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Archive for the ‘Medicare and Medicaid’ Category

Medicaid and the Elderly

July 31, 2014 Comments off

Medicaid and the Elderly
Source: Center for Retirement Research at Boston College

The brief’s key findings are:

  • Medicaid covers not only the low-income elderly but also those with higher incomes who become impoverished by health costs, such as nursing home care.
  • The percentage of high-income single retirees receiving Medicaid rises with age – from near zero for those in their 70s to 20 percent for those in their late 90s.
  • Even higher-income retirees who never receive Medicaid benefit from the insurance value that it provides, which allows them to maintain smaller reserves.
  • The analysis suggests that single retirees of all incomes value current Medicaid benefits at more than their cost but an expansion at less than its cost.
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New From the GAO

July 29, 2014 Comments off

New GAO Reports and Testimonies
Source: Government Accountability Office

Reports

1. USDA Farm Programs: Farmers Have Been Eligible for Multiple Programs and Further Efforts Could Help Prevent Duplicative Payments. GAO-14-428, July 8.
http://www.gao.gov/products/GAO-14-428
Highlights – http://www.gao.gov/assets/670/664671.pdf

2. 401(K) Plans: Improvements Can Be Made to Better Protect Participants in Managed Accounts. GAO-14-310, June 25.
http://www.gao.gov/products/GAO-14-310
Highlights – http://www.gao.gov/assets/670/664392.pdf

3. National Flood Insurance Program: Additional Guidance on Building Requirements to Mitigate Agricultural Structures’ Damage in High-Risk Areas Is Needed. GAO-14-583, June 30.
http://www.gao.gov/products/GAO-14-583
Highlights – http://www.gao.gov/assets/670/664517.pdf

4. Medicaid Financing: States’ Increased Reliance on Funds from Health Care Providers and Local Governments Warrants Improved CMS Data Collection. GAO-14-627, July 29.
http://www.gao.gov/products/GAO-14-627
Highlights – http://www.gao.gov/assets/670/665076.pdf

Testimonies

1. Screening Partnership Program: TSA Has Improved Application Guidance and Monitoring of Screener Performance, and Continues to Improve Cost Comparison Methods, by Jennifer Grover, acting director, homeland security and justice, before the Subcommittee on Transportation Security, House Committee on Homeland Security. GAO-14-787T, July 29.
http://www.gao.gov/products/GAO-14-787T
Highlights – http://www.gao.gov/assets/670/665067.pdf

2. Budget Issues: Opportunities to Reduce Federal Fiscal Exposures Through Greater Resilience to Climate Change and Extreme Weather, by Alfredo Gomez, director, natural resources and environment, before the Senate Committee on the Budget. GAO-14-504T, July 29.
http://www.gao.gov/products/GAO-14-504T
Highlights – http://www.gao.gov/assets/670/665090.pdf

3. Federal Real Property: Better Guidance and More Reliable Data Needed to Improve Management, by David J. Wise, director, physical infrastructure issues, before the Subcommittee on Government Operations, House Committee on Oversight and Government Reform. GAO-14-757T, July 29.
http://www.gao.gov/products/GAO-14-757T
Highlights – http://www.gao.gov/assets/670/665086.pdf

4. Tobacco Taxes: Disparities in Rates for Similar Smoking Products Continue to Drive Market Shifts to Lower-Taxed Options, by David Gootnick, director, international affairs and trade, before the Senate Committee on Finance. GAO-14-811T, July 29.
http://www.gao.gov/products/GAO-14-811T
Highlights – http://www.gao.gov/assets/670/665082.pdf

5. Medicaid: Completed and Preliminary Work Indicate that Transparency around State Financing Methods and Payments to Providers Is Still Needed for Oversight, by Katherine M. Iritani, director, health care, before the Subcommittee on Energy Policy, Health Care and Entitlements, House Committee on Oversight and Government Reform. GAO-14-817T, July 29.
http://www.gao.gov/products/GAO-14-817T
Highlights – http://www.gao.gov/assets/670/665070.pdf

6. Combating Nuclear Smuggling: Past Work and Preliminary Observations on Research and Development at the Domestic Nuclear Detection Office, by David C. Trimble, director, natural resources and environment, before the Subcommittee on Cybsersecurity, Infrastructure Protection, and Security Technologies, House Committee on Homeland Security. GAO-14-783T, July 29.
http://www.gao.gov/products/GAO-14-783T
Highlights – http://www.gao.gov/assets/670/665073.pdf

CBO — What Are the Causes of Projected Growth in Spending for Social Security and Major Health Care Programs?

