|
Original
#
|
Original
Recommendation
|
Final
#
|
Final
Recommendation
|
Reason
for Change
|
|
1 |
Immediate:
Take action necessary to publish a final rule on the
previously proposed rule (i.e. Conditions of Participation
(CoPs) for Home Health Agencies (HHA) currently in
the queue. |
1 |
Publish
a final rule on the previously proposed rule on Conditions
of Participation (COPs) for home health agencies (HHAs)
currently in the queue. |
Clarification. |
|
2 |
Short-Term
Proposal:
Announce removal of the HHA CoP Proposed Rules from the
docket if it remains dormant for more than 6 months. |
2 |
Announce
removal of the Proposed Rules on HHA COPs from the docket
if the proposed rule remains dormant for more than six
months from the date of adopting this recommendation. |
Clarification. |
|
3 |
Immediate:
Eliminate or modify Medicares Home Health Agency Branch
Office and Sub-Unit definitions to reflect current
technology and accepted practices. |
3 |
Eliminate
or modify the definitions of branch office and sub-unit
contained within Medicares COPs for HHAs to reflect
current technology and accepted practices. |
Clarification. |
|
4 |
Immediate:
Allow M+COs to access State and county codes and input
changes to that data element this summer. Direct access to
proprietary information held in Federal databases would be
limited in accordance with the Privacy Act. |
4 |
Allow
Medicare+Choice Organizations (M+COs) to access State and
county codes and input changes to that data element during
the summer of 2002 for payment reconciliation of special
status Medicare enrollees. (Direct access to proprietary
information held in Federal databases would be limited in
accordance with the Privacy Act.) |
Clarification. |
|
5 |
Intermediate
reform:
Determine new procedure for processing working aged
enrollments and establish pilot. Analyze systems issues
with ESRD enrollments and propose workarounds. |
5 |
Determine
new procedures for processing working aged enrollments for
M+CO payment reconciliation purposes and establish pilot.
Analyze systems issues with ESRD enrollments and propose
workarounds. |
Clarification. |
|
6 |
Immediate:
Begin simplifying the ACRP filing process by examining the
following options and prepare a report due 9/30/02
containing recommendations regarding:
(a)
Statutory recommendations that would allow plans to use
M+C only data in doing their ACR;
(b)
Allowing M+COs to make greater use of
actuarially-generated information rather than information
from the accounting systems in the ACR;
(c)
Reducing the number of filings for the 2004 filing;
(d)
Reducing the back-up documentation required for the 2004
filing;
(e)
Using simpler filing forms similar to those used in state
Department of Insurance filings; and
(f)
Reducing the number of benefit categories submitted in the
ACR for the 2004 filings. |
6 |
Simplify
the Medicare programs data filing process requirements
in Adjusted Community Rate Proposals (ACRPs) for
Medicare+Choice (M+C) health plans; prepare a report due
September 30, 2002, to inform that goal which examines the
following options.
- Statutory
recommendations that would allow plans to use M+C only
data in doing their ACRs.
- Allow
M+COs to make greater use of actuarially-generated
information rather than information from the
accounting systems in the ACR.
- Reduce
the number of filings for the 2004 filing.
- Reduce
the back-up documentation required for the 2004
filing.
- Use
simpler filing forms similar to those used in State
Department of Insurance filings.
- Reduce
the number of benefit categories submitted in the ACR
for the 2004 filings.
|
Clarification. |
|
7 |
Immediate:
Based on consultation obtained from industry experts,
provide additional comprehensive training for auditors
concerning the development of ACR proposals, in order to
decrease the occurrence of erroneous and incorrect
findings; include industry experts in the faculty for the
training sessions |
7 |
Provide
additional comprehensive training for auditors concerning
the development of ACR proposals in order to decrease the
occurrence of erroneous and incorrect findings; include
industry experts in the faculty for the training sessions.
Consult with industry experts in the design of the
training. |
Clarification. |
|
8 |
Immediate:
Convene a work group to continue to pursue alternative
methods of determining compliance with regulations,
including those areas where the M+COs compliance plan
meets CMS standards. Plans with good performance should
not be subject to total review. |
8 |
Convene
a work group whose goal is to pursue alternative methods
of determining a M+COs compliance with Medicares
regulations, such as by data-driven and "focused
review"-based, biennial monitoring visits. (Plans
with good performance should not be subject to total
review.) Implement work groups recommendations no later
than January 1, 2004. |
Consolidation
of similar
recommendations. |
|
9 |
Intermediate:
Work group recommendations should be approved by 6/1/03
for implementation 1/1/04. |
8 |
Convene
a work group whose goal is to pursue alternative methods
of determining a M+COs compliance with Medicares
regulations, such as by data-driven and "focused
review"-based, biennial monitoring visits. (Plans
with good performance should not be subject to total
review.) Implement work groups recommendations no later
than January 1, 2004. |
Consolidation
of similar
recommendations. |
|
10 |
Immediate:
Continue to standardize and streamline the marketing
review process, including nationwide use of "use
& file" standards, and intermediately, establish
uniform performance standards for all ROs, and
conduct CO/RO/M+CO training regarding standards for review
that do not exceed statutory standards. |
9 |
Continue
to standardize and streamline the process of reviewing
M+CO marketing materials, including nationwide use of
"use & file" standards; establish uniform
performance standards that do not exceed statutory
requirements and provide training prior to their use by
all CMS Regional Offices (ROs). |
Clarification. |
|
11 |
Immediate:
Establish a policy wherein joint training is
conducted for M+CO, RO and CO staff regarding major CMS
initiatives and issuance of significant changes in
existing policy. |
10 |
Establish
a policy wherein joint training is conducted for
M+CO CMS Regional Office (RO) and Central Office (CO)
staff in one setting regarding major initiatives and
issuance of significant changes in existing M+C policy. |
Clarification. |
|
12 |
Intermediate:
Establish a policy to provide sufficient notice to M+COs
to implement major systems changes allowing M+COs to
adequately budget for said changes. CMS establishes
policies that often require plans to change their systems
on short notice resulting in unbudgeted and hectic
"fire drills," many of which occur when M+COs
are in the midst of implementing other statutory system
upgrades such as Y2K and HIPAA. |
11 |
Establish
a policy to provide sufficient notice to M+COs to
implement major CMS information systems changes
allowing M+COs to adequately budget for said changes, many
of which occur when M+COs are in the midst of implementing
other statutory system upgrades, such as Year 2000 and
HIPAA. |
Clarification. |
|
13 |
Immediate:
Establish a Special Election Period (SEP) for current M+CO
members who wish to enroll in a zero-premium plan offered
by the same M+CO in 2002. |
12 |
Establish
a Special Election Period (SEP) for current M+CO members
who wish to enroll in a zero-premium plan offered by the
same M+CO in 2002 consistent with the "lock-in"
requirement. |
Clarification. |
|
14 |
Immediate:
Establish a policy that allows M+C plans to default
members to replacement plans based on the members
primary care physician choice. |
13 |
Establish
a policy that allows M+C plans to default members to
replacement plans based on the members primary care
physician choice. |
Clarification. |
|
15 |
Immediate:
Review and revise the language of its template on Medicare
Health Plan Compare in situations where there is a $0
premium or $0 co-pay. The fill-in-the-blank default
template language does not make sense for situations where
the dollar amount is greater than $0. The result is
confusing, misleading and possibly contradictory language
as to financial liability. |
14 |
Review
and revise the language of its template on Medicare Health
Plan Compare in situations where there is a $0 premium or
$0 co-pay. The fill-in-the-blank default template language
does not make sense for situations where the dollar amount
is greater than $0. The result is confusing, misleading,
and possibly contradictory language as to financial
liability. |
Clarification. |
|
16 |
Immediate:
CMS should clarify the 36-month rule to ensure that the
36-month window runs from the time an M+CO submits its
information or claim rather than the time CMS acts on and
enters the information or claim into the system. |
15 |
Clarify
the 36-month payment reconciliation rule to ensure that
the 36-month window runs from the time an M+CO submits its
information or claim rather than the time CMS acts on and
enters the information or claim into the system. |
Clarification. |
|
17 |
Proposal:
Finalize
and publish the newest revision of the Technical Guide for
states. |
16 |
Publish
regulations in a timely fashion. States are left in limbo
or held financially responsible for unclear policies. (For
example, finalize and publish the newest revision of Medicaid
and School Health: A Technical Guide for States;
clarify the policy related to payment for these services.
[The "old" version of the Technical Guide still
references Medicaid as a payer of last resort for
health-related services. The transmittal of May 2000
indicates the opposite.]) |
Consolidation
of similar
recommendations. |
|
18 |
Immediate:
Clarify the policy related to payment for these services.
"Old" version still references Medicaid as payer
of last resort for health related services. Transmittal of
May 2000 indicates the opposite. |
16 |
Publish
regulations in a timely fashion. States are left in limbo
or held financially responsible for unclear policies. (For
example, finalize and publish the newest revision of Medicaid
and School Health: A Technical Guide for States;
clarify the policy related to payment for these services.
[The "old" version of the Technical Guide still
references Medicaid as a payer of last resort for
health-related services. The transmittal of May 2000
indicates the opposite.]) |
Clarification. |
|
19 |
Modify
the definition of "hospital property" to be only
the Emergency Department and any facility that holds
itself out to the public as being available to provide
emergency or urgent care, and the immediate vicinity (such
as the hospital lawn, parking lot, waiting room, or
similar location) in situations where someone seeking
emergency care is physically unable to proceed to the
actual emergency department or urgent care facility. |
17 |
Modify
the definition of "hospital property" to be only
the emergency department and any other health facility
that holds itself out to the public as being available to
provide emergency or urgent care, as well as the
"immediate vicinity" to the hospital property
(such as the hospital lawn, parking lot, waiting room, or
similar location) in situations where someone seeking
emergency care is physically unable to proceed to the
actual emergency department or urgent care facility. |
Clarification. |
|
20 |
Provide
immediate guidance that use of community based EMS
protocols, including established 911 protocols, is not a
violation of EMTALA |
18 |
Issue
immediate interpretive guidance that use of
community-based Emergency Medical Service (EMS) protocols,
including established 911 protocols, is not a violation of
the Emergency Medical Treatment and Active Labor Act (EMTALA). |
Clarification. |
|
21 |
Exclude
from EMTALA patients who are referred to the Emergency
Department for diagnostic or scheduled therapeutic
services, unless the diagnosis is part of the EMTALA-required
screening or the treatment is part of the EMTALA-required
stabilization. |
19 |
Exclude
from the purview of EMTALA patients who are referred to
the emergency department for diagnostic or scheduled
therapeutic services, unless the diagnosis is part of the
EMTALA-required screening or the treatment is part of the
EMTALA-required stabilization. |
Clarification. |
|
22 |
Eliminate
requirement for ABNs to be provided in the Emergency Room.
Provide guidance that in the event of disaster or
conventional attack involving multiple casualties and
where hospitals use an established disaster plan, EMTALA
does not apply. |
20
+
21
|
Resolve
the Medicare coverage issues underlying the need for
advanced beneficiary notices (ABNs) to have
to be provided in the emergency room. Consider waiving the
requirement for ABNs and the associated denial of coverage
in emergency room and other urgent care settings.
Issue
interpretive guidance that EMTALA does not apply:
- In
the event of an attack involving multiple casualties
and where hospitals use an established disaster plan.
- In
the event of bioterrorism, or the threat of
bioterrorism, to those hospitals directly affected and
where hospitals follow a community-based, regional or
Centers for Disease Control and Prevention (CDC)-directed
protocol (especially for highly contagious outbreaks,
like smallpox).
|
Clarification.
Consolidation of similar
recommendations.
|
|
23 |
Provide
guidance that in the event of bioterrorism, or the threat
of bioterrorism, EMTALA does not apply to those hospitals
directly affected and where hospitals follow a community
based, regional or CDC directed protocol (especially for
highly contagious outbreaks like small pox). |
21 |
Issue
interpretive guidance that EMTALA does not apply:
- In
the event of an attack involving multiple casualties
and where hospitals use an established disaster plan.
- In
the event of bioterrorism, or the threat of
bioterrorism, to those hospitals directly affected and
where hospitals follow a community-based, regional or
Centers for Disease Control and Prevention (CDC)-directed
protocol (especially for highly contagious outbreaks,
like smallpox).
|
Clarification. |
|
24 |
Review,
update, and clarify in the Preamble to the Rule as well as
in the Interpretive Guidelines what is mandated by EMTALA
for the physician, separate from what is the hospitals
and the physician medical staffs responsibilities. This
should cover the issues already outlined as well as
provide an explanation as to whether there is a
recommended threshold for the application of EMTALA as it
relates to the number of specialists and type of
specialists on staff who are available to be
"on-call" at a particular hospital; and
identifies safe harbors when physician specialists who are
in short supply are on call at more than one hospital at
the same time, which is another instance where local EMS
policies may preempt EMTALA. |
22 |
Review,
update, and clarify in regulation and interpretive
guidance what is mandated by EMTALA for the physician;
clearly distinguish physician medical staff
responsibilities from hospital responsibilities. In
particular, Centers for Medicare & Medicaid Services
(CMS) guidance should provide an explanation as to whether
there is a recommended threshold for the application of
EMTALA as it relates to the number of specialists and type
of specialists on staff who are available to be
"on-call" at a particular hospital (e.g.,
identify safe harbors when physician specialists who are
in short supply are "on-call" at more than one
hospital at the same time). |
Clarification. |
|
25 |
Notify
hospitals when EMTALA investigations are completed,
regardless of the outcome. |
23 |
Require
that hospitals be notified when EMTALA investigations are
completed, regardless of the outcome. |
Clarification. |
|
26 |
Modify
enforcement practices by making PRO review mandatory early
in the process and improving training of regional offices
and state agencies to improve performance and consistency
of review of complaints. The CMS Atlanta Regional Office
procedures should be used as a model. |
24 |
Make
Quality Improvement Organization (QIO) review mandatory
early in the process and improve training of regional
offices and State Agencies to improve performance and
consistency of review of complaints. (CMS Atlanta
Regional Office procedures should be used as a model.) |
Clarification. |
|
27 |
Create
an Emergency Services Cooperative Project that would
follow the format of the Diabetes and Cardiovascular
Quality Improvement Project. This should be developed and
implemented with a scientific and technical advisory board
of emergency physicians, first responders, emergency
transportation specialists, consumers and other advisers.
This group should also guide development of future
regulations that would assure availability of effective
emergency services in all parts of the country. This group
would include on-call physicians (medical and surgical
specialists who provide care for emergencies) as part of
the scientific and technical advisory board for the
Emergency Services Cooperative Project. In the future this
group should take on thorny issues such as reimbursement
mechanisms for EMTALA related services when patients don't
have insurance. |
132 |
Create
an Emergency Services Cooperative Project that would
follow the format of the Diabetes and Cardiovascular
Quality Improvement Project. This should be developed and
implemented with a scientific and technical advisory board
of emergency physicians, hospitals, first responders,
emergency transportation specialists, consumers and other
advisers. This group should also guide development of
future regulations that would assure availability of
effective emergency services in all parts of the country.
This group would include on-call physicians (medical and
surgical specialists who provide care for emergencies) as
part of the scientific and technical advisory board for
the Emergency Services Cooperative Project. In the future,
this group should take on thorny issues such as
reimbursement mechanisms for EMTALA-related services when
patients dont have insurance; foster appropriate
consultation with and involvement by QIOs; appropriate due
process for hospitals and health care professionals before
CMS can issue a public notice of termination and proceed
with a termination letter. |
Clarification. |
|
28 |
Develop,
fund and implement a comprehensive, ongoing communications
plan that will be coordinated among HHS, CMS and its
contractors, as recommended by the Advisory Panel on
Medicare Education, to aggressively reach specific
segments of the audience, using the appropriate channels
including radio, TV, 1-800-MEDICARE, web and print media,
as well as other strategies supported by research results. |
25 |
Develop,
fund and implement a comprehensive, ongoing communications
plan that will be coordinated among HHS, CMS and its
contractors, as recommended by the Advisory Panel on
Medicare Education, to aggressively reach specific
segments of the audience, using the appropriate channels
including radio, TV, 1-800-MEDICARE, web and print media,
as well as other strategies supported by research results. |
No
changes. |
|
29 |
Improve
efforts to educate elderly and /or disabled individuals
approaching Medicare eligibility. |
26 |
Continuously
improve efforts to educate elderly individuals and/or
individuals with disabilities approaching Medicare
eligibility. |
Clarification. |
|
30 |
Add
the 1-800 MEDICARE phone number and website address to the
beneficiarys Medicare card. |
27 |
Add
the 1-800 MEDICARE phone number and website address to the
beneficiarys Medicare card. |
No
changes. |
|
31 |
Eliminate
overly burdensome Medicare Secondary Payer requirements. |
28 |
Eliminate
overly burdensome Medicare Secondary Payer requirements. |
No
changes. |
|
32 |
Research,
consumer-test and evaluate the current MSN and incorporate
those enhancements that result in improved beneficiary
understanding of the content. Incorporate reasons for
noncoverage or denial of service on MSNs in plain language
and refer beneficiaries to relevant regulations regarding
the noncoverage or denial. |
29 |
Research,
consumer-test, and evaluate the current Medicare Summary
Notice (MSN) and incorporate those enhancements that
result in improved beneficiary understanding of the
content. Incorporate reasons for noncoverage or denial of
service on MSNs in plain language and refer beneficiaries
to relevant regulations regarding the noncoverage or
denial. |
No
changes. |
|
33 |
Improve
and consistently update the Medicare Plan Finder (which
includes original Medicare and Medicare + Choice). |
30 |
Improve
and consistently update the Medicare Plan Finder (which
includes original Medicare and Medicare+Choice). |
No
changes. |
|
34 |
Develop/implement
performance standards for education and communication
efforts that can be implemented consistently by CMS and by
all its agents and partners. |
31 |
Develop/implement
performance standards for CMSprogram of beneficiary
education and communication efforts so that the program
can be implemented consistently by CMS and all its agents
and partners. |
Clarification. |
|
35 |
Refine
the timeframes for MDS assessments so that payment and
quality cycles coincide and such cycles require the least
number of assessments in short periods of time. |
44 |
Consolidate
the number and timing of all MDS assessments to those that
are required for care planning purposes, to the maximum
extent possible. Refine the time frames for MDS
assessments so that payment and quality cycles coincide
and such cycles require the least number of assessments
during short periods of time. |
Consolidation
of similar
recommendations. |
|
36 |
To
the maximum extent possible, develop shorter versions of
the MDS (e.g., one of the quarterly assessments forms) for
Medicare and Medicaid resident assessment. As part of this
streamlining process, define the specific uses of any data
elements prior to retaining any element on the form.
