Washington Report – June, 2003
Bill Finerfrock
Capitol Associates
Medicare Reform Progresses
The House and Senate have each completed their respective versions of Medicare reform legislation. H.R. 1 and S. 1 would authorize the most dramatic changes in the Medicare program since it began in 1965. In some respects, getting bills passed by the respective houses was the easy part; reconciling the differences between the House and Senate versions of Medicare reform may prove to be the hard part.
Because the rules of the House of Representatives provide tremendous parliamentary advantage to the majority party, it has generally been considered that getting bills supported by the majority party through the House is easier than in the Senate. The Senate’s rules are designed to protect the rights of the minority party, making it more difficult for the majority party to exercise its political power. For these reasons, many found it ironic that getting a Medicare bill through the House proved to be a more difficult task than getting the bill through the Senate.
The House bill, H.R. 1, was passed by a single vote margin 216 – 215 with a few Representatives “missing” the vote on final passage. As there are 435 voting Members of the House, it normally takes 218 votes to pass a bill. However, the fact that the leadership could not get to the 218 vote threshold meant that a least a few GOP members who were inclined to vote against the bill took what is called a “walk”.
A “walk” occurs when, rather than voting against a bill that has the strong backing of their Party Leaders, Members conveniently miss a vote or “go for a walk” while the vote is occurring in order to allow a bill to pass. On the final vote in the House, four GOP Members either missed the vote or voted “present”. In the case of the Member who voted present, it was a Republican who originally voted against the bill and then “paired” with a member who was absent. Pairing is a process where a member announces how he or she would have voted and then “pairs” with a colleague who is not present and had the opposite view. The idea here is that if both members had been present, they would have cancelled each others votes and thus not affected the outcome of the vote. In this case, the fact that one of the two was actually present meant that by voting, the present Member could have changed the outcome of the final vote.
During final passage on H.R. 1, there was a GOP member who was out of town who would have voted for the bill. Because that Member was absent he was “paired” with a GOP Member who was in attendance at the vote and who voted against the bill. The GOP member who was in attendance was able to technically record his opposition to the bill but did so in manner that would not prevent the bill from being passed.
The record also indicates that two GOP members changed their votes at the last minute from Nay to Aye, thereby giving the Leadership the one vote margin necessary to pass the bill.
While these types of vote trading initiatives are not unprecedented, they are uncommon on such major issues as Medicare reform. What is particularly surprising is that this is occurring just months after the GOP increased the size of its majority in the House. What this suggests is that while the GOP has a stronger numerical advantage in the 108th Congress than it enjoyed in the 107th, the philosophical divide in the Republican Caucus may have widened.
The House GOP Leadership opted to work almost exclusively within the GOP Caucus to secure the votes necessary for final passage of the Medicare reform bill. This is not unusual but typical of the way both parties have chosen to run the House when they have had the majority over the past several Congresses. The fact is, the rules of the House generally support this type of legislative process where the majority, no matter how slim, can typically control the outcomes of most votes.
By comparison the Senate bill, S. 1, passed, in the end, with relative ease. By a vote of 76 – 21, the Senate approved its version of the Medicare reform legislation. A majority of members from both parties supported the final bill. Those opposed to the final version of the Senate bill were an interesting mix of Senators who thought the bill did not go nearly far enough in creating a prescription drug benefit, aligned with those Senators who thought the final bill went too far in creating a new entitlement.
Because the Senate does not typically operate under such tight rules (some might argue that the Senate has no rules), there is often a need to pursue legislation that is more bi-partisan. In deciding how to pursue Medicare reform legislation, Senate leaders opted to use the normal legislative process rather than what is referred to as the “reconciliation” process. I have described the reconciliation process in previous Washington Reports; but suffice it to say that under the rules of reconciliation, a simple majority is all that is necessary to pass legislation because reconciliation bills are not subject to a filibuster.
By opting to use the normal legislative process for consideration of the Medicare bill, the Senate leadership opened the possibility that the bill could be filibustered. In order to avoid a filibuster, a bill must be able to secure 60 votes rather than a simple majority of 51. In a Senate that is divided 51 Republicans, 48 Democrats and 1 Independent, it would therefore be necessary to attract at least 9 Senators to the GOP majority.
The fact that a majority of Senate Republicans and Senate Democrats supported the bill on final passage was impressive. However, this overwhelming public vote of support should not mask the fact that there are serious misgivings about the details of the bill within both the Republican and Democrat Caucuses in the Senate.
Emblematic of those divisions was a vote that occurred/did not occur late Thursday evening.