July 18, 2014 Comments off

What Are the Causes of Projected Growth in Spending for Social Security and Major Health Care Programs?
Source: Congressional Budget Office

A CBO blog post yesterday noted that federal spending is projected to rise noticeably relative to the size of the economy over the long term because of growth in spending for Social Security, major health care programs, and interest on the government’s debt. Today we will discuss the factors that account for the projected growth in the first two of those major components of the budget.

Under current law, spending for Social Security would increase from almost 5 percent of gross domestic product (GDP) in 2014 to more than 6 percent in 2039 and beyond (see the figure below). Even more of the anticipated growth is expected to come from the government’s major health care programs (Medicare, Medicaid, the Children’s Health Insurance Program, and subsidies offered through health insurance exchanges): CBO projects that, under current law, total outlays for those programs, net of Medicare premiums and certain other offsetting receipts, would grow much faster than the overall economy, increasing from just below 5 percent of GDP now to 8 percent in 2039.

New From the GAO

July 16, 2014 Comments off

New GAO Reports and Testimonies
Source: Government Accountability Office

Reports

1. Medicaid: Assessment of Variation among States in Per-Enrollee Spending. GAO-14-456, June 16.
http://www.gao.gov/products/GAO-14-456
Highlights – http://www.gao.gov/assets/670/664114.pdf

2. Special Education: Additional Federal Actions Could Help Address Unique Challenges of Educating Children in Nursing Homes. GAO-14-585, July 16.
http://www.gao.gov/products/GAO-14-585
Highlights – http://www.gao.gov/assets/670/664821.pdf

3. Coastal Zone Management: Opportunities Exist for NOAA to Enhance Its Use of Performance Information. GAO-14-592, July 16.
http://www.gao.gov/products/GAO-14-592
Highlights – http://www.gao.gov/assets/670/664805.pdf

4. Supplemental Security Income: Wages Reported for Recipients Show Indications of Possible SSN Misuse. GAO-14-597, July 16.
http://www.gao.gov/products/GAO-14-597
Highlights – http://www.gao.gov/assets/670/664795.pdf

Testimonies

1. U.S. Launch Enterprise: Acquisition Best Practices Can Benefit Future Efforts, by Cristina Chaplain, director, acquisition and sourcing management, before the Senate Committee on Commerce, Science, and Transportation and the Subcommittee on Strategic Forces, Senate Committee on Armed Services. GAO-14-776T, July 16.
http://www.gao.gov/products/GAO-14-776T

2. High-Containment Laboratories: Recent Incidents of Biosafety Lapses, by Nancy Kingsbury, Ph.D., managing director, applied research and methods, before the Subcommittee on Oversight and Investigations, House Committee on Energy and Commerce. GAO-14-785T, July 16.
http://www.gao.gov/products/GAO-14-785T
Highlights – http://www.gao.gov/assets/670/664800.pdf

CRS — Low-Income Assistance Programs: Trends in Federal Spending

July 16, 2014 Comments off

Low-Income Assistance Programs: Trends in Federal Spending (PDF)
Source: Congressional Research Service (via University of North Texas Digital Library)

This report examines the spending trends of 10 major need-tested benefit programs or groups of programs: (1) health care from Medicaid and the Children’s Health Insurance Program (CHIP); (2) the refundable portion of the health insurance tax credit enacted in the 2010 health care reform law; (3) the Supplemental Nutrition Assistance Program (SNAP); (4) assisted housing; (5) financial assistance for post-secondary students (Pell Grants); (6) compensatory education grants to school districts; (7) the Earned Income Tax Credit (EITC); (8) the Additional Child Tax Credit (ACTC); (9) Supplemental Security Income (SSI); and (10) Family Support Payments. The common feature of need-tested programs is that they provide benefits, services, or funding based on a measure of limited financial resources (income and sometimes assets). However, other than that common feature, the programs differ considerably in their target populations, services, and focus.

