The CMS Blog

Fighting Improper Payments And Fraud – Protecting Taxpayer Dollars

Centers for Medicare & Medicaid Services — Fri, 24 Feb 2012 23:14:11 +0000

By Marilyn Tavenner, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS)

Fighting fraud and waste in the health care system is a top priority for the Obama Administration. We are committed to using all resources at our disposal in these efforts – and they are paying off.

Just last week, the Departments of Justice and Health and Human Services (HHS) released an updated annual report showing that in FY 2011 anti-fraud efforts have recovered more than $4.1 billion in fraudulent Medicare payments – the second year in a row recovery efforts reached this unprecedented level. Compare this to just $2.14 billion recovered in FY 2008. Prosecutions are way up too: the number of individuals charged with fraud increased from 821 in fiscal year 2008 to 1,430 in fiscal year 2011 – nearly a 75 percent increase.

But we know we need keep doing more to end the “pay and chase” model of fighting fraud. We need to stop fraud and waste from happening in the first place. Today we’re taking an important step to protect taxpayer dollars by reducing improper payments to Medicare Advantage plans, an action that is estimated to save $370 million in the first audit year alone. By improving the way we audit Medicare Advantage contracts, we will reduce the payment error rate for the Medicare Advantage program and that saves money for Medicare.

We are also using new, advanced techniques to fight fraud. Starting last year, we have been using “predictive modeling” technology – similar to technology used by credit card companies to identify and fight fraud nationwide. This effort is just getting started but it’s already making a difference. Since the predictive modeling system was activated, CMS has stopped, prevented or identified $20 million in payments through November 2011 that should not have been made.

In addition, predictive modeling has identified 2,500 leads for further investigation, 600 preliminary law enforcement cases under review and resulted in 400 direct interviews with providers who would not have otherwise been contacted.

Predictive modeling won’t reach its full potential in overnight, but it’s already making an incredible difference and will do even more in the weeks, months and years ahead.

Filed under: Uncategorized

Better Coordination Leading to Swifter Medicare Coverage and Access

Centers for Medicare & Medicaid Services — Thu, 02 Feb 2012 21:48:59 +0000

Marilyn Tavenner, Acting Administrator, Centers for Medicare and Medicaid Services

Today, CMS is proposing that Medicare patients across the country have access to a new procedure, known as “transcatheter aortic valve replacement.”

The result of an unprecedented level of collaboration between CMS, the Food and Drug Administration (FDA), the Agency for Healthcare Research and Quality (AHRQ), the American College of Cardiology, the Society of Thoracic Surgeons and Edwards Lifesciences, this proposed National Coverage Determination continues CMS’ commitment to cross-agency collaboration and ensuring patients have access to the latest and best medical technology.

Aortic valve replacements are used in patients whose aortic heart valves are damaged and cause the valve to narrow – a condition known as “aortic stenosis.” Once patients experience symptoms of aortic stenosis, treatment is critical to improve their chances of survival. Until recently, aortic stenosis has been treatable only through surgical aortic valve replacement. And as our population ages, the number of Americans with aortic stenosis progressively increases.

Transcatheter aortic valve replacement allows doctors to replace a patient’s aortic valve through a small opening in the leg. This less invasive procedure gives patients who cannot undergo open heart surgery a new way to repair their damaged heart valve.

The first transcatheter aortic valve replacement system was approved by the FDA on November 2, 2011. Since then, we have worked closely with the FDA, AHRQ, the American College of Cardiology, the Society of Thoracic Surgeons, and the device manufacturer, Edwards Lifesciences, to bring this new procedure to Medicare enrollees across the country.

Because this technology is still relatively new, it is important that these procedures are performed by highly trained professionals in optimally equipped facilities. This decision proposes “coverage with evidence development” which, as a condition of coverage, would require certain provider, facility, and data collection criteria to be met. Such requirements are important to ensure beneficiaries receive the safest and most appropriate care.

We are hopeful that this proposed decision will lead to increased access to less invasive treatment options for Medicare beneficiaries and save lives.

