December 1, 2011 Legislation




Congress has passed the fix in the Obamacare plan to allow Social Security to count toward eligibility for Medicaid.  Tacked on to the bill passed by both houses was an incentive to hire unemployed vets.  Obama has said he will sign the bill.

When one becomes an ACO they will now have to prove they are what they say.  The NCQA will be inspecting for ACO compliance.  One more reason to think twice before becoming an ACO.

CMS is delaying their enforcement of the 5010 compliance of claim submission standards.  This was to go into effect on January 1, 2012.  The organizations of hospitals and physicians will have to March 31, 2012 to start sending all transmissions with the 5010 requirements.  All will still have to be in compliance by the January deadline.  Until March the 4010 form can still be used.  The 5010 form is a precursor to the dreaded ICD 10 that the AMA is trying to either delay or scuttle all together.

The FDA has ruled that Avastin should not be used for metastatic breast cancer.  The medication is still allowed for several other cancers.  The FDA based its reasoning on scientific matters not, as they do in England, on money.  As a matter of fact, Avastin is still being paid for by all insurance companies including Medicare except for Blue Shield.  They are continuing to pay for the med for those already on it. 

Well, the time has come and passed.  As usual Congress did not act and now all medical providers will get a 2% decrease for Medicare patients.  This is on top of the almost 30% decrease under the SGR if not repealed and a huge decrease in payments for radiological and cardiac procedures.  It will be interesting how many non-employed physicians will continue to see Medicare patients and how much employed physicians will get their salaries cut.

The "Super Committee's" failure also sunk a great opportunity for a SGR fix.  Congress will need to pass a special bill to not allow the SGR to go into effect.

The House Democrats are calling for a SGR fix of some kind by December 16.  This will be another short term extension and not any permanent fix.  Congress can not agree on how to do anything.

Bye Bye Donald Berwick.  The interim appointee to the head of CMS is gone on December 2.  The new appointee will be Marilyn Tavenner, the current number two.  This person will have to be confirmed since Berwick could never have passed the confirmation process. She seems to be the antithesis of Berwick so should be confirmed easily.

HHS, the big Washington power, has flexed its muscle against a small Pennsylvania insurer run by the Mennonite Church.  HHS believes that Everence Insurance raised rates more than necessary.  They have no power to do anything about it. 

The CMS has come out with new Conditions of Participation Guidelines.  They cover hospital governance, medical staff governance, medical records, notification processes of patients who die while under restraint or seclusion.  The Joint Commission will be citing under these new rules after they become final.

Medicare is now paying for counseling for the obese.  This will include face to face encounters weekly for one month and one other session per month for the following six months.  If the person is successful in losing weight they may be allowed more monthly sessions.

The People's Republic of Massachusetts continues to try to dig out of the mess it made for itself with insurance for all.  They still can not afford what they wrought.  The newest gimmick is to set up a ten person panel of mostly non hospital people.  If an insurer refuses to pay a hospital bill that they believe is too costly the dispute will go to the panel.  The panel will have the power to make the insurer pay or the hospital take less.  Which do you think will happen?  This is called by HealthLeaders and by me rate setting.  This is a forerunner of Obamacare if it ever comes to pass.  

The Republic continues to attempt to find new ways to fund the unfundable health care law.  The newest gimmick is to take $50 million from one time fees for three casino licenses to pay providers prepare for the new way they are planning to pay for health care.  It is the old failed way of the HMOs, per member per month.  

California usually leads the nation and they do again.  They are the first state to realize the folly of Obamacare's pre-existing health plan that is now in place.  As all know there has been a dearth of sign-ups for the plan due to the costs which the government has reduced to no avail.  Now California is planning on stopping enrollment in the plan due to the costs involved in the few who have enrolled.  After the first year of only 5000 enrollees the costs were almost three times the government expected.  If the feds don't allocate more money to the program it will close the program to new enrollees. 

The National Union of Healthcare Workers who are involved in a law suit with Kaiser have asked California officials to inspect Kaiser's mental health system for major flaws.  They contend that Kaiser does not conform to the laws regulating HMOs for seeing patients within 10 days.  Kaiser denies the shady tactics stated by the Union.  

Canada is a great place of live.  The female patients will get screening mammograms every three years and they and the Canadian physicians have been told not to screen for breast cancer by self palpation or physician exam.  This is from the Canadian Task Force on Preventive Public Health.  The equivalent of the US task force that said not to do mammograms or PSA tests here.  Nobody paid any attention to them here as they had no qualified members on their panel.        Top


The Wisconsin Medical Board has formally reprimanded seven physicians for writing fraudulent prescriptions for sick leave for protestors.  They also have to pay to take a course is medical record keeping.  They will have a permanent black mark on their Wisconsin license and will be reported to the National Practitioner Data Bank.  Two others got lesser punishment since they were resident physicians.        Top




DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.