New From the GAO

July 15, 2014 Comments off

New GAO Report and Testimonies
Source: Government Accountability Office

Report

1. Medicaid Payment: Comparisons of Selected Services under Fee-for-Service, Managed Care, and Private Insurance. GAO-14-533, July 15.
http://www.gao.gov/products/GAO-14-533
Highlights – http://www.gao.gov/assets/670/664783.pdf

Testimonies

1. VA Disability Claims Processing: Preliminary Observations on Accuracy Rates and Quality Assurance Activities, by Daniel Bertoni, director, education, workforce and income security issues, before the House Committee on Veterans’ Affairs. GAO-14-731T, July 14.
http://www.gao.gov/products/GAO-14-731T
Highlights – http://www.gao.gov/assets/670/664762.pdf

2. Helium Program: BLM’s Implementation of the Helium Stewardship Act of 2013, by Anne-Marie Fennell, director, natural resources and environment, before the Subcommittee on Energy and Mineral Resources, House Committee on Natural Resources. GAO-14-751T, July 15.
http://www.gao.gov/products/GAO-14-751T
Highlights – http://www.gao.gov/assets/670/664778.pdf

3. Federal Workforce: Human Capital Management Challenges and the Path to Reform, by Robert Goldenkoff, director, strategic issues, before the Subcommittee on Federal Workforce, U.S. Postal Service and the Census, House Committee on Oversight and Government Reform. GAO-14-723T, July 15.
http://www.gao.gov/products/GAO-14-723T
Highlights – http://www.gao.gov/assets/670/664773.pdf

The ACA and America’s Cities: Fewer Uninsured and More Federal Dollars

July 14, 2014 Comments off

The ACA and America’s Cities: Fewer Uninsured and More Federal Dollars
Source: Urban Institute

This report estimated the effect of the Affordable Care Act (ACA) on 14 large and diverse cities: Los Angeles, Chicago, Houston, Philadelphia, Phoenix, Indianapolis, Columbus, Charlotte, Detroit, Memphis, Seattle, Denver, Atlanta, and Miami. For each city we estimated changes in health coverage under the ACA, particularly the resulting decline in the uninsured. We also estimated the additional federal spending on health care that would flow into these cities. For cities in states that have not expanded Medicaid eligibility, we provide estimates both with and without expansion.

See also: Increase in Medicaid under the ACA Reduces Uninsurance, According to Early Estimates

OIG HHS — Questionable Billing for Medicare Part B Clinical Laboratory Services

July 11, 2014 Comments off

Questionable Billing for Medicare Part B Clinical Laboratory Services
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
Medicare is the largest payer of clinical laboratory (lab) services in the nation. From 2005 to 2010, Part B Medicare enrollment increased by 10 percent, while spending for lab services increased by 29 percent. In 2010, Medicare payments for all Part B lab services totaled $8.2 billion. We conducted this study to identify questionable billing patterns among Medicare lab services.

HOW WE DID THIS STUDY
We based this study on an analysis of Part B claims for lab services with dates of service in 2010. Labs submit claims for each lab service provided for Medicare beneficiaries. Each claim contains information about the lab provider, the ordering physician, the beneficiary, and the lab service. We developed 13 measures to describe labs’ billing patterns and to identify labs with questionable billing patterns. We calculated and analyzed the distribution of the measures for each lab. We then calculated a statistical threshold for the 13 measures and determined whether a lab’s billing was unusually high for each measure. Additionally, we calculated the total number of claims and total allowed amount associated with certain measures of questionable billing.