Today’s proposed decision will be open for 30 days of public comment before CMS issues a final decision later this year. To read the proposal, visit the CMS website at: http://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=257

Filed under: Uncategorized

New CBO Report Supports Innovation Center’s Approach to Improving Care

Centers for Medicare & Medicaid Services — Tue, 24 Jan 2012 20:36:12 +0000

By Rick Gilfillan, Acting Dir. of the Center for Medicare & Medicaid Innovations. Crosspost from Healthcare.gov

The United States has one of the best health care systems in the world – and one of the most innovative. We lead the world in developing new treatments, drugs and procedures to help heal patients. At the same time, we know that we need to do more to help ensure every patient gets the very best care – and that we are spending our health care dollars wisely.

Last week, a report from the independent, non-partisan Congressional Budget Office (CBO) outlined how difficult this challenge is. The report showed how projects implemented by previous Administrations struggled to reduce Medicare costs.

And the same report recommended that future efforts focus on collecting better data, targeting resources at the patients who need it most, and encouraging care providers to work together.

Even before this report came out, the Center for Medicare and Medicaid Innovation was already putting some of these lessons and recommendations into practice. The Innovation Center is charged with engaging doctors, hospitals, and other providers that want to try new approaches to keeping their patients healthy and out of the hospital. Here are just a few examples of how the Innovation Center has already adopted some of CBO’s recommendations:

CBO Recommendation: Gather timely data on the use of care, especially hospital admissions.
Innovation Center Action: Health systems participating in the Pioneer ACO and ACO Shared Savings models will receive updates on care received by their patients within a few weeks of when it occurred, down from 6 months or more in previous demonstrations.
CBO Recommendation: Focus on transitions in care settings.
Innovation Center Action: The Community-Based Care Transitions Program will invest up to $500 million in organizations such as Area Agencies on Aging that help seniors as they leave the hospital, including through home visits. In addition, the Demonstration to Reduce Hospitalizations of Nursing Facility Residents will invest $134 million in providing additional care and supports to help reduce preventable hospitalizations among nursing home residents.
CBO Recommendation: Use team-based care.
Innovation Center Action: The Comprehensive Primary Care Initiative provides new supports from both Medicare and private health insurers to make sure that participating primary care practices have robust care teams – which could include nurses, pharmacists, and dieticians – available 7 days a week to coordinate care and avert visits to the emergency room.
CBO Recommendation: Target interventions toward high-risk enrollees.
Innovation Center Action: Along with the Medicare-Medicaid Coordination Office, the Innovation Center is empowering states to invest in new models targeted toward beneficiaries that are eligible for both Medicare and Medicaid, a group of beneficiaries at particularly high risk for having multiple chronic health conditions and high health care costs.
CBO Recommendation: Limit the costs of intervention.
Innovation Center Action: The Innovation Center is testing several new payment models, such as the Pioneer ACO Model and the Bundled Payments for Care Improvement, with no upfront payments to participating doctors and hospitals. Rather, these groups will be rewarded once their innovative approach is proven to have reduced costs and kept patients healthier.

In addition, the CBO report cited the Medicare Participating Heart Bypass Center Demonstration as one example of a pre-Affordable Care Act project that succeeded in reducing Medicare costs without harming the quality of care seniors received. Based on this evidence, the Innovation Center launched in August of last year the Bundled Payment for Care Improvement initiative, which will allow seniors in other parts of the country to benefit from the success of the Heart Bypass Center Demonstration.

The Innovation Center is a new way of doing business for Medicare and Medicaid. We are looking to models of health care that are already working in communities across America and finding ways to help doctors and hospitals in many other parts of the country make similar improvements for their patients. And we’re learning from Medicare’s previous work to develop better, more effective ways to save money and improve the quality of care. By putting into practice important lessons learned from both the private and public sectors, the Affordable Care Act is working to ensure that seniors in every community can enjoy the benefits of higher-quality, more affordable health care.

For more information on the Innovation Center you can visit www.innovations.cms.gov.

