Radiology Digest – September 6, 2022

September 1, 2022

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Radiology Digest: News from the week of September 6, 2022.
CMS Proposes Big Changes to Medicaid, CHIP Enrollment
By Maya Goldman | August 31, 2022 | Included in Radiology Digest – September 6, 2022

Applying for Medicaid or Children’s Health Insurance Program benefits would become much easier under a proposed rule the Centers for Medicare and Medicaid Services published Wednesday.

The draft regulation includes several policies that would ease access to the low-income health programs, such as limiting eligibility checks to once every 12 months, requiring renewal forms to be pre-populated with certain information and establishing consistent processes across states. The plan also includes measures to help qualified beneficiaries remain on the programs from year to year.

“This proposed rule will ensure that these individuals and families, often from underserved communities, can access the healthcare and coverage to which they are entitled—a foundational principle of health equity,” CMS Administrator Chiquita Brooks-LaSure said in a news release.

Nearly 89 million people were enrolled in Medicaid or CHIP as of May, the most recent CMS data show. These two programs combine to cover 51% of U.S. children, according to a CMS news release.

States must maintain their Medicaid rolls in order to receive extra federal funding during the ongoing COVID-19 public health emergency. After that expires, states are free to resume eligibility redeterminations and remove people who no longer qualify. The emergency designation is set to lapse in October but likely will be extended at least once into mid-January. 

Approximately 15 million people will lose coverage when the public health emergency ends, the Department of Health and Human Services projects. In addition, HHS expects that approximately 6.8 million who are still eligible will lose coverage because of administrative roadblocks. Children, young adults, and Black and Latino beneficiaries are more vulnerable to losing benefits than other groups, according to HHS.
To read more, go to Modern Healthcare.  
  ‘Not So Optimistic:’ Surprise Billing Arbitrations Cause Frustration
By Maya Goldman | Nona Tepper | August 30, 2022 | Included in Radiology Digest – September 6, 2022

The surprise billing arbitration process has gotten off to a rocky start. 

Insurers are accusing providers of submitting every possible claim, even when they know some cases are not eligible for mediation. Providers allege insurers are holding up the federal dispute process by delaying submissions of clear and complete information. The recently published final rule on the process from the Health and Human Services, Labor and Treasury departments likely will not resolve all these problems.

“I’m a generally optimistic person. But I’m not so optimistic,” said Dr. Lisa Maurer, a physician at Emergency Medicine Specialists in Milwaukee and chief medical officer for medical management services organization ConsensioHealth.

The No Surprises Act, which took effect Jan. 1, requires insurers and providers that fail to agree on rates for out-of-network care to engage in independent dispute resolutions overseen by arbiters. The Centers for Medicare and Medicaid Services unveiled the federal mediation portal in April.

Mediators decided just 1,200 out of 46,000 disputes submitted to the portal as of Aug. 11, according to the most recent federal data. CMS received “substantially more” cases to review than initially expected, the agency reported this month. Three of the 11 independent dispute resolution entities are no longer accepting new cases, according to CMS. 

“If all of that potential revenue is just being delayed six months, nine months, who knows—that really does affect the bottom line,” Maurer said. Emergency Medicine Specialists has not felt much financial pressure from arbitration delays because of its low volume of out-of-network services, she said.

Under the final rule, mediators must consider insurers’ median in-network payment rates for services but can also consider other qualitative factors in determining the correct sums, such as where patients were treated, the severity of their conditions and the level of their doctors’ experience. The median rate, called the qualifying payment amount, is often so low that providers feel forced to enter the independent dispute resolution process, said Manuel Bonilla, chief advocacy officer for the American Society of Anesthesiologists. 

Time spent determining how many of these cases qualify for federal arbitration has been the primary cause of delays, CMS reported in a notice this month. Insurers and providers that did not initiate disputes have challenged the eligibility of mediation for more than 21,000 cases, and arbiters tossed out 7,000 more.

