scoanet

MEDICAID BULLETIN

TO: All Medicaid Providers

SUBJECT: Program Integrity Overpayment Identification Contractor

The South Carolina Department of Health and Human Services (SCDHHS) is implementing an expansion of its program Integrity review function in order to provide more efficient and effective oversight of the Medicaid program. In order to meet this objective, we have awarded a competitive procurement to Health Management Systems, Inc. (HMS). Founded in 1974, HMS provides cost containment, recovery, and program integrity services to government healthcare agencies nationwide. HMS will assist the Division of Program Integrity in the identification and recovery of overpayments made to Medicaid providers. SCDHHS will work with HMS to alleviate undue burdens on providers that may be caused by requests for information needed for the audits. All audits will be carried out under SCDHHS oversight and in accordance with SCDHHS policies and procedures.

If you have any questions, please call Sherry Ward, RN, Director, Division of Program Integrity, at (803) 898-2640.

Thank you for your continued participation in the Medicaid program.
/S/
Emma Forkner
Director

Uncompensated care cost each insured family $1,017 last year.

A report released by not-for-profit advocacy group Families USA states that subsidizing uncompensated health care for the uninsured cost insured American families an average of $1,017 each during 2008. According to the report, which was based on data from the Medical Expenditures Panel Survey and other federal and private sources, 37 percent of care is paid for out-of-pocket by the uninsured, with third-party sources such as government programs and charities, paying for another 26 percent of care for the uninsured. The remaining costs were considered uncompensated and totaled $42.7 billion across the United States in 2008.
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Read the complete report (PDF)...

HEAT initiative created to chill purveyors of Medicare fraud.

The U.S. Department of Justice (DOJ) and the U.S. Department of Health and Human Services (HHS) have announced the creation of a joint task force to combat Medicare fraud. The Health Care Fraud Prevention and Enforcement Action Team (HEAT) will include senior officials from DOJ and HHS who will strengthen existing programs to combat fraud and invest in new resources and technology designed to prevent future fraud, waste, and abuse.
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Majority of Physicians Now Compensated for ER Call

Modern Physician reported on April 1st that according to a report released by the Medical Group Management Association that almost two-thirds (62%) of healthcare providers receive some form of additional compensation for on-call coverage.  The report notes that compensation agreements are in the form of a daily stipend or hourly rate with variations for specialty, group size and region.

See the full story, Most providers receive compensation for on-call duty, MGMA survey finds or go to www.modernphysician.com.

AMA, medical associations file suit over Ingenix database.

The Associated Press reports that the American Medical Association (AMA) and several state medical associations have joined to sue health insurers Aetna Inc. (Hartford, Conn.) and Cigna Corp. (Philadelphia) over a database the associations claim was rigged to underpay out-of-network physicians for more than 10 years. The complaints allege that Aetna deleted valid high charges from figures contributed to the UnitedHealth (Minnetonka, Minn.)-owned Ingenix database, and accuse Cigna of hiding "serious, systemic flaws" in the data. UnitedHealth has already agreed to close the database, and—along with Aetna—fund the creation of a replacement system.
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Dear SCAOE Members,

Attached is a bulletin distributed by the South Carolina Department of Health & Human Services concerning budget cuts that went into effect as of January 1, 2009.   These reductions in benefits may impact your patients and practice so we wanted to pass them along to you.   It seems at first glance that the changes dealing with DME, Group Therapy, and strict limits on the total number of physician visits per year by adult Medicaid beneficiaries may be those changes that might impact our specialty.

Download MedicaidBulletinDecember30

If you have any questions please let me know.

Sincerely,
Fraser Cobbe

Executive Director

South Carolina

Orthopaedic Association

South Carolina

Association of Orthopaedic Executives

Tel: 813-949-3121

Proposal would "rebase" Medicare SGR.

U.S. Rep. Pete Stark (D-Calif.) has outlined a plan to "rebase" the Medicare sustainable growth rate (SGR) formula. Rep. Stark’s proposal to reform Medicare includes setting a new baseline for reimbursement rates. Physicians currently face a 21 percent reduction in reimbursement when a July 2008 SGR patch expires on Dec. 31, 2009. A new patch would cost an estimated $20 billion. According to Mr. Stark, eliminating the overall rate cuts under the current SGR system over the next 10 years would cost the federal government from $200 billion to $300 billion, so Congress must change the baseline that the SGR uses to set up fee increases.

Delays in Medicaid Payment Drive Physicians Away

Modern Physician is reporting on a study published by the Center for Studying Health System Change that indicates that slow payment to physicians discourages their participation in Medicaid even in those states with higher Medicaid reimbursement.  

For the full story, please click here or go to modernphysician.com.

Reduced reimbursement for DXA may cost government more in the long run.

A report published in the November issue of the journal Osteoporosis International notes that Medicare reimbursement for dual-energy X-ray absorptiometry (DXA)—a key tool in the monitoring of osteoporosis—has been cut to levels substantially below the cost to perform the procedure, and as a result, healthcare providers may consider discontinuing the service. The authors cite a recent study that found that restoring DXA reimbursement to 2006 levels would save the Medicare program $1.14 billion over five years due to the reduced number of osteoporotic fractures.
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Read the abstract...

The Wall Street Journal reports that some health insurers have hired outside firms to serve as radiology benefits managers (RBMs) to ensure that physicians use high-tech scans such as CTs and MRIs only when patients will clearly benefit from them. According to some physicians, however, the RBMs' review procedures can result in delays or rejections that sometimes pose risks for patients, waste staff time, and force physicians to justify decisions to reviewers who haven't seen the patients.
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