Medicare Compliance & Reimbursement

New CMS administrator, with links to physicians, reaches out to embattled industry.

In one of his first public presentations as Centers for Medicare & Medicaid Services Administrator, Mark McClellan, MD, offered a two-sided message to the American Medical Association's annual national advocacy conference in Washington March 30. His theme: We'll play ball with you on regulatory matters, if you exert your influence to help hold down health-care spending. The "or else" implicit in McClellan's remarks: If you don't help develop a more cost-effective care system, it may be your reimbursement that suffers in the end.
 
Like his predecessor Tom Scully -- who came to CMS after a successful, multi-year tenure as top dog at the for-profit hospital association, Federation of American Hospitals -- McClellan claims insider status in one of the most influential provider populations: physicians. Like Scully -- who won hospitals' agreement to begin reporting quality data -- McClellan seems poised to wield his influence to bring doctors some boons they particularly crave in return for their willingness to get on board with cost-efficiency measures many have shunned in the past.

To win docs' favor, McClellan -- who received a lengthy standing ovation after his remarks -- pledged that he'll help push for damages limits in medical-liability cases and move aggressively both to implement regulatory streamlining enacted in last year's Medicare bill and to identify other ways to cut paperwork and enforcement burdens.

CMS will reexamine claims documentation requirements with an eye to cutting paperwork; require claims-processing contractors to respond to inquiries with reliable, binding guidance in 45 days; and end the practice of "extrapolation" in claims audits, McClellan said. Previously, auditors have extrapolated the amount of a physician's past overpayments from examination of a small sample of claims, and CMS has required full repayment up front even when a physician was appealing the judgment. That practice will now end, McClellan promised.

In return, however, physicians need to lead the push toward more efficient treatments, or see a return to the traditional Medicare pattern of dinging provider payments as health-care spending rises uncontrollably, the new administrator said. He asked that physicians ante up by doing the following:

Physicians must be in the forefront of choosing the most cost-effective treatments, helping to develop solid information about cost and effectiveness and actively sharing it with patients. McClellan urged the AMA audience to promote generic substitutes in place of more expensive brand-name drugs and to foster "smart choices about class substitution" -- use of a cheaper but still effective drug from a treatment class with a different biological mechanism of action - as well.

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