Value Based Purchasing and Health Care Reform

CMS Releases Proposed Changes to Hospital and Physician Payment Systems for 2012

For additional information, see the following:

CMS PROPOSES POLICY AND PAYMENT CHANGES FOR OUTPATIENT CARE IN HOSPITALS AND AMBULATORY SURGICAL CENTERS (Centers for Medicare & Medicaid Services Press Release 7/1/2011)

Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012 (Proposed Rule 7/1/2011).  Scheduled to be published in Federal Register on July 19, 2011.

CMS PROPOSES POLICY, PAYMENT RATE CHANGES FOR THE PHYSICIAN FEE SCHEDULE IN 2012 (Centers for Medicare & Medicaid Services Press Release 7/1/2011) 

Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical Center Payment; Hospital Value-Based Purchasing Program; Physician Self-Referral; and Provider Agreement Regulations on Patient (Proposed Rule 7/1/2011).  Scheduled to be published in Federal Register on July 18, 2011. 

ACO Proposed Rule Released; Federal Agencies Request Comments

HHS News Release (3/31/2011): "The U.S. Department of Health and Human Services (HHS) today released proposed new rules to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs).  ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program will reward ACOs that lower health care costs while meeting performance standards on quality of care and putting patients first.  Patient and provider participation in an ACO is purely voluntary."

HHS News Release: Affordable Care Act to improve quality of care for people with Medicare (3/31/2011)

Read the ACO Proposed Rule (published in Federal Register on April 7, 2011): Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations (Comments due by June 6, 2011)

Read the Federal Trade Commission/Department of Justice Proposed Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program (3/31/2011) (Comments due by May 31, 2011)

Read the IRS Guidance and Solicitation of Comments (Notice 2011-20) (Comments due by May 31, 2011)

Affordable Care Act Adds Disclosure Requirement to Stark Law Exception

    On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (“PPACA”) into law.  One regulatory change included in PPACA is the addition of certain disclosure requirements to the in-office ancillary services (“IOAS”) exception to the federal physician self-referral law, commonly known as the Stark Law.

  

 

    Briefly, the Stark Law prohibits a physician from making referrals for designated health services (“DHS”) payable by Medicare or Medicaid to an entity with which the physician (or an immediate family member) has a financial relationship, unless an exception applies.  The Stark Law also prohibits the DHS entity from filing a claim for those referred services unless an exception applies.  The Stark Law is a strict liability statute and each element of an exemption must be satisfied.  In general terms, the IOAS exception mandates: (1) who can provide the DHS; (2) where the DHS can be provided; and (3) who can bill for the DHS.  As a result of PPACA, physicians must also meet certain disclosure requirements to meet the requirements of the IOAS exception.

  

    Section 6003 of the PPACA amends the IOAS exception by adding the requirement that referring physicians provide notice to their Medicare patients in writing, at the time of a referral for magnetic resonance imaging (MRI), positron emission tomography (PET), and computed tomography (CT) (and other imaging services that the Secretary of Health and Human Services determines appropriate): (1) that the patient may obtain such services from a provider other than the referring physician or a member of the referring physician’s group practice; and (2) provide the patient with a list of other providers who furnish the service in the area where the patient resides.  Under Section 6003, the disclosure requirements apply to MRI, PET, and CT services furnished on or after January 1, 2010.