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35 posts from May 2016

May 31, 2016

E&C Subcommittee Hearing, HHS OIG and GAO Reports on Medicare and Medicaid Fraud Enforcement – More Work to Be Done

On May 24, 2016, the House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing entitled, "Medicare and Medicaid Program Integrity: Combatting Improper Payments and Ineligible Providers." The hearing also coincided with a series of reports released by the Health and Human Services (HHS) Office of Inspector General (OIG) related to Centers for Medicare and Medicaid Services (CMS) oversight in the federal programs, as well as with a report issued by the Government Accountability Office (GAO) relating to CMS.

Opening Statements

Full Committee Chairman Fred Upton and Subcommittee Chairman Tim Murphy opened the hearing, and they, along with some of their politically-aligned colleagues noted the work of both the OIG and the GAO and highlighted the need for CMS to continue to implement recommendations made by the agencies. Both Chairmen expressed concern about improper payments, including Rep. Murphy mentioning the approximately $89 million in improper payments and Rep. Upton mentioned improper payments to locations that do not exist.

Subcommittee Ranking Member Diana DeGette (D-CO) said in her opening remarks that fraud and abuse in Medicare and Medicaid was a "longstanding, pervasive challenge." She mentioned she was encouraged by recent successes of CMS implementing program integrity efforts that were brought about by the Affordable Care Act (ACA) and that these new tools should greatly enhance CMS' ability to achieve antifraud goals.


Testimony was elicited first from Ann Maxwell, the Assistant Inspector General at the Office of Evaluation and Inspections within HHS OIG. She testified that oversight of provider enrollment in both Medicare and Medicaid is critical. She believes that enrollment in the program is truly "where is starts" and that once they are enrolled, providers essentially have a "green light" to start billing CMS. She also noted that she had some concerns about the different information about the same providers between Medicare and Medicaid; she believes that it was hard to know who you are doing business with "if you can't even get the name right."

Dr. Seto Bagdoyan, the Director of Audit Services with the GAO discussed that his office had recommended that CMS improve address verification processes. He believes that such a move will help to prevent future instances of CMS making incorrect payments to non-existent addresses.

The Deputy Administrator at the Center for Program Integrity at CMS, Dr. Shantanu Agrawal, noted that there are efforts underway to improve payment accuracy including site visits, automated risk based screening efforts, and targeted enforcement efforts. He said that CMS' work so far as resulted in a $2.4 billion program savings.


Ensuring Access to Quality Medicaid Providers Act

This legislation, which would require the states to report Medicaid provider terminations to CMS, received bipartisan support from the Subcommittee. Ranking Member Diana DeGette encouraged her colleagues in the Senate to take the bill up, following its passage in the House of Representatives.

Improper Payment Rate

The vast majority of the hearing's discussion focused on improper payments in both Medicare and Medicaid. Improper payments occur when federal fund go to the wrong recipient, when the recipient receives the incorrect amount of funds (overpayments and underpayments), documentation is not available to support a payment, or the recipient uses federal funds in an improper manger. A recent OIG report found that HHS had a payment error rate of 12% in FY 2015.

Prior Authorization

Dr. Agrawal mentioned that CMS was increasing the use of prior authorization, which requires the service to be approved by CMS prior to the service being rendered. Dr. Agrawal feels as though it is a useful tool and that while he may be open to more focused prior authorization usage, he thinks that the agency needs more experience before begin able to do so successfully.

The OIG and GAO Reports


The HHS OIG released three reports: "Medicaid: Vulnerabilities Related to Provider Enrollment and Ownership Disclosure," "Medicare: Vulnerabilities Related to Provider Enrollment and Ownership Disclosure," and "Medicaid Enhanced Provider Enrollment Screenings Have Not Been Fully Implemented."

