease have been accepted by the American Medical Association (AMA) RVS Update Committee (RUC) and multiple payers, including CMS.”
Aetna, a CVS Health company, covers close to 40 million individuals, according to the company.
Full SNMMI announcement here.
To read more, go to Radiology Business.
|Payers Must Post Negotiated Prices Starting Today
By Jakob Emerson | July 1, 2022
CMS’ Transparency in Coverage final rule took effect July 1, requiring payers nationwide to publish the cost of nearly every healthcare service they’ve negotiated with providers.
Eight things to know:
The rule was set to take effect Jan. 1, but CMS delayed implementation for six months over concerns with the time and effort it would take payers to come into compliance with the new policy.
The rule requires payers to disclose in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for all covered items and services, and negotiated rates and historical net prices for covered prescription drugs administered by providers.
Prices must be posted in machine-readable files containing the following sets of costs for items and services:
In-network rate file: rates for all covered items and services between the payer and in-network providers. Allowed amount file: allowed amounts for and billed charges from out-of-network providers. Payers not in compliance could face fines of up to $100 per day for each violation and for each individual affected by the violation.
An enforcement exception will be granted when health plans using alternative reimbursement arrangements cannot accurately provide a specific dollar amount until after services are rendered. Those plans can instead list the formula, variables, methodology or other information about how the rate would be derived.
For contractual arrangements where a health plan agrees to pay an in-network provider a percentage of the billed charges and is not able to assign a dollar amount until a bill is generated, the plans may instead report the percentage number.
In 2023, payers must provide an internet-based price comparison tool that allows members to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers for 500 items and services, and for all services by 2024.
Provider price disclosure rules went into effect at the start of 2021, but the majority of facilities have not complied. CMS warned 342 hospitals they were not in compliance in February and fined the first health system in June for violations.
To read more, go to Becker’s Payer Issues.
|Some Medical Debt is Being Removed From U.S. Credit Reports
Associated Press | July 1, 2022
Help is coming for many people with medical debt on their credit reports.
Starting Friday, the three major U.S. credit reporting companies will stop counting paid medical debt on the reports that banks, potential landlords and others use to judge creditworthiness. The companies also will start giving people a year to resolve delinquent medical debt that has been sent to collections before reporting it — up from six months previously.
Next year, the companies also will stop counting unpaid medical debt under at least $500.
The companies say these moves will wipe out nearly 70% of the medical debt listed on consumer credit reports.
Patient advocates call that a huge advance. But they question whether medical debt should be on credit reports at all, given that many see it as a poor indicator of whether someone is trustworthy for a loan or rent.
“These aren’t people who bought shoes they couldn’t afford,” said Amanda Dunker, of the nonprofit Community Service Society of New York. “They went to a doctor because they were sick or needed help with an injury.”
To read more, go to Modern Healthcare.