Medi-Cal is California's Medicaid program — a public health insurance program that provides needed health care services for low-income families with children, seniors, people with disabilities, foster caregivers, pregnant women and low-income people with specific diseases, such as tuberculosis, breast cancer or HIV/AIDS. Medi-Cal is financed equally by the state and federal governments.
Medi-Cal is California’s Medicaid program — a public health insurance program that provides needed health care services for low-income families with children, seniors, people with disabilities, foster caregivers, pregnant women and low-income people with specific diseases, such as tuberculosis, breast cancer or HIV/AIDS. Medi-Cal is financed equally by the state and federal governments.
Yesterday, the Department of Health Care Services (DHCS) issued two all-plan letters (APLs) to provide Medi-Cal managed care health plans (MCPs) information about the appropriate billing of inpatient services for beneficiaries with California Children’s Services (CCS)-eligible conditions who are also enrolled in a MCP. One APL provides instructions for billing inpatient services at private, municipal and district hospitals; the other provides instructions for billing the same services at designated public hospitals.
The Health Resources and Services Administration’s (HRSA) Office of Pharmacy Affairs (OPA) will host a webinar July 20 from 10-11 a.m. (PT) to assist covered entities with the recertification process for the 340B Drug Pricing program. All 340B hospitals are required to recertify with HRSA to ensure they continue to meet the 340B hospital eligibility requirements. The hospital recertification process runs from mid-August to mid-September. Hospitals can join the webinar by visiting https://hrsa.connectsolutions.com/recertification/; the conference number is (888) 787-0207, and the participant passcode is 7814467.
The Department of Health Care Services (DHCS) has notified Medi-Cal providers that the Centers for Medicare & Medicaid Services (CMS) is conducting a payment and error rate measurement (PERM) review in California. The review measures improper payments in Medicaid and the Children’s Health Insurance Program (CHIP), as required by the Improper Payments Information Act. Error rates are based on reviews of the fee-for-service, managed care and eligibility components of Medicaid and CHIP in the fiscal year under review.
Approximately 383 Medi-Cal claims will be selected from each quarter between Oct. 1, 2015, and Sept. 30, 2016. Providers whose claims have been selected for review will receive requests from CNI Advantage, the review contractor, for copies of medical records. Providers will also be required to send a duplicate copy of the requested records to DHCS, which is taking this proactive step to review the submitted documentation and determine if further information is needed to support the claim.
An expert committee convened by the National Academies of Sciences, Engineering, and Medicine has released a new report — titled Accounting for Social Risk Factors in Medicare Payment — requested by the Department of Health and Human Services (HHS). As Medicare replaces fee-for-service payments with value-based payments, concerns have been raised over social risk factors’ effect in determining the quality of care provided and corresponding value-based payments. Health providers that predominantly care for patients with social risk factors may fare poorer on quality rankings and be unfairly reimbursed at lower rates.
The committee’s primary task was to determine the social risk factors that could be accounted for in evaluating the quality of care provided, including income, education, dual eligibility, race, ethnicity, language, nativity, marital/partnership status, living alone, neighborhood deprivation, urbanity and housing. HHS will conduct a webinar on the report on July 20; registration is available online. The committee is now tasked with designing a method for collecting data that could be used in accounting for social risk factors, to be detailed in its next report.
This week, the Department of Health Care Services (DHCS) announced it will temporarily suspend all hospital attestation reviews and payments related to the Electronic Health Record (EHR) Incentive program. DHCS recently received preliminary results from EHR audits that the Office of the Inspector General (OIG) conducted at 60 hospitals, which found overpayments and underpayments at a number of hospitals; DHCS is awaiting the OIG’s final report to determine the full impact of its findings. CHA is aware that some hospitals that have undergone an EHR audit by the OIG have concerns about next steps the state may take in implementing the OIG findings, and the appropriateness of those actions in light of providers’ concerns raised during the audits. To discuss further and provide feedback, contact Amber Ott, CHA’s vice president, finance, at firstname.lastname@example.org.
Providers who wish to receive Medi-Cal news updates may register for the Medi-Cal Subsciption Service, a free mailing that provides urgent announcements and other Medi-Cal news. Subscribers can sign up to receive NewsFlash announcements, Medi-Cal update bulletins and/or system status alerts. Registration is available at http://files.medi-cal.ca.gov/pubsdoco/mcss/mcss.asp.
