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As reported in CHA News last week, the Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that creates a new model in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for hip and knee replacements beginning Jan. 1, 2016. This week, the CMS Innovation Center will host two webinars for providers to discuss the new model: July 15 from 10 – 11 a.m. (PT) and July 16 from 11 a.m. – noon.

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The Centers for Medicare & Medicaid Services (CMS) yesterday issued the attached proposed rule that creates a new model in which acute care hospitals in certain selected geographic areas, including three in California, will receive retrospective bundled payments for episodes of care for hip and knee replacements beginning Jan. 1, 2016 through Dec. 31, 2020. The Comprehensive Care for Joint Replacement (CCJR) model would hold participant hospitals financially accountable for the quality and cost of a  90-day episode of care and is intended to incentivize increased coordination of care among hospitals, physicians and post-acute care providers.

Participation in the model would be required by hospitals paid under the inpatient prospective payment system (IPPS) in 75 geographic areas defined by metropolitan statistical areas (MSAs). CMS has proposed participation for three California MSAs, including Los Angeles-Long Beach-Anaheim (Orange County and Los Angeles County), Modesto (Stanislaus County), and San Francisco-Oakland-Hayward (Alameda County, Contra Costa County, San Francisco County, San Mateo County and Marin County).

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CHA has submitted the attached comment letter to the Centers for Medicare & Medicaid Services (CMS) about its proposed rule revising the Medicare Shared Savings Program for accountable care organizations (ACOs). CHA generally supports a number of the proposed changes, but offers additional changes that will improve the engagement of hospitals in shared savings agreements. While supporting improvements to the beneficiary assignment methodology, CHA also urges CMS to adopt a prospective assignment methodology across all tracks. CHA also supports the expansion of Track 1 beyond the first three-year performance period, but opposes the reduction of the shared savings rate for participants continuing in Track 1. CHA appreciates changes to Track 2 and the addition of Track 3. However, CHA also urges CMS to consider multiple pathways that allow participants to transition to more population-based payments over time. Additionally, CHA urges CMS to make regulatory changes to allow ACOs to participate fully in patient safety organizations.

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CHA has submitted the attached comments to the Office of Medicare Hearings and Appeals (OMHA), responding to its request for information (RFI) on initiatives to address the current backlog of claims pending at the administrative law judge (ALJ) level of appeals. While CHA applauds OMHA’s willingness to begin to address the backlog through a number of pilot programs, the increase in recovery audit contractor (RAC) claim denials will intensify challenges at the ALJ level without fundamental RAC reform. CHA urges OMHA to improve the transparency of data by continuing to release it on a quarterly basis and including additional information, such as the total number of claims, total charges being appealed by the individual Medicare payment system, the most frequent reason for appeals, the number of requests overturned on appeal and the number of cases that moved to the ALJ level. CHA also urges OMHA to improve communication on its established pilots, such as hosting a provider call to educate hospitals on the methodology of its statistical sampling pilot.

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The Office of Medicare Hearings and Appeals (OMHA) has issued the attached request for information (RFI) regarding its current initiatives at the Administrative Law Judge (ALJ) level to address the Medicare claim and entitlement appeals workload and backlog. Since its Feb. 12 Medicare Appellant Forum, OMHA has implemented two pilot programs to provide appellants with options to address claims at the ALJ appeal level. One program provides appellants with an option to use statistical sampling during the ALJ hearing process, enabling them to obtain a decision on large numbers of appealed claims based on a sampling of those claims. The other initiative provides appellants with an option for settlement conference facilitation with an independent OMHA facilitator to discuss potential settlement of claims with authorized settlement officials.