Hope for Permanent SGR Reform in 2014 Ends

On Thursday, December 4, lawmakers who back legislation that would permanently repeal and replace the Sustainable Growth Rate (“SGR”) announced that efforts to pass the measure this year have ended. According toPolitico, the co-chairman of the House Republican Doctors Caucus, Rep. Phil Roe (R-TN), said there is no chance of permanent repeal this year and that he’s focusing on efforts to get support for permanent repeal before the current “patch” expires on March 31 of next year.  Since Congress returned from the November 4 midterm election, physician groups had been lobbying aggressively for lawmakers to pass the physician pay reform legislation before the legislative calendar ends on December 11.  

Ways and Means Introduces a Medicare Anti-Fraud Bill

On Tuesday, December 2, the House Ways and Means Health Subcommittee introduced the Protecting the Integrity of Medicare Act of 2014, which is intended to combat Medicare fraud.  The committee intends to take the legislation to the full House of Representatives on the suspension calendar next week, which means it may be passed by a simple voice vote.

The bill includes aspects from a number of other bills sponsored by Ways and Means members including proposals that would:  remove social security numbers from Medicare beneficiary cards; set up a Medicare administrative contractor outreach and education program; broaden the scope of who can sign off on durable medical equipment and face-to-face requirements; and require changes to gainsharing restrictions to apply only to medically necessary services.

CMS Finalizes Medicaid DSH Rule

Late last Friday, November 28, CMS issued a final rule on Medicaid disproportionate share hospital (“DSH”) funding.  In the rule, CMS defines “uninsured” as someone who has no health insurance for services furnished during the year for the purposes of calculating DSH hospital-specific payment limit.

Effective December 31 for DSH audits and reports submitted for state plan rate year 2011 and after, the amended definition allows the cost of inpatient and outpatient hospital services furnished to Medicaid patients who have exhausted applicable state coverage limits to be included in calculating the Medicaid shortfalls.  It also allows uncompensated care provided to hospital patients who have exhausted their private insurance benefits or lifetime insurance limits to be counted as uninsured costs.

CMS Announces Final Rules Addressing Medicare Provider Oversight

On Wednesday, December 3, CMS announced final rules intended to keep providers with a history of Medicare debt or abusive billing practices from participating in the program.  According to CMS, the new provisions enable the agency to refuse enrollment to providers associated with any entity that has unpaid Medicare debt, which prevents providers from leaving the program only to re-enroll in order to avoid paying their debts.

CMS can also refuse or revoke Medicare participation if an entity employs someone in a managing role who has been convicted of a felony that poses a threat to Medicare beneficiaries. Finally, CMS can revoke enrollment of any entity engaging in abusive billing practices.

AMA Calls for RAC Overhaul

On Wednesday, December 3, the American Medical Association sent a letter to CMS asking the agency to overhaul its recovery audit contractor (“RAC”) program and clear a two-year backlog of appeals of rejected Medicare payments. The letter also asks CMS to provide doctors with an optional appeals settlement process similar to one provided for short-term hospital care and says RAC reviews should be performed by physicians in the same specialty as the physician submitting the claim. The letter notes that in 2013 more than 60% of appealed RAC rulings on physician payments were overturned.

Next Week in Congress

With the current government funding set to expire on December 11, House and Senate leaders will continue negotiations on a spending agreement that would avoid a government shutdown.

Bills Introduced This Week

Sen. Rob Portman (R-OH) introduced a bill (S. 2975) that would amend Title XVIII of the Social Security Act to require State licensure for entities submitting bids under the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding program.  The bill intends to ensure a competitive bidding program by disallowing intentional low-ball bidding for CMS contracts.

Sen. Robert Menendez (D-NJ) introduced a bill (S. 2980) that would amend Title XVIII of the Social Security Act to modify payment under the Medicare program for outpatient department procedures that utilize drugs as supplies.