The Centers for Medicare & Medicaid Services has released hospital-specific reports (HSRs) on the claims-based Medicare Spending per Beneficiary measure for the federal fiscal year 2017 hospital value-based purchasing program review and correction period, as well as for the hospital inpatient quality reporting program preview period. The HSRs are available for review via the QualityNet Secure Portal until July 11. CHA encourages hospitals to review their HSRs and, if needed, submit a review and correction request to email@example.com by midnight (PT) on July 11.
The review and correction period allows hospitals the opportunity to review measure results and the discharge data used to calculate the measures, and to replicate their results. The HSRs’ discharge-level data and a user guide may also be found on the QualityNet Secure Portal for hospital users.
The House Energy & Commerce Committee passed the Helping Families in Mental Health Crisis Act (H.R. 2646) yesterday by a unanimous vote. The legislation, supported by CHA, would reform the nation’s mental health system to expand access to care.
H.R. 2646 would provide funding for assisted outpatient treatment programs and would codify a Centers for Medicare & Medicaid Services rule allowing Medicaid reimbursement for mentally ill patients who require less than a 15-day inpatient stay in a psychiatric hospital with more than 16 beds. Currently, many of those patients are denied inpatient psychiatric care due to an Institute for Mental Disease exclusion. These reforms, among others, would collectively work to increase the available beds in the mental health system so patients can receive psychiatric care in an appropriate setting. CHA sent the attached letter to the California members of the House Energy & Commerce Committee applauding their support of H.R. 2646.
A new report from the Kaiser Family Foundation (KFF) examines the impact of Medicaid payments to hospitals and other providers on those providers’ finances, and the ultimate effect on beneficiaries’ access to care. The brief provides an overview of Medicaid payments for hospitals and explores the implications of the Affordable Care Act’s (ACA) Medicaid expansion, as well as payment policy changes, on hospital finances.
Key findings include:
Overall, hospitals have benefitted financially from the ACA coverage expansions and the increase in Medicaid payments, especially in states that expanded Medicaid coverage. Analysis of the Medicare Cost Report data for 2013 and 2014 shows overall declines in uncompensated care from $34.9 billion to $28.9 billion in 2014 nationwide. Nearly this entire decline occurred in expansion states, where uncompensated care costs were $10.8 billion in 2014 and fell 35 percent, to $5.7 billion, in 2013.
The Centers for Medicare & Medicaid Services (CMS) has issued the attached proposed rule revising the Conditions of Participation for hospitals and critical access hospitals (CAHs). The proposed rule, if finalized, would require hospital-wide infection prevention and control programs for the surveillance, prevention and control of health care-associated infections and other infectious diseases, as well as antibiotic stewardship programs to emphasize the appropriate use of antibiotics. CMS also proposes to require hospitals and CAHs to designate leaders for each program, and to establish and implement a policy prohibiting discrimination. CHA is reviewing the proposed rule and will provide members with additional details in the coming weeks. Comments on the proposed rule are due Aug. 15. More information is available in a CMS fact sheet.
The Department of Health Care Services will host a series of webinars addressing upcoming changes to the DRG payment methodology, including a transition to the statewide base rate. The 90-minute webinars will be offered at two times: May 24 at 1:30 p.m. (PT) and June 2 at 9:30 a.m. (PT). Both sessions address the same information. Attendees must register prior to the start of the webinar in order to receive meeting details, and will receive instructions for joining the meeting after the registration request has been approved.
The California Department of Health Care Services (DHCS) is seeking volunteers to be part of the second phase of district/municipal public hospitals, and private hospitals transitioning to a treatment authorization request (TAR) free process for fee-for-service Medi-Cal beneficiaries. To participate in the TAR-free process, hospitals must:
Use an evidence-based standardized utilization review (UR) criteria for acute inpatient hospital stays for any payer
Have the ability to provide DHCS electronic access to medical records and UR reviews/decisions
The Department of Health Care Services (DHCS) is initiating a pilot project to measure the effectiveness of newly created marketing materials, attached, for the Community Care Transitions (CCT) program. CCT, California’s Money Follow the Person demonstration, is funded through a federal grant awarded to rebalance the state’s Medicaid spending on long-term care for residents who wish to live and receive care in the community. Under CCT, eligible residents who have lived in an institution or facility for 90 consecutive days and want to transition back to the community are provided with transition coordination, support and follow-up from contracted service providers. Facilities unable to meet residents’ needs for long-term home and community-based services are required to refer identified residents to state-designated local contact agencies (LCAs).
The Centers for Medicare & Medicaid Services (CMS) has issued the attached final rule extending the deadline for states to develop and submit an access monitoring review plan for Medicaid beneficiaries from July 1 to Oct. 1. The rule also changes the deadline for subsequent review periods to Oct. 1.