WHAT WE FOUND
In 2010, over 1,000 labs exceeded the thresholds (i.e., had unusually high billing) for 5 or more measures of questionable billing for Medicare lab services. For example, a lab might have an unusually high percentage of claims with ineligible and/or invalid ordering-physician numbers, or an unusually high allowed amount per ordering physician. Almost half of the labs that exceeded the thresholds for five or more measures of questionable billing-compared to 13 percent of all labs-were located in California and Florida, areas known to be vulnerable to Medicare fraud. Some labs that exceeded the thresholds for fewer than five measures also exhibited billing that may warrant further review. Medicare allowed $1.7 billion across all labs for claims associated with questionable billing.

WHAT WE RECOMMEND
There may be some labs that have legitimate reasons for exceeding certain thresholds. However, collectively, these findings call for stronger oversight of labs and identify specific issues with Medicare payments for lab services that need to be addressed to more effectively safeguard Medicare. Therefore, we recommend that CMS (1) review the labs identified as having questionable billing and take appropriate action, (2) review existing program integrity strategies to determine whether these strategies are effectively identifying program vulnerabilities associated with lab services, and (3) ensure that existing edits prevent claims with invalid and ineligible ordering-physician numbers from being paid. CMS concurred with all recommendations.

New From the GAO

July 2, 2014 Comments off

New GAO Reports
Source: Government Accountability Office

1. Climate Change Adaptation: DOD Can Improve Infrastructure Planning and Processes to Better Account for Potential Impacts. GAO-14-446, May 30.
http://www.gao.gov/products/GAO-14-446
Highlights – http://www.gao.gov/assets/670/663733.pdf

2. Prescription Drugs: Comparison of DOD, Medicaid, and Medicare Part D Retail Reimbursement Prices. GAO-14-578, June 30.
http://www.gao.gov/products/GAO-14-578
Highlights – http://www.gao.gov/assets/670/664522.pdf

3. Nuclear Security: NNSA Should Establish a Clear Vision and Path Forward for Its Security Program. GAO-14-208,May 30.
http://www.gao.gov/products/GAO-14-208
Highlights – http://www.gao.gov/assets/670/663746.pdf

State-Based Medicaid Costs for Pediatric Asthma Emergency Department Visits

June 28, 2014 Comments off

State-Based Medicaid Costs for Pediatric Asthma Emergency Department Visits
Source: Preventing Chronic Disease (CDC)

Introduction
The prevalence of childhood asthma in the United States increased from 8.7% in 2001 to 9.5% in 2011. This increased prevalence adds to the costs incurred by state Medicaid programs. We provide state-based cost estimates of pediatric asthma emergency department (ED) visits and highlight an opportunity for states to reduce these costs through a recently changed Centers for Medicare and Medicaid Services (CMS) regulation.

Methods
We used a cross-sectional design across multiple data sets to produce state-based cost estimates for asthma-related ED visits among children younger than 18, where Medicaid/CHIP (Children’s Health Insurance Program) was the primary payer.

Results
There were approximately 629,000 ED visits for pediatric asthma for Medicaid/CHIP enrollees, which cost $272 million in 2010. The average cost per visit was $433. Costs ranged from $282,000 in Alaska to more than $25 million in California.

Conclusions
Costs to states for pediatric asthma ED visits vary widely. Effective January 1, 2014, the CMS rule expanded which type of providers can be reimbursed for providing preventive services to Medicaid/CHIP beneficiaries. This rule change, in combination with existing flexibility for states to define practice setting, allows state Medicaid programs to reimburse for asthma interventions that use nontraditional providers (such as community health workers or certified asthma educators) in a nonclinical setting, as long as the service was initially recommended by a physician or other licensed practitioner. The rule change may help states reduce Medicaid costs of asthma treatment and the severity of pediatric asthma.

HHS OIG — Performance Data for the Senior Medicare Patrol Projects: June 2014 Performance Report

June 26, 2014 Comments off

Performance Data for the Senior Medicare Patrol Projects: June 2014 Performance Report
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
This memorandum report presents performance data for the Senior Medicare Patrol (SMP) projects, which receive grants from the Administration for Community Living (ACL) to recruit and train retired professionals and other senior citizens to recognize and report instances or patterns of health care fraud. (ACL was established in 2012, bringing together the Administration on Aging (AoA) and two other offices.) In July 2010, AoA requested that OIG continue to collect and report performance data for the projects to support its efforts to evaluate and improve their performance. OIG currently reports this performance data on an annual basis.

