In The News: Doc Fix, Essential Benefits Package, Supreme Court to hear ACA Challenge in March

Quite an interesting weekend preceeding the holidays with new information released concerning the Essential Health Benefits Package, the Supreme Court agreeing to hear oral arguments on challenges to the Affordable Care Act in March 2012, oh, and that whole “doc fix” saga that just won’t go away!

Still No ‘Doc Fix’, Political Squabbling Continues After Senate Bill Passes    The House has rejected the bipartisan agreement reached in the Senate over the weekend that would have extended for two months the Social Security payroll tax cut and unemployment insurance, while averting a 27% reimbursement cut to physicians beginning January 1st. Both Republicans and Democrats have turned up the spin machine to talk about the failure of the other, meanwhile, the provisions listed above, that affect 95% of Americans, still weigh in the balance. The Senate has adjourned for the holidays, leaving the House to decide whether to pass the bipartisan Senate bill, or risk not extending these important provisions scheduled to expire on January 1st, 2012.  Read the key differences between the House and Senate bills here.

UPDATE: House Republicans appear to have relented and agreed to the 2 month extension of the important tax, unemployment and doc fix reimbursement provisions included in the bipartisan agreement passed by the Senate earlier this week.  The House will likely pass a similar version of the bill that will set up a full conference committee to negotiate a full year extension early next year. MORE

Update: CMS said Monday it would instruct its claims administrators to hold off processing claims for the first 10 business days of January to allow more time to end the impasse, which would last through January 17th.

HHS Punts Tough Decisions on ‘Essential Benefits’ Package Makeup to States  After spending more than a year “gathering input” from the Department of Labor, Institute of Medicine and industry stakeholders, the Department of Health and Human Services has decided to give individual states “wide latitude” in determining which benefits will be given “essential benefit” status by insurance companies when creating the minimum plans that can be sold on “state-based health exchanges” beginning in 2014.  The guidance, which also delays inevitably final federal rules on the issue, provides four choices for states to use in creating their benchmark plans:

  • One of the three largest small group plans in the state by enrollment;
  • One of the three largest state employee health plans by enrollment; 
  • One of the three largest federal employee health plan options by enrollment;
  • The largest HMO plan offered in the state’s commercial market by enrollment. 

More information about the new HHS guidance on the essential benefits package can be found here.

Medicaid RAC’s: More Challenges on the Horizon for O&P Providers (O&P Business News) One of the most aggressive tactics used by the Centers for Medicare and Medicaid Services (CMS) to recover overpayments under the Medicare program is the use of Recovery Audit Contractors (RACs). These Medicare contractors are incentivized financially to deny claims and have been an ongoing source of concern and frustration for health care providers in general, and O&P professionals in particular. RACs tend to target areas that are identified in reports issued by the Department of Health and Human Services (HHS) Office of Inspector General (OIG), which involve areas susceptible to high levels of fraud and abuse, such as in the DME industry. There are now permanent Medicare RACs in all 50 states and these RACs have already begun to address the DME and O&P fields. They are about to be joined by 50 additional auditors — the Medicaid RACs. MORE

Supreme Court Announces it will Hear Oral Arguments in ACA Case — The Supreme Court announced late last week they will hear oral arguments in the case challenging the constitutionality of the Affordable Care Act’s “individual mandate” provision in March of 2012.  Five hours, a nearly unparallelled amount in modern times, of debate has been scheduled and will be split into four sections:

1.) Debate on whether legal action is premature since the individual mandate and penalties won’t go into effect until 2014. 2.) Debate on the constitutionality of the individual mandate provision. 3.) Whether striking the individual mandate necessitates striking the entire Affordable Care Act and all related provisions. 4.) Whether the law goes too far in cohercing states to comply by choking off federal funding to existing programs.

With oral debate now set, a likely ruling by the Court will come in the summer of 2012, right in the middle of the President’s re-election campaign.  MORE

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