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Prescription drug abuse is a serious and growing problem nationwide. Unfortunately, the Medicare Part D prescription drug program (Part D) is not immune from the abuses associated with this nationwide epidemic. The Centers for Medicare & Medicaid Services (CMS) takes this problem seriously and is taking steps to protect Medicare beneficiaries and the Medicare Trust fund from the harm and damaging effects associated with prescription drug abuse.

CMS’ fraud and abuse strategy for Part D is data driven and focuses on the validation and analysis of Part D claims data (Prescription Drug Event, or PDE, data) that CMS receives from Part D sponsors. We are leveraging CMS’ access to all PDE data and using it to guide our anti-fraud efforts and share the results of our analysis with Part D plan sponsors, law enforcement agencies and pharmacy and physician licensing boards, as appropriate, so this information can assist our joint efforts to combat fraud and abuse. A centerpiece of this strategy that focuses on protecting beneficiaries is the identification of Part D enrollees who have potential opioid or acetaminophen overutilization issues that indicate the need to implement appropriate controls on these drugs for the identified beneficiaries. In addition, data analysis is employed to identify prescribers and pharmacies that may warrant further action to curb fraudulent or abusive activities. With the proposed rule issued January 6, 2014, CMS seeks to provide the agency with new tools to employ when problematic prescribers and pharmacies are identified. The key provisions of the proposed rule are discussed below, as are the ongoing CMS actions to combat fraud and abuse.  

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If you have not yet recertified your access to FISS DDE, your user ID may be terminated.

The Centers for Medicare & Medicaid Services (CMS) requires National Government Services, Inc. to conduct an annual recertification of all current Medicare online FISS DDE users for Part A providers. This process will recertify all user IDs assigned to your employees or third parties that you have authorized to access National Government Services systems on your behalf.  

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On January 6, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule with comment period that would strengthen protections, improve health care quality and reduce costs for Medicare beneficiaries with private Medicare Advantage (MA) and Part D prescription drug plans in Contract Year (CY) 2015. Among the technical and program changes this rule proposes are new criteria for identifying protected classes of drugs, revisions that promote competition in Part D plans, changes to the regulatory definition of negotiated prices, and changes to ensure that plan choices are meaningful for beneficiaries. This fact sheet discusses the major provisions of the proposed rule. The proposed rule would save $1.3 billion over the five years 2015 – 2019 if finalized.

Summary of Proposed Changes

New criteria for drug categories or classes of clinical concern:
In the first year of the Medicare prescription drug benefit, CMS implemented a policy that required all Part D plans to include on their formularies “all or substantially all” Part D drugs within six drug classes—antineoplastics, anticonvulsants, antiretrovirals, antipsychotics, antidepressants, and immunosuppressants. The Affordable Care Act later codified this policy, and allowed CMS to specify criteria for identifying protected classes through notice and comment rulemaking. CMS proposes to change the categories or classes of Part D drugs of clinical concern using criteria established through this notice and comment rulemaking. Under the proposed criteria, CMS would require formulary inclusion of all drugs within the antineoplastic, anticonvulsant, and antiretroviral drug classes (subject to proposed exceptions), but would no longer require all drugs from the antidepressant and immunosuppressant drug classes to be on all Part D formularies. A Although antipsychotics do not meet the criteria, they will remain protected at least through 2015 while CMS evaluates additional considerations and the need for any other formulary exceptions. 

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The Connecticut Department of Social Services has issued its Provider Bulletin 2014-19 in March 2014, to notify home health agencies serving CHCPE clients of changes being made to the program. These changes will be implemented in a staggered approach throughout April 2014 and will impact how medical services are authorized and will appear on the client’s care plan.

The following is a summary of the changes being implemented to the program:

  • Implementation of a new modifier, U2 One Time Only.  This modifier will uniquely identify a care plan service that overlaps with another service order for the same time period, and is retroactive to dates of service July 1, 2013 and forward.
  • Unique Provider Code with modifier Lists for one-time services are being added when authorized and will appear on the care plan for skilled nursing and medication authorization services.
 

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On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of 2014. This new law prevents a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking effect on April 1, 2014. This new law maintains the 0.5 percent update for such services that applied from January 1, 2014 through March 31, 2014 for the period April 1, 2014 through December 31, 2014. It also provides a zero percent update to the 2015 Medicare Physician Fee Schedule (MPFS) through March 31, 2015.

The new law extends several expiring provisions of law. We have included Medicare billing and claims processing information associated with the new legislation. Please note that these provisions do not reflect all of the Medicare provisions in the new law, and more information about other provisions will be forthcoming. 

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This week the Senate Finance Committee approved a two-year extension of tax provisions that expired at the end of 2013. This is the first step towards a broader discussion on tax changes Congress will work through during the year.

Key tax extenders – including the Research and Experimentation (R&D) Tax Credit and the Energy Efficient Commercial Building (Section 179D) – were passed with bipartisan support with few adjustments. 

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The Senate voted today to approve a bill that will delay the implementation of ICD-10-CM/PCS by at least one year. The bill now moves to President Obama, who is expected to sign it into law. The bill was passed 64-35 at 6:59 pm ET on Monday, March 31.

The bill, H.R. 4302, Protecting Access to Medicare Act of 2014, mainly creates a temporary “fix” to the Medicare sustainable growth rate (SGR). A seven-line section of the bill states that the Department of Health and Human Services (HHS) cannot adopt the ICD–10 code set as the standard until at least October 1, 2015. The healthcare industry had been preparing to switch to the ICD-10 code set on October 1, 2014. 

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Initiative Promotes Freedom of Choice In Long-Term Care System

Governor Dannel P. Malloy today announced that his administration is awarding $9 million in first-time funding to help Connecticut’s nursing home industry diversify services to meet the changing needs of older adults and other citizens with disabilities.

The grants are part of the state’s Strategic Plan to Rebalance Long-Term Services and Supports, a ground-breaking initiative to expand long-term service options for people who can live safely in the community instead of an institution.  

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By David Pittman, Washington Correspondent, MedPage Today

While Congress is grappling with the myriad of issues that make up the budget, a quantum change in the annual ruckus around RVU payment amounts may be changing, maybe for the better, but that may depend on your specialty. We suggest physicians stay up on what’s happening, stay in touch with your legislators and make them hear what the real practice of medicine is like, and what the impact of these prospective changes will be in your office.

WASHINGTON - Some Democratic lawmakers have expressed interest in extending the pay increases for primary care physicians in Medicare and Medicaid that are temporarily in effect under the Affordable Care Act (ACA). 

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Talk about a new way of doing business marketing in medicine; this is either a slide into very commercial patient recruiting or the next best thing to come along in patient marketing.

Certainly, if it works its way into higher level patients trying to understand cost while maintaining quality, and knowing who the patient is dealing with, this could be a plus. Our concern is it looks more like the PI attorney methodology for going after the low end of the barrel. 

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