Senators Dianne Feinstein (D-CA), Don Nickles (R-OK), Lincoln Chafee (R-RI) and Lindsey Graham (R-SC) offered an amendment, “To provide for an income-related increase in the Part B premium for individuals with income in excess of $75,000 and married couples with income in excess of $150,000”. This amendment would have created a means test for the Medicare Part B premium – something that has been talked about, but never approved.
The Democratic and Republican leadership in the Senate sought to “table” or kill the amendment. However, much to the surprise of the leadership, the tabling motion failed by a vote of 38 in favor of tabling and 59 against. Normally, once a tabling motion fails, the Senate moves to the immediate consideration of the actual amendment, the assumption being that the vote on the amendment would be the reverse of the tabling motion. In this case, however, the Senate went into a quorum call – a delaying tactic used to allow for off-the-record discussions on the floor of the Senate.
If you happened to stay awake Thursday evening and were watching all this on C-SPAN, you would have witnessed some rather emotional discussions occurring in the Senate Chamber. Unfortunately, because the microphones were turned off, we could only watch the conversations, not hear them.
In talking with individuals who heard the conversations, I’ve learned that they were rather heated and animated. I can tell you they were certainly animated. The gist of the conversations were that several Senators who were vehemently opposed to including a means test in the bill threatened to begin an immediate filibuster of the bill and delay any further action on S. 1. Rather than see the entire process come to a screeching halt, the sponsors of the amendment agreed to back off. After a delay of approximately 45 minutes, the Senate resumed the pubic debate on the bill. Instead of asking for a roll call vote – one where each Senator votes by name, the sponsors asked for a “voice vote”. This is where each side shouts as loud as they can and the chair decides who wins by virtue of the volume of the respective votes. On this particular vote, the Chair ruled that the side opposed to the amendment (38 people) shouted louder than the side favoring the amendment (59 people) and, in the opinion of the chair, the amendment was defeated.
I’m sharing this particular story as an example of how heated and tense the discussions were throughout the Medicare reform debate.
While at one level the Senate Medicare debate looked like a celebration, behind the scenes there were a fair number of Senators who were not pleased with the final bill and who are looking for substantial change during the House-Senate conference.
The final bills were rather lengthy and with floor amendments and other changes, are only now beginning to appear in print. At the end of this report is a summary of some of the major provisions of the House and Senate bills so you can compare how each of the chambers dealt with different issues. This comparison does not incorporate any additions made on the floor of the Senate.
Although the President has asked Congress to complete action on the Medicare bill before the August recess, I do not believe that will be possible. At this point, I think a more realistic completion date is late fall.
Are you ready for HIPAA? Don’t you wish everybody was?
The following information was received from the Centers for Medicare and Medicaid Services.
THE HIPAA DEADLINE - OCTOBER 16, 2003 - IS RIGHT AROUND THE CORNER! WILL YOU BE READY?
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that administers the Medicare and Medicaid programs, and the HIPAA Awareness and Readiness for Kansas organization (HARK), cordially invite you to attend a FREE HIPAA seminar for Kansas Health Care Providers in SALINA, KANSAS. Complimentary lunch will be provided.
You will learn about:
· How To Test And Ensure Your Office Systems Are HIPAA-Ready
· Important HIPAA Deadlines You MUST Know
· Specific Information on Electronic Transactions & Code Sets
· Your Medicare Contractor's Readiness
· HIPAA Privacy
· FREE Provider Resources* And Much, Much More!
Who Should Attend? Providers, Medical Office Managers, Billers, Computer Systems Managers, Privacy/Compliance Officers, Vendors
JULY 11, 2003
11 - 4 P.M. Central
ROLLING HILLS ZOO
625 N Hedville Road
SALINA, KANSAS
RSVP by July 3, 2003 by emailing: or by calling Uvonda Meinholdt (CMS) at: 816-426-5783. Seating is limited and RSVP required. Please include your name, company name, title, e-mail address, and mailing address when you rsvp.
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THE UPPER GREAT LAKES HIPAA IMPLEMENTATION WORKSHOP
When: Thursday July 24 and Friday July 25, 2003
Where: Duluth Entertainment and Convention Center ~ Duluth, Minnesota
Purpose: The main purpose of the conference is to offer small and rural providers in the Upper Great Lakes region an opportunity to hear practical applications, experiences and next steps towards compliance with HIPAA privacy, security and transactions and code sets regulations.
Audience: Privacy officers, security officers, administrators of hospitals, LTC facilities, clinics and other provider organizations, medical records administrators, accounting and billing office staff, IT staff.