Delete or revise all MDS data elements whose reliability
is below generally accepted statistical standards. |
32 |
Develop
shorter versions of the Minimum Data Set (MDS) (e.g., one
of the quarterly assessments forms) for Medicare and
Medicaid resident assessment, to the maximum extent
possible. Define the specific uses of any data elements
prior to retaining any element on the form as part of an
overall streamlining process. Delete or revise all MDS
data elements whose reliability is below generally
accepted statistical standards. |
Clarification. |
|
37 |
Clarify
with interpretive guidance that MDS is a source document
and does not require supporting documentation to justify
coded responses. |
33 |
Clarify
with interpretive guidance that the MDS is a source
document and does not require supporting documentation to
justify coded responses. |
No
changes. |
|
38 |
Automate
the RAPs process at the facility level to free-up more
time to meet patient care needs. |
34 |
Automate
the Resident Assessment Protocols (RAPs) process at the
facility level to free up more time to meet patient care
needs. |
No
changes. |
|
39 |
Update
the Coverage Manual relevant to Medicare Part A; e.g., who
can be covered, authorized benefit periods, breaking the
spell of illness and other administrative issues. |
35 |
Update
the Coverage Manual relevant to Medicare Part A (e.g., who
can be covered, authorized benefit periods, breaking the
spell of illness, and other administrative issues). |
No
changes. |
|
40 |
Integrate
updates of the MDS Manual and Resident Assessment User
Guide and documentation into one manual, and keep the one
manual up-to-date. Revise the current manual to
incorporate all interpretive guidance and answers to
frequently asked questions. Keep a downloadable,
up-to-date manual available on the CMS website and make an
annual print edition available each year which
incorporates all life-to-date regulation and guidance with
date certain. Publish any interpretive guidance as a
quarterly addendum to the annual edition of the manual. |
36 |
Integrate
updates of the MDS Manual and Resident Assessment (RAI)
User Guide and documentation into one manual, distribute
the updated guide as soon as possible, and keep the one
manual up-to-date. Revise the current manual to
incorporate all interpretive guidance and answers to
frequently asked questions. Keep a downloadable,
up-to-date manual available on the CMS website and publish
an annual print edition each year on a set date which
incorporates all life-to-date regulation and guidance.
Post quarterly updates on interpretive guidance to the CMS
website. |
Consolidation
of similar
recommendations. |
|
41 |
Continue
to develop the MDS 3.0 which will include an analysis of
the clinical relevancy of its contents and the capability
to capture short stay assessment data, with an expected
release date of 2004. |
37 |
Continue
to develop the MDS 3.0, which will include an analysis of
the clinical relevancy of its contents and the capability
to capture short stay assessment data, with an expected
release date of 2004. |
No
changes. |
|
42 |
Work
with scientific and technical advisory panels, which
include provider representatives, to continuously improve
the RAI process. In addition, the advisory panels should
be involved in the development and use of quality
measures. |
38 |
Adopt
a continuous quality improvement process to keep the MDS
tool and the RAI process current with medical practice and
changing delivery systems. Establish a scientific and
technical advisory panel to guide MDS use (measure
work-ups, interpretation of data quality, and
interpretation of results, quality reporting, assessment
of need for new measures). |
Clarification. |
|
43 |
Allow
a provider to have joint property rights of any data it
submitted as part of the MDS process. This will allow the
provider to access backup copies and may reduce the need
for providers to warehouse redundant manual versions of
the data. |
39 |
Give
providers joint property rights to any data submitted as
part of the MDS process. (This will allow the provider to
access backup copies and may reduce the need for providers
to warehouse redundant manual versions of the data.) |
Clarification. |
|
44 |
Develop
facility-specific analytic reports that allow facilities
to compare their own performance in relation to local,
regional and national trends. Develop reports and other
tools to share aggregate data with all persons. |
40 |
Develop
facility-specific analytic reports that allow facilities
to compare their own performance in relation to local,
regional and national trends. Develop reports and other
tools to share aggregate data with all persons. |
No
changes. |
|
45 |
Shorten
the interval from when MDS data were originally collected
to when the reports of those data are made public. The
older the data are, the less relevant the application and
inferences to be drawn from those data. |
41 |
Shorten
the interval from when MDS data were originally collected
to when the reports of those data are made public. The
older the data are, the less relevant the application and
inferences to be drawn from those data. |
No
changes. |
|
46 |
Enhance
CMSs investment in education related to the use of MDS,
including web-based training tools such as the Medicare
Learning Network. Update the SNF section of the Medicare
Learning Network to include a detailed tutorial on MDS. |
42 |
Enhance
CMS investment in education related to the use of the
Minimum Data Set (MDS), including web-based training
tools, such as the Medicare Learning Network. Update the
skilled nursing facility (SNF) section of the Medicare
Learning Network to include a detailed tutorial on MDS. |
No
changes. |
|
47 |
For
those Resident Assessments performed solely for the
purpose of complying with Medicare payment requirements,
eliminate data elements that are not used for payment or
quality measurement. The Committee understands that a new,
abbreviated MDS is currently being made available for PPS
only assessments performed on or after July 1, 2002. |
43 |
Eliminate
data elements that are not used for payment, quality
measurement, or survey purposes for those resident
assessments performed solely for the purpose of complying
with Medicare payment requirements. |
Clarification.
|
|
48 |
To
the maximum extent possible, consolidate the number and
timing of all MDS assessments to those that are required
for care planning purposes. See separate issue statement:
"Consolidating and Abbreviating the MDS". |
44 |
Consolidate
the number and timing of all MDS assessments to those that
are required for care planning purposes, to the maximum
extent possible. Refine the time frames for MDS
assessments so that payment and quality cycles coincide
and such cycles require the least number of assessments
during short periods of time. |
Consolidation
of similar
recommendations. |
|
49 |
Add
case mix / risk adjustment to quality indicators, as
appropriate. |
45 |
Add
case mix/risk adjustment to quality indicators, as
appropriate. |
No
changes. |
|
50 |
In
respect to the Nursing Home Compare website, improve the
legend of key terms to accurately portray the facilitys
data. |
46 |
Improve
the legend of key terms on the Nursing Home Compare
website. |
Clarification. |
|
51 |
Focus
on further automation of the MDS process, including the
design of publicly available software with "interview
wizards" and other intuitive data accumulation
methods. |
47 |
Further
automate the Minimum Data Set (MDS) process, including the
design of publicly available software with "interview
wizards" and other intuitive data accumulation
methods. |
Clarification. |
|
52 |
Improve
the balance of comparative data available for the public,
to include both quality of life and quality of care
measures. |
48 |
Improve
the balance of nursing home comparative data available for
the public to include both quality of life and quality of
care measures. |
Clarification. |
|
53 |
Standardize
the investigative protocols of HHS and state survey teams.
The Committee feels that here is considerably more
training needed for state survey teams. This training
should focus on the proper interpretation of the
regulatory compliance requirements placed on nursing
facilities. |
49 |
Standardize
the investigative protocols of HHS and State survey teams.
Increase training for State survey teams. Focus training
on the proper interpretation of the regulatory compliance
requirements placed on nursing facilities. |
Clarification. |
|
54 |
Use
the HIPAA mandate as the basis to standardize terminology
and identify common data elements used by payers,
programs, providers and suppliers of care; and to
determine whether RAPs are confidential and if any access
protections are needed. |
50 |
Use
the Health Insurance Portability and Accountability Act (HIPAA)
mandate as the basis to standardize terminology and
identify common data elements used by payers, programs,
providers, and suppliers of care and to determine whether
the Resident Assessment Protocols (RAPs) are confidential
and if any access protections are needed. |
No
changes. |
|
55 |
Develop
a standard instrument for the assessment of the health and
functional status of patients receiving post acute
services; to the extent feasible, integrate communication
standards adopted under the Consolidated Health
Information (CHI) eGov initiative as part of the
development of this tool. |
51 |
Develop
a standard instrument for the assessment of the health and
functional status of patients receiving post acute
services as mandated by the Benefit Improvement and
Protection Act (BIPA); integrate, to the extent feasible,
communication standards adopted under the Consolidated
Health Information (CHI) eGov initiative as part of the
development of this tool. |
Clarification. |
|
56 |
CMS
Provider Relations staff should seek greater partnerships
and outreach to the full continuum of academic medical,
nursing, and other allied health care training programs in
order to expose all health care professionals (not just
specialists) to the value of training in gerontology and
participation in interdisciplinary teams, and to the
utility of clinical patient care data sets in the process
of care planning. |
52 |
Seek
greater partnerships and outreach to the full continuum of
academic medical, nursing, and other allied health care
training programs in order to expose all health care
professionals (not just specialists) to the value of
training in gerontology and participation in
interdisciplinary teams, and to the utility of clinical
patient care data sets in the process of care planning. |
Clarification. |
|
57 |
Establish
an appeal process for default payments with a specified
timeframe for the appeal. |
53
|
Establish
an appeal process for default Resource Utilization Group
(RUG) payments with a specified time frame for the appeal.
Establish clear and reasonable rules concerning submission
of the MDS instrument so that providers are not penalized
with default RUG payments for legitimate, minor delays in
completing an MDS assessment. |
Consolidation
of similar
recommendations. |
|
58 |
CMS
must put in writing that the MDS is a source document and
does not require supporting documentation to justify coded
responses. |
33 |
Clarify
with interpretive guidance that the MDS is a source
document and does not require supporting documentation to
justify coded responses. |
Consolidation
of similar
recommendations. |
|
59 |
CMS
to issue a memorandum that clearly defines the MDS as a
"source document." |
33 |
Clarify
with interpretive guidance that the MDS is a source
document and does not require supporting documentation to
justify coded responses. |
Consolidation
of similar
recommendations. |
|
60 |
CMS
should distribute the updated RAI Users Guide as soon
as possible. |
36 |
Integrate
updates of the MDS Manual and Resident Assessment (RAI)
User Guide and documentation into one manual, distribute
the updated guide as soon as possible, and keep the one
manual up-to-date. Revise the current manual to
incorporate all interpretive guidance and answers to
frequently asked questions. Keep a downloadable,
up-to-date manual available on the CMS website and publish
an annual print edition each year on a set date which
incorporates all life-to-date regulation and guidance.
Post quarterly updates on interpretive guidance to the CMS
website. |
Consolidation
of similar
recommendations. |
|
61 |
Expand
the time for completion of the OASIS instrument, for
example from 5 days to 7 days to better reflect operations
of HHAs. |
54 |
Change
the Outcome and Assessment Information Set (OASIS)
policies to better reflect actual home health agency (HHA)
operations:
- Expand
the time for completion of the OASIS instrument, for
example, from 5 days to 7 days.
- Change
the lock-in time for the OASIS instrument, for
example, from 7 days to 14 days. (For example, HHA
nurses, especially in rural areas, come to the HHA
central office only once a week.)
|
Consolidation
of similar
recommendations. |
|
62 |
Change
the lock-in time for the OASIS instrument, for example,
from 7 days to 14 days to better reflect actual HHA
operations. HHA nurses, especially in rural areas, only
come to the HHA central office once a week. |
54 |
Change
the Outcome and Assessment Information Set (OASIS)
policies to better reflect actual home health agency (HHA)
operations:
- Expand
the time for completion of the OASIS instrument, for
example, from 5 days to 7 days.
- Change
the lock-in time for the OASIS instrument, for
example, from 7 days to 14 days. (For example, HHA
nurses, especially in rural areas, come to the HHA
central office only once a week.)
|
Consolidation
of similar
recommendations. |
|
63 |
Delete
elements that are duplicative or not used for payment,
quality management, or survey purposes. CMS should
particularly scrutinize elements listed in Miami testimony
including MO190, MO340, MO640-680, MO780. |
59 |
Ensure
that data collection efforts facilitate development of
care plan.
- Delete
elements that are duplicative or not used for payment
(including risk adjustment), quality management, or
survey purposes. CMS should particularly scrutinize
elements listed in Miami testimony, including MO190,
MO340, MO640-680, and MO780.
- Eliminate
OASIS encounters that are not used for payment,
quality management, or survey purposes.
|
Consolidation
of similar
recommendations. |
|
64 |
Eliminate
separate form for significant change in condition when it
occurs in the 5 day window of the follow up assessment. |
55 |
Eliminate
separate form for significant change in condition when it
occurs in the 5-day window of the follow-up assessment. |
No
changes. |
|
65 |
Delete
elements that are duplicative or not used for payment,
quality management, or survey purposes. CMS should
particularly scrutinize elements listed in Miami testimony
including MO190, MO340, MO640-680, MO780. |
59 |
Ensure
that data collection efforts facilitate development of
care plan.
- Delete
elements that are duplicative or not used for payment
(including risk adjustment), quality management, or
survey purposes. CMS should particularly scrutinize
elements listed in Miami testimony, including MO190,
MO340, MO640-680, and MO780.
- Eliminate
OASIS encounters that are not used for payment,
quality management, or survey purposes.
|
Consolidation
of similar
recommendations. |
|
66 |
Create
the option to use one form for all situations of care or
change in status. |
56 |
Create
the option to use one OASIS form for all situations of
care or change in status. |
Clarification. |
|
67 |
Share
risk-adjustment methodology with all users put on
website. |
57 |
Share
OASIS risk-adjustment methodology with all users; make the
information available on the CMS website. |
Clarification. |
|
68 |
Provide
access to the studies on the validity of OASIS data,
adverse event measurements, and the University of Colorado
study on OASIS quality and outcomes. |
58 |
Provide
access to the studies on the validity of OASIS data,
adverse event measurements, and the University of Colorado
study on OASIS quality and outcomes. |
No
changes. |
|
69 |
Make
sure that data collection efforts facilitate development
of care plan; eliminate data collection that does not
contribute to development of a care plan or a valid and
reliable risk adjustment process related to outcome
measurement, or which is clinically unnecessary. |
59 |
Ensure
that data collection efforts facilitate development of
care plan.
- Delete
elements that are duplicative or not used for payment
(including risk adjustment), quality management, or
survey purposes. CMS should particularly scrutinize
elements listed in Miami testimony including MO190,
MO340, MO640-680, and MO780.
- Eliminate
OASIS encounters that are not used for payment,
quality management, or survey purposes.
|
Consolidation
of similar
recommendations. |
|
70 |
CMS
should consider the impact of HIPAA on home health
agencies with respect to the timing of any changes to
OASIS. |
60 |
Consider
the impact of HIPAA on home health agencies with respect
to the timing of any changes to OASIS. |
Clarification. |
|
71 |
Adopt
a CQI process to keep the OASIS tool current with medical
practice and changing delivery systems. |
61 |
Adopt
a continuous quality improvement process to keep the OASIS
tool current with medical practice and changing delivery
systems. Establish a scientific and technical advisory
panel to guide OASIS use (measure work-ups, interpretation
of data quality, interpretation of results, quality
reporting, assessment of need for new measures). |
Consolidation
of similar
recommendations. |
|
72 |
Establish
a scientific and technical advisory panel should guide
OASIS use (measure work-ups, interpretation of data
quality, interpretation of results, quality reporting,
assessment of need for new measures). |
61 |
Adopt
a continuous quality improvement process to keep the OASIS
tool current with medical practice and changing delivery
systems. Establish a scientific and technical advisory
panel to guide OASIS use (measure work-ups, interpretation
of data quality, interpretation of results, quality
reporting, assessment of need for new measures). |
Consolidation
of similar
recommendations. |
|
73 |
Field
tests (pilot studies) of new measures should be done
before new measures are put into use. |
62 |
Field
test new OASIS measures before they are put into use. |
Clarification. |
|
74 |
Clarify
the definition of "significant change". Consider
using re-hospitalization as a proxy for "significant
change." |
63 |
Clarify
the definition of "significant change." Consider
using re-hospitalization as a proxy for "significant
change." |
No
changes. |
|
75 |
Conduct
an independent evaluation of the cost-benefit of using the
OASIS form. |
64 |
Conduct
an independent evaluation of the cost-benefit of using the
OASIS form. |
No
changes. |
|
76 |
Create
modern day electronic and on-line enrollment processes for
physicians and Part B suppliers. |
65 |
Create
modern-day electronic and on-line enrollment processes for
physicians and Part B suppliers.
- Immediately
implement a system that allows providers to submit
electronic applications via e-mail.
- Develop
a secure website for provider enrollment.
|
Consolidation
of similar
recommendations. |
|
77 |
Allow
electronic filing via e-mail. |
65 |
Create
modern-day electronic and on-line enrollment processes for
physicians and Part B suppliers.
- Immediately
implement a system that allows providers to submit
electronic applications via e-mail.
- Develop
a secure website for provider enrollment.
|
Consolidation
of similar
recommendations. |
|
78 |
Develop
a modern provider enrollment secure website. |
65 |
Create
modern-day electronic and on-line enrollment processes for
physicians and Part B suppliers.
