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Welcome to the weekend and to all you dads I hope you have a wonderful Father’s Day. Thanks for checking in.

We’re bringing you the news from the past week as well as providing you with a look at the week ahead. 


HCC Code Story Sparks Interest

“Doubt Cast on HCC Risk Score to Predict Payments,” by Frank Cohen in Thursday’s RACmonitor e-news generated a lively discussion. 

In particular, the sentence “In general, HCC codes are used by Medicare to negotiate payment rates for Medicare Advantage (MA) plans,” caught the attention of Dennis Bryon who wrote to us, in part: 

“The per-capita monthly fee received by each public Part C health plan (of which Medicare Advantage is one type) is not negotiated at all. The government sets a benchmark per county and the plan bids against that benchmark. That benchmark is based on what was spent on people on Medicare Parts A and B in that county the previous year (or possibly most recent year for which data is available). If the bid meets certain criteria (most do) then the plan uses the money it will receive as a per-capita fee based on that bid to set a monthly premium for the plan. If the bid is lower than a certain amount, it gets a little more complicated but basically the same process is followed to get to the premium cost. That bidding process — primarily based on Medicare Part A and B costs by age and sex not risks — establishes on average 99% of what the insurance plan receives per capita for people that sign up for the plan.

After people sign up for the plan, risk adjustment — estimated to account for 1% of the money public Part C Medicare health plans receive on average — takes place based on the health of the people that signed up. Some of the per-capita adjustments are up. Some are down.” 

Frank Cohen is scheduled to discuss HCC codes on Monitor Mondays this coming Monday, June 20, 10-10:30 a.m. ET


Preview of Upcoming Stories 

Here’s a preview of stories we’re working for next Thursday’s edition of the RACmonitor eNews:

Provider-Based Rule: Questions and Interpretations

By Duane Abbey, PhD

The Provider-Based Rule (PBR) is codified by the Centers for Medicare & Medicaid Services (CMS) at 42 CFR §413.65, along with the supervision regulations at 42 CFR §410.27. Guidance for the PBR has morphed since the rule was formally established through the April 7, 2000 Federal Register. Guidance relative to the PBR continues to evolve, with the CMS regional offices (ROs) focusing on different issues. For instance, interpretations of the propriety of shared space and under-arrangement operations have occasionally become issues. Sometimes hospitals must establish policies without specific guidance, even at the subregulatory level. Thus, maintaining compliance with the PBR and associated requirements is difficult because hospitals are dealing with a moving target. 

Manual Medical Review

By Nancy J. Beckley, MS, MBA, CHC

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through Dec. 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. MACRA eliminated the requirement for manual medical review of all claims exceeding the thresholds and instead allows for a targeted review process.

Upcoming Webcasts

New Strategies That Are Removing Rural Health from Life Support

Presented By Janelle Ali-Dinar, PhD
Thursday, June 23
1:30-2:30 PM ET

Rural healthcare authority Janelle Ali-Dinar, PhD, is producing a webcast for RACmonitor readers on the state of rural facilities. The presentation will address rural precision medicine, advanced diagnostics, and population health methods/services of treatment to bridge the gap of care for the most critical needs of rural populations including chronic disease management, opioid abuse, and medication management and premature deaths. Register here.

esMD: The Best News Yet from CMS

Complimentary Special Edition Broadcast
Sponsored by VYNE
Tuesday, June 28
1:30-2:30 PM ET

esMD, electronic submission of medical documentation, can cut turnaround time, reduce labor and hard costs, and even begin to realize significant financial savings. This exclusive webcast will feature Joyce Davis, deputy director for the Electronic Submission of Medical Documentation Program in the Office of Financial Management Provider Compliance Group. Rudy Braccili, Jr., MBA, executive director of revenue cycle services for Boca Raton Regional Hospital in Boca Raton, Fla. and Nicole Smith, vice president of operations and government services at Vyne. Register here.

Incident-To Services That Can Hemorrhage Your Facility and Physicians

Presented By Michael G. Calahan, PA, MBA
Thursday, July 14
1:30-2:30 PM ET 

Incident-to services are increasing, making them “low-hanging fruit” for federal auditing entities. Getting incident-to rules wrong can cost your facility or physician practice hundreds of thousands of dollars during federal audits. Learn the top ten federal audit targets have could ravage your potential revenue. Register here.


Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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