For more Information please visit:
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HIPAA 101: the Basics of HIPAA Administrative Simplification Satellite Broadcast - July 16 and 30, 2003 both 2-3 ET
The program is designed to help you understand:
· The history of HIPAA and its benefits,
· How to tell if you are a 'covered entity' under HIPAA,
· The standards that have been adopted for electronic transactions and code sets,
· Why the Designated Standards Maintenance Organizations may be important to you,
· What you need to do to be compliant with the administrative simplification provisions of HIPAA and,
·How HIPAA's rules and deadlines will be enforced.
For more information go to and click on "satellite broadcast" to:
· Find a site near you to see the broadcast
· Register to host this broadcast in your community
· The latest information on satellite coordinates
Host Sites
This Medicare Learning Network satellite broadcast will be available, free of charge, to anyone with an analog steerable satellite dish. Test time is from 1:30 to 2:00.
The coordinates are:
Satellite: Galaxy 3C
Orbit Location: 95 West
Transponder: 22
Downlink Frequency: 4140
Polarization: Vertical
Audio: 6.2, 6.8
A satellite troubleshooter will be available from 1-3 ET by calling 410-736-3618.
Program Memos Issued by CMS
The following are Program Memos issued by CMS from May 1 through June 30th. These issuances are official agency transmittals used for communicating reminder items, requests for action or information of a one time only, nonrecurring nature. To obtain a link to any of these documents, go to:
PM Number / SUBJECT / Effective DateB-03-048 / Addition of Temporary Codes Q4052 and Q4053 / 7/1/2003
B-03-049 / Additional Instructions to Assist in the Implementation of Program Memorandum B-02-75 - Carrier Review of Payment Amounts for Portable X-Ray Transportation Services (HCPCS Code R0070) / 7/7/2003
B-03-047 / Changes to Correct Coding Edits, Version 9.3, Effective October 1, 2003 / 10/1/2003
AB-03-087 / Common Working File (CWF) Edits with Unsolicited Responses for Skilled Nursing Facility (SNF) Consolidated Billing / 7/1/2002
AB-03-089 / Coverage and Billing for Home Prothrombin Time International Normalized Ratio (INR) Monitoring for Anticoagulation Management / 12/27/2002
AB-03-090 / Coverage of Compression Garments in the Treatment of Venous Stasis Ulcers / 10/1/2003
AB-03-092 / Expanded Coverage of Positron Emission Tomography (PET) Scans and Related Claims Processing Requirements—for Thyroid Cancer and Perfusion of the Heart Using Ammonia N-13 / 10/1/2003
AB-03-091 / Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) / 10/1/2003
AB-03-086 / New Automatic Notice of Change to Medicare Secondary Payer (MSP) Auxiliary File / 7/1/2001
A-03-053 / Nurse Practitioner Services Under Medicare Hospice / 7/1/2003
AB-03-088 / Prohibition on New Trading Partner Agreements (TPAs) with Certain Entities for the Purpose of Coordination of Benefits (COB) / 7/5/2002
A-03-052 / Revision to Billing for Swing Bed Services Under Skilled Nursing Facility Prospective Payment System (SNF PPS) / 7/12/2002
A-03-054 / Revision to CR 2573, Transmittal A-03-013, dated February 14, 2003: 3-Day Payment Window Refinements Under the Short-Term Hospital Inpatient Prospective Payment System / 7/1/2003
A-03-051 / July 2003 Update of the Hospital Outpatient Prospective Payment System (OPPS) / 7/1/2003
AB-03-085 / Beneficiary Notice of Implementation of Outpatient Therapy Service Limitations / 7/1/2003
B-03-046 / Provider Education: Establishing New Requirements for ICD-9-CM Coding on Claims Submitted to Medicare Carriers - Increased Role for Physicians/Practitioners / 6/24/2003
AB-03-084 / Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 1, 2003 / 7/1/2003
B-03-044 / CORRECTION TO BUSINESS REQUIREMENT # 2 / See PM
A-03-049 / Fiscal Intermediaries (FIs) Must Install and Use SuperOp with the Fiscal Intermediary Standard System (FISS) / 6/20/2003
B-03-045 / ICD-9-CM Coding Requirements for Claims Submitted to Medicare Carriers / 10/1/2003
A-03-050 / July Medicare Outpatient Code Editor (OCE) Specifications Version 18.2 For Bills From Hospitals That Are Not Paid Under the Outpatient Prospective Payment System (OPPS) / 7/1/2003
