Reimbursement

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Recent legislative changes indicate that Congress is committed to continuing to allow patients to access telehealth services after the COVID-19 public health emergency (PHE) ends, but it is gathering more information before making such changes permanent. Comments from the U.S. Department of Health & Human Services (“HHS”) Secretary Xavier Becerra and the HHS Office of Inspector General (“OIG”) indicate that HHS is committed to expanding telehealth beyond the end of the PHE and that the OIG recognizes the long-term benefits of access to these services.

On April 23, 2020, the Centers for Medicare & Medicaid Services (“CMS”) released a new COVID-19 toolkit. While the toolkit is directed to the states, it should serve the American telehealth community as a focal point for the organization and alignment of the infinite number of state and federal regulations relevant to telehealth. So, it serves as a great organizing tool for provider’s own operational use but also as an architecture for providers to catalogue the changes they would like to suggest to the states in order to improve access to telehealth.

Insurers providing health care benefits to federal employees can obtain reimbursement when their insured obtains a tort recovery, despite a state law prohibiting such reimbursement, based on the preemption provision of the Federal Employees Health Benefits Act (FEHBA), pursuant to the U.S. Supreme Court’s decision in Coventry Health Care of Missouri, Inc., fka Group Health Plan, Inc. v. Nevils, issued April 18, 2017.

Since the first managed care plans were introduced, relationships between physicians and payers have been rocky. It has not been uncommon for controversies between the two sides to result in lawsuits, contract terminations and regulatory intervention. Both sides recognize that each needs the other to survive — payers must populate their networks with sizeable numbers of physicians, while physicians must contract with payers to get reimbursed for patient care.

As of January 2016, there were 433 Medicare Shared Savings Program (MMSP) Accountable Care Organizations (ACOs) with almost 7.7 million assigned beneficiaries and more than 14,000 participants (a participant may be a group or an individual). Most of these ACOs are one-sided model ACOs that may generate shared savings and do not involve shared losses (Track 1 ACOs).

Importantly, Track 1 ACOs are not considered advanced alternative payment models (APMs) for purposes of MACRA. As a result, a clinician participating in a Track 1 ACO is subject to the merit-based incentive payment system (MIPS) just like a clinician that is not in an ACO (a participant in an advanced APM is not subject to MIPS).

On April 27, 2016, the Department of Health & Human Services Centers for Medicare & Medicaid Services (CMS) released its proposed rule regarding models for tying professional reimbursement to quality. While this may be great news for providers who enjoy the challenges of tracking and reporting data, these challenges are going to cause problems (namely, reimbursement reductions) for some providers. Regardless of whether providers think this is good or bad, providers should start looking at the proposed regulations now because, as proposed, quality-based payments will be a fact of life for all physicians, mid-levels, CRNAs and groups effective Jan. 1, 2019. The regulations will be published in the May 9, 2016, Federal Register. The comment period will officially start at that time and run through 5 p.m. on June 27, 2016.

The Centers for Medicare & Medicaid Services (“CMS”) issued its Final Rule on Nov. 16 for the Comprehensive Care for Joint Replacement (“CJR”) model, which mandates that CMS pay providers a bundled payment per episode of care for a Medicare beneficiary undergoing a hip or knee replacement, also referred to as lower extremity joint replacement or LEJR. This marks the first mandated episode-based bundled payment by CMS; all other episode-based bundled payments programs (e.g., Bundled Payment for Care Improvement, or BPCI, initiatives) are voluntary with regard to provider participation. The CJR model will require hospitals in 67 markets to participate in the program initially. A list of the participant hospitals in the selected markets is available here.

On Thursday, July 16, 2015, the Texas Health and Human Services Commission (HHSC) held a public meeting regarding its request to seek an extension of its Section 1115 Medicaid Transformation Waiver. The current waiver covered a five year period ending September 30, 2016. Under the waiver Texas has expanded Medicaid managed care, created a funding pool to offset uncompensated care and provided incentives for hospitals and other providers to develop delivery system infrastructure in Texas. Over the waiver period, Texas will commit $29 Billion to the uncompensated care and delivery system payment pools (approximately 58% or $16.82 Billion represent federal funds).