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MEDICARE UPDATE May, 2005. Gerald N. Rogan, MD Presented to MOASC May 25, 2005. OUTLINE. Medicare Updates for 2005 Participating in Medicare Medicare Bonus Payments LCD process to include appeals to CMS Proposed Rule for National Coverage with Evidence Development (CED)

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medicare update may 2005

MEDICARE UPDATEMay, 2005

Gerald N. Rogan, MD

Presented to MOASC

May 25, 2005

outline
OUTLINE
  • Medicare Updates for 2005
  • Participating in Medicare
  • Medicare Bonus Payments
  • LCD process to include appeals to CMS
  • Proposed Rule for National Coverage with Evidence Development (CED)
  • Upcoming changes to Medicare appeals, 2006
  • Upcoming Carrier reform/consolidation 2006-2011
  • Medical imaging

Rogan Consulting

drug changes in 2005
Drug Changes in 2005
  • Changes in drug pricing --ASP + 6%
  • Changes in drug administration coding-new G codes—still under revision—look to 2006 CPT book for any additional changes.
  • Where to find coding information for drug administration?—see the hand out for web site information.

Rogan Consulting

drug supply 2006
DRUG SUPPLY-2006
  • The 2006 competitive acquisition program—proposal is under revision—it is unclear how suppliers can make money.
  • The 2006 Medicare part D program – will not switch covered drugs from the medical benefit (physician office) to the new part D pharmacy benefit.

Rogan Consulting

participating in medicare
Participating in Medicare
  • Participating in Medicare means accepting assignment on all claims.
  • Not participating in Medicare allow you to accept assignment on selected claims.
  • Those who do not participate in Medicare receive 95% of the drug allowable, even for assigned claims. (non-par amount).

Rogan Consulting

available medicare bonuses
Available Medicare Bonuses
  • Bonuses available for medical care in rural areas—HPSA and SSA.
  • Demonstration project bonuses
  • Quality Improvement Demonstration project.

Rogan Consulting

local coverage rules
Local Coverage Rules
  • IOM 100-8 Chapter 13.5.1 – Reasonable and Necessary Provisions in LCDs (Rev. 71, 04-09-04)
  • A service may be covered by a contractor if:
  • It is reasonable and necessary to diagnose or treat an illness or injury under 1862(a)(1)(A) of The Act.

Rogan Consulting

local coverage rules1
Local Coverage Rules
  • Safe and effective;
  • Not experimental or investigational (with certain exceptions):
  • Furnished in accordance with accepted standards of medical practice
  • Furnished in a setting appropriate to the patient's medical needs and condition;
  • Ordered and furnished by qualified personnel;
  • One that meets, but does not exceed, the patient's medical need; and
  • At least as beneficial as an existing and available medically appropriate alternative.

Rogan Consulting

proposed rule for ncds
Proposed Rule for NCDs
  • Non-coverage
  • Coverage with Conditions
    • Limited to specific clinical or demographic characteristics
    • Certain providers or facilities (qualified personnel)
    • Prospective data collection activity
  • Coverage without Conditions

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coverage with evidence development
Coverage with Evidence Development
  • The propose rule requires evidence showing improvement in net health outcomes for the beneficiary.
  • Certain restrictions may apply.
  • Without sufficient evidence, coverage is contingent upon development of additional evidence.
  • Without sufficient evidence and no studies, coverage will be denied.

Rogan Consulting

coverage with evidence development implications
Coverage with Evidence Development -Implications
  • Carriers may refer controversial or expensive requests for local coverage to the CMS CO for a NCD
    • Home brew lab tests.
    • Off-label drug use.
    • New cardiology tests.
    • New imaging uses.
    • http://www.cms.hhs.gov/coverage/download/guidanceced.pdfCOMMENT by June 6, 2005

Rogan Consulting

coverage with evidence development implications1
Coverage with Evidence Development -Implications
  • Oncologists may have more off-label clinical trials available for patient referrals.
  • Off-label drug use may be compared head to head, vs. drug to placebo.
  • The value of expensive diagnostic tests may be more carefully reviewed.
  • The value of a diagnostic test may be evaluated against another test.

Rogan Consulting

medicare appeals 2006
Medicare Appeals- 2006
  • Reviews will move from the carrier to a Qualified Independent Contractor (QIC).
  • Carrier HEARING OFFICERS will be replaced by QIC RECONSIDERATION SPECIALISTS
  • Reconsideration specialists need not follow LCDs.
  • Medicare ALJs will move from SSA to CMS.

Rogan Consulting

local coverage decision changes section 940 a
Local Coverage Decision ChangesSection 940 A.
  • The CAC-co chair may file an LCD appeal to the CMS regional administrator
  • The regional administrator may require mediation if the carrier shows a pattern and large number of LCD complaints
  • Resolution will be by mediation using a CMS trained physician.

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contractor reform consolidation
Contractor Reform/Consolidation
  • Carriers and FI’s will be part of one contractor.
  • CMS will establish 15 contiguous contracting regions.
  • California and Nevada will be one region.
  • Changes will start 2006 and complete by 2011
  • Existing contactors will partner with each other.

Rogan Consulting

contractor reform consolidation1
Contractor Reform/Consolidation
  • Contracts will be renewed annually and be re-competed every 5 years according to Federal acquisition rules (FAR).
  • CMS will offer contractors a financial incentive to perform better than average.

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contractor measures
Contractor Measures

Contractor evaluation will include

  • A measure of customer service.
  • A measure of claims payment and denial accuracy through the CERT program.
  • A measure of adequate program safeguards.
  • Timeliness and production goals.
  • Financial integrity.

Rogan Consulting

mac jurisdiction 1
MAC Jurisdiction 1

California, Nevada, Hawaii

American Samoa, Guam, Northern Mariana Islands

  • 3,049,449 F-F-S beneficiaries 67% of total;
  • 99,706 Practitioners
  • 521 Medicare Hospitals
  • 8.6% of national claims workload

(2003 data)

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mac jurisdiction 11
MAC Jurisdiction 1

The MAC Replaces:

  • National Heritage Insurance Company (California) --carrier
  • Noridian Mutual Insurance Company --carrier
  • Mutual of Omaha Insurance Company --FI
  • United Government Services, LLC --FI

RFP Issuance – September 2006

Award Date – September 2007

http://www.cms.hhs.gov/medicarereform/contractingreform/maps/ab_map.asp

Rogan Consulting

medical imaging
Medical Imaging
  • Look for greater scrutiny of medical imaging, especially self-referred office based imaging.
  • See the MedPAC report.
  • http://www.medpac.gov/publications/generic_report_display.cfm?report_type_id=1&sid=2&subid=0

Rogan Consulting

questions
QUESTIONS
  • Medicare Updates for 2005
  • Participating in Medicare
  • Medicare Bonus Payments
  • LCD process to include appeals to CMS
  • Proposed Rule for National Coverage with Evidence Development (CED)
  • Upcoming changes to Medicare appeals, 2006
  • Upcoming Carrier reform/consolidation 2006-2011
  • Medical imaging

Rogan Consulting

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