- Immediately
implement a system that allows providers to submit
electronic applications via e-mail.
- Develop
a secure website for provider enrollment.
|
Consolidation
of similar
recommendations. |
|
79 |
Seek
legislation that would require all insurance companies and
other government payors to recognize the validity of the
Medicare enrollment process and prohibit them from
developing their own processes. |
66 |
Seek
legislation that would require all insurance companies and
other government payers to recognize the validity of the
Medicare enrollment process and prohibit them from
developing their own processes. (For provider enrollment.) |
No
changes. |
|
80 |
A
central repository of forms on various HHS websites should
be created and maintained. |
67 |
Create
and maintain one central repository of forms required or
allowed by HHS or its principal components from all of the
various HHS websites. |
Clarification. |
|
81 |
Create
a continuous review process for all forms with an eye to
constantly improving and streamlining existing forms and
eliminating obsolete forms. |
68 |
Create
a continuous review process for all forms with an eye to
constantly improving and streamlining existing forms and
eliminating obsolete forms. |
No
changes. |
|
82 |
Re-design
all forms and data requirements to seamlessly interface
with the Information Technology architecture of HHS so as
to minimize human intervention and optimize IT output. Do
not publish new forms until IT issues have been addressed. |
69 |
Redesign
all forms and data requirements to seamlessly interface
with the Information Technology (IT) architecture of HHS
so as to minimize human intervention and optimize IT
output. Do not publish new forms until IT issues have been
addressed. |
No
changes. |
|
83 |
Eliminate
Medicare credit balance reporting. |
70 |
Eliminate
Medicare credit balance reporting. |
No
changes. |
|
84 |
Eliminate
HCFA 1513 and HCFA 1514. |
71 |
Eliminate
forms HCFA 1513 and HCFA 1514. |
No
changes. |
|
85 |
Incorporate
HCFA 2572 into CMS 855.
|
72 |
Incorporate
form HCFA 2572 into CMS 855. |
No
changes. |
|
86 |
Implement
use of electronic signatures |
73 |
Reduce
costs and speed up administrative activities for
providers, suppliers, health plans, and consumers by
modernizing HHS IT, processes, and applications:
- Implement
use of electronic signatures.
- Implement
use of e-filing.
- Integrate
data acquisition into IT architecture of HHS and data
providers.
- Maximize
use of web-based transactions.
|
Consolidation
of similar
recommendations. |
|
87 |
Implement
use of e-filing |
73 |
Reduce
costs and speed up administrative activities for
providers, suppliers, health plans, and consumers by
modernizing HHS IT, processes, and applications:
- Implement
use of electronic signatures.
- Implement
use of e-filing.
- Integrate
data acquisition into IT architecture of HHS and data
providers.
- Maximize
use of web-based transactions.
|
Consolidation
of similar
recommendations. |
|
88 |
Integrate
data acquisition into IT architecture of HHS and data
providers |
73 |
Reduce
costs and speed up administrative activities for
providers, suppliers, health plans, and consumers by
modernizing HHS IT, processes, and applications:
- Implement
use of electronic signatures.
- Implement
use of e-filing.
- Integrate
data acquisition into IT architecture of HHS and data
providers.
- Maximize
use of web-based transactions.
|
Consolidation
of similar
recommendations. |
|
89 |
Modernize
current MCR, make it more useful, more creative, less
burdensome. |
74 |
Modernize
the current Medicare Cost Report (MCR), make it more
useful, more creative, and less burdensome:
- Eliminate
CMS 339; fold data into the MCR.
- Eliminate
need to file redundant manual data to support the MCR.
- Modernize
and speed up current audit process, settle MCRs within
one year and first round appeals within six months.
- Establish
a method to electronically file MCRs into a central
repository similar to the U.S. Securities and Exchange
Commissions Electronic Data Gathering and Retrieval
(EDGAR) system.
|
Consolidation
of similar
recommendations. |
|
90 |
Eliminate
CMS339, fold data into cost report. |
74 |
Modernize
the current Medicare Cost Report (MCR), make it more
useful, more creative, and less burdensome:
- Eliminate
CMS 339; fold data into the MCR.
- Eliminate
need to file redundant manual data to support the MCR.
- Modernize
and speed up current audit process, settle MCRs within
one year and first round appeals within six months.
- Establish
a method to electronically file MCRs into a central
repository similar to the U.S. Securities and Exchange
Commissions Electronic Data Gathering and Retrieval
(EDGAR) system.
|
Consolidation
of similar
recommendations. |
|
91 |
Eliminate
need to file redundant manual data. |
74 |
Modernize
the current Medicare Cost Report (MCR), make it more
useful, more creative, and less burdensome:
- Eliminate
CMS 339; fold data into the MCR.
- Eliminate
need to file redundant manual data to support the MCR.
- Modernize
and speed up current audit process, settle MCRs within
one year and first round appeals within six months.
- Establish
a method to electronically file MCRs into a central
repository similar to the U.S. Securities and Exchange
Commissions Electronic Data Gathering and Retrieval
(EDGAR) system.
|
Consolidation
of similar
recommendations. |
|
92 |
Modernize
and speed up current audit process, settle MCRs within one
year and first round appeals within six months. |
74 |
Modernize
the current Medicare Cost Report (MCR), make it more
useful, more creative, and less burdensome:
- Eliminate
CMS 339; fold data into the MCR.
- Eliminate
need to file redundant manual data to support the MCR.
- Modernize
and speed up current audit process, settle MCRs within
one year and first round appeals within six months.
- Establish
a method to electronically file MCRs into a central
repository similar to the U.S. Securities and Exchange
Commissions Electronic Data Gathering and Retrieval
(EDGAR) system.
|
Consolidation
of similar
recommendations. |
|
93 |
Establish
method to E-file MCR in central repository similar to SECs
EDGAR system. |
74 |
Modernize
the current Medicare Cost Report (MCR), make it more
useful, more creative, and less burdensome:
- Eliminate
CMS 339; fold data into the MCR.
- Eliminate
need to file redundant manual data to support the MCR.
- Modernize
and speed up current audit process, settle MCRs within
one year and first round appeals within six months.
- Establish
a method to electronically file MCRs into a central
repository similar to the U.S. Securities and Exchange
Commissions Electronic Data Gathering and Retrieval
(EDGAR) system.
|
Consolidation
of similar
recommendations. |
|
94 |
Move
to GAAP reporting for providers who no longer receive cost
reimbursement; continue to use modernized MCR for
cost-based providers. |
75 |
Use
Generally Accepted Accounting Principles-based cost
reporting for providers who no longer receive cost
reimbursement; continue to use a simplified and
streamlined version of the MCR for cost-based providers. |
Clarification. |
|
95 |
Issue
clear directions to carriers and state agencies that
observations made on MDS, OASIS, and other HHS-approved
survey instruments do not require redundant manual
documentation to support the observations. |
76 |
Issue
clear directions to carriers and State Agencies that
observations made on the MDS, OASIS, and other
HHS-approved survey instruments do not require redundant
manual documentation to support the observations. |
No
changes. |
|
96 |
Connect
data instruments and acquisition efforts so data can be
transferred and applied to another use or another site of
service. |
77 |
Connect
data instruments and acquisition efforts so data can be
transferred and applied to another use or another site of
service. |
No
changes. |
|
97 |
Provide
resources to meet Congress January 1, 2005 deadline for
the development of standard patient assessment
instruments. Involve providers and patients in this
process. |
78 |
Provide
resources to meet the January 1, 2005, deadline set by
Congress for the development of standard patient
assessment instruments as mandated by BIPA. Involve
providers and patients in this process. |
Clarification. |
|
98 |
Adopt
protocols for joint ownership of data thus eliminating the
need for manual backup copies of data. |
79 |
Adopt
protocols for joint ownership of data thus eliminating the
need for manual backup copies of data. |
No
changes. |
|
99 |
It
is the strong recommendation of the Coordination
Subcommittee that a Task Force be established and
funded to address specific issues related to multiple
reviews and regulatory oversight. The task force will be
established no later than 12/31/02 and it will have a 6
month time frame for recommendations to be submitted. |
80 |
Establish
a task force funded to address specific issues related to
current practices, whereby a single provider or health
plan may be reviewed/surveyed/audited by numerous State
and Federal entities (especially those under the auspices
of the Secretary of HHS), none of which are required to be
coordinated. The task force should also address regulatory
oversight. The task force will be established no later
than December 31, 2002 and it will have a six-month time
frame for recommendations to be submitted. |
Clarification. |
|
100 |
Simplify
the Authorization Process |
81 |
Simplify
the authorization process by adopting the Notice of
Proposed Rulemaking (NPRM) proposal at 45 CFR § 164.508
that would permit a single, relatively straightforward
form to cover all authorization settings. |
Clarification. |
|
101 |
Reveal
Any Third Party Remuneration in Requested Authorizations |
82 |
Require
a covered entity that obtains direct or indirect
remuneration from a third party for requesting any
authorization relating to use or disclosure of an
individuals medical information to reveal that fact, as
well as the third party source of the remuneration. (This
may be achieved by including the following provisions
within 45 CFR § 164.508(c)(2):
"(_)
If use or disclosure of protected health information by
any entity pursuant to an authorization requested by a
covered entity will result in direct or indirect
remuneration to the requesting covered entity from a
third party, a statement that such remuneration will
result and identification of the third party or class of
third parties who will furnish the remuneration".)
|
Clarification. |
|
102 |
Allow
Newsletters and similar general circulation communications
without authorizations. |
83 |
Allow
a covered entity to use and disclose the minimum necessary
protected health information without individuals
authorizations to distribute a newsletter or similar
general circulation communication to a broad cross-section
of patients, enrollees or other broad group of
individuals. Clarify that this activity is allowed by
adding the following new rule as 45 CFR
§ 164.508(a)(3)(i)(C):
"(C)
A newsletter or similar type of general communication
device that the covered entity distributes to a broad
cross-section of patients, enrollees, or other broad
group of individuals."
|
Clarification. |
|
103 |
Redefine
Marketing Carve Outs, Reveal Third Party Remuneration, and
Allow Opt-Out from Third Party Funded Carve Out
Communications |
84 |
Redefine
activities that are not marketing as follows. As
the NPRM proposes, add "care coordination" and
"case management" to activities that are not marketing,
and allow medical information use and disclosure without
authorization for communications regarding (a) members of
a providers or health plans network, (b) products or
services, or payments for such products or services,
provided by a covered entity or included in health plan
benefits, (c) treatment of the individual, or (d)
directing or recommending alternative treatments,
therapies, health care providers, or care settings.
Close
loopholes in the NPRM proposal by requiring covered
entities to reveal the fact and source of any third-party
remuneration for making "non-marketing"
communications and allowing individuals to opt out of
future such communications. (This may be accomplished by
adding the following provisions as new 45 CFR
§ 164.514(e):
"(e)(1)
Standards: certain communications involving
remuneration. Except when the communication is
contained in a newsletter or similar type of general
communication device that the covered entity distributes
to a broad cross-section of patients, enrollees, or
other broad group of individuals, a covered entity that
uses or discloses an individuals protected health
information to communicate with that individual by any
means, other than face-to-face with that individual,
about any of the matters described in paragraphs (e)(1)(i)-(iii)
of this section, and that receives or will receive
direct or indirect remuneration from a third party for
making the communication, must meet the requirements of
paragraph (e)(2) of this section.
"(i)
The covered entity communicates with an individual to
describe the entities participating in a health care
provider network or a health plan network, or to
describe if, and the extent to which, a product or
service (or payment for such product or service) is
provided by a covered entity or included in a plan of
benefits.
"(ii)
The covered entity communicates with an individual for
treatment of that individual.
"(iii)
The covered entity communicates with an individual for
case management or care coordination for that
individual, or to direct or recommend alternative
treatments, therapies, health care providers, or
settings of care to that individual.
"(2)
Implementation specifications: requirements relating
to certain communications involving remuneration.
Except when the communication is contained in a
newsletter or similar type of general communication
device that the covered entity distributes to a broad
cross-section of patients, enrollees, or other broad
group of individuals or is face-to-face with the
individual, a covered entity that makes a communication
as described in paragraphs (e)(1)(i)-(iii) of this
section and that receives or will receive direct or
indirect remuneration from a third party for making the
communication must in the communication:
"(i)
Identify the covered entity as the party making the
communication;
"(ii)
Prominently state that the covered entity has received
or will receive remuneration from a third party for
making the communication and disclose the name of the
third party providing the remuneration; and
"(iii)
Provide instructions describing how the individual may
opt out of receiving future such communications, and for
each individual who so opts-out, avoid any future such
communications with that individual.")
Clarify
in the rule, or at least in the preamble to the rule, that
an activity that the Privacy Rule characterizes as
"not marketing" may still be marketing regulated
by other applicable Federal and State laws, such as FDA
regulations, CMS rules addressing Medicare+Choice (M+C)
materials, and the anti-kickback and anti-influencing laws
(Social Security Act §§ 1128A(a)(5), 1128B(b)). HHS
Office of Civil Rights (OCR) should coordinate the final
"marketing" provisions of the Privacy Rule with
the HHS Office of Inspector General, FDA, and other
appropriate Federal agencies to ensure consistency in
regulatory provisions among these agencies. |
Clarification. |
|
104 |
Clarify
that Incidental Use and Disclosure Is Permitted |
85 |
Clarify
that incidental use and disclosure is permitted (45 CFR
§§ 164.502(a), 164.530(c)) by adopting the NPRM
provisions that specify that uses and disclosures
reasonably incidental to permitted uses and disclosures of
medical information are not violations of the Privacy
Rule. |
Clarification. |
|
105 |
Clarify
the Provisions on Informal Permission for Persons Involved
in Payment Related to an Individuals Health Care |
86 |
Clarify
the provisions on informal permission for persons involved
in payment related to an individuals health care, so
that communications with family or others acting for an
individual "not present" to resolve payment
matters relating to the individuals health care, are
permitted. (This can be accomplished by rewording of the
first sentence of 45 CFR § 164.510(b)(3) as follows:
"(3)
Limited uses and disclosures when the individual is
not present. If the individual is not present, or
the opportunity to agree or object to the use or
disclosure cannot practicably be provided because of the
individuals incapacity or an emergency circumstance,
the covered entity may, in the exercise of professional
judgment, determine whether the disclosure is in the
best interests of the individual and, if so, disclose
only the protected health information that is directly
relevant to the persons involvement with the
individuals health care or payment related to the
individuals health care.")
|
Clarification. |
|
106 |
Reconcile
Potential Conflict between Confidential Communications and
Explanations of Benefits Issuance |
87 |
Reconcile
potential conflict between confidential communications and
explanations of benefits (EOB) issuance (45 CFR §§
164.501 ("Payment"), 164.522(b)(1)) by
clarifying that a health plan may require the person
demanding confidential communication to explain how the
health plan can perform its payment obligations of issuing
EOBs to the subscriber.
Require
the HHS OCR to coordinate the Privacy Rule with the rules
of the Department of Labors (DOL) Pension and Welfare
Benefits Administration, which regulates Employee
Retirement Income Security Act (ERISA) group health plans,
in order to avoid conflicting compliance obligations for
ERISA group health plans and the health insurers that
administer or underwrite them.
(This
may be accomplished by rewording 45 CFR
§ 164.522(b)(2)(ii)(A) to state, "When
appropriate, information as to how payment activities,
including issuance of explanations of benefits to the
insured under a health plan, will be handled."
Another
potential solution is to allow a health plan to warn in
its notice of privacy practices that requests for
confidential communications may not prevent the insured
under a health plan from receiving other information, such
as explanations of benefits for others covered by the
insureds policy or benefits plan, that may alert the
insured that the individual requesting confidential
communications obtained health care. Yet another is to
permit a health plan to inform an individual requesting
confidential communication that the individual may have to
pay for the care to avoid the health plan providing
information to the insured through other explanations of
benefits or similar communications that may alert the
insured that the individual obtained health care in
confidence.) |
Clarification. |
|
107 |
Revise
the Procedure for Access Denial for Endangerment |
88 |
Delete
the endangerment requirement at 45 CFR §§ 164.524(a)(3),
(4), (d)(2) and leave it to the health care professionals
judgment, exercised in the best interest of the individual
or others, whether requested protected health information
should be made available to an individual or the
individuals personal representative. Continue to grant
the individual or the individuals personal
representative denied access, based on that exercise of
professional judgment, the right to have another
professional review the access denial. Allow the
explanation for the denial to be, simply,
"Information has been withheld based on the judgment
of a qualified health care professional."
(The
revised rule and procedures would thus state:
"§
164.524(a) . . .
"(3)
Reviewable grounds for denial. A covered entity may
deny an individual or an individuals personal
representative access to specific protected health
information concerning the individual if a licensed health
care professional has determined, in the exercise of
professional judgment, that providing access to that
protected health information is not in the best interest
of the individual or others. The individual or the
individuals personal representative has the right to
have such denial reviewed in accordance with the
procedures of paragraph (d)(4) of this section.
"[Delete
paragraphs (a)(3)(i)-(iii) and (a)(4) of this section.]
"(b)
Implementation specifications: requests for access and
timely action. . . .
"(2)
Timely action by the covered entity. (i) . . . the
covered entity must act on a request for access no later
than 30 days after receipt of the request as follows. . .
.
"(B)
if the covered entity denies the request, in whole or in
part, it must provide the individual with a written
denial, in accordance with paragraph (d) of this section.
. . .
"(d)
Implementation specifications: Denial of access. If
the covered entity denies access, in whole or in part, to
protected health information, the covered entity must
comply with the following requirements. . . .
"(2)
Denial. The covered entity must provide a timely,
written denial to the individual, in accordance with
paragraph (b)(2) of this section. The denial must be in
plain language and contain:
"(i)
The basis for the denial. If the denial of access is in
accordance with paragraph (a)(3) of this section, it is
sufficient to state, "Information has been withheld
based on the judgment of a qualified health care
professional."
