Centers for Medicare and Medicaid Services (CMS)

AHA asks CMS to review details of 'never event' policy

Anne Zieger — Wed, 03 Sep 2008 15:41:07 -0400

Citing an analysis of patients undergoing the wrong surgery or surgery on the wrong patient or body part, the American Hospital Association has asked CMS to give some thought to the complexities of implementing its 'no pay for mistakes' policy. Before withholding payment, CMS should take several mitigating factors into account, AHA said. For example, it's asking CMS to create a policy to consider mixed events, such as when a provider nearly but doesn't complete a procedure on a wrong site, discovers the error, stops the procedure and begins on the correct site.

The AHA has adopted its own set of principles that describe when hospitals should not expect payment for care related to preventable, serious adverse events. Along those lines, it's asking CMS to consider three key questions as it begins to consider a national coverage determination for the three surgical conditions. These questions include how the adverse event will be defined, how accountability will be assigned and what costs or services should not be covered.

To learn more about the AHA's position:
- read this Healthcare Finance News article

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FL hospital cited for two deaths in three days

Anne Zieger — Tue, 26 Aug 2008 13:41:15 -0400

Tampa General Hospital came under investigation recently after two psych patients were able to kill themselves within three days. The hospital is being sued by at least one of the dead patient's families already, who say that the psychiatric unit is understaffed. That family's attorney is asking the state attorney's office to file manslaughter charges against the hospital.

Now, the facility has worse troubles, as CMS has concluded that care there falls under its minimum levels, as well. According to CMS staffers, who threatened to stop permitting the hospital to bill for Medicare funding in one month unless problems are fixed, at least five patients from the hospital's psych ward were sleeping in the hallways so they could be watched by one staff member.

To learn more about the hospital's issues:
- read this St. Petersburg Times piece

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Man gets $350,000 heart bypass by stealing friend's identity

Anne Zieger — Fri, 22 Aug 2008 06:31:21 -0400

John Parsons apparently believed he would die without heart bypass surgery. To get it, the uninsured 57-year-old ex-convict took a step that has hospital officials shaking their heads--he managed to pass himself off as a mentally-disabled friend and, using the friend's Medicaid card, obtained the surgery. Now, officials at Chicago's Northwestern Memorial Hospital are stuck with a big bill and a lot of questions as to how Parsons pulled it off.

According to the authorities, Parsons got the surgery at Northwestern in 2007, generating about $350,000 in expenses. When bills started arriving at the home of the friend, Philip Johnson, Johnson's live-in caregiver discovered the alleged scam and notified officials. Parsons has since admitted stealing Johnson's identity. Northwestern, for its part, has agreed to cover the cost of the surgery so Johnson won't be responsible for it.

What has healthcare officials puzzled is the extent of the apparent deception. To get the heart bypass, doctors would have needed a lot of clinical information, including patient blood type, cardiac history, medical history and more, records that would be very difficult to fake, notes CMS spokesman Jeff Nelligan. Northwestern continues to investigate the incident.

To learn more about the alleged scam:
- read this Chicago Tribune piece

Medicare fraud cuts disputed by IG

Anne Zieger — Thu, 21 Aug 2008 10:20:44 -0400

In 2006, CMS said that it had managed to cut the level of Medicare fraud by billions of dollars, and basked in the praise of lawmakers who commended the agency's good stewardship. The problem: the gains may have been an illusion, or arguably, a deliberate deception. That, at least, is the conclusion drawn by the HHS Inspector General's office, according to a confidential draft of a report investigating Medicare fraud-fighting.

According to the IG, Medicare officials engaged in questionable methods when they calculated fraud levels. For example, they instructed auditors not to compare invoices submitted by salespeople against doctors' records to make sure that medical equipment actually went to patients. (This step is required by law.) Because they didn't take this step, Medicare officials missed more than one-third of improper spending for wheelchairs, oxygen supplies and other medical equipment for fiscal 2006. That accounts for about $2.8 billion in improper spending, negating the $700 million for which officials took credit. Now, some members of Congress are outraged, and say that they're not sure they can trust other Medicare figures either. (Can't say I blame them!)

To learn more about the IG's report:
- read this piece from The New York Times

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CMS posts death rate estimates for hospitals

Anne Zieger — Thu, 21 Aug 2008 00:04:48 -0400

For a long time, hospital-specific death rates were secrets. Administrators argued that publishing such rates was unfair, as it would be easy to make unfair comparisons if rates weren't adjusted properly for acuity. That being said, CMS has essentially taken things out of their hands. The agency has made estimates by specific hospital and posted that information on its quality website, hospitalcompare.hhs.gov.

The data offers comparisons of performance on more than two dozen measures, including death rates for pneumonia, heart attacks and heart failure. The formula used to calculate death rates captures all deaths among 35 million Medicare beneficiaries occurring within 30 days of the patients' hospital admission. The formula took into account the hospital's patient mix and how many deaths would be expected in those populations.

While the data is more specific than it has been in the past, it's still using somewhat conservative measures, critics say. The death rate scoring ends up rating the majority of hospitals as average, which doesn't do much to guide employers or consumers in their health purchasing decisions. However, the new measures have little to complain about, others say.