Filed under: CMS Center for Medicare & Medicaid Innovation

23 States Recognized for Success – Getting More Eligible Children Enrolled in Health Coverage

Centers for Medicare & Medicaid Services — Wed, 28 Dec 2011 17:30:00 +0000

by Cindy Mann, CMS Deputy Administrator and Director, Center for Medicaid and CHIP Services

Families across the country are experiencing hard times. The good news is that, despite the challenges States themselves are facing, many States are moving forward to adopt strategies that help get more eligible children enrolled in Medicaid and CHIP and stay enrolled for as long as they qualify. We are working hard, together with the states, to keep children’s health coverage a high priority.

We are pleased to be able to recognize and support states that are improving their programs and are enrolling more children in health coverage as a result. Performance Bonuses, authorized by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), were designed to reward states for making access to health coverage easier for eligible children and signing up more children who qualify.

This year, 23 states qualified for CHIPRA Performance Bonuses totaling nearly $300 million. States were eligible for a bonus if they reached targets for the number of additional children enrolled in Medicaid, and if they took steps to simplify their enrollment and renewal processes, adopting at least five out of eight options. In addition to providing an incentive for States to make lasting positive changes to their programs, the performance bonuses help offset the added costs of insuring the lowest income children.

Of the states that earned bonuses, seven are new this year: Connecticut, Georgia, Montana, North Carolina, North Dakota, South Carolina, and Virginia. And, many of the states that have received bonuses in the past haven’t stopped improving their programs – five of these states implemented a sixth strategy in an effort to further streamline procedures.

The states awarded performance bonuses for the first time have simplified enrollment and renewal in a variety of ways. For example:

Georgia is using information from the WIC program to make Medicaid enrollment simpler, using the “express lane eligibility” option.
Virginia has simplified the eligibility renewal process so that children have an easier time keeping their coverage when it’s time to renew.
North Carolina and North Dakota both guarantee eligible children enrollment for a full year, to be sure they get continuous coverage and don’t lose access to care.
Montana and Connecticut have adopted the “presumptive eligibility” option, which jump-starts enrollment for children who appear eligible and lets them see a doctor or get a prescription while their full eligibility is being determined.

These and other activities to simplify the process and enroll eligible children are paying off: New data from the CDC’s National Center for Health Statistics found that an additional 1.2 million children have gained health insurance coverage since CHIPRA was signed into law in 2009. This increase has been entirely due to greater enrollment in public programs such as Medicaid and CHIP.

Learn more about CHIPRA – and find out what states and communities are doing to get more eligible children covered.

Filed under: Uncategorized

As Open Enrollment Ends, People with Medicare save $1.5 billion on prescriptions

Centers for Medicare & Medicaid Services — Tue, 06 Dec 2011 15:37:48 +0000

by Kathleen Sebelius

If you’ve had a Medicare Advantage or Prescription Drug Plan for a few years, you’ll know that December is the end of Medicare Open Enrollment. This year, the last day for you to choose new Medicare health or prescription drug coverage for 2012 is December 7, earlier than it’s been in previous years.

December 7 is tomorrow. But you still have until midnight tomorrow if you want to make a change to your medical or prescription drug coverage.

And as you are reviewing your plan, remember that Medicare is only getting stronger. New data released today shows how millions of seniors have gotten cheaper prescription drugs and free preventive services, all thanks to the President’s health reform law.

Thanks to the Affordable Care Act, the Medicare prescription drug coverage gap known as the donut hole is starting to close. Through the end of October, 2.65 million people with Medicare have received discounts on brand name drugs in the donut hole. These discounts have saved seniors and people with disabilities a total of $1.5 billion on prescriptions – averaging about $569 per person. For State-by-State information on the number of people who are benefiting from this discount in 2011, visit this page.

Over the coming years, the Affordable Care Act will help close the coverage gap completely. Each year from now to 2020, you’ll pay less for brand name and generic drugs in the coverage gap. And in 2020, the coverage gap will be eliminated and the donut hole will be closed for good.

In addition to cheaper prescription drugs, the Affordable Care Act also made preventive services available to people with Medicare for free. Preventive care helps people stay healthy and live longer lives. Through the end of November nearly 24.2 million people with Medicare have received one or more free preventive services, including Medicare’s new free Annual Wellness Visit. For State-by-State information on the numbers of people who are utilizing preventive services in 2011, visit this page.