"(ii)
If the denial is in accordance with paragraph (a)(3) of
this section, a statement of the individuals review
rights under paragraph (d)(4) of this section, including a
description of how the individual may exercise such review
rights.
"(iii)
A description of how the individual may complain to the
covered entity pursuant to the complaint procedures in §
164.530(d) or to the Secretary pursuant to the procedures
in § 160.306. The description must include the name, or
title, and telephone number of the contact person or
office designated in § 164.530(a)(1)(ii)
"(4)
Review of denial requested. If the individual or
the individuals personal representative requests review
of a denial of access under paragraph (a)(3) of this
section, the covered entity must designate a licensed
health care professional to review the decision to deny
access. This designated reviewing official must not have
been directly involved in the denial and must be qualified
by training or experience to make an informed evaluation
whether withholding the protected health information to
which access has been denied is in the best interest of
the individual or others. The covered entity must promptly
refer the request for review to such designated reviewing
official. The designated reviewing official must
determine, within a reasonable time, whether to deny or
grant the access requested based on the designated
reviewing officials professional judgment, exercised in
the best interest of the individual or others. The covered
entity must promptly provide written notice to the
individual or the individuals personal representative
of the determination of the designated reviewing official,
and take all action required by this section to carry out
the designated reviewing officials
determination.") |
Clarification. |
|
108 |
Business
Associate Contract Transition Year and Model Terms |
89 |
Allow
an additional year for covered entities to conform
pre-existing contracts with business associates to the
Privacy Rules requirements and issue the model business
associate terms suggested by the NPRM. |
Clarification. |
|
109 |
Simplify
Business Associate Contracting when a Covered Entity Is
the Business Associate |
90 |
Modify
the Privacy Rule to specify that a covered entity serving
as a business associate must comply with each provision of
45 CFR § 164.504(e)(2) applicable to that business
associate relationship. Continue to require that the
covered entity specify in writing the uses and disclosures
that the business associate covered entity is allowed to
make, as required by 45 CFR § 164.504(e)(2)(i).
(This
provision is needed because a business associate is
permitted to use and disclose the protected health
information of the covered entity it serves only as that
covered entity allows.
This
approach can be implemented as follows. Revise 45 CFR §
164.502(e)(1)(iii) to state:
"(iii)
A covered entity acting as the business associate of
another covered entity will be in noncompliance with the
standards, implementation specifications, and requirements
of this paragraph and § 164.504(e) of this subpart if the
business associate covered entity violates any of the
provisions of § 164.504(e)(2) of this subpart, including
any use or disclosure of the protected health information
of the covered entity on whose behalf the covered entity
business associate is acting that is inconsistent with the
uses and disclosures of such information specified in
writing as required by paragraph (e)(2)(i) of this section
by the covered entity on whose behalf the business
associate covered entity is acting."
Revise
45 CFR § 164.502(e)(2) to state:
"(2)
Implementation specification: satisfactory assurance.
A covered entity must document the satisfactory assurances
required by paragraph (e)(1) of this section by:
"(i)
For a business associate who is also a covered entity,
specifying in writing the permitted and required uses and
disclosures of the covered entitys protected health
information by the business associate in compliance with
§ 164.504(e)(2)(i) of this subpart.
"(ii)
For a business associate who is not a covered entity,
obtaining a written contract or other written agreement or
arrangement with the business associate that meets the
applicable requirements of § 164.504(e) of this
subpart.") |
Clarification. |
|
110 |
Clarify
that State Law Controls Parents Access to Unemancipated
Minors Protected Health Information |
91 |
Adopt
the NPRM proposal at 45 CFR §§ 160.202, 164.502(g) to
clarify that parents access to the medical information
of their unemancipated children is controlled by State
law, and when State law is silent, by the covered entitys
professional judgment. |
Clarification. |
|
111 |
Allow
a Covered Entity with Non-Covered Functions to Be a Hybrid
Entity |
92 |
Adopt
the NPRM proposal at (45 CFR § 164.504(a)) to remove
"primary" from the hybrid entity definition and
give any covered entity with non-covered functions the
option to designate itself a hybrid entity. (By adopting
this proposal, the covered entity will be required to
identify each of its operations that perform covered
functions and subject these health care components, as
well as each component that serves the health care
components in a business associate capacity, to Privacy
Rule compliance.
The
effect will be that the health care components, and the
components serving them in a business associate capacity,
may not disclose their protected health information to, or
allow their protected health information to be used by,
non-health care components unless the Privacy Rule allows
such disclosure or use. For example, a health care
component will not be allowed to disclose its protected
health information to the covered entitys human
resources personnel performing non-covered employment
functions. It also means that individually identifiable
health information held by the covered entitys
non-health care components [e.g., health
information in the human resources department is not
protected health information subject to the Privacy
Rule.]) |
Clarification. |
|
112 |
Clarify
that Employment Records Are Not Protected Health
Information |
93 |
Adopt
the NPRM proposal at 45 CFR §164.501 ("Protected
Health Information") that would exclude employment
records from the protected health information definition. |
Clarification. |
|
113 |
Clarify
that Enrollment Data May Be Disclosed to Plan Sponsors |
94 |
Adopt
the NPRM proposal at 45 CFR § 164.504(f) to explicitly
state that a health plan may disclose enrollment data to
the employer or other sponsor of the group health plan,
even if the sponsor does not qualify under the Privacy
Rule to perform plan administration functions. |
Clarification. |
|
114 |
Clarify
the Status of Re-Identification Codes |
95 |
Adopt
the NPRM proposal at 45 CFR § 164.514(b)(2)(i)(R) that
would make clear that a re-identification code or key
under 45 CFR § 164.514(c) does not have to be deleted to
de-identify data. |
Clarification. |
|
115 |
Clarify
the De-Identification Safe Harbor Knowledge Requirement |
96 |
Clarify
the de-identification safe harbor knowledge requirement 45
CFR § 164.514(b)(2) by making clear that "other
information" must be available outside the covered
entity and by clarifying the meaning of "actual
knowledge" in the corporate context.
(This
may be accomplished by revising 45 CFR
§ 164.514(b)(2)(ii) as follows:
"(ii)
The covered entity determines, after documented inquiry of
those of its components that may be reasonably expected to
know, that it has no actual knowledge that the information
could be used alone or in combination with other
information available outside of the covered entity to
identify an individual who is a subject of the
information.") |
Clarification. |
|
116 |
Adopt
Defined Schedule for Rule Amendments and Modifications |
97 |
Set
a defined schedule (45 CFR § 160.104) for issuance of
final modifications, additions, and deletions to the
privacy standards, and for compliance with those
modifications and additions as follows:
- Publish
final modifications, additions, and deletions to
privacy standards as final rules in the Federal
Register on the same, pre-set calendar date each
year (for example, December 1 or nearest business day
before that date).
- Establish
a six-month compliance date for routine modifications
and additions to privacy standards.
- Specify
a longer compliance period for major privacy standards
changes that require the industry to have very long
planning periods.
(This
recommendation assumes that the nature of modifications
will vary from year to year. In some years, changes may be
minor in nature, while in others may be far-reaching.) |
Clarification. |
|
117 |
Establish
a privacy rule Advisory Panel to Ensure Continuous
Improvement to keep The Privacy Rule Current |
98 |
Establish
a Privacy Rule advisory panel either within the National
Committee on Vital and Health Statistics or as a separate
advisory committee or task force, to concentrate on
improving the operation and consumer privacy protections
of the Privacy Rule and to advise HHS on the modification,
additions, and deletions to the Privacy Rules standards
and implementation specifications for the defined annual
Privacy Rule Modification cycle. The advisory panel or
task force should be comprised of health industry
representatives, patients, and health plan enrollees with
significant operational experience in the delivery and
financing of health care and representative of various
government agencies, including FDA, DOL, OIG, Department
of Justice, State Medicaid programs, etc. that regulate
activities affecting health care delivery or financing. |
Clarification. |
|
118 |
CMS
should eliminate the E&M Documentation Guidelines. |
99 |
CMS
should eliminate the Evaluation & Management
documentation guidelines. |
No
changes. |
|
119 |
The
D&I Subcommittee supports action taken by CMS
effective July 1, 2002 and recommends that skilled nursing
facilities certified to participate in Medicare use the
new shorter assessment form [called the Medicare Payment
Assessment Form] to update a Medicare beneficiary's
condition on days 5, 14, 30, 60 and 90 of the person's
stay in the nursing home. Further, the Subcommittee
supports using the Medicare Payment Assessment Form to
measure the quality of care and to ensure correct Medicare
payments providers. The Subcommittee believes these same
skilled nursing facilities should continue to complete the
full MDS to assess resident status on admission, annually
and upon significant change in resident status thereafter.
(Note, the requirement that the admission MDS is to be
completed no later than l4 days after the resident's
admission would continue in force.) In addition, it is
very important that CMS undertake increased efforts to
work with providers concerning the required completion
dates of each MDS assessment and establish clear and
reasonable rules on how providers can remedy instances of
legitimate, minor delays in completing an MDS assessment. |
53
+
100
|
Establish
an appeal process for default Resource Utilization Group
(RUG) payments with a specified time frame for the appeal.
Establish clear and reasonable rules concerning submission
of the MDS instrument so that providers are not penalized
with default RUG payments for legitimate, minor delays in
completing an MDS assessment.
Encourage
skilled nursing facilities (SNFs) certified to participate
in Medicare to use the new shorter assessment form (called
the Medicare Payment Assessment Form) to update a Medicare
beneficiarys condition on days 5, 14, 30, 60 and 90 of
the person's stay in the nursing home. Maintain the policy
that SNFs complete the full MDS to assess resident status
on admission, annually and upon significant change in
resident status thereafter. (Note: the requirement that
the admission MDS is to be completed no later than l4 days
after the residents admission would continue in force.) |
Consolidation
of similar
recommendations. |
|
120 |
Consider
the efficacy of making the collection of OASIS mandatory
for Medicare patients only. |
101 |
Consider
the efficacy of making the collection of OASIS mandatory
for Medicare patients only. |
No
changes. |
|
121 |
Establish
incentives to encourage state Medicaid programs to
discontinue requiring HCFA 1513, HCFA 1514, HCFA 1561,
HCFA 2572 and other forms no longer used by CMS. |
102 |
Establish
incentives to encourage State Medicaid programs to
discontinue requiring forms HCFA 1513, HCFA 1514, HCFA
1561, HCFA 2572 and other forms no longer used by CMS. |
No
changes. |
|
122 |
In
the near term: CMS
should expand the J Code system to more accurately define
package size used. If available package sizes are 100 mg,
200 mg, and 1 gram, have separate codes for each of those
with corresponding reimbursements. |
103 |
Expand
the J Code system to more accurately define the package
size used. If available package sizes are 100 mg, 200 mg,
and 1 gram, have separate codes for each of those sizes,
with corresponding reimbursements. |
Clarification. |
|
123 |
In
the near term: CMS
should further clarify the HIPAA final transaction rules
to allow providers to make changes in the event the NDC
system is going to remain a part of the initial HIPAA
transactions codes implementation. |
104 |
Further
clarify the HIPAA final transaction rules to allow
providers to make changes in the event the National Drug
Code (NDC) system is going to remain a part of the initial
HIPAA transactions codes implementation. |
Clarification. |
|
124 |
In
the near term: CMS
should clearly define covered products instead of broadly
defining what may qualify as self-administered. |
105 |
Clearly
define covered drug products instead of broadly defining
what may qualify as self-administered. |
Clarification. |
|
125 |
In
the near term: CMS
should allow for patient specific modifiers that may move
drugs into a covered category for patients with limited
mobility and/or capability to understand therapeutic
schedules. |
106 |
Use
patient-specific modifiers that may move drugs into a
covered category for patients with limited mobility and/or
capability to understand therapeutic schedules. |
Clarification. |
|
126 |
In
the near term: CMS
should move toward a coding system that is standard,
updates electronically, and specifically states the
product administered. Currently the only such coding
system that exists is the NDC coding system. |
107 |
Implement
a drug coding system that is standard, updates
electronically, and specifically states the product
administered. (Currently, the only such coding system that
exists is the NDC coding system.) |
Clarification. |
|
127 |
In
the short term: CMS
should follow GAOs recommendation that regarding the
accuracy and effectiveness of MDS data that CMS NOT
establish its own separate review program, distinct from
state efforts, to ensure the accuracy of MDS data for
payment purposes. |
108 |
Follow
the GAOs February 2002 recommendation that CMS NOT
establish its own separate review program, distinct from
State efforts, to ensure the accuracy of MDS data for
payment purposes. Reorient CMS proposed MDS accuracy
program and confine its monitoring activities to
determining the adequacy of each States efforts to
ensure MDS accuracy and providing guidance and technical
assistance to individual States, as needed. |
Consolidation
of similar
recommendations. |
|
128 |
CMS
should reorient its proposed MDS accuracy program and
confine its monitoring activities to determining the
adequacy of each states efforts to ensure MDS accuracy
and providing guidance and technical assistance to
individual states as needed. |
108 |
Follow
the GAOs February 2002 recommendation that CMS NOT
establish its own separate review program, distinct from
State efforts, to ensure the accuracy of MDS data for
payment purposes. Reorient CMS proposed MDS accuracy
program and confine its monitoring activities to
determining the adequacy of each States efforts to
ensure MDS accuracy and providing guidance and technical
assistance to individual States, as needed. |
Consolidation
of similar
recommendations. |
|
129 |
In
the short term,
CMS should establish a customer satisfaction survey
process to be conducted by an organization independent of
CMS and its contractors. The process should include
periodic (e.g., quarterly or semi-annual) survey events
along with a continuous customer feedback process. The
process should include different approaches for
beneficiaries, physicians, providers and suppliers.
Publish customer satisfaction survey results of each
contractor in the media and on the CMS and Medicare.gov
websites.
|
109 |
Improve
CMS oversight of contractor customer performance by
establishing a customer satisfaction survey process to be
conducted by an organization independent of CMS and its
contractors.
- Include
periodic (e.g., quarterly or semi-annual) survey
events along with a continuous customer feedback
process.
- Include
different approaches for beneficiaries, physicians,
providers, and suppliers. Include different
approaches for beneficiaries, physicians, providers
and suppliers.
- Publish
customer satisfaction survey results of each
contractor in the media and on the CMS and
Medicare.gov websites.
- Include
the results in the contractor performance scores.
Use these results in establishing the bidding
schedule and as a major consideration in contract
awards.
|
Consolidation
of similar
recommendations. |
|
130 |
In
the near term,
CMS should include the customer satisfaction survey
process in the criteria established annually for carriers
and fiscal intermediaries, starting with Federal fiscal
year 2004. The contractor performance scores should
include the results of the customer satisfaction survey
results. These results would be used in establishing the
bidding schedule and be a major consideration in contract
awards. |
109 |
Improve
CMS oversight of contractor customer performance by
establishing a customer satisfaction survey process to be
conducted by an organization independent of CMS and its
contractors.
- Include
periodic (e.g., quarterly or semi-annual) survey
events along with a continuous customer feedback
process.
- Include
different approaches for beneficiaries, physicians,
providers, and suppliers. Include different
approaches for beneficiaries, physicians, providers
and suppliers.
- Publish
customer satisfaction survey results of each
contractor in the media and on the CMS and
Medicare.gov websites.
- Include
the results in the contractor performance scores.
Use these results in establishing the bidding
schedule and as a major consideration in contract
awards.
|
Consolidation
of similar
recommendations. |
|
131 |
In
the short term,
HHS should consolidate existing definitions of rural into
one communicable definition. Currently rural can mean one
thing for a hospital and another for a rural health
clinic. |
110 |
Consolidate
existing definitions of "rural" into one
communicable definition. (Currently "rural" can
mean one thing for a hospital and another for a rural
health clinic.) |
Clarification. |
|
132 |
In
the short term,
HHS should, for the purposes of rule making and rate
setting, disaggregate data describing rural healthcare
delivery from data describing urban healthcare delivery. |
111 |
Disaggregate
data describing rural health care delivery from data
describing urban health care delivery to ensure accurate
representation of resources and expenses for the purposes
of rule-making and rate-setting. |
Clarification. |
|
133 |
In
the short term, CMS
should eliminate the ceiling regarding the maximum number
of surgeries a rural hospital can perform in order to bill
Part A for CRNA services instead of Part B. This will
eliminate the burden of having to get Part B provider
numbers for rural CRNAs. |
112 |
Eliminate
the ceiling regarding the maximum number of surgeries a
rural hospital can perform in order to bill Part A for
Certified Registered Nurse Anesthetist (CRNA) services
instead of Part B, to eliminate the burden of having to
get Part B provider numbers for rural CRNAs. |
Clarification. |
|
134 |
In
the near term, CMS
should establish a Part A fee schedule for CRNA services.
This schedule could be used to reimburse rural hospitals
in lieu of the pass-through cost of CRNA services. |
113 |
Establish
a Part A fee schedule for CRNA services. (This schedule
could be used to reimburse rural hospitals in lieu of the
pass-through cost of CRNA services.) |
Clarification. |
|
135 |
In
the short term, CMS
should allow hospitals, SNFs and other affected entities
to file an annual, renewable three-year geographic
reclassification application. CMS should consult with OGC
and industry legal experts to determine if BIPA does
indeed permit the filing of renewable, three-year
geographic reclassification applications. If it is
determined that three-year renewable geographic
reclassification applications are permitted by statute,
the first renewable application should be accepted by
September 1, 2003. |
114 |
Allow
hospitals, skilled nursing facilities, and other affected
entities to file an annual, renewable, three-year,
geographic, reclassification application. Consult with the
Office of General Counsel and industry legal experts to
determine if the Medicare, Medicaid and SCHIP Benefits
Improvement and Protection Act of 2000 does indeed permit
the filing of renewable, three-year, geographic,
reclassification applications. Accept the first renewable
application by September 1, 2003, if it is determined that
three-year, renewable, geographic, reclassification
applications are permitted by statute. |
Clarification. |
|
136 |
In
the near term,
CMS should address rural workforce issues, including i.)
consideration of the continuance of hold harmless
provisions under the Prospective Payment System for
ambulatory services, ii.) recognition of advance
Registered Nurse Practitioners as providers of services,
iii.) retaining the states statutory flexibility
regarding use of Certified Registered Nurse Anesthetists,
iv.) recognition of need for educational support for
preparation of rural healthcare providers, and v.)
recognition of the impact of tighter immigration
regulations on access to foreign physicians and immigrant
entry level caregivers and the need to work with rural
healthcare providers to resolve these issues. |
115 |
Address
rural workforce issues.