To learn more about the ratings:
- read this USA Today article

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CMS says doctors earned $16.7M on P4P demo

Anne Zieger — Fri, 15 Aug 2008 10:43:11 -0400

You've gotta love it when CMS gives out money above and beyond the usual reimbursement rates--and it's even better when the bonuses involved work out for pretty much everyone involved. That's the cheery outcome for the second year of CMS's pay-for-performance demonstration project, under which 10 physician groups earned a total of $16.7 million in incentive payments. Under the terms of the demonstration project, which addresses the quality of care for heart patients and diabetics, physician groups were asked not only to improve outcomes for Medicare patients, but also to coordinate their care.

The groups involved were strikingly successful at meeting CMS's goals. All of the groups involved in the Physician Group Practice Demonstration met performance goals on at least 25 of 27 quality markers for patients with diabetes, coronary artery disease and congestive heart failure. Five of the groups, including Forsyth Medical Group, Geisinger Clinic, Marshfield Clinic, St. John's Health System and the University of Michigan Faculty Group Practice--achieved all 27 performance goals.

To learn more about the P4P payouts:
- read this Modern Healthcare piece (reg. req.)

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Hospitals in nearly half of states won't bill for never events

Anne Zieger — Wed, 13 Aug 2008 14:49:52 -0400

A new analysis suggests that hospitals in almost half of U.S. states will no longer bill patients for serious medical errors, up sharply from the beginning of 2008. In February, an analysis by a news organization concluded that hospital associations in 11 states had asked members to waive payment for never events. Now, the number states with such policies in place is 23, according to research by MSNBC.com.

This trend, of course, has gained a great deal of momentum as hospitals and their trade groups have braced themselves for Medicare, and commercial health plans, to roll out no-pay rule for serious errors. Medicare will cease such payments as of October 1, while various commercial plans like Cigna, Aetna and a number of Blue Cross Blue Shield affiliates have set their own policies and schedules.

The next wave may come from Medicaid agencies, which CMS has urged to enact their own non-payment policies. To date, Massachusetts, New York and Pennsylvania have done so, but no one knows yet how many more will follow.

To learn more about this trend:
- read this MSNBC.com article

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CMS releases regs for shared on-call coverage

Anne Zieger — Wed, 13 Aug 2008 14:36:10 -0400

CMS has issued final rules that clarify how hospitals need to manage shared on-call arrangements under EMTALA. Under the final rule, a "community plan"--two or more hospitals coordinating on-call coverage within a specific geographic area--must designate the facility that will offer specific coverage. The other participating hospital(s) would transfer patients needing such care to that facility. Hospitals involved are required to establish the time period during which this on-call coordination is in effect.

The rule will also require hospitals to develop a formal plan, including a clear assignment of on-call responsibilities for each hospital participating in th e plan, as well as a description of the geographic area covered by the plan, and a yearly assessment of the plan by hospitals participating in it.

To learn more about the regulation:
- read this HFMA News item

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IL Blue plan won't pay for errors

Anne Zieger — Fri, 08 Aug 2008 11:22:18 -0400

Blue Cross and Blue Shield of Illinois has become the latest Blue plan to roll out a policy banning payment for medical errors by hospitals. It's become one of several fellow Blue plans to announce such a policy in the wake of an announcement by the Blue Cross and Blue Shield Association last November that its affiliates would be introducing such rules. Plans in states including Texas, Massachusetts, Michigan and Rhode Island have already announced their participation in the initiative.

According to the health plan, it will work with hospitals to roll out the policy, but it hasn't yet defined which conditions and events will be addressed. More typically, health plans that make such an announcement have been modeling their policies after CMS's list of conditions and never events for which it won't reimburse. Never events, typically those named by the National Quality Forum, usually include wrong-side surgery or discharge of an infant to the wrong family.

This is part of a larger national movement emerging to support non-payment for never events and preventable conditions. For example, earlier this summer the trade group for California health insurers, the California Association of Health Plans, announced that it had passed a resolution in favor of no longer paying for CMS's list of never events, as well as three preventable mistakes.

To learn more about this trend:
- read this Modern Healthcare article (reg. req.)

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GAO finds gaps in equpment-supplier oversight

Anne Zieger — Tue, 05 Aug 2008 10:15:34 -0400

A series of tests conducted on behalf of the Government Accountability Office has found significant weaknesses in CMS's medical-equipment supplier screening process. In a new report, the agency described how investigators set up two phony DME providers, using deceptive names and bank accounts, which were approved for Medicare billing despite having no inventory or clients. While CMS originally rejected the phony companies' applications because they had no inventory, the sham companies were able to convince CMS that they had contracts with nonexistent wholesale suppliers, GAO said.

CMS, in looking at the investigation's results, admitted that the tests had found meaningful gaps in oversight, and said it would make more efforts to strengthen its supplier enrollment process. The agency itself estimates that that Medicare paid $1 billion in improper durable medical equipment, prosthetics, orthotics and supplies claims from April 2006 through March 2007, partly due to supplier fraud.

While this must be painful for CMS to admit, it's just one of a handful of painful public disclosures regarding oversights that have come of late. For example, last month CMS was forced to acknowledge that it had paid out almost $100 million to DME providers for equipment "prescribed" by doctors who were dead at the time.

To find out more about the GAO report:
- read this Modern Healthcare article (reg. req.)

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