Literature Review

Getting your claims denied? Here are reasons why and what you can do about itMedial Economics; by Gretchen Heinen, RN, PHN, BSN and Wael Khouli, MD, MBA; 4/25/24A recent voluntary, national survey by Premier shed new light on denied claims. The survey, conducted from October to December 2023, revealed that nearly 15% of all claims across Medicare Advantage, Medicaid, Commercial, and Managed Medicaid are denied. Of those denied claims, 45% to 60% were overturned, albeit with a costly appeal process sometimes involving multiple appeals. ... With a skillfully crafted appeal letter, a denial can be overturned 50% to 70% of the time. In this article, we will cover denial basics, reasons for claim denials, and actions to take. It is crucial to address all potential reasons for claim denial, including: ...

Relief provisions not enough to mitigate damage of 80/20 policy, providers say McKnights Home Care; by Adam Healy; 4/24/24 Though newly finalized changes to the Medicaid Access Rule attempted to soften the blow of its controversial 80/20 provision, home care providers remained vehemently opposed to the Centers for Medicare & Medicaid Services’ strict new spending mandate. “Overall, while there are many positive provisions within the final rule as well as mitigations to make the payment adequacy provision less onerous, NAHC remains extremely concerned about the negative consequences of the pass-through policy,”  the National Association for Home Care & Hospice said in an analysis for NAHC members released after the rule was published. 

Quality in Motion: Acting on the CMS National Quality Strategy CMS - Centers for Medicare & Medicaid Services; 4/22/24In 2022, the Centers for Medicare & Medicaid Services (CMS) launched the CMS National Quality Strategy (NQS), a plan aimed at improving the quality and safety of health care for everyone, with a special focus on people from underserved and under-resourced communities. ... The CMS National Quality Strategy has four priority areas, each with two goals. This action plan provides details on how CMS is putting these eight goals into action.

Analysis finds 4 in 5 nursing facilities don’t meet staffing requirements McKnights Long-Term Care News, by Josh Henreckson; 4/24/24 More than 80% of nursing homes do not meet the updated requirements in the final staffing mandate from the Centers for Medicare & Medicaid Services, according to new analysis from media outlet KFF. Those findings further amplify the chorus of concerns raised by providers following the news that CMS was raising its proposed requirement of 3.0 hours of care per resident per day to 3.48 in Monday’s final rule. CMS leaders, including Administrator Chiquita Brooks-LaSure, attempted to address sector questions and concerns at a press event Tuesday afternoon. ...

Extra: CMS publishes rule outlining final staffing requirements McKnights Long-Term Care News, by Kimberly Marselas; 4/22/24 The Centers for Medicare & Medicaid Services said it would exempt nursing homes from having registered nurse coverage for up to 8 out of 24 hours a day “under certain circumstances,” unveiling a critical new detail in the second part of today’s staffing rule rollout. A director of nursing also can count toward the rule’s 24/7 RN requirement, CMS said, noting a change that providers will likely appreciate given their persistent challenges hiring RNs across the country. “The RN onsite 24 hours a day, seven days a week requirement ensures that there is an RN available to help mitigate, and ultimately reduce, the likelihood of preventable safety events, particularly during evenings, nights, weekends, and holidays,” CMS said. ...

Medicare Advantage fight shifts to 340B arena Modern Healthcare, by Alex Kacik; 4/22/24Hospitals' fight to boost Medicare Advantage reimbursement has extended to plans' pay for 340B drugs. The hospitals’ plea to adjust Medicare Advantage pay stems from regulation aimed at making providers that participate in the drug discount program whole after the Supreme Court reversed 340B rate cuts that were in place from 2018 to 2022.