A-03-048 / July Outpatient Code Editor (OCE) Specifications Version (V4.2) / 7/1/2003
AB-03-082 / Medicare Secondary Payer (MSP) Prepayment and Post Payment Workload Reporting -Activity Code (AC) Definitions / 10/1/2003
A-03-047 / Medicare’s Coordination of Benefits Contractor (COBC) Shall Discontinue the Dissemination of the Right of Recovery Letter to Intermediaries / 6/20/2003
AB-03-083 / Screening of Complaints Alleging Fraud and Abuse / 6/13/2003
A-03-044 / Audit Guidance Pertaining to Write-offs of Small Debit Balances in Patients’ Accounts Receivable / 10/1/2002
AB-03-081 / Data Center Testing and Production - Electronic Correspondence Referral System (ECRS) User Manual 6.0 / 8/4/2003
A-03-046 / Demonstration--Settlement of Payments for Home Health Services to Beneficiaries Eligible for both Medicare and Medicaid in Connecticut, and Massachusetts. Regional Home Health Intermediaries (RHHIs) Only. / 6/13/2003
A-03-045 / Payment to Hospitals and Units Excluded from the Acute Inpatient Prospective Payment System (IPPS) for Direct Graduate Medical Education (DGME) and Nursing and Allied Health (N&AH) Education for Medicare+Choice (M+C) Enrollees / 10/1/2003
AB-03-080 / Single Drug Pricer (SDP) Clarification for Code J7342l / 6/6/2003
B-03-042 / Bi-Annual Updates to the Health Care Provider Taxonomy Code (HPTC) / 6/16/2003
A-03-043 / Changes to Fiscal Year (FY) 2001 Nursing and Allied Health Education Payment Policies / See PM
B-03-043 / Diabetes Outpatient Self-Management Training (DSMT) and the "Incident to" Provision / 6/6/2003
AB-03-074 / Instructions for Fiscal Intermediary Standard System (FISS) and Multi-Carrier System (MCS) Healthcare Integrated General Ledger Accounting System (HIGLAS) Changes / 7/1/2003
AB-03-078 / Medicare Fee-for-Service (FFS) Contractor Guidance on the HIPAA Privacy Rule Business Associate Provisions / 5/31/2003
B-03-041 / National Council for Prescription Drug Programs (NCPDP) Batch Transaction Standard 1.1 Billing Request Companion Documen / 6/6/2003
AB-03-073 / Provider Education Article: Financial Limitation of Claims for Outpatient Rehabilitation Services / 6/6/2003
AB-03-075 / Provider Education Article: Quarterly Provider Update / 5/23/2003
AB-03-076 / Remittance Advice Message for Denial of Clinical Diagnostic Laboratory Services Denied Due to Frequency Edits / 10/1/2003
AB-03-077 / Revised Disclosure Desk Reference for Call Centers / 6/23/2003
A-03-042 / Updated Revision to Change Request (CR) 2508, Suspension, Offset, and Recoupment of Medicare Payments to Providers and Suppliers of Services / 6/1/2003
A-03-041 / Health Insurance Portability and Accountability Act (HIPAA) Version 4010A1 Institutional 837 Health Care Claim Additional Implementation Direction / 5/27/2003
AB-03-066 / Issuance of the Eligibility File-Based Standard Trading Partner Agreement (TPA) for the Purpose of Coordination of Benefits (COB) / 5/23/2003
AB-03-072 / Mammography Computer Aided Detection (CAD) Equipment / 5/31/2003
B-03-040 / Update of the Place of Service (POS) Code Set / 10/1/2003
A-03-040 / Clarification of Bill Types 22x and 23x Submitted by Skilled Nursing Facilities (SNFs) / See PM
AB-03-069 / Clarification of the Criteria for a Valid Written Statement of Intent (SOI) To File a Medicare Claim / 5/23/2003
A-03-039 / Clarification to Correction to Updated Instruction on Receipt and Processing of Non-Covered Charges on Other Than Part A Inpatient Claims (Transmittals A-02-071, A-02-117) - CHANGE IN EFFECTIVE AND IMPLEMENTATION DATE ONLY / 10/1/2003
B-03-039 / Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) Bypass to Allow Separate Payment for Drugs / See PM
AB-03-068 / CWF Change For The 270/271 Eligibility Transaction / 10/6/2003
AB-03-071 / July Quarterly Update for 2003 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule / 7/1/2003
AB-03-067 / Revision to CR 2170: Appeals Quality Improvement and Data Analysis Activities / 7/24/2003
AB-03-065 / Scheduled Release for July Updates to Software Programs and Pricing/Coding Files / See PM
AB-03-070 / Second Update to the 2003 Medicare Physician Fee Schedule Database / 7/1/2003
A-03-032 / Addition of Patient Status Code 43, Deletion of Patient Status Codes 71 and 72, and Information on New Patient Status Code 65 / 10/1/2003