HOW WE DID THIS STUDY
We based this review on data reported by the SMP projects. In addition, we requested and reviewed documentation from the projects for expected recoveries of funds for the Medicare and Medicaid programs. We also requested and reviewed documentation for actual savings to beneficiaries and others that were attributable to the projects, as well as for cost avoidance. We did not review documentation for the other performance measures.

WHAT WE FOUND
In 2013, the 54 SMP projects had 5,406 active volunteers, a 5-percent increase from 2012. These volunteers conducted 148,235 one-on-one counseling sessions, a 31-percent increase from 2012. They also conducted 14,924 group education sessions in 2013, compared to 14,748 in 2012.

In 2013, expected Medicare and Medicaid recoveries that were attributable to the projects were 9.1 million, a 50-percent increase from 2012. However, total savings to beneficiaries and others decreased from $133,971 in 2012 to $41,718 in 2013. Finally, cost avoidance on behalf of Medicare, Medicaid, beneficiaries, and others increased by 26 percent, from $113,692 in 2012 to $143,282 in 2013.

We continue to emphasize that it is not always possible to track referrals to Medicare contractors or law enforcement from beneficiaries who have learned to detect fraud, waste, and abuse from the projects. Therefore, the projects may not be receiving full credit for savings attributable to their work. In addition, the projects are unable to track the substantial savings derived from a sentinel effect whereby fraud and errors are reduced by Medicare beneficiaries’ scrutiny of their bills.
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New From the GAO

June 25, 2014 Comments off

New From the GAO
Source: Government Accountability Office

Reports

1. Information Security: Additional Oversight Needed to Improve Programs at Small Agencies. GAO-14-344, June 25.
http://www.gao.gov/products/GAO-14-344
Highlights – http://www.gao.gov/assets/670/664420.pdf

2. Aviation Safety: Additional Oversight Planning by FAA Could Enhance Safety Risk Management. GAO-14-516, June 25.
http://www.gao.gov/products/GAO-14-516
Highlights – http://www.gao.gov/assets/670/664401.pdf

3. Traffic Safety: Alcohol Ignition Interlocks Are Effective While Installed; Less Is Known about How to Increase Installation Rates. GAO-14-559, June 20.
http://www.gao.gov/products/GAO-14-559
Highlights – http://www.gao.gov/assets/670/664282.pdf

4. Diplomatic Security: Overseas Facilities May Face Greater Risks Due to Gaps in Security-Related Activities, Standards, and Policies. GAO-14-655, June 25.
http://www.gao.gov/products/GAO-14-655
Highlights – http://www.gao.gov/assets/670/664423.pdf
Podcast – http://www.gao.gov/multimedia/podcasts/664325

Testimonies

1. Export-Import Bank: Status of GAO Recommendations on Risk Management, Exposure Forecasting, and Workload Issues, by Mathew J. Scirè, director, financial markets and community investment, before the House Committee on Financial Services. GAO-14-708T, June 25.
http://www.gao.gov/products/GAO-14-708T
Highlights – http://www.gao.gov/assets/670/664379.pdf

2. Medicare Fraud: Further Actions Needed to Address Fraud, Waste, and Abuse, by Kathleen M. King, director, health care, before the Subcommittee on Oversight and Investigations, House Committee on Energy and Commerce. GAO-14-712T, June 25.
http://www.gao.gov/products/GAO-14-712T
Highlights – http://www.gao.gov/assets/670/664382.pdf

Medicare Advantage Money Grab

June 24, 2014 Comments off

Medicare Advantage Money Grab
Source: Center for Public Integrity

Congress created private Medicare Advantage health plans 11 years ago to help control health care spending on the elderly. But a Center for Public Integrity investigation found that billions of tax dollars are wasted every year through manipulation of a Medicare payment tool called a “risk score.” The formula is supposed to pay health plans more for sicker patients and less for healthy people, but often it pays too much. The government has for years missed opportunities to corral tens of billions of dollars in overcharges and other billing errors tied to abuse of risk scores. Meanwhile, the growing power of the Medicare Advantage industry has muzzled many critics in Congress, and turned others into cheerleaders for the program.

