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News August 2014

Washington Watch

Medicare Slow Flow – Diagnoses, Disbursements and Decisions Slog On

By Alan M. Schlein

Worldwide, lung cancer is the top cancer killer, with more than 156,000 American patients dying each year, mainly because it’s usually found too late for treatments to do much good. Most of those deaths involve seniors and most are due to smoking.
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“We have elderly or disabled Medicare clients waiting as long as two years for a hearing and nine months for a decision.” The kinds of cases are usually appealing the denial of coverage for home care, nursing home care, ambulance trips, challenging observation classification and other services.
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While Medicare plans to eliminate a regulatory hurdle intended to reduce fraud and abuse in Medicare home health claims, that hurdle appears to be stopping some elderly patients from getting the care they need.

Smoker Screenings: Politicians, Docs, Medicare and Patients Weigh In

Bipartisanship has surfaced, at least briefly, on Capitol Hill. More than 130 lawmakers, from both parties, are urging the Obama Administration to expand coverage for a lung-cancer test under Medicare  – screening they see as vital for vulnerable seniors. But the decision could cost Medicare billions of dollars.

In a letter to the Centers for Medicare and Medicaid Services, the lawmakers called for a timely decision on coverage for low-dose CT scans for older patients at higher risk of developing lung cancer.

Last winter, the U.S. Preventive Services Task Force recommended the test for people ages 55 through 79 who smoke a pack of cigarettes a day for 30 years or the equivalent. That’s about 10 million Americans. The low-dose CT scan will be covered by private insurance as required by the Affordable Care Act, with no copays, beginning January 1, 2015.

But the new law doesn’t require Medicare to cover the screenings, which cost between $100 and $400. CMS is reviewing the proposal with a preliminary decision expected by November.  “Americans pay into Medicare throughout their working lives and deserve to have access to potentially life-saving evidence-based screenings that can prevent further health costs down the road,” wrote Reps. Jim Renacci, R-Ohio, Charles Boustany, R-La., John Barrow, D-Ga. and Richard Neal, D-Mass., and 126 other lawmakers.

A CMS spokesman said the agency’s decision will be based on whether the test is “reasonable and necessary,” without regard to its cost to Medicare.

Worldwide, lung cancer is the top cancer killer, with more than 156,000 American patients dying each year, mainly because it’s usually found too late for treatments to do much good. Most of those deaths involve seniors and most are due to smoking. But one major study found that annual CT scans, a type of X-ray, could cut the chances of dying from lung cancer by up to 20 percent in those most at risk. Another study released last month, estimated that it would cost Medicare $2 billion a year to offer the lung scans. Every person covered by Medicare would pay an additional $3 a month, the study from the Fred Hutchinson Cancer Research Center in Seattle found.

But physician groups are somewhat divided about the merits of the CT screenings. The American Academy of Family Physicians says the evidence is insufficient to recommend for or against the CT screening. It says doctors and patients must weigh the benefits and potential harm, such as radiation from over-testing and false positive results.

On the other side is the American College of Radiology, which argues that without Medicare coverage, seniors face a “two-tier coverage system in which those with private insurance will be covered for these exams and many of their lives saved, while Medicare beneficiaries are left with lesser access.”


At its most recent policy meeting, the American Medical Association agreed to support efforts to gain Medicare coverage for low-dose CT screening in high-risk adults, with a long history of smoking.

 

Appeals Backlog Overwhelming but HHS Moves Beneficiary Cases up the Priority List

After years of waiting for months – and in some cases, even years – for an appeals hearing for coverage, Medicare beneficiaries may finally get a break as the agency tries to fix a huge backlog problem.

Last month, Nancy Griswold, the chief judge of the Office of Medicare Hearings and Appeals (OMHA), announced that her office has a backlog of 357,000 claims. As a result, the agency says it has suspended acting on new requests for hearings filed by hospitals, doctors, nursing homes and other health care providers, which make up about 90 percent of the cases. The remaining cases come mostly from individual Medicare beneficiaries. She projected that the suspension would last about two years.

But beneficiaries’ appeals will continue to be processed, Medicare said in a recent announcement. Medicare officials are seeking to “ensure that the relatively small numbers of beneficiary-initiated appeals are being immediately addressed by prioritizing their cases, the Department of Health and Human Services said. Griswold stressed that because seniors are among the most vulnerable populations, her agency will continue to push to decrease processing times for Medicare appeals.

