Tuesday, November 5, 2013
Last week, CMS posted to its website the responses it received to arequest for comment on whether physicians have a privacy interest regarding their Medicare reimbursements, MedPage Today reports (Pittman, MedPage Today, 11/1).
CMS issued the request after a federal judge in May lifted a 33-year-old injunction that barred the government from giving the public access to a confidential database of Medicare insurance claims.
The court injunction stemmed from a lawsuit that the American Medical Association and the Florida Medical Association filed to prevent former President Jimmy Carter's administration from publishing a list of annual Medicare reimbursements.
The database, known as the Carrier Standard Analytic File, contains information on physicians and other health care providers participating in Medicare who are paid on a fee-for-service basis. It incorporates all physician claims that Medicare paid directly.
Federal investigators can use the database to find fraud, but its information on physicians and other individual providers has been kept confidential from the public.
If the agency determines that doctors have a privacy interest related to their Medicare payments, CMS plans to create a review system to balance health care providers' privacy with public interest (iHealthBeat, 9/13).
Details of Responses
CMS received 248 pages of responses to its request, with most sent by or before the Sept. 4 deadline.
However, the agency waited until last week to publicly post all of the comments online (MedPage Today, 11/1).
In a response to CMS, Robert Wood Johnson Foundation President and CEO Risa Lavizzo-Mourey said the agency should ensure such data are available to "entities that are reasonably experienced with handling data and will partner with CMS in the common goal of achieving high-value care in the public and private sector."
However, the group did not recommend widespread public release of the data to any interested parties.
Meanwhile, the American Academy of Family Physicians, AMA and other physician-led groups sent a letter to CMS urging the agency to develop data protection policies before releasing such Medicare data.
The group said CMS should "engage with experienced data statisticians, physician organizations and other relevant stakeholders on ways to further protect such data."
The letter also argues that individual payment data should be presented in conjunction with clinical quality information to facilitate value-based decisionmaking among consumers (iHealthBeat, 9/13).
In a separate letter, the American Medical Group Association urged CMS to account for the various ways in which Medicare payments are made.
American Osteopathic Association told CMS that the release of Medicare data on individual physicians should be delayed until:
Technology is available to ensure data accuracy;
Data are used by consumers for health care decisionmaking;
Transparency requirements do not add administrative burdens to physician practices; and
Physicians have the opportunity to review their data before they are published online and are allowed to add comments.
Meanwhile, the American College of Physician Executives told CMS that a survey of its membersfound that:
- 46% were against Medicare payment data being released publicly;
- 42% supported such a move; and
- 12% were unsure (MedPage Today, 11/1).
Ben van der Meer
Sacramento Business Journal
Date: Monday, November 4, 2013, 2:12pm PST
Sacramento-based Sutter Health has agreed to pay $46 million and make changes in billing as part of a settlement of a California Department of Insurance lawsuit concerning the health system's charges for anesthesia.
The suit, prompted by a 2011 whistle-blower complaint by billing auditor Rockville Recovery Associates, claimed Sutter often charged patients or their insurance companies up to three times for anesthesia, totaling thousands of dollars, even though the services were supposed to be covered under one charge.
“The settlement requires Sutter to disclose on its website every component of its anesthesia billing and what those services cost Sutter.” Insurance Commissioner Dave Jones said in a news release. “Patients, insurers and the public will now be able to compare Sutter’s costs to what it charges for anesthesia. They will see any mark-ups.”
As a result of the settlement, Sutter agreed to the $46 million payment, to stop billing for operating room anesthesia on a time-based basis and instead doing so with a flat fee, to describe every component of its anesthesia billing, to publicly disclose to patients and insurers the cost of anesthesia services, to clarify the relationship between its master schedule of charges for services and what’s on its bills, and to more readily permit payers to contest its bills.
The settlement also includes two other defendants, MultiPlan Inc. and Private Healthcare Systems Inc.. They must pay $925,000 and provide patients with notifications of their audit rights.
Of the $45 million, the state will receive $20 million to be used for investigating and preventing insurance fraud. Under state insurance law, whistle-blower Rockville is entitled to a portion of the settlement.
In the settlement agreement, Sutter, MultiPlan and PHCS do not admit to wrongdoing.
“Sutter Health’s method of billing for these services was, and still is, consistent with federal and state laws and regulations,” Duane Dauner, president and CEO of the California Hospital Association, said in a news release. “In fact, more than 90 percent of California hospitals, including hospitals operated by the state, bill for anesthesia services in this same manner.”
It was difficult to come to an agreement on the size of a monetary settlement, but given Sutter’s status as a not-for-profit health system, doing so was preferable to going to court, Sutter spokesman Bill Gleeson said in a news release.
A trial of the suit was scheduled to start this month in Sacramento Superior Court, according to Sutter.
By Rob Nikolewski │ New Mexico Watchdog
SANTA FE, N.M. — In a wide-ranging case where allegations of $36 million of alleged fraud have been leveled against 15 New Mexico behavioral health providers, the state’s Human Services Department reauthorized Medicaid funding to two organizations on Monday — but only after they agreed to pay a combined $4.24 million due to alleged improper billing.
Presbyterian Medical Services and Youth Development, Inc. are back in business. But, in addition to the payments, they had to sever ties with another behavioral service provider under investigation — TeamBuilders Counseling Services, Inc. of Santa Fe — and agreed to “intensive new training and oversight of its management.”
PMS will repay $4 million. YDI will repay $240,000.
“This is a positive outcome that allows us to recoup a significant portion of the Medicaid funding that has been identified as overpayments,” HSD Secretary Sidonie Squier said in a news release.
“While we have never agreed with the state’s contentions, allegations, or actions, PMS’s primary motivation in settling was to preserve its critical safety net behavioral health services and over 200 New Mexico behavioral health jobs.” PMS CEO Steve Hansen said in a statement.
YDI, in its own news release, also said it “did not fully agree with the processes employed” by HSD, but said the most “prudent” path was to reach an agreement. YDI said the $240,000 in must repay represents about 8 percent of the its billings in the past three years.
“According to the GAO, the national average claim failure rate is between 3 percent and 9 percent,” the release said.
HSD spokesman Matt Kennicott told New Mexico Watchdog no other agencies under investigation are being considered for having their funding restored.
Monday’s announcement is the latest chapter in a controversy that broke out in late June, when the HSD suspended Medicaid payments to 15 providers after an audit conducted by a Boston-based firm alleged some $36 million in misspending.
HSD officials say they had no choice, but critics have disputed that , accusing Squier and the administration of Gov. Susana Martinez of overreaching.
“These two entities (PMS and YDI) were given the chance to respond to the audit,” stateSen. Bill O’Neill, D-Albuquerque, told New Mexico Watchdog Monday night. “They, at least, could learn what the charges were against them, but the others were not … The bottom line is that the other agencies were not given due process … The Martinez administration is just trying to put a positive spin on a terrible situation.”
The allegations have been shrouded in secrecy as HSD and the New Mexico Attorney General’s Office have refused to disclose the details of the audit, saying doing so could compromise the investigation.
But in Monday’s news release, HSD did say that in addition to PMS and YDI, the companies under investigation face allegations that “employees were told to intentionally up-code services as a means of siphoning extra money out of the Medicaid system, told to bill for services never provided, or told to obstruct the reporting of critical incidents to proper authorities and regulators.”
In August, a story in the Albuquerque Journal reported that the husband and wife who run TeamBuilders earn as much as $1.5 million a year in salaries and other income, something the couple’s attorney said was “grossly inaccurate.”