June 23, 2000
WEEKLY UPDATE for June 23, 2000
***LEGISLATIVE UPDATE Patient Protections- Behind
the Scenes! Balanced Budget Act of 1997 Funding
Restorations The Medicare RX 2000 Act Enhanced
Budget Surplus ***REGULATORY UPDATE HCFA Holds
Town Hall Meeting on Evaluation and Management
Documentation Guidelines HCFA Sends Letter to
Physicians Regarding Payment Errors OIG Issues
Semiannual Report
LEGISLATIVE UPDATE
Patient Protections- Behind the Scenes!
Republican patient protection conferees are pursuing
two paths toward crafting a Patients' Bill of Rights-one
by holding talks between Republican and Democratic
conferees and another by holding intense discussions
between House and Senate GOP conferees. House and Senate
Democrats are unified in their desires for passage of
something very close to the Norwood-Dingell bill (HR
2990); however, the Republican leadership has been
divided on some of the key components of a bill. This
week there have been almost daily meetings between House
and Senate Republicans with House Speaker Dennis Hastert
(R-IL) pushing for resolution and a bill the President
can sign. Hastert's personal involvement reflects his
own interest and his understanding that a compromise
measure is essential for Republicans this election
year.
Though not a member of the conference on patient
protections, Rep. Charlie Norwood (R-GA) has been a
participant in the internal GOP negotiations, indicating
the GOP leadership in both chambers is ready to move to
the end game on the Patients' Bill of Rights. Norwood
suggested the recent Supreme Court decision on managed
care could influence discussions and that the main
difference continues to be the "scope" of bill. Rep.
Norwood believes that Republicans will ultimately
achieve a compromise that he and many Democrats can
support, thus ensuring its passage.
During a meeting this week with ACEP, Rep. Norwood's
chief health staffer confirmed that the conference on
the bill is stalled, at least for the moment. There are
no separate talks going on between Democrats and
Republicans. However, Senate and House Republicans are
meeting to see if they can achieve a compromise proposal
that will pass both Houses. Rep. Tom Coburn, MD (R-OK)
told ACEP President Dr. Michael Rapp in a recent meeting
that he too was optimistic about the chances for a bill
this year.
Despite the absence of formal conference progress on
the Patients' Bill of Rights, discussions continue over
the 1 hour /3 hour call-back provision. It now appears
conference staff and Members are considering revisions
to that portion of the bill. Earlier this week several
Republican House Members told ACEP that if a Senate
Republican pushes to change the language, they will push
the change through.
IF YOU HAVE NOT CONTACTED YOUR LEGISLATOR THIS
SPRING-DO IT NOW!
The House and Senate are scheduled to begin the
Fourth of July recess on July 1 and return on July 10.
With just 30 legislative days when they return, Members
will be under intense pressure to pass legislation
important to their constituents. It is therefore
extremely important that you make every effort to meet
with or call your Representative and Senators during the
July 4 recess. Next week's 911 Update will include
talking points on the Patients' Bill of Rights, the
appropriations bills, and other pertinent legislative
issues.
Balanced Budget Act of 1997 Funding
Restorations
This week President Clinton announced his support for
a plan to increase Medicare payments to health care
providers by $21 billion over five years in an effort to
off-set deeper than anticipated cuts caused by the BBA
of 1997. The proposal would cost $40 billion over 10
years. Under the plan, hospitals would receive $5
billion over five years and a "full allowance for
inflation." Special payments for teaching hospitals and
facilities that serve primarily indigent patients also
would increase. The proposal also calls for a one-year
delay in the 15% payment cut to the home health care
industry. Home health agencies hard hit by 1997 Medicare
cuts, would receive $2 billion over five years and a
3.4% inflation allowance, rather than the 2.3% currently
provided by law. Clinton's plan offers nursing homes $1
billion over five years, postpones restrictions on
physical, occupational and speech therapy for one year.
This approach has the support of key Democrats and
Republicans in Congress. Ways & Means Chairman Rep.
Bill Thomas (R-CA) has pledged to correct the unintended
inequities of the 1997 law. It is almost a certainty
that additional Medicare "givebacks" will reach the
President's desk later this year.
The Medicare RX 2000 Act (HR 4680)
Almost every legislator up for reelection has been
talking about the need to give seniors a prescription
drug benefit under Medicare this year. In a 23-14
party-line vote, the House Ways & Means Committee
approved Rep. Bill Thomas' (R-CA) "The Medicare RX 2000
Act." Republican leaders hope to hold a floor vote
before the July 4 recess believing that their bill will
pass the House with a handful of Democratic supporters.
The Congressional Budget Office estimates that the House
bill would cost $39.7 billion over five years.
In the Senate, Democrats used a parliamentary
maneuver to bring their own plan to an unsuccessful
floor vote that was killed by Senate Republicans in a
53-44 party line vote. House Republicans favor private
insurers providing the benefit, with subsidies for
low-income seniors and seniors with extremely high
costs. The Democrats' plan would provide a benefit
through Medicare for all seniors, regardless of income.
Seniors would pay a $250 yearly deductible, after which
the government would pay part of drug expenses under
$4,000 and all expenses over that amount. The Democrats'
plan would cost an estimated $240 billion over 10 years.
The full text of the Chairman Thomas' bill is available
at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=106_cong_bills&docid=f:h4680ih.txt.pdf
Enhanced Budget Surplus
According to unnamed budget experts, this fiscal
year's budget surplus is expected to be $60 billion
greater than forecasted in February 2000. If this
projection is substantiated by the Congressional Budget
Office and the Office of Management and Budget, the
budget surplus will reach $230 billion. Tax cut
proponents in the House and on the campaign trail will
renew their calls for tax cuts. Others will see the
opportunity to start new programs and expand existing
ones.
