Final rule on Medicaid Prescription Drug Programs

In January of 2016, the Centers for Medicare and Medicaid Services (CMS) issued a final rule on covered outpatient drugs. The rule changes the Medicaid Drug Rebate Program by the Patient Protection and Affordable Care Act (PPACA) and the overall Medicaid drug reimbursement program.  These changes have several goals, including reducing the cost to the federal and state governments and improving beneficiary access to covered outpatient drugs.

CMS claims the changes implemented will help the government save money in the Medicaid Drug Rebate Program, which had been subject to sustainability issues. One key change in the final rule is a definition of the Average Manufacture Price, which in turn gets used to determine rebates and pharmacy reimbursements subject to the federal upper limit. Similarly, the changes to the federal upper limit formula will incentivize pharmacies to use certain generic drugs. The final rules clarify many of the ambiguous sections of the Medicaid Drug Rebate Program by the PPACA, including the manufacturer reporting requirements. The rule also aligns the pharmacy reimbursement system with the actual acquisition cost of the drug.

Overall, the new incentives and changes should improve the reimbursement system and help manage drug costs. This rule becomes effective April 1, 2016, although CMS is allowing comment for 60 days after publication on certain elements of the rule. The new rule can be found at the following link:

https://www.gpo.gov/fdsys/pkg/CFR-2014-title42-vol4/pdf/CFR-2014-title42-vol4-part447.pdf

 © 2015 Vandenack Williams LLC
For more information, Contact Us

CMS Reveals Star Ratings for Home Health Care Agencies

By Matthew J. Effken.

The Centers for Medicare and Medicaid Services (CMS) has added star ratings to its Home Health Compare website that provides information about Medicare-certified home health care agencies. The new feature is intended to help consumers identify differences in quality among home health care providers and also help agencies identify areas where they can improve. Ratings range from 1 star for the worst performers to 5 stars for the best performers. Agencies are awarded more stars when they follow recommended care practices for more patients and when more of their patients show improvement.

Nationally, nearly half of all agencies fall in the 3 to 3½ star range. Less than 3% of home health agencies achieve the highest 5 star rating. Quality measurements used in determining the star ratings include: managing daily activities, managing pain and treating symptoms, treating wounds and preventing pressure sores, preventing harm, and preventing unplanned hospital care.

The star ratings are determined based on patient surveys and Medicare claims data, and will be updated by CMS each quarter. Further information and the website can be found at the following link: http://medicare.gov/homehealthcompare/

© 2015 Houghton Vandenack Williams
For more information, Contact Us

CMS Reveals Star Ratings for Home Health Care Agencies

By Matthew J. Effken.

The Centers for Medicare and Medicaid Services (CMS) has added star ratings to its Home Health Compare website that provides information about Medicare-certified home health care agencies. The new feature is intended to help consumers identify differences in quality among home health care providers and also help agencies identify areas where they can improve. Ratings range from 1 star for the worst performers to 5 stars for the best performers. Agencies are awarded more stars when they follow recommended care practices for more patients and when more of their patients show improvement.

Nationally, nearly half of all agencies fall in the 3 to 3½ star range. Less than 3% of home health agencies achieve the highest 5 star rating. Quality measurements used in determining the star ratings include: managing daily activities, managing pain and treating symptoms, treating wounds and preventing pressure sores, preventing harm, and preventing unplanned hospital care.

The star ratings are determined based on patient surveys and Medicare claims data, and will be updated by CMS each quarter. Further information and the website can be found at the following link: http://medicare.gov/homehealthcompare/

© 2015 Houghton Vandenack Williams
For more information, Contact Us

CMS Expands Proposed Five-Star Rating System for Providers

The Centers for Medicare and Medicaid Services have announced another expansion to their planned five-star rating system for various medical facilities. At present, CMS uses star ratings to allow consumers to compare Medicare Advantage plans and nursing homes on its website.

Over the past six months, CMS has stated that it would include star ratings on its Physician Compare website. Now, CMS will also include star rankings for hospitals, home health agencies, and dialysis providers. CMS plans on rolling out the new star ranking system in late 2014 to early 2015.

© 2014 Parsonage Vandenack Williams LLC

For more information, Contact Us

Medicare Part D Drug Plans Can Withhold Payments on Suspicious Claims

In a growing effort to prevent “doctor shopping,” Medicare Part D prescription drug plan sponsors can now safely withhold pharmacy payments on suspicious claims without violating prompt payment requirements.  A recent CMS Notice clarifies that when a sponsor suspects fraud with respect to a particular claim, payment need not be made until the claim has been investigated further to determine that it is not fraudulent.  The Notice reflects an increasing trend of moving away from anti-fraud policies that inadvertently require sponsors to “pay and chase” claims believed to be fraudulent and instead moving towards policies that prevent the payment in the first place.

The CMS Notice can be read at: Clarification of Medicare Part D Policies with Respect to Overutilization.

© 2012 Parsonage Vandenack Williams LLC

For more information, contact info@pvwlaw.com

Senate Passes Medicare “Doc Fix”

The Senate unanimously passed a one-year “SGR doc-fix” on Wednesday, December 8, 2010, preventing a 25 percent cut to Medicare payments that would commence on January 1, 2011.  The measure would extend through 2011 the current reimbursement rates for physicians who treat Medicare patients.

The $19.3 billion bill still needs to be approved by the House before Congress recesses for the holidays. House approval is expected.

The bill would be paid for by changing a provision of the health reform act that provides tax credits for individuals who purchase coverage. The credit is scaled to a person’s income. The legislation would increase the amount individuals would be required to repay if they underestimate their earnings.

© 2010 Parsonage Vandenack Williams LLC

  For more information, contact info@pvwlaw.com