Recently in Diagnostic Imaging Category

October 5, 2012

OIG Work Plan 2013

On October 3, 2012, the OIG released its Work Plan for the FY of 2013. Throughout the week, we will be posting on various aspects of the Work Plan pertinent to our clients and our readers in the following areas:

• Hospitals
• Home Health Agencies
• Hospices
• Evaluation and Management Services
• Imaging Services
• Diagnostic Testing
• Sleep Testing
• Medical Equipment and Supplies
• Medicare Audits and the Appeals Processes

Check back every day for updates!

Continue reading "OIG Work Plan 2013" »

December 30, 2011

OIG Releases Report: Questionable Billing Patterns of Portable X-Ray Suppliers

The Office of Inspector General ("OIG") recently released a report entitled Questionable Billing Patterns of Portable X-Ray Suppliers ("Report") wherein it identified portable x-ray suppliers with billing patterns associated with inappropriate Medicare payments. As a result of its Report, the OIG made recommendations to the Centers for Medicare and Medicaid Services ("CMS") to account for inefficiencies in its reimbursement of portable x-ray suppliers.

Reimbursement for Portable X-Ray Services
By way of brief background, the conditions of participation for portable x-ray services, at 42 CFR 486.106, provides, in its entirety, the following:

§ 486.106 Condition for coverage: Referral for service and preservation of records.
All portable X-ray services performed for Medicare beneficiaries are ordered by a doctor of medicine or doctor of osteopathy and records are properly preserved.
(a) Standard--referral by a physician. Portable X-ray examinations are performed only on the order of a doctor of medicine or doctor of osteopathy licensed to practice in the State. The supplier's records show that:
(1) The X-ray test was ordered by a licensed doctor of medicine or doctor of osteopathy, and
(2) Such physician's written, signed order specifies the reason an X-ray test is required, the area of the body to be exposed, the number of radiographs to be obtained, and the views needed; it also includes a statement concerning the condition of the patient which indicates why portable X-ray services are necessary.
(b) Standard--records of examinations performed. The supplier makes for each patient a record of the date of the X-ray examination, the name of the patient, a description of the procedures ordered and performed, the referring physician, the operator(s) of the portable X-ray equipment who performed the examination, the physician to whom the radiograph was sent, and the date it was sent.
(c) Standard--preservation of records. Such reports are maintained for a period of at least 2 years, or for the period of time required by State law for such records (as distinguished from requirements as to the radiograph itself), whichever is longer.

Moreover, the Medicare Claims Processing Manual (Pub. 100-4, Ch. 13 Sec. 90) provides that Medicare reimburses portable suppliers separately for up to four (4) components of the portable x-ray services:
1. Transportation Component - Transporting the equipment to the beneficiary's location,
2. Setup Component - Setting up the equipment for use,
3. Technical Component - Administering the test, and
4. Professional Component - Interpreting the results.

According to the Report, "[e]ighty percent of the amount Medicare paid to portable suppliers in 2009 reimbursed them for transporting and setting up the x-ray equipment." When reimbursing for the Transportation Component, Medicare pays for the full Transportation Component once per each trip to a particular location. Therefore, if a supplier is furnishing x-ray services to three beneficiaries at one nursing home, on one trip, it will pay 1/3 of the Transportation Component for each beneficiary (totaling one full Transportation Component). On the other hand, if a supplier furnishes x-ray services to three beneficiaries at one nursing home on three separate trips, on the same day, Medicare will pay for the full Transportation Component for each return trip to a facility on a particular day.

Questionable Billing Patterns
In is evaluation, the OIG developed the following eight (8) characteristics that described questionable billing patterns:

1. Portable services ordered by nonphysicians
2. No recent contact between beneficiary and ordering provider
3. Same-day services in multiple settings
4. Billing for return trips
5. Portable x-rays per beneficiary
6. Beneficiary contact with multiple portable suppliers
7. Beneficiary use of stationary x-ray services
8. Beneficiary durable medical equipment ("DME") utilization

Results
The OIG found the following of the 352 portable x-ray suppliers in its population:

