Medicare Compliance & Reimbursement

OPOs face new quality measures, competitive certification.

A new final rule will change the way organ procurement organizations (OPOs) obtain Medicare and Medicaid coverage.

In a final rule--appearing in the May 31 Federal Register--the Centers for Medicare & Medicaid Services (CMS) has established new data reporting requirements and quality measures for OPOs. "This rule establishes a competitive framework for OPO certification" based on rigorous performance-oriented quality measures, CMS Administrator Mark McClellan said in a May 30 statement.

Health and Human Services Secretary Michael Leavitt told reporters that he expects the new OPO rule to increase organ donations during its first year.

CMS made "substantial changes" to the final rule based on comments on the proposed rule it published early last year, the agency said. The final rule sets forth three new outcome measures, performance-data reporting requirements, "new and more objective criteria for selecting the winner of a competition for an open donation service area," and "a new appeals process for OPOs that includes an OPO's right to request reconsideration from CMS," the agency explains.

The rule will also ensure that OPOs can continue their organ procurement services uninterrupted by recertifying 58 OPOs through July 31, 2010 and extending their agreements with the Secretary until Jan. 31, 2011, CMS notes.

Intestine Transplant Facilities Still Must Have 10 Surgeries Per Year

In related coverage news, CMS won't change its current rule for approving intestinal transplant facilities, the agency announced in National Coverage Decision memo 168. Medicare only allows intestinal and multi-visceral transplantation in facilities that have at least 10 intestinal transplants a year. Also, the facilities must have a one-year "actuarial survival rate" of at least 65 percent, meaning two-thirds of patients live a year after the procedure.

Providers had asked CMS to loosen the criteria for transplant facilities, but the agency reviewed the evidence and decided that the evidence supported the current policy.

Medicare Funding Problems Could Pull Health Plans Into The Red

CMS recently released this year's Medicare Trustees Report--and along with it, some serious program funding concerns.

Per Medicare Modernization Act (MMA) guidelines, the report compares Medicare's overall projected expenditures to its dedicated revenues, which include Hospital Insurance Trust Fund payroll taxes, certain income taxes on Social Security benefits, beneficiary premiums and special state payments to Part D. The difference between Medicare's expenditures and dedicated revenues will exceed 45 percent of total Medicare outlays by the end of 2012, the report projects. This projection prompted a determination of "excess general revenue Medicare funding"--an MMA first.

Should an excess recur in next year's Trustees Report, CMS will issue a "Medicare funding warning" that would require President Bush and Congress to address the issue--and expedite a resolution--with new budget legislation.

The report is available online at www.cms.hhs.gov/ReportsTrustFunds/.