- Consider
continuance of "hold harmless" provisions
under the prospective payment system for ambulatory
services.
- Recognize
Advanced Registered Nurse Practitioners as providers
of services.
- Retain
the States statutory flexibility regarding use of
CRNAs.
- Recognize
the need for educational support for preparation of
rural health care providers.
- Recognize
the impact of tighter immigration regulations on
access to foreign physicians and immigrant,
entry-level caregivers and the need to work with rural
health care providers to resolve these issues.
|
Clarification. |
|
137 |
In
the near term,
CMS should develop a pilot survey process for Critical
Access Hospitals which would entail a single survey to
examine all aspects of the hospitals operations and
allied health services. |
116 |
Develop
a pilot certification survey process for Critical Access
Hospitals (CAHs) that would entail a single survey to
examine all aspects of a hospitals operations and
allied health services. |
Clarification. |
|
138 |
In
the long term, based on the results of the single
survey process for Critical Access Hospitals, CMS should
develop a single survey process for all providers of rural
health services, including hospitals, skilled nursing
facilities, home health agencies, rural health clinics,
community health centers, etc. |
117 |
Develop
a legislative proposal with Congress for a single
certification survey process for all providers of rural
health services, including hospitals, skilled nursing
facilities, home health agencies, rural health clinics,
community health centers, etc., based on the results of
the single survey process for CAHs. |
Clarification. |
|
139 |
In
the long term,
the National Advisory Committee on Rural Health, the
advisory body to the Secretary, should establish a process
whereby HHS works with knowledgeable representatives of
rural America to analyze the impact of a new statute or
regulation on the rural delivery system before it is
enacted. The full resources of HRSA and CMS and related
HHS program staff should be brought to bear in conducting
such analysis.
|
118 |
Urge
the National Advisory Committee on Rural Health to advise
HHS on a process whereby HHS works with knowledgeable
representatives of rural America to analyze the impact of
a new statute or regulation on the rural delivery system
before it is enacted. |
Clarification. |
|
140 |
In
the long term,
CMS and Congress should address the current fragmented
approach to rural Medicare payment policy (e.g., Sole
Community Hospitals, Critical Access Hospitals, bonus
payments for rural primary care physicians, etc.) with an
eye towards replacing this fragmented approach with a
system that recognizes the unique operating
characteristics of rural providers in all settings.
|
119 |
Develop
a legislative proposal with Congress to address the
current fragmented approach to rural Medicare payment
policy (e.g., Sole Community Hospitals, CAHs, bonus
payments for rural primary care physicians, etc.) with an
eye toward replacing this fragmented approach with a
system that recognizes the unique operating
characteristics of rural providers in all settings. |
Clarification. |
|
141
|
Application
of the Home Health CoPs to all patients served by a
Medicare Certified Home Health provider places
inappropriate constraints on home health agencies
ability to meet patient care needs and to adapt to the
rapidly changing marketplace. |
120 |
Limit
the application of the Medicares Home Health COPs
based on certain payers (e.g., apply to Medicare patients
only) and service criteria (e.g., the criteria would
exclude services that do not meet the definition of
"home health services" in the Social Security
Act, Section 1861, such as those that are custodial in
nature or considered personal care and may not result from
a signed physician order). |
Consolidation
of similar
recommendations. |
|
142
|
Limit
the application of the CoPs based on certain patient and
service criteria, i.e. services requiring a physician
established plan of care at the discretion of the
Secretary. |
120 |
Limit
the application of the Medicares Home Health COPs
based on certain payers (e.g., apply to Medicare patients
only) and service criteria (e.g., the criteria would
exclude services that do not meet the definition of
"home health services" in the Social Security
Act, Section 1861, such as those that are custodial in
nature or considered personal care and may not result from
a signed physician order). |
Consolidation
of similar
recommendations. |
|
143
|
Revise
the Interpretive Guidance on Separate Entities to give all
agencies more flexibility in managing their business. |
121 |
Revise
the CMS Interpretive Guidance on Medicares HHA COPs
(the State Operations Manual Provider Certification,
Section 2183, "Separate Entities") to give all
agencies more flexibility in managing their operations,
such as the requirements for separate policies and
procedures for admission, separate clinical records,
separate licensure (unless required by the State),
separate timesheets and personnel records, and separate
budgets. (The Interpretive Guidance contains directions to
State surveyors for recognizing and qualifying an
organization as a "separate entity" so that they
can properly certify that an HHA meets Medicares COPs.
The surveyors would not apply the COP requirements to the
patients served by the "separate entity.") |
Clarification. |
|
144 |
Immediate:
For
those M+COs that wish to have their routine periodic and
scheduled CMS reviews take place at the same time,
establish a coordinated annual schedule for on-site
audits/reviews to ensure that oversight activities are
coordinated to the greatest extent possible and to avoid
requiring M+COs to prepare for multiple audits.
Unannounced reviews or visits would not be affected by
this provision. |
122 |
Establish
a coordinated annual schedule for CMS-related on-site
audits/reviews of M+COs to ensure that oversight
activities are coordinated to the greatest extent possible
for those M+COs that wish to have their routine periodic
and scheduled reviews take place at the same time.
(Unannounced reviews or visits would not be affected by
this provision.) |
Clarification. |
|
145 |
Immediate:
CMS
should establish a process for making timely changes to
the standardized SB language so that beneficiaries can
rely on it to make informed choices. Permit limited
variations from the standardized language when they are
needed for accuracy and are made in a way that does not
undermine the utility of the SB for plan-to-plan
comparison.
|
123 |
Establish
a process for making timely changes to the standardized
Summary of Benefits (SB) language so that beneficiaries
can rely on it to make informed choices. Permit limited
variations from the standardized language when they are
needed for accuracy and are made in a way that does not
undermine the utility of the SB for plan-to-plan
comparison. |
Clarification. |
|
146 |
Immediate:
Examine plan termination notices, Social Security
Administration disenrollment forms and Medicare & You
Handbook information to ensure that verbiage does not
stimulate an unintended disenrollment that triggers the
"lock-in." |
124 |
Examine
Social Security Administration (SSA) disenrollment forms
and Medicare & You Handbook information to ensure that
the text does not stimulate an unintended disenrollment
that triggers the "lock-in." |
Clarification. |
|
147 |
Immediate:
Explore the feasibility of permitting members of employer
group health plans or individuals who have access to a
personal computer to enroll and disenroll electronically
and begin a pilot to test said procedures, respecting
security, privacy, and other related matters. |
125 |
Explore
the feasibility of permitting members of employer group
health plans or individuals who have access to a personal
computer to enroll and disenroll electronically from M+C
plans, and begin a pilot to test said procedures,
respecting security, privacy, and other related matters. |
Clarification. |
|
148 |
Immediate:
Clarify the policy that in the event that a M+CO becomes
insolvent, and can no longer pay the provider network, the
beneficiary is still responsible for any pre-determined
obligations (e.g., co-pays, etc.) but should not be
balance-billed for any unpaid services beyond that
obligation. |
126 |
Clarify
the policy that in the event that a Medicare+Choice
Organization (M+CO) becomes insolvent, and can no longer
pay the provider network, the beneficiary is still
responsible for any pre-determined obligations (e.g.,
co-pays, etc.) but should not be balance-billed for any
unpaid services beyond that obligation. |
Clarification. |
|
149
|
CMS
should consider making the changes necessary to implement
the M+C enrollee health risk adjustment methodology with
the M+C program on a budget neutral basis, without
increasing or decreasing total funding for the M+C program
as intended by Congress. |
127 |
Make
the changes necessary to implement the M+C enrollee health
risk adjustment methodology with the M+C program on a
budget-neutral basis, without increasing or decreasing
total funding for the M+C program, as intended by
Congress. |
Clarification. |
|
150 |
Intermediate:
For the next publication of Medicare & You, reduce the
number of pages of referring telephone numbers in the
Medicare & You Handbook focusing on 1-800 MEDICARE
so as to avoid overwhelming readers. Further, CMS
should work with consumer testing groups to determine
the best content and organization of the Medicare &
You handbook, if not currently doing so. Ensure that all
transferred callers from 1-800-MEDICARE are connected
expeditiously with a "live" person at the
connected number. |
128 |
Reduce
the number of pages of referring telephone numbers in the
next publication of the Medicare & You Handbook by
focusing on 1-800 MEDICARE so as to avoid overwhelming
readers. Ensure that all transferred callers from
1-800-MEDICARE are connected expeditiously with a
"live" person at the connected number.
Furthermore, work with consumer testing groups to
determine the best content and organization of the
Medicare & You Handbook, if not currently doing so. |
Clarification. |
|
151 |
Improve
communication between CMS and States, including the
consistency of policy interpretations across CMS Regional
Offices |
129 |
Improve
communication between CMS and States, including the
clarity and consistency of Medicaid policy interpretations
across CMS by conducting centralized training for all RO
and CO staff to ensure uniformity. |
Consolidation
of similar
recommendations. |
|
152 |
Proposal:
Establish
a process to improve communication between CMS and states
resulting in clear and consistent CMS policies. |
129 |
Improve
communication between CMS and States, including the
clarity and consistency of Medicaid policy interpretations
across CMS by conducting centralized training for all RO
and CO staff to ensure uniformity. |
Consolidation
of similar
recommendations. |
|
153 |
Immediate:
Conduct centralized training for all CMS Regional and
Central Office staff to ensure uniformity.
|
129 |
Improve
communication between CMS and States, including the
clarity and consistency of Medicaid policy interpretations
across CMS by conducting centralized training for all RO
and CO staff to ensure uniformity. |
Consolidation
of similar
recommendations. |
|
154 |
Immediate:
Within statutory parameters, CMS should seek
administrative solutions to reduce TMA reporting from
quarterly to annually, until such time as the statutory
parameters are addressed. Currently, families receiving
transitional Medicaid coverage must report requested
information quarterly, and they lose eligibility if the
information is not submitted.
|
130 |
Seek
administrative solutions within statutory parameters to
reduce Transitional Medical Assistance (TMA) reporting
requirements from quarterly to annually, until such
time as the statutory parameters are addressed.
(Currently, families receiving transitional Medicaid
coverage must report requested information quarterly, and
they lose eligibility if the information is not
submitted.) |
Clarification. |
|
155 |
Define
limits of EMTALA by clarifying that EMTALA requirements
end when a qualified medical person has made a decision:
(a) that no emergency exists; (b) that an emergency
exists and the patient is stabilized; (c) that an
emergency exists which requires transfer to another
facility where the EMTALA obligation rests with the
transferring hospital until arrival at the receiving
hospital; or (d) that an emergency exists and an unstable
patient (who) is admitted to the hospital has been
stabilized. |
131 |
Define
limits of EMTALA by clarifying that EMTALA requirements
end when a qualified medical person has made a decision:
- that
no emergency exists;
- that
an emergency exists and the patient is stabilized;
- that
an emergency exists which requires transfer to another
facility where the EMTALA obligation rests with the
transferring hospital until arrival at the receiving
hospital; or
- that
an emergency exists and an unstable patient (who) is
admitted to the hospital has been stabilized.
|
No
changes. |
|
156 |
Create
an Emergency Services Cooperative Project that would
follow the format of the Diabetes and Cardiovascular
Quality Improvement Project. This should be developed and
implemented with a scientific and technical advisory board
of emergency physicians, hospitals, first responders,
emergency transportation specialists, consumers and other
advisers. This group should also guide development of
future regulations that would assure availability of
effective emergency services in all parts of the country.
This group would include on-call physicians (medical and
surgical specialists who provide care for emergencies) as
part of the scientific and technical advisory board for
the Emergency Services Cooperative Project. In the future
this group should take on thorny issues such as
reimbursement mechanisms for EMTALA related services when
patients don't have insurance; foster appropriate
consultation with and involvement by PROs; appropriate
due process for hospitals and health care professionals
before CMS can issue a public notice of termination and
proceed with a termination letter. |
132 |
Create
an Emergency Services Cooperative Project that would
follow the format of the Diabetes and Cardiovascular
Quality Improvement Project. This should be developed and
implemented with a scientific and technical advisory board
of emergency physicians, hospitals, first responders,
emergency transportation specialists, consumers and other
advisers. This group should also guide development of
future regulations that would assure availability of
effective emergency services in all parts of the country.
This group would include on-call physicians (medical and
surgical specialists who provide care for emergencies) as
part of the scientific and technical advisory board for
the Emergency Services Cooperative Project. In the future,
this group should take on thorny issues such as
reimbursement mechanisms for EMTALA-related services when
patients dont have insurance; foster appropriate
consultation with and involvement by QIOs; appropriate due
process for hospitals and health care professionals before
CMS can issue a public notice of termination and proceed
with a termination letter. |
Clarification.
Consolidation
of similar
recommendations. |
|
157 |
Clarify
"prudent layperson" concept as follows: The term
"prudent" has a commonly understood meaning, and
we would refer the reader to the general dictionary
definition to this term. A "layperson" refers to
an individual with an average knowledge of health and
medicine, as the definition of "emergency medical
condition" states. |
133 |
Clarify
the "prudent layperson" concept as per the
EMTALA NPRM as follows:
- The
term "prudent" has a commonly understood
meaning, and we would refer the reader to the general
dictionary definition to this term.
- A
"layperson" refers to an individual with an
average knowledge of health and medicine, as the
definition of "emergency medical condition"
states.
|
Clarification. |
|
158 |
Expand
contractual relationships to community-based
organizations, for example organizations that REACH
currently works with (in addition to SHIP programs) for
translation services, information/education services, and
outreach to individuals with limited English proficiency,
persons with disabilities, and beneficiaries in
rural areas. Consider the RFP process as a means of
establishing these relationships. |
134 |
Expand
contractual relationships to community-based organizations
(in addition to SHIP programs, organizations with whom
Regional Education About Choices in Health (REACH)
currently works) for translation services,
information/education services, and outreach to
individuals with Limited English proficiency (LEP),
persons with disabilities, and beneficiaries in rural
areas. Consider the Request for Proposal (RFP) process as
a means of establishing these relationships. |
Clarification. |
|
159 |
Improve
the accuracy and effectiveness of beneficiary counseling
and assistance programs (e.g. SHIPs) with consistent
training programs and fully integrate them into regional
and local outreach activities. Training programs should be
based on national standards with implementation tailored
to community needs. |
135 |
Improve
the accuracy and effectiveness of beneficiary counseling
and assistance programs (e.g., State Health Insurance
Assistance Program [SHIPs]) by fully integrating them into
regional and local outreach activities and by providing
consistent training to these programs. Training programs
should be based on national standards with implementation
tailored to community needs. |
Clarification. |
|
160 |
Encourage
and/or incentivize State Medicaid plans to provide
reimbursement to community agencies providing education
and outreach activities. |
136
|
Encourage
and/or incentivize State Medicaid plans to provide
reimbursement to community agencies providing education
and outreach activities. |
No
changes. |
|
161 |
On
an ongoing basis, simplify beneficiary forms, use plain
language in forms, and use peer focus groups to rigorously
re-test the clarity of communication. Test recommendations
to target literacy at the 4th grade level. |
137 |
Simplify
beneficiary forms, use plain language in forms, and use
peer focus groups to rigorously re-test the clarity of
communication on an ongoing basis. Test the effectiveness
of targeting communications literacy to the fourth grade
level. (Currently, Medicare policy targets a sixth grade
literacy level.) |
Clarification. |
|
162 |
Simplify
the Medicare application using plain language, and
encourage states to develop their own simplified,
universal application for Medicaid and other services. |
138 |
Simplify
the Medicare application using plain language and
encourage States to develop their own simplified,
universal application for Medicaid and other services. |
No
changes. |
|
163 |
Continually
evaluate and improve education and communication
strategies to ensure that beneficiaries find materials
easy to access and understand so they can make informed
decisions about their rights, options and obligations. |
139 |
Continually
evaluate and improve education and communication
strategies to ensure that beneficiaries find materials
easy to access and understand so they can make informed
decisions about their rights, options, and obligations. |
No
changes. |
|
164 |
Implement
education and training of intermediaries and carrier call
centers regarding the rules for disclosing
beneficiary-specific information to others (Transmittal
AB-01-87). Publish these guidelines in plain language for
the general public on the medicare.gov website. |
140 |
Implement
education and training of fiscal intermediaries (FIs) and
carrier call centers regarding the rules for disclosing
beneficiary-specific information to others (as covered in
Transmittal AB-01-87). Publish these guidelines in plain
language for the general public on the Medicare.gov
website. |
Clarification. |
|
165 |
Enhance
provider education efforts by ensuring that comprehensive
communication plans are coordinated among HHS, CMS, and
its contractors, to aggressively reach the various
provider communities (including physician, nurses and
other provider groups). These plans should consider the
most effective use of local and national educational
campaigns and advisory committees and be responsive to the
needs of all provider groups. |
141 |
Enhance
provider education efforts by ensuring that comprehensive
communication plans are coordinated among HHS, CMS, and
its contractors to aggressively reach the various provider
communities (including physician, nurses, and other
provider groups.) These communication plans should include
how to use local and national educational campaigns and
advisory committees in the most effective way possible and
be responsive to the needs of all provider groups. |
Clarification. |
|
166 |
On
an ongoing basis, simplify communications to providers,
using plain language, and accurate and understandable
formats easy to use by the provider groups. Target
communications appropriately and include an executive
summary of key points in all bulletins and updates. |
142 |
Simplify
communications to providers using plain language and using
formats that are accurate and easy to use by the provider
groups on an ongoing basis. Target communications
appropriately and include an executive summary of key
points in all bulletins, updates, and instructions. (For
example, develop a simplified "executive
summary" set of instructions for physicians and staff
to use the new advanced beneficiary notices.) |
Consolidation
of similar
recommendations. |
|
167 |
Maximize
the use of technology-based educational initiatives (for
example, MedLearn), targeting content to the different
types of providers, including non-physician providers, and
suppliers of care. |
143 |
Maximize
the use of technology-based educational initiatives (for
example, MedLearn), targeting content to the different
types of providers, including non-physician providers and
suppliers of care. |
No
changes. |
|
168 |
Proactively,
consult with advisory panels or groups of providers to
provide real-time review of new communication strategies
or materials. Use focus groups of the intended audiences
to rigorously test clarity of communications and
educational programs. |
144 |
Consult
with advisory panels or groups of providers to provide
real-time review of new communication strategies or
materials in a proactive manner. Use focus groups of the
intended audiences to rigorously test clarity of
communications and educational programs. |
Clarification. |
|
169 |
Require
carriers to give answers based on regulations and CMS
guidelines and not on their own interpretations. Providers
should not be subject to penalties or denial of payment
for errors due to incorrect advice from carriers or fiscal
intermediaries. |
145 |
Ensure
that interpretations of regulations are consistent within
all manuals and that every program memorandum clearly
describes the modifications or introductions of
regulations. Require carriers to give answers based on
regulations and CMS guidelines and not on their own
interpretations. Eliminate penalties or denial of payment
to providers for errors due to incorrect advice from
carriers or FIs. |
Consolidation
of similar
recommendations. |
|
170 |
Continue
to develop a central repository of information (ie.