The final rule with comment period, originally issued in November 2015, required the plans to provide for state reviews of five core services: primary care, physician specialists, behavioral health, pre- and post-natal obstetrics (including labor and delivery), and home health services. In comments on the previous final rule, CHA urged CMS to modify the core services to include hospital services — such as hospital inpatient/outpatient, long-term acute care hospital and inpatient psychiatric services — as well as skilled-nursing services and hospital-based post-acute care services in the review process by modifying the final rule or by reissuing it as a proposed rule for public comment. In the attached final rule, CMS declined to expand the list of core services subject to access reviews.
Labor and business groups have formed an alliance to seek voter passage of the Medi-Cal Funding and Accountability Act, CHA’s hospital fee initiative, on the November 2016 ballot. Recently, labor giant United Food and Commercial Workers Western States Council added its support, joining almost 70 other labor organizations in California. The growing list includes the State Building and Construction Trades Council of California, the California State Association of Electrical Workers, the International Brotherhood of Boilermakers and a range of union locals.
Last year, the Centers for Medicare & Medicaid Services (CMS) finalized its Comprehensive Care for Joint Replacement (CJR) payment model. Starting April 1, the program will be mandatory for Los Angeles-Long Beach-Anaheim, Modesto and San Francisco-Oakland-Hayward hospitals that are not already participating in the bundled payment care initiative. In addition to the CJR Connect website, which CMS hopes to make available soon, the agency has scheduled a series of webinars aimed at helping providers prepare for the new program. Upcoming webinars, all scheduled for noon to 1 p.m. (PT), are March 10, focusing on quality measures and voluntary reporting; March 15, focusing on preparing for and key details about the program; and March 17, focusing on quality measures and quality composite scores.
Registration links for the webinars have been sent to primary points of contact at each affected CJR hospital but can also be obtained by contacting firstname.lastname@example.org. CJR program details — including model background documents, a list of hospitals and other materials — can be found at https://innovation.cms.gov/initiatives/cjr.
On March 1, the U.S. House of Representatives unanimously supported the Ensuring Access to Quality Medicaid Providers Act (H.R. 3716) to strengthen the Medicaid program. The legislation, also supported by the White House, would ensure that providers terminated from Medicare or a state Medicaid program for reasons related to fraud, integrity or quality are terminated from all other state Medicaid programs. It would also require state Medicaid programs that operate fee-for-service and/or primary care case management programs to include an electronic directory of physicians who served Medicaid patients in the prior year on the Medicaid program’s website. The Congressional Budget Office estimates the bill’s reforms would save $15 million by eliminating payments to fraudulent providers.
The Department of Health Care Services (DHCS) has resolved a previously identified claim processing issue that caused diagnosis-related group (DRG) claims with remittance advice details code “9953: APR-DRG — Length of Stay Invalid for Interim Claim” to be erroneously denied. Hospital providers may resubmit previously denied level one or two administrative day claims and rehabilitation claims, provided the claims meet certain criteria. More information on resubmitting claims is available at the DHCS website.
The Centers for Medicare & Medicaid Services (CMS) has issued the attached final rule implementing reforms to the rebate and reimbursement systems for Medicaid prescription drugs, as required by the Affordable Care Act (ACA). CMS estimates the final rule, which is intended to address the rising cost of prescription drugs, will save federal and state governments $2.7 billion over five years. The final rule creates a regulatory definition for Average Manufacturer Price, which is the program’s key metric for determining manufacturer rebates and pharmacy reimbursement for certain generic drugs that are subject to the federal upper limit (FUL). The final rule updates the FUL formula for the payment of certain generic drugs, which is intended to create an incentive for pharmacies to utilize generic drugs. The final rule also implements an ACA provision extending rebates to covered outpatient drugs provided to beneficiaries enrolled in Medicaid managed care organizations.
The California Department of Health Care Services (DHCS) seeks private and district/municipal hospital volunteers for the second phase transition to a treatment authorization request (TAR) free process for fee-for-service Medi-Cal beneficiaries. To participate in the TAR-free process, hospitals must:
Utilize an evidence-based standardized utilization review (UR) criteria for acute inpatient hospital stays for any payer; and
Have the ability to provide DHCS electronic access to medical records and UR reviews/decisions.
In the TAR-free process, hospitals would no longer submit a TAR for most acute inpatient stays, and instead would utilize standardized medical review criteria — such as InterQual or Milliman Care Guidelines — to perform their own utilization review. DHCS would provide monitoring and oversight post-payment.