New From the GAO

June 23, 2014 Comments off

New From the GAO
Source: Government Accountability Office

Reports

1. DOD Financial Management: The Defense Finance and Accounting Service Needs to Fully Implement Financial Improvements for Contract Pay. GAO-14-10, June 23.
http://www.gao.gov/products/GAO-14-10
Highlights – http://www.gao.gov/assets/670/664319.pdf

2. Telecommunications: USDA Should Evaluate the Performance of the Rural Broadband Loan Program. GAO-14-471,May 22.
http://www.gao.gov/products/GAO-14-471
Highlights – http://www.gao.gov/assets/670/663577.pdf

3. Medicaid: Financial Characteristics of Approved Applicants and Methods Used to Reduce Assets to Qualify for Nursing Home Coverage. GAO-14-473, May 22.
http://www.gao.gov/products/GAO-14-473
Highlights – http://www.gao.gov/assets/670/663416.pdf

4. Advanced Reactor Research: DOE Supports Multiple Technologies, but Actions Needed to Ensure a Prototype Is Built. GAO-14-545, June 23.
http://www.gao.gov/products/GAO-14-545
Highlights – http://www.gao.gov/assets/670/664297.pdf

5. VA Spina Bifida Program: Outreach to Key Stakeholders and Written Guidance for Claims Audit Follow-up Activities Needed. GAO-14-564, June 23.
http://www.gao.gov/products/GAO-14-564
Highlights – http://www.gao.gov/assets/670/664304.pdf

6. Debt Management: Floating Rate Notes Can Help Treasury Meet Borrowing Goals, but Additional Actions Are Needed to Help Manage Risk. GAO-14-535, June 16.
http://www.gao.gov/products/GAO-14-535
Highlights – http://www.gao.gov/assets/670/664107.pdf

Related Product

Debt Management: Survey of Investors in Treasury Securities (GAO-14-562SP, June 16, 2014), an E-supplement to GAO-14-535. GAO-14-562SP, June 16.
http://www.gao.gov/products/GAO-14-562SP

New From the GAO

June 18, 2014 Comments off

New GAO Reports and Testimonies
Source: Government Accountability Office

Reports

1. Medicaid Program Integrity: Increased Oversight Needed to Ensure Integrity of Growing Managed Care Expenditures. GAO-14-341, May 19.
http://www.gao.gov/products/GAO-14-341
Highlights – http://www.gao.gov/assets/670/663305.pdf

2. Coast Guard Acquisitions: Better Information on Performance and Funding Needed to Address Shortfalls. GAO-14-450, June 5.
http://www.gao.gov/products/GAO-14-450
Highlights – http://www.gao.gov/assets/670/663880.pdf

3. Defense Health Care: More-Specific Guidance Needed for TRICARE’s Managed Care Support Contractor Transitions. GAO-14-505, June 18.
http://www.gao.gov/products/GAO-14-505
Highlights – http://www.gao.gov/assets/670/664197.pdf

4. Management Report: Areas for Improvement in the Federal Reserve Banks’ Information Systems Controls. GAO-14-691R, June 18.
http://www.gao.gov/products/GAO-14-691R

Testimonies

1. Coast Guard Acquisitions: Better Information on Performance and Funding Needed to Address Shortfalls, by Michele Mackin, director, acquisition and sourcing management, before the Subcommittee on Coast Guard and Maritime Transportation, House Committee on Transportation and Infrastructure. GAO-14-650T, June 18.
http://www.gao.gov/products/GAO-14-650T

2. Airport Funding: Aviation Industry Changes Affect Airport Development Costs and Financing, by Gerald L. Dillingham, Ph.D., director, physical infrastructure issues, before the Subcommittee on Aviation, House Committee on Transportation and Infrastructure. GAO-14-658T, June 18.
http://www.gao.gov/products/GAO-14-658T
Highlights – http://www.gao.gov/assets/670/664187.pdf