The first report resulted in seven recommendations being made by OIG to resolve issues revolving around disclosure and ownership information. Those seven recommendations included CMS: working with State Medicaid programs to identify and correct gaps in their collection of required provider ownership data; require State Medicaid programs to verify the completeness and accuracy of provider ownership information; and work with State Medicaid programs to review providers that submitted nonmatching owner names and take appropriate action.

The second report ended with four recommendations for CMS, including: reviewing providers that submitted nonmatching owner names and take appropriate actions; educate providers on the requirement to report changes of ownership; and increase coordination with State Medicaid programs on the collection and verification of provider ownership information in Medicare and Medicaid.

The third report included six recommendations, all of which CMS concurred with. The recommendations included: CMS assist the states in implementing fingerprint based criminal background checks for all high risk providers; enable the States to substitute Medicare screening data by ensuring the accessibility and quality of Medicare data; and strengthen minimum standards for fingerprint-based criminal background checks and site visits.


The GAO report, titled "Continued Action Required to Address Weaknesses in Provider and Supplier Enrollment Controls," highlighted progress that CMS has made in implementing previous recommendations related to oversight of providers that are enrolling in the agency's Provider Enrollment, Chain and Ownership System (PECOS).


May 27, 2016

CMS Administrator Goes to Twitter to Explain the Proposed Rule for the Medicare Access and CHIP Reauthorization (MACRA)

In an very unusual move for a government regulator, the CMS acting administrator Andy Slavitt took to Twitter to explain his agency's strategy around the new Medicare payment law, also known as MACRA. This comes as CMS released the long-awaited proposed MACRA rule which is open for comment until June 27. The proposed rule creates a "Quality Payment Program" to replace old reporting programs. There two tracks, the first called the Merit-based Incentive Payment System (MIPS) consolidates components of the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program. A second track involves alternative payment models (APM). Because of the high bar set to qualify for the APM track, CMS projects that only 30,000 to 90,000 clinicians will be in the APM track. An estimated 687,000 to 746,000 physicians will be in MIPS.

Here are the highlights from Slavitt's tweet-storm:


1- Today I will summarize how much listening we've been doing around #MACRA & lay out the opportunities to hear the basics & get engaged.

3:04 PM - 21 May 2016


2. Our goal is to close the gap between Washington DC and front line realities of patient care. In May, we have over 35 events on #MACRA.

3:06 PM - 21 May 2016


3. We've hosted ten #MACRA webinars this month with over 30,000 attendees.

3:06 PM - 21 May 2016


4. To join one of our five upcoming #MACRA webinars, visit: …

3:07 PM - 21 May 2016


5. We're hosting #MACRA listening sessions. We've visited specialties, PC, & rural. You can invite #CMS to events …

3:10 PM - 21 May 2016


6. With each event, we take common Qs & answer them through fact sheets. Our latest is on #MACRA & small practices: …

3:11 PM - 21 May 2016

7. We post new content each week. Join the #CMS #MACRAlistserv to keep up-to-date: …3:11 PM - 21 May 2016


8. Or you can visit our #MACRA website to learn the latest: …

3:12 PM - 21 May 2016


He continued the next day:


Today, I will lay out some of the top interest & feedback areas we have heard for the Quality Payment Program under#MACRA.

11:32 AM - 22 May 2016


1. One area of input is the need to use #MACRA to increase focus on practice of medicine/pt care, not reporting/measurement & paperwork.

5:30 PM - 22 May 2016


2. A 2nd area is how small practices will fare relative to larger sized practices under #MACRA. We put this out: …

5:33 PM - 22 May 2016


3. A 3rd area is the availability of payment models like med homes, ACOs, including how they overlap & how to ease the path in to qualify.

5:34 PM - 22 May 2016


4. We have received other questions around flexibility, burden, timing, specialty care & payment adjustments.

5:37 PM - 22 May 2016


5. Will create fact sheets 4 key questions as we answer them as we've been doing.

5:39 PM - 22 May 2016


6. My takeaways: first, very encouraged by all the engagement, particularly the critics.

5:42 PM - 22 May 2016


7. My takeaways: Second, people want a philosophical change- a program that doesn't get in the way of practicing medicine, but supports it.