• 20 (5.7%) suppliers met the criteria for identifying questionable billing patterns where the suppliers exceeded thresholds for questionable billing on at least two (2) individual characteristics as well as the threshold on the combined score (describing the suppliers' overall billing patterns)
• Medicare paid portable x-ray suppliers roughly $12.8 million for return trips to nursing facilities
• Medicare paid at least $6.6 million for portable x-ray services that were ordered by nonphysicians and, therefore, not covered

Recommendations
The OIG recommended the following to CMS in connection with its findings:

• Take appropriate action on the 20 portable x-ray suppliers referred by the OIG;
• Establish a process to periodically identify portable x-ray suppliers that merit greater scrutiny and follow up as appropriate;
• Determine what portion of the $12.8 million CMS paid for return trips in 2009 actually reimbursed suppliers for incorrectly billed Transportation Component claims and collect overpayments where appropriate;
• Collect the $6.6 million in overpayments for portable x-ray services rendered in 2009 that were ordered by nonphysicians; and
• Implement procedures to ensure that CMS pays for portable x-ray services only when ordered by a physician and establish appropriate controls.

CMS concurred with the OIG's recommendations and has taken action to address its reimbursement processes as they relate to portable x-ray suppliers. Portable x-ray suppliers should continue to monitor and assess their billing practices and claims submission to ensure compliance with the applicable laws and regulations.


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December 28, 2011

Professional Component MPPR Will NOT Apply to Group Practices at This Time

As we reported in previous blog entries regarding the 2012 Physician Fee Schedule, the Centers for Medicare and Medicaid Services ("CMS") will be expanding its application of the Multiple Procedure Payment Reduction ("MPPR") to the professional component ("PC") of certain diagnostic imaging procedures. Currently, the MPPR only applies to the technical component ("TC") of certain diagnostic imaging services where full payment is made for the service with the highest TC payment and payment is made at 50% for each subsequent service furnished by the same physician to the same patient in the same day. Under the new rule, full payment will be made for each PC and TC service with the highest payment with payment made at 75% for each subsequent PC service furnished by the same physician to the same patient on the same day. CMS will not be applying the imaging PC MPPR provided by group practices at this time.

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November 11, 2011

CMS Expands MPPR to Professional Component of Advanced Diagnostic Imaging


On July 19, 2011, the Centers for Medicare and Medicaid Services ("CMS") published in the Federal Register its CY 2012 Physician Fee Schedule Proposed Rule ("Proposed Rule"). On November 1, 2011, CMS issued its CY 2012 Physician Fee Schedule Final Rule ("Final Rule"), in part, to "address changes to the physician fee schedule and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services." Most notably for providers and suppliers of radiology services, is the expansion of the multiple procedure payment reduction ("MPPR") policy to the professional component ("PC") of certain advanced diagnostic imaging services (e.g., CT, MRI and Ultrasound). For a more detailed explanation regarding the MPPR and the Proposed Rule, please see this article published by The HLP founding shareholders, Adrienne Dresevic, Esq. and Carey F. Kalmowitz, Esq.

In response to an overwhelming majority of negative feedback CMS received on the Proposed Rule with respect to the MPPR, CMS determined that a 25% reduction in the PC of second and subsequent advanced imaging services was appropriate (versus the proposed-50% reduction). Therefore, beginning January 1, 2012, the MPRR would apply to the PC of certain advanced imaging services.

Radiology providers and suppliers are being called upon to urge their Representatives to support HR 3269, the "Diagnostic Imaging Services Access Protection Act of 2011," which, if enacted, would prevent the MPPR from being applied to the PC of imaging services.

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November 11, 2011

CMS Issues 2012 Final Physician Fee Schedule

On July 19, 2011, the Centers for Medicare and Medicaid Services ("CMS") published in the Federal Register its CY 2012 Physician Fee Schedule Proposed Rule ("Proposed Rule"). On November 1, 2011, CMS issued its 2012 Final Physician Fee Schedule ("Final Rule"), in part, to "address changes to the physician fee schedule and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services." Some key provisions of the Final Rule are set forth below:


  • Payment Reduction Pursuant to the Sustainable Growth Rate - Payments to providers under the Medicare Physician Fee Schedule is set to be reduced by 27.4%, as required by the Sustainable Growth Rate formula, beginning January 1, 2012 absent legislative measures to block to reduction.