3. Civilian Intelligence Community: Additional Actions Needed to Improve Reporting on and Planning for the Use of Contract Personnel, by Timothy J. DiNapoli, director, acquisition and sourcing management, before the Senate Committee on Homeland Security and Governmental Affairs. GAO-14-692T, June 18.
http://www.gao.gov/products/GAO-14-692T
Highlights – http://www.gao.gov/assets/670/664169.pdf

4. VA Health Care: Further Action Needed to Address Weaknesses in Management and Oversight of Non-VA Medical Care, by Randall B. Williamson, director, health care, before the House Committee on Veterans’ Affairs. GAO-14-696T, June 18.
http://www.gao.gov/products/GAO-14-696T
Highlights – http://www.gao.gov/assets/670/664172.pdf

HHS OIG — Medicare Market Share of Mail Order Diabetes Test Strips From July-September 2013

June 17, 2014 Comments off

Medicare Market Share of Mail Order Diabetes Test Strips From July-September 2013
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
Medicare covers diabetes test strips provided by mail order suppliers and local pharmacies or supplier storefronts. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 requires CMS to phase in, with several rounds of bidding, a Competitive Bidding Program for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Under this program, suppliers compete to become Medicare contract suppliers for selected DMEPOS items. The payment amounts resulting from the competition replace the Medicare fee-schedule amounts for these items.

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) prohibits CMS from awarding Competitive Bidding Program contracts for mail order diabetes test strips to suppliers that do not demonstrate that their bid covers at least 50 percent, by volume, of all types of mail order diabetes test strips. Further, section 154(d)(3)(B) of MIPPA requires OIG to complete a study to determine market shares of diabetes test strips in the Competitive Bidding Program before each round of competitive bidding following Round 1. This report fulfills the MIPPA requirement for the pending third round of competitive bidding.

HOW WE DID THIS STUDY
We determined the Medicare market shares for diabetes test strip types associated with a random sample of Medicare claims for the 3-month period of July to September 2013. Our sample of 1,210 claims was drawn from a population of approximately 505,000 claims for mail order diabetes test strips provided to beneficiaries during this period. To estimate the Medicare market shares, we surveyed suppliers and projected our sample data to the population of mail order diabetes test strips.

WHAT WE CONCLUDED
Twenty-two suppliers submitted at least 43 types of mail order diabetes test strips for the 3-month period of July to September 2013. Two types of diabetes test strips accounted for approximately 45 percent of the Medicare mail order market share. Three types of diabetes test strips accounted for 59 percent of the Medicare mail order market share, and 10 types accounted for 90 percent. CMS may choose to consider these data when determining whether subsequent rounds of suppliers’ mail order diabetes test strip bids comply with the MIPPA 50-percent requirement.

CRS — Medicare Trigger

June 6, 2014 Comments off

Medicare Trigger (PDF)
Source: Congressional Research Service (via National Conference of State Legislatures)

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA, P.L. 108- 173) requires the Medicare Board of Trustees to provide in its annual reports an expanded analysis of Medicare expenditures and revenues (§801 of MMA). Specifically, if the trustees determine that general revenue funding for Medicare is expected to exceed 45% of Medicare outlays for the current fiscal year or any of the next six fiscal years, a determination of excess general funding is made. If the determination is issued for two consecutive years, a funding warning is issued, which triggers certain presidential and congressional actions (§802-§804 of MMA).

Because such a determination was issued in both the 2006 and 2007 Medicare Trustee’s reports, the President was required to submit a legislative proposal to Congress within 15 days of submitting his budget in 2008 that would lower the ratio to the 45% level. Similarly, each of the subsequent Annual Reports of the Boards of Trustees through 2013 has included an estimate that general revenue funding would exceed 45% at some point during the current or six subsequent fiscal years, thus “triggering” a response from the President and Congress. While such a proposal was submitted by President George W. Bush in 2008, no such legislative proposals have been submitted since that time. The House approved rules changes for a portion of the 110th Congress (H.Res. 1368) and for all of the 111th Congress (H.Res. 5) that waived the parliamentary procedures for the House contained in Section 803 of the MMA. The 112th Congress did not pass a similar measure, nor has the 113th Congress, and the trigger provision has gone back into effect in the House.

