Reimbursement Roundup
December 1, 1999 4 minutes read
Reimbursement Roundup
Vote planned on bargaining bill
House Speaker Dennis Hastert (R-IL) has promised Rep. Tom Campbell (R-CA) that his bill allowing physicians and other self-employed health providers to group together to bargain collectively with managed care organizations will be brought up for a floor vote around mid-February.
HMO interests, afraid there may be just enough votes in the House to pass the bill, are putting on a full-court press to stop — or at least water down — the legislation. One of their arguments is that the bill, combined with recent passage of a strong patients’ rights proposal allowing members to sue their HMOs, could drive may plans out of business, which could leave many individuals without medical coverage and cause higher prices for everyone else.
NCQA adds external appeals requirement
Starting in July 2000, health plans must establish procedures that allow patients to appeal medical decisions to an outside body and permit patients to continue to see a physician who has left the plan, if they want to be accredited by the National Committee for Quality Assurance in Washington, DC.
Under the proposed standards, a patient who exhausts a plan’s internal appeals process will have the right to a hearing before an independent review organization. Patients already have that right in about 20 states, as do all federal employees and Medicare beneficiaries enrolled in managed care plans.
The draft also stipulates that members who are currently under an active course of treatment, such as new mothers, pregnant women, or patients receiving chemotherapy, must be allowed to continue seeing their physician for up to 90 days after the physician leaves the health plan.
Medicare 2000 premiums held steady
The Health Care Financing Administration says Part B premiums paid by Medicare beneficiaries will not increase next year, staying at the current $45.50. This is the second time in three years senior premiums have not been increased.
The Medicare Part A deductible for up to 60 days of inpatient hospital care, however, is being raised about 1% ($8) to $776. Last year, the deduct ible rose by $4.
Next year’s deductible for hospital stays over 60 days will rise by $2 to $194 per day, and by $4 to $388 per day for stays longer than 90 days. The skilled nursing facility deductible, paid after the first 20 days of such care, increases by $1 to $97 per day.
Medicare wants to add PPOs
Part of the White House’s latest plan to revamp Medicare includes copying a private-sector practice of creating a new class of "preferred provi ders" that seniors would be given incentives to patronize if they reduce their Medicare rates.
In exchange for shaving their fees, practices joining this new Medicare Preferred Provider Option (PPO) would have their claims paid faster and be subject to less burdensome administrative and paperwork procedures. Rather than develop its own networks, Medicare says it wants to contract with existing PPOs.
Panels reject bundled payments
In late October, both the Senate Finance Com mit tee and the House Ways and Means Com mittee rejected White House attempts pass proposals allowing the use of competitive bidding to set payment rates for Part B items and services (except physician services).
Opposed by most provider specialties, HCFA wants the power to contract for a single, bundled payment that pays a single amount per case for all services at a site of care.
Despite the fall rejection, expect HCFA to try to keep this issue alive.
Medicare covers some insulin pumps
HCFA says it will cover insulin infusion pumps, which allow diabetics to more closely maintain blood sugar levels, for beneficiaries with Type I diabetes. The agency says it is not providing similar coverage for Type II diabetes because this kind of treatment has not yet been shown to be effective for these patients.
"Making the insulin pump available to Medicare beneficiaries will improve the quality of their lives. The infusion pump offers them a choice to better control their condition so that they are more active and productive," HCFA deputy administrator Michael Hash said in a statement.
MiniMed Inc. of Sylmar, CA, and the Swiss health equipment group Disetronic Holding AG are the major manufacturers of external insulin pumps.
Studies show pump users have significantly fewer diabetic complications like heart and kidney disease, nerve damage, and impaired vision than people with diabetes who continue to use syringe therapy.
OIG warns about hiring excluded providers
In a recent special advisory bulletin, the Office of the Inspector General went out of its way to underscore the government’s position that "no federal health care program payment may be made for any items or services" furnished directly or indirectly by an excluded individual, entity, or provider.
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