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A new brief from the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured examines how states in every region have responded to five key opportunities available under the health reform law to help them prepare for the significant expansion of Medicaid in 2014. The options covered in the brief include incentives for states to get an early start on the Medicaid coverage expansion; increased federal funding to upgrade Medicaid eligibility systems; money to improve care for beneficiaries with chronic conditions by providing “health home” services; special funding for chronic disease prevention; and help in developing service delivery and payment models that integrate care for beneficiaries who are dually eligible for Medicare and Medicaid. 

The new brief is available online. 

The Kaiser Family Foundation, a leader in health policy analysis, health journalism and communication, is dedicated to filling the need for trusted, independent information on the major health issues facing our nation and its people. The Foundation is a non-profit private operating foundation, based in Menlo Park, California. 

James Carroll, for HealthLeaders Media, May 17, 2012

A recent spate of Office of Inspector General audit reports calls into question some programs from the Centers for Medicare & Medicaid Services. It remains uncertain why the release of these audit reports have come within such a short window of time, but the fact that they are occurring should be an indication that CMS’s methods and processes are far from perfect.

The following is a look at some of the recent OIG critiques of CMS.

Audit MIC performance

An early assessment of the efforts of Audit Medicaid Integrity contractors to identify overpayments in Medicaid, generated this report. Released on March 20, it indicates that only 11% of the study-assigned audits were completed with findings of $6.9 million in overpayments, $6.2 million of which resulted from seven completed collaborative audits involving Audit MICs, Review MICs, states, and CMS.

This leaves 81% of audits in which the MICs were unable or unlikely to identify any underpayments or overpayments. The OIG deduced that problems with the data used and analyses conducted by Review MICs and CMS to identify audit targets hindered the performance of the Audit MICs.

In addition to showing the ineffectiveness of the Audit MICs, this report also may provide an early look at what to expect with Medicaid RACs. William Malm, ND, RN, CMAS, senior data projects manager at Craneware, Inc., based in Edinburgh, Scotland with a US office in Atlanta, suggests that the report essentially verifies CMS concerns about the Medicaid RAC proposed and final rules.

"States are having difficulty auditing on the Medicaid side due to the diversity and complexity of the regulations, and the lack of billing specifics in the individual state guidelines," Malm says. "These business practices have not been well documented and there is no defensible source authority to proclaim that something is an overpayment or an underpayment."

Report on CERT errors overturned through appeals 

On March 9, the OIG published a review of the comprehensive error rate testing errors overturned through the appeals process for fiscal years 2009 and 2010. The report details the OIG’s review of the Medicare fee-for-service error rate, which is calculated by CMS and used in the estimate of improper payments that CMS submits to Congress each year.

CERT claim payment denials overturned after the cutoff date for determining the error rate for each fiscal year would have reduced the reported error rates from 7.8% to 7.2% for FY 2009 and from 10.5% to 9.9% for FY 2010, according to the report.

Approximately 5.5% of the CERT claim payment denials for FY 2009 and 7.6% for FY 2010 were overturned during one of the first three levels of the appeals process, but if these overturned CERT claim payment denials had been included in the initial error-rate calculations, the estimated value of reported errors for FYs 2009 and 2010 would have decreased by approximately $2 billion each year, according to the report.

In other words, the OIG report determined that the methodology used by CMS in calculating the error rate is flawed, which led to CMS overstating the amount of improper payments by approximately $2 billion in both 2009 and 2010. CMS failed to account for some providers’ successful appeals from denials issued by the CERT contractor, which led to the overstating.

Good news for providers

In an odd way, this is good news for providers in the sense that the OIG has publicly announced that the error rate is flawed, but unfortunately this information is unlikely to reach the audience that it should, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

"In general, the public hears so much from the media about how providers have bilked the Medicare and Medicaid system out of billions of dollars," she says. "We rarely hear a follow-up story like this that shows that what was originally published is not accurate. A $4 billion error is a considerable overstatement by any account."

The other good news for providers is that this report shows that provider appeals are successful, which should add a little fuel to their fire, according to Mackaman.

"Providers should be encouraged by this report and continue to appeal denials when appropriate and cost-effective to do so," she says. "It also might not be a bad idea for providers to lobby their own local media and congressional members to make sure that this side of the story is also told."

CMS’s Medi-Medi program

Though it’s not a CMS audit program, the Medicare-Medicaid data match program (Medi-Medi program) was also reviewed by the OIG in a report released on April 17. This program enables program safeguard contractors and participating state and federal government agencies to collaboratively analyze billing trends across the Medicare and Medicaid programs to identify potential fraud, waste, and abuse.