REGULATORY UPDATE
HCFA Holds Town Hall Meeting on Evaluation and
Management Documentation Guidelines
On June 22, the Health Care Financing Administration
held a town hall meeting to discuss the current status
of the agency's work on revising the documentation
guidelines for evaluation and management (E/M) services.
HCFA has drafted a new version of the E/M documentation
guidelines, based on the 1995 guidelines. HCFA believes
that the current guidelines are too complex and that its
new draft is simpler and less burdensome for physicians.
The agency noted that while most physicians are honest,
there is inconsistency in coding for identical services.
HCFA noted that the OIG has found that incorrect coding
is a major factor in improper payments to physicians,
especially for E/M services. HCFA stated that E/M
services represent about 18 billion dollars in Medicare
spending, accounting for about 40 percent of spending
for physician services. Until new guidelines are
finalized, tested, and implemented, Medicare contractors
will be instructed to continue review of medical records
according to the 1995 and 1997 E/M documentation
guidelines.
HCFA stated that its goal is to develop and implement
new E/M documentation guidelines that are consistent
with documentation practices within the physician
community. HCFA seeks to ensure that its requirements
are clinically appropriate and facilitate consistency,
improve reliability of medical review, facilitate
accurate payment, and ensure work equivalency among
specialties. At the meeting, HCFA discussed the concerns
that have been raised by physicians regarding the 1995
and 1997 E/M documentation guidelines and its concerns
with the guidelines proposed by the AMA CPT Editorial
Panel in June 1999.
HCFA conducted a number of technical assessments of
the current guidelines, and found that the 1995 E/M
documentation guidelines result in more consistent,
reliable medical review than the 1997 guidelines or the
AMA's 1999 proposal. Therefore, the 1995 guidelines were
used as a starting point for HCFA's new draft. HCFA also
found that some of the problems with documentation are
attributable to the structure and descriptors of the CPT
E/M services. HCFA stated that it would support an
effort to revisit the current CPT structure and
descriptors. In addition, the agency seeks to minimize
counting in the documentation guidelines and to develop
an alternative method for distinguishing between levels
of service.
An important element of developing the new
documentation guidelines will be developing
specialty-specific vignettes for multi-system exams,
single system exams, and medical decision-making. HCFA
will work with specialty societies to develop vignettes
for all levels of service. HCFA hopes to develop the
vignettes over the next three to four months. HCFA will
also conduct two studies of the new draft guidelines.
The first will weight each key component of the
guidelines equally and the second will assign
significantly greater weight to the medical
decision-making component. There was a lot of discussion
at the meeting regarding HCFA's plans for pilot testing
the guidelines with records for E/M services that would
be voluntarily provided by physicians. HCFA stated that
it would not be able to provide any "immunity" for
volunteers. Many physician representatives noted that
they would not advise their members to participate in
the study without immunity. It was suggested that HCFA
consider reviewing de-identified records. HCFA will
consider this approach.
Working with an outside contractor, HCFA hopes to
complete initial studies of the new draft guidelines by
the spring of 2001, with the goal of implementing them
by January 2002. HCFA pledged to work closely with the
physician community throughout the entire process. The
agency is seeking comments on the draft guidelines and
its plans for testing by August 11. The next meeting of
the Practicing Physicians Advisory Council (PPAC),
scheduled for September 11, will be devoted to E/M
documentation guidelines.
HCFA Sends Letter to Physicians Regarding Payment
Errors
In early June, Health Care Financing Administration
Administrator Nancy-Ann Min DeParle sent a letter to all
physicians participating in the Medicare program
regarding reducing payment errors. The letter emphasized
the importance of paying close attention to billing
requirements, especially for documenting services
delivered and the reason for care. The letter announced
that HCFA has instructed Medicare contractors that
process Medicare claims to establish toll free lines
this fall. The letter also asked physicians to cooperate
with the Office of Inspector General if the physicians'
claims are randomly selected as part of the OIG's FY
2000 error rate study.
The letter is available on HCFA's web site at: http://www.hcfa.gov/medicare/mip/physltr.htm.
OIG Issues Semiannual Report
The Office of Inspector General recently released its
semiannual report for the period October 1, 1999 to
March 31, 2000. The OIG reported savings of $9.5
billion, including $8.4 billion in actions that put
funds to better use, $40.5 million in audit
disallowances and $968.1 million in investigative
receivables. In addition, the OIG reported 1278
exclusions of individuals and entities, 205 convictions
and 198 civil actions. The OIG noted that while the
majority of health care providers submit claims to
Medicare for services that are medically necessary,
billed correctly and documented properly, documentation
errors and medically unnecessary services continue to be
pervasive problems. The OIG reported that during the six
month period, the OIG collected $643,000 in settlements
for EMTALA violations from 24 hospitals and physicians.
In addition, the OIG reported that under the physicians
at teaching hospitals (PATH) initiative, six
institutions have entered into settlements totaling $75
million to resolve potential False Claims Act liability
related to improper claims for Part B physician services
submitted in the teaching setting. Reviews completed at
four other institutions revealed no major problems with
either billings in the teaching setting or upcoding.
The OIG's semiannual report is available on the OIG's
web site at: http://www.dhhs.gov/progorg/oig/new.html. |