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CMS Proposes PPC Medicaid Payment Reductions

Mike Iarrobino, for HealthLeaders Media, February 16, 2011

Provider-preventable conditions (PPC) would receive a payment reduction under Medicaid, similar to the treatment of hospital-acquired conditions (HAC) by the Medicare program, under a proposed rule posted by CMS February 16.

The proposal comes on the heels of increased attention to Medicaid as a result of the Patient Protection and Affordable Care Act; previous months have seen a proposed expansion of the recovery audit contractor program to Medicaid and an extension of the National Correct Coding Initiative edits to Medicaid claims. Although some states already have Medicaid provisions to reduce payment for conditions that match the Medicare HACs, the new rule would require such payment reductions nationwide. States will also have the flexibility to individually designate additional conditions that would result in reduced payment.

This flexibility may be a concern to Medicaid providers, says Debbie Mackaman RHIA, CHCO, regulatory specialist for HCPro, Inc., in Danvers, MA. “They’re giving Medicaid a long leash on this. This opens a huge window that allows them to create new restrictions on payments that are already minimal.” Importantly, CMS would allow states to expand beyond the inpatient setting, to include outpatient hospitals, nursing facilities, and ambulatory care settings.

PPCs would be divided into two types:

  1. Healthcare-acquired conditions (HCAC), which would track the HACs identified for Medicare
  2. Other provider-preventable conditions (OPPC), which states could specify as extensions of the payment reduction program

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2 comments on "CMS Proposes PPC Medicaid Payment Reductions"


Cody Page (3/18/2011 at 1:07 PM)
Mike, You noted that 29 states already have in place Medicaid reimbursement penalties for potentially preventable readmissions. Where did you get this information? If you can point me to a website or data source for this, I would appreciate it. Thanks!

Dan Harrah, MD (2/17/2011 at 4:34 PM)
This is clearly a case of toxic leadership. You can't legislate away infection or blood clots. Doctor's are not a bunch of idiots making sloppy mistakes all the time. Medicaid patients are sicker than the average patient due to lifestyle choices; unhealthy living rather than factors under a doctors control. Yet we get paid less for treating them already, and now you want to blame us for doing a bad job??? What will you do when doctors refuse to see these patients because we are tired of the hassle and lack of reward for taking on these difficult patietns who are way more likely to abuse prescription drugs?