Insurance news
CMS' Subset Modifiers for Modifier 59 Possibly on Hold
Written by Editor   
Wednesday, December 31, 2014 04:25 PM

On December 10th, ACA sent out a release to members concerning the new subset of modifiers for modifier 59 that were proposed by CMS in August, 2014. The new subset modifiers were proposed by CMS in August to provide greater detail in outlining the specific need for where the 59 modifier should be used.  ACA strongly advises providers to continue using modifier 59 according to standard CPT directives.

The following are the new subset modifiers:

PQRS 2015
Written by Editor   
Wednesday, December 31, 2014 04:24 PM

The Patient Protection and Affordable Care Act (PPACA) mandated that non-participation or unsuccessful/unsatisfactory reporting in Medicare’s Physician Quality Reporting System (PQRS), formerly referred to as PQRI, will result in negative payment adjustments to Medicare reimbursement beginning in 2015.

In the 2012 Medicare Physician Fee Schedule Final Rule, the Centers for Medicare and Medicaid Services (CMS) ruled that providers who did not successfully/satisfactorily participate in PQRS by the 2013 reporting period will have their Medicare reimbursement decreased by 1.5 percent beginning on January 1, 2015. Non-participation or unsuccessful/unsatisfactory reporting during the 2014 performance period will result in a 2% reduction in a provider's 2016 Medicare reimbursement, and further non-participation or unsuccessful/unsatisfactory reporting this year (Jan. 1 -  Dec. 31, 2015) will affect a provider's 2017 Medicare reimbursement by applying a payment reduction of 2%.

Court Invalidates Payment Hold for Minor Medicaid Violations
Written by Editor   
Wednesday, December 31, 2014 04:12 PM

The Texas Third Court of Appeals struck a major blow to the Texas Health & Human Services Commission (HHSC) Office of Inspector General's (OIG's) investigative framework. Judges invalidated rules that allowed the agency to place payment holds on Medicaid physicians for non-fraudulent program violations. The court also declared invalid a rule that allowed OIG to retain a health care professional's funds after termination of the payment hold period.  The appeals court's decision came after the Sunset Advisory Commission's scathing report on HHSC, which the court used to support its interpretation of Texas' Medicaid laws.

The report says OIG — tasked with preventing, detecting, and investigating fraud, waste, and abuse in the Medicaid system — fails at fraud prevention, takes more than three years to resolves cases, and wins back only a fraction of the amount of allegedly abusive or wasteful spending it identifies. According to the report, the OIG collected only $5.5 million in 2012 and 2013, during which it identified $1.1 billion in possible Medicaid overpayments.  The report states OIG uses payment holds as a bargaining tool, "even for cases that do not pose significant financial risks to the state." 

U.S. Military Health Care Reform
Written by Editor   
Wednesday, December 31, 2014 04:11 PM

On December 19, the Center on 21st Century Security and Intelligence (21CSI) at the Brookings Institution held a wide-ranging event on military health care reform.  Assistant Secretary of Defense for Health Affairs Jonathan Woodson described the value of the DoD health care system—which cares for nearly 10 million beneficiaries, costs more than $50 billion a year and has treated more than 50,000 war wounded in the conflicts of the 21st century to date. It employs roughly 140,000 full-time personnel at more than 50 hospitals and some 600 medical or dental clinics. It also involves a network of private providers who treat DoD patients as well; that network includes some 400,000 providers.

Among Woodson’s most important points were that the value of military medicine has to be determined across the broad missions for which the military health system is responsible — readiness, health and hospital care, public health, research and development and education and training; and that global security and global health crises have increased the demand for DoD's health expertise even as combat operations are diminishing.

ACOs What’s Next for DCs
Written by Editor   
Wednesday, December 31, 2014 04:00 PM

On November 2, 2011 CMS released their final rule regarding the CMS Shared Savings/Accountable Care Organization Program.  The CMS’ final rule indicated that nothing would “preclude Medicare enrolled chiropractors from participating in ACOs, or from sharing in the savings that an ACO may realize in part because of the quality and cost-effective services they may be able to provide.”

While doctors of chiropractic cannot independently establish an ACO, they can partner with other providers and share in savings demonstrated by the ACO. DCs who wish to participate in this program will need to partner with MDs or DOs who are establishing an ACO to participate in the Medicare Shared Savings Program.

As a first step, DCs will need to identify MDs/DOs in their state who intend to develop an ACO. When approaching other provider types to discuss the development of an ACO, information regarding the services that doctors of chiropractic provide may be helpful. 

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