MedLearn) so that general information for providers, and
rules/regulations are disseminated from CMS and not
individual carriers, while being cognizant of regional
sensitivities. |
146 |
Continuously
improve the development of a central repository of
information (i.e., MedLearn) so that general information
for providers and rules/regulations are disseminated from
CMS and not individual carriers, while being cognizant of
regional sensitivities. |
Clarification. |
|
171 |
Survey
and publicize results of carrier best practices relating
to provider education and communication. |
147 |
Survey
FIs and carriers and publicize the results of what are
discovered to be the contractors "best
practices" relating to provider education and
communication. |
Clarification. |
|
172 |
Compile
and publish a yearly report of provider best practices to
serve as guidance for compliance. Distribute and publicize
best practices of rural health programs, clinics or
providers widely among the rural health care community
using national and regional outreach. CMS teleconferences
and listening sessions should periodically focus on
sharing best practices addressing problematic rules and
regulations. |
148 |
Compile,
publish, and distribute widely a yearly report of provider
best practices to serve as guidance for compliance. Give
specific emphasis to best practices of rural health
programs, clinics or providers among the rural health care
community using most effective national and regional
outreach methods. Periodically focus CMS teleconferences
and listening sessions with various communities of
interest on sharing best practices addressing problematic
rules and regulations. |
Clarification. |
|
173 |
Ensure
that carriers are meeting with the medical community and
stakeholders when systemic problems are identified, and
that such meetings be used as a basis for provider
education programs. |
149 |
Ensure
that carriers are meeting with the medical community and
stakeholders when systemic problems are identified and
that such meetings are used as a basis for provider
education programs. |
No
changes. |
|
174 |
Require
carriers/ FI to give specific reasons for denial of claims
in plain language, explain what additional information is
needed and reference the specific regulation, policy
memorandum or LMRP upon which denial was based. |
150 |
Require
carriers/FIs to report the specific reasons for their
denial of claims in plain language, explain what
additional information is needed, and reference the
specific regulation, policy memorandum or Local Medical
Review Policies (LMRP), upon which the denial was based.
Appeals to decisions should be reviewed and responded to
within 45 days. |
Consolidation
of similar
recommendations. |
|
175 |
Work
with the hospice and nursing home communities so that both
better understand how Medicare beneficiaries living in
nursing facilities can access hospice services. |
151 |
Conduct
outreach with the hospice and nursing home industries so
that both better understand how Medicare beneficiaries
living in nursing facilities can access hospice services. |
Clarification. |
|
176 |
Develop
educational initiatives to address the discrepancies and
confusion in the home care and long-term care communities,
for example on Oasis, MDS, and homebound status. |
152
|
Develop
and continuously improve provider educational initiatives
programs to address systemic misperceptions and confusion
that exist in the home care and long-term care industry
about CMS policies and requirements (e.g., on OASIS,
MDS, and "homebound status.") |
Clarification. |
|
177 |
Involve
all stakeholders early in the course of policy development
to ensure that subsequent regulations and interpretations
will be understandable and workable in diverse settings. |
153 |
Involve
all stakeholders early in the course of policy development
to ensure that subsequent regulations and interpretations
will be understandable and workable in diverse settings. |
No
changes. |
|
178 |
Reevaluate
current weights given to performance standards for
provider education and customer service to providers. Use
the evaluation data as part of a report card. |
109 |
Improve
CMS oversight of contractor customer performance by
establishing a customer satisfaction survey process to be
conducted by an organization independent of CMS and its
contractors.
- Include
periodic (e.g., quarterly or semi-annual) survey
events along with a continuous customer feedback
process.
- Include
different approaches for beneficiaries, physicians,
providers, and suppliers. Include different
approaches for beneficiaries, physicians, providers
and suppliers.
- Publish
customer satisfaction survey results of each
contractor in the media and on the CMS and
Medicare.gov websites.
- Include
the results in the contractor performance scores.
Use these results in establishing the bidding
schedule and as a major consideration in contract
awards.
|
Consolidation
of similar
recommendations. |
|
179 |
Assess
the effectiveness and publish results of educational
evaluations, including the new Resident and New Physician
Training Manual. |
154 |
Assess
the effectiveness and publish results of the evaluations
of provider educational materials, including but not
limited to the new Resident and New Physician Training
Manual. |
Clarification. |
|
180 |
Establish
a workgroup to evaluate the impact and feasibility of
standardized medical review policies. |
155 |
Establish
a workgroup to evaluate the impact and feasibility of
standardized medical review policies. |
No
changes. |
|
181 |
Continue
to streamline the frequency of communication output,
particularly rules and regulations, ultimately moving to
an annual publication of CMS regulations (Medicare
Provider Manual) with quarterly updates for new
technologies, treatments and coverage decisions. Make this
available online and in easy to update paper format. |
156 |
Streamline
the frequency of communication output, particularly rules
and regulations, by ultimately moving to an annual
publication of CMS regulations (Medicare Provider Manual)
with quarterly updates for new technologies, treatments,
and coverage decisions. Make this available online and in
easy-to-update paper format. |
Clarification. |
|
182 |
Provide
assistance for small rural communities to learn and apply
for the competitive requests for proposals. Provide
account service representatives to rural health
clinics/providers. |
157 |
Provide
assistance for small rural communities to learn and apply
for competitive requests for proposals. Provide account
service representatives to rural health clinics/providers. |
No
changes. |
|
183 |
Market/publicize
regional technical assistance workshops and
train-the-trainer programs to assist rural health care
providers and programs in each state. |
158 |
Market/publicize
regional technical assistance workshops and
train-the-trainer programs to assist rural health care
providers and programs in each State. |
No
changes. |
|
184 |
Enhance
outreach efforts to educate rural health clinics and
providers about the specific programs that focus on rural
communities. Develop a rural health care section on the
website for providers that will include all appropriate
resources, technical and financial assistance programs,
and best practice models for rural communities. |
159 |
Intensify
outreach efforts to educate rural health clinics and
providers about the specific programs that focus on rural
communities and invest in rural "best
practices." Develop a rural health care section on
relevant HHS websites for providers that will include all
appropriate resources, technical and financial assistance
programs, and best practice models for rural communities. |
Clarification. |
|
185 |
Explore
means of investing in rural best practices and develop
models to educate people from rural communities as health
care practitioners with incentives to remain in their own
community. |
160 |
Develop
models to educate people from rural communities to become
health care practitioners and provide incentives for these
practitioners to remain in their own rural communities. |
Clarification. |
|
186 |
Develop
a simplified "executive summary" instruction set
for physicians and staff. |
142 |
Simplify
communications to providers using plain language and using
formats that are accurate and easy to use by the provider
groups on an ongoing basis. Target communications
appropriately and include an executive summary of key
points in all bulletins, updates, and instructions. (For
example, develop a simplified "executive
summary" set of instructions for physicians and staff
to use the new advanced beneficiary notices.) |
Consolidation
of similar
recommendations. |
|
187 |
Convene
focus groups to continue to improve the clarity the ABN
for both beneficiaries and providers. Emphasis should
include the minimizing of any question of medical
judgment. |
161 |
Convene
focus groups to continue to improve the clarity of the
advance beneficiary notice (ABN) for both beneficiaries
and providers. Emphasis should include the minimizing of
any question of medical judgment. |
Clarification. |
|
188 |
Continue
to improve the LMRP web site so it is more user-friendly. |
162 |
Continue
to improve the LMRP web site so it is more user-friendly. |
No
changes. |
|
189 |
Waive
the requirements for ABNs and the associated denial of
coverage in emergency room and other urgent care settings. |
20 |
Resolve
the Medicare coverage issues underlying the need for
advanced beneficiary notices (ABNs) to have
to be provided in the emergency room. Consider waiving the
requirement for ABNs and the associated denial of coverage
in emergency room and other urgent care settings. |
Consolidation
of similar
recommendations. |
|
190 |
Evaluate
the potential for an automated system that could, using
computer edits similar to those in current claims
processing systems, efficiently determine whether most
claims will or will not be covered. This should include a
review of such systems used by private insurance companies
for pre-authorization. |
163 |
Evaluate
the potential for CMS to develop an automated prior
authorization system that could, using computer edits
similar to those used by insurance companies in their
current claims processing systems, efficiently determine
whether most claims will or will not be covered; develop a
pilot program to test use of such a system in Medicare;
determine the extent to which additional resources beyond
computer edits may be needed for accurate prior coverage
determinations; implement and evaluate the pilot program,
focusing on the benefits perceived by beneficiaries and
providers and the potential to minimize costs to the
program; and based upon lessons learned in the pilot
program, develop and implement a full national Medicare
system to furnish prior coverage determinations to both
beneficiaries and providers. |
Consolidation
of similar
recommendations. |
|
191 |
Develop
a pilot program to test use of such a system in Medicare
and determine the extent to which additional resources
beyond computer edits may be needed for accurate prior
coverage determinations. |
163 |
Evaluate
the potential for CMS to develop an automated prior
authorization system that could, using computer edits
similar to those used by insurance companies in their
current claims processing systems, efficiently determine
whether most claims will or will not be covered; develop a
pilot program to test use of such a system in Medicare;
determine the extent to which additional resources beyond
computer edits may be needed for accurate prior coverage
determinations; implement and evaluate the pilot program,
focusing on the benefits perceived by beneficiaries and
providers and the potential to minimize costs to the
program; and based upon lessons learned in the pilot
program, develop and implement a full national Medicare
system to furnish prior coverage determinations to both
beneficiaries and providers. |
Consolidation
of similar
recommendations. |
|
192 |
Implement
and evaluate the pilot program, focusing on the benefits
perceived by beneficiaries and providers and the potential
to minimize costs to the program. |
163 |
Evaluate
the potential for CMS to develop an automated prior
authorization system that could, using computer edits
similar to those used by insurance companies in their
current claims processing systems, efficiently determine
whether most claims will or will not be covered; develop a
pilot program to test use of such a system in Medicare;
determine the extent to which additional resources beyond
computer edits may be needed for accurate prior coverage
determinations; implement and evaluate the pilot program,
focusing on the benefits perceived by beneficiaries and
providers and the potential to minimize costs to the
program; and based upon lessons learned in the pilot
program, develop and implement a full national Medicare
system to furnish prior coverage determinations to both
beneficiaries and providers. |
Consolidation
of similar
recommendations. |
|
193 |
Based
upon lessons learned in the pilot program, develop and
implement a full national Medicare system to furnish prior
coverage determinations to both beneficiaries and
providers. |
163 |
Evaluate
the potential for CMS to develop an automated prior
authorization system that could, using computer edits
similar to those used by insurance companies in their
current claims processing systems, efficiently determine
whether most claims will or will not be covered; develop a
pilot program to test use of such a system in Medicare;
determine the extent to which additional resources beyond
computer edits may be needed for accurate prior coverage
determinations; implement and evaluate the pilot program,
focusing on the benefits perceived by beneficiaries and
providers and the potential to minimize costs to the
program; and based upon lessons learned in the pilot
program, develop and implement a full national Medicare
system to furnish prior coverage determinations to both
beneficiaries and providers. |
Consolidation
of similar
recommendations. |
|
194 |
Exclude
from Medicare local medical review policies (LMRP) those
diagnostic services ordered by a qualified medical
professional when medically necessary pursuant to
satisfying the Hospitals EMTALA obligations; and
require FIs and carriers to pay for diagnostic services
when ordered and provided in connection with satisfying
the Hospitals EMTALA obligation. |
164 |
Exclude
from Medicare LMRP those diagnostic services ordered by a
qualified medical professional when medically necessary
pursuant to satisfying the Hospitals EMTALA
obligations; and require FIs and carriers to pay for
diagnostic services when ordered and provided in
connection with satisfying the hospitals EMTALA
obligation. |
No
changes. |
|
195 |
Simplify
and clarify the CLIA requirements using plain language
when possible to assist laboratory and physician office
laboratory (POL) staff in understanding and complying with
guidelines. |
165 |
Simplify
and clarify the Clinical Laboratory Improvement Act (CLIA)
requirements using plain language whenever possible to
assist laboratory and physician office laboratory (POL)
staff in understanding and complying with CLIA guidelines. |
Clarification. |
|
196 |
Provide
information to POLs about training opportunities by the
state survey agencies and other accrediting bodies such as
the College of American Pathologists (CAP) and the
Commission on Office and Laboratory Accreditation (COLA)
to assist with interpretation and implementation of new
CLIA requirements. |
166 |
Provide
information to POLs about training opportunities by the
State Survey Agencies (SAs) and other accrediting bodies,
such as the College of American Pathologists (CAP) and the
Commission on Office and Laboratory Accreditation (COLA)
to assist with interpretation and implementation of new
CLIA requirements. |
No
changes. |
|
197 |
Update
the CLIA website, and develop a more user-friendly website
with links to the Centers for Disease Controls National
Laboratory Training Network. |
167 |
Update
and make more user friendly CMS CLIA website; include
links to the Centers for Disease Control and Preventions
National Laboratory Training Network. |
Clarification. |
|
198 |
In
the application package include the CLIA requirements and
a basic laboratory practices document in plain language
tailored to the POLs test system menu for moderate
complexity tests. |
168 |
Include
a plain-language version of the CLIA requirements as well
as a basic laboratory practices document tailored to the
POLs test system menu for moderate complexity tests, as
part of the CLIA application package. |
Clarification. |
|
199 |
Help
laboratories interpret the CLIA requirements. |
169 |
Help
laboratories to interpret the new CLIA requirements by
offering training and simplified guidelines at meetings of
laboratory professionals, accreditation bodies, and
medical organizations. |
Consolidation
of similar
recommendations. |
|
200 |
If
compliance surveys are performed by CMS on waived
laboratories, the evaluations should be according to CLIA
guidelines and using criteria established in consultation
with accrediting agencies and physician organizations. |
170 |
Develop
protocols of compliance surveys for waived POLs that use
criteria established in consultation with accrediting
agencies and physician organizations. Perform compliance
surveys when indicated on waived laboratories according to
CLIA guidelines and using criteria established in
consultation with accrediting agencies and physician
organizations. |
Clarification. |
|
201 |
Modify
the Alternate Quality Assessment Survey (AQAS) self survey
form as an educational tool to facilitate the survey and
certification process. |
171 |
Modify
the Alternate Quality Assessment Survey (AQAS) self survey
form as an educational tool to facilitate the survey and
certification process. |
No
changes. |
|
202 |
Increase
the number of POL representatives serving on the Clinical
Laboratory Advisory Committee (CLIAC) to more accurately
reflect the number of POLs being regulated. |
172 |
Increase
the number of POL representatives serving on the Clinical
Laboratory Advisory Committee (CLIAC) to more accurately
reflect the number of POLs being regulated. |
No
changes. |
|
203 |
Offer
training and simplified guidelines to assist laboratories
with new CLIA requirements at meetings of laboratory
professionals, accreditation bodies and medical
organizations. |
169 |
Help
laboratories to interpret the new CLIA requirements by
offering training and simplified guidelines at meetings of
laboratory professionals, accreditation bodies, and
medical organizations. |
Consolidation
of similar
recommendations. |
|
204 |
Collaborate
with the CDC on an educational brochure for POLs
containing plain language interpretation of the regulatory
requirements. |
173 |
Develop
an educational brochure for POLs containing a
plain-language interpretation of the regulatory
requirements by having CMS and CDC collaborate. |
Clarification. |
|
205 |
Provide
open forums with professional, medical, and accreditation
laboratory organizations to solicit feedback on ways to
improve outreach to POLs and to increase understanding of
the CLIA program among physicians. |
174 |
Provide
open forums with professional, medical, and accreditation
laboratory organizations to solicit feedback on ways to
improve outreach to POLs and to increase understanding of
the CLIA program among physicians. |
No
changes. |
|
206 |
Solicit
interest in developing an educational
"Clearinghouse" on the CLIA website that
includes a multimedia educational program package.
