The table below contains the "crosswalk" linking the original recommendation text (Column 2) as adopted by the SACRR, to the recommendation as it exists in its final form (Column 4). The SACRR instructed its staff to edit the originally approved recommendation text for clarity and uniformity, and elimination of redundancy. The SACRR reaffirmed its adoption of the recommendations, as modified in the Final Master List. As such, we have included the recommendation’s original numbering (Column 1) as well as the numbering used for the Final Master List (Column 3). Column 5 includes the reason for any change(s), where applicable. Those seeking additional information should e-mail the Regulatory Reform staff at regreform@hhs.gov.

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 Medicare’s 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 Medicare’s 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:

(f) Reducing the number of benefit categories submitted in the ACR for the 2004 filings.

6

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+CO’s 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 Medicare’s 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 group’s 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 Medicare’s 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 group’s 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 member’s primary care physician choice.

13

Establish a policy that allows M+C plans to default members to replacement plans based on the member’s 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.

21

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

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 hospital’s and the physician medical staff’s 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 don’t 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 beneficiary’s Medicare card.

27

Add the 1-800 MEDICARE phone number and website address to the beneficiary’s 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 CMS’program 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 CMS’s 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.

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 facility’s 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.

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 User’s 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

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

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

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

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

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

Consolidation of similar
recommendations.

77

Allow electronic filing via e-mail.

65

Consolidation of similar
recommendations.

78

Develop a modern provider enrollment secure website.

65

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

72

Incorporate form HCFA 2572 into CMS 855.

No changes.

86

Implement use of electronic signatures

73

Consolidation of similar
recommendations.

87

Implement use of e-filing

73

Consolidation of similar
recommendations.

88

Integrate data acquisition into IT architecture of HHS and data providers

73

Consolidation of similar
recommendations.

89

Modernize current MCR, make it more useful, more creative, less burdensome.

74

Consolidation of similar
recommendations.

90

Eliminate CMS339, fold data into cost report.

74

Consolidation of similar
recommendations.

91

Eliminate need to file redundant manual data.

74

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

Consolidation of similar
recommendations.

93

Establish method to E-file MCR in central repository similar to SEC’s EDGAR system.

74

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

"(_) 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

"(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

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 Individual’s Health Care

86

"(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 individual’s 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 person’s involvement with the individual’s health care or payment related to the individual’s health care.")

Clarification.

106

Reconcile Potential Conflict between Confidential Communications and Explanations of Benefits Issuance

87

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 insured’s 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

"(4) Review of denial requested. If the individual or the individual’s 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 official’s 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 individual’s personal representative of the determination of the designated reviewing official, and take all action required by this section to carry out the designated reviewing official’s 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 Rule’s 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

"(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 entity’s professional judgment.

Clarification.

111

Allow a Covered Entity with Non-Covered Functions to Be a Hybrid Entity

92

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 entity’s human resources personnel performing non-covered employment functions. It also means that individually identifiable health information held by the covered entity’s 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

"(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

(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 Rule’s 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.

100

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 beneficiary’s 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 resident’s 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 GAO’s 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 GAO’s 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 State’s 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 state’s efforts to ensure MDS accuracy and providing guidance and technical assistance to individual states as needed.

108

Follow the GAO’s 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 State’s 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 CRNA’s.

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 state’s 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

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 hospital’s 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 hospital’s 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.

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 Medicare’s 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.

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 Medicare’s 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.

Revise the Interpretive Guidance on Separate Entities to give all agencies more flexibility in managing their business.

121

Revise the CMS Interpretive Guidance on Medicare’s 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 Medicare’s 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.

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

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 PRO’s; 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 don’t 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

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.

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 4^th 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.

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 Hospital’s EMTALA obligations; and require FIs and carriers to pay for diagnostic services when ordered and provided in connection with satisfying the Hospital’s EMTALA obligation.

164

Exclude from Medicare LMRP those diagnostic services ordered by a qualified medical professional when medically necessary pursuant to satisfying the Hospital’s EMTALA obligations; and require FIs and carriers to pay for diagnostic services when ordered and provided in connection with satisfying the hospital’s 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 Control’s National Laboratory Training Network.

167

Update and make more user friendly CMS’ CLIA website; include links to the Centers for Disease Control and Prevention’s 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 POL’s 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 POL’s 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

185

(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 entity’s 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 entity’s 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 state’s 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 1^st, 2002 with recommendations by July 1^st, 2003 and a pilot by September 1^st, 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 beneficiary’s initial Medicaid eligibility is being determined, from being counted as an asset in determining the beneficiary’s 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.

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 beneficiary’s initial Medicaid eligibility is being determined, from being counted as an asset in determining the beneficiary’s 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 Connecticut’s 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

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

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

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

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