WEDI Presents Results of Recent Transactions Survey to NCVHS. WEDI was asked by the Centers for Medicare & Medicaid Services (CMS) to present the findings from our recent industry survey on the 008020 version of the X12 835 Electronic Remittance Advice and X12 837 Electronic Claim (Dental, Institutional, and Professional) to the National Committee on Vital and Health Statistics (NCVHS) Joint Meeting of the Subcommittee on Privacy, Confidentiality and Security and the Subcommittee on Standards. Respondents to the WEDI survey indicated support for the updated versions of the transactions and highlighted the potential cost associated with the changes. WEDI Board Chair Ed Hafner and Chair-Elect Merri-Lee Stine presented the results of the survey to the NCVHS. Special thanks to WEDI Claims Sub Workgroup Co-Chairs Beth Davis (Veradigm PayerPath), Stanley Nachimson (Nachimson Advisors), and Chuck Veverka (Kunz, Leigh, and Associates), and the Co-Chairs of the Remittance Advice and Payments SWG, Pam Grosze (PNC Bank) and Pat Wijtyk (Cognizant), and members of both SWGs for developing the survey and slide deck. Go here to download the NCVHS presentation.
Key Congressional Committee Passes Telehealth Extension Legislation. The U.S. House of Representatives Energy and Commerce Committee passed the Telehealth Modernization Act of 2024 (H.R. 7623). The legislation seeks to make permanent certain telehealth flexibilities under the Medicare program. The bipartisan bill was introduced by Rep. Carter (R-GA) and is co-sponsored by 19 Representatives (10 Democrats and 9 Republicans). The Committee vote was unanimous. The legislation now moves to the full House for consideration.
CMS Creates Qualified Health Plan (QHP) Directory Pilot. In partnership with the state of Oklahoma, CMS has initiated a Qualified Health Plan (QHP) directory pilot program. The pilot project aims to develop an automated statewide centralized directory for qualified health plans and providers in the state. The goal of the pilot is to develop an automated, single, statewide centralized directory for QHPs and providers in Oklahoma. The expectation is that the program will result in improved data accuracy, reduced burden on providers and plans, lowered administrative costs, enhanced interoperable data exchange, and improved patient and provider experiences. The pilot also seeks to inform future efforts for a National Directory of Healthcare. Read more here.
CMS Identifies ACO REACH Model Claims Issue. CMS announced an issue that occurred on July 26, 2024, that affected some 2021 – 2024 professional claims for the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model. The agency indicated it is working with the Medicare Administrative Contractors (MACs) to correct this issue. According to CMS, the MACs will reconcile the impacted claims, including adjusting or refunding amounts owed and recouping funds CMS paid in error. CMS encourages impacted providers to contact their MAC with any questions or if additional information is needed.
CMS Launches TCET Pathway. CMS recently launched a new initiative called the Transitional Coverage for Emerging Technologies (TCET) pathway that will encourage greater medical innovation while giving people with Medicare faster and more consistent access to the latest technologies. TCET was developed through collaboration with the medical device industry, physicians and other clinicians, patient groups, and other stakeholders and builds on the existing Medicare coverage review process to provide an efficient, predictable, and transparent coverage pathway for certain Food and Drug Administration (FDA)-designated Breakthrough Devices. For devices in the TCET pathway, CMS’ goal is to finalize a coverage decision within six months after FDA market authorization.
The TCET pathway will also help coordinate other aspects of Medicare payment – such as benefit category determination, coding, and payment reviews – which will further expedite access to these devices for people with Medicare. According to CMS, TCET is an example of how engagement with stakeholders can result in new initiatives that can benefit people with health care needs, the people who serve them, and industry innovation. CMS gathered extensive feedback from patient groups, medical professionals, device manufacturers, innovators, and other federal agencies to develop this new coverage pathway. Go here to learn more about the TCET pathway.
Study Suggests US Lags Behind Other Nations in Health Care, Administrative Efficiency. The Commonwealth Fund has released its new report Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System-Comparing Performance in 10 Nations. The analysis includes 70 health system performance measures for the 10 nations in five areas: access to care, care process, administrative efficiency, equity, and health outcomes. The US ranked last in overall health system performance, and 9th in administrative efficiency. The administrative efficiency measures in the report center on the challenges clinicians experience in dealing with insurance or medical claims issues; requirements for providers to report clinical or quality data to governmental agencies; and patients’ time spent resolving medical bill disputes and completing paperwork.
Study Examines the Value Teaching Hospitals Bring to ACO Beneficiaries. A study was published in the American Journal of Managed Care entitled “What Value Do Teaching Hospitals Provide Commercial Beneficiaries When in an ACO?” Researchers examined commercial claims data from 2019 to 2021 to compare beneficiaries attributed to participants in Medicare Shared Savings Program ACOs with and without a major teaching hospital. The study found that, compared with per-beneficiary rates at nonteaching ACOs, major teaching ACOs have lower mortality rates by up to 2.2 percentage points depending on the patient age group, $283 lower inpatient spending, and lower emergency department utilization in inpatient and outpatient settings.
ASTP ONC Announces Real World Testing Submission Window Now Open. The Assistant Secretary for Technology Policy, Office of the National Coordinator for Health IT (ASTP ONC) announced the opening of the Real World Testing submission window. The submission window runs through December 15, 2024. Developers with Health IT Modules certified to eligible Real World Testing criteria as of August 31, 2024 are required to submit a Real World Testing plan for 2025. Developers should check with their ONC-ACB to determine eligibility and learn more about their specific submission deadlines for this fall. Health IT developers can go here for the Real World Testing Resource Guide and here for the Real World Testing webpage.