July 7, 2000
WEEKLY UPDATE for July 7, 2000
Congress to Return from
July 4th Recess!
Pressure on Congress for a Patients'
Bill of Rights
Congressional Schedule for the
H.R. 4577, Labor-HHS Appropriations Bill for
Fiscal Year 2001
Letter Regarding Enforcement Related to OPPS
HCFA Issues Medicare+Choice Final
Congress to Return from July 4th Recess!
Members of the House and Senate will return to
Washington on July 10. A raft of unfinished business
awaits lawmakers as they begin to focus on the political
conventions. They will have approximately three and a
half weeks in which to complete action on a number of
appropriations bills and other controversial matters.
Reaching accord on a Patients' Bill of Rights is a
priority for many Members. House Republican leaders have
indicated their intention to redouble their efforts to
craft yet another bipartisan measure they hope will
strengthen their negotiations with Senators. (More
information on developments surrounding this issue will
appear in the next Weekly Update.) The President's
declaration in Missouri this week that Congress must
pass a responsible bill has added a degree of political
urgency to the matter.
Congress Eyes Adjournment in October
Congress is scheduled to recess between July 31 and
September 5 for its month-long district work period.
During that time, Republicans will gather in
Philadelphia between July 31 through August 3 to choose
their presidential nominee (Gov. George Bush and his
running mate) and adopt the party's platform. Democrats
convene in Los Angeles August 14 through August 17 to
confirm the nomination of their standard bearer (Vice
President Gore and his running mate). Thereafter, the
political season will move into full swing when Congress
returns for the final stretch of 106th Congress. The
curtain is set to come down on the Second Session
Labor-HHS Appropriations Bill Heads to
House/Senate conferees on the Labor-HHS
Appropriations bill (H.R. 4577) may meet next week to
resolve differences between their respective versions of
the measure. Senate conferees have been appointed:
Senators Byrd (D-WV), Cochran (R-MS), Craig (R-ID),
Domenici (R-NM), Feinstein (D-CA), Gorton (R-WA), Gregg
(R-NH), Harkin (D-IA), Hollings (D-SC), Hutchison
(R-TX), Inouye (D-HI), Kohl (D-WI), Kyl (R-AZ), Murray
(D-WA), Reed (D-RI), Specter (R-PA) and Stevens (R-AK).
House conferees have not yet been named, but Health
Subcommittee Chairman John Porter (R-IL) and Ranking
Member David Obey (D-WI) will be among those who will be
named. As soon as we have the complete list of House
conferees we will send them to you.
In next week's Weekly Update, we will identify those
issues about which we will urge you to write to the
conferees. Included in that list will be trauma control
funding and a recommendation to House members to accept
the Senate poison control funding level of $20
IG Issues Letter Regarding Enforcement Related to
HHS Inspector General June Gibbs Brown recently sent
a letter to the American Hospital Association regarding
the OIG's enforcement policies surrounding
implementation of the new Medicare hospital outpatient
prospective payment system (OPPS). The AHA and its
members expressed concern to the OIG that coding and
billing errors are likely to occur as hospitals and
fiscal intermediary's work to implement the new system.
The OIG stated that billing errors, honest mistakes or
negligence will not result in penalties - they will
result only in the return of funds claimed in error. The
OIG noted that the False Claims Act covers only offenses
that are committed with actual knowledge of the falsity
of the claim or reckless disregard or deliberate
ignorance of the truth or falsity of the claim.
The letter is available on the OIG's web site at http://www.hhs.gov/oig/testimony/aha.htm.
HCFA Issues Medicare+Choice Final Rule
On June 29, the Health Care Financing Administration
published a final rule in the Federal Register
implementing the Medicare+Choice program that was
established by the Balanced Budget Act of 1997 (BBA).
The agency had issued an interim final rule in June
1998. In the final rule, HCFA left the prudent layperson
definition of emergency medical services in tact. The
final rule also made several clarifications and changes
to the emergency services provisions. For instance, HCFA
included a specific requirement that Medicare+Choice
organizations assume financial responsibility for
services meeting the prudent layperson definition,
regardless of the patient's final diagnosis.
HCFA discussed the steps it is taking to ensure that
Medicare+Choice organizations comply with the emergency
services provisions of the BBA. The agency is reviewing
all organization materials provided to beneficiaries
including pre-enrollment marketing materials and
post-enrollment member materials, including handbooks
and wallet-sized instruction cards, to ensure that the
materials contain compliant language regarding what to
do in an emergency. In addition, as part of its
monitoring of the prudent layperson standard, the agency
has requested its independent review entity to report on
a quarterly basis on each instance in which it overturns
a denial of a claim for emergency services.
In the final rule, HCFA specified that
Medicare+Choice organizations are required to cover
ambulance services provided outside of the organization
that are dispatched through 911 or its local equivalent.
The Medicare+Choice organization must cover the costs of
ambulance services if other means of transportation
would endanger the beneficiary's health.
HCFA clarified that both the beneficiary and
emergency services provider are protected from prior
authorization requirements. Prior authorization may not
be required in any enrollee materials. In addition, an
enrollee's rights to use the 911 system must
specifically be disclosed. Also, contracts with
providers may not include instructions to seek prior
authorization before an enrollee has been
Regarding post-stabilization care services, HCFA
retained the one-hour time requirement for
Medicare+Choice organizations to respond to a request
for authorization of post-stabilization care services.
HCFA declined to include a requirement that an emergency
provider contact the Medicare+Choice organization within
an hour of the point at which the patient is stabilized.
However, the agency is considering including such a
requirement in future hospital conditions of
participation. In addition, HCFA clarified that
post-stabilization services are services related to the
emergency episode. HCFA also addressed the issue of
services furnished while waiting for a response to a
request for authorization of post-stabilization care
services. HCFA stated that it is necessary to ensure
that the patient receive necessary treatment during this
one-hour time frame. The services consist of those
necessary to maintain the stable condition that was
achieved through provision of emergency services. If the
Medicare+Choice organization does not respond during the
one-hour time period, the treating physician can proceed
with post-stabilization services that are provided not
only to ensure stability, but also to improve or resolve