Legal

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Friday, January 31, 2003

Are there any checks, balances on IR authority?
With Elizabeth Hogue
Q: The interim final rule on IR becomes effective Feb. 11, 2003. Wary providers have been assured there are “checks and balances” on CMS’s ability to reduce payments based on IR. Will these checks and balances be adequate?

A: Checks on CMS’s authority to exercise IR include a requirement that DMERCs use “valid and reliable” data when performing IR. CMS and the DMERCs must also use a consistent process to develop data to support adjustments. The obvious problem with these criteria is that they are very nebulous. In addition, there is always a question about whether data and processes used to reduce rates under IR will include on-going monitoring of compliance and evaluating the data used by CMS and the DMERCs. Moreover, evaluating the effects of changes in payments on quality of care and access have historically been extremely difficult to demonstrate. When providers must rely on anecdotes to attempt to prove this point, they are likely to run into regulators with anecdotes and/or statistics that refute their claims.

The “bottom line” seems to be that limitations on the use of IR are unlikely to prevent adverse effects on quality of care and access.

Elizabeth Hogue is in privacte practice. Reach her at 301-421-0134

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