These new benefits are just two ways the Affordable Care Act is making Medicare and our health care system stronger and giving hardworking families the security they deserve. It has helped lower your Part B premium in 2012 by $22. And, on average, Medicare Advantage premiums will be lower in 2012 as enrollment continues to rise.

And if you haven’t reviewed your Medicare coverage, take time now to compare your current coverage with other options to make sure your plan will meet your health care needs for the coming year. Medicare now offers better choices, more benefits, and lower costs thanks to the Affordable Care Act. Visit www.Medicare.gov/open-enrollment/ for more information.

Filed under: Uncategorized

CMS Online Information Just Got Better

Centers for Medicare & Medicaid Services — Mon, 05 Dec 2011 14:50:34 +0000

By Julie Green Bataille, Director, Office of Communications

We’re always looking for ways to make your experience with the Medicare, Medicaid, Children’s Health Insurance, and other health care programs better. Today, we’re expanding and enhancing our online presence at the Centers for Medicare & Medicaid Services (CMS): we’re debuting a new look and feel for CMS.gov, and launching a brand-new site for the Medicaid program, Medicaid.gov.

These changes reflect what we’ve heard from you – our users – and respond to what you’ve said you want to be able to do on our site. Here’s what you’ll find on the new CMS and Medicaid sites:

A significantly improved search engine that gets you to the information you’re looking for, fast.
More in-depth information about what we’re doing to implement the Affordable Care Act and other new initiatives, and details about how you can apply for new programs.
Up-to-date, real-time updates that reflect important developments and initiatives happening with CMS programs.
Medicaid program information that’s readily available, easy to find, and easy to use— and we’ll be continually looking for ways to enhance your experience on this site.
Easy-to-access links to Healthcare.gov, which will continue to be the primary site for consumer information.

While we’ve moved content around to make it easier to find, don’t worry that you’ll lose access to any of the current Medicare and Medicaid information you rely on now. We’re launching an archive version of each of our websites too, so that historic information can remain online without adding clutter to our primary sites.

We think these changes are a good first step to improving our online presence and making information more accessible for all the patients, partners, providers, States, advocates and others who interact with our programs. However, this is just the first step — we have plans for continuous, ongoing improvements.

Take a look around at our www.cms.gov and www.Medicaid.gov, and let us know what you think. We’d like to use your feedback to help drive the direction of future website improvements.

Filed under: CMS.gov, Medicaid

Better quality of life and improved health care for individuals living with HIV

Centers for Medicare & Medicaid Services — Thu, 01 Dec 2011 15:55:35 +0000

By Don Berwick, M.D., Administrator of the Centers for Medicare & Medicaid Services

Today, we celebrate the vast improvements in treatments and the quality of life for individuals living with HIV. This day serves as a reminder of the many accomplishments in fighting AIDS during the past three decades, but also highlights how much more work we have left in fighting this disease.

Thanks to major advances in science and medicine, people living with HIV face a much different reality today. In 1981, when AIDS first emerged in the US, the disease was equivalent to a death sentence. Now, thirty years later, people with HIV who receive medication and proper care live longer, healthier lives — just as they could with any other chronic illness.

Despite the powerful arsenal at our disposal, some of our best defenses remain out of reach for a significant proportion of the more than 1.2 million Americans living with HIV. An estimated 30 percent of this group does not have health coverage of any kind. As a result, they have no way to cover the cost of medications and treatment that we know are life-preserving.

We took an important step to remove this barrier this past summer. The Centers for Medicare & Medicaid Services (CMS), in collaboration with, the Health Resources and Services Administration (HRSA), and the Centers for Disease Control (CDC), released new guidance that encourages States to take advantage of important Medicaid options that will help improve care for individuals living with HIV.