The number of appeals jumped by 184 percent from 2010 to 2013, but the resources to adjudicate the appeals has remained constant. The office received 1,250 appeals weekly in January, 2012, but that has exploded to more than 15,000 a week last November, with the average wait time pushing up to 16 months, according to Kaiser Health News. Since 2010 the number of administration law judges has increased by two to 65.

OMHA’s caseload has grown even larger with the increased number of Medicare beneficiaries and because the agency now handles appeals of prescription drug coverage, a benefit that was added in 2006.

Judith Stein, executive director of the Center for Medicare Advocacy, told Kaiser Health News that “we have elderly or disabled Medicare clients waiting as long as two years for a hearing and nine months for a decision.” The kinds of cases are usually appealing the denial of coverage for home care, nursing home care, ambulance trips, challenging observation classification and other services.

Hospitals are also facing exceedingly long waits for decisions on their appeals – far exceeding the legal limit of 90 days, according to Melissa Jackson of the American Hospital Association. Adding two years to the process “is a violation of the statute,” she told Kaiser Health News recently. Jackson blames the stepped-up scrutiny of hospital charges by recovery audit contractors whose payments are based on the number of questionable claims they uncover. Hospitals are then forced to appeal these denials, she said, “in order to get paid for medically necessary services.” Most of the time, they win these challenges, she added.

Recently, the hospital association asked Medicare chief Marilyn Tavenner to suspend the audits until all pending appeals have been processed. But Stein worries that the suspension will not help seniors much or at all. She suggests that the cases should never have to get to an appeals process. “There are too many people who can’t get a fair shake at the lower levels of appeals and that’s a big reason why so many have to go on to a hearing.”

But the administrative law judge hearing is actually the third level of appeal for most Medicare beneficiaries and the first opportunity for appellants to present arguments to a person, since the first two appeals are decided by Medicare contractors who review case files. Not surprisingly, a 2012 HHS inspector general’s report found that the judges reversed the lower level denials a majority of the time, although just 28 percent of the time for beneficiaries.

 

Lack of Docs’ Documents and New Regs Could Cut Home Health Care Aid

The Centers for Medicare and Medicaid Services, which controls Medicare, has proposed several new changes to how it pays for Medicare home health services, which the agency says will save it $58 million next year.

The agency hopes to save money by toughening requirements to be eligible for home health services, setting a minimum requirement on home health agencies to prove their effectiveness and revising how much Medicare pays for certain services. The proposal is also part of the agency’s four-year plan under the President’s Affordable Care Act to gradually reduce costs for home health care services by 2017 and require more efficiency from home health providers.

While Medicare plans to eliminate a regulatory hurdle intended to reduce fraud and abuse in Medicare home health claims, that hurdle appears to be stopping some elderly patients from getting the care they need. In 2013, Medicare paid about 12,000 home health agencies $18 billion to provide services to 3.5 million beneficiaries.

The health care law requires that a Medicare beneficiary have a face-to-face encounter with a physician before the physician can certify that the patient is homebound and in need of skilled care. The CMS also required that the physicians provide a detailed narrative explaining the patient's circumstances. But the National Association for Home Care & Hospice, an advocacy group, says home health providers saw a dramatic upsurge in the number of retroactive denials of claims because of inadequate narratives supporting the services.

The bottom line is no one really understood what it would take to make the narratives sufficient, NAHC officials suggest. Last April, HHS’ Office of the Inspector General found that physicians in a third of sampled claims provided only a vague description of the patient or nothing at all. The OIG estimated the failures led to $2 billion in improper payments. So the advocacy group sued Medicare arguing that the narrative requirement goes beyond the law’s requirement that physicians document their face-to-face encounter.

As a result, Medicare, in new rules issued recently, has proposed eliminating the narrative
requirement to simplify the face-to-face encounter regulations and reduce the burden on home health agencies and physicians. Doctors will still be required, however, to document the encounter to certify the patient’s eligibility.

 

[Also contributing to this story: Kaiser Health News, AP, Modern Healthcare; and The Hill]

 

Alan Schlein is the author of "Find It Online," and an internet consultant. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it.

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