  • Addition of Certain Telehealth Services - Generally speaking, CMS reimburses providers for telehealth services--located at a distant site--furnished to an eligible telehealth beneficiary in an originating site. In the Final Rule, CMS proposes adding smoking cessation services to the services to the list of Medicare telehealth services, but notably, chose not to include online evaluation and management ("E&M") services (i.e., to add CPT code 99444) because "(1) these services are non-face-to-face; and (2) the code descriptor includes language that recognizes the provision of services to parties other than the beneficiary and for whom Medicare does not provide coverage (for example, a guardian)."

  • Expansion of the Multiple Procedure Payment Reduction ("MPPR") - The MPPR has been expanded to include the professional component of certain advanced diagnostic imaging services. For a more detailed explanation of this change, please see this blog entry.

  • Anesthesia Fee Schedule Conversion Factor - For 2012, the anesthesia conversion factor is $24.6712 with the national average anesthesia conversion factor equal to $15.5264, a decrease of 26.2% from 2011.

  • Additions to the Physician Self-Referral List of CPT/HCPCS Codes - Beginning January 1, 2012, the following tables provide the codes will be added and removed as designated health services ("DHS") for purposes of the physician self-referral law (a/k/a the Stark Law):


Table 82.bmp

Table 83.bmp

Continue reading "CMS Issues 2012 Final Physician Fee Schedule" »

June 15, 2011

MedPAC Recommendation for Reduction in Imaging Services is Being Met with Strong Opposition

The Medical Payment Advisory Commission (MedPAC) plans to release a recommendation calling for a reduction in the use of imaging services, including MRIs, CT scans and nuclear medicine. MedPAC's advisory opinion would require some physicians and their patients to obtain pre-approval from Medicare for advanced imaging services. The proposal, if implemented without modification, would apply to physicians determined to have higher-than-average rates of inappropriate use of such imaging.

Imaging is one of the fastest-growing Medicare costs, rising from $6.5 billion to $11.7 between 2000 and 2009. CMS believes such restrictions "could add more front-end approaches to better ensure appropriate payments, such as requiring physicians to obtain prior authorization from Medicare before ordering an imaging service."

Detractors of MedPAC's recommendations argue that such restrictions on imaging services are premature on account of the regulations enacted in recent years to slow the growth of imaging expenditures. In response to the recommendation, a coalition of imaging manufactures, medical providers and patient groups urged MedPAC to reconsider, warning that implementation of the recommendation would limit access to life-saving diagnostic imaging services, which has the potential to impact the delivery of care to nearly 48 million Medicare beneficiaries.

The MedPAC proposal has also been met by opposition from lawmakers. House Energy and Commerce Health Subcommittee Chairman Joe Pitts, R-Pa., and ranking member Frank Pallone, D-N.J., two Congressman who fought with one another over last year's health law, joined forces to oppose MedPAC's recommendation. While Congress is not required to adopt MedPAC recommendations, some Capitol Hill observers believe that Congress may seek to incorporate certain of MedPAC's proposals, especially in light of the motivation to reduce federal health care expenditures.

For more information on government regulation of imaging services or for professional assistance navigating the ever-evolving healthcare landscape, please contact Carey F. Kalmowitz, Esq. or Adrienne Dresevic, Esq. at (248) 996-8510 or (212) 734-0128, or visit the HLP website.

June 10, 2011

False Claims Act Allegations Resulted in Florida Radiology Clinic and Others to Pay $3 Million Settlement

A Florida radiology clinic, Midtown Imaging LLC, and its former owners--Midtown Imaging PA and PBC Medical Imaging--have agreed to pay $3 million to settle allegations that Midtown Imaging LLC submitted false claims to Medicare between 2000 and 2008. The allegations arose from Midtown Imaging LLC's lease and professional services agreements with referral sources that were in violation of the Anti-Kickback Statute (AKS) and Stark Law (Stark), according to a Department of Justice press release. The whistleblowers, Dr. Teresa M. Cortinas and Dr. Walter E. Wojcicki, will receive $600,000.

Since January 2009, the Justice Department has recovered over $7.3 billion in False Claims Act cases.