In the report, the OIG analyzed data from 2007 and 2008 that was collected from CMS, PSC, State Medicaid program integrity agencies, and other federal and state agencies participating in the program. The review found that the Medi-Medi program produced limited results and few fraud referrals.

During 2007 and 2008, the 10-state voluntary program received $60 million in appropriations and avoided and recouped $57.8 million. It produced 66 referrals to law enforcement and law enforcement accepted 27 of these referrals. Among the 10 participating states, each State averaged 2.8 Medicare referrals to law enforcement per year and law enforcement accepted an average of 1.15 referrals per state per year.

Few fraud referrals

In comparison, each state averaged 0.5 Medicaid referrals to law enforcement per year; law enforcement accepted an average of 0.2 referrals per state per year, according to the report. As a result of these findings, the OIG recommended that CMS reevaluate the goals, structure and operations of the Medi-Medi program to determine what aspect of the program, if any, should be part of CMS’ overall program integrity strategy.

CMS agreed with the OIG’s assessment, stating that since the period of the review, it has made significant strides in enhancing the effectiveness of the Medi-Medi program, but the OIG states that CMS has yet to provide any data to illustrate the enhanced effectiveness of the program.

Providing this data would enable Congress to make an informed decision whether to continue to fund the program and enable State and Federal agencies to make an informed decision on whether to participate.

By Shaun Heasley | May 15, 2012

With a number of parents turning to the courts to sue after unexpectedly giving birth to a child with a disability, several states are considering legislation to ban “wrongful birth” suits.

Lawmakers from Arizona to New Jersey are looking to sharply limit the ability of parents to pursue legal action against doctors when their children are born with conditions ranging from Down syndrome to genetic diseases like Tay-Sachs.

The efforts come just months after an Oregon couple made headlines when a jury awarded them almost $3 million over claims that their daughter was born with Down syndrome despite assurances from doctors that prenatal testing for the condition came back negative.

Proponents of the bills argue that parents should not be able to bring a case under the presumption that the life of a child with a disability is somehow worth less than others.

Parents who have brought such suits counter, however, that for them the issue comes down to quality of life for the child.

Critics of the bills say they’re also concerned that by banning “wrongful birth” suits, lawmakers could open the door for doctors to withhold information from parents without facing any recourse, reports NPR. To read more click here.

Printed from Disability Scoop

KidsWell Florida is a new statewide campaign organizing families, service providers, businesses, civic leaders, and others to improve public policies so all kids have access to affordable, quality health care.

 

The webinar will discuss:

Florida’s child health coverage gaps

State and federal opportunities to expand access to coverage

How KidsWell Florida will lead the effort to get all kids covered

KidsWell Florida includes Florida CHAIN, the Children’s Movement of Florida, the Florida Center for Fiscal and Economic Policy, the Children’s Trust of Miami-Dade County, and the Florida Children’s Healthcare Coalition. 

NOTE: The Twitter hashtag for the webinar is: #KidsWellFLCoversAllKids 

Click here to register for webinar.

Bill Cotterell, 05/08/2012, the Current Florida

Kevin Cate, a public relations and campaign adviser, said his survey of legislative staff shows that personal contact matters most. 

Going to see legislators in person with a personal message about how a bill affects their home districts is still the best way of influencing what happens in Florida's Capitol, according to an insider survey of House and Senate staff members.

The staff survey by Kevin Cate, a governmental public relations and campaign adviser, shows that cranking out form letters or bombarding lawmakers with identical emails are probably the worst ways of getting their attention. And "new media" -- especially Facebook -- are increasingly influential for those who know how to use it, Cate said Tuesday.

"Never under-estimate the power of a person with acompelling story to tell," Cate told an interviewer. "Despite what people believe about bundling campaign money and the shady reputation of Tallahassee, there is nothing more important than an advocate with information to rise to a level of importance for lawmakers."

Cate asked 52 House and Senate aides what influences their bosses the most. He said "in person visits" were cited by more than 99 percent of the staffers, followed by personal letters (97.7 percent) and individual emails (93.2 percent). Phone calls and visits by a designated member of an interest group also outscored visits by lobbyists -- who were still in the 95th percent range.

News media endorsements also were rated highly by legislative staff, but "comments on social media sites" were cited by about two-thirds of the veteran aides.

