Category: CMS
Home Health Care Providers Struggle With State Laws And Medicare Rules As Demand Rises
“We can send prescriptions to the pharmacy, including [for] narcotics,” says Marie Grosh, a geriatric advanced practice nurse practitioner and the owner of a medical house calls practice in a Cleveland suburb. “We can order lab work, x-rays, ultrasounds, EKGs [electrocardiagrams]; interpret them; and treat patients based on that. But we’re just not allowed to order home care—which is absurd.”
By SUSAN JAFFE | Health Affairs | June 2019 | Volume 38, Number 8
When Christine Williams began working as a nurse practitioner some forty years ago in Detroit, Michigan, older adults who couldn’t manage on their own and had no family nearby and no doctor willing to make house calls had few options besides winding up in a nursing home.
Not anymore.
Home check: Nurse practitioner Marie Grosh visits Leroy Zacharias at his home in a Cleveland suburb, He has Parkinson disease, and Grosh says he would be living in a nursing home if he couldn’t get medical care at home. (Photo by Lynn Ischay.)
“The move towards keeping seniors in their homes is a fast-galloping horse here,” says Williams, who settled in Cleveland, Ohio, more than a decade ago. “We don’t have space for them in long-term care [facilities], they don’t want to be in long-term care, and states don’t want to pay for long-term care. And everybody wants to live at home.”
But despite the growing desire for in-home medical care for older adults from nearly all quarters, seniors’ advocates and home health professionals claim that rules set by the Centers for Medicare and Medicaid Services (CMS) along with state regulations have created an obstacle course for the very providers best positioned—and sometimes the only option—to offer that care. [Continued here] …
CMS lost $84M in two years for ineligible nursing home stays
IG investigators said such improper payments are accumulating year after year.
By Susan Jaffe | Modern Healthcare | February 20, 2019
The CMS pays millions of dollars a year to nursing homes for taking care of older adults who don’t qualify for coverage, according to an investigation by HHS’ inspector general.
The IG’s report, released Wednesday, includes steps the CMS should take to fix the problem; but in a written response, CMS Administrator Seema Verma rejected some key recommendations. [Continued here.]…
As HHS Moves To End Overload Of Medicare Claims Appeals, Beneficiaries Will Get Top Priority
By Susan Jaffe Jan. 21, 2014 KAISER HEALTH NEWS in collaboration with
Medicare beneficiaries who have been waiting months and even years for a hearing on their appeals for coverage may soon get a break as their cases take top priority in an effort to remedy a massive backlog.
Nancy Griswold, the chief judge of the Office of Medicare Hearings and Appeals (OMHA), announced in a memo sent last month to more than 900 appellants and health care associations that her office has a backlog of nearly 357,000 claims. In response, she said the agency has suspended acting on new requests for hearings filed by hospitals, doctors, nursing homes and other health care providers, which make up nearly 90 percent of the cases. But beneficiaries’ appeals will continue to be processed.
“We have elderly or disabled Medicare clients waiting as long as two years for a hearing and nine months for a decision,” said Judith Stein, executive director of the Center for Medicare Advocacy. [More from KHN] [More from Washington Post]…
Fighting ‘Observation’ Status
By Susan Jaffe | January 10, 2014, 2:41 pm 
Every year, thousands of Medicare patients who spend time in the hospital for observation but are not officially admitted find they are not eligible for nursing home coverage after discharge. 
…Medicare officials have urged hospital patients to find out if they’ve been admitted. But suppose the answer is no. Then what do you do?
Medicare doesn’t require hospitals to tell patients if they are merely being observed, which is supposed to last no more than 48 hours to help the doctor decide if someone is sick enough to be admitted. (Starting on Jan. 19, however, New York State will require hospitals to provide oral and written notification to patients within 24 hours of putting them on observation status. Penalties range as much as $5,000 per violation.) [Continued in The New York Times.]…
UnitedHealthcare Dropping Hundreds Of Doctors From Medicare Advantage Plans
By Susan Jaffe | November 29, 2013 | Kaiser Health News produced in collaboration with 
Dorathy Senay’s doctor had some bad news after her last checkup, but it wasn’t about her serious blood disorder called amyloidosis. Her Medicare Advantage managed care plan from UnitedHealthcare/AARP is terminating the doctor’s contract Feb. 1. She is also losing her oncologist at the prestigious Yale Medical Group — the entire 1,200 physician practice was axed. Senay, 71, of Canterbury, Conn., is among thousands of UnitedHealthcare Medicare members in 10 states whose doctors will be cut from their plan network.
The company is the largest Medicare Advantage insurer in the country, with nearly 3 million members. More than 14 million older or disabled Americans are enrolled in Medicare Advantage plans, an alternative to traditional Medicare that offers medical and usually drug coverage but members have to use the plan’s network of providers.