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November 8, 2010

Key Updates from the CMS 2011 Final Physician Fee Schedule

CMS's 2011 Final Physician Fee Schedule (the "Fee Schedule") provides for over 2000 pages of new rules and regulations pertaining to physician reimbursement under Medicare for 2011. With the passing of the Patient Protection and Affordable Care Act ("PPACA") and the Healthcare and Education Reconciliation Act (collectively referred to as the "Affordable Care Act"), physicians have found many new conditions tied to their reimbursement for rendering services to Medicare beneficiaries. Some of the notable changes are below:

• Sustainable Growth Rate ("SGR") - The SGR is an annual growth rate that applies to physicians' services paid by Medicare. According to the Fee Schedule, by January 1, 2011, the SGR for physicians will be cut by a total of 24.9%--once on December 1, 2010 and once on January 1, 2011. This SGR cut has been anticipated for physicians as it was to be in effect in June of 2010.

• Annual Wellness Visit ("AWV") - Beginning January 1, 2011, Medicare will reimburse physicians for performing an AWV. An AWV takes into account a health risk assessment and creates a personalized prevention plan for beneficiaries. Certain elements must be identified in the beneficiary's first visit that include: establishing or updating the beneficiary's family and medical history, a list of the individual's current providers and suppliers and medications prescribed, height, weight, and body-mass index, blood pressure, detection of any cognitive impairment, establishing a screening schedule for the next 5-10 years, establishing a list of risk actors and conditions for which interventions are recommended or underway, furnishing personalized health advice and referral to health education or preventive counseling services or programs.

• Elimination of Deductible and Coinsurance for most Preventive Services - Beginning January 1, 2011, the Part B deductible and 20% coinsurance will be waived for preventive services that have been either "strongly recommended" or "recommended" by the US Preventive Services Task Force.

• Incentive Payments to Primary Care Physicians - Primary care physicians are eligible for incentive payments of 10% of the primary care practitioner's allowed charges for primacy care services under Part B. According to the Fee Schedule, a primary care practitioner is defined as:

1. A physician who has a primary specialty designation of family medicine internal medicine, geriatric medicine, pediatric medicine, nurse practitioner, clinical nurse specialist, or physician assistant; and

2. For whom primary care services accounted for at least 60% of the allowed charges under Part B for the practitioner in a prior period as determined by the Secretary.
Primary care services are defined as those services identified by the HCPCS codes of 99201-99215, 99304-99340, and 99341-99350. The incentive payments will be made on a quarterly basis based on the primary care services furnished and any other physician bonus payments for services that are furnished in Health Professional Shortage Areas.

• In Office Ancillary Services - for MRI, CT, and PET scans, physicians must disclose to patients, in writing, at the time of the referral that a patient may obtain the services from another provider. At the time of the referral, the referring physician must provide the patient with a list of five alternative suppliers (who supply the same service) within a 25-mile radius of the physician's office location (please check back for a more detailed entry regarding this change).

• Modification of Multiple Procedure Payment Policy for Advanced Imaging Services - Effective January 1, 2011, CMS will reduce the payment rates for procedures associated with expensive diagnostic equipment assigning a 75% equipment utilization rate assumption to expensive diagnostic imaging equipment used in CT and MRI services.

• Maximum Period for Submitting Medicare Claims - For services furnished after January 1, 2010, the maximum period for submitting Medicare fee-for-service claims has decreased to 12-months from the date of service. However, there are four exceptions to this rule:

1. If CMS or one of its contractors determines that the failure to meet the 12-month deadline was due to a CMS or CMS contractor error or misrepresentation;

2. If CMS or one of its contractors determines that the failure to meet the 12-month deadline was due to the fact that a beneficiary was retroactively entitled to Medicare;

3. If CMS or one of its contractors determines that the failure to meet the 12-month deadline was due to a beneficiary being retroactively entitled to Medicare, but a state Medicaid agency recovered the Medicaid payment for the furnished service 6 months after the service was furnished; or

4.CMS or one of its contractors determines that the failure to meet the 12-month deadline was because, at the time the service was furnished, the beneficiary was enrolled, and subsequently disenrolled, in a Medicare Advantage plan or a PACE provider organization and the Medicare Advantage plan or PACE provider organization recovered its payment for the furnished service 6 months or more after the service was furnished.