"Facebook is the most effective way for lawmakers to gauge public opinion," said Cate.

Putting bundles of mail on a lawmaker's desk has traditionally be considered a good way of exerting pressure, but Cate found that form letters, postcards and petitions were not as highly regarded as the personal touch. And he said it's important for citizens to have a personal story or data to show how a government decision will affect a legislators' constituents.

That was demonstrated in the past session when the Department of Corrections moved to close Jefferson Correctional Institution. With 167 jobs, the prison is the largest employer in Jefferson County, so city and county officials banded together to bring scores of families to the Capitol, pleading with budget writers to spare the prison -- and they succeeded.

Cate said the outpouring of public concern about Florida's "Stand Your Ground" law, following the Trayvon Martin shooting in Sanford, was another example of personal contact causing legislators to feel pressure from both sides of the gun issue.

Veteran lobbyist Barney Bishop, former CEO of Associated Industries of Florida, said he was not surprised by Cate's findings. Even lawyers with mounds of statistics and polling data can't compete with a well-organized show of strength from a legislator's district, he said.

"The Legislature sees us lobbyists all the time," said Bishop. "That's why a good lobbyist brings the clients into town -- and it's extremely important that the hometown folks go see the legislators back there, too. They'll have more time to talk, more focus, because up here they can only talk with you for a little while, then they got somebody else pressing to see them."

Cate, who has worked for several Democratic officeholders and candidates, said his Internet-based survey of legislative staffers tilted Republican -- about 79 percent of those polled worked for GOP members. That is a somewhat higher than the proportion of Republicans to Democrats in the House and Senate.

And where do legislators get their most influential information?

Cate's survey said almost all staffers rated public events, personal contacts and "town hall" forums as the most effective ways legislators gather information. But Facebook was cited by 71 percent and 60 percent rated Twitter either "effective" or "very effective."

No matter the means of reaching a legislator, Cate said the message matters most.

He said almost four out of five legislative aides in his survey believed a personal story of how a bill would affect a constituent was most effective, followed by more than three-fourths who said the impact of legislation on a legislator's local community was most effective.

By Christine Jordan Sexton, 05/08/12 © Health News Florida

While Florida waits to see whether the Supreme Court will kill the Affordable Care Act, a state agency is laying the groundwork to carry it out, just in case.

The Agency for Health Care Administration today will answer questions from  companies that have shown an interest in competing for a $700,000 study on creating a modern Medicaid information system. The IT system needs to be able to  handle not just the current job, but the health insurance exchange called for under the federal health law.

Answers to the questions will help guide whether the companies will respond to the bid by the May 22 deadline. The agency plans on awarding the contract by June 12. It wants the study completed by July 30.

That leaves the winner only seven weeks  to do the work. If the company can’t meet the deadline for the final report it could be fined upward of $5,000 per day. There also are fines if the vendor misses weekly meetings with the agency or  draft report deadlines.

The tight time line isn't the only difficulty, industry experts say.

Companies are barred from participating if they  implement any information technology systems, conduct any project management or provide technology integration services. The conflict-of-interest language in the request for proposals is taken directly from the law the Legislature passed.

Danny Jordan, a lobbyist for 180 Consulting in Tallahassee, said that while it may be a laudable goal to have no potential conflict, most technology companies do some of the work that is banned, including project management.

“If you look at those requirements, I don’t have anybody who can do (the feasibility study),” said  Jordan, who represents KPMG, CGI Technologies and Solutions, and Ciber, among others. “They all do at least one or all three of those things.”

The money for the study, as well as the $30 million in state revenue needed to build the IT system, was included in the budget that Gov. Rick Scott approved in April.

Florida is updating the computer system that determines whether applicants for Medicaid or Florida KidCare are eligible because it is out-of-date and no longer complies with federal requirements.

The system being planned also needs to be capable of serving as the platform for a health insurance exchange, as called for under the federal health law.  Florida is leading a multi-state challenge to the law, now pending before the U.S. Supreme Court.

While loathe to implement a law they think is unconstitutional, Florida’s Republican lawmakers passed language allowing the state to establish an exchange if the court lets the law stand.

“I have to prepare for every scenario,” said Rep. Matt Hudson, Naples Republican who chaired the House Health Care Appropriations Subcommittee.

And lawmakers let die a Senate Memorial--1840-- urging Congress to stop funding planning grants that make state operated health insurance exchanges a possibility.The measure was sponsored by Senate Health Regulation Committee Chairman Sen. Rene Garcia, R-Hialeah.

