News in brief - Nov. 22/29, 2004

Pay for performance scrutinized - Physicians settle Medicare billing charges - Idaho SCHIP premium assistance gets federal OK

Pay for performance scrutinized

The National Quality Forum will hold a workshop early next year to begin standardizing guidelines for pay-for-performance programs.

NQF aims to develop a set of criteria that can be used to judge incentive-based initiatives that involve public or private payers and that center on the hospital setting. The group, whose members include the American Medical Association, will hold the Washington, D.C., event at the behest of the Centers for Medicare & Medicaid Services.

Although the number of pay-for-performance programs in the United States is rapidly growing, there is a concern about the lack of standards for how to implement them, said Kenneth Kizer, MD, president and CEO of the forum. "It is highly likely that within a relatively short time, pay-for-performance programs will become the norm for health care reimbursement," he said.

Physicians settle Medicare billing charges

Temple University Physicians in late October agreed to pay the federal government nearly $1.9 million to settle allegations over the way it billed Medicare in the mid-1990s.

The organization, which consists of the physician practices of the Temple University School of Medicine in Philadelphia, did not have enough documentation to support claims it submitted to the Medicare Part B program in 1995-96, according to the U.S. Attorney's Office for the Eastern District of Pennsylvania. The government also alleged that claims were improperly upcoded or represented a greater level of service than was actually provided.

The physicians' decision to settle is not an admission of guilt. The institution said it settled to avoid lengthy and costly litigation.

The civil settlement arises from an investigation and audit that the Dept. of Health and Human Services conducted as part of its Physicians At Teaching Hospitals initiative, commonly known as PATH. Nationally, 20 other teaching institutions have reached settlements with the government.

Idaho SCHIP premium assistance gets federal OK

The Centers for Medicare & Medicaid Services has approved a waiver for Idaho allowing the state to use funds from the State Children's Health Insurance Program to help families buy individual or employer-based coverage for their children. Families with incomes at or below 185% of the poverty level can receive $100 per child per month in premium assistance.

The money is paid directly to health insurance companies participating in the Access Card Program. "This new plan will help more kids receive the kind of care that can prevent long-term health care problems," said CMS Administrator Mark McClellan, MD, PhD.