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Payment Matters
August 21, 2008
PRRB Issues New Rules, Effective August 21, 2008
The Provider Reimbursement Review Board (PRRB) recently published on its website, new rules for appeals before the PRRB, which replace the old Instructions. The new rules implement the regulations published on May 27, 2008. [See "CMS Adopts Final Rule Addressing Part A Appeals Before Intermediaries and the PRRB," Payment Matters, 6/11/08] Both the new rules and the new regulations have an implementation date of August 21, 2008. The new rules are found at www.cms.hhs.gov/PRRBReview/Downloads/PRRBRules2008.pdf. Due to the fact that the new rules impact position papers due as soon as September 1 of this year, the PRRB also issued an Alert, which gives providers an automatic extension of four months for preliminary papers due on or after Sept. 1, 2008, in cases where the provider received the acknowledgement from the PRRB assigning the due dates prior to Aug. 21, 2008. In these same cases, final position paper due dates are completely removed and will be reissued by the PRRB. [See www.cms.hhs.gov/PRRBReview/02_PRRB_Instructions.asp]
Click to continue...CMS' Do-Not-Pay List Continues to Grow
By: Emily H. Wein*
Last year we informed you of CMS' selection of eight "hospital acquired conditions" (HACs) for which Medicare would no longer reimburse hospitals the higher costs of treatment, effective October 1, 2008. [See "To Err is Human. But It Won't Get Paid: Denial of Medicare Payment for Hospital-acquired Conditions," Payment Matters, 9/27/07] In the proposed FY 2009 IPPS rule, CMS proposed to add an additional ten HACs to this "do not pay" list. However, in the final FY 2009 IPPS rule, published in the August 19, 2008 Federal Register, CMS only finalized four HACs.
Click to continue...CMS Adds Thirteen New Quality Measures for Reporting in the Hospital Quality Data Program
By: Kristin Cilento Carter and Leslie Demaree Goldsmith
The fiscal year (FY) 2009 Hospital Inpatient Prospective Payment System (IPPS) Final Rule, which went on display on the Centers for Medicare and Medicaid Services' website on July 31, 2008, incorporated several changes to the Reporting of Hospital Quality Data for Annual Hospital Payment Update (RHQDAPU) Program, including the addition of 13 quality measures and subtraction of 1 quality measure for the FY 2010 payment update. These changes, which are discussed in more detail below, increase the total number of quality measures for reporting from 30 measures for the FY 2009 update to 42 measures for FY 2010. This also marks the first time that CMS has removed a quality measure from the RHQDAPU program.
Click to continue...Kyphon, Inc. Settles Fraud Allegations; Hospitals Next in the Government's Sights?
By: S. Craig Holden
In May, Kyphon, Inc. (now owned by Medtronics) agreed to pay the federal government $75M and enter into a Corporate Integrity Agreement to resolve allegations of Medicare fraud. The case arose as a result of a whistleblower law suit brought by former Kyphon sales employees. They alleged that Kyphon engaged in a seven year marketing scheme which resulted in hospitals billing Medicare for Kyphoplasties on an inpatient rather than outpatient basis. Kyphoplasty is a minimally-invasive surgery for compression fractures of the spine, generally caused by osteoporosis. According to the complaint, Kyphoplasty is generally appropriate in an outpatient setting. Thus, inpatient surgery allegedly was not medically necessary for the vast majority of patients receiving the procedure.
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