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CCH® Reimbursement Integrated Library
The Reimbursement Integrated Library delivers the key performance indicators for maximizing reimbursement. The Library includes three invaluable titles:

• Dennis Barry's Reimbursement Advisor - This monthly newsletter provides all the facts about reimbursement strategies to minimize the adverse effects of DRGs, RBRVs, APCs and capitation to optimize hospital reimbursement.
• Receivables Report - This monthly newsletter includes actual profit-improvement examples from facilities nationwide, secrets for successfully challenging denials, tips for using automation to increase cash flow, and strategies your colleagues are using now to prepare for health care reform.
• Hospital Accounts Receivable Analysis - This quarterly journal is a synopsis of statistical data related to hospital receivables.

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August 2008, Volume 23, No. 12

As the Centers for Medicare and Medicaid Services (CMS) continuously clarifies, amends and revises rules governing the myriad aspects of the Medicare regulations, so do the rules and their transformations continuously receive scrutiny. In the August 2008 issue, authors examine CMS’ final rule revising Provider Reimbursement Review Board (PRRB) appeals as well as the agency’s new additional criteria to define what is considered a new graduate medical education program. In addition, authors examine two recent federal district court decisions in which hospitals’ scrutiny of CMS policy results in rulings with favorable implications for providers.

• CMS issues final rule on PRRB appeals: An overview of changes and practical tips. A final rule issued in May revising the regulations governing Provider Reimbursement Review Board (PRRB) appeals makes significant changes that are effective August 21. Gone are the days a provider could mail its appeal to the PRRB on the 180th day after receiving its notice of program reimbursement and add issues up to the day of the hearing. In this article, the author examines the changes, as well as practical tips in managing the changes and new requirements in the PRRB appeals process.

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Fourth Quarter 2007, Volume 22, Number 1

• Uncollectibles. In the fourth quarter 2007, write-offs fell to 4.59 percent, a 0.20 percentage point improvement from the prior quarter. With improved uncollectibles performance in the fourth quarter, hospitals responding to the HARA Report secured better than benchmark level performance for this major financial indicator in three of the four quarterly financial reporting periods of 2007. The uncollectibles benchmark is to hold the percent of gross revenue written off as charity or bad debt to 5 percent or less of total gross revenue. For more on bad debt and charity, please see the HARA Report on Fourth Quarter 2007.

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CMS has expanded the number of preventable conditions for which it will not pay inpatient hospitals, under the final rule for the inpatient hospital prospective payment system (IPPS) for fiscal year 2009. The list of so-called "never" events—preventable medical errors that result in serious consequences for the patient—will expand from eight to 11.

As part of the FY 2008 IPPS update, CMS listed eight preventable hospital-acquired conditions (HACs) for which it would not make additional payments. In the proposed rule for FY 2008 (see ¶220,527), CMS nine additional more HAC categories; the final rule includes three of these:

• Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity;
• certain manifestations of poor control of blood sugar levels; and
• deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures.

CMS also sent a letter to state Medicaid directors encouraging states to adopt the same no payment policy regarding never events. The final rule also expands the Reporting Hospital Quality Data for Annual Payment Update program. Hospitals currently are required to report 30 quality measures on Medicare claims in order to qualify for the full market basket update. Under the proposed rule, CMS suggested adding 43 new quality measure, but the final rule only include 13 new measures. One measure—oxygenation assessment—will be retired, so hospitals will be required to report on 42 measures in FY 2009.

The final rule will be published in the Federal Register on Aug. 19, 2008, and will go into effect Oct. 1, 2008. The advance release copy of the rule is published at ¶180,744. CCH Chicago Bureau, Aug. 1, 2008.

On August 8, 2008, CMS will publish the final rules related to prospective payment updates for inpatient rehabilitation facilities (IRF) and skilled nursing facilities (SNF). The inflation update for IRFs is set at zero percent for fiscal year 2009. The final rule also retains the requirements that at least 60 percent of a IRF's patient population have at least one of 13 qualifying conditions.

The SNF market basket is increasing 3.4 percent. A recalibration of payment categories which had been proposed for FY 2009 has been delayed.

More details about both rules will be included in Report 1522; the text of the final rules will be included in Report 1523. CCH Chicago Bureau, Aug. 1, 2008.

An analysis of confidential data on Medicare Part D and Medicaid drug prices by the majority staff of the House Committee on Oversight and Government Reform reported that private Medicare Part D insurers pay significantly higher prices for prescription drugs than does the Medicaid program. According to the committee report, for the six million dual eligible beneficiaries, the Part D insurers paid $3.7 billion more in 2006 and 2007 to purchase the top 100 drugs than they would have paid if they had access to the lower Medicaid drug prices. Eliminating this drug manufacturer windfall over the next 10 years would save taxpayers $86 billion if the Medicare Part D insurers paid Medicaid prices for drugs used by their dual eligible beneficiaries. CCH Washington Bureau, July 2008, ¶52,318.

Medicare Advantage (MA) organizations will no longer be permitted to offer midyear benefit enhancements (MYBEs) to their health plans. Employer and union group health plans sponsors offering “800 series” MA plans (not open to general enrollment) will continue to be able to offer benefit enhancements as they do currently, through means other than MYBEs under existing CMS employer group waiver policies. Programs of all-inclusive care for elderly (PACE) plans are not affected by this prohibition. Final rule, 73 FR 43628, July 28, 2008, ¶180,757.

National Coverage Determinations Manual, Pub. 100-03, Transmittal No. 88, July 25, 2008, ¶157,443. Premium content

Medicare Benefit Policy Manual, Pub. 100-02, Transmittal No. 93, July 25, 2008, ¶157,442; National Coverage Determinations Manual, Pub. 100-03, Transmittal No. 89, July 25, 2008, ¶157,444. Premium content

Medicare National Coverage Determination Manual, Pub. 100-03, Transmittal No. 90, July 25, 2008, ¶157,445; Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1562, July 25, 2008, ¶157,448. Premium content

Medicare National Coverage Determinations Manual, Pub. 100-03, Transmittal No. 91, July 25, 2008, ¶157,446. Premium content

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1561, July 25, 2008, ¶157,447. Premium content

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1563, July 25, 2008, ¶157,449. Premium content

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1564, July 25, 2008, ¶157,450. Premium content

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1565, July 25, 2008, ¶157,451. Premium content

Program Integrity Manual, Pub. 100-08, Transmittal No. 236, July 25, 2008, ¶157,452. Premium content

Medicare One-Time Notification Manual, Pub. 100-20, Transmittal No. 361, July 25, 2008, ¶157,453. Premium content

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1566, July 29, 2008, ¶157,454. Premium content