“I have a rare incurable disease and these doctors have saved my life,” said Senay. “I am in good hands and I will not change doctors.”
…Medicare officials review the private plans every year to make sure they comply with network adequacy and other requirements, but the agency did not approve the reconfigured networks resulting from the new provider cancelations. Spokesman Raymond Thorn said the agency “is currently reviewing UHC and other plans’ provider networks and closely monitoring all areas that have experienced disruptions to ensure that beneficiaries have full, transparent and timely information and access to needed care.” [More from KHN] [More in USA Today]…
Link
By December 17, 2012 | Kaiser Health News in collaboration with 
Dan Driscoll used to be a smoker. During a regular doctor’s visit, his primary-care physician suggested that Driscoll be tested to see if he was at risk for an abdominal aortic aneurysm, a life-threatening condition that can be linked to 
smoking. The doctor said Medicare would cover the procedure. So Driscoll, 68, who lives in Silver Spring, had the test done and was surprised when he got a bill from Medicare for $214.
“I didn’t accept that,” he said, because based on everything he had read from Medicare, he was sure this was a covered service. So Driscoll did something that seniors rarely do: He filed an appeal. Of the 1.1 billion claims submitted to Medicare in 2010 for hospitalizations, nursing home care, doctor’s visits, tests and physical therapy, 117 million were denied. Of those, only 2 percent were appealed.
“People lose, and then they lose heart, or they are too sick, too tired or too old, and they give up,” said Margaret Murphy, associate director of the Center for Medicare Advocacy, which has offices in Washington and Connecticut. “Or their kids are handling the appeal and they are too overwhelmed caring for Mom or Dad.” [Continued at Kaiser Health News and The Washington Post.]
How To File A Medicare Appeal Here are some basic steps for challenging Medicare coverage denials…. [Continued at Kaiser Health News.]
Seniors Need To Be Tenacious In Appeals To Medicare
By December 17, 2012 | Kaiser Health News in collaboration with
Dan Driscoll used to be a smoker. During a regular doctor’s visit, his primary-care physician suggested that Driscoll be tested to see if he was at risk for an abdominal aortic aneurysm, a life-threatening condition that can be linked to smoking. The doctor said Medicare would cover the procedure. So Driscoll, 68, who lives in Silver Spring, had the test done and was surprised when he got a bill from Medicare for $214.
“I didn’t accept that,” he said, because based on everything he had read from Medicare, he was sure this was a covered service. So Driscoll did something that seniors rarely do: He filed an appeal. Of the 1.1 billion claims submitted to Medicare in 2010 for hospitalizations, nursing home care, doctor’s visits, tests and physical therapy, 117 million were denied. Of those, only 2 percent were appealed.
“People lose, and then they lose heart, or they are too sick, too tired or too old, and they give up,” said Margaret Murphy, associate director of the Center for Medicare Advocacy, which has offices in Washington and Connecticut. “Or their kids are handling the appeal and they are too overwhelmed caring for Mom or Dad.” [Continued at Kaiser Health News and The Washington Post.]
How To File A Medicare Appeal Here are some basic steps for challenging Medicare coverage denials…. [Continued at Kaiser Health News.]
Medicare Combats Fraud With Billing Statements That Beneficiaries Can Understand
Susan Jaffe | March 7, 2012 | KAISER HEALTH NEWS produced in collaboration with 
In the latest effort to enlist seniors in the fight against Medicare fraud, federal officials have overhauled Medicare billing statements to make it easier to find bogus charges without a magnifying glass. ….And for those who might need an incentive to scour their bills, the new statements promise a reward of up to $1,000 for a tip that leads to uncovering fraud.[Continued here.]…
Medicare Steps Up Efforts To Monitor Seniors’ Prescriptions
By Susan Jaffe | KAISER HEALTH NEWS | March 23, 2010
This story was produced in collaboration with
Irene Mooney survived four heart attacks and still copes with high cholesterol, persistent indigestion and heart problems. Recently, she developed some dangerous new symptoms – suspicious bruising all over her body and severe fatigue. “I could barely put one foot in front of the other,” she says. A pharmacist discovered the culprit: Some of the very medications Mooney was taking to manage her medical conditions.
The pharmacist met with Mooney, examined her 13 medications and then contacted her doctor, who cut the dosage of one drug and replaced another, reducing her risk of uncontrollable bleeding. Mooney, 82, one of the devoted card players at her seniors’ complex, soon noticed the change. “I’ve been so much better,” she says.
The help Mooney got – called “medication therapy management” – was provided by Senior PharmAssist, a Durham, N.C., non-profit group that makes sure seniors use the right prescription drugs and take them correctly to prevent harmful side effects or drug interactions.
Now, medication management is coming to nearly 7 million seniors and disabled Americans enrolled in Medicare drug plans. [Continued at Kaiser Health News and USA Today
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