Interested parties would include: CMS, other Federal
agencies, professional, medical and accreditation
laboratory organizations, and CLIAC. Methods for
evaluation of effectiveness of educational programs should
be designed. |
175 |
Solicit
interest in developing an educational
"Clearinghouse" on the CLIA website that
includes a multimedia educational program package from
interested parties, including: CMS; other Federal
agencies; professional, medical, and accreditation
laboratory organizations; and the CLIAC. Design methods
for evaluating the effectiveness of educational programs. |
Clarification. |
|
207 |
Collaborate
with states and private laboratory organizations to
develop and promote self-assessment tools for
laboratories, as well as other types of educational
programs. These should include evaluation of
effectiveness. |
176 |
Collaborate
with States and private laboratory organizations to
develop and promote self-assessment tools for
laboratories, as well as other types of educational
programs. Include in these efforts an evaluation of the
effectiveness of such educational programs. |
Clarification. |
|
208 |
Stress
Collegiality. CMS should stress to staff the importance of
collegiality and clarity in communication with providers,
and incorporate these factors into employee performance
evaluations. |
177 |
Stress
to CMS staff the importance of collegiality and clarity in
communication with providers and incorporate these factors
into employee performance evaluations. |
Clarification. |
|
209 |
Target
Education First. Efforts to address program integrity
problems should start with a general understanding that
most providers want to comply with program rules and that
targeted education is the best way to address problems.
Other approaches should be reserved for when targeted
education efforts have failed or there is clear evidence
of intentional misconduct. |
178 |
Address
program integrity problems with a general understanding
that most providers want to comply with program rules and
that targeted education is the best way to address
problems. Reserve other approaches for instances when
targeted education efforts have failed or there is clear
evidence of intentional misconduct. |
Clarification. |
|
210 |
Strengthen
Education Efforts with Feedback. Ongoing efforts to
increase and improve provider education should be
continued and strengthened, with a new emphasis on
incorporating feedback from providers into continuous
quality improvement efforts. This will require development
of mechanisms to routinely obtain and evaluate such
feedback, such as focus groups, surveys, and other
methods. |
179 |
Strengthen
efforts to increase and improve provider education on an
ongoing basis, with a new emphasis on incorporating
feedback from providers into continuous quality
improvement efforts. Develop mechanisms to routinely
obtain and evaluate such feedback, such as focus groups,
surveys, and other methods. |
Clarification. |
|
211 |
Maximize
Writing Talent. CMS should have staff with well-developed
talent for explaining complex matters in plain language
work with policy experts to ensure that written
communications to providers are clear, concise, and
collegial. This will involve hiring and/or extensive
training of staff to achieve the relatively high skill
levels needed to explain complex Medicare policies
clearly. |
180 |
Ensure
that CMS has staff with well-developed talent for
explaining complex matters in plain language, and work
with policy experts to ensure that written communications
to providers are clear, concise, and collegial. Hire
and/or train staff extensively to achieve the relatively
high skill levels needed to explain complex Medicare
policies clearly. |
Clarification. |
|
212 |
Ensure
Consistency. Eliminate the practice of having contractors
and regional offices rewrite materials from CMS central
office, allowing exceptions only when required by unique
local conditions. |
181 |
Eliminate
the practice of having contractors and ROs rewrite
materials from CMS central office, allowing exceptions
only when required by unique local conditions. |
Clarification. |
|
213 |
Conduct
Annual Evaluations. HHS should publish annual reports that
establish a baseline and track progress over time in
efforts to improve the clarity and collegiality of
communications. |
182 |
Publish
annual reports that establish a baseline and track
progress over time of efforts to improve the clarity and
collegiality of communications. |
Clarification. |
|
214 |
Evaluate
the impact of newly revised materials to determine if they
reduce the number of beneficiaries who make inappropriate
decisions based on a misunderstanding of their rights and
options. |
183 |
Evaluate
the impact of newly revised materials to determine if they
reduce the number of beneficiaries who make inappropriate
decisions based on a misunderstanding of their rights and
options. |
No
changes. |
|
215 |
Evaluate
whether instructing newly eligible beneficiaries to call
1-800 MEDICARE with questions about Part B eligibility, in
order to help them become accustomed to that resource,
would be better than instructing them to call a Social
Security phone number. |
184 |
Evaluate
whether instructing newly eligible beneficiaries to call
1-800-MEDICARE for questions about Medicare Part B
eligibility is more effective in helping them to become
accustomed to this resource than instructing them to call
a toll-free SSA online number, which is current practice. |
Clarification. |
|
216 |
Adopt
Defined Schedule for Rule Amendments and Modifications (45
C.F.R. § 160.104). Set a defined schedule for issuance of
proposed and final modifications, additions, and deletions
to the transaction standards, and for compliance with
those modifications and additions as follows:
- Publish
proposed modifications and additions to transaction
standards as NPRM in the Federal Register on May 1 (or
nearest business day before May 1) each year, with 90
day public comment period.
- Publish
Final modifications, additions, and deletions to
transaction standards as final rules in the Federal
Register on October 1 (or nearest business day before
October 1) each year. That should make December 1 the
"effective date" for the final rules (after
the two month Congressional review period has lapsed).
- Implement
a compliance date for final modified or added
transaction standards on June 1 each year (which is 7
months after the "effective date").
|
185 |
Set
a defined schedule (45 CFR § 160.104) for issuance of
final modifications, additions, and deletions to the
transactions standards, and for compliance with those
modifications and additions as follows:
- Publish
final modifications, additions, and deletions to
transactions standards as final rules in the Federal
Register on the same pre-set calendar date each
year (for example, December 1 or nearest business day
before that date).
Establish
a six-month compliance date for routine modifications
and additions to transactions standards.
Specify
a longer compliance period for major transactions
standards changes (e.g., replacement of a clinical code
set) that require the industry to have very long
planning periods.
Investigate
development of a process to identify "minor"
modifications and expedite their publication (perhaps
via abbreviated rule making) in recognition of the
opportunity for public input that is already afforded by
the industry standards development process, again based
on specified publication and effective dates.
(This
recommendation assumes that the nature of modifications
will vary from year to year. In some years, changes may be
minor in nature, while in others may be far-reaching
because of proposals for new transactions, replacing
clinical code sets, etc.) |
Clarification. |
|
217 |
Complete
Transaction Definitions (45 C.F.R. §§ 162.1101
162.1801). Require the definition of every standard
transaction to include a "sender" specification
and a "receiver" specification. For example, the
"health care claims status" and "referral
certification and authorization" standard
transactions should be revised to add "sender"
and "receiver" requirements to their
definitions. |
186 |
Require
the definition of every standard transaction (45 CFR §§
162.1101 162.1801) to include a "sender"
specification and a "receiver" specification.
(For example, revise the "health care claims
status" and "referral certification and
authorization" standard transactions to add
"sender" and "receiver" requirements
to their definitions.) |
Clarification. |
|
218 |
Meaning
of "Within the Same Covered Entity" (45 C.F.R §
162.923(a)). Either eliminate "within the same
covered entity" from the Transactions Rule or define
what it means in a useful manner. For example, if the
intent of this provision is to require that transactions
between health care components doing different covered
functions that are part of the same corporate entity ought
to be in standard formats, then apply the concepts of
"hybrid entity," "covered functions,"
"multiple-function covered entity," and
"health care components" (now applicable only to
the HIPAA Privacy Rule) to all of the HIPAA rules,
including the Transactions Rule. The "within the same
covered entity" provision could then be redefined to
apply only to transactions that are between a covered
entitys health care components that do different
covered functions. |
187 |
Eliminate
or define in a useful manner the meaning of "Within
the Same Covered Entity" (45 C.F.R § 162.923(a)).
(For example, if the intent of this provision is to
require that transactions between health care components
doing different covered functions that are part of the
same corporate entity ought to be in standard formats,
then apply the concepts of "hybrid entity,"
"covered functions," "multiple-function
covered entity," and "health care
components" [now applicable only to the HIPAA Privacy
Rule] to all of the HIPAA rules, including the
Transactions Rule. The "within the same covered
entity" provision could then be redefined to apply
only to transactions that are between a covered entitys
health care components that do different covered
functions.) |
Clarification. |
|
219 |
Direct
Data Entry (DDE) Transactions (45 C.F.R. § 162.923(b)).
Issue clearer rules regarding conduct of DDE transactions
to furnish more meaningful compliance guidance for covered
entities |
188 |
Issue
clearer rules, including more meaningful compliance
guidance, for covered entities regarding conduct of Direct
Data Entry (DDE) Transactions (45 CFR § 162.923(b).) |
Clarification. |
|
220 |
Streamline
the federal Medicaid waiver review process so that more
states can promptly operate a continuum of services
program available to the full spectrum of unimpaired,
moderately impaired, and severely impaired dual eligible
beneficiaries in the least restrictive setting. |
229 |
Collaborate
with States to ensure that State Plan Amendments and State
waiver requests (for example, 1115 waivers) are approved
in a manner that is timely, significantly decreases
unnecessary documentation, and fosters State program
innovation. CMS should adopt a reasonable, workable,
preset schedule for completing State requests for plan
amendment approvals and waivers. (This would enable States
to promptly provide a
continuum of services to all
beneficiaries in the least restrictive setting,
regardless of whether those beneficiaries have
disabilities.) |
Consolidation
of similar
recommendations. |
|
221 |
CMS
should explicitly recognize that budget neutrality is
measured across all benefit programs, not solely Medicaid.
A specific situation to apply the recognition is when
determining whether waiver services are cost-effective,
CMS should uniformly clarify or adopt the policy that
"cost-effective" means waiver services will cost
no more to the Medicare and Medicaid programs combined
than the combined costs of providing Medicare and Medicaid
services on a fee-for-service basis to the same
population. |
189 |
Work
with the Office of Management and Budget to recognize that
budget neutrality is measured across Medicare and all
benefit programs under the purview of the Secretary of the
Department of Health and Human Services, not solely
Medicaid. A specific situation to apply the recognition is
when determining whether waiver services are
cost-effective, CMS should uniformly clarify or adopt the
policy that "cost-effective" means waiver
services will cost no more to the Medicare and Medicaid
programs combined than the combined costs of providing
Medicare and Medicaid services on a fee-for-service basis
to the same population. |
Clarification. |
|
222 |
Coordination
and cooperation between states and CMS need to be enhanced
so that development of cost-effective demonstration
programs can occur that integrate state and federal
benefit packages, and their funding streams, to produce
better health outcomes for dual eligibles. |
229 |
Collaborate
with States to ensure that State Plan Amendments and State
waiver requests (for example, 1115 waivers) are approved
in a manner that is timely, significantly decreases
unnecessary documentation, and fosters State program
innovation. CMS should adopt a reasonable, workable,
preset schedule for completing State requests for plan
amendment approvals and waivers. (This would enable States
to promptly provide a
continuum of services to all
beneficiaries in the least restrictive setting,
regardless of whether those beneficiaries have
disabilities.) |
Consolidation
of similar
recommendations. |
|
223 |
Shift
the state Medicaid program approval process from one that
is restrictive and heavily regulated to one where the
focus is on outcomes. Move from a micromanage mindset to
one that affords flexibility (without begging for waivers)
to states. One concept is for CMS to issue standards and
allow states to utilize innovation in creating a Medicaid
program that is optimal for their states low-income
citizens and citizens with disabilities. |
190 |
Give
States greater flexibility in developing their programs by
stating the purpose of the programs (for example,
providing health care for low-income individuals) and
giving the States the ability to design their own
programs, in compliance with Federal law, while holding
States accountable for achieving the outcomes in
accordance with pre-established criteria. (Do not specify
how States should meet those criteria.) |
Clarification. |
|
224 |
Publish
regulations in a timely fashion. States are left in limbo
or held financially liable for unclear laws. |
16 |
Publish
regulations in a timely fashion. States are left in limbo
or held financially responsible for unclear policies. (For
example, finalize and publish the newest revision of Medicaid
and School Health: A Technical Guide for States;
clarify the policy related to payment for these services.
[The "old" version of the Technical Guide still
references Medicaid as a payer of last resort for
health-related services. The transmittal of May 2000
indicates the opposite.]) |
Consolidation
of similar
recommendations. |
|
225 |
The
impact of a "Dear State Medicaid Director"
should be advisory and not have the force of
Congressionally determined law. |
191 |
Work
with States when drafting State Medicaid Letters and
solicit States input prior to the letter being formally
issued. |
Clarification. |
|
226 |
Convene
by September 1st, 2002 with recommendations by
July 1st, 2003 and a pilot by September 1st,
2003 an inter-agency working group consisting of CMS
(including the Center for Beneficiary Choice and State
Medicaid Directors) to work on an improved system for
timely and accurate identification of dual eligibles. |
192 |
Convene
by September 1, 2002, with recommendations by July 1,
2003, and have a pilot ready to implement by September 1,
2003, an interagency working group consisting of CMS,
State Medicaid Directors, and the Social Security
Administration (SSA) to work on an improved system for
timely and accurate identification, enrollment, and
notification of dual eligibles. |
Consolidation
of similar
recommendations. |
|
227 |
Identify
which states have IT systems that can identify dual
eligible beneficiaries and encourage states to use those
systems. Identify best practices in those states and
encourage their use in states that do not have IT
systems that can currently identify dual eligible
beneficiaries. Additionally, states without adequate
systems should be encouraged to develop clear
communication systems, such as e-mail or the telephone,
that can quickly identify and enroll qualified dual
eligible beneficiaries. |
193 |
Identify
the best practices of States that have been most
successful in identifying and enrolling dual eligible
beneficiaries (QMBs, SLMBs, QI-1s, QI-2s), including
through electronic data matches, and encourage through
incentives, use of those best practices in other States
that are not as successful. Develop pilot studies and
other demonstrations of innovative methods to integrate
Medicare and Medicaid data on a near real-time basis, so
that States could be provided continuous ability to access
and analyze their dual eligibility data on a command
basis. |
Consolidation
of similar
recommendations. |
|
228 |
Ensure
that CMS, SSA, and state Medicaid computer systems
exchange information about dual eligibles. |
194 |
Institute
in those 15 States where there is no electronic
information exchange to identify dual eligibles, data
match agreements between the State, and CMS and/or SSA.
Until those data match agreements have been
operationalized, develop or refine interim working
agreements between States and CMS and/or SSA to ensure
timely notification about dual eligibility and enrollment.
Work to continuously improve the quality and accuracy
of the Medicaid eligibility data States bring to CMS
and/or SSA for new and existing electronic information
exchanges to identify and enroll dual eligibles. |
Consolidation
of similar
recommendations. |
|
229 |
Survey
each state to see how they handle identifying and
enrolling qualified Medicaid beneficiaries in Medicare and
determine if any are meeting the 90-day Federal
requirement. |
195 |
Determine
what barriers exist to State Medicaid Agencies complying
with Federal timelines for enrolling qualified Medicare
beneficiaries into premium assistance programs, and seek
remedies (e.g., best practices for technical problems,
information technology improvements, etc.) to remove those
barriers. (The timelines apply only after an individual
has filed an application through the State Medicaid
Agency.) |
Clarification. |
|
230 |
Immediately
exempt dual eligible refund checks for withheld Medicare
Part B premiums from being counted as an asset in
determining continuing qualification for Medicaid
eligibility. |
196 |
Institute
immediately a policy requiring States to exempt lump sum
Medicare Part B premium refunds, currently allowed to be
deducted from the Social Security benefit payments of a
dually eligible beneficiary during the period in which the
beneficiarys initial Medicaid eligibility is
being determined, from being counted as an asset in
determining the beneficiarys continuing eligibility
for Medicaid. |
Consolidation
of similar
recommendations. |
|
231 |
Where
possible, immediately move to using IT systems for
notifying CMS and SSA of qualified dual eligible
beneficiaries. |
193 |
Identify
the best practices of States that have been most
successful in identifying and enrolling dual eligible
beneficiaries (QMBs, SLMBs, QI-1s, QI-2s), including
through electronic data matches, and encourage through
incentives, use of those best practices in other States
that are not as successful. Develop pilot studies and
other demonstrations of innovative methods to integrate
Medicare and Medicaid data on a near real-time basis, so
that States could be provided continuous ability to access
and analyze their dual eligibility data on a command
basis. |
Consolidation
of similar
recommendations. |
|
232 |
In
States that do not currently have IT systems, develop an
interim system of timely notification of CMS and SSA about
qualified dual eligibility status. |
194 |
Institute
in those 15 States where there is no electronic
information exchange to identify dual eligibles, data
match agreements between the State, and CMS and/or SSA.
Until those data match agreements have been
operationalized, develop or refine interim working
agreements between States and CMS and/or SSA to ensure
timely notification about dual eligibility and enrollment.
Work to continuously improve the quality and accuracy
of the Medicaid eligibility data States bring to CMS
and/or SSA for new and existing electronic information
exchanges to identify and enroll dual eligibles. |
Consolidation
of similar
recommendations. |
|
233 |
Utilize
E-mail, telephones or other systems, so that dual eligible
beneficiaries do not have their Part B premium deducted
from their SSDI/SSI check for an endless amount of time. |
192
+
196
|
Convene
by September 1, 2002, with recommendations by July 1,
2003, and have a pilot ready to implement by September 1,
2003, an interagency working group consisting of CMS,
State Medicaid Directors, and the Social Security
Administration (SSA) to work on an improved system for
timely and accurate identification, enrollment, and
notification of dual eligibles.
