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GOVERNMENT WATCH

RULE GRANTS RIGHTS TO APPEAL MEDICARE COVERAGE POLICY

Should individuals have the right to challenge Medicare policies regarding coverage of medical treatments? A proposed rule published in the Federal Register answers “yes” to that question. The comment period on the rule ends October 21st.

Prior to this rule, Medicare beneficiaries had no method of appealing a national policy decision by the Centers for Medicare and Medicaid Services (CMS); appeals could only be made on a case-by-case basis. Under this rule, Medicare beneficiaries who have been denied coverage can take a more active role in changing Medicare policy.

According to AMNews, the American Medical Association newspaper, CMS has made less than 200 national policy coverage decisions. Several pending national coverage decisions address neurological disorders, such as Parkinson disease and Alzheimer disease.

One section of the proposed rule might be of particular interest to practicing neurologists. It reviews the process already in place to challenge a coverage decision through the presentation of new scientific or clinical evidence – or a different interpretation of existing evidence.

One hurdle to the new rule will be funding. According to AMNews, Congress has not provided additional funds to implement the review program, and the proposal is not specific about where the funding for the program will come from.

FINAL HIPAA PRIVACY RULE PUBLISHED

The Department of Health and Human Services (HHS) published the final revisions to the Health Insurance Portability Administration Act (HIPAA) rules. The compliance date for the rules is April 14, 2003. These final changes were made in response to concerns that had been raised by physicians and other groups to the original rules. Following are some changes in the HIPAA rules that might be of interest to practicing neurologists.

  • In the event of the “sale, transfer, consolidation or merger'' of one heath care institution to another, a clarification was issued that medical records could be passed on and accessed without specific individual consent.
  • The final rule explicitly protects health care providers from liability in the case of unintentional disclosures of health information, such as, for example, when a patient overhears a discussion between a doctor and a nurse regarding a second patient's medical condition. Physicians must take reasonable precautions to avoid unintentional disclosures, however.
  • The rule clears up practical problems with regard to consent requirements for the sharing of information for treatment, payment, or health care operations reasons, especially in the instance of medical care that is initiated before face-to-face contact and before a consent form could be signed. For example, pharmacists can fill prescriptions and check for drug-drug interactions or allergies without a signed consent form. Health care providers still must make a good faith effort to obtain written acknowledgment that their patients have received their privacy policy, except in emergency situations.
  • The new rule streamlines and consolidates the legal paperwork for consent requirements that must be signed by human study participants. It also eliminates the requirement for an expiration date for the use of personal medical information for research purposes, although the consent forms must contain a statement specifying that there is no expiration date.

Commenting on the final changes to the HIPAA rules, Marc Raphaelson MD, Director of the Greater Washington Sleep Disorders Center in Rockville, MD, said: “Only time and practice will tell whether the revisions strike a successful balance or include all necessary changes…[but] I am satisfied that the government has fostered and documented an open, wide-ranging and considered dialogue with interested health care professionals.”

Based on discussions that he has had with information technology (IT) specialists, Dr. Raphaelson believes that “each physician and practice will need regular and expensive meetings with a professional IT specialist, as we now need regular and expensive meetings with accountants, lawyers, and pension planners,” in order to comply with HIPAA.

HOUSE CONSIDERS MOSQUITO CONTROL BILL

In response to the rapidly spreading West Nile virus (see cover story), the House is considering a bill to provide matching grants to assist the “political subdivisions of States” in their mosquito control activities.

The grants will be administered by the Centers for Disease Control and Prevention (CDC), with preference given to applicants that are more severely affected by mosquito-borne diseases. The maximum grant award available will be $50,000, and the amount of the grant must be matched, dollar for dollar, by the recipient using non-federal funds. Grants will be available for a variety of mosquito-control program expenses, including “purchasing or updating equipment and laboratory facilities.” Through the bill, grants would be available in fiscal years 2003 through 2007.

Although this bill, if passed, would be a significant contribution to containing the West Nile virus, there are already funds available to assist states hit hard by the West Nile outbreak. Earlier this year, the CDC made additional funds available for mosquito control, bringing the agency's total mosquito-fighting pledge to $27 million. A few states have already received a portion of these additional funds.

NEW MEDICARE CHOICE PROGRAM

The CMS is hoping to expand the health care options of Medicare beneficiaries with a new Medicare Choice program modeled after private PPO (preferred provider organizations) insurance plans. The PPO-like plans will be offered in a limited number of states beginning in January as part of a demonstration program, according to an HHS press release that stated some of the expected benefits of the plan.

PPO insurance plans are an increasingly popular option among those with private insurance, and CMS officials believe that instituting a similar plan will be a good way to give Medicare beneficiaries more health care choices while expanding the array of benefits available to them, according to the press release.

One crucial benefit that the new plans will have is prescription drug coverage. According to an article in The New York Times, all 33 of the health plans scheduled to participate in the demonstration program plan on offering some form of prescription drug benefits with their PPO-type plan. This is expected to be one of the most attractive features of the new plan, which will be open to around 11 million Medicare beneficiaries in 23 states. A list of participating health plans and states can be found at www.hhs.gov/news/press/2002pres/20020827att.html.

The plans will have all of the benefits required by Medicare, but will offer a greater choice of health care providers than the current Medicare HMOs. In addition to prescription drug benefits, the plans will cover a larger selection of disease management services. CMS officials call the demonstration program “a big step toward making these plans widely available to seniors.”