Under the Affordable Care Act, every state is required to have an exchange, a place where those who don’t have employer-sponsored insurance can shop. If the state does not implement one, the federal government will.

Those who shop on the exchange can get subsidies if their income falls below certain limits, which depend on the size of the family.

After the 2010 elections, the Republican-led Legislature and Gov. Rick Scott had ordered the state to halt any efforts associated with implementing federal health reform.  Prior to Scott’s election Florida health care planners had applied for, and received, a $1 million planning grant for an insurance exchange. After Scott got elected, the state never used the grant money.

The new system must be completed by October 2013 and be operational by January 2014, dates that dovetail with requirements for the federal health insurance exchange.

Specifically, AHCA’s request for proposals requires the winning vendor to study whether to invest money to improve Florida’s current eligibility determination system  or scrap it and develop a new one. The current system is called ACCESS, for Automated Community Connection to Economic Self Sufficiency Florida.

AHCA asked vendors to submit any questions regarding the $700,000 contract in writing to the agency by May 1. Spokeswoman Shelisha Coleman said the agency received some questions, but she declined to discuss them until their release today.

--Christine Jordan Sexton, an independent journalist in Tallahassee, can be reached at             850-251-0358       or by e-mail. Health News Florida is an independent online publication dedicated to journalism in the public interest.

By Michelle Diament, May 3, 2012, disabilityscoop

The panel responsible for crafting new diagnostic criteria for autism, intellectual disability and other disorders is seeking public comment for a third and final time.

The American Psychiatric Association said Wednesday that it will accept public comments now through June 15 on proposed changes for the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders. The first revision in more than a decade to what’s considered the bible of mental health disorders, the new edition of the manual is expected to be published in May 2013.

Among the most controversial proposals is a dramatic change to the definition of autism. Those behind the DSM are looking to fold autistic disorder, Asperger’s syndrome, childhood disintegrative disorder and pervasive developmental disorder, not otherwise specified under one umbrella diagnosis of “autism spectrum disorders,” with diagnosticians indicating a level of severity associated with an individual’s condition.

In order to qualify under the new criteria, individuals would have to exhibit specific types of deficits in socialization as well as behavior.

The change has many in the autism community worried after a study released earlier this year found that a significant number of people currently diagnosed with autism may be stripped of the label under the new definition, potentially leaving them without needed services.

Nonetheless, the DSM panel tasked with revising the autism diagnosis is standing firm on their proposal. In a commentary published in the April issue of the Journal of the American Academy of Child & Adolescent Psychiatry the group said that preliminary results from field tests on the proposed changes found the criteria to be “sensitive and specific.”

In addition to the autism changes, the DSM committee has also proposed replacing the term “mental retardation” with “intellectual developmental disorder,” reflecting a shift that many government entities and education institutions have already undertaken in recent years. What’s more, the criteria for the condition would also be altered to focus more heavily on mental abilities and adaptive functioning skills rather than IQ alone.

Other conditions slated to be changed in the forthcoming DSM include those related to communication, socialization, motor skills and behavior.

Two previous DSM comment periods in 2010 and 2011 have already netted nearly 10,800 responses, which led to some alterations to the proposals, officials with the American Psychiatric Association said.

“The comments we have received over the past two years have helped sharpen our focus, not only on the strongest research and clinical evidence to support DSM-5 criteria but on the real-world implications of these changes,” said John Oldham, president of the organization.

Once the current public comment period comes to a close, those behind the DSM revision will incorporate any additional feedback in their final recommendations which are expected to go before the psychiatric organization’s board in December, officials said.

By Tovin Lapan, Las Vegas Sun, Sunday, April 29, 2012 

When a child is diagnosed with a disability, parents often feel isolated undefined especially as the child enters school.

Instead of stocking a pencil case with school supplies and purchasing an X-Men lunch box, parents of a child with disabilities are working with school officials on a course of action for the child’s educational needs, collaborating with therapists and taking a crash course on the ramifications of the diagnosis.

Add a language barrier to that process, and the parents can get lost as they try to navigate the maze of available services and determine the best educational track for their child.

“A lot of families, when they first receive the diagnosis, feel like they are alone,” said Cynthia Escamilla, who runs a Spanish-language support group at Nevada PEP, a nonprofit organization that works with parents of children with disabilities. “The whole process can be intimidating. If Spanish, or some other language, is your first language, it can be frustrating. You are navigating a culture and system that is unfamiliar. Parents don’t get all the information they need, and they feel isolated.”

