Chapter
Chapter 2 MEDICARE PHYSICIAN PAYMENT UPDATES AND THE SUSTAINABLE GROWTH RATE (SGR) SYSTEM
BACKGROUND ON THE MEDICARE FEE SCHEDULEUPDATES
Updates and the Sustainable Growth Rate (SGR) System
Conversion Factor Calculation
Sustainable Growth Rate (SGR)
HISTORICAL UPDATES AND LEGISLATIVE OVERRIDES
ANALYSIS AND CRITICISMS OF SGR SYSTEM
General and Conceptual Concerns
Per Capita Gross Domestic Product (GDP) and the AnnualUpdate
POTENTIAL MODIFICATIONS AND ALTERNATIVES
RECENT LEGISLATIVE ACTIVITY
H.R. 3162 (110th Congress)
H.R. 3961 (111th Congress)
A Senate Amendment in the form of a Substitute to H.R. 3590(111th Congress)
Department of Defense Appropriations Act, 2010 (P.L. 111-118)
Increasing the Statutory Limit on the Public Debt (P.L. 111-139)
Temporary Extension Act of 2010 (P.L. 111-144)
Tax Extenders Act of 2009 (H.R. 4213)
Continuing Extension Act of 2010 (P.L. 111-157)
House Amendment to the Senate Amendment to the TaxExtenders Act of 2009 (H.R. 4213)
Preservation of Access to Care for Medicare Beneficiaries andPension Relief Act (H.R. 3962)
Chapter 3 MEDICARE PHYSICIAN PAYMENTS: FEES COULD BETTER REFLECT EFFICIENCIES ACHIEVED WHEN SERVICES ARE PROVIDED TOGETHER
Process for Defining Medicare Fee Schedule Services
Process for Developing and Updating Resource Estimates Usedto Set Fees
Initiatives to Account for Efficiencies in Multiple Services
CMS HAS RECOGNIZED EFFICIENCIES IN SOMESERVICES, BUT HAS NOT FOCUSED ON HIGH-SPENDINGSERVICES
RUC Workgroup Examines Efficiencies in Services CommonlyFurnished Together, but Does Not Target Services with GreatestPotential for Savings
CMS’s MPPR Policy Reflects Efficiencies but Is Limited inScope
CMS’S MPPR POLICY COULD BE APPLIED TO OTHERSERVICES COMMONLY FURNISHED TOGETHER ANDEXPANDED TO REFLECT EFFICIENCIES IN PHYSICIANWORK
Potential Exists for Reducing at Least One-Half Billion Dollarsin Excessive Payments Annually through an MPPR to ReflectEfficiencies in the Practice Expense Component
Potential Exists for Reducing about $175 Million Annuallythrough Expanding the Current MPPR for Imaging Services toReflect Efficiencies in the Physician Work Component
RECOMMENDATION FOR EXECUTIVE ACTION
MATTER FOR CONGRESSIONAL CONSIDERATION
AGENCY AND PROFESSIONAL ASSOCIATION COMMENTSAND OUR EVALUATION
Broader Application of MPPR
Exempting Savings from Budget Neutrality Requirement
APPENDIX I: ESTIMATING POTENTIAL FOR FURTHERSAVINGS FROM EFFICIENCIES IN MULTIPLE SERVICE
Estimating Potential for Further Savings from Efficiencies in thePractice Expense Component of Multiple Services throughSystematic Review of Medicare Claims Data
Estimating Potential Savings from an MPPR to ReflectEfficiencies in Physician Work Component
APPENDIX II: EXAMPLES OF VIGNETTE AND PRACTICEEXPENSE ESTIMATE
APPENDIX III: COMMENTS FROM THE DEPARTMENT OFHEALTH AND HUMAN SERVICES
Chapter 4 MEDICARE PROGRAM INTEGRITY: ACTIVITIES TO PROTECT MEDICARE FROM PAYMENT ERRORS, FRAUD, AND ABUSE
THE PROBLEM OF HEALTH CARE FRAUD
OVERVIEW OF MEDICARE PROGRAM INTEGRITY
TYPES OF PROGRAM INTEGRITY ACTIVITIES
Medicare Secondary Payer (MSP)
Medicare-Medicaid Data Match Program
TYPES OF PROGRAM INTEGRITY CONTRACTORS
Medicare Administrative Contractors (MACs)
Program Safeguard Contractors (PSCs) and Zone ProgramIntegrity Contractors (ZPICs)
Medicare Drug Integrity Contractors (MEDICs)
Recovery Audit Contractors (RACs)
Comprehensive Error Rate Testing (CERT) Contractor
National Supplier Clearinghouse (NSC) Contractor
Coordination of Benefits (COB) Contractor
PROGRAM INTEGRITY PARTNERS
FUNDING FOR PROGRAM INTEGRITY ACTIVITIES
Discretionary Funding for Program Integrity Activities
Other Funding Sources for Program Integrity Activities
OVERSIGHT OF MEDICARE’S PROGRAM INTEGRITYEFFORTS
OMB Program Assessment Rating Tool (PART)
OIG Audit and Evaluation Reports
Chapter 5 MEDICARE’S RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM: BACKGROUND AND ISSUES
BRIEF INTRODUCTION TO IMPROPER PAYMENTS
RECOVERY AUDIT CONTRACTORS (RACS) IN MEDICARE
CLAIMS REVIEW PROCESS USED BY RACS
COMPARISON OF CLAIMS REVIEW PROCESSES BETWEENRACS AND OTHER MEDICARE ADMINISTRATIVECONTRACTORS
CONCERNS RELATED TO THE RAC PROGRAM
Medicare Payment Policies and Issues
( Health Care Issues, Costs and Access )
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