The final rule will appear in the November 29, 2010 Federal Register. Except as otherwise specified, the policies and payment rates adopted in the final rule will be effective for services furnished on or after January 1, 2011. As is evident from these select provisions from the Fee Schedule (oftentimes driven by the provisions in the Affordable Care Act), physicians' reimbursement for services rendered to Medicare beneficiaries is becoming increasingly more difficult for physicians to receive, especially with the significant decrease in the SGR. If the decrease in SGR is not postponed (or even eliminated), senior citizens will experience difficulty in accessing medical care--one of the evils the Affordable Care Act sought to address.

Continue reading "Key Updates from the CMS 2011 Final Physician Fee Schedule" »

October 13, 2010

OIG 2011 Work Plan: Diagnostic Testing

The OIG will review the high-cost diagnostic tests to ensure that they were medically necessary by looking at the same diagnostic tests ordered by the primary care physician as well as the specialist. With respect to independent diagnostic testing facilities (IDTFs), federal regulations require compliance with 17 standards. The OIG will look at IDTFs to ensure compliance with all standards in addition to identifying billing patterns of non-compliant IDTFs.

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October 12, 2010

OIG 2011 Work Plan: Imaging Services

Currently, Medicare Part B pays for imaging services pursuant to the physician professional cost component, the malpractice costs, and the practice expenses. Practice expenses are resources used in furnishing the services (i.e., rent, personnel costs, equipment costs, etc.). The OIG will review whether the Medicare payments for practice expenses "reflect the expenses incurred and whether the utilization rates reflect industry practices." Furthermore, the OIG will review providers of portable x-ray services with unusual claim patterns.

Continue reading "OIG 2011 Work Plan: Imaging Services" »

October 5, 2010

OIG 2011 Work Plan

On October 4, 2010, the OIG released its Work Plan for the FY of 2011. Throughout the week, we will be posting on various aspects of the Work Plan pertinent to our clients and our readers in the following areas:
• Hospitals
• Home Health Agencies
• Hospices
• Evaluation and Management Services
• Imaging Services
• Diagnostic Testing
• Sleep Testing
• Medical Equipment and Supplies
• Medicare Audits and the Appeals Processes

Check back every day for updates!

Continue reading "OIG 2011 Work Plan" »

September 30, 2010

OIG Continues to Permit Free Pre-Authorization Services

On September 28, the Office of Inspector General (OIG) posted Advisory Opinion 10-20 in which it analyzed another pre-authorization arrangement. This is the OIG's third Advisory Opinion issued this year that favorably reviews the provision of free pre-authorization services to referral sources (please visit our September 9 and May 14 blogs both of which address favorable pre-authorization arrangements).

Under the Proposed Arrangement, Requestor is a physician-owned provider of professional radiology services. When a patient comes to Requestor's facility, Requestor proposes to contact the insurer to provide any necessary information to obtain preauthorization. According to the Proposed Arrangement, free preauthorization services would be made available on an equal basis to all patients and referring physicians without regard to any physician's volume or value of expected of past referrals. Further, in cases when the Requestor's contract with an insurer precludes it from performing the pre-authorization services, Requestor would not do so. Under the Proposed Arrangement, the Requestor would ensure transparency by providing each physician with a copy of the information submitted to obtain the pre-authorization services, and it would make such information available to the Secretary of health and Human Services upon request. Because Requestor, ultimately, bears the risk of not getting paid by the insurance company, it offers this service to ensure that it obtains reimbursement for the services that it furnishes.

The OIG analyzed the Proposed Arrangement under the Anti-Kickback Statute (AKS) and, reiterated many concerns it expressed in its prior preauthorization opinions. However, similar to its previous opinions addressing pre-authorization issues, the OIG again concluded that even though the Proposed Arrangement could potentially generate prohibited remuneration under the AKS, it would not impose administrative sanctions as there was a low level of risk under the AKS for the following reasons:

1. The Proposed Arrangement would not target any referring physicians;

2. There are no implicit or explicit arrangements with the referring physicians to reward them for their referrals;

3. Requestor would be transparent with the insurance company--identifying itself while obtaining pre-authorization--and would provide physicians with a copy of the information submitted to the insurance companies; and

4. Requestor has a legitimate business interest in offering pre-authorization services because its payments are at stake if pre-authorization is not obtained for the services.