These options can make it easier for States to prevent or delay the institutionalization of people living with HIV and can help people living in nursing homes or other institutions transition back home when they are able. States can expand Medicaid access to low-income people living with HIV, enabling them to become eligible for services without having to be considered permanently disabled due to an AIDS diagnosis. States can provide more effective, earlier treatment of HIV by making available a limited or comprehensive package of services, which may include anti-retroviral therapies or case management to ensure adherence to treatment. Better coordinated care opportunities were also made available to support physical and behavioral health and linkages to long-term supports for individuals with multiple chronic conditions through the state option to establish health homes.

This epidemic has claimed the lives of 600,000 Americans. We can and are doing more to slow transmission of the disease and to ensure people living with HIV have access to the health care that will help them lead longer and healthier lives. I am confident of the positive quality of life effects that these options will make for Medicaid beneficiaries living with and fighting through HIV/AIDS every day.

Filed under: Uncategorized

Millions of Seniors Saving Money on Prescription Drugs, Thanks to the Affordable Care Act

Centers for Medicare & Medicaid Services — Tue, 29 Nov 2011 15:09:48 +0000

By Nancy-Ann DeParle. Crosspost from The White House Blog

Over the weekend, a report by the Associated Press detailed how the Affordable Care Act is dramatically reducing drug costs for seniors who hit the prescription drug coverage gap known as the donut hole. This year, seniors are benefiting from a 50 percent discount on brand-name drugs in the donut hole. And the discount and other provisions in the law are saving money for seniors. As the AP reported:

The average beneficiary who falls into the coverage gap would have spent $1,504 this year on prescriptions. But thanks to discounts and other provisions in President Barack Obama’s health care overhaul law, that cost fell to $901, according to Medicare’s Office of the Actuary, which handles economic estimates.

So far this year, more than 2.2 million people with Medicare have saved more than $1.2 billion on their prescriptions. The Associated Press spoke with two of them:

For retired elementary school teacher Carolyn Friedman, it meant she didn’t need a loan to pay for drugs that keep her epilepsy under control.

“What a change for the better,” said Friedman, 71, of Sunrise, Fla. “This year it was easier to pay my bills, whereas last year I had to borrow money to pay for my medications when I was in the doughnut hole.”

…

Joan Gibbs thought her pharmacy had made a mistake. Her total cost for a brand-name painkiller in the doughnut hole came out lower than her co-payment earlier in the year, at a time her plan was picking up most of the tab.

“I reluctantly called the insurance company,” said Gibbs, 54, who lives near Cleveland. “If they had made a mistake, I knew they would catch it sooner or later. I was very surprised that it turned out to be such a good discount.”

Gibbs is on Medicare because of an auto-immune disorder and other medical problems that left her unable to work.

Thanks to the Affordable Care Act, seniors will receive bigger discounts in the years ahead. By 2020, the donut hole will be closed completely.

And even if you don’t hit the donut hole, there’s still good news for beneficiaries with Medicare Part D. Prescription drug premiums will not rise next year, and thanks to health reform, seniors can get preventive services like mammograms and other cancer screenings for free.

Nancy-Ann DeParle is the Assistant to the President and Deputy Chief of Staff

Filed under: Uncategorized

We Can’t Wait: Jumpstarting Innovation in Health Care, Reducing Costs

Centers for Medicare & Medicaid Services — Mon, 14 Nov 2011 17:33:02 +0000

By Donald M. Berwick M.D., Administrator, Centers for Medicare & Medicaid Services. Crosspost from Healthcare.gov

Health care costs remain a significant drain on the budgets of families, businesses, and federal and state governments. The health reform law, the Affordable Care Act, made significant strides in making Medicare more affordable and insurance companies more accountable. Congress is considering other ways to build on this progress, but we can’t wait to do more to help make our health care system more affordable.

In that spirit, the Obama Administration recently launched the Health Care Innovation Challenge. Made possible by the Affordable Care Act, this initiative will invest up to $1 billion in the best projects that doctors, hospitals, and other innovators propose to deliver high-quality medical care and save money. Projects that win this competition will use health care dollars more wisely, help create jobs, and help professionals improve the work they do for patients.

Innovation doesn’t happen in a vacuum and usually doesn’t start in Washington — we need the vision and experience of people who are already proving that our health care providers can and do provide better care and better health at lower cost. So we want to hear from you. Send us your innovative ideas and solutions, and submit a proposal outlining your vision for helping us transform the health care system. We’ll sort through these proposals and help put the best ones into practice.

