Medicare Regulatory Reform
Legislation
Current Status
Strong bipartisan/bicameral support for regulatory relief and contracting
reform among the Medicare Conferees permitted a relatively uncontested
agreement on Title IX of the “Medicare Drug, Improvement, and
Modernization Act of 2003” (P.L.
108-173): “Administrative Improvements, Regulatory Reduction,
and Contracting Reform.” Similar support from the Bush Administration
assured that the regulatory reforms would remain in the final Conference
Report.
The Title IX reforms address inconsistencies, lack of clarity,
and excessive provider burdens related to Medicare audits and appeals,
the regulatory process, and the selection of contractors. Of the
numerous reform provisions in P.L. 108-173), the brief summaries
below feature provisions of interest to academic physicians:
- Regulatory Issuance and Compliance: Additions to final
rules that are not “logical outgrowths” of proposed/interim
final rules are treated as proposed rules. Compliance actions
against providers are limited to services furnished on or after
the effective date of the relevant regulatory change. Providers
are not subject to penalties or interest if they follow written,
yet inaccurate, guidance related to services or claims.
- Contractor Reforms: The functions of Fiscal Intermediaries
and Carriers are consolidated and placed under the authority
of new “Medicare Administrative Contractors” (MACs).
Starting in FY 2006, MACs are selected/renewed on a competitive
basis that incorporates provider satisfaction levels and claims
payment error rates. Contractors will be required to offer clear
and accurate responses to written provider inquiries within
45 business days.
- Expedited Access to Judicial Review: The DHHS Secretary
will establish a process whereby providers obtain access to
judicial review when a “review entity” determines
(within 60 days of a written request) it lacks authority to
decide a question of law/regulation (where material facts are
not in dispute). Decisions are subject to review by the Secretary.
The process applies to appeals filed in or after FY 2005.
- Written Notices: Written notices of determination,
redetermination, or appeal decisions that result in claims denial
must address the reasons, how to obtain information about the
decision, and the next step in the appeals process. Notices
must summarize any clinical/scientific evidence used in the
decision-making process.
- Provider Enrollment Process: By June 9, 2004, a provider
enrollment process must be in place. It will include the right
to a hearings/judicial review for application/enrollment denials
or non-renewals. The DHHS Secretary will set contractor deadlines
for acting on enrollment applications and renewals (a performance
measure for the competitive bidding process). Changes in provider
enrollment forms must be made in consultation with providers.
- Provider Audits: Random prepayment reviews by MACs
are limited to program-wide or contractor-wide analyses. MACs
must adhere to a review process to be established by the DHHS
Secretary. Initial identification of billing errors may not
trigger a prepayment review unless “there is a likelihood
of sustained or high level payment error.” Providers must
be notified in writing of any intent to conduct a post-payment
audit.
- Recovery of Overpayments: Extrapolation of overpayments
is limited to situations of “sustained or high level of
payment error” or when educational intervention failed
to remedy the errors. Providers may qualify for a repayment
plan of up to 5 years if they demonstrate how repayment poses
“extreme hardship”
- Pilot Testing New E&M Documentation Guidelines:
DHHS may not implement/modify E&M documentation guidelines
unless they are developed in collaboration with practicing physicians
and tested via one-year voluntary pilot projects (to be analyzed
by MedPAC). At least one pilot must be conducted in a “teaching
setting,” and any changes must reduce paperwork.
- EMTALA Improvements: The DHHS Secretary must request
reviews by Peer Review Organizations before issuing EMTALA compliance
determinations that will terminate program participation. The
DHHS Secretary must allow 5 business days for the review and
notify the hospital/physician(s) when an investigation concludes.
The PRO must provide the hospital and physician(s) with a copy
of their final report. When determining payment for EMTALA-mandated
services, Medicare must establish whether a service was “reasonable
and necessary” based on the information available at the
time services were ordered. Medicare may not consider provision
of the service to a patient before or after the visit. An EMTALA
Technical Advisory Group is created to review related issues
and advise the DHHS Secretary accordingly (does not mandate
representation by teaching hospitals or teaching physicians).
Background
Many of the agreed upon provisions represent sustained collaborative
efforts by the AAMC and members of the physician community to reduce
the regulatory burden on Medicare providers and enhance their rights
related to overpayments, audits, and appeals.
The regulatory relief provisions in P.L. 108-173 are similar to
those passed by the House Ways and Means and Energy and Commerce
Committees (separate versions of H.R.
810) in March and April 2003. The Senate Health, Education,
Labor and Pensions (HELP) Committee also passed similar reforms
(S.
720) in July 2003. The HELP Committee bill and both versions
of H.R. 810 incorporated provisions initially outlined in S.
452/H.R.
868, a regulatory relief bill introduced in March 2001 and supported
by the AAMC, American Medical Association, and many physician specialty
groups.
|