The Medicare funding warning focuses attention on the impact of program spending on the federal budget, and provides one measure of the financial health of the program. However, some options for reducing general revenue spending below the 45% level would have a greater impact than others. Proponents of the trigger maintain that it forces fiscal responsibility, while critics of the trigger suggest that other measures of Medicare spending, such as total Medicare spending as a portion of federal spending, would be more useful indicators.

New From the GAO

June 2, 2014 Comments off

New GAO Reports
Source: Government Accountability Office

1. State Department: Pervasive Passport Fraud Not Identified, but Cases of Potentially Fraudulent and High-Risk Issuances Are under Review. GAO-14-222, May 1.
http://www.gao.gov/products/GAO-14-222
Highlights – http://www.gao.gov/assets/670/662920.pdf

2. Medicare Physical Therapy: Self-Referring Providers Generally Referred More Beneficiaries but Fewer Services per Beneficiary. GAO-14-270, April 30.
http://www.gao.gov/products/GAO-14-270
Highlights – http://www.gao.gov/assets/670/662859.pdf

HHS OIG — Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010

May 30, 2014 Comments off

Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
Evaluation and management (E/M) services are visits performed by physicians and nonphysician practitioners to assess and manage a beneficiary’s health. Medicare paid $32.3 billion for E/M services in 2010, representing nearly 30 percent of Part B payments that year. In 2012, OIG reported that physicians increased their billing of higher level codes, which yield higher payment amounts, for E/M services in all visit types from 2001 to 2010. CMS found that E/M services are 50 percent more likely to be paid for in error than other Part B services; most improper payments result from errors in coding and from insufficient documentation.

HOW WE DID THIS STUDY
We conducted a medical record review of a random sample of Part B claims for E/M services from 2010, stratifying claims from physicians who consistently billed higher level codes for E/M services (i.e., “high-coding” physicians) and claims from other physicians. Certified professional coders determined whether the E/M service documented in the medical record for each sampled claim was correctly coded and/or sufficiently documented.

WHAT WE FOUND
In total, Medicare inappropriately paid $6.7 billion for claims for E/M services in 2010 that were incorrectly coded and/or lacking documentation, representing 21 percent of Medicare payments for E/M services that year. We found that 42 percent of claims for E/M services in 2010 were incorrectly coded, which included both upcoding and downcoding (i.e., billing at levels higher and lower than warranted, respectively), and 19 percent were lacking documentation. Additionally, we found that claims from high-coding physicians were more likely to be incorrectly coded or insufficiently documented than claims from other physicians.

WHAT WE RECOMMEND
We recommend that CMS (1) educate physicians on coding and documentation requirements for E/M services, (2) continue to encourage contractors to review E/M services billed for by high-coding physicians, and (3) follow up on claims for E/M services that were paid for in error. CMS concurred with our first recommendation, did not concur with our second recommendation, and partially concurred with our third recommendation.

Earnings and Employment Data for Workers Covered Under Social Security and Medicare, by State and County, 2011

May 23, 2014 Comments off

Earnings and Employment Data for Workers Covered Under Social Security and Medicare, by State and County, 2011
Source: Social Security Administration

Social Security

  • In 2011, 158.6 million workers had earnings taxable under the Social Security program. About 140.9 million had only wages, 10.4 million had only self-employment income, and 7.3 million had both.
  • Social Security taxable earnings totaled $5.487 trillion, which includes earnings up to the taxable maximum of $106,800.
  • Social Security taxes totaled about 680 billion.

Medicare

  • In 2011, 162.6 million workers had earnings taxable under the Medicare program. About 144.1 million had only wages, 10.2 million had only self-employment income, and 8.4 million had both.
  • Medicare taxable earnings totaled $6.810 trillion.
  • Medicare taxes totaled about $197 billion.
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