Institute
immediately a policy requiring States to exempt lump sum
Medicare Part B premium refunds, currently allowed to be
deducted from the Social Security benefit payments of a
dually eligible beneficiary during the period in which the
beneficiarys initial Medicaid eligibility is
being determined, from being counted as an asset in
determining the beneficiarys continuing eligibility
for Medicaid. |
Consolidation
of similar
recommendations. |
|
234 |
Develop
a simplified application form that allows enrollment in
all eligible federal/state programs on one form. The form
should be standardized for enrollment in all eligible
programs. Use IT where possible. |
197 |
Look
at States that have enacted a single enrollment form for
all eligible programs such as the District of Columbia.
Develop a simplified, model, "one-stop-shop"
application form that constitutes a formal beneficiary
enrollment into all eligible Federal/State entitlement or
assistance programs (for example, Medicaid, food stamps,
Women, Infants and Children (WIC), housing, etc.). To the
maximum extent possible, work with relevant agencies to
standardize the form in order to develop an electronic
enrollment process. Immediately have HHS look at those
State programs that are most successful in enrolling dual
eligible beneficiaries into all eligible Federal/State
entitlement or assistance programs (especially those
programs under the auspices of the Secretary of HHS). |
Consolidation
of similar
recommendations. |
|
235 |
If
IT is not currently possible, develop forms and
applications that are easily transferable to an IT system
when an IT system is put in place. |
197 |
Look
at States that have enacted a single enrollment form for
all eligible programs such as the District of Columbia.
Develop a simplified, model, "one-stop-shop"
application form that constitutes a formal beneficiary
enrollment into all eligible Federal/State entitlement or
assistance programs (for example, Medicaid, food stamps,
Women, Infants and Children (WIC), housing, etc.). To the
maximum extent possible, work with relevant agencies to
standardize the form in order to develop an electronic
enrollment process. Immediately have HHS look at those
State programs that are most successful in enrolling dual
eligible beneficiaries into all eligible Federal/State
entitlement or assistance programs (especially those
programs under the auspices of the Secretary of HHS). |
Consolidation
of similar
recommendations. |
|
236 |
Look
at states that have enacted a single enrollment form for
all eligible programs such as the District of Columbia
form. Immediately have HHS look at which state programs
are best meeting their goal of enrolling dual eligible
beneficiaries in all eligible federal/state programs. |
197 |
Look
at States that have enacted a single enrollment form for
all eligible programs such as the District of Columbia.
Develop a simplified, model, "one-stop-shop"
application form that constitutes a formal beneficiary
enrollment into all eligible Federal/State entitlement or
assistance programs (for example, Medicaid, food stamps,
Women, Infants and Children (WIC), housing, etc.). To the
maximum extent possible, work with relevant agencies to
standardize the form in order to develop an electronic
enrollment process. Immediately have HHS look at those
State programs that are most successful in enrolling dual
eligible beneficiaries into all eligible Federal/State
entitlement or assistance programs (especially those
programs under the auspices of the Secretary of HHS). |
Consolidation
of similar recommendations. |
|
237 |
Ensure
that policies are enforced regarding assistance with the
application for people with a compromised ability to read
and write. |
198 |
Determine
if States provide assistance to individuals who require
assistance to complete beneficiary enrollment applications
for Federal/State entitlement or assistance programs,
consistent with applicable Federal, State and local laws,
requirements, and established policies, including but not
limited to those regarding individuals with Limited
English Proficiency (LEP) and the Americans with
Disabilities Act. Work with States to eliminate any
technical barriers they may encounter to meeting those
requirements and share best practices that demonstrate
effective methods of doing so. |
Clarification. |
|
238 |
Develop
appropriate educational materials that clearly assist dual
eligibles to clearly understand exactly what programs they
are entitled to as well as explaining exactly their
financial responsibility, if any. |
199 |
Work
in coordination with States on development of appropriate
educational materials for dual eligibles that are equal in
quality to those published for all Medicare beneficiaries,
to assist dual eligibles in understanding the programs
(including the core set of Federally mandated Medicaid
services) to which they are entitled and their financial
responsibility in those programs. Use these materials as
part of outreach efforts with this population. |
Consolidation
of similar
recommendations. |
|
239 |
Work
on development of materials for dual eligibles that are
equal in quality to those for Medicare beneficiaries. |
199 |
Work
in coordination with States on development of appropriate
educational materials for dual eligibles that are equal in
quality to those published for all Medicare beneficiaries,
to assist dual eligibles in understanding the programs
(including the core set of Federally mandated Medicaid
services) to which they are entitled and their financial
responsibility in those programs. Use these materials as
part of outreach efforts with this population. |
Consolidation
of similar
recommendations. |
|
240 |
Look
at states that are using the 211 information systems for
beneficiary information. Encourage the use of the 211
information system for all Medicare and Medicaid
beneficiaries. |
200 |
Evaluate
for best practices the State of Connecticuts 211 system
for beneficiary information, called "Info Line"
(www.infoline.org). Determine the extent to which other
States are using this model and encourage the use of
systems like "Info Line" by States as a model
for all Medicare & Medicaid beneficiaries. |
Clarification. |
|
241 |
Work
on developing appropriate educational materials in
coordination with states, including the core set of
federally mandated Medicaid services that will clearly
help dual eligibles understand the benefits and programs
for which they are qualified. |
199 |
Work
in coordination with States on development of appropriate
educational materials for dual eligibles that are equal in
quality to those published for all Medicare beneficiaries,
to assist dual eligibles in understanding the programs
(including the core set of Federally mandated Medicaid
services) to which they are entitled and their financial
responsibility in those programs. Use these materials as
part of outreach efforts with this population. |
Consolidation
of similar
recommendations. |
|
242 |
Create
outreach efforts to maximize understanding of dual
eligibility. |
199 |
Work
in coordination with States on development of appropriate
educational materials for dual eligibles that are equal in
quality to those published for all Medicare beneficiaries,
to assist dual eligibles in understanding the programs
(including the core set of Federally mandated Medicaid
services) to which they are entitled and their financial
responsibility in those programs. Use these materials as
part of outreach efforts with this population. |
Consolidation
of similar
recommendations. |
|
243 |
CMS
should state that the examples in the Medicare Provider
Manual are only intended to be as examples and not as the
only configurations that are allowed. |
201 |
Clarify
in the State Operations Manual (SOM) section(s) dealing
with "Medicare-Medicaid Certification Distinct
Part Designation" that any reference to particular
examples (mentioned either in relevant Instructions,
Survey Procedures, Interpretive Guidelines, or Forms) is
intended only to be EXEMPLARY of how compliance may be
achieved, but does not constitute the only configurations
that are allowed for compliance with the statute or
regulations. Clarify for State surveyors that in the
absence of a facility complying with one or more examples
that are mentioned, the facility must still be able to
demonstrate how it complies with the regulation or
statute. Provide guidance and training to surveyors and
providers. Follow up and monitor consistency in
application. (Recommendation refers to just SNF/NFs.) |
Clarification. |
|
244 |
Require
fiscal intermediaries to render decisions on demand bills
within 45 days after receiving all medical records
documentation to support the original decision made by the
Provider. If the FI decision is not rendered by 90 days,
providers are automatically paid by Medicare. Require
administrative law judges to render a decision within a
90-day period of time after an appeal is filed. Allow
payment without prejudice during the appeals period. |
202 |
Require
FIs to render decisions on demand bills within 45 days
after receiving all medical records documentation required
by the FI to support the original decision made by the SNF.
If the FI decision is not rendered by 90 days, require FIs
to pay the SNF automatically. Require administrative law
judges (ALJs) to render a decision within a 90-day period
of time after an appeal is filed at the ALJ level. Allow
payment without "prejudice" during the appeals
period. |
Clarification. |
|
245 |
CMS
should work with SNF providers and accountants to review
data collected on the Medicare and Medicaid cost reports
and to make appropriate changes to reflect the current
purpose and use of the documents. The data should be
sufficient to create, as required by Congress, a SNF wage
index, appropriate market basket update and other purposes
that CMS can identify. |
203 |
Revise
the Medicare and Medicaid cost reports to reflect the
current purpose and use of these two separate documents.
The data should be sufficient to create, as required by
Congress, a SNF wage index, appropriate market basket
update and other purposes that CMS can justify. |
Clarification. |
|
246 |
Fiscal
Intermediaries should be required to provide specific
information as to why a claim is being denied. Appeals to
decisions should be reviewed and responded to within 45
days. |
150 |
Require
carriers/FIs to report the specific reasons for their
denial of claims in plain language, explain what
additional information is needed, and reference the
specific regulation, policy memorandum or Local Medical
Review Policies (LMRP), upon which the denial was based.
Appeals to decisions should be reviewed and responded to
within 45 days. |
Consolidation
of similar
recommendations. |
|
247 |
CMS
should ensure that regulations are consistent within all
manuals and that every program memorandum clearly
describes the modifications or introductions of
regulations. Furthermore, CMS should ensure that Medicare
contractors consistently interpret regulation and monitor
Medicare contractor to ensure consistent application of
the regulations. |
145 |
Ensure
that interpretations of regulations are consistent within
all manuals and that every program memorandum clearly
describes the modifications or introductions of
regulations. Require carriers to give answers based on
regulations and CMS guidelines and not on their own
interpretations. Eliminate penalties or denial of payment
to providers for errors due to incorrect advice from
carriers or FIs. |
Consolidation
of similar
recommendations. |
|
248 |
Provide
comprehensive training for intermediary representatives so
that they would be more knowledgeable in specific areas as
opposed to broad based generalized training. |
204 |
Provide
comprehensive training, as opposed to broad-based
generalized training, for carrier and FI telephone
customer service representatives (CSRs) so that CSRs are
more knowledgeable in specific areas and can improve their
level of consistency in providing answers. Consider the
merits of credentialing some or all of the contractors'
CSRs in order to ensure that issue experts can directly
respond to specific provider inquiries. |
Clarification. |
|
249 |
Revise
CMS regulations and/or policy for both hospice and nursing
facility to resolve the outstanding issues of professional
management, accountability, and liability. |
205 |
Convene
relevant stakeholders to work with CMS to:
- Reconcile
conflicts in regulations and/or guidance that prevent
clear delineation as to which entity (the SNF or the
hospice) is required to be the lead in providing
required end-of-life care to SNF residents once they
elect their hospice benefit.
- Revise
guidance and procedures to recognize end-of-life care
in the context of the survey protocol and the SNF/NFs
operations under each individual agreement with
hospice.
- Define
the precise, unambiguously stated conditions under
which, terminally ill beneficiaries who are residents
of SNFs/NFs may access their statutorily entitled
hospice benefit.
Incorporate
these revisions and criteria-based conditions into the SOM
as part of interpretive guidance for surveyors of hospice
and SNFs/NFs, at Task 6, K., at other relevant sections of
the Guidance to Surveyors, as well as into relevant
Program Integrity Instructions that ultimately affect the
ability of hospice and SNFs/NFs to provide these services.
Reconvene all relevant stakeholders to determine if more
structural changes are needed, based on the degree of
success achieved by the newly issued guidance. If
necessary, revise and incorporate changes (including
criteria developed from above) to the CMS conditions for
participation for both hospice and SNFs/NFs in order to
assure that beneficiaries may access their statutorily
entitled benefits and the appropriate entity can be held
accountable. Implement final rule and provide training to
both hospice and SNF/NF surveyors and providers. |
Consolidation
of similar
recommendations. |
|
250 |
Immediate:
Convene stakeholders by CMS to draft revised regulations
and/or State Operations Manual guidance for hospice and
nursing facility providers. |
205 |
Convene
relevant stakeholders to work with CMS to:
- Reconcile
conflicts in regulations and/or guidance that prevent
clear delineation as to which entity (the SNF or the
hospice) is required to be the lead in providing
required end-of-life care to SNF residents once they
elect their hospice benefit.
- Revise
guidance and procedures to recognize end-of-life care
in the context of the survey protocol and the SNF/NFs
operations under each individual agreement with
hospice.
- Define
the precise, unambiguously stated conditions under
which, terminally ill beneficiaries who are residents
of SNFs/NFs may access their statutorily entitled
hospice benefit.
Incorporate
these revisions and criteria-based conditions into the SOM
as part of interpretive guidance for surveyors of hospice
and SNFs/NFs, at Task 6, K., at other relevant sections of
the Guidance to Surveyors, as well as into relevant
Program Integrity Instructions that ultimately affect the
ability of hospice and SNFs/NFs to provide these services.
Reconvene all relevant stakeholders to determine if more
structural changes are needed, based on the degree of
success achieved by the newly issued guidance. If
necessary, revise and incorporate changes (including
criteria developed from above) to the CMS conditions for
participation for both hospice and SNFs/NFs in order to
assure that beneficiaries may access their statutorily
entitled benefits and the appropriate entity can be held
accountable. Implement final rule and provide training to
both hospice and SNF/NF surveyors and providers. |
Consolidation
of similar
recommendations. |
|
251 |
Intermediate:
Issue revised guidance to SOM, Task 6, K. and other
relevant sections of Guidance to Surveyors that affect the
ability of hospice and nursing facilities to provide these
services. |
205 |
Convene
relevant stakeholders to work with CMS to:
- Reconcile
conflicts in regulations and/or guidance that prevent
clear delineation as to which entity (the SNF or the
hospice) is required to be the lead in providing
required end-of-life care to SNF residents once they
elect their hospice benefit.
- Revise
guidance and procedures to recognize end-of-life care
in the context of the survey protocol and the SNF/NFs
operations under each individual agreement with
hospice.
- Define
the precise, unambiguously stated conditions under
which, terminally ill beneficiaries who are residents
of SNFs/NFs may access their statutorily entitled
hospice benefit.
Incorporate
these revisions and criteria-based conditions into the SOM
as part of interpretive guidance for surveyors of hospice
and SNFs/NFs, at Task 6, K., at other relevant sections of
the Guidance to Surveyors, as well as into relevant
Program Integrity Instructions that ultimately affect the
ability of hospice and SNFs/NFs to provide these services.
Reconvene all relevant stakeholders to determine if more
structural changes are needed, based on the degree of
success achieved by the newly issued guidance. If
necessary, revise and incorporate changes (including
criteria developed from above) to the CMS conditions for
participation for both hospice and SNFs/NFs in order to
assure that beneficiaries may access their statutorily
entitled benefits and the appropriate entity can be held
accountable. Implement final rule and provide training to
both hospice and SNF/NF surveyors and providers. |
Consolidation
of similar
recommendations. |
|
252 |
Long-term:
Implement final rule; Provide training to both hospice and
nursing facility surveyors and providers. |
205 |
Convene
relevant stakeholders to work with CMS to:
- Reconcile
conflicts in regulations and/or guidance that prevent
clear delineation as to which entity (the SNF or the
hospice) is required to be the lead in providing
required end-of-life care to SNF residents once they
elect their hospice benefit.
- Revise
guidance and procedures to recognize end-of-life care
in the context of the survey protocol and the SNF/NFs
operations under each individual agreement with
hospice.
- Define
the precise, unambiguously stated conditions under
which, terminally ill beneficiaries who are residents
of SNFs/NFs may access their statutorily entitled
hospice benefit.
Incorporate
these revisions and criteria-based conditions into the SOM
as part of interpretive guidance for surveyors of hospice
and SNFs/NFs, at Task 6, K., at other relevant sections of
the Guidance to Surveyors, as well as into relevant
Program Integrity Instructions that ultimately affect the
ability of hospice and SNFs/NFs to provide these services.
Reconvene all relevant stakeholders to determine if more
structural changes are needed, based on the degree of
success achieved by the newly issued guidance. If
necessary, revise and incorporate changes (including
criteria developed from above) to the CMS conditions for
participation for both hospice and SNFs/NFs in order to
assure that beneficiaries may access their statutorily
entitled benefits and the appropriate entity can be held
accountable. Implement final rule and provide training to
both hospice and SNF/NF surveyors and providers. |
Consolidation
of similar
recommendations. |
|
253 |
CMS
should issue a written statement declaring that due to the
national nursing shortage, we are in a period of
"extraordinary circumstances". Due to this
problem, contracting for nursing services for continuous
care is allowed. The statement should restate the
responsibility of hospice when contracting for services,
located in 42 CFR 418.80. |
206 |
Issue
a revised policy declaring that due to the national
nursing shortage, we are in a period of
"extraordinary circumstances." Due to this
problem, contracting for nursing services for continuous
care is allowed. The statement should restate the
responsibility of hospice when contracting for services,
located in 42 CFR § 418.80. |
Clarification. |
|
254 |
Revise
the definition of deficiency at 42 CFR 488.301 by CMS to
incorporate the concepts of systematic investigation,
information analysis, validation, and the determination of
facility response and responsibility in identifying a
potential problem and acting to prevent it. |
|
|
Not
reaffirmed by Committee. Deleted from final list. |
|
255 |
Immediate:
Notice
of rulemaking published by CMS. |
|
|
Not
reaffirmed by Committee. Deleted from final list. |
|
256 |
Long-term:
Implementation
of a final rule. |
|
|
Not
reaffirmed by Committee. Deleted from final list. |
|
257 |
Provision
of guidance and training to surveyors and providers.
Follow-up and monitoring of consistency in application. |
|
|
Not
reaffirmed by Committee. Deleted from final list. |
|
258 |
Immediate:
Convening
of stakeholders by CMS to draft a definition of harm. |
207 |
Convene
relevant stakeholders to work with CMS to revise the
threshold definition of "harm" as applied in the
SNF/NF enforcement process and operationalize
item-specific criteria for decision making at each
relevant survey requirement. Publish the results of this
collaboration in a Notice of Proposed Rulemaking (NPRM)
and revise relevant regulations as needed. Implement the
final rule; develop guidance for survey and enforcement;
provide training to surveyors and providers; and require
CMS to monitor its application by surveyors. |
Consolidation
of similar
recommendations. |
|
259 |