Providers are unclear if disputes should be decided by federal or state mediators because insurers are not disclosing the types of plans the patients have, which is one reason they are submitting some ineligible cases to the federal system, said Ed Gaines, vice president of regulatory affairs and industry liaisons at revenue cycle management firm Zotec Partners. 

“[Mediators] need more resources, they need more [independent dispute resolution entities], they need more training and they need more clarity around their rules and regulations,” said Gaines, who is a member of the reimbursement committee at the American College of Emergency Physicians.

To read more, go to Modern Healthcare.  
CMS Releases Shared Savings Program Results for 2021
By Maya Goldman | August 30, 2022 | Included in Radiology Digest – September 6, 2022

More than half of accountable care organizations in the Medicare Shared Savings Program generated savings in 2021, the Centers for Medicare and Medicaid Services announced Tuesday. 

These ACOs saved Medicare $1.66 billion last year—0.2% of total Medicare spending—making 2021 the fifth consecutive year the program netted savings. Still, performance declined from the prior year, when the ACOs saved $1.9 billion. About 58% of participating ACOs shared in the savings in 2021, down from 67% in 2020.

The decrease does not seem significant to the National Association of Accountable Care Organizations, CEO Clif Gaus said. 

“This is almost the fourth year of no growth, yet we’re at least holding our level here in savings despite all the disruptions from COVID,” Gaus said. “I hope that hospitals that have really been impacted financially by COVID will still see a way to invest money in new accountable care organizations,” he said.

Growth in the program has leveled off in recent years: ACOs covered 10.7 million lives in 2021, down from 11.2 million in 2020, according to CMS data. Low-revenue ACOs created $237 in per capita net savings last year, while high-revenue ACOs garnered $124 per capita. Low-revenue ACOs’ Medicare yield is less than 35% of their Medicare spending, a distinction that allows them to remain in lower-risk arrangements for longer. Hospital-led ACOs tend to be classified as high-revenue. ACOs comprising mostly primary care providers saw $281 in per capita net savings, compared to $149 for ACOs composed of fewer than 75% primary care clinicians.

Ninety-nine percent of ACOs in the program met quality standards that enable them to earn shared savings for last year. ACOs earned $1.96 billion in performance bonus payments in 2021 compared with $2.3 billion the year before.

To read more, go to Modern Healthcare.  
ASTRO: ‘We Hope This Official Delay Provides an Opportunity for CMS to … Work More Closely with the Radiation Oncology Community’
By Dave Pearson | August 28, 2022 | Included in Radiology Digest – September 6, 2022

Last week CMS dug in with its decision to put off finalizing an alternative value-based payment model for radiation oncology services to “a date to be determined through future rulemaking.”

The American Society for Radiation Oncology issued a statement almost immediately.

Attributing the response to ASTRO’s board chair, Laura Dawson, MD, the organization encouraged the agency to work with practitioners of the specialty on formulating an episode-based, i.e., bundled, approach to reimbursement.

“ASTRO continues to believe that episodic payments will improve access and quality, advance health equity and reduce costs in cancer care,” Dawson says in the prepared remarks posted Aug. 25. “We hope that this official delay provides an opportunity for CMS to work with stakeholders on a new value-based reimbursement structure for radiation therapy.”

More from Dawson on behalf of ASTRO: “Fair and stable Medicare payments are essential to support modern cancer care, especially as clinics face rising inflation costs. We are optimistic that CMS will work more closely with the radiation oncology community on a reformed push for episodic payments.”

ASTRO also points out that it sent CMS a letter in June summarizing “longstanding concerns” held by members of both parties in Congress as well as radiation oncology professionals. The comments focused on the evident emphasis the currently conceived model places on cost savings over treatment quality.

The June letter also proposed revisions to the standing RO model that, in ASTRO’s estimation, would “foster successful participation from physicians and generate substantial saving for the Medicare program.”

To read more, Radiology Business.  
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