List of Providers Sent Revalidation Requests Published on CMS Website – CMS has posted downloadable files on its revalidation website listing providers and suppliers who have been mailed revalidation requests, available by clicking here. The most recent set of notices were mailed between February and March, 2012. We recommend that providers check these lists to confirm whether they have been mailed revalidation requests, as mail correspondence often does not reach its intended address and a failure to respond could lead to the deactivation of a provider's enrollment in Medicare.
The Affordable Care Act requires all providers and suppliers enrolled in Medicare Part A or Part B prior to March 25, 2011 to revalidate their participation in the program upon receiving a request to do so from their Medicare contractors. (Providers and suppliers that submitted enrollment applications on or after March 25, 2011 are not affected.) The revalidations will take place on a rolling basis through 2015. CMS will deactivate the enrollment status of providers and suppliers that do not complete the revalidation application within the timeframe contained in the notice.
To those providers enrolled in the Provider, Enrollment, Chain and Ownership System (PECOS), contractors will send the revalidation request to both the "special payments" and "correspondence" addresses listed in the provider's file. Contractors will send notices to providers and suppliers not enrolled in PECOS to the "special payments" or "primary practice" addresses on file.
Reporter, Christopher Kenny, Washington, D.C., + 1 202 626 9253, email@example.com.
Joint Commission Announces New Monograph Aimed at Decreasing Central Line Infections – On May 16, 2012, The Joint Commission announced a new monograph that aims to decrease central line-associated bloodstream infections (CLABSIs). Research and guidance compiled in the monograph indicates that the risk of serious bloodstream infections associated with the use of central venous catheters (CVCs) can be significantly reduced by following evidence-based guidelines for insertion and maintenance of CVCs. The 152-page monograph contains information about the following:
- The types of central venous catheters and risk factors for and pathogenesis of CLABSIs
- The evidence-based guidelines, position papers, patient safety initiatives, and published literature on CLABSI and its prevention
- CLABSI prevention strategies, techniques and technologies, and barriers to best practices
- CLABSI surveillance, benchmarking, and public reporting
- The economic aspects of CLABSIs and their prevention, including the current approaches to developing a business case for infection prevention resources
According to The Joint Commission’s press release, available by clicking here, publication of this monograph is phase one of a project (funded by Baxter Healthcare Corporation) to identify and disseminate information and solutions to help prevent CLASBI. Phase two will be the development of a “toolkit” including evidence- and expert-based interventions, guidelines, and resources for organizations seeking to reduce CLASBI rates. The monograph is available by clicking here.
Hospitals should note that CMS has proposed adding CLABSI rates to the outcome domain of the 2015 Value-Based Purchasing program. CMS has proposed that the performance period for the measure would begin January 26, 2013.
Reporter, Susan Banks, Washington, D.C., +1 202 626 2953, firstname.lastname@example.org.
OIG Issues Report on Retail Pharmacies with Questionable Part D Billing – On May 9, 2012, the Office of Inspector General for the Department of Health & Human Services (OIG) issued a report addressing retail pharmacies identified as having questionable billing for Medicare Part D prescription drug coverage.
OIG analyzed all prescription drug event records from retail pharmacies in 2009 using eight measures to identify questionable billing. These measures included calculating each pharmacy's:
- average amount billed per Part D beneficiary;
- average number of Part D prescriptions per prescriber;
- percentage of Part D prescriptions that were refills; and
- percentage of Part D-covered prescriptions for Schedule II and III drugs.
Based on results of the analysis showing extremely high billing for Part D prescriptions at more than 2,600 pharmacies nationwide, OIG developed a list of six recommendations to bolster government oversight of retail pharmacies and the private Prescription Drug Plan (PDP) sponsors who provide Part D coverage to Medicare beneficiaries.
Pharmacies were found to have “questionable billing” where OIG identified extremely high billing for at least one of the eight measures used to analyze the Part D records. For example, while retail pharmacies nationwide billed an average of $1,576 per Part D beneficiary, those pharmacies with questionable billing recorded an average of $4,050 per beneficiary.
OIG recommended that CMS implement "risk scores" to detect pharmacies "with a high risk for fraud," while also recommending that CMS provide additional guidance to PDP sponsors on the monitoring of pharmacy billing. Further, OIG recommended that CMS "require all Part D sponsors to report incidents of potential fraud and abuse that may warrant further investigation to CMS or other appropriate entities." The report noted that questionable retail pharmacy billing was most likely to be found in the Detroit, Los Angeles, and Miami areas, with high rates also seen in Baltimore, New York, and Tampa.
In a letter responding to the OIG's report, CMS concurred in full with four of OIG's recommendations, while partially concurring with the other two. Notably, CMS wrote that it "will consider developing a high, medium, and low risk assessment for pharmacies and sharing that information with sponsors, as appropriate."
More information regarding the OIG report is available by clicking here. A copy of OIG's report is available by clicking here.
Reporter, Brian Basinger, Atlanta, +1 404 572 3502, email@example.com.
2012 Managed Care Update Roundtable – On Friday, June 15, 2012, King & Spalding will be hosting an Atlanta-based Roundtable focused on recent developments related to managed care, including contracting, antitrust developments, tiered provider networks, and litigation updates. We are also offering a Webinar option for the Roundtable. The Roundtable will include the following topics:
- Marketplace Developments Affecting Contracting and Contract Enforcement
- Tiered Networks: Dealing with the New Market Dynamic
- Rate Confidentiality and Consumer Transparency
- Recent Antitrust Class Actions Against Blue Cross
- Antitrust Agency Skepticism Regarding ACOs
- Trends in Out-of-Network Reimbursement After Ingenix
- Managed Care Litigation Update
In-person attendance is limited, so please register soon to reserve seats for your organization. You do not have to be a client to attend, and there is no charge. You can register to attend in person or by Webinar by visiting http://www.kslaw.com/HealthcareRoundtable.
This bulletin provides a general summary of recent legal developments. It is not intended to be and should not be relied upon as legal advice.
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