5 ways the AMA is fighting for physicians in 2024 AMA - American Medical Association; by Kevin B. O'Reilly; 4/18/2024 ... Physicians face far too many challenges that interfere with patient care. That’s why the AMA is advocating to keep doctors at the head of the health care team, reform the Medicare physician payment system, relieve the burden of overused prior authorizations and so much more. These advocacy initiatives are part of the AMA Recovery Plan for America’s Physicians, which includes:

Hospice handoffs may lower odds of Medicare denials Medscape, by Lara Salahi; 4/29/24Clearer communication between primary care clinicians and hospice providers may decrease the number of denied Medicare approvals for end-of-life treatment, according to a small study presented on April 18 at the American College of Physicians Internal Medicine Meeting 2024. Tyler Haussler, MD, acting medical director at  Brookestone Home Health & Hospice in Carney, Nebraska, said he conducted the study. ... CMS requires a "face-to-face encounter" between a physician and hospice caregiver to communicate clinical findings and determine the patient's terminal status. Missing or incomplete documentation of a patient's medical condition remains one of the main reasons the agency denies hospice coverage. 

Mississippi Capitol sees second day of hundreds rallying for ‘full Medicaid expansion now’Mississippi Today - Legislature; by Bobby Harrison and Geoff Pender; 4/17/24Hundreds of people rallied at the Mississippi Capitol for a second day Wednesday, urging lawmakers to expand Medicaid to provide health coverage for an estimated 200,000 Mississippians. ... Speakers recounted their struggles with access to affordable health care in Mississippi and chanted for the Legislature to, “Close the coverage gap now,” and for “Full Medicaid expansion now.” ... [Dr. Randy] Easterling recounted a story of two of his friends diagnosed with similar cancers. One was uninsured and self-employed, and did not get early diagnosis or treatment. He’s now in hospice and on death’s door. The other friend, with insurance, received an early diagnosis and treatment and is now cancer free.

Summaries: FFY 2025 Hospice, Inpatient Rehabilitation Facility, Skilled-Nursing Facility Medicare Payment Rules California Hospital Association, 4/17/24 What’s happening: Summaries of the hospice wage index, inpatient rehabilitation facility (IRF) prospective payment system (PPS), and skilled-nursing facility (SNF) PPS proposed rules are now available.What else to know: Comments on the proposed rules are due by May 28. The members-only summaries, from Health Policy Alternatives, Inc., describe proposals for the post-acute care Medicare prospective payment systems for federal fiscal year 2025: 

CMMI’s proposed TEAM Model offers another risk-based opportunity for home health providers Home Helath Care News, by Andrew Donlan; 4/15/24Last week, the Centers for Medicare & Medicaid Services (CMS) Innovation Center announced a new proposed model that will undoubtedly affect home health providers, and also allow them the opportunity to get more involved in value-based care initiatives. The Transforming Episode Accountability Model (TEAM), which would eventually be mandatory if finalized, would have selected acute care hospitals put under full responsibility for the cost – and quality – of care from surgery up until the first 30 days after hospital discharge.

New DOJ rules for online healthcare content make sure seniors aren’t taken offline McKnights Senior Living, by Aaron Dorman; 4/11/24The Department of Justice took steps earlier this week to help make sure old adults have appropriate access to valuable web content they need for understanding important healthcare and coverage decisions. State and government agencies, such as the Centers for Medicare & Medicaid Services, must abide by new technical standards, according to a new DOJ rule signed Monday [4/1/24]. “Just as stairs can exclude people who use wheelchairs from accessing government buildings,” the official rule states, “inaccessible web content and mobile apps can exclude people with a range of disabilities from accessing government services.” The technical requirements of the rule are extensive — the updated document is almost 300 pages long — but the overall purpose is to instruct agencies on their obligations to account for possible disabilities.

AMA, AHIP, NAACOS outline value-based care best practices Modern Healthcare, by Nona Tepper; 4/10/24 Health insurers, physicians and accountable care organizations issued recommendations Wednesday outlining what they see as the best ways to boost value-based care initiatives. The report from the health insurance trade group AHIP, the American Medical Association and the National Association of ACOs focuses on total-cost-of-care contracts, ACOs that typically span three to five years and have demonstrated success improving quality and reducing costs, according to the organizations.