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Published 5/1/2011

Second Look—Advocacy

If you missed these Headline News Now items the first time around, AAOS Now gives you a second chance to review them. Headline News Now—the AAOS thrice-weekly, online update of news of interest to orthopaedic surgeons—brings you the latest on clinical, socioeconomic, and political issues, as well as important announcements from AAOS.

Medicare fraud prosecutions pay off
The U.S. Departments of Justice (DOJ) and Health and Human Services (HHS) have announced that federal fraud prosecutions resulted in more than $4 billion returned to the Medicare Health Insurance Trust Fund during fiscal year (FY) 2010—a $1.4 billion increase (56 percent) over FY 2009. The $4 billion includes $2.5 billion in settlements and judgments obtained by the DOJ for False Claims Act violations connected to healthcare fraud.

CMS issues proposed ACO regulations
The Centers for Medicare & Medicaid Services (CMS) has issued proposed rules for accountable care organizations (ACOs)—arrangements among healthcare providers designed to reduce healthcare expenses through improved care coordination. Under the rules, ACOs will be measured against a benchmark and will be rewarded financially for meeting quality standards and achieving cost savings. Quality is to be measured in the following areas: patient/caregiver experience of care, care coordination, patient safety, preventive health, and at-risk population/frail elderly health.

ACOs will enter into a 3-year participation agreement and must have a minimum of 5,000 beneficiaries, as well as primary care professionals. Unlike Medicare Advantage plans, patients will not sign up for an ACO but will be assigned to the one in which their primary care physician participates. The comment period for the CMS proposal runs through June; stakeholders, including providers and Medicare beneficiaries, may submit comments to CMS. The American Association of Orthopaedic Surgeons is reviewing the rules and plans to submit written comments.

MedPAC recommendations
The Medicare Payment Advisory Commission (MedPAC) has recommended that Medicare require physicians who order more imaging studies than their peers to obtain prior authorization for advanced imaging and that CMS reduce reimbursement for successive imaging studies performed during the same imaging session. According to one MedPAC analyst, 10 percent of physicians account for more than 50 percent of advanced imaging orders.

Virginia law protects ED workers
A law offering protection for emergency department (ED) workers will take effect in Virginia on July 1. The law calls for up to 15 days in jail for anyone who knowingly assaults an ED physician or nurse. ED physicians have argued that they are at a 400 percent greater risk of injury than the average worker and therefore deserve the same protections granted to paramedics and other emergency responders.

Successful e-prescribers and Medicare reimbursement
Under the Medicare Improvements for Patients and Providers Act of 2008, CMS can negatively adjust the pay of eligible professionals who are not determined to be successful e-prescribers based on claims submitted between Jan. 1, 2011, and June 30, 2011. In 2012, the adjustment will result in an eligible professional or group practice receiving 99 percent of their Medicare Part B Physician Fee Schedule amount. The adjustment will continue to increase on a yearly basis until 2014. Eligible professionals can avoid the 2012 payment adjustment if they:

  • Are not physicians, nurse practitioners, or physician assistants as of June 30, 2011
  • Do not have prescribing privileges
  • Do not have at least 100 cases containing an encounter code in the measure denominator
  • Become successful e-prescribers and report the e-prescribing (eRx) measure for at least 10 unique eRx events for patients in the denominator of the measure

Group practices participating in e-prescribing initiatives during 2011 are required to successfully report a number of unique e-prescribing events based on the size of the practice.

Two new bills to watch
Two new bills recently introduced in Congress could have significant implications for physicians. H.R.1409, the Quality Health Care Coalition Act of 2011, introduced by Rep. John Conyers (D-Mich.) would exempt healthcare professionals engaged in negotiations with a health plan for items or services from the Federal antitrust laws. Under S.756, the Medicare Data Access for Transparency and Accountability Act, introduced by Sen. Charles Grassley (R-Iowa), individual physician reimbursement information would be posted online on a government Web site containing Medicare billing data for all providers and suppliers, including physicians.