Nevada PEP is one of the Southern Nevada organizations offering services for parents of disabled children, and one of the few offer programs in Spanish. There is a monthly parents support group, and also training courses in Spanish, such as an upcoming anti-bullying session.

“Every disabled child is eventually a victim of bullying,” Gonzalo Loya, a member of the support group, said in Spanish. “That is a big topic at meetings. We get so many parents who arrive frustrated. A lot of time is spent on helping people navigate the system and sharing information. It’s tough to find help in Spanish, and a lot of this stuff is very complicated.”

Last year Loya, with the help of Nevada PEP, was able to arrange a new assessment for his 9-year-old son, Jovy. Loya felt like Jovy was still not in the right program. In Arizona, Jovy had been diagnosed with attention deficit hyperactivity disorder, Loya said. Later, Jovy was diagnosed as autistic and was placed in a special education class in Las Vegas.

“He is very intelligent but has problems controlling his movements,” Loya said about Jovy. “He is very advanced from an academic standpoint, but his social skills are unfocused. He was in a special education class with kids with much stronger problems, and he was falling behind academically.”

After Loya pushed for a new evaluation, Jovy was reassessed, and it was determined that he fell at the less severe end of autism spectrum. Jovy was finally diagnosed with Asperger’s syndrome, which is characterized by difficulties in social interaction accompanied by repetitive patterns of behavior and interests but typically allows for normal cognitive and linguistic development. Jovy was moved into a regular class at C.P. Squires Elementary School but still has a therapist who works with him when he has an episode of uncontrolled or disruptive behavior. He also meets with the therapist throughout the week.

“I came to Nevada for work,” said Loya, who is a computer technician. “But I lived in Texas and Arizona, and the level of services there was much better. Here, it is not very personal, and the level of education is very low.”

Just as Nevada ranks low among state spending on education per student at every level, the state also ranks near the bottom for special education funding. A May 2011 report on special education from Fordham University placed Nevada well below national averages for per-pupil spending and teacher-to-student ratio.

Funding for special education comes from the federal, state and local governments, and Nevada has increasingly pushed the burden toward local districts.

A 2009 Nevada Department of Education report on special education pointed to a 14-year trend of reductions in state support, noting the state portion of special education funding fell from 56 percent in 1988 to 35 percent in 1994 and 23 percent in 2008.

“The diminishing level of support creates a vulnerability to legal challenges on the basis of ‘adequacy,’” the report concluded, referring to federal guidelines for providing an “adequate” level of education to all students.

That is where organizations like Nevada PEP, a nationwide nonprofit organization with offices in every state, comes in. Nevada PEP, where most of the employees have family members with disabilities, strives to empower and educate parents, and provide them with the tools they need to take control of their child’s education and treatment.

“We work with parents of children with disabilities from birth until age 26,” said Robin Kincaid, Nevada PEP’s training director. “Sometimes families feel like they don’t have many options. It’s not just early schooling but later in life, too. Does the child plan to go to college? What will they do after high school? What kind of jobs might they train for?”

In Southern Nevada, Milagros Escondidos (Hidden Miracles) also works with Spanish-speaking people with disabilities and their families, and Talk About Curing Autism and Families for Effective Autism Treatment are two autism-specific organizations.

“We hear about a wide range of issues,” said Guadalupe Alvarez-Cerna, one of Nevada PEP’s bilingual staff members. “We here about a lot of bullying issues. Sometimes parents will formally request something in a letter, but the school won’t take it because it’s in Spanish. Well, they have to accept it. Sometimes they just say they don’t feel welcome.”

Olivia Espinosa, who participates in the support group, moved from Pahrump to Las Vegas after her son, Matthew Villalobos, was diagnosed with autism when he was 20 months old. She has since started her own discussion group for parents.

“There is a lack of preparation, information and training. Sometimes the school staff don’t even know what services are available from the district,” Espinosa said of the school system. “That is what moved me as a mother. The Hispanic community doesn’t have sufficient services. If it weren’t for groups like Nevada PEP and the others, we would be lost.”

Loya is happy with the new educational plan for Jovy and credits Nevada PEP with helping him to push the district for a re-evaluation. Still, he would like to see more support made available for Spanish-speakers from the district and other organizations.

“We need more of these groups,” Loya said. “Once a month is not enough. The need is great when you think of all the Spanish-speaking families who have children with disabilities. The classes could be once a week. Support for Spanish speakers is very limited.”