2005 Reimbursement Updates
November 9 - 10, 2005 - MDMA Reimbursement Conference Big Success
MDMA hosted its 8th Annual Coverage and Reimbursement conference at the Hyatt Regency on Capitol Hill. The two-day event was a big success as there were more than 100 people in attendance. The conference kicked off on Wednesday afternoon with an interactive Reimbursement 101 & Your Business Plan session hosted by Maren Anderson, President of MDA Consulting. Thursday included an opening address from Mark Miller, Executive Director of MedPAC, and then a series of panel discussions on subjects including trends in evidence development at CMS and FDA, payment factors in the prospective payment system, CPT and coding developments and pay for performance vs. device contract gainsharing. The day wrapped up with a Capitol Hill update on Medicare policy, presented by Joel White, Staff Director for the House Ways and Means Committee, Subcommittee on Health, and Pat Bousliman, Acting Director, Senate Finance Committee Democratic Health Staff.
Click here to view the agenda and list of our sponsors.
November 2, 2005 – CMS releases OPPS Final Rule for CY 2006
On November 2nd, CMS issued the Outpatient Prospective Payment System Final Rule for Calendar Year 2006. The new rates for hospital outpatient services will become effective on January 1, 2006. MDMA was pleased to see that CMS agreed with our comment and decided not to adopt the proposal that would have required a medical device manufacturer to submit an application to the AMA’s CPT Editorial Panel for a new technology service when applying to CMS for a New Technology APC. In addition, MDMA was pleased that CMS adopted the APC Panel’s recommendation to delay implementation of the multiple diagnostic imaging procedure reduction. MDMA will continue to encourage CMS to use confidential external data when setting or adjusting median costs for device-dependent APCs.
To read the OPPS Final Rule, please click here.
To read CMS’s press release, please click here.
September 15, 2005 – MDMA submits comments on the 2006 Hospital Outpatient Prospective Payment System proposed rule.
MDMA submitted comments on the Hospital OPPS proposed rule which CMS released on July 18, 2005. The Final rule is scheduled to be published by November 1, 2005. In MDMA’s comments we praised CMS for its proposal to eliminate the requirement that a device be implanted through a surgical incision in order to qualify for pass-through payment. In addition, we voiced the following concerns: 1) volatility in the OPPS payment rates; 2) perpetuation of inappropriate payment levels based on flawed data; and 3) the numerous barriers in place for qualifying for pass-through and new technology APCs.
To read MDMA's comments to CMS please click here.
To read the OPPS proposed rule, please click here.
To read CMS’s OPPS press release, please click here.
Second Biannual Meeting of the Advisory Panel on Ambulatory Payment Classification (APC) Groups: August 17 – 19, 2005
The second biannual meeting of the APC Advisory Panel for 2005 will be August 17 – 19, 2005 at CMS headquarters in Baltimore, MD. The Panel will review the APC groups and associated weights to advise the Secretary of HHS and the CMS Administrator about the clinical integrity of the APC groups and their associated weights. The Panel's advice will be considered by CMS as it prepares updates to the hospital Outpatient Prospective Payment System through rulemaking. Attendees must register by August 8, 2005.
Comments, suggested agenda topics, and hardcopy presentations must be received by CMS by August 1, 2005 at 5:00 p.m. EDT. All comments and presentations must be submitted in hardcopy and electronically and be accompanied by Form CMS-20017. CMS will not accept comments or presentations by fax.
Click here to read the APC Panel's recommendations to CMS.
Click here to read a copy of MDMA's comments to the APC Advisory Panel.
Click here for a copy of the Federal Register notice for the APC Panel meeting.
July 25, 2005 - CMS Issues Quality Improvement Roadmap
CMS issues long awaited Medicare roadmap articulating it's vision to lower costs and increase efficiency. In the Quality Improvement Roadmap, CMS features five strategies to achieve high quality care, “care that is personalized, prevention-oriented, and patient-centered, and based on evidence about the benefits and costs for each particular patient.” CMS states that “high-quality care is the only kind of care we can afford” and in order to achieve this goal it is willing to pay more for higher-quality, efficient care.
To read the full text of the document, please click here.
June 24, 2005 - MDMA submits comments to CMS on FY 2006 IPPS Proposed Rule
MDMA submitted to the Centers for Medicare and Medicaid Services (CMS) its comments on the FY 2006 Inpatient Prospective Payment System Proposed Rule. MDMA made the following recommendations to CMS in its letter:
- Create a more transparent, open, and predictable process when evaluating new technologies for add-on payment status;
- Minimize the need for new technology add-on payments by expediting correct DRG assignment for technologies once they are approved;
- Expand the definition of “new” so that there is greater flexibility to acknowledge that FDA approval, ICD-9 coding and the manner and timing by which products are introduced are all considered;
- Reconsider the substantial clinical improvement requirement for new technology add-on payments;
- Increase the payment level of new technology add-ons to more accurately reflect the device cost and CMS payment levels within the IPPS;
- Maintain confidentiality of external data;
- Carefully analyze and conduct a public, comprehensive review of the MedPAC recommendations and the Complications and Co-morbidities list to minimize dramatic shifts in revenue for hospital providers that may adversely impact patients; and
- Expedite the introduction of ICD-10.
Click here to read the full text of MDMA’s comments to CMS.
To read the 2006 Final rule for IPPS please click here.
To read the 2006 IPPS proposed rule, please click here.
June 6, 2005 - MDMA submits Coverage with Evidence Development (CED) comments to CMS
MDMA submitted comments to CMS in response to CMS’s draft guidance document on factors CMS considers in making a determination of coverage with evidence development (CED). The main points which MDMA articulated to CMS in the letter include: the importance of CMS working with industry to define the clinical questions that need to be answered so that efforts aren’t duplicated and manufacturers have some certainty about the duration and scope of the effort required to secure Medicare coverage and that decisions about whether or not to apply CED are made in an open and transparent way. Furthermore, MDMA reiterated to CMS the costliness of imposing data collection requirements. MDMA urged CMS to apply CED in limited circumstances and to continue utilizing the local coverage process to determine a technology’s clinical significance.
Click here to read the full text of MDMA’s letter to CMS.
Click to read CMS's draft CED guidance document.
Click to read CMS's response to stakeholder feedback regarding CED draft guidance.
To read public comments CMS received on the CED draft guidance, please click here.
May 6, 2005 - MDMA submits comments to CMS regarding: Factors CMS considers in opening a National Coverage Determination (NCD); Factors CMS considers for requesting a Medicare Coverage Advisory Committee (MCAC) referral for an NCD; and Factors CMS considers for requesting an External Health Technology Assessment (TA) when making an NCD.
Click here to read NCD draft guidance.
Click here to read draft guidance on referring to MCAC.
Click here to read draft guidance on refering for an External Technology Assessment.
January 13, 2005 - MDMA submits comments to CMS regarding Device Categories and changes to Ambulatory Payment Classification.