5:44 PM - 22 May 2016


8. My takeaways: third, walking thru basics has been critical. Payment adjusts., measurement, paperwork r all better than today's Medicare.

5:49 PM - 22 May 2016


9. My takeaways: fourth, more time, more to learn, more#MACRA meetings coming up. 35 in May alone. Grateful for all the engagement.

5:54 PM - 22 May 2016



Stakeholders have been struggling with the rule's complexity and length, so it is not surprising that CMS wants to explore all possible avenues for communication. It is unlikely these tweets will do much to change the confusion and challenges facing physicians, but it is laudable that the government is thinking outside of the box and looking to connect over social media. But the biggest takeaway seems to be that CMS recognizes the complexity of the rule and this could be insight into the possible comments that should be sent to the agency. 60 days to analyze one of the most important Medicare regulations in a quarter century is simply not sufficient. CMS is bound by difficult congressional deadlines, but it may be smart for all of Washington, D.C. to rethink the MACRA implementation process. It is too important for physicians and patients alike to rush through massive changes that almost no physician truly understands.

May 26, 2016

New Report: Industry and Physician Interaction Considered Acceptable by Many Patients

In this contentious election year, favorable coverage of the pharmaceutical industry is, for some reason, hard to come by. However, Wayne Pines, the President of Healthcare at APCO Worldwide and former Associate Commissioner of the Food and Drug Administration, recently authored a post at The Hill, where he acknowledged how "unfortunate" it is that the industry has been the target of much negative publicity. He further acknowledges that those "who have worked with the pharmaceutical and medical device industries for many years recognize that medical advances since World War II, continuing to this day, have extended lifespan and enhanced the quality of lives for hundreds of millions of people."

As many of our readers know, the Physicians Payment Sunshine Act was the result of industry critics who felt that industry relationships with healthcare providers are reprehensible and that disclosure of payment information would curtail their interactions with industry. When the law was enacted, it was not clear how the information would be accessed, nor how patients would be able to find it.

APCO Insight recently polled Americans in an attempt to learn whether the data was useful to them and whether it has actually changed their relationships with their physicians. The study, Return on Reputation, has provided insights into how stakeholders view medical products companies.

Report Results

The majority of both Opinion Leaders and Policy Leaders indicated that they were either very or somewhat interested in knowing how much money their healthcare providers receive from companies (90%/86%), but fewer were likely to check online information to see if their own doctor was receiving payments (85%/75%). Unsurprisingly, even fewer were likely to ask their doctor directly about their payments (66% of Opinion Leaders and 42% of Policy Leaders).

Further, while the majority of patients want to know how much industry spends on healthcare providers, few patients are so "angry" with industries that they take any action. Patients are more likely to be okay with industry and healthcare provider interaction when it leads to benefits, such as discussing a medical advance or new research.

A majority of respondents were okay with healthcare providers receiving payments/items of value if they are receiving those financial benefits in connection when: communicating with other medical professionals to share experiences and learn about best practices; conducting research studies or clinical trials to develop new medicines or medical devices; continuing physician education by receiving educational materials, such as textbooks, journal reprints, or patient demonstration kits; consulting with companies on specific projects that require specialized medical expertise; or speaking at events as a medical expert on a specialized health topic.


The report has shown that there is no indication that public disclosure has changed how patients relate to their healthcare providers, or how they view the pharmaceutical or medical device industries. The report also shows that patients actually may look favorably upon doctors who receive financial benefits from the pharmaceutical industry, provided they are received through education and interaction with industry and other providers, a position we have long held.

The pharmaceutical industry is unfortunately a large target, and will continue to remain the target of politicians. It is incumbent upon the industry to work to educate the public and other stakeholders about their contributions to healthcare and how collaboration with healthcare providers actually benefits patients, not hurts them.


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