Advisory Opinion 10-20, the third pre-authorization opinion in four months, continues to reinforce the OIG's prevailing view that free pre-authorization services, when carefully implemented and without regard for the value or volume of referrals, pose low, limited risks under the AKS. This opinion, in particular, has particular significance insofar as the OIG analyzed a structure consistent with the common paradigm of pre-authorization arrangements among imaging providers.

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September 9, 2010

OIG Permits Hospital to Seek Pre-Authorization for Diagnostic Imaging Services

The OIG released Advisory Opinion 10-13 on August 31, 2010, concerning a proposed-arrangement where a hospital would be providing pre-authorization services for diagnostic imaging. Requestor, a non-profit hospital, provides diagnostic imaging services to patients. Because many commercial insurers have begun requiring pre-authorization prior to covering diagnostic imaging services, the hospital has proposed to provide free pre-authorization services for all patients. Under this proposed arrangement, when a patient comes to the hospital, if the patient's imaging procedure requires pre-authorization, the hospital's Pre-Access Department contacts the patient's insurer, provides it with the necessary information, and obtains the pre-authorization. The patient is not charged for this service and it is provided to all patients and referring physicians without regard to the volume or value of referrals. No physicians are paid under this arrangement.

The OIG determined that the potential remuneration generated under this arrangement did not rise to the level of sanctioning the hospital for the following reasons. First, while this service may relieve a physician's administrative duties of obtaining pre-authorization him/herself, the arrangement does "not target any particular referring physicians" and any relief of administrative duties would "occur by chance, not design." Furthermore, this service is offered to all patients and physicians, without regard to referrals. Second, the hospital will "not make payments to physicians under the...[a]rrangement, and it has no ancillary agreements with referring physicians that would otherwise reward referrals" to the hospital. Third, the hospital's Pre-Access Department is transparent with insurers and physicians. Finally, the hospital has a "legitimate business interest in offering uniform pre-authorization services" because it is the hospital's payments that are at stake if pre-authorization is not obtained.

Thus, the OIG has determined that, under this particular proposed-arrangement, a hospital providing pre-authorization for imaging services for patients seeking diagnostic imaging procedures is permissible.

This opinion is the second opinion the OIG has released regarding pre-authorization for imaging services. On May 14, 2010, we blogged on the first opinion, Opinion 10-04, in which the OIG approved a proposed-arrangement where an imaging center would provide free pre-authorization services under a similar arrangement as was proposed in Opinion 10-13.

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September 7, 2010

HLP's Adrienne Dresevic, Esq. Quoted in Kaiser Health News

Founding partner, Adrienne Dresevic, Esq. was quoted in Kaiser Health News on August 23, 2010 in an article on the recent regulations pertaining to physician disclosure requirements involving imaging machines. Dresevic often writes articles and speaks across the nation about the laws and policies surrounding imaging arrangements.

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August 17, 2010

CARE Act Would Create Credentialing Standards for Medical Imaging Personnel

A bill introduced in the Senate on August 5, 2010 would set forth minimum credentialing standards for medical personnel who "perform or plan" medical imaging or radiation therapy procedures. The Consistency, Accuracy, Responsibility and Excellence (CARE) in Medical Imaging and Radiation Therapy Act, introduced by Sen. Harkin (D-IA) and Sen. Enzi (R-WY) responds to concerns that procedures like x-rays, CT scans, and MRIs are increasingly being performed by personnel without adequate training, and would go into effect in 2013. Currently, standards vary from state to state; the CARE Act isn't meant to supplant or diminish more stringent standards that exist in some states. In addition, the Bill creates a grandfathering process for technicians who currently provide medical imaging or radiation therapy but don't meet the new education standards. It also establishes alternative standards for rural and underserved populations.

Given broad-based support, according to a press release from Sen. Harkin, the Bill is expected to pass this year.

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