If your proposal has strong evidence that it can start quickly, reduce costs, and improve health care, you can qualify for approximately $1 million to $30 million in an up-front investment. Priority is given to proposals that retrain workers and support job creation. You can find a fact sheet and the Funding Opportunity Announcement on our Healthcare Innovation Challenge Web page.

We’ll work with a wide variety of public and private organizations, including providers, payers, local governments, community and faith-based organizations, and other innovators whose compelling ideas can improve health care for patients. We are also looking for projects that help patients with the greatest health care needs, projects that can be up and running soon, and projects that rapidly hire, train and deploy health care workers.

For example, the Health Care Innovation Challenge could support the use of personal and home care aides to help the elderly stay in their homes or expanding the use of community-based paramedics to provide basic services to individuals in rural communities.

Different communities have different needs and circumstances—some require unique, locally driven innovations. With the Health Care Innovation Challenge, we hope to give providers even more opportunities to make our health care system even stronger.

We look forward to hearing your ideas on how to make this happen. For more information, you can also visit http://innovations.cms.gov/.

Filed under: CMS Center for Medicare & Medicaid Innovation

New Flexibilities Expand and Promote Partnerships

Centers for Medicare & Medicaid Services — Tue, 11 Oct 2011 15:33:01 +0000

By Melanie Bella, Director of the CMS Medicare-Medicaid Coordination Office

Cross-posted from healthcare.gov.

A top priority for this Administration is improving the quality and lowering the cost of care for the millions of Americans enrolled in both Medicare and Medicaid (known as “dual eligibles” or Medicare-Medicaid enrollees). The Affordable Care Act created the new CMS Medicare-Medicaid Coordination Office to improve the coordination and quality of care for Medicare-Medicaid enrollees. Through our work and with our State partners, our efforts are advancing to the next level.

Medicare-Medicaid enrollees are low-income seniors and people with disabilities. Although most have complex care needs, too often their care is fragmented, resulting in poor health outcomes and increased costs. When their primary care doctors and specialists coordinate their care, including their long-term care services and supports, these individuals get better health care at a reduced cost.

In July, the Medicare-Medicaid Coordination Office announced a new opportunity for States to participate in demonstration projects that will help improve the quality of care for Medicare-Medicaid enrollees. These approaches provide States the opportunity to share in reduced costs that result from improved quality.

We’re pleased to report that 37 States and the District of Columbia have indicated interest in exploring these demonstrations in their states. Across the country States are moving forward and proposing new ways to better serve their Medicare-Medicaid enrollees. These innovative initiatives vary regionally and in their approach, ranging from using health homes that provide total care management to expanding existing programs to meet all of an individual’s needs by incorporating behavioral health and long-term supports and services, as well as making current coordinated care models available to new populations, such as individuals with long-term care needs or those with serious and persistent mental illness. Two examples of these new approaches are:

Massachusetts is developing an innovative approach to ensure that enrollees under age 65 have one organization responsible for coordinating their medical and non-medical needs. In addition to integrating all Medicare and Medicaid services, enrollees would have new access to enhanced behavioral health services and community support services not normally available to this population in a traditional fee-for-service model. These services will help beneficiaries in the community and avoid unnecessary hospitalizations.

Oklahoma is expanding its efforts to coordinate care to better serve Medicare-Medicaid enrollees Statewide. Building on existing models, with newfound access to Medicare data and an opportunity to share in savings from care management investments, the State seeks to develop a person-centered approach that provides for the totality of an individual’s needs, through coordination of primary, acute, and behavioral health care as well as prescription drugs and long-term services and supports.

Over the next several months, we will be working closely with the States interested in further developing their approaches and will serve as a resource for any State interested in improving care for their Medicare-Medicaid enrollees. These models provide States and the Federal government with new flexibilities and pathways to make Medicare and Medicaid stronger. Together, with our State partners, we will continue our commitment to caring for the most vulnerable individuals we serve.

Filed under: Uncategorized