CMS may impose minimum provider-network standards for ACA plans

The CMS has proposed mandating minimum network standards for health plans sold on the federal insurance marketplace in 2017 as part of an effort to handle the broad shift toward narrow provider networks.

The Affordable Care Act requires that all medical policies on the exchanges have enough in-network hospitals and doctors for members so that “all services will be accessible without unreasonable delay.” In addition, ACA-compliant plan networks must update their provider directories monthly and include at least 30% of essential providers.

However, the 381-page proposed rule (PDF) released Friday goes a step further, asking states to establish a quantitative measure to ensure ACA policyholders have sufficient access to healthcare providers. If states don’t choose a standard, the CMS proposed a default setting that would measure network adequacy by maximum travel times or distances to providers. Those minimum criteria would be established at a later date, the agency said.

“HHS would discuss with states their selection in advance of the start of the certification cycle to determine whether the state’s network adequacy standard would be acceptable,” the proposed rule states. “We would thereafter notify issuers via subregulatory guidance whether the state standards or federal default standards apply.”

More health insurers have built narrow-network […]

By |November 24th, 2015|Health Reform|Comments Off on CMS may impose minimum provider-network standards for ACA plans

First Mandatory Bundled Payment Program to Start in April

The start of Medicare’s first mandatory bundled payment program was pushed back by three months in a final rule issued this week.

The delay to April 1, 2016, was less than was sought by some hospital advocates but praised by others for giving organizations more time to implement the complex new requirements.

Rick Pollack, president and CEO of the American Hospital Association, raised concerns “that hospitals will still be pressed to put in place the processes and procedures necessary for the program.”

In addition to the delay, the final rule for the Comprehensive Care for Joint Replacement (CCJR) model, issued by the Centers for Medicare & Medicaid Services (CMS) on Nov. 16, included other tweaks.

For instance, it included a more gradual phase-in of downside risk, which begins in the second year, as well as a lower stop-loss limit.

Hospital advocates also praised the slightly reduced scale of the initiative, which will be required for most hospitals in 67 metropolitan statistical areas (MSAs) instead of the proposed 75 MSAs. That change was in response to recommendations to remove regions with large numbers of providers already participating in Medicare’s voluntary Bundled Payments for Care Improvement (BPCI) initiative.

The final rule also included a risk stratification of […]

By |November 21st, 2015|Medicare/Medicaid|Comments Off on First Mandatory Bundled Payment Program to Start in April

OIG to Focus on Hospital Finances in 2016

The chief federal healthcare fraud watchdog plans to focus on hospital finances in 2016, according to its annual planning document.

Much of the FY16 work plan issued this month by the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services consisted of plans to complete previously launched investigations, many of which examined hospital finances, including cost reports, outlier reports, salary data, wage data, comparisons between regions, and graduate medical education payments.

“Obviously the OIG is always focused on Medicare payments, and in this instance it appears they are focused on the number crunchers’ role as much as they are on the provider or the provision of services for which they make payments,” Sarah Lord, a partner for Arnall Golden Gregory in Atlanta, said in an interview.

Some of the highest-impact reviews of hospital finances could come in OIG’s examination of wage data, which are used to calculate the wage indexes for Medicare payments.

Hospitals should know that OIG plans to use costs across regions to drive down costs within specific hospitals, according to Lord. For example, hospitals paying wages and salaries significantly greater than others in the area could face pressure to bring those payments down.

“It certainly is worthwhile […]

By |November 21st, 2015|Health Reform|Comments Off on OIG to Focus on Hospital Finances in 2016


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