AB-03-053 / Availability of Online Screens for the Laboratory National Coverage Determinations (NCDs) / 10/1/2003
AB-03-058 / Collection of Fee-for-Service Payments made during periods of Managed Care Enrollment / 10/1/2003
B-03-032 / Continuation of April and July 2003 Change Requests (CRs 2424 and 2524): Create Import/Export Functionality Between the Unique Provider Identification Number System (UPIN) and the Provider Enrollment Chain Ownership System (PECOS) / 7/1/2003
B-03-033 / Continuation of April and July 2003 Change Requests (CRs 2425 and 2525): Create Import/Export Functionality Between the Medicare Claims System (MCS) and the Provider Enrollment Chain Ownership System (PECOS) / See PM
B-03-034 / Continuation of April and July 2003 Change Requests (CRs 2426 and 2526): Process all Medicare Part B Provider Enrollments in the Provider Enrollment Chain Ownership System (PECOS). Modify the Medicare Claims System (MCS) to Incorporate all Claim Payment and Provider Correspondence Functionality that is Included in the Provider Enrollment System (PES) but will not be a part of PECOS / See PM
B-03-035 / Continuation of April and July 2003 Change Requests (CRs 2427 and 2527): Process all Medicare Part B Provider Enrollments in the Provider Enrollment Chain Ownership System (PECOS). Create Import/Export Functionality Between the VIPS Medicare System (VMS) and PECOS / See PM
A-03-037 / Contractor Reporting of Operational and Workload Data (CROWD) for Electronic Data Interchange (EDI) and Manual Transactions / 10/1/2003
AB-03-054 / Diagnosis Code for Screening Pap Smear and Pelvic Examination Services / 10/1/2003
B-03-025 / Durable Medical Equipment Regional Carriers (DMERCs) - DeWall Posture Protector Orthotic Body Jacket (L0430 / 4/11/2003
A-03-033 / End Stage Renal Disease (ESRD) Reimbursement for Automated Multi-Channel Chemistry (AMCC) Tests / 10/1/2003
B-03-037 / Excluding from Home Health Consolidated Billing Edits Claims for Therapy Services Rendered by Physicians / 10/1/2003
B-03-036 / Expansion of Beneficiary History and Claims In Process (CIP) Files in the VIPS Medicare System (VMS). Phase 1 - Beneficiary History File Expansion / 10/1/2003
AB-03-060 / Flat File Changes in the Health Care Claim Professional (837 Professional) Version 4010A1, Health Care Claim Payment/Advice (835) Version 4010&4010A1 and 3051.4A, and Health Care Claim Status Inquiry and Response (276/277) Version 4010A1 Transactions / 10/1/2003
AB-03-057 / Implementation of the Financial Limitation for Outpatient Rehabilitation Services / 10/1/2003
AB-03-052 / Managing Medicare Appeals Workloads in FY 2003 / 5/15/2003
A-03-034 / Modification to Medicare Timely Filing Edit for Claims Paid Under Certain Prospective Payment Systems / 10/1/2003
B-03-031 / Multi-Carrier System (MCS) Reporting of 2003 Participating Data to the Contractor Reporting of Operational & Workload Data (CROWD) System / 10/1/2003
AB-03-062 / New Common Working File (CWF) Edits and Standard System Responses on Skilled Nursing Facility (SNF) Claims / 4/1/2002
AB-03-063 / New Common Working File (CWF) Medicare Secondary Payer (MSP) Edit to Reject MSP Records for Medicare Beneficiaries Who Are Only Entitled to Medicare Part B, and Are Covered by a Group Health Plan (GHP) / See PM
AB-03-056 / New Waived Tests - March 21, 2003 / 7/1/2003
B-03-038 / Oral Anti-Cancer Drugs / 5/9/2003
A-03-038 / Program Integrity Management Reporting (PIMR) System for Part A -Phase 2 / 10/1/2003
AB-03-061 / Program Memorandum on Written Statements of Intent (SOI) to Claim Medicare Benefits / 4/24/2002
A-03-035 / Reporting of Revenue Codes Under the Outpatient Prospective Payment System (OPPS) / 10/1/2003
AB-03-055 / Shared System Maintainer Hours for Resolution of Problems Detected During Health Insurance Portability and Accountability Act (HIPAA) Transaction Release Testing / 10/1/2003
AB-03-059 / Shared Systems Changes for Name Change from HCFA to CMS (FISS and VMS external changes only) / 10/1/2003
AB-03-064 / System Networking Electronic Correspondence Referral System (SNECRS) User Guide / 3/30/2002
A-03-036 / This Program Memorandum has been rescinded and the number will be used in the future. / 7/7/2003
